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Performance measurement—A strategic imperative and a call to action

An overview of forthcoming papers from the American Academy of Nursing Expert Panel on Quality

      Introduction

      In 2010, the American Academy of Nursing Expert Panel on Health Care Quality identified performance measurement in the transforming health care delivery system as a strategic imperative and agreed that a synthesis of key concepts was needed to guide policy and provide direction for the Academy and nursing’s partners in health care. Envisioned as a “call to action,” the Expert Panel affirmed the foci of target papers, recruited members as lead authors and co-authors, and launched an ambitious effort to develop 6 substantive position papers in 2011. The first 2 papers, developed by writing teams led by Drs. Joyce Verran and Gerri Lamb, were presented at the Academy’s Pre-Conference on October 14, 2011. Additional papers under development are currently on track for draft review in 2011 and all papers will be forwarded to the Academy’s Board of Directors for review and endorsement. The Expert Panel on Health Care Quality acknowledges the direct and indirect contribution of its dedicated members, particularly the thought leaders whose insight and expertise are shaping this work. Importantly, the Panel is collaborating with other Academy Expert Panels in reviewing emerging papers and is informally collaborating with organizations who share a commitment to advancing nursing’s performance measurement imperative.

      Measuring Episode of Care Outcomes

      Lead Author: Joyce Verran, PhD, RN, FAAN

      This paper focuses attention on the need to develop and measure generic patient outcomes across the health care continuum, specifically, in an Episode of Care. Generic outcomes are those that are appropriate across settings of care and are applicable for all patients, no matter their diagnosis or health condition. To make care safer, to ensure patient/family engagement, and to promote effective communication and coordination, a system of care perspective should be used. Further, not only must we think in terms of that system, but evaluation methods for performance measurement should be consistent across sites and providers of care. Although 2 generic outcomes have been proposed within the first domain of performance measurement for an episode of care, building on the ongoing and early work of the Expert Panel on Quality and aligned with the National Strategy for Quality Improvement in Health Care, the National Quality Forum’s Patient-Focused Episodes of Care, and the proposed work of the Measure Application Partnership, it is the Expert Panel’s contention that at least 2 other generic outcomes should be considered for initial measurement: Self Care Management and Symptom Management.

      Measuring Care Coordination

      Lead Author: Gerri Lamb, PhD, RN, FAAN

      Care coordination is a prominent feature of all major initiatives and models to improve health care outcomes and reduce health care costs in the United States and is viewed as the missing link to connect patients and families to the most appropriate services at the most appropriate time. It is seen as the necessary but often missing ingredient in reducing overuse and underuse of increasingly scarce and inaccessible health care resources. As care coordination takes center stage in the National Quality Strategy, in the National Quality Forum’s National Priorities Partnership, and in the Center for Medicare and Medicaid Services’ new call for proposals, the nursing community must take stock of its role in care coordination and ensure that nursing’s contributions to care coordination and their impact on quality and cost outcomes are measured, recognized, and fully integrated into the evolving design of health care delivery. The purpose of this paper is to highlight the current state of performance measurement of care coordination and to set out strategic and urgent priorities for the nursing community.

      Measuring the Economic Value of Nursing

      Lead Author: Jack Needleman, PhD, FAAN

      Nursing is a core service of hospitals ensuring the safe and reliable delivery of ordered care, coordinating services within nursing and across other departments, educating patients and their families and preparing patients for discharge, and monitoring and assessing patients to ensure appropriate and timely interventions to prevent or treat hospital-acquired complications. Current research and analysis has documented the costs of nursing services and assessed the cost and cost savings associated with higher nurse staffing given current staffing and payment models. This paper will summarize this literature, identify measurement issues in assessing the economic impact and business case for nursing, and present directions for further development of measurement in this area. Among the areas for future development that will be discussed are: (1) analyzing how changes in payment can influence the business case for nursing (eg, expanding quality-related payment incentives and penalties for nursing-influenced complications); and (2) developing approaches to assessing the cost and payment impacts of process improvement and work redesign efforts within health care settings.

      Measuring Nurses’ Workload

      Lead Authors: Mary A. Blegen, PhD, RN, FAAN, Bonnie Jennings, DNSc, RN, FAAN, Patricia Patrician, PhD, RN, FAAN, Vallire Hooper, PhD, RN, CPAN, FAAN

      There is evidence that nurses’ workload is understated, potentially increasing risks for adverse events and poor patient outcomes. Current measures used to reflect nursing workload consider only daily patient census or the care for those individual patients, by reporting the hours of care per patient day or the patient-to-nurse ratios. These metrics ignore the varying intensity of each assigned patient’s need for nursing care and the fact that, of the patients assigned to a nurse, many will “turnover” during any given shift, increasing demands on nurses’ time for the extra assessments and coordination of care for patients who are admitted, discharged, or transferred. These metrics and other work in the area also ignore the increasing complexity of care, the cognitive workload of managing and coordinating multiple treatments, and the growing number of regulatory and policy initiatives implemented for the purpose of protecting patients, all of which add to the amount of work that nurses must accomplish within set time periods. The work done by nurses to maintain health care system functioning has never been addressed by workload measures. This paper analyzes currently identifiable components of nurses’ workload in hospitals and how they have changed in the last 30 years. The impact and importance of these various components are discussed and recommendations for actions that will further our understanding of the scope and complexity of nurses’ responsibilities in acute care are suggested. Nurses’ work involves ensuring that the system is working and the care quality is improved and maintained, both of which serve to achieve the goal of providing safe, high-quality care to assigned patients.

      Measuring Patient Engagement

      Lead Author: Luc R. Pelletier, MSN, APRN, PMHCNS-BC, FAAN

      The concept of patient-centered care, in which patients are the “final arbiters in deciding what treatment and care they receive,” is core to efforts to transform health care in the United States.1 In such a model of care delivery, success is defined by whether patients achieve their desired outcome.2 National priorities to achieve patient-centered care have declared the necessity for patient/family engagement, a process by which “each person or family are engaged as partners in their care.”2 Engagement is an active process of synthesizing health information, recommendations of health care professionals, and personal beliefs and preferences to manage one’s illness or adopt health behaviors. It is critical for patients and their families to be actively involved in the decisions about their health care; such engagement has been shown to increase desired clinical outcomes and is essential to achieving wellness. It is essential to develop and implement performance measures that clearly make operational patient/family engagement and can guide national and local improvement efforts. This paper reviews the current environment and state of the science related to measuring engagement and sets an action agenda to guide practice, education, research, and policy initiatives.

      References

      • 1.
        Institute of Medicine. Crossing the quality chasm: a new heath care system for the 21st century. Washington, DC: National Academy Press; 2001.
      • 2.
        U.S. Department of Health and Human Services. National strategy for quality improvement in health care. Washington, DC: U.S. Department of Health and Human Services; 2001.

      Harmonizing Performance Measures—Implications for Practice, Education, and Research

      Lead Author: Nancy Donaldson, DNSc, RN, FAAN

      Conceptually and operationally aligning measures is at the heart of harmonization. In an environment demanding data from providers and institutions along the continuum of care, harmonizing measures is crucial to data aggregation, benchmarking, and public reporting. Understanding how variation in sources of data and levels of analysis may impact interpretation of findings is a gap in knowledge related to performance measurement. This paper builds on National Quality Forum recommendations related to measure harmonization and work in progress now by the Agency for Healthcare Research and Quality. This paper posits that measure harmonization is relevant to clinical and administrative leaders, researchers, and educators. In adopting authoritative metrics in measuring clinical quality, safety, and outcomes, clinicians build capacity for vital benchmarking and reporting. In integrating authoritative measures of quality, safety, and outcomes in research, investigators build capacity for evidence translation and meta-syntheses. In adopting authoritative measures of clinical quality, safety, and outcomes as metrics in clinical nursing education, academicians build capacity among graduates to use these measures and to understand their specifications and implications. Disharmony in clinical measurement threatens the integration of evidence and slows the quest for cumulative science and explication of clinical best practices.