CONSENSUS STANDARDS FOR NURSING-SENSITIVE CARE AND

IMPLICATIONS FOR CERTIFICATION

Diane K. Boyle, PhD, RN;Diane K. Boyle, PhD, RN;Peggy A. Miller, PhD, RN; & Nancy Dunton, PhDPeggy A. Miller, PhD, RN; & Nancy Dunton, PhD

University of Kansas School of NursingUniversity of Kansas School of NursingKansas City, KSKansas City, KS

ABNS Spring ConferenceMarch 5, 2010

Costa Mesa, CA

Objectives1. Describe the evolution of nursing-sensitive

indicators.

2. Discuss the National Quality Forum’s development & maintenance of the National Voluntary Consensus Standards for Nursing-Sensitive Care: An Initial Performance Measure Set.

3. Describe a model for linking nursing specialty certification with process & outcome indicators.

4. Indentify research linking nursing specialty certification with process & outcome measures.

Historical Context(Dawn of Nursing-Sensitive Indicators)

Genesis ofNursing-Sensitive Indicators

Late 1980s — New payment/reimbursement structures and expansion of managed care• RN jobs at risk, care compromised

1994 — American Nurses Association (ANA) launched Patient Safety and Quality of Care Initiative• Established Panel of Experts• Commissioned a literature review to identify valid

and reliable nursing-sensitive indicators

Expert Panel Findings 1995 ANA’s Nursing Report Card for Acute

Care Settings identified 21 indicators likely related to availability and quality of nurses

10 indicators selected for development• TNHPPD*, Skill Mix, RN Satisfaction with work

environment• Injury Falls, Pressure Ulcers, Nosocomial Infections,• Patient Satisfaction (nursing care, pain management,

educational information, care)

*TNHPPD = total nursing hours per patient day

Next Steps 1996 — ANA funded pilot studies in 7

states to assess feasibility of data collection by nurses in hospitals:• CA, AZ, TX, ND, VA, MN, OH

1996 – IOM released report stating there was a paucity of scientific evidence linking nursing with hospital patient outcomes (other than mortality).

1998 — ANA issued request for proposals to develop and manage the National Database of Nursing Quality Indicators® (NDNQI®).o Provide hospitals with comparative data for quality

improvement activitieso Develop a national data resource for investigating the

relationship between nursing and patient outcomes

NDNQI Development

1998 — Contract awarded to Midwest Research Institute and University of Kansas School of Nursing

1999 — First reports Issued to ~30 hospitals, almost all of whom were pilot study participants

2010 — ~ 1570 hospitals and 15 indicators

Other HealthcareMeasurement Initiatives

CMS — Centers for Medicare and Medicaid Services (CMS), Long history of quality measurement: Care Measures

1986 — The Joint Commission began to plan for performance measurement• 2002 Hospitals begin collecting core measures and hospital

quality measures

1993 — National Committee for Quality Assurance, HEDIS measures

1996 – CalNOC – One of the original state pilot projects for ANA

Measurement Initiatives

1998-2002 — Agency for Healthcare Research & Quality (AHRQ): developed Quality Indicators & Patient Safety Measures • National Quality Measures Clearinghouse

(http://www.qualitymeasures.ahrq.gov/) 1999 – National Quality Forum founded 2007 — AHRQ launched HCAHPS (Consumer Assessment of

Healthcare Providers & Systems) which includes questions on nursing

• 2008, public reporting began

Quality Measurement and Consensus Standards for Nursing-Sensitive Care

Quality Measurement

What is a quality indicator?

How are measures developed and endorsed?

Key DefinitionsNursing-Sensitive

“…nursing-sensitive performance measures are processes and outcomes— and structural proxies for these processes and outcomes (e.g., skill mix,

nurse staffing hours)—that are affected, provided, and/or influenced by nursing personnel, but for

which nursing is not exclusively responsible. Nursing-sensitive measures must be quantifiably

influenced by nursing personnel, but the relationship is not necessarily causal

National Quality Forum: National Voluntary Consensus Standards for Nursing-Sensitive Care: An Initial Performance Measure Set. Washington, DC: 2004

Key Definitions Quality of Care: Degree to which health

services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge (Institute of Medicine)

Indicator: Valid and reliable quantitative process or outcome measure related to one or more dimensions of performance, such as effectiveness or appropriateness (The Joint Commission)

Quality Assessment

Antecedents Structure Process Outcome

Factors that can influence structure, process:Environmental factorsPatient factors (also influence outcomes)

Organiza-tional character-istics

Interactions between healthcare practitioner & patient

Changes (desirable or undesirable) in individuals & populations

Donabedian’s Structure – Process - Outcome

Types of Quality Indicators/Measures

Structure Process Outcome Use of services (used as

proxy for outcome) Efficiency/cost Patient experience

National Quality Forum (NQF)

Private, non-profit voluntary consensus standards-setting organization

Multi-stakeholder member organization Three-part mission to improve quality of

American healthcare:• Setting national priorities and goals for improvement• Endorsing national consensus standards for

measuring and publicly reporting on performance• Promoting attainment of national goals through

education and outreach programs

NQF Consensus Development Process

Nine Steps1. Call for Intent to Submit Candidate Standards2. Call for Nominations3. Call for Candidate Standards4. Candidate consensus standard review5. Public and member voting6. Consensus Standards Approval Committee (CSAC)

Decision7. Board Ratification8. Appeals

Original NQF Consensus Standards for Nursing-Sensitive Care (2004)

Patient-Centered Outcome Measures “Failure to rescue”* Pressure ulcer prevalence Falls prevalence** Falls with injury Restraint prevalence (vest & limb only) Urinary catheter-associated UTI rate

(ICU)** Central line catheter-associated blood

stream infection rate (ICU & HRN)** Ventilator-associated pneumonia rate

(ICU & HRN)**

Nursing-Centered Intervention Measures Smoking cessation*** counseling for

o Acute myocardial infarctiono Heart failureo Pneumonia

System-Centered Measures Skill mix Nursing care hours per patient day Practice Environment Scale - NWI Voluntary Turnover

* Death among surgical inpatients with treatable serious complications**Also an NQF-endorsed voluntary consensus standard for hospital care

*** The smoking cessation standards were not re-endorsed

NQF Measure Maintenance Annual updates provided by measure steward Ad hoc review for evolving evidence or

identified problems with measure Routine full reviews

• Moving to 3-year cycles by topic area• Meet evaluation criteria with focus on data from

implementation• Harmonization with other NQF-endorsed measures• Best-in-class• Publicly reported

NQF Measure Maintenance Notice of topic with notice of maintenance review and

call for new measures Stewards submit information demonstrating criteria are

met Reviewed by Steering Committee Steering Committee make recommendations

• If competing measures, recommend best-in-class Public comment NQF member voting CSAC approval Board ratification

Measure Evaluation Criteria Importance to measure & report

• Important to make gains in quality (e.g., safety, effectiveness, efficiency, patient-centeredness)

• Evidence supports measure focus

Scientific acceptability• Specifications, reliability, validity, risk-adjustment is evidence-

based, clinically meaningful differences in practice

Usability• Are results understandable and usable in decision making?• Useful for public reporting

Feasibility• By-product of care processes• Unintended consequences

Issues to Ponder

Outcome or Process Measures?

Most medical indicators are process measures.• Critics say that we should measure outcomes not process

Many nursing measures are outcomes• Falls, pressure ulcers, nosocomial infections, PIV

infiltrations

NQF recently suggested that outcomes should be accompanied by best practice process measures• e. g., along with fall rate: fall risk assessment and

prevention protocol implementation

Absolute or Relative Measure?

Sentinel event (Absolute)• Serious, undesirable, and largely avoidable outcome• Utility of a measure that is Yes/No as opposed to a

rate?

Rate-based indicators (Relative)• Patient care events expressed as a proportion or ratio

Risk Adjustment Issue Considerations:

• Adjust for differences in patient populations?• Evaluation based on providing care for

population you have?• Are data available to make effective

adjustment?• Is adjusted measure interpretable by users?

Risk stratification—looking within

DesirableIndicator Qualities

Covers a large segment of the patient population—a typical patient experience

Related to a costly or serious condition

Fosters quality improvement• Should not create incentive for providers to game the system

(improve measures without improving quality)• Focus on interventions, not documentation• Does not focus on what’s being measured to detriment of

aspects of care

Measuring QualityIs Difficult

How do we isolate nursing’s impact or contribution?• Strongly related to nursing (workforce or

processes) Many confounding factors

• Characteristics or actions of the patients• Influence of other healthcare providers• Organization and environment of hospital

What model can be used for linking specialty certification

with processes and outcomes?

Nurse-Sensitive Quality Care (NDNQI Conceptual Model)

Structureof Care

Nursing CareProcesses

PatientOutcomes

Donabedian Model

Example Measures for Nursing-Sensitive Care

Structure Process Outcome

• Size• Teaching status• Payer mix• Magnet status• CNO/manager• Practice environment (e.g., autonomy)• NHPPD• Staff mix• Use of agency staff• Education• Specialty Certification • Other credentials• Turnover

• Risk assessment• Implementation of prevention protocols• Pain management• Medication administration• Counseling • Communication, teamwork, decision making

• Injury falls• HAPUs• Nosocomial infections• “Failure to rescue”• Mobility• Satisfaction with care• Unplanned readmissions

What research exists linking specialty certification with

improved processes and outcomes?

Certification and Patient Outcomes

Nelson et al. (2007), in a study of 54 randomly selected rehabilitation units in the US found:• For every 6% increase in certified rehabilitation nurses (CRRN)

on a unit, mean case-mix adjusted patient length of stay decreased by one day.

• Conversely, more years experience as a rehabilitation nurse corresponded with a longer length of stay.

Lange et al. (2009) found that on units staffed with 2 or more certified nurses, there was a significantly lower fall rate than on units with one or no certified nurses. • Results were confounded by a 3-month education program on

care of geriatric patients.

Certification and Patient Outcomes

Hiser et al. (2006) implemented a quality improvement program that specifically enhanced utilization of Certified Wound Ostomy Continence Nurses (CWOCN) in one medical intensive care unit and found that pressure ulcer prevalence dropped from 29% to near 0%.

Both Frank-Stromborg et al. (2002) and Coleman et al. (2009) found no difference in outcomes (e.g., management of pain & nausea) between certified and noncertified nurses.

Certification and Nursing Processes

Critical care certification was found to be associated significantly with the correct use of a pulmonary artery catheter (Iberti et al., 1994) and decision-making regarding the withholding of digitalis (Walthall et al., 1993).• In both studies certification was confounded with years of

experience.

Kendall-Gallagher (2009) found the proportion of certified nurses and the rates of medication errors had no significant association via correlation or hierarchical linear model analysis.

Certification and Nursing Processes

Zulkowski, Ayello, and Wexler (2007) reported that certified wound care nurses scored wounds significantly more accurately than nurses certified in other specialties or non-certified nurses.

Using a national sample of hospitals and hierarchical

linear modeling, NDNQI investigators found that nurses with wound, continence and/or ostomy certifications were significantly better at identifying (B=0.12, SE=0.03, p<0.001) and staging (B=0.13, SE=0.04, p<0.001) pressure ulcers than other nurses (Gajewski et al., 2007; Hart et al., 2006).

Research Critique Some studies have small sample sizes and weak research

designs. Education and experience often confound the results. Experience as certified nurse may confound the results.

• RNs certified < 5 years report more autonomy, confidence, & collaboration (Cary, 2001).

Much of the research on specialty certified nurses and clinical performance is based on self-report or manager-report data. • Lacks quantitative measurement of performance• No patient outcome data

Research may been conducted in environments where few differences exist between the autonomy of certified and non-certified nurses.

Issues/Questions Need to specify measureable processes and outcomes

that each specialty certification is expected to impact, for example:• Wound, ostomy, continence: pressure ulcer assessment,

pressure ulcer rate, urinary tract infections, etc.• Lactation consultants: exclusive breast milk feeding, etc.• Critical care: ventilator associated pneumonia, etc.

Are there measures that an RN with any specialty certification would impact?• Pain assessment, fall risk assessment

Many processes and outcomes need measure development

Issues/ Questions Is certification a skill level net of education and

experience or as a proxy for education & experience (they are confounded)?• Is there a combination of education and certification

that effects processes and outcomes? • Example: BSN + Certification

Does certification ‘wear off’ over time? Is there a critical prevalence of certified nurses

(unit, workgroup, hospital, clinic) needed to make an impact?

Issues/Questions The impact of specialty certification may be

more difficult to capture when certified nurses:• Exist outside the usual workgroups• Are poorly utilized• Employed in units/workgroups outside their specialty

certification• Have not reached a critical prevalence

RN vs ARPN certification – What are outcomes? Level of analysis – Individual? Unit/Workgroup?

Organization? Multi-level?

Snapshot of Specialty Certified Nurses from the 2009 NDNQI RN Survey

NDNQI RN Survey

RN inclusion criteria:• Full or part-time, regardless

of job title• >50% of time in direct

patient care• Employed a minimum of 3

months on unit• Unit based PRN or per-diem

nurses employed by the hospital (agency or contract nurses are excluded)

Survey Certification Question

Specialty certification inclusion criteria:• Standards have been verified by either the American

Board of Nursing Specialties or the National Organization for Competency Assessment

• Are direct-care related• Are nursing certifications

2009 data are collected on 64 specialty certifications from 18 different specialty entities

NDNQI Certification Question

NDNQI Certification Question

2009 RN Survey Respondents

270,423 US total survey respondents

Category Number Percent

Selected a specialtyCertification

37,579 13.9

Selected ‘other’ option

8,431 3.1

Total 46, 010 17

Where Do Certified RNs Work?

Certifications by Specialty Entity

26.6

13.9

Q & A

References American Nurses Association (ANA). (2004). Measures and indicators that reflect the impact

of nursing actions on outcomes. Scope and Standards for Nurse Administrators, 2nd Ed., Washington, DC.

Davies SM, Geppert J, McClellan M, et al. (May 2001). Refinement of the HCUP Quality Indicators. Technical Review Number 4 (Prepared by UCSF-Stanford Evidence-based Practice Center under Contract No. 290-97-0013). AHRQ Publication No. 01-0035. Rockville, MD: Agency for Healthcare Research and Quality.

Donabedian A. (1988). The quality of care: How can it be assessed? JAMA, 260,1743-1748. Donabedian, A. (1992). The role of outcomes in quality assessment and assurance. Quality

Review Bulletin, 11, 356-60. National Quality Forum. (2004). National Voluntary Consensus Standards for Nursing-Sensitive

Care: An Initial Performance Measure Set. Washington, DC. Available at: http://www.qualityforum.org/Projects/n-r/Nursing-Sensitive_Care_Initial_Measures/Nursing_Sensitive_Care__Initial_Measures.aspx

Wunderlich GS, Sloan FA, Davis CK, eds. (1996). Nursing staff in hospitals and nursing homes: Is it adequate? Institute of Medicine, National Academy Press, Washington, DC.

Research References Cary, A.H. (2001). Certified registered nurses: Results of the study of the certified

workforce. American Journal of Nursing, 101(1), 44-52. Coleman, E., Coon, S., Lockhart, K., Kennedy, R., Montgomery, R., Copeland, N., et al.

(2009). Effect of certification in oncology nursing on nursing-sensitive outcomes. Clinical Journal of Oncology Nursing, 13(2), 165-172.

Frank-Stromborg M, Ward S, Hughes L, et al. Does certification status of oncology nurses make a difference in patient outcomes? ONF. 2002;29:665-672.

Gajewski B, Hart S, Bergquist S, Dunton N. Inter-rater reliability of pressure ulcer staging: ordinal probit Bayesian hierarchical model that allows for uncertain rater response. Statistics in Medicine. 2007;26:4602-4618.

Hart S, Bergquist S, Gajewski B, Dunton N. Reliability testing of the National Database of Nursing Quality Indicators pressure ulcer indicator. Journal of Nursing Care Quality. 2006;21:256-265.

Hiser B, Rochette J, Philbin S, Lowerhouse N, TerBurgh C, Pietsch C. Implementing a pressure ulcer prevention program and enhancing the role of the CWOCN: impact on outcomes. Ostomy/Wound Management. 2006;52(2):48-59.

Iberti TJ, Daily EK, Leibowitz, AB, Schecter, CB, Fischer EP, Silverstein JH. Assessment of critical care nurses’ knowledge of the pulmonary artery catheter. Critical Care Medicine.1994;22:1674-1678.

Research References Kendall-Gallagher, D., & Blegen, M. A. (2009). Competence and certification

of registered nurses and safety of patients in intensive care units. American Journal of Critical Care, 18(2), 106-114.

Lange, J., Wallace, M., Gerard, S., Lovanio, K., Fausty, N., & Rychlewicz, S. (2009). Effect of an acute care geriatric educational program on fall rates and nurse work satisfaction. The Journal of Continuing Education in Nursing, 40(8), 371-379.

Nelson A, Powell-Cope G, Palacios P, et al. Nurse staffing and patient outcomes in inpatient rehabilitation settings. Rehabilitation Nursing. 2007;32(5):179-202.

Walthall SA, Odtohan B, McCoy MA, Fromm B, Frankovich D, Lehmann MH. Routine withholding of digitalis for heart rate below 60 beats per minute: widespread nursing misconceptions. Heart & Lung.1993;22: 472-476.

Zulkowski K, Ayello EA, Wexler S. Certification and education: do they affect pressure ulcer knowledge in nursing? Advances in Skin & Wound Care. 2007;20(1):34-38.