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Adverse Events: Nursing Management: Quality and Safety XIV International Congress of Nursing Santiago, Chile September 6

Adverse Events: Nursing Management: Quality and Safety XIV International Congress of Nursing Santiago, Chile September 6-7, 2012. Lisa G. Green, MSN, RN, AOCN Nurse Educator, Nursing Professional Practice and Education The University of Texas MD Anderson Cancer Center. Objectives.

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Adverse Events: Nursing Management: Quality and Safety XIV International Congress of Nursing Santiago, Chile September 6

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  1. Adverse Events: Nursing Management: Quality and SafetyXIV International Congress of NursingSantiago, ChileSeptember 6-7, 2012 Lisa G. Green, MSN, RN, AOCN Nurse Educator, Nursing Professional Practice and Education The University of Texas MD Anderson Cancer Center

  2. Objectives • Describe the key elements of quality measures for cancer care and the current state of cancer quality measures • Recognize the producers and consumers of quality data and the diverse needs of these groups • Identify barriers to quality measures for cancer and potential strategies for overcoming barriers

  3. The Purpose of Quality Measurement • How can patients know if they’re receiving high quality healthcare? • How can providers identify which aspects of care should be improved for better patient outcomes? • How can consumers and payers assess the value of their healthcare dollars? • How can regulatory agencies ensure that healthcare consumers are receiving evidence-based, skilled, and compassionate care? http://www.qualityforum.org/Measuring_Performance/ABCs_of_Measurement.aspx

  4. Key Attributes of Quality Measures • Relevant to stakeholders • Addresses high volume or high burden conditions • Highlights disparities in care • Addresses known or suspected care issues • Actionable • Importantto Measure • Evidence-based • Reliable • Valid • Can be stratified or adjusted • Understandable • Scientifically Sound • Well-defined numerator , denominator and measures • Data is available • Feasible http://www.qualitymeasures.ahrq.gov/tutorial/attributes.aspx

  5. Priorities: Chile

  6. Demonstrating Value in Cancer Care

  7. Definition: Health Care Quality • The extent to which health services provided to individuals and patient populations improve desired health outcomes. Institute of Medicine, 2008 • Care should be: ● Strongest Clinical Evidence ● Technically and Culturally Competent ● Good communication ● Shared decision making

  8. Demonstrating Value in Cancer Care x

  9. What are “Meaningful Measures?” • Quantifiable factors that: • Assess aspects of care that are important to patients, caregivers, providers, payers, and policy makers • Support informed decision making of these groups • A measure is a well-defined end-point that can be measured and recorded as data when evaluating the effectiveness of a process.

  10. Types of Measures • Structure • Process • Outcomes

  11. Type of Measures: Structure A measure that assesses whether organizational resources and arrangements are in place to deliver health care, such as the number, type, and distribution of medical personnel, equipment, and facilities

  12. Type of Measures: Process A measure which focuses on a process which leads to a certain outcome, meaning that a scientific basis exists for believing that the process, when executed well, will increase the probability of achieving a desired outcome.

  13. Type of Measures: Outcome A measure that indicates the result of the performance (or non-performance) of a function(s) or process(es).

  14. What are “Meaningful Measures?” • Encompass objective and subjective criteria • Ex. Can a patient walk following treatment for sarcoma of the leg? • Ex. Does a breast cancer patient feel attractive following therapeutic and reconstructive surgery? • Dependent on what processes we are measuring and from who’s perspective • Patient, Family/Consumer • Health Care Provider(s): Physicians, Nurses • Third party: Regulatory bodies, insurance companies x

  15. Cancer Quality Management Ladder • Outcomes • Process • Clinical • Structure • Outcomes • Process • Clinical • Structure Advance Care Planning • Outcomes • Process • Clinical • Structure Survivorship 2 nd Line Tx Surveillance • Outcomes • Process • Clinical • Structure Primary Tx • Outcomes • Process • Clinical • Structure Evaluation • Outcomes • Process • Clinical • Structure Detection • Outcomes • Process • Clinical • Structure Prevention • Outcomes • Process • Clinical • Structure

  16. Audience for Meaningful Measures • Patients and Caregivers • Make informed treatment decisions • Clarify expectations of treatment • Manage personal obligations • Manage fear and uncertainty • Providers • Inform patients of treatment options • Improve outcomes and quality of care • Identify research opportunities • Guide patients to high value care • Negotiate insurer reimbursement • Payers • Monitor provider performance • Guide patients to high value care • Negotiate provider reimbursement • Negotiate contracts with buyers • Policy Makers • Monitor provider performance • Guide patients to high value care • Fund research to improve long-term outcomes of care

  17. Barriers to Meaningful Measurement • Approach to MeasuresQuality of care is measured from the provider’s perspective, not the patient’s perspective • Narrow Focus of Individual MeasuresIncreasedgranularity of measures undermines efforts toward patient centeredness, coordinated care and accountability

  18. Barriers to Meaningful Measurement • Redundancy Across Measure CollectionsIndependent measure development and reporting produces fragmented measure results of varying quality and validity • Data AvailabilityElectronic systems and automated data collection fail to capture critical data elements in discrete formats Institute of Medicine. For the Public’s Health: The Role of Measurement in Action and Accountability. National Academies Press, Washington, DC 2011. Spinks TE, Walters R, Feeley TW, Albright HW, Jordan VS, Bingham J, Burke TW. Improving cancer care through public reporting of meaningful quality measures. Health Aff (Millwood). 2011;30(4).

  19. Regulatory and Special Interest Groups Legislation: ARRA, DRA, HCERA, HITECH, PPACA, PSQIA, TRHCA Guidelines: WHO Patient Safety Solutions, TJC National Patient Safety Goals, IOM Quality Domains, NQF Safe Practices Related Events: TJC Sentinel Events, CMS Never Events / HACs, NQF Serious Reportable Events Developer/Endorsement Orgs Healthcare Measures Reporting Tools Government Agencies HHS (AHRQ, CDC, CMS, NCI) • Domains • Access, Outcome, Patient Experience, Population Health, Process, Structure, Use of Services • Clearinghouse • NGC (2500 guidelines,500+ cancer)NQMC (2000+ measures,140+ cancer)QualityNet Academic / Cancer Center Groups ADCC, C4QI • Measure Collections • AHRQ QI, ASC QC, CAHPS, CMS Core, IP & OP Measures, HEDIS, HOP QDRP, NDNQI, NSQIP, OASIS, OBQI, PCHQR, PCPI, PQRS, TJC ORYX, Disease-specific (e.g., ASCO QOPI) Comparative Database • C4QI, NCCN DB, NCDB, NDNQI, NNIS, NSQIP, Press Ganey, UHC • Hospital Accreditation Organizations • TJC Other Private Organizations • ACS, ACoS, AMA, ANA, ASCO, ASC QC, ICSI, IHI, IOM, NCCN, NQF, RAND Corp • Measure Levels • Clinician, Hospital, Health Insurance Plan, Population Consumer Evaluation • Health Grades, Hospital Compare, Leapfrog, USNWR Please see Appendix A for acronym key

  20. Why So Many Measures and Organizations? • Multiple organizations interested in improving healthcare delivery through quality measurement • Multiple federal and state organizations responsible for monitoring and improving healthcare delivery • Similar measures with different applications (e.g., physician vs. hospital, disease-specific, age-specific) • Organizations with different priorities (e.g., academic vs. community, medical vs. surgical) • Financial opportunities for organizations offering benchmarking and comparative services

  21. Multiple Organizations and Measurements • Highlight a few: • The Joint Commission • Institute of Medicine (IOM) • National Quality Forum (NQF) • National Database of Nursing Quality Indicators (NDNQI)

  22. The Joint Commission 2011-2012 :National Patient Safety Goals • Improve the accuracy of patient identification • Improve the effectiveness of communication among caregivers • Improve the safety of using medications • Reduce the risk of patient harm resulting from falls Prevent healthcare associated pressure ulcers

  23. TJC 2011-2012 NPSGs • The organization identifies safety riskd inherent in its patient population • Universal protocol for preventing wrong site, wrong procedure and wrong person surgery • Effective, January 1, 2012- implement evidence based practices to prevent indwelling catheter associated UTI (CAUTI)

  24. Institute of Medicine • 1999’s Ensuring quality cancer care included ten recommendations to improve the quality of cancer care • Recommendation 3: Measure and monitor the quality of care using a core set of quality measures • Recommendation 7: A cancer data system is needed that can provide quality benchmarks for use by systems of care Hewitt, ME and Simone JV, eds: Ensuring quality cancer care, Institute of Medicine National Research Council, National Academies Press, Washington, DC 1999.

  25. Institute of Medicine • 2001’s Crossing the Quality Chasm recommended national monitoring and reporting of healthcare performance relative to six aims for improvement • Safety • Effectiveness • Patient-Centeredness • Timeliness • Efficiency • Equity Institute of Medicine: Crossing the quality chasm: a new health system for the 21st century, National Academies Press, Washington, DC 2001.

  26. National Quality Forum (NQF) • 2009 contract to establish a portfolio of quality and efficiency measures– Social Security Act, Sec. 1890 • 85% of measures used in US federal reporting are NQF-endorsed • Through 2010, endorsed over 150 measures applicable to cancer, including more than 50 cancer-specific measures www.qualityforum.org

  27. National Quality Forum (NQF) • 2009 contract to establish a portfolio of quality and efficiency measures– Social Security Act, Sec. 1890 • Does not “develop” measures • Follows a consensus process to endorse healthcare quality measures for public reporting www.qualityforum.org

  28. National Quality Forum-Endorsed Measures & Gaps • Endorsed Measures • Common cancers (e.g., breast and colon) • Disease-specific measures • Measure Gaps • Less common cancers (e.g., ovarian) • Endorsed Measures • Screening; initial cancer treatment • Continuumof care • Measure Gaps • Post-treatment follow-up; long-term consequences of care • Endorsed Measures • Physical consequences of care (e.g., treatment complications) • Consequences of disease • Measure Gaps • Emotional, functional, and social well-being during and after treatment (e.g., ability to work) Spinks TE, Walters R, Feeley TW, Albright HW, Jordan VS, Bingham J, Burke TW. Improving cancer care through public reporting of meaningful quality measures. Health Aff (Millwood). 2011;30(4).

  29. Nursing sensitive indicators

  30. National Database of Nursing Quality Indicators (NDNQI) • American Nurses Association (ANA) initiated efforts to collect and evaluate nursing-sensitive indicators • Invested in the development of a database to collect data for tracking and comparison • NDNQI is a part of ANA’s National Center for Nursing Quality (NCNQ)

  31. What is NDNQI? • Proprietary database of the American Nurses Association • The only national, nursing quality measurement program which provides hospitals with unit-level performance comparison reports • Mission: to aid the RN in patient safety and quality improvement efforts • Collects and evaluates unit-specific, nurse-sensitive data from hospitals in the United States • All indicator data are reported at the nursing unit level

  32. What is NDNQI? • NDNQI’s nursing-sensitive indicators reflect the structure,process, and outcomes of nursing care • Over 1500 participating hospitals in U.S. use NDNQI data to improve patient safety and quality of patient care • Participating facilities receive unit-level comparative data reports to use for quality improvement purposes

  33. Nursing Sensitive Indicators • Skill mix • Nursing Hours per patient day • Patient falls • Falls with injury • Pressure ulcers • Community acquired • Hospital acquired

  34. Nursing Sensitive Indicators • Healthcare-associated infections • Ventilator-associated pneumonia (VAP) • Central line-associated blood stream infections (CLABSI) • Catheter-associated urinary tract infections (CAUTI)

  35. Nursing Sensitive Indicators • Pediatric pain assessment cycle, IV infiltration rate • Psychiatric patient assault rate • Restraints prevalence • Nurse turnover • RN Surveys • Job satisfaction • Practice environment scale • RN education and certification

  36. NDNQI Value • Provides patient and staffing outcomes • Reliable research • Data comparisons • Education

  37. Categories Pediatric Bone Marrow Transplant Adult step down Critical Care Medical Med/Surg Adult Surgical Blended Acuity Adult Comparison Groups • Academic Medical Centers • >500 beds • National Cancer Institutes • Magnet status • Unit clinical category comparison

  38. Benefits of NDNQI NDNQI provides a quarterly information stream that includes: • National comparison data • Allows staff and leadership the opportunity to review data from and evaluate nursing performance related to patient outcomes • Reports provide structure, process and outcome indicator data

  39. Benefits and Outcomes • Establishes: • Goals for improvement • Avoidance costly complications

  40. RN Satisfaction Survey • Biannual survey • 3 to choose from • Practice environment scale • Job satisfaction scales • Job satisfaction scales-short • Action plans developed based on unit scores

  41. NDNQI and Magnet • Standards state that nursing structures and processes support a culture of patient safety • Outcomes – our nursing sensitive indicator data aggregated at our organization level outperform the mean of the national database • Must include falls, nosocomial pressure ulcer prevalence and/or two additional indicators

  42. Strategies for meaningful measurement

  43. Realign Measurement Perspective • Measure quality from the patient’s perspective – What do patients really want from their care? • Successful, curative treatment • Courtesy and respect from providers • Minimize the impact of care provision on their lives • Time • Costs • Treatment delays • Side effects / adverse events • Stress / fear / uncertainty

  44. Expand Measurement Scope • Assess quality using measures that span the continuum of care • Apply a “top down” approach, beginning with intermediate- and long-term outcomes of care

  45. Collect and Report Meaningful Data 3. Collect and report data with patient needs in mind What data are most valuable to patients? • Talk to patients • What information do patients need to make informed decisions about their care? • At what point in the care cycle is this information needed? • Involve patients in data collection (e.g., patient-reported outcomes surveys)

  46. Collect and Report Meaningful Data • Modify provider workflow to capture key data points in an efficient way (e.g., structured dictation; high-level “face sheets” and structured clinical documentation) • Are providers asking the right questions? • Do patients feel comfortable answering these questions honestly? • Are providers documenting in the medical record patients’ answers to these questions?

  47. Acknowledgements • Debra Adornetto-Garcia, MS, RN, AOCN, NEA-BC, Executive Director, Nursing Professional Practice • Jackie Anderson, PhD, RN, CPHQ, Director, Nursing Programs, Quality • Kimberly Curtin, MS, RN, ACNS-BC, AD, Clinical Nurse Leaders Program • Tracy Spinks BBA, Project Director, Clinical Operations

  48. References • Hewitt, ME and Simone JV, eds: Ensuring quality cancer care, Institute of Medicine National Research Council, National Academies Press, Washington, DC 1999. • Institute of Medicine: Crossing the quality chasm: a new health system for the 21st century, National Academies Press, Washington, DC 2001. • Institute of Medicine. For the Public’s Health: The Role of Measurement in Action and Accountability. National Academies Press, Washington, DC 2011. • Spinks TE, Walters R, Feeley TW, Albright HW, Jordan VS, Bingham J, Burke TW. Improving cancer care through public reporting of meaningful quality measures. Health Aff (Millwood). 2011;30(4).

  49. References • www.nursingquality.org • www.qualityforum.org • http://www.qualityforum.org/Measuring_Performance/ABCs_of_Measurement.aspx • http://www.qualitymeasures.ahrq.gov/tutorial/attributes.aspx

  50. Appendix A: Acronyms ACoS: American College of Surgeons ACS: American Cancer Society ADCC: Alliance of Dedicated Cancer Centers AGS: American Geriatrics Society AHRQ QI: Agency for Healthcare Research and Quality Quality Indicators AHRQ: Agency for Healthcare Research and Quality AMA: American Medical Association ANA: American Nurses Association APNs: Advanced Practice Nurses AQA: Ambulatory Care Quality Alliance ASC: Ambulatory Surgery Center ASC QC: Ambulatory Surgery Center Quality Collaboration ASCO QOPI: American Society of Clinical Oncology Quality Oncology Practice Initiative ASCO: American Society of Clinical Oncology C4QI: Comprehensive Cancer Center Consortium for Quality Improvement CAHPS: Consumer Assessment of Healthcare Providers and SystemsIP & OP Measures: Inpatient and Outpatient MeasuresHEDIS: Healthcare Effectiveness Data and Information Set CDC: Centers for Disease Control CMS: Centers for Medicare & Medicaid Services HAC: Hospital-Acquired Conditions HHS: U.S. Department of Health and Human Services HOP QDRP: Hospital Outpatient Quality Data Reporting Program ICSI: Institute for Clinical Systems Improvement

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