Nurses Contributions to Quality Health Outcomes PDF
Preview Nurses Contributions to Quality Health Outcomes
Nurses Contributions to Quality Health Outcomes Marianne Baernholdt Diane K. Boyle Editors 123 Nurses Contributions to Quality Health Outcomes Marianne Baernholdt • Diane K. Boyle Editors Nurses Contributions to Quality Health Outcomes Editors Marianne Baernholdt Diane K. Boyle School of Nursing Fay W. Whitney School of Nursing University of North Carolina at Chapel Hill University of Wyoming Chapel Hill, NC Laramie, WY USA USA ISBN 978-3-030-69062-5 ISBN 978-3-030-69063-2 (eBook) https://doi.org/10.1007/978-3-030-69063-2 © Springer Nature Switzerland AG 2021 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland So never lose an opportunity of urging a practical beginning, however small, for it is wonderful how often in such matters the mustard-seed germinates and roots itself. – Florence Nightingale Florence Nightingale Quotes. (n.d.) BrainyQuote.com. https://www.brainyquote. com/quotes/florence_nightingale_121022 In this year of the nurse, we dedicate this book to all nurses who tirelessly work to provide quality healthcare. We would also like to acknowledge the two women whom set us on our research journey as our dissertation Chairs and long-term research mentors: Norma M. Lang and Roma Lee Taunton Foreword Riveting headlines 20 years ago from the Institute of Medicine (IOM, now National Academy of Medicine, NAM) revealed healthcare errors were a leading cause of death, projecting upward of 100,000 preventable deaths annually. This transforma- tional report, To Err is Human: Building a Better Health System, compelled health- care professionals to embark on an aggressive quest to reduce harm by improving quality and safety across the system. Two decades later, nurses face a formidable foe in the COVID-19 pandemic, killing hundreds of thousands of Americans and almost 1.5 million people worldwide. Nurses are addressing multiple crises to keep them- selves, their co-workers, and their patients safe while enduring moral distress in the face of inadequate personal protective equipment, broken supply chains, and woe- fully inadequate staffing. Nurses are fulfilling their duty to provide care by adopting crisis care standards while worrying about themselves and their loved ones. They are often confronted with the moral dilemma of deciding how much high-quality care they can provide in suboptimal conditions. In response, nurses continue to advocate for the supports they need to allow them to provide care in all situations, mitigate risks, and remain dedicated to assuring acceptable levels of care quality during this crisis and beyond. Over the last half century, healthcare organizations and clinicians have re- engineered systems, implemented quality improvement tools, peer review, public reporting of outcomes, participated in programs that reward good versus penalizing poor performance, and redesigned our education of professionals. The initial condi- tions of participation implemented when Medicare legislation was enacted in 1965 to ensure beneficiaries’ health and safety included a provision for 24-hour nursing services in hospitals. A primary focus was on determining the extent of underuse, overuse, and misuse of services, establishing a link between quality and reimburse- ment for necessary care but rarely, if ever, did measurement of nursing care enter into the assessment. Consistent with the conceptualizations of Avedis Donabedien, who proposed structure, process, and outcomes as domains for evaluating the quality of care, the nursing profession had adopted a quality assurance model in the 1970s to address the outcomes, processes, and structure of standards and criteria of care. The model was predicated on nurses embracing professional accountability for the outcomes of their care. ix x Foreword The Quality Health Outcomes Model (QHOM) described in the pages that fol- low was developed and introduced in 1998 before the NAM report. It presented the need to generate, organize, and use evidence in the approach to find the linkage between nursing interventions and patient outcomes. At about the same time, the American Nurses Association established the National Database of Nursing Quality Indicators® (NDNQI®) in 1998, which ultimately became the roadmap for under- standing and taking action to address conditions that threatened hospitalized patients' outcomes. It also helped establish the relationship of nurse staffing and other nurse characteristics to outcomes and demonstrate nurses' value in promoting quality patient care. Both the QHOM model and NDNQI reinforce the need for evidence to guide improvement in care and outcomes. Initial quality measures developed by multi-stakeholder groups through the National Quality Forum (NQF) for implementation by the Centers for Medicare and Medicaid (CMS) focused primarily on physician processes. The introduction of a set of voluntary Consensus Standards for Nursing-Sensitive Care by NQF in 2004 provided an impetus to quantify and study the impact of nursing care on patient outcomes. Today the relationship of nursing care—both quantity and quality—to patient safety and outcomes is well established. However, what continues to be elusive is recognizing and valuing the evidence that supports more significant resourcing of nurses to make their maximum contribution to care delivery. Concomitantly nurses should occupy top leadership roles influencing policy, rei- magining care delivery models that address team-based interprofessional practice, redesigning work environments and workflow, and commanding resources that allow the right dosing of nursing care to meet patient needs. As care was re-envisioned for a twenty-first century healthcare system that would reduce the burden of injury, illness, and disability and provide safe, effective, patient-centered, timely, efficient, and equitable, nurses stepped up. But they were never the leaders of the band. Instead, nurses were the “functional doers” as described in the Future of Nursing Report. They became care coordinators, case managers, quality data entry clerks, quality monitors, black belts, green belts, the ones who forced teams to conduct time-outs for safety checks, filled out checklists, and populated countless other forms by hand or electronically to ensure organiza- tions could have good report cards and satisfy compliance requirements to payers. Nurse scientists had to scramble for funding to study nurses’ contributions to care and outcomes, as well as patient characteristics and conditions that increase vulner- ability in the hospital setting. In 2011, CMS launched the Partnership for Patients as a network of organiza- tions to improve healthcare quality, safety, and affordability. The primary aims were to reduce hospital-acquired conditions and readmissions. The first 4 years’ impres- sive results showed a reduction of more than 2 million hospital-acquired conditions, equating to an approximate 87,000 fewer associated deaths and savings of close to $20 billion. Nurses’ innovation, vigilance, and commitment to actions that improved quality drove reductions in all the categories of harm. Those highly associated with preventing deaths, pressure ulcers, and catheter-associated urinary tract infections are clearly related to nurses’ actions. Yet, in analyzing the successes, attributes such Foreword xi as financial incentives, public reporting, and investment in electronic health records were highlighted as major contributors to progress. Similarly, despite two or more decades of data on the effects of nurse staffing on hospital-acquired conditions and patient outcomes, nurses still struggle to be recog- nized as the ones who provide vigilant surveillance of a patient’s condition that could mean the difference between life and death, or the critical information that helps a family care for a loved one, or the insights to constantly problem-solve almost any challenging situation. Nursing’s contributions can no longer remain invisible. It is widely recognized that nurses are fundamental to any healthcare sys- tem, but these must also translate into power and influence. Conveying the impact that nursing care has on improving the human experience, and ultimately quality, is priceless and without parallel. This book tells the undeniable story of nursing’s contributions at the individual, group, and systems levels. It spotlights the unrewarded reliance on nurses’ brain- power, curiosity, and tenacity to ensure the practice environment and intellectual work of nurses support better care and outcomes. What will be essential is that every nurse who reads this book puts it in the hands of a powerbroker who can support nurses in any care delivery setting. Nothing should speak louder than our contribu- tions to quality. The world has seen the inextricable dependence on nurses and sur- vival in the pandemic. And as nurses have repeatedly vocalized, “don’t call me a hero, give me what I need to do my job and protect myself and my patients,” the expert authors have done just that throughout. They have produced evidence of what is needed for nurses to provide safe, effective, patient-centered, timely, efficient, and equitable care. They have staked out the space for nurses to influence policy for quality measurement. They have illuminated the rationale for supporting the work- force and work environment and the advances nurses have been making to deploy technology solutions better to improve and support clinical workflow. The case is made clear that nurses are implementing solutions to transform care delivery by improving care processes, interprofessional relationships, and communication, as well as implementing roles that address the holistic needs of patients and families in a complex system. Most compelling is the articulation of outcomes that help those we serve and the workforce and organizations at large. These outcomes come at the hands of nurses who bring to bear systems thinking, keen observations and critical reasoning, scientific inquiry and measurement, and a dedication to amplify this work so that nurses are recognized as the experts who have largely operated behind the scenes and must now emerge as the leaders they are and have been for some time. Pamela F. Cipriano, PhD, RN, NEA-BC, FAAN Dean and Sadie Heath Cabaniss Professor, University of Virginia School of Nursing, Charlottesville, Virginia Past President, American Nurses Association Contents Part I Introduction 1 Overview of the Quality Health Outcomes Model . . . . . . . . . . . . . . . . . 3 Diane K. Boyle and Marianne Baernholdt Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Background of the Quality Health Outcomes Model . . . . . . . . . . . . . . . . 4 The Quality Health Outcomes Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Theoretical and Analytic Advantages of the QHOM . . . . . . . . . . . . . . . . 7 Use of the QHOM in the Literature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 How This Book Is Organized . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Part II Context 2 Healthcare Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Lauryn S. Walker and Deborah E. Trautman Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Healthcare Policy Linkages to QHOM . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Access to Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Healthcare Spending . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Quality Measurement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Other Policy Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Using Multilevel Policies to Manage the Opioid Crisis . . . . . . . . . . . . . . 34 Summary and Future Directions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 3 The Nurse Workforce . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Sean P. Clarke Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 The Nurse Workforce: Context for the Quality Health Outcomes Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 Interplay of Nursing Supply and Demand at Various Levels of the Healthcare System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 xiii
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