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HOW WE ALL BENEFIT WHEN FRONT LINE NURSES UNDERSTAND QUALITY SHOSHANNA SOFAER, DR.P.H. SCHOOL OF PUBLIC AFFAIRS BARUCH COLLEGE CITY UNIVERSITY OF NEW YORK OVERVIEW 2 Who influences quality? How do nurses influence quality? What does the public think about how nurses influence quality? Why we measure quality How can we measure how nurses contribute to quality? What can you do about quality? American Nurses Association November 20, 2012 WHO INFLUENCES QUALITY? 3 Health care is complex Many people, including clinicians, patients, family members and managers can influence quality Among clinicians, most members of the public seem to think that it is the individual physician who makes the most difference However, it is clear that everyone on the clinical team, and those who create the context for their work, all make a difference Indeed, the extent to which the team really IS a team is very important American Nurses Association November 20, 2012 WHO INFLUENCES QUALITY? 4 This is true across settings Hospitals Ambulatory care Home health care Nursing homes In the community And for all kinds of quality problems Overuse Underuse Misuse Safety American Nurses Association November 20, 2012 HOW DO NURSES INFLUENCE QUALITY? 5 Nurses are everywhere – across settings and playing multiple roles Some focus exclusively on quality, often managing quality measurement, assurance or improvement Some manage those on the front lines and should take responsibility for supporting high quality care Most do not appear to focus on quality, i.e. they do the actual clinical work, but these are the people who can and do actually influence quality the most – for good, or not so good American Nurses Association November 20, 2012 HOW DO NURSES INFLUENCE QUALITY? 6 Front-line nurses influence quality by doing the right thing at the right time in the right way This includes: Initial assessments Developing and carrying out their own care plan Following (or when appropriate questioning) the overall care plan (i.e. what the doctor ordered) Monitoring closely patient’s response to care Supervising and supporting others with less expertise or experience Being a productive member or leader of a team American Nurses Association November 20, 2012 HOW DO NURSES INFLUENCE QUALITY? 7 The National Quality Forum (NQF) is a non-profit organization with a mandate to “endorse” measures of quality if they meet technical and policy-oriented criteria For example, to be endorsed an measure must Examine something of significance to individuals and society Be valid and reliable Be usable and, ultimately, be used American Nurses Association November 20, 2012 HOW DO NURSES INFLUENCE QUALITY? 8 NQF endorsed 15 “nursing sensitive” hospital quality measures By doing so, they were saying these are specific ways that we can measure in which nurses influence hospital quality Your handout presents these 15 measures, translated into plain English rather than using technical jargon such as “failure to rescue” We translated because we wanted to see if the public found these measures important and useful to them and could understand what they were getting at American Nurses Association November 20, 2012 HOW DO NURSES INFLUENCE QUALITY? 9 What do you think? Do you and your colleagues make a difference in these areas? Notice that some of them are pretty important from a clinical perspective, even “life and death” Others are quite different, like the more “structural” measures of the work environment, staffing ratios and nursing mix And just a few focus on process American Nurses Association November 20, 2012 WHAT DOES THE PUBLIC THINK? 10 In the last 20 years, literally thousands of quality measures have been identified or developed More and more of them are being included in reports to the public to compare the quality of different health care providers Many of the measures in these reports, however, have never been tested to see if they matter to consumers and patients We wanted to do just that with these nursing measures American Nurses Association November 20, 2012 WHAT DOES THE PUBLIC THINK? 11 We conducted nine focus groups in three cities to find out what recent hospital patients of all kinds thought of these measures Here’s what we learned: Most of the “safety” measures were considered very important by almost everyone People, based on their own life experience, thought that the working environment of nurses would also be very important Almost no one cared about the smoking measures American Nurses Association November 20, 2012 WHAT DOES THE PUBLIC THINK? 12 Here’s what we learned (continued): People were uncertain about the measures of falls and restraints People didn’t really “get” the measures of things like “nursing mix” or turnover Overall, the public isn’t sure what nurses are actually responsible for – they didn’t want to blame nurses if nurses were not responsible However, this meant they ended up thinking that physicians were responsible Although typically someone pointed out that the nurses is always there, unlike the physician American Nurses Association November 20, 2012 WHAT DOES THE PUBLIC THINK? 13 Here’s what we learned (continued): The public trusts and depends on nurses but they don’t have a true sense of what they DO They tend to think nurses do only what the physician tells them to do Instead of realizing that nurses have their own care plan independent of the physician The public has high expectations of nurses They expect them to know what they need even if they don’t tell them They expect them to have the answers to almost all their questions American Nurses Association November 20, 2012 WHY DO WE MEASURE QUALITY? 14 There are two major reasons we measure quality, outside of a purely research context To increase accountability To improve care We now live in a time when the quality of health care is not taken for granted; we have to demonstrate that we provide quality of care, and we DO NOT always do it Given that quality can be improved, we have an obligation, especially given how much money we spend on health care, to improve it as much as possible We can’t improve it, however, if we don’t measure it American Nurses Association November 20, 2012 WHY DO WE MEASURE QUALITY? 15 To measure quality, we have to define it Whose definition do we use? What role do nurses play in defining quality? What role should they play? Right now, nurses are not as involved as they could be and should be in defining quality Does the front line nurse realize that they as a profession can benefit from participating in quality measurement? Probably not? Many see quality measurement as just more time documenting rather than caring for patients American Nurses Association November 20, 2012 WHY DO WE MEASURE QUALITY? 16 Another issue: who is responsible for quality overall? For specific aspects of quality? How do nurses fit in? Nurses do many things on their own But they do most things with other people; they collaborate and communicate So this makes their role “fuzzy” to many It is hard to see this in the abstract – easier when you talk about something concrete like avoiding a central line infection But even here – lots of people have a piece of the puzzle! American Nurses Association November 20, 2012 GETTING INVOLVED IN MEASURING AND IMPROVING NURSING QUALITY 17 What can front line nurses do about measuring nursing quality? First, think about it Ask yourself and your colleagues Are we being measured now? How? Does that make sense? What’s important but not getting measured? What’s the connection between all this paperwork that I do and measuring quality? American Nurses Association November 20, 2012 GETTING INVOLVED IN MEASURING AND IMPROVING NURSING QUALITY 18 An example: Hospital CAHPS (Consumer Assessment of Health Providers and Systems) A survey of recent hospital patients Being used now not only to report on performance to the public but to determine how much hospitals get paid Many items in this survey involve nurses, e.g.: Patient-Nurse communication Information about medications Pain management Staff responsiveness American Nurses Association November 20, 2012 GETTING INVOLVED IN MEASURING AND IMPROVING NURSING QUALITY 19 Do you know what these items are? Do you know how your hospital is doing on these items, compared to others? How is your hospital responding? What do you think can be done to improve scores? Specifically, what can nurses do? How can nurses help more generally, by getting involved in quality improvement efforts This won’t improve by shaming and blaming It will only improve if people realize they can do it and will be better off if they do it American Nurses Association November 20, 2012 GETTING INVOLVED IN MEASURING AND IMPROVING NURSING QUALITY 20 Quality measurement and improvement are not going away The standing of nursing as a profession will depend in part on what they contribute to health care quality Nursing can let other health professionals make the decisions, or they can get in the mix In many ways, they know more about the specific moment by moment processes of delivering care They have a lot to contribute and to gain American Nurses Association November 20, 2012