measuring quality and excellence: identifying indicators · 2019. 4. 30. · why we need...
TRANSCRIPT
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Measuring Quality and Excellence:Identifying Indicators
April 2019
Margaret Fitch RN PhD
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Why We Need Measurement
Measurement allows identification of those with difficulties and monitoring of their status over time
Important to be able to measure the impact of interventions in a standardized way
Measurement facilitates comparisons and quality improvement
“If you can not measure it, you cannot improve it” ~Sir William Thomson
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Measuring ‘service’ performance
Access
Quality
‘Client’ satisfaction
Efficiency
Outcomes (service, client)
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Measuring quality
“Sensitive” indicators used to measure quality of {named} care delivered
defined as “ those outcomes that are relevant, based on
program/discipline scope and domain of practice, and for which there is empirical evidence linking inputs and interventions to the outcome for patients”
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Reflection
Make a list of 5-8 variables you think ought to be measured to show that nursing care occurred and made a difference.
Share your list with your neighbour…
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Quality of Care (CIHI)
Quality of care contributes to patient safety and health outcomes; considers how well health care services are provided to patients.
Quality of Care addresses these questions: Do these services measure up to health care evidence?
Are they patient-centred?
Do they produce desired health outcomes?
Do they contribute to patient safety?
Outcomes of care are the direct results of the care patients receive
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Urgency to measure outcomes and demonstrate quality care
Driving influences: Patient safety, fiscal concerns, patent expectations
Mounting expectation to demonstrate quality of nursing care delivered
{discipline} sensitive indicators are proposed as a way to meet this demand
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Patient reported outcomes are useful to report on quality
Patient reported outcomes can be used to guide clinical care, assist in quality improvement, allow benchmarking and comparative effectiveness research
Instruments need to be reliable, measures sensitive to change, and outcomes associated with nursing interventions
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Performance Indicator
Definitionnumerical measures that can
be used as a guide to monitor process performance
data often requires further investigation to isolate actual problem/pinpoint solution
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What do we need to measure?
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Indicator Framework
Structure Process Outcomes
Safe
Effective
Person Centred
Access
Equitable
Efficient
Qu
ali
ty D
ime
nsi
on
s
Program Design Dimensions
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Indicators needed at all levels
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Examples
Where data are
collected
Examples of variables
At point of patient care Pain, constipation, delirium,
nausea
Quality of life
At program or service
level
Experiences, perspectives on
care, satisfaction
What worked well
At system level
(regional, national)
Emergency visits
ICU admissions
Home care visits
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Completing a standardized symptom screening tool
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Examples of indicators (CIHI) Accessibility
Comprehensiveness
Continuity of care
Integration
Appropriateness of care
Effectiveness
Safety
Competence or capability
Patient experiences
Equity
Productivity or technical efficiency
Expenditure or cost
Responsiveness/trust in the health system
Efficiency
Healthy lives or health status improvement
Efficient allocation of resources
Innovation and capacity to improve
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Effectiveness of specializedpalliative care teams: lit reviewZimmerman et al, JAMA, 2008
Indicators Caregiver satisfaction, Quality of life
Patient satisfaction, quality of life
Symptom distress: Pain, dyspnea, constipation, sleep
Place of death
Cost
Advanced directives
Medications
Treatment planning attitude
Psychosocial, depression , anxiety
Spiritual well being
Health care professional knowledge
Social support
Referral
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Candidate National Indicators (Canada draft)
Place of death (home, hospital, preferred location)
# days in acute care setting during last 30 days of life
% cancer deaths occurring in hospital
New chemotherapy within the last two weeks of life
ICU Admission within the last 30 days of life
Emergency department visit in the last two weeks of life
Home care within 6 months of death
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Nurse sensitive indicators:Literature review(Burston et al., 2013)
Exploration of nurse sensitive indicators has primarily focused on:
Relationship between structural variables and patient outcomes in acute care settings
Potential indicators for specific patient groups and nursing roles
Selection, reporting and sustained use are key aspects
Evidence inconsistent due to disparity in definitions used, data collected and analysis methods
Consensus regarding indicators to be used and integration into daily practice are required
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Indicators must
Measure important phenomena
Be scientifically sound
Provide useable information
Be feasible to collect
Be clear regarding context in which they are measured
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Nurse sensitive indicators
Indicators must be measureable
Data must be obtained at relatively low cost
Data gathering must not place undue additional burden on the clinical team
Significant variation in the indicator must be attributable to nursing
There must be wide applicability within settings, applying to a large number of patients
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Variation attributable to nursing
The phenomenon is recognized as important
There is a recognized contribution of nursing
There is evidence to support sensitivity to nursing
Nurses must ‘own’ responsibility (in terms of legitimate authority, self perception, and sphere of practice)
Variation in outcome attributable to nursing must be substantial or the link between a nursing structure or process and the outcome must be strong
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Example
Nursing sensitive outcomes and indicators in chemotherapy
Griffiths, Richardson & Blackwell
United Kingdom
November, 2009
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Conclusions
Wide number of possible indicators but evidence weak regarding link to outcomes
Clearest direct impact of nurses was to safety and experience dimensions of quality
Impact on treatment effectiveness is indirect and mediated by the ability to support patients in managing toxicities (in turn based on link to accurate problem identification and access to therapies)
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Attributes of nursing sensitive indicators identified via concept analysis(Frequency>10) (Heslop & Lu, 2014)
Structural – setting related
Hours of nursing care per patient day
Nurse staffing (staff mix, skill mix, staff ratio)
Process (none)
Outcome – patient related
Safety
Pressure ulcer
Falls and falls with injury
Nosocomil selective infection
Perception
Patient/family satisfaction with nursing care
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Nursing sensitive indicators(Heslop & Lu, 2014)
Structural
Patient related :
patient characteristics
Nursing related:
RN Education level, years of experience
Setting related:
Hours of nursing care per patient day
Nursing staffing (staff mix, skill mix, staff ratio)
Patient acuity
Patient turnover
Workload intensity
% hours suppled by RNs
Organizational factors of nursing practice environment
Support for nursing education
Manager ability leadership and support
Relationships with other practitioners
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Nursing sensitive indicators(Heslop & Lu, 2014)
Process
Nursing related
Nursing intervention/nursing practice
Setting related
Nursing documentation/nursing care plan
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Outcome-patient related
Safety Pressure ulcer
Falls and falls with injury
Nosocomial selective infection
Nosocomial urinary tract infection
Medication error
Pneumonia
Vein system complication
Failure to rescue
Perception
Patient/family satisfaction with nursing care
Patient/family satisfaction with pain management
Use of health care
Length of stay
Waiting time for nursing care
Unplanned hospital visits post-discharge
Functional status
Symptom resolution/reduction
Clinical management
Nursing sensitive indicators(Heslop & Lu, 2014)
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Creating/analyzing nursing quality database(Aydin et al., 2004)
Created a large ongoing reliable and valid quality database to examine nurse staffing and patient care outcomes in acute care hospitals
Contains prospective nurse staffing, process of care, and patient outcomes based on ANA nursing quality indicators
Variables: Hospital nursing staffing, patient days, patient falls, pressure ulcer and restraint prevalence, RN education, and patient perceptions of care
Voluntary contribution; largest state database
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Steps in indicator development
Establishing the purpose of the indicators
Designing the conceptual framework
Selecting and designing the indicators
Interpreting and reporting the indicators
Maintaining and reviewing the indicators
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Identify purpose and audience for indicator
Who will be responsible for the final selection and publication of the indicators?
How will key stakeholders be involved?
Will an expert group be established to provide specialist advice?
Will public consultation be undertaken?
How will the indicators be sustained and funded over time?
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Design conceptual framework
Offers a guide for developing indicators
Provides a formal way of thinking about the topic area
Helps ensure relevant and balanced selection of indicators
Aids in understanding links between indicators
Provides useful device for organizing and reporting in a structured and meaningful way
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Selecting/designing indicators Valid and meaningful
Sensitive and specific to the underlying phenomenon
Statistically sound
Intelligible and easily interpreted
Related where appropriate to other indicators
Allows international comparison
Ability to be disaggregated over time
Consistency over time
Timeliness
Linked to policy or emerging issues
Compel interest and excite
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Indicators of APN on outcomesIngersoll et al, 2000
TOP TEN: Delphi with practicing APNs in USA
satisfaction with care delivery,
symptom resolution/reduction,
perception of being well cared for,
compliance/adherence with treatment plan,
knowledge of patients and families,
trust of care provider,
collaboration among care providers,
frequency and
type of procedures ordered
quality of life.
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Example (www.hope.org)
Strategy
Nurses conduct bedside change of shift reporting
Measurement
Nursing staff and physician satisfaction scores
Patient satisfaction scores
Outcomes
Increase in staff satisfaction scores
Increase in patient satisfaction scores
Improved ability of nurses to prioritize work
Decrease in staff time
Decrease in handoff errors
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Example (www.hope.org)
Strategy
Patients and families participate in rounds
Measurement
% families that participate in rounds
Number of stories in which new information is discovered from family
Length o time for rounds
Patient satisfaction scores
Staff satisfaction scores
Length of stay
Outcome
Length of stay decreased
Increase in satisfaction scores
Decrease in readmissions rate, safety outcomes
Change in percentage of misses versus errors
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Example (www.hope.org)
Strategy
Patients and families have access to medical records or online portals for personal health information
Measurement
Number of times the portals are used
Surveys of patient’s use of portals
Outcome
Increase in patient satisfaction scores
Increased medication adherence
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Nursing sensitive screening measures (Stalpers et al., 2016)
Deliberative screening – detection of risks otherwise may not be noticeable
Nursing (mandatory) screening -Delirium malnutrition, pain and pressure ulcers
In hospital records ranged low of 59% for delirium to high of 94% for pain
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Interpreting and reporting indicators
Bridges the gap between measurement and understanding
Report objectively and in policy neutral manner; over context as appropriate
Keep audience in focus
Ensure dissemination strategy facilitates data report reaching intended audience
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Examples of indicators
% patients with a written care plan
my health care provider and I worked together to set personal goals to manage my health care
My health care provider listened carefully to me at today’s visit
I understand my health care provider’s advice and what I need to do to manage my illness
My health visit helped me to gain confidence in managing my health problems
You and your family were able to participate in decisions about your care
Clinician and staff respected your choice of whether or not to have a family member or friends with you during your care
Clinician staff respected your family’s cultural and spiritual needs
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Maintaining and reviewing indicators
Indicators need on-going assessment
Be open to discussion and refinement or modification
Consultation with stakeholders is critically important to obtain feedback about the relevancy and usefulness of the indicator
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What do you think now?
Has you thinking about your list of indicators changed in any way?
Talk it over with your colleague beside you?
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Top ten measures that matter:nursing hospice and palliative care
March 2017
Facilitator: Margaret Fitch
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Measure 1
NAME:
hospice and palliative care – comprehensive assessment
Definition:
Percentage of patients for whom a comprehensive assessment was completed
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Measure 2
NAME:
Screening for physical symptoms
Definition:
Percentage of seriously ill patients receiving palliative care in an acute hospital setting >1 day or patients enrolled in a hospice >7 days who had a screening for physical symptoms (pain, dyspnea, nausea, and constipation) completed
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Measure 3
NAME:
Pain treatment (any)
Definition:
Percentage of seriously ill patients receiving specialty palliative care in an acute hospital setting >1 day or patients enrolled in a hospice >7 days who screened positive for moderate to severe pain on admission, and the percent receiving medication or nonmedication, within 24 hours of screening
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Measure 4
NAME:
Dyspnea Screening and Management
Definition:
Percentage of patients with advanced chronic or serious life-threatening illnesses that are screened for dyspnea, for those who are diagnosed with moderate or severe dyspnea, a documented plan of care to manage dyspnea exists
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Measure 5
NAME:
Discussion of emotional or psychological needs
Definition:
Percentage of seriously ill patients receiving specialty palliative care in an acute hospital setting >1 day or patients enrolled in a hospice >7 days with chart documentation of a discussion regarding emotional or psychological needs
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Measure 6
NAME:
Discussion of spiritual/religious concerns
Definition:
Percentage of hospice patients with documentation in the clinical record of a discussion of spiritual and religious concerns or documentation that the patient or caregiver did not want to discuss these issues
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Measure 7
NAME:
Documentation of surrogate
Definition:
Percentage of seriously ill patients receiving specialty palliative care in an acute hospital setting >1 day or enrolled in a hospice >7 days with the name and contact information for the patient’s surrogate decision-maker in the chart or documentation that there is no surrogate
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Measure 8
NAME:
Treatment preferences
Definition:
Percentage of seriously ill patients receiving specialty palliative care in an acute care hospital setting >1 day or enrolled in a hospice for >7 days with chart documentation of preferences for life-sustaining treatments
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Measure 9
NAME:
Care consistency with documented care preferences
Definition:
If a vulnerable elder has documented treatment preferences to withhold or withdraw life-sustaining treatment (e.g., a do-not-resuscitate order, no tube-feeding, no hospital transfer), then these treatment preferences should be followed
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Measure 10
NAME:
Global measure
Definition:
Patient and/or family assessments of the quality of care is a key part of measuring quality for any setting caring for palliative or hospice patients