Nursing report cards—a virtual reality
By Sonora Hudson
September 17, 1997The link between nursing and hospital performance, as measured by patient outcomes, has been poorly documented in the past. But that’s changing, thanks to efforts to collect hard data on nurses’ impact on outcomes—efforts that are pushing nursing report cards a step closer to reality.
Demands by consumers, employers, and legislators for objective measures of healthcare quality have led to the development of report cards. But most have focused on a limited number of quality indicators such as mortality and length of stay. Nursing’s role in patient outcomes has not been well documented or understood; the lack of standardized data from a centralized source has also been a problem.
However, some information on nursing’s role in quality is available. Concerned about patient outcomes and the professional well-being of nurses, the American Nurses Association (ANA) began to identify nursing-sensitive quality indicators in 1994. Since then, several ANA-sponsored studies have explored the nature and strength of correlations between nursing care and patient outcomes, with results published as Nursing Report Cards for Acute Care Settings (1995), Nursing Quality Indicators, Definitions, and Implications (1996), and Implementing Nursing’s Report Card (May 1997).
The May report looked at the incidence of pressure ulcers, noncommunity-acquired pneumonia, urinary tract infections, and postoperative infections in patients in 502 hospitals in California, Massachusetts, and New York. The study also evaluated total nursing hours per "nursing intensity weight" (a factor developed by the New York State Nurses Association to adjust for case mix) and RN hours as a percentage of all nursing hours. To control for variables, the study measured case mix, too, and noted hospitals’ teaching status and various care settings.
Results indicated shorter length of stay was strongly related to higher nurse staffing per acuity-adjusted day. Also, patient mortality rates were significantly lower when there were more RNs in the skill mix. Nurse staffing per acuity-adjusted day also affected patient mortality.
The results indicated that nursing report cards could work, according to Robert A. Knauf, president of NETWORK Inc., the Dover, New Jersey, hospital and healthcare consulting firm that conducted the study. But Knauf was surprised that the quality of data concerning nurse staffing turned out to be highly variable.
"This one variable was almost haphazardly reported in many cases, and organizations responsible for monitoring this variable weren’t doing much," Knauf said. He said that information about complications, which has always been variable and prone to incomplete reports, is "not as bad a problem as nurse staffing variables. I was surprised such information is not available." The study excluded the hospitals with bad data, Knauf said, so the problems did not affect the study results.
The ANA has sponsored state projects in California, Texas, Arizona, North Dakota, Minnesota, and Virginia that look at nursing quality indicators. Those involved in the California project, California Nursing Outcomes Coalition (CalNOC), are happy with the project so far. "We now have an established infrastructure and strategic vision," said Nancy Donaldson, DNSc, RN, CalNOC project director for the American Nurses Association\ California (ANA\ C). She said the groundwork has been laid for "measuring structure, process, and outcomes in a way that is valid, reliable, and comparable."
The CalNOC project involves the ANA\ C, ONE-California, the California Association of Colleges of Nursing, the California Healthcare Association, the California Organization for ADN Program Directors, Hospital Services for Continuing Care, the Nursing Executive Council Hospital Association of Southern California, and the University of California, San Francisco (UCSF) School of Nursing.
All six ANA-sponsored state projects have been working with ANA-identified variables, but the indicators selected for the first phase of the different studies were inconsistent. The first phase of the CalNOC project—which involved 11 hospitals and was carried out from November 1996 to February 1997—collected data on skill mix, hours per patient day, skin integrity, patient falls, and antibiotic medication errors. Indicators will be added and sites expanded in the next phase, Donaldson said.
"We’re totally delighted with the progress," said Suzanne Henry, DNS, RN, FAAN, associate professor of nursing and medical information science at UCSF. Her institution helped develop the database and data collection tools and did data analysis for CalNOC. "Pilot sites were able to reliably collect data, and we were able to merge data and do an analysis. From all points of view, it was a very successful project," Henry said.
Although it’s too soon to predict results, participation in the study may have already affected the way things are done at some institutions. "Some groups have added variables to their quality management data collection and identified strengths and limitations in their ongoing efforts," Donaldson said. Preliminary results of the state projects were presented at a May 20 meeting of participants. Final results are being prepared for publication.
The next phase of research is expected to involve expanded efforts at data collection; at the May meeting participants decided that all six projects should examine the same indicators. The ANA funding for the next phase of state projects is expected to move forward within the next month, according to Patricia Rowell, PhD, RN, senior policy fellow in the ANA department of nursing practice. The rest of the funding will be at the state level, with the American Nurses Foundation seeking additional resources.
The effort is very important in refocusing emphasis on safety and quality rather than cost containment, Rowell said. "First and foremost it raises the healthcare community’s consciousness to make sure that it looks to see its array of indicators is capturing all variables affecting patient care. We recognize patient care as being interdisciplinary. We wouldn’t see a nursing report card as a stand-alone, but would look at the full range of indicators of patient care, therefore gaining a better understanding of all aspects of that care."
Related Sites Joint Commission on Accreditation of Healthcare Organizations
National Committee for Quality Assurance Provider Page
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