Nurses’ report card project under way
Indicators narrowed to five
Taking RNs out of patient care could be detrimental to patients, says the American Nurses Association (ANA) in Washington, DC. But collecting and analyzing more data could be detrimental to you. It clearly means more work.
To prove its point, the ANA wants to measure nursing’s impact on selected patient outcomes and explore the nature of the linkages between nursing care and patient outcomes. Its report card project promises to accomplish that. The ANA commissioned the project in mid-1994 as a part of its Nursing’s Quality Initiative.
LOS, morbidity related to skill
The project achieved several of its objectives, among them establishing a connection between favorable patient outcomes and high-skilled hospital personnel. Shorter lengths of stay were found to be strongly related to higher nurse staffing per acuity-adjusted day. Patient morbidity indicators for preventable conditions arising as a result of hospitalization were found to be significantly related to lower RN skill mixes and less nurse staffing. In addition, nursing intensity weights by DRG were found to be significantly related to differences in nurse staffing ratios.
Sarah Stanley, RN, MS, director of nursing practice with the ANA, has been director of the report card project since November 1994. "The report card project is a positive beginning," Stanley says. "We wanted to see what, if any, data were being collected by hospitals. We knew that many report card projects are collecting administrative outcomes, such as how long a patient waits for an office visit or how long the phone call is. But we wanted to encourage hospitals and networks to begin to collect data in the areas of nursing care-sensitive activities, especially related to clinical outcomes of patients. Our focus is the patient and how he is affected by nursing that patient’s clinical outcomes."
Hospital Peer Review asked Stanley how the report card project could affect day-to-day activities of QM/QI managers, as well as the RN on duty. "Nurses have told us that unsafe conditions exist in their institutions," she answered. "We’re at the point of asking hospitals to begin to collect data so that experiential data can be supported scientifically."
A prospective took at staffing and outcomes
The report card project statistically tests the relationships between nurse staffing and specific patient outcome indicators, and assesses the feasibility of capturing the information necessary to develop specific staffing and outcome measures for hospitals.
Implementing Nursing’s Report Card: A Study of RN Staffing, Length of Stay, and Patient Outcomes is the just-published report on substantial amounts of data collected in California, Massachusetts, and New York. Once scientific backup is established, the project will extend to other parts of the country and provide a framework for educating consumers and policy-makers about nursing’s contributions to care a contribution often not well-understood, especially in today’s cost-containment-centered arena.
"Most of our focus has been prospective," says Stanley. "We’re working with six state nurses’ associations Texas, Arizona, ANA/ California, Minnesota, Virginia, and North Dakota all funded by the ANA to build coalitions that will acquire agreements with hospitals to go in and collect data. We’re establishing a national databank where data will be analyzed."
The first step was to identify measurable quality indicators of nursing structure, process, and outcome for acute care settings. A committee narrowed a list of 71 possibilities down to 21, later to become a core set of 10. Three types of quality indicators were categorized:
• Patient-focused. How patients and their conditions are affected by their interactions with nursing staff.
• Process of care. How care is delivered. This includes how nurses perceive and discharge their roles and the nature, amount, and quality of care provided.
• Structure of care. Measures of staffing patterns expected to affect quality and quantity of care. This includes ratio of RNs (as opposed to LPNs and unlicensed technicians) to patients and number of care hours provided to patients.
From the following 10 indicators, the committee selected the first seven as seeming to show the strongest link to patient care:
• Mix of RNs, LPNs/LVNs, and unlicensed staff.
Only full-time employees are measured when establishing the mix of RNs, LPNs/LVNs, and unlicensed staff. Nurse staffing is quantified by measuring total nursing hours per nursing intensity weight, and RN hours as a percentage of all nursing hours.
• Ratio of nursing staff to patients.
Total nursing care hours provided per patient day is measured as the ratio of nursing staff to patients.
• Nursing staff satisfaction and turnover.
Staff satisfaction and attitude are measured by scaled responses to questionnaires.
• Nosocomial infections.
The study focused particularly on urinary tract infection (UTI). Nosocomial infection rate is measured as the rate per 1,000 patient acute care days at which patients develop UTI following the first 72 hours. There must be no evidence that the infection existed at admission.
• Decubitus ulcers.
Maintenance of skin integrity is the rate per 1,000 patient days at which patients develop decubitus ulcers, Grade II or higher, 72 hours following admission. A "look-back" measure would look at the relationship between nursing assessment for risk of skin breakdown and the development of ulcers.
• Patient injury rate.
Patient injury is measured by the rate at which patients fall and incur injury, unrelated to their diagnosis or therapy, per 1,000 patient days. A "look-back" evaluation would be a part of this: the relationship between nursing assessments performed and falls resulting in injury.
• Patient satisfaction.
Patient satisfaction is measured by questionnaire and subcategorized into opinion of care as a whole and nursing care, satisfaction with pain management, and opinion of patient education.
• RN education and qualifications.
• Use of agency nurses.
• Medication errors.
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