Defining the nursing contribution to quality of care

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Defining the nursing contribution to quality of
care
Presented by Professor Anne Marie RaffertyKings
College London April 2009
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Aims

• Consider the role of nursing in driving up the
  quality of care
• Contextualise within wider system reform process
• Highlight how nursing raising its game

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FlorenceNightingale
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The stages to our journeyWhere we have been and
where we are going
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High quality care for all

• NHS Next Stage Review local clinical visions,
  national enabling report and NHS Constitution

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Introducing the reforms

• Patient choice and payment by results
• Foundation trusts
• Stronger commissioning

1
Building capacity in the system

• NHS Plan saw greatest investment in the history
  of the NHS
• More doctors, more nurses, better facilities

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NHS Next Stage Review
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Measuring and Rewards
Commissioning for Quality and Innovation
Better evidence
Quality accounts
Quality metrics
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Challenges for nursing
Public confidence, image and identity
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Variability in quality care
2
Focusing on health - transforming primary and
community care
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Access, choice and personalisation
4
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Why now?
'I was shocked by the lack of care A report by a
committee of MPs and peers warns that many
hospitals and care homes are not protecting the
human rights of older patients.
'Grubby' nurses slammedby peer A Conservative
peer has launched an attack against nurses at
Bath's Royal United Hospital.
BBC News 2007
Patricia Balsom Diary of my final days How one
cancer patient suffered at the hands of the NHS
BBC News 2008
Is caring a lost art in nursing?
The Independent. Thursday, 16 November 2006.
International Journal of Nursing Studies
200842(2)163
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• What does all this mean
• for nursing?
• Driving up the quality of care

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The new professionalism

• World class services
• Innovation, consistency, continuous
  self-improvement,
• responsiveness,
• Driven by public services themselves
• Responsive to the needs of the public
• Compare performance with peers

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Implications for role development

• Practitioner
• Partner
• Leader

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Measurement and Management

• Delivering care that is effective, safe and
  compassionate
• Metrics to define and measure the quality of
  nursing care
• State of the Art Metrics for Nursing a rapid
  appraisal
• Care line management - accountability
  framework that spans delivery of care to the
  boardroom
• Extend the Productive Series to community
  services refreshing Essence of Care
• Innovations and Incentives

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The Task

• To develop an indicative set of metrics to define
  and measure the quality of nursing care
• To develop a model for accountability that spans
  from the delivery of care to the boardroom
• (care line management)
• National Task and Finish groups April and May
  2008

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Why metrics

• Evaluating and indicating quality
• Understanding
• Accountability
• Performance management

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By closely defining the aims of our initial work
on metrics, we have built a strong starting point
for the measurement of nursing care quality - (1)
DRAFT

• Aim Rationale

• Quickly developing a robust indicative set of
  metrics will demonstrate to nurses and nurse
  leaders that nursing care quality can be defined
  and measured, and will act as a platform for
  further work
• Stress-testing and iterative refinement of
  metric sets can only be achieved through
  practical use and evaluation in the field

Develop a starting point, not the finished article

• Demonstrating the usability of nursing care
  quality metrics in one setting will act as a spur
  to the development and roll-out of metrics in
  other settings
• Metrics more readily available for the acute
  setting, making it a natural starting point
• Many of the domains and categories of care, and
  some individual metrics, will be applicable
  across settings

Focus on the acute sector first
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By closely defining the aims of our initial work
on metrics, we have built a strong starting point
for the measurement of nursing care quality (2)
DRAFT

• Aim Rationale

• Focus on outcomes means that we measure, drive
  and incentivise the achievement of the end goals
  of nursing care, not merely the performance of
  actions
• Allowing nurses and nurse leaders as skilled
  clinical professionals to judge the best way to
  deliver outcomes provides flexibility across
  settings and practice areas
• Activity-focused metric systems can be prone to
  gaming

Aim to measure outcomes, not processes

• Isolating outcomes solely determined by nurses
  is difficult if not impossible
• Focusing on outcomes for which nurses can
  realistically be held accountable, rather than
  outcomes which nurses alone determine, is
  consistent with the vision of the nurse as
  practitioner, partner and leader
• Detailed academic evaluation of
  nurse-sensitivity of outcomes is not at this
  stage complete

Measure outcomes not influenced, not solely
controlled, by nurses
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Indicative metric set for an acute medical ward
(1)

• Care Domain Category Metrics

This would be a new metric that hospitals would
have to audit using their own customised local
patient surveys
Pain Control
Prevention of harm caused by lack of movement
Effectiveness
Nutrition hydration
Preventing avoidable emergencies (failure to
rescue)
Clinical stabilisation/recovery
Co-ordination management of care
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State of the art for Nursing indicators
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Most frequently identified indicators
Process / Structure
Outcomes
Use of restraints Smoking cessation
counseling Staffing level Skill mix Sickness
rates Bank and agency usage Practice environment
/ perceived quality Voluntary turnover Staff
knowledge and expertise
Perception of adequate staffing Staff
satisfaction wellbeing Sickness rates
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Kane et als systematic reviewDecember 2007
Medical Care 45 (12), 1195-1204

• 96 studies
• Increased RN staffing was associated with lower
  hospital related mortality in
• intensive care units (OR 0.91 CI 0.860.96)
• surgical units (OR 0.84 95 CI, 0.800.89),
• medical patients (OR, 0.94 95 CI, 0.940.95)
• per additional full time equivalent nurse per
  patient day.

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Other associations

• Respiratory failure (all groups) 6
• Failure to rescue (surgery) 16
• Hospital acquired pneumonia (all groups) 19
• Length of stay (ICU, Surgery) 24
• Cardiac arrest (all groups) 28
• Hospital acquired bloodstream infection
  (surgery) 36
• Unplanned extubation (ICU) 51
• Surgical wound infection (surgery) 85

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Is the evidence consistent with cause?

• Dose response Yes
• Evidence of a curvilinear relationship
• Study design Yes
• Some modifications in estimates but conclusions
  unchanged
• Temporal association Yes
• Lower estimate of effect on failure to rescue in
  studies assessing temporal association

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What about the most nurse sensitive outcomes?

• No consistent association
• patient falls,
• pressure ulcers,
• urinary tract infections
• ? Coding / recording issues

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Best bets

• Failure to rescue
• Infection
• Falls
• Pressure sores
• Compassion

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Challenges ahead

• Technical developments
• Indicators for
• Mental health
• Community
• Children
• Indicators that cross care path ways and
  boundaries
• Delivering action to improve quality

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Annex 1Overview of the quality indicators
framework
Key purposes
Example product

• Improvement against national priorities
• Accountability to taxpayers
• International benchmarking

National

• Improvement in quality within the region and
  progress against the regional vision
• Enable benchmarking

Co-production at all levels of the system
Regional

• Service improvement
• Board accountability
• Provider benchmarking

Local
Subsidiary

• Service improvement
• Team benchmarking for improvement

Team
Local clinical ownership of indicators
Sources of evidence-based indicators include
Royal Colleges, specialist societies, NHS
Information Centre, universities, commercial
sector
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Conclusion

• Feed in and follow through on nursing metrics
  into policy
• recommendations
• Historically unique moment in policy formulation
  and
• implementation, alignment of workforce,
  leadership and
• wider policy initiatives
• Package of system reforms, step change in
  driving up the
• quality of care