The History of the National Quality Forum's Nursing Sensitive Measures

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The History of the National Quality Forum's
Nursing Sensitive Measures

• Ellen T. Kurtzman, MPH, RN

February 2009
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The History of the NQF15

• Webinar Overview
• NQF and the quality enterprise
• Role in nursing quality
• Endorsing national voluntary consensus standards
  for nursing-sensitive care
• NQF15 standards development and impact
• Questions and answers

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The History of the NQF15
NQFs Mission

• To enhance the quality of American healthcare by
  
• setting national priorities and goals for
  performance improvement,
• endorsing national consensus standards for
  measuring and publicly reporting on performance,
  and
• promoting the attainment of national goals
  through education and outreach programs.

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The History of the NQF15

• History
• Presidential Advisory Commission on Consumer
  Protection and Quality in the Health Care
  Industry (1996)
• Commission recommended creation of a private
  sector entity to standardize healthcare
  performance measures and standards (1998)
• Quality Forum Planning Committee convened by
  White House (1998)
• NQF incorporated in District of Columbia (1999)
• Merger with the National Committee for Quality
  Healthcare
• Janet M. Corrigan, PhD, MBA named as new
  President CEO (2006)
• Congressional support (2008)
• Future, possible role in coordinating the
  quality enterprise

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The History of the NQF15
Unique Features

• Formal consensus process (voluntary consensus
  standards)
• Public and private sector representation on
  governing board
• Open membership an organization of organizations
• Attention to overall strategy for measuring and
  reporting healthcare quality, including
  establishing national goals
• Focus is on the entire continuum of healthcare

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The History of the NQF15
NTTAA and OMB Circular A-119
NQF endorses national voluntary consensus
standards pursuant to the National Technology
Transfer and Advancement Act (NTTAA) of 1995 and
OMB Circular A-119

• Defines five key attributes of a voluntary
  consensus standards body (i.e., openness,
  balance of interest, due process, consensus,
  appeals)
• Obligates federal government to adopt VCS in lieu
  of government-unique standards except where
  inconsistent with law or otherwise impractical
• Encourages federal government to participate in
  standards setting
• NQF-endorsed akin to the Good Housekeeping
  Seal of Approval for healthcare performance
  measures, quality indicators, and other metrics

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The History of the NQF15

• NQFs Focus on Nursing
• Key nursing organizations represented on the
  membership
• Historic focus on nursing as part of consensus
  development process
• Endorsement of 15 national voluntary consensus
  standards for nursing-sensitive care
• Study of their use vis-a-vis Nurse Tracking
  project
• Measurement maintenance following Joint
  Commission testing
• Ongoing interests in improving, aligning measures
  across initiatives, and facilitating rapid
  adoption

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The History of the NQF15

• Developing NVCS nursing-sensitive care
• Identify and endorse a core set of evidence-based
  performance measures for evaluating the quality
  of nursing care in acute care hospitals
• Measures to improve nursing, patient outcomes
• Endorse measures for public reporting
• Identify a framework for how to measure nursing
  care performance
• Prioritize unresolved issues and research needs

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The History of the NQF15
NQF NVCS Timeline 2003 - NQF project initiated
to quantify the influence of nursing personnel on
inpatient quality 2004 Endorsement of NQF15,
a set of performance measures intended for use by
the public in evaluating the ways and the extent
to which nurses in acute care hospitals
contribute to patient safety, healthcare
outcomes, and a professional work
environment 2005 Interest in determining the
degree to which implementation of the NQF15 is
widespread advances need for study 2007 Nurse
Tracking project releases findings 2008
Maintenance in response to Joint Commissions
test, measure maintenance 2010 CMS requirement
to collect and submit measure(s)
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The History of the NQF15

• NQF15
• Purpose of consensus standards is to promote
  highest levels of patient safety and healthcare
  outcomes
• All have been endorsed for public reporting
• Represent measures that are
• processes and outcomes of care influenced by
  nursing personnel consensus that evidence links
  a nursing variable to an outcome or a
  process/intervention
• structural proxies (e.g., staffing measures)
  consensus that measure is sufficiently linked to
  inpatient outcome to serve as indicator of
  performance

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The History of the NQF15

• Approach to Measure Screening, Evaluation, and
  Endorsement
• Identification universe of measures
• Steering Committee guidance
• Purpose (e.g., QI, public reporting)
• Conceptual, organizing framework
• Scope (e.g., setting) and priorities (e.g.,
  address all IOM aims)
• Review of the evidence
• Is it an adequate measure based on NQF accepted
  evaluation criteria (i.e., important,
  scientifically acceptable, usable, feasible)
• Is it nursing-sensitive (i.e., linked to
  nursing variables and/or structural proxy)
• Review by a Technical Advisory Panel
• Recommendations formulated public comment and
  voting process
• Endorsement by NQF Board of Directors

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Approach to Measure Screening, Evaluation, and
Endorsement
Step 1 Establish Purpose of Nursing Care
Performance Measure Set What should be the
Steering Committees explicitly stated purpose
for the set? Should purpose statements be
prioritized?
Step 2 Construct a framework for measurement
that incorporates established purpose On what
principles should the framework be based?
Universe of Measures
(gt 150 candidates)
Step 3 Identify Scope What elements should
drive the scope of this measure set (e.g.,
definition of nurse, scope of hosp services)?
Final Steps Public Comment, Voting, BOD
Endorsement (CDP) of NVCS (N15)
Step 6 Recommend nursing care measures (N13)
Step 5 Evaluate candidate measures within
framework via standard criteria AND to determine
nursing sensitivity (gt 50 candidates evaluated)
Step 4 Establish Priorities What kinds of
measures should get high-priority attention?
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The History of the NQF15

• NQF15
• Failure to rescue (death among surgical
  inpatients with treatable serious complications)
• Pressure ulcer prevalence
• Falls
• Falls with injury
• Restraint (vest and limb) prevalence
• Urinary catheter-associated UTI (ICU)
• Central line catheter-associated BSIs (ICU)
• Ventilator-associated pneumonia (ICU)

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The History of the NQF15

• NQF15, cont.
• Smoking cessation counseling for AMI
• Smoking cessation counseling for pneumonia
• Smoking cessation counseling for HF
• Skill mix
• Nursing care hours per patient day
• Practice Environment Scale-Nursing Work Index
  (PES-NWI)
• Voluntary turnover

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The History of the NQF15

• NQF15 does not reflect all outcomes and
  processes influenced by nurses
• NQF15 does include measures which are influenced
  by non-nurse practitioners

NQF15 intended to represent an initial set of
measures to quantify nursings contribution to
inpatient care
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The History of the NQF15

• Research Recommendations
• Measure development in gap areas
• Workforce measures and the supporting
  evidence-base
• Areas for which measures dont exist (e.g., care
  coordination, efficiency, symptom management,
  patient comfort, malnutrition)
• Measures that address all patients regardless of
  setting (e.g., pain assessment and management)
• Expansion of existing measures to all patient
  populations (e.g, ICU-only measures)
• Inadequate or insufficient at the time of
  consensus review
• Under development at the time of endorsement
• Evidence base that explores the adequacy of
  measures against NQF evaluation criteria

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The History of the NQF15

• Impacts of NQF15
• Quality improvement
• Transforming Care at the Bedside
• National and state nursing benchmarking systems
  (e.g., NDNQI, CalNOC, VANOD)
• Research through INQRI
• Policy
• Hospital Compare and RHQDAPU program (i.e.,
  smoking cessation, FTR in 2010)
• Hospital-acquired conditions policy (e.g.,
  pressure ulcers)
• Emergence of state reporting efforts focused on
  nursing performance (Maine, Massachusetts)
• HQA approval of NQF15 for future rulemaking

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The History of the NQF15

• Webinar Series
• Part 2 The Collaboration Between NQF and The
  Joint Commission
• Date February 26, 2009 4 p.m. EST - 5 p.m. EST
• Part 3 Measurement Panel, featuring
  representatives from CalNOC, NDNQI, VANOD, JCAHO,
  NQF.
• Date April 13, 2009 4 p.m. EST - 5 p.m. EST

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The History of the NQF15
Questions and Answers? National Quality
Forum http//www.qualityforum.org Download
executive summary at http//www.qualityforum.org
/pdf/reports/nsc.pdf