Performance-based payment incentives increase burden and blame for hospital nurses. McCulloch, G., & Tegethoff, G. (2013). 2, Manuscript 1. endstream endobj 142 0 obj <>/Metadata 13 0 R/Pages 139 0 R/StructTreeRoot 23 0 R/Type/Catalog>> endobj 143 0 obj <>/MediaBox[0 0 612 792]/Parent 139 0 R/Resources<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI]/XObject<>>>/Rotate 0/StructParents 0/Tabs/S/Type/Page>> endobj 144 0 obj <>stream Consequently, few evidence based changes in practice have materialized. (1995). Medical care research and Review, 64(2), 10S-43S. Patient Experience. The development of robust nurse process measures is hindered by issues related to incomplete and unstandardized documentation, documentation burden, and data collection burden. SNL/Ts have developed gradually over time beginning with use of the term nursing diagnosis.In a 1953 issue of the American Journal of Nursing, Fry wrote about use of nursing diagnosis as a creative approach to nursing practice. Fasolino, T., & Verdin, T. (2015). (2005). 2. National Quality Forum Endorsed Nurse-Sensitive Indicators. In contrast, measures based on manual audits (e.g. Specific and measurable: tracking data to monitor outcomes is practical and timely. Holubowich, E. J. Unfinished nursing care: An important performance measure for nursing care systems. Journal of Health Care Compliance, 12(1), 36-68. This action translates into a downsized nursing workforce, fewer patient services, and decreased quality of care (Kurtzman et al., 2011; Timmers, Hulstaert, & Leenan, 2014). Nurse-Sensitive examples in Figure extrapolated from domain specific frameworks described in the following publications: Burston, Chaboyer, & Gillespie (2013); Doran (2011); Dubois, D’Amour, Pomey, Girard, & Brault (2013); and Heslop & Lu (2014). Citation: Jones, T., (May 31, 2016) \"Outcome Measurement in Nursing: Imperatives, Ideals, History, and Challenges\" OJIN: The Online Journal of Issues in Nursing Vol. Enhancing nursing practice by utilizing voice recognition for direct documentation. The outcomes addressed in current VBP policies primarily relate to the prevention of injury (e.g., nosocomial infection, pressure ulcers) and do not address other outcomes germane to the nursing profession’s social contract (i.e., health promotion and the alleviation of suffering). Consequently, many colleges and universities have not developed active research programs in this area. Computers in Nursing, 33(11), 487-494. doi:10.1097/CIN.0000000000000187. Notably, nurse-sensitive indicators account for < 3% of the 500-plus measures endorsed by the NQF. Professionalism: (demonstrates accountability as a life-long learner for the delivery of evidence … Achievable: This target is challenging but specific, measurable, and achievable for your capabilities, resources, and skills. Quality Management in Health Care, 17(4), 312-319. H��V]o�H}G�?�G� Nursing-sensitive indicators in ambulatory care. chart abstraction, direct observation) and surveys have been considered less desirable. Journal of Nursing Administration, 40(7/8), 336-343. doi: 10.1097/NNA.0b013e3181e93994. Medical Care Research and Review, 64(2), 144S-169S. Brennan, C. W., Daly, B. J., & Jones, K. R. (2013). Journal of Nursing Scholarship, 36(4), 371-378. However, the effect of staffing and nursing education on patient outcomes, though statistically significant, is relatively small by scientific and clinical standards. Patient will decrease their depression by 50%.Measurable, time-limited goals Patient will score 20 or below on the Beck Depression Inventoryfor 5 consecutive sessions. This is problematic for patients and nurses. Start the Measurable Outcomes section of the grant by stating the program Goal, followed by an Objective, and concluded with the Measurable Outcome. Once developed, researchers must be given access to these systems for the kind of robust research needed to develop nurse-sensitive measures that satisfy NQF consensus standards. Nurse-related variables associated with patient outcomes: A review of the literature 2006-2012. An evolving science. American Health & Drug Benefits, 1(6), 34-42. Key Words: Nurse Sensitive Indicators, nursing outcomes, nursing process measures, quality assessment, quality metrics, quality measures, outcomes management, outcomes research, Minimum Nursing Data Sets, nursing taxonomy, nursing documentation system, electronic health record, value based purchasing, Meaningful Use Criteria. More emphasis is needed on establishing clinically meaningful relationships between specific nurse process measures and patient outcomes that reflect the full spectrum included in the nursing profession’s social mandate. Despite the proliferation of national and regional nursing databases, participation is voluntary and no available databases contain information on all of the 15 nurse-sensitive measures endorsed by the NQF (Kurtzman, Dawson, & Johnson, 2008; Kurtzman & Jennnings, 2008; VanFosson, Jones, & Yoder, 2015). Federal law stipulates that policy makers defer to these standards when establishing healthcare policies such as VBP (Bodrock & Mion, 2008; Needleman et al., 2007). Systematic review and meta-analysis. Goal. Outcome statements describe specific changes in your knowledge, attitudes, skills, and behaviors you expect to occur as a result of your actions. Though highly relevant to quality assessment and self-regulation in nursing, development and routine monitoring of nurse process measures has fallen into the “too hard to do” domain. Examples of Measurable Learning Outcomes. Western Journal of Nursing Research, 35(6), 760-794. doi:10.1177/01939549137476577, Burston, S., Chaboyer, W., & Gillespie, B. (2007). (2009). Quality and performance measurement: National efforts to improve quality of care through measurement development. Expending resources on nursing services with no clear benefit or failing to allocate resources for nursing services with a clear benefit is not good stewardship. She has been recognized as one of the Great 100 Nurses in Dallas-Ft. Worth and an Outstanding Graduate in her doctoral and undergraduate programs. Quality assessment and self-regulation cannot move forward without substantial investments to support adequate documentation of nursing practice and patient outcomes. Overall Goal: I want to lose weight and be in better health.. S.M.A.R.T. Therefore, quality assessment is best achieved through a set of measures that include outcomes and associated structures and processes. The National Database of Nursing Quality Indicators (NDNQI), Online Journal of Issues in Nursing, 12(3). Thus, the social contract between health professionals and the public dictates that nurses engage in self-regulation to assure quality performance. Although the nursing quality agenda should accommodate measures related to efficiency, accreditation requirements, and VBP, it should be driven by the social contract. Diagnosis. Are you part of the shift? Terry L. Jones, PhD, RN Lapses in nursing documentation hinder the ability to establish empirical links between nursing care and patient outcomes (Alexander, 2007; Anthony, 2008; Needleman et al., 2007). Worldviews on Evidence-Based Nursing, 8(1), 40-50.doi: 10.1111/j.1741-6787.2010.00183x, Jones, T., Hamilton, P., & Murry, N. (2015) Unfinished nursing care, missed care, and implicitly rationed car: State of the science review. New York, NY: Oxford University Press. In response to declining reimbursement and escalating quality and safety problems, stakeholders in the healthcare industry now challenge traditional assumptions across the delivery system and seek empirical evidence to guide system redesign. Martinez, K., Battaglia, R., Start, R. Mastal, M.F., & Matlock, A.M. (2015). Moving healthcare quality forward with nursing-sensitive value-based purchasing. Nursing surveillance and physiological signs of deterioration. Provide a complete evidence-based model of the intervention of interest. A systematic review of the international evidence. Keyboard entry of data into the EHR continues to be as burdensome as handwritten documentation. As empirical evidence emerged and data collection efforts intensified, the number of proposed nurse-sensitive increased incrementally. Fessele, K., Yendro, S., & Mallory, G. (2014). Public Health Nursing, 29(4), 370-379. doi:10.1111/j.1525-1446.2011.01006. Metric-driven harm: An exploration of unintended consequences of performance measurement. In contrast to frameworks based on the medical model of care (Donabedian, 2003), patient outcome categories proposed in nursing quality frameworks are typically more closely aligned with nursing’s social mandate. The Obama administration bets yes. Evidence suggests that time spent on documentation increases immediately after implementation but eventually returns to baseline (Hakes & Whittington, 2008; Munyisia, Yu, & Hailey, 2011). Note: outcomes generally begin with a verb like increase, expand, or improve. The combined dependent, independent, and interdependent components of nursing practice add to this challenge (Doran, 2011). Additionally, nurses are primarily responsible for the coordination of care activities within and across healthcare teams. Ways to stay focused on your patients, not your EHR. The association of registered nurse staffing levels and patient outcomes. Though highly relevant to quality assessment and self-regulation in nursing, development and routine monitoring of nurse process measures has fallen into the “too hard to do” domain. While these tools may result in more complete documentation, they also may increase documentation burden (Cutugno et al., 2015). Quraishi, J., & Jordan, L. (2014). Bodrock, J. Instead, specific quality measures must be derived from domain and/or problem specific frameworks. (Remember your outcome needs to be measurable, so you need to provide something to measure against and discuss why it's a problem, such as a delay in care, increased length of stay, decreased nursing satisfaction, etc. Notice how they’re formatted/written. doi:10.1186/1472-6955-12-7. Examples of Goals and Aims from Precise Proposals [Examples and full proposals are made accessible by 4Good, a collaborative on-line useful resource SMART objective setting is a software utilized by small companies to transcend the realm of fuzzy goal-setting into an actionable plan for outcomes. Standards for scientific acceptability relate to the reliability and validity of measures and the strength of evidence linking measures to quality. Measures that are too burdensome and costly are less likely to be adopted for quality assessment. The intervention of surveillance also may require communication with other providers to initiate action that falls outside a nurse’s independent scope of practice. The current state of nursing performance measurement, public reporting, and value-based purchasing. The American Recovery and Reinvestment Act of 2009 provided incentives for healthcare organizations to invest in electronic health records (McCulloch & Tegethoff, 2013). Hobbs, J. Nursing-sensitive indicators: A concept analysis. Consequently, organizations that fail to meet established performance targets incur penalties and lose revenue (Hines & Yu, 2009). Measuring the effectiveness of school nursing interventions: A review of outcome tools. Computers, Informatics, Nursing, 30(5), 237-241. doi:10.1097/NXN.0b013e31824b29a8. Direct method used: Standardized Exams Learning Outcome (knowledge based): Students will demonstrate mastery of basic principles of gross and microscopic anatomy, Citation: Jones, T., (May 31, 2016) "Outcome Measurement in Nursing: Imperatives, Ideals, History, and Challenges" OJIN: The Online Journal of Issues in Nursing Vol. Evidence suggests that direct care nurses are skeptical about whether or not expanded VBP policies will ultimately improve quality and safety for patients, but they are confident that an expansion of quality targets will increase their documentation burden (Kurtzman et al., 2011). (Ed.). Electronic documentation systems have not reduced the documentation burden for nurses. The selection of quality measures sets is guided by conceptual models of quality, scientific standards, and the pragmatics of data collection. Nursing–Sensitive Indicators included in Major Nursing Databases, Catheter Associated Urinary Tract Infection, Central Line Associated Blood Stream Infection, Patient Satisfaction with Discharge Planning, Patient Satisfaction with Pain Management, a=National Database of Nursing Quality Indicators (Montalvo, 2007) International Journal of Nursing Studies, 52(6), 1121-1137. doi:10.1016/jijnstu.2015.02.012. Therefore, surveillance cannot be conceived or measured as a discrete intervention (e.g. Due to the paucity of available clinical data at that time, the UHDDS was based on administrative data collected primarily for billing purposes. His now-famous quote about making quality improvement measureable says, Some is not a number; soon is not a time. Limited Range of Patient Outcome Measures. Costs. Behavior Change Outcome Objectives Step 4.2: Write specific, measurable objectives for each intervention activity. Goals are general, broad, often abstract statements of desired results. Substance Use Disorders and Related Concerns, The 200th Birthday of Florence Nightingale, Addressing Social Determinants of Health: Progress and Opportunities, Translational Research: From Knowledge to Practice, Kavanagh, Comiotti, Abusalem, & Coty, 2012, Klieb, Sales, Doran, Mallette, & White, 2011, Patrician, Loan, McCarthy, Brosch, & Davey, 2010, Kane, Shamliyan, Mueller, Duval, & Wilt, 2007, Cutugno, Hozak, Fitzsimmons, & Ertogan, 2015, Martinez, Battaglis, Start, Mastal, & Matlock, 2015, Association of Women’s Health, Obstetric and Neonatal Nurses [AWHONN], 2014,,, officeofnursingservices-ons_annual_report_2009-web.pdf, Information and Communication Technology: Design, Delivery, and Outcomes from a Nursing Informatics Boot Camp, A Case Review: Integrating Lewin’s Theory with Lean’s System Approach for Change, Potential of Virtual Worlds for Nursing Care: Lessons and Outcomes, A National Comparison of Rural/Urban Pressure Ulcer and Fall Rates, Multigenerational Challenges: Team-Building for Positive Clinical Workforce Outcomes, Why Causal Inference Matters to Nurses: The Case of Nurse Staffing and Patient Outcomes. 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