ANA Indicator History

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BACKGROUND

Rapid and dynamic changes in health care delivery and policy environments have placed the issues of patient safety and quality of care at the center of health care and the nursing profession. The ongoing restructuring of the health care system has resulted in a greater emphasis on cost-cutting measures, leading to a reduction in the numbers of registered nurses (RNs) who provide direct patient care. Concurrently, RNs have been replaced with unlicensed personnel during this restructuring and downsizing. In addition, changes in health care reimbursement have led to decreasing lengths of hospital stays, which means that only the acutely ill are treated as inpatients. Thus, the need for nursing care of hospitalized patients has escalated with the decreasing lengths of stay. With fewer RNs and lesser skilled personnel caring for sicker patients, patient care can be jeopardized, a cause for great concern by RNs, patients and their families.

In March of 1994, the American Nurses Association (ANA) Board of Directors launched a major multi-phase initiative to investigate the impact of health care restructuring on the safety and quality of patient care as well as on nursing. Through Nursing's Safety & Quality Initiative, ANA highlights the strong linkages between nursing actions and patient outcomes.

The Safety & Quality Initiative has focused on educating RNs about quality measurement, informing the public and purchasing/regulating constituencies about safe, quality health care, and investigating research methods and data sources to empirically evaluate the safety and quality of patient care. Some of these efforts include:

  • Principles for Nurse Staffing (1999, See Below)
  • Implementing Nursing's Report Card: A Study of RN Staffing, Length of Stay, and Patient Outcomes (March 1997)
  • Nursing Quality Indicators: Definitions and Implications (June 1996)
  • Nursing Quality Indicators: Guide for Implementation (June 1996)
  • Nursing Care Report Card for Acute Care (March 1995)
  • Continuing education programs on Nursing Quality Outcomes provided by State Nurses Associations (SNAs) and ANA
  • Nursing Quality Report Card Request for Data Collection Planning Proposals to financially support the implementation of pilot studies in a sample of hospitals
  • National Database of Nursing-Sensitive Quality Indicators
  • Continual lobbying by ANA and the SNAs for federal and state legislation requiring the collection, dissemination, and publication of hospital data. Some SNAs have been successful in passing state legislation to protect nurses who speak out about unsafe care. Ongoing efforts are underway to have similar legislation passed nationwide.
  • ANA remains at the forefront of the movement to free nurses to speak out on behalf of those for whom they care through the introduction of federal whistle blower protection and patient safety legislation.
  • Development of community indicators to monitor the quality of patient care delivered outside of the acute care hospital setting.

All of these projects contribute to the profession's efforts to focus the nation's attention on the most critical issues in health care — the safety and quality of patient care and the measurement of outcomes of care.

ISSUES OF CONCERN

  • Large gaps exist between the care people should receive and the care they do receive according to a Rand Corporation survey. These gaps are present in different types of health care facilities and in different types of health insurance, for all age groups, throughout the entire country.
  • More and more Americans are concerned about shrinking health care benefits and spiraling insurance premiums.
  • More and more individuals do not have health care benefits at all. By 2002, 45.6 million Americans are expected to be without health insurance, according to the American Hospital Association.
  • Americans are worried about many of the changes in our health care delivery system and how they affect the quality of patient care, according to a 1996 survey commissioned by ANA. Three-quarters of the adults polled indicated serious concern that the quality of patient care is being diminished by some cost-cutting practices — a concern that has increased significantly since 1994 (Princeton Survey Research Associates, 1996). Concerns
  • Insurers and managed care organizations are ratcheting down reimbursement rates and reducing the number of services covered.
  • Hospitals are reacting to cost pressures by looking at the cost of labor, in particular that of RNs, as the primary target area for cutbacks in an effort to streamline expenses and remain competitive.
  • Patients are ultimately paying the price for decisions made by hospital administrators and management consultants (in the absence of any clinical research to evaluate appropriateness) concerning cutbacks in patient care in an attempt to "save" money.
  • Under plans to "save" money, hospitals have substituted minimally trained, unlicensed assistive personnel for RNs. RNs report that hospitals are asking these unlicensed workers to provide direct patient care, such as inserting urinary catheters, starting IVs, and, in some cases, even performing complex, high-risk procedures, such as changing sterile dressings and stapling head wounds.
  • Short-term financial gains may be achieved, but long-term savings are far from a reality. These short-sighted decisions will eventually play out in increased costs as a result of increased complications, increased readmissions, increased lengths of stay, increased legal liability, and increased mortality rates and overall human suffering.
HOW DOES THE COLLECTION OF DATA ADDRESS THESE CONCERNS?

Preliminary studies comparing staffing information and information on patient outcomes show that when there are more registered nurses, patients experience fewer complications, shorter lengths of stay, decreased mortality rates, and even lower overall costs. However, a critical need remains for more definitive data to show the clear linkages between nursing interventions, staffing levels, and positive patient outcomes. A 1997 ANA pilot study, described below, is one effort demonstrating this linkage with statistically significant results.

Implementing Nursing's Report Card: A Study of RN Staffing Length of Stay and Patient Outcomes was based on the analyses of data collected by state agencies in 1992 and 1994 from 502 hospitals in California, Massachusetts, and New York. The purpose of the study was to quantify nurse staffing, patient incidents, and lengths of stay at the hospitals, as well as the relationship between these variables, with the aim of

  1. statistically testing the relationships between nurse staffing and specific patient outcome indicators and
  2. assessing the feasibility of capturing the information necessary to develop specific nurse staffing and outcome measures for hospitals with acceptable degrees of reliability and validity.

The study found that shorter lengths of stay are strongly related to higher RN staffing per acuity-adjusted day (a statistical adjustment to data based upon the patient's needs for nursing care) and that patient morbidity indicators for preventable conditions-such as pressure ulcers, pneumonia, postoperative infections, and urinary tract infections-are inversely related to RN skill mix. In other words, the more RNs' taking care of patients, the fewer preventable conditions those patients will experience.

Another study conducted by Blegen, et al., found that a higher proportion of RNs was directly related to lower incidences of negative patient outcomes, such as medication errors, pressure ulcers, and complaints by patients and families. While some health care facilities have already noted this phenomenon and are rearranging their staffing to better meet patient care needs, more facilities need to become aware of such research and should collect such data at their facilities. SOLUTIONS

  • Nurses are insisting that an appropriate number and mix of nursing personnel (RNs, LPNs, and Unlicensed Staff) be used to deliver safe, cost-effective quality care.
  • Nursing needs to continue to implement research projects that will collect data to establish the relationship between the right mix of licensed and unlicensed staff and positive patient outcomes in an effort to lobby more effectively for change.
  • Nursing's Safety & Quality Initiative provides a framework for educating nurses, consumers, and policy makers about nursing's contributions to safe, quality health care, and the application of the Nursing Care Report Card for Acute Care.
WHAT ARE NURSING-SENSITIVE QUALITY INDICATORS?

Nursing-Sensitive Quality Indicators are those indicators that capture care or its outcomes most affected by nursing care.

As the SNAs have compiled data during their research on nursing-sensitive quality indicators, the indicators have been amplified from the original seven conceptualized in 1995. As more research is gathered and the indicators continue to be tested, additional alterations may occur.

CMAs Funded for Data Collection
  • ANA\California
  • Arizona Nurses Association
  • Minnesota Nurses Association
  • North Dakota Nurses Association
  • Ohio Nurses Association
  • Texas Nurses Association
  • Virginia Nurses Association
  • To date, the following represent the CMAs' findings and make up the 10 Nursing-Sensitive Quality Indicators for Acute Care Settings:

    • Mix of RNs, LPNs, and Unlicensed Staff Caring for Patients in Acute Care Settings
      Recommended Definition: the percent of registered nursing care hours as a total of all nursing care hours. This measure would include only those staff on acute care units. A secondary measure would be the percent of RN contracted hours of total nursing care hours.

    • Total Nursing Care Hours Provided per Patient Day
      Recommended Definition: total number of productive hours worked by nursing staff with direct patient care responsibilities on acute care units per patient day. Secondary measures would be RN contracted hours, total contracted hours, RN nursing care hours per 1,000 patient days.

    • Pressure Ulcers
      Recommended Definition: this measure would be defined and calculated as:

      Total Number of Patients with NPUAP-AHCPR Stage I, II, III, or IV Ulcers
      Number of Patients in a Prevalence Study

      A secondary measure should explore the relationship between nursing assessments using a standardized tool and the development of pressure ulcers. The secondary measure would be collected on a "look-back" basis by auditing the charts of patients. Use of the Braden or Norton scales is required. (These can be obtained at a local health services library.)

    • Patient Falls
      Recommended Definition: the rate per 1,000 patient days at which patients experience an unplanned descent to the floor during the course of their hospital stay. The measure would be computed as:

      Total Number of Patient Falls Leading to Injury
      Total Number of Patient Days X 1,000

      A secondary measure should explore the relationship between nursing assessments performed and falls. The measure would be defined, for those patients who fell, as the number of patients who had nursing fall assessments as compared to the total number of patients who fell. This secondary measure would be collected on a "look-back" basis by auditing the charts of patients.

    • Patient Satisfaction with Pain Management
      Recommended Definition: patient opinion of how well nursing staff managed their pain as determined by scaled responses to a uniform series of questions designed to elicit patient views regarding specific aspects of pain management. The questions would be administered to a sample of all patients admitted to the hospital for acute care services.

    • Patient Satisfaction with Educational Information — A measure of patient perception of the hospital experience related to satisfaction with patient education.
      Recommended Definition: patient opinion of nursing staff efforts to educate them regarding their conditions and care requirements as determined by scaled responses to a uniform series of questions designed to elicit patient views regarding specific aspects of patient education activities. The questions would be administered to a sample of all patients admitted to the hospital for acute care services.

    • Patient Satisfaction with Overall Care — A measure of patient perception of the hospital experience related to satisfaction with overall care.
      Recommended Definition: patient opinion of the care received during the hospital stay as determined by scaled responses to a uniform series of questions designed to elicit patient views regarding global aspects of care. The questions would be administered to a sample of all patients admitted to the hospital for acute care services.

    • Patient Satisfaction with Nursing Care — A measure of patient perception of the hospital experience related to satisfaction with nursing care.
      Recommended Definition: patient opinion of care received from nursing staff during the hospital stay as determined by scaled responses to a uniform series of questions designed to elicit patient views regarding satisfaction with key elements of nursing care services. The questions would be administered to a sample of all patients admitted to the hospital for acute care services.

    • Nosocomial Infection Rate
      Recommended Definition: this measure would be defined and calculated as:

      Number of Laboratory Confirmed Bacteremia Associated with Sites of Central Lines
      1,000 Patient Days per Unit

      [This indicator is under investigation for its usefulness. For purposes of this effort, infection would be defined according to parameters established by the Centers for Disease Control and Prevention.]

    • Nurse Staff Satisfaction
      Recommended Definition: job satisfaction expressed by nurses working in hospital settings as determined by scaled responses to a uniform series of questions designed to elicit nursing staff attitudes toward specific aspects of their employment situation. The questions would be administered to all RNs in direct patient care or middle management roles at the institution. The six SNAs funded to implement the indicators are using either the Kramer & Schmalenberg or Stamps & Piedmont tools. (These can be obtained at a local health services library.)
    IMPORTANCE OF NURSE-SENSITIVE DATA

    All hospitals collect data, including most of those data listed above, to monitor the ongoing quality of patient care. However, few publicize data for review by others. ANA is proposing, and has been lobbying, that all hospitals collect and report on the 10 nursing-sensitive quality indicators to better demonstrate what nurses have known intuitively for a long time-RNs make the critical, cost-effective difference in providing safe, high-quality patient care.

    While ANA works to ensure that these indicators are included in data collected by the federal government and accrediting organizations and that the data are shared with key groups, ANA is asking all RNs to call for the collection of nursing-sensitive quality indicators in their own facilities.

    For example, ANA is assisting the SNAs to lobby state legislatures for the inclusion of nursing-sensitive quality indicators into regulations or state law.

    The importance of articulating nursing-sensitive quality measures for use in publicly available report cards cannot be overstated. Since RNs are an integral part of our health care delivery system, both in terms of patient contact and hospital spending, they can make a tremendous impact in pushing for data collection.

    In 1998 ANA funded the development of a national database to house nursing-sensitive quality indicators. the database is housed at the Midwest research Institute (MRI) in Kansas City, MO and is jointly managed by MRI and the University of Kansas School of Nursing. The goals of the National Database of Nursing Quality Indicators (NDNQI) are to promote and facilitate the standardization of information submitted by hospitals across the United States on nursing quality and patient outcomes. Data on the 10 Nursing-sensitive Quality Indicators for Acute Care Settings are collected. To date more than 60 hospitals from across the United States are participating in data collection on adult medical-surgical, and critical care populations. Data are reported to the database on a quarterly basis and quarterly feedback reports are provided to the hospitals. the unique features of this database are that nursing-sensitive indicators are collected and reported at the unit level, stratified by type of unit and size of hospital, and confidential benchmarking reports are provided to the participating hospitals. The reports can be used by the hospitals to examine their own process of care with feeback to their nursing care units and support systems and potential relationships to nurse staffing levels. the database is actively recruiting new hospitals. A series of rigorous procedures have been developed to ensure that institutional identity will not be disclosed through data transmission, data storage, or NDNQI reports. For more information on the national database contact the NDNQI Hospital Liasons at (913) 588-1691 or via e-mail: ndnqi@kumc.org.

    Individual Actions — WHAT YOU CAN DO!

    • Ask RNs to become active members of their State Nurses Association (link below) — and work together with other nurses locally, and across the country, fighting for safety and quality of care.
    • Encourage RNs to push for the enactment of federal and state legislation requiring the collection, dissemination, and publication of hospital data and staffing information.
    • Determine which data are collected in your facility, who collects the data, and where the data go once summarized.
    • Advocate for nursing quality indicators to be included in health care facility improvement programs.
    • Demand that the facility data are shared with the public in a meaningful format.
    • Sign up for workshops, sponsored by your State Nurses Association (SNA) and ANA, on nursing-sensitive quality indicators.
    • Inform patients, neighbors, legislators, and your community about the problems that result from inappropriate staffing.
    • Campaign and advocate for standardized state and federal accountability for the safety and quality of care delivered in all acute care settings.
    • Work with your SNA to seek state laws or regulations to ensure safe, quality patient care.

    Call your State Nurses Association for
    more information on how you can protect the safety
    and quality of patient care and preserve nursing practice.

    For more information on quality or a listing of CMAs,
    please call the American Nurses Association at
    1-800-274-4ANA (4262)

    website: www.nursingworld.org

    REFERENCES

    Adams, Robin Williams. (1997, July 13). Unhealthy Trend. The Lakeland Ledger, p. A1

    Aiken, Linda H., Sochalski, Julie, and Anderson, Gerard F. (1996). Downsizing the Hospital Nursing Workforce. Health Affairs: 15(4),88-92.

    Aiken, Linda H., Smith, Herbert L., and Lake, Eileen T. (1994). Lower Medicare Mortality Among a Set of Hospitals Known for Good Nursing Care. Medical Care; 32: 771-787.

    American Nurses Association (1997). Implementing Nursing's Report Card. Washington, DC: ANA.

    American Nurses Association. (1995). Nursing Care Report Card For Acute Care. Washington, DC: ANA.

    American Nurses Association. (1996). Nursing Quality Indicators: Definitions and Implications. Washington, DC: ANA.

    American Nurses Association. (1996). Nursing Quality Indicators: Guide for Implementation. Washington, DC: ANA.

    American Nurses Association (1999). Principles for Nurse Staffing (1999). Washington, DC: ANA.

    Barter, Marjorie, McLaughlin, Frank E., and Thomas, Sue A. (1994). Use of Unlicensed Assistive Personnel by Hospitals. Nursing Economic$: 12 (2), 82-87.

    Blegen, Mary A. and Vaughn, Tom. (1998). A Multisite Study of Nurse Staffing and Patient Occurrences. Nursing Economic$: 16 (4), 196-203.

    Blegen, Mary A., Goode, Colleen J., and Reed, Laura. (1998). Nurse Staffing and Patient Outcomes. Nursing Research: Jan./Feb. 47(1), 43-50.

    Burda, David. (1998, Jan. 12). A Fat Year for Hospitals. Modern Healthcare: 28(2), 2.

    Princeton Survey Research Associates. (1996). Nursing and the Quality of Patient Care 1996 Survey. Princeton, NJ.

    Shindul-Rothschild, Judith. (1996). What's Happening to Patient Care? Final Results of the AJN Survey. American Journal of Nursing; 96; 11: 24-39.


    Single copies of this brochure (item PR-28) are available free to state nurses association members only by calling 1-800-274-4ANA. Ask for item PR-28. Multiple copies of this brochure and information about ordering other ANA publications can be obtained by calling 1-800-637-0323.

    THIS INFORMATION COPYRIGHT 1999 AMERICAN NURSES ASSOCIATION

    The American Nurses Association is the only full-service professional organization representing the nation's 2.2 million Registered Nurses through its 53 constituent associations. ANA advances the nursing profession by fostering high standards of nursing practice, promoting the economic and general welfare of nurses in the workplace, projecting a positive and realistic view of nursing, and by lobbying the Congress and regulatory agencies on health care issues affecting nurses and the public.

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