Essential Concepts for Staff Nurses:
The Outcomes Imperative
*Denise M. Korniewicz DNSc., RN, FAAN
and
**Joanne Duffy DNSc., RN, CCRN
*Denise M. Korniewicz DNSc., RN, FAAN
President
AdviSolutions
1569 Redhaven Drive
Severn, Md. 21144-1032
Phone: 410-551-1131 or 410-706-7250
Fax: 410-706-0344 Email: dkornie@comcast.net
Website: www.@advisolutions.com
Joanne R. Duffy DNSc., RN, CCRN
Associate Professor
The Catholic University of America
Washington, DC 20064
Phone: 202-319-6466
Email: duffy@cua.edu
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Table of Contents
Abstract
Objectives
Introduction
Historical perspectives
Defining quality in nursing care
New science of outcome measurement
Risk adjustment
Risk stratification
Evidence Based Practice and Patient Safety
Defining and measuring nursing outcomes
Abstract
This module is designed to help staff nurses begin to pursue more knowledge about the outcomes
movement. The historical foundation of quality improvement in healthcare, definitions of quality
and models of quality are presented. The science of measuring nursing outcomes is reviewed
including risk adjustment and risk stratification. Recent research related to evidence-based
practice and patient safety is included. Specific outcome indicators and their importance to
healthcare are discussed. Additional links to websites are identified for use as a guide for
additional references.
Objectives
At the end of this article, the nurse will be able to:
1.
2.
3.
4.
5.
Describe the outcomes imperative.
Define quality nursing.
Differentiate the different models of quality.
Explain risk adjustment and risk stratification.
Evaluate clinical indicators research associated with evidence-based practice.
Introduction
The changes in the delivery of health care services have shifted from a process oriented
system to an outcomes and performance based system. These changes have been endorsed by
the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the National
Committee on Quality Assurance (NCQA) and the Center for Medicare and Medicaid Services
2
(CMS) as ways to measure quality health care 1. Increased consumer awareness, cost of health
care and increased health care competition has resulted in the need for all health professionals to
define, quantify, and objectively evaluate how their work influences a patient’s health status.
Moreover, the need to determine work practices, numbers of health care providers available and
policies associated with quality patient care continue to be of concern 2. Now more than ever
before, nurses need to document how nursing care influences their patients’ health status, quality
of life, health knowledge and ability to continue activities that maintain their independence.
Factors that have fueled the new science of outcome measurement have included the
diversity of medical treatment from one region to another, the frequency of surgical procedures
and the competency of health care providers3. Consumers have questioned the variety of care
available, the inconsistency in which it is delivered and its impact on safety. One response to the
consumer’s concerns about the delivery of health care services has been a trend to determine the
most appropriate and cost-effective treatment available. To date, much of the data available
includes monitoring patient outcomes based on the medical model of care and treatment
strategies consistent with effective medical care. The effects of many nursing interventions have
not been studied and often nursing interventions have not been quantified or linked to patient
outcomes 4.
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Historical Overview
Historically, Florence Nightingale was the first nurse to measure nursing outcomes by simply
documenting that wherever nurses were, far fewer patients died, and wherever they were not, far
more died. In fact, the first database in nursing outcomes was demonstrated by Nightingale in
1854 when she illustrated that hospital death rates were reduced from 42% to 2.2% within six
months when nursing interventions (cleanliness, wound dressing changes, bathing) were
performed 5.
In 1910, a group of British surgeons formed the American Colleges of Surgeons and
collected national data related to surgical mortality 6. Eventually, this group established the Joint
Commission for Accreditation of Hospitals (JCAH) and described quality of health care as the
absence of defects. JCAHO, as it is now called, became known as the official accreditation body
that defined a minimum standard for patient care while mandating hospitals to comply 7. During
the sixties (1960-1970) quality was related to good care and measured subjectively by what
patients reported as a result of medical care provided. However, during the seventies, healthcare
providers were held accountable for a variety of structure and process standards such as numbers
of environmental hazards, amount of care that nurses provided and documentation of patient
nurse ratios, as well as general patient statistics related to mortality and morbidity. It was not until
the mid-eighties, when the Health Care Financing Administration (HCFA) (now CMS) began to
release mortality data on Medicare patients that quality was associated with the cost of healthcare
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. However, evaluation of effective health care continued to be linked with structure and process
standards versus patient care outcome indicators.
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During the nineties JCAHO expanded its mission which became known as the health care
agenda for change and required reporting of healthcare outcome indicators such as infection
control rates, surgical outcome data and medical treatment options that related to the overall
health status of patients. Today, these outcome indicators are correlated with the number of
readmission rates and adverse events resulting from hospitalization and their impact on the
overall cost of hospital care. Research related to patient care outcomes continues to be evaluated
and correlated with access to healthcare, type of care rendered (medical versus surgical), provider
(traditional versus alternative approach), and number of services needed (nursing, occupational or
physical therapy, social work) 9-11. Therefore, measuring the quality of healthcare continues to be
redefined and expanded to include patient care outcome indicators that can be easily defined and
readily computed.
Defining Quality in Nursing Care
Although quality health care is associated with the absence of negative outcomes in
patients, quality itself cannot always be assured. However, methods to assess or improve patient
care can be measured. Although many health care institutions have embraced quality
improvement models to provide effective care, few have developed nursing specific quality
measures that encompass how nursing care can influence the overall health outcomes of the
patient. Recently, the nursing profession has been pressured to demonstrate its contributions to
patient outcomes and to provide evidence of nursing sensitive indicators that directly or indirectly
measure the quality of nursing care.
Nursing outcomes may be considered the end product of care: the direct result of a
nursing action or intervention. Nursing is increasingly concerned with assisting patients to define
and achieve the end product for themselves. For nursing outcomes to be relevant and
meaningful, the patient’s perspective and participation have to be central features. Quality of
nursing care may be influenced by the nurse-patient relationship, the patient’s active participation
in decisions about their care and public awareness of nursing care. Other factors that can link
quality of nursing care may be associated with the nurse’s role, such as patient advocate,
mediator, guide, or coordinator of care 12,13.
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Most nursing interventions for conditions such as pain, symptom management, self-care,
or activities of daily living can generate specific nursing outcomes that enumerate patients’
responses to their care. For example, data generated from staff nurses caring for patients with
pain would include a patient’s self-reported pain level or score, percent of body affected and
length of the pain episodes. The quality of nursing care would be correlated with the patient’s
response to symptom control and resolution of the problem. Therefore, nursing care no longer is
processed based (documenting that the pain medication was given), but rather it is based on
nursing outcome data that is evidenced by patient response to the nursing action.
Models to evaluate quality. The evaluation and management of quality healthcare has
shifted from structures and processes to outcomes. One of the first models to evaluate healthcare
quality was developed by Donabedian 14 and included the elements of: structure, process and
outcomes (figure 1). Lohr15 defined outcomes as the 5D’s: death, disease, disability, discomfort,
and dissatisfaction. What these initial models lacked was the role of nursing and how nurses
influenced patient care. Irvine16 developed the nursing role effectiveness model, which
encompassed Donabedian’s work (structure, process, outcome) and emphasized the individual
nurse, the healthcare organization, patient centered outcomes or how nursing actions influenced
the patient.
Duffy’s 17 “Quality – Caring Model” incorporates aspects of Donabedian, Irvine, and Watson’s work
with special emphasis on nursing’s unique role for improving patient outcomes (Figures 2).
During the decade of the nineties, various nursing interventions, health care systems, and
outcomes management approaches were adopted as methods for which healthcare was
delivered. Little research, however, has demonstrated evidence of their effectiveness. Recently,
more positive approaches to measuring health care outcomes, such as functional status or quality
of life, have been used to evaluate a patient’s improvement. The ability to evaluate the quality of
care has shifted from structures (having the right things) to processes (doing the right things) to
outcomes (having the right things happen)18.. One result of this effort has been the development of
the American Nurses Association (ANA) National Database for Nursing Quality Indicators
(NDNQI). These acute care quality indicators include specific measures to obtain data about
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nosocomial infection rates, patient injury rates, nursing care, pain management, pressure ulcers
and patient satisfaction during hospitalization. Additional community quality indicators have been
developed to include smoking cessation, therapeutic alliances and functional status 19.
The Science of Outcomes Measurement
Currently, the practice of healthcare remains wrought with variation and continuous
change. Changes in health policy related to reimbursement, organizational and structural change
and nursing manpower issues impact on the way data are collected, summarized, and reported.
Neither structure nor process variables have shown consistent relationships to patient outcomes
when examined alone. During the last fifteen years, health service researchers have
demonstrated that quality can be measured. However, without accounting for patient
characteristics that influence outcomes of interest, the results are not considered credible.
Therefore, the new science of outcomes measurement requires nursing sensitive measures,
appropriate risk adjustment for nursing quality indicators, data collection methods that are
accurate and readily available, and data sets that are easily suitable for the healthcare
organization.
Two examples noted in the literature have been age 20 and its association with the
number of patient falls, and gender and its association with coronary artery disease21. Other
variables that may influence measuring health outcomes include genetics, demographic
characteristics (race, socioeconomic status, marital status, religion,health beliefs), co-morbid
conditions, and overall health status prior to an illness episode. These are important variables
that need to be considered when analyzing risk categories for a given patient population.
Risk adjustment. The term risk adjustment simply refers to comparing like things for a
defined patient population. It can also be defined as the probability of a selected outcome while
controlling for a predetermined set of risk factors. Risk factors, such as demographics, medical
diagnosis, and scores related to the severity of a patient’s illness or to physiological variables
within a given patient population are examples of risk adjustment variables. Typically, these
variables are correlated with the outcome indicator of interest in a sophisticated regression model
that demonstrates how much variance is explained by the set of risk factors. Many such models
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have been published in the medical literature and are used in ongoing research. There are a
variety of outcome data-based software programs that are risk adjusted and used within the health
care system that classify patient populations and predict mortality, morbidity, length of stay and
costs. One example of a risk adjustment database used to determine medical cost is the
International Classification of Disease (ICD) codes 22, which are not costly and can be readily
abstracted from hospital data records. A more clinically relevant medical risk adjustment model
would be the Acute Physiological and Chronic Health Evaluation (APACHE) 23 system that
records data based on the physiological indicators of a patient=s response to medical care. Lastly,
the Computerized Severity Index (CSI) 24
AND
the Medis Groups 25 are risk adjustment models
that classify patients according to their overall need for medical care.
Although risk adjustment models for medical care are available, little if any of the models
incorporate the effectiveness of nursing care. For example, none of the risk adjustment models
include data about how nursing interventions impact on medical treatment or how nurses
intervene to enhance patient care. Other variables such as physical functional status,
psychosocial factors, culture and co-morbid factors should be considered when risk adjusting and
when determining overall patient outcomes. The role of pre-determined risk factors such as age,
gender and cognitive functioning needs to be considered since these factors contribute to the
overall health of a population and may affect the predicted outcome of a patient. However, many
of the risk adjustment models that are used in health care systems today are concerned with
selected demographics, medical diagnosis and physiological variables versus variables that may
predict quality and effectiveness of nursing care.
Risk stratification. The term risk stratification refers to grouping patient outcomes indicators
according to the factors that are known to influence the risk of a given population. Since nursingsensitive risk adjustment models are limited, one way to report nursing sensitive outcomes with
some credibility is to group them according to risk categories. For example, pressure ulcer data
could be grouped according to age categories, while nosocomial infection rates could be grouped
according to diagnoses or treatment settings. Such categorization provides a means of
representing outcomes data that takes pertinent risk factors into consideration.
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Attempts to assess outcomes of patient care associated with nursing activities among
high risk patient populations have not been clearly evaluated, nor are there measurable data to
demonstrate the effect of the role of the nurse on patients. Evidence-based practice linkages
between the role of nurses, their actions with the patient and documentation related to patient
response must be provided to determine the impact nursing has on the overall health status of a
patient population. Therefore, risk adjustment models and risk stratification techniques need to
address not only medical care results, but also nursing interventions that assist in the overall
treatment plan for a patient population.
Evidence-Based Practice and Patient Safety
The way nurses work together with other members of the health care team may indirectly
influence patient care. Sherwood 26 found that how health care teams (nurses, physicians and
other technical support members) worked together, communicated and organized their work
environment influenced patient safety outcomes related to medication errors and patient injuries.
Aiken, Clarke, Sloane, Sochalski et al. 27 noted that when hospital administrators provided
training, quality assurance programs, and continuing education programs, nurses were less likely
to injure patients and provided safer comprehensive care. Therefore, the work environment, as
well as the ability of the health care team to effectively work together, indirectly impacts on the
safety of patients.
Most recently, Aiken 27 demonstrated that poor nurse staffing based on the number of
nurses available to provide patient care, was directly linked to patient mortality. Furthermore,
Needleman, Buerhaus, Mattke, Stewart et al. 28 have shown that when nurses have more patients
to care for, the patients experience more adverse medical complications such as urinary tract
infections, pneumonia, shock, and increased gastrointestinal bleeding resulting in increased
hospital stays. The medical complications cited can be directly linked to nursing actions and
interventions associated with the prevention of patient complications. This example demonstrates
the use of clinical data by linking the data to nursing functions associated with evidence based
nursing practice. Using quality indicators will help clinical practice nurses continue to measure the
actions associated with quality nursing care and directly impact on the patient’s safety.
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It is important to assure that there is an ongoing monitoring system to track core patient
indicators which is based on identified patient outcomes within an institution. Nursing care can be
directly or indirectly measured when data are routinely collected and made available to staff. It is
important to provide feedback to all nursing staff, so that quality patient care can be monitored,
improved and safely provided. Other examples of initiatives associated with evidence-based
practice models that effect the overall safety of patients include: monitoring of vital signs for early
detection of sepsis; prevention of self-extubation; use of pre-connected urinary catheters to
decrease urinary tract infections; prevention of deep vein thrombosis by monitoring ambulation;
and providing time for institutional quality improvement teams to meet.
Defining & Measuring Nursing Outcomes
The purpose of outcomes research is to evaluate: the quality of care for health conditions
and diagnoses of enrolled populations and the performance of health plans in meeting patient
needs while determining accountability.
McCormick 29 has defined health outcomes within three
domains: 1) effective clinical interventions used to prevent, diagnose, treat and manage clinical
conditions; 2) methods and data to advance the clinical application of outcomes; and 3) evaluation
of the impact of clinical outcomes on patient populations. The use of clinical practice guidelines
grounded in research, in addition to the use of appropriate diagnostic treatment regimens can
improve the quality of patient care without increasing the cost of care30.
Measuring nursing outcomes to determine if nursing care makes a difference (what the
nurse does for the patient, with predicted health outcomes that result from specified nursing
interventions) requires a new set of clinical skills. Nurses need to demonstrate the value of
nursing care in terms of improved outcomes linked to nursing activities and interventions by
evaluating the rate of improvement in a patient’s health status (functional status/self-care,
psychological adjustment and involvement with managing their health) within the health care
system. Examples of nursing sensitive outcome measures as defined by the ANA31 for acute
care settings include: nosocomial infection rates; patient injury rates from falls; patient satisfaction
with nursing care; pain management; educational information; nursing job satisfaction;
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maintenance of skin integrity; and staff mix (RNs, LPNs, technicians). These nursing quality
indicators are defined in operational terms to specifically measure nursing actions (Table 1).
Much work needs to be done to adequately address the contributions of nursing care on
the overall status of patient outcomes. Currently, the science of nursing outcomes has
progressed from structure and process models to outcomes-based models. Specifically, nursing
needs to: 1) establish the difference nurses make in patient care versus other health
professionals, 2) provide data related to specific interventions such as pain control, patient safety,
or decrease in adverse events (wound care, decubitus ulcers), and 3) determine nursing’s impact
on the continuum of care or management of a defined patient population. Outcomes based on the
results of nursing care will increase professional accountability, decrease adverse patient events,
provide changes related to nursing interventions and, over time, revamp the practice of
healthcare. The ANA’s Code for Nurses and Interpretative Statements actually benefits patients
and families and is considered the hallmark of current professional nursing practice. Therefore, it
is important for staff nurses and consumers of health care to be aware of the trends associated
with evidence- based clinical outcomes and become familiar with requirements mandated by
accreditating agencies.
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References
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American Journal of Nursing, 99(9), 40-46.
2. Donaldson, N.E., Brown, D.S. & Aydin, B. (Feb.2001). Nurse staffing in California
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4. Micek, W., Berry, L.,Gilski, D., Kallenbach, A., et al. (1998). Patient outcomes: the link
between nursing diagnosis and interventions. JONA, 26 (11): 29-35.
5. Nightingale, F. (1858). Notes on matters affecting the health, efficiency, and hospital
administration of the British army. London: Harrison and Sons.
6. Donabedian, A. (1988). Quality assessment and assurance: unity of purpose, diversity of
means. Inquiry, 25, 173-192.
7. Joint Commission on Accreditation of Healthcare Organizations. ORYX: the next
evolution in accreditation. Available from: URL:
http://www.jcaho.org/perfmeas/oryx_qa.html.
8. McCormick, K. (1998). New tools-new models to integrate outcomes into quality
measurement. Seminars for Nurse Managers, 6 (3): 119-125.
9. Duffy, J.R. (Mar 2002). The clinical leadership role of the CNS in the identification of
nursing-sensitive and multidisciplinary quality indicator sets. Clin Nurse Spec,16 (2): 708.
10. Hilton, B.A., Budgen, C., Molzahn, A.E. & Attridge, C.B. (Sept-Oct. 2001). Developing and
testing instruments to measure client outcomes at the Comox Valley Nursing Center. Public
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11. Kaufman, M.W. (June 2001). The WOC nurse: economic, quality of life, and legal
benefits….reprinted with permission from Nursing Economics 18(6), 298-303. Dermatol
Nurs (June 2001),13(3): 215-9, 222.
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12. Santy, J. (Feb. 2001). An investigation of the reality of nursing work with orthopaedic
patients. J Orthop Nurs, 5 (1): 22-9.
13. Allen, G. (May 2000). Maximizing nurse’s advocacy role to improve patient outcomes.
AORN J, 71 (5): 1038-43.
14. Donabedian, A. (1966). Evaluating the quality of medical care. Milbank Memorial Fund
Quarterly, 44(part2), 166-206.
15. Lohr, K.N. (1988). Outcomes measures: concepts and questions. Inquiry, 25 (1), 37-50.
16. Irvine, D.M., Sidani, S. & McGillis, Hall L. (1998). Linking outcomes to nurse’s roles in
health care. Nursing Economics, 16 (21), 58-64.
17. Duffy, J. & Hoskins, L. (2003). The Quality-Caring Model: blending dual paradigms.
Advances in Nursing Science, 26 (1), 77-88.
18. Donabedian, A. (1966). Evaluating the quality of medical care. Milbank Memorial Fund
Quarterly, 44(part2), 166-206.
19. American Nurses Association. (1995). Nursing care report card for acute care.
Washington, DC: American Nurses Association.
20. US Dept. of Health and Human Services. (1991).Aging America: Trends and projections.
Washington, DC: US Dept of Health and Human Services.
21. Dunbar, S.B., & Dracup, K. (1996). Agency for health care policy and research: clinical
practice guidelines for heart failure. J Cardiovasc Nurs 10:78-81.
22. Aday, L.A., Begley, C.E., Lairson, D.R., & Slater, C.H. (1993). Evaluating the medical
system: effectiveness, efficiency and equity. Ann Arbor, MI: Health Administration Press.
23. Knaus, W., Draper, E.,& Wagner, D. (1985). APACHEII: a severity of disease
classification system. Crit Car Med.13:818-829.
24. Horn, S.,& Horn, R. (1986). The computerized severity index: a new tool for case-mix
management. J Med Syst, 10: 73-78.
25. Brewster, A.C., Karlin, B.G., Hyde, L.A., Jacobs, C.M., Bradbury, R.C.& Chae, C.M.
(1985). MEDIGRPS: a clinically based approach to classifying the hospital patients at
admission. Inquiry; 22:377-387.
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26. Sherwood, G., Thomas, E., Bennett, D.S., & Lewis, P. (Dec 2002). A teamwork model to
promote patient safety in critical care. Crit Care Nurs Clin North Am. 14 (4): 333-40.
27. Aiken, L.H., Clarke, S.P., Sloane, D.M., Sochalski, J., & Silber, J.H. (Oct 23-30 2002).
Hospital nurse staffing and patient mortality, nurse burnout, and job satisfaction. JAMA,
288 (16): 1987-93.
28. Needleman, J., Buerhaus, P., Mattke, S., Stewart, M.,& Zelevinsky, K. (May 30, 2002).
Nurse-staffing levels and quality of care in hospitals.
N Engl J Med, 346(22): 1715-22.
29. McCormick, K., Cummings, M. & Kovner, C.(1997).
The role of the agency for health
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30. Better quality can cost less. Interim Report of the National Advisory Council. Rockville,
MD, US, DHHS, PHS, AHCPR, Publication no. 95-R011.
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implications. Washington, DC: American Nurses Publishing adapted from: Duffy, J. &
Korniewicz, D. (2000). Outcomes measurement using the ANA safety and quality
indicators. URL:http://ana.org.
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Figure 1. Donabedian’s Quality of Medical Care Model
Structure
Process
Outcomes
System characteristics Technical style
Clinical end points
Provider characteristics Interpersonal style
Satisfaction with care
Patient characteristics
Functional status
General well-being
Source: Donabedian, A. (1988).Quality assessment and assurance: unity of purpose, diversity of
means. Inquiry,25:173-192.
15
Figure 2. The Quality-Caring Model
Source: Duffy, J.& Hoskins, L.M. (2003). The Quality-Caring Model: Blending Dual Paradigms.
Advances in Nursing Science, 26(1), 81.
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Table 1. ANA Nursing Quality Indicators and their Operational Definitions *
Nosocomial Infection Rate: The rate per 1000 patient acute care days at which patients develop
clinically active bacteremia (as defined by CDC) in whom there is no evidence to suggest that
infection was present or incubating at admission (using CDC differential criteria).
Patient Injury Rate: The rate at which patients fall and incur physical injury (unrelated to a surgical
or diagnostic procedure) during the course of their hospital stay per 1000 patient days.
Patient Satisfaction with Nursing Care: 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 key elements of nursing care services.
Patient Satisfaction with Pain Management: 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.
Patient Satisfaction with Educational Information: Patient opinion of nursing staff efforts to
educate them regarding their condition 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.
Patient Satisfaction with Care: 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.
Nursing Job Satisfaction: 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.
Maintenance of Skin Integrity: Rate per 1000 patient days at which patients develop pressure
ulcers (Grade II or greater) during the course of their hospital stay, but, 72 hours or more following
their admission.
Mix of RNs, LPNs, Unlicensed Staff Caring for Patients in Acute Care Settings: The ratios
(expressed in FTEs) of registered nurses with direct patient care responsibilities to LPNs and
unlicensed workers.
Total Nursing Care Hours Provided per Patient Day: Total number of hours worked by nursing
staff with direct patient care responsibilities on acute care units per patient day.
•
American Nurses Association. (1996). Nursing quality indicators: Definitions and
implications. Washington, DC: American Nurses Publishing.
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List of useful websites for more information on Quality / Outcome Measures:
http://www.indmedica.com/hospad/hindex1.cfm?haid=73 (J Acad Hosp Adm article)
http://www.rand.org/cgi-bin/health/lookup.pl (Rand health abstracts, bibliography)
http://www.ahqa.org/pub/media/159_678_3276.CFM (American Health Quality Association
website)
http://www.nih.gov/ninr/news-info/pubs/porcontents.htm (Ninr website that has historical overview
of papers presented related to patient outcomes research)
http://www.mriresearch.org/Markets/Health/Health_Serv/nursing.htm (Midwest research institute
gives information about the ANA National Database of Nursing Quality Indicators)
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