Quality measures allow hospitals to benchmark performance against peers and provide insurers and consumers with a common metric to evaluate hospital quality. But which types of measures provide the best insight for nurses and other healthcare providers?
Battelle is the Measures Management System contractor. As such, the company manages the Quality Measures Blueprint that recommends quality measure development methods to contractors. Battelle educates developers and other stakeholders on the design and use of measures and maintains the measures library. Most recently CMS selected Battelle to conduct outreach to stakeholders, such as specialty societies and patient advocacy groups to increase their exposure and involvement in quality measure development. This is important for nurses to know, because of the many opportunities this provides for involvement as thought leaders. Nurses can bring a unique and valuable perspective to the design and implementation of quality measures.
BackgroundThe National Quality Forum (NQF) lists more than 1,083 quality measures (653 hold endorsed status) that track hospital and clinician performance on metrics ranging from readmission rates to medication adherence.
The Measures that Matter for NursesOutcome measures provide a high-level look at how hospital performance is changing over time and how the hospital compares to peers. These measures provide information about the end result. To uncover the causes that influence different outcomes, evaluators must also look at structure and process measures.
For nurses, this difference is critical. In an acute care setting, nurses rarely have final, direct control over the total outcome of care. Nurses can however control individual actions taken that influence outcomes such as mortality rates. Did the patient receive all recommended medications on the correct schedule? For surgical patients, did the nurse follow best practices for wound care? Did the nurse remove the urinary catheter as soon as reasonable after surgery? Did the nurse not only provide the right discharge instructions to the patient at the end of the hospital stay, but also ask the patient to repeat those instructions back to ensure understanding? These process measures help to determine the ultimate outcome and are greatly influenced by nurses.
Process measures are most directly tied to the activities of caregiving, and therefore they are highly actionable. Looking at an outcome measure – such as a high rate of mortality following a stent procedure – does not suggest an immediate and direct action that nurses can take to prevent it. But nurses can immediately and effectively address a process measure that shows that recommendations for antiplatelet therapy after a stent implantation are only followed 70 percent. Nurses can use this number as a baseline, develop a method of addressing the issue with the interdisciplinary team and then measure progress towards improved adherence. RN Quality improvement professionals can later assist in the evaluation of unit based quality improvement projects to evaluate whether the improved adherence has had a measurable effect on patient outcomes.
Using Quality Measures to Drive Evidence-Based CareUse of nursing sensitive quality measures can help the industry in its drive towards evidence-based practice and paying for value. Process measures provide evidence to encourage individual clinicians to follow best practices. Structure measures can help hospitals maximize the effectiveness of the systems and facilities that they have in place to provide the best possible care to their patient populations.
As the quality measure movement evolves, measure developers continue to find ways to reduce the administrative burden on caregivers and hospitals. Using electronic clinical quality measures, developers are more closely tying information entered into electronic health records to quality measurement. These efforts can reduce double entry and ensure that entry of measure data fits smoothly into the workflow. Minimizing the total number of measures tracked to only those that truly make a difference could also significantly reduce the burden.
Researchers are working to identify which types of measures provide the best picture of overall quality. We recommend that they consider how measures are used by different members of the healthcare community, from nurses on the front lines of patient care to government agencies making policy decisions. Highly effective use of measures to drive quality improvement requires making sure that users apply the right measures to the correct systems.
About the Author
Dr. Darryl Roberts is a Registered Nurse and a Healthcare Quality Research Leader at Battelle Memorial Institute. He has more than 25 years of experience as a clinician and scientist in psychiatry, neurology, informatics, management, research and education. His recent work includes developing quality measures for SAMHSA’s Zero Suicide project, supporting the quality Measures Management System for CMS, developing economic metrics for public health interventions and developing qualitative research methodologies useful in natural language processing and big data analytics. He has presented and published much of his work at conferences and in scholarly literature.