The clinical nurse leader: helping psychiatric mental health nurses transform their practice

The national movement to transform the health care delivery systems must include a focus on mental health treatment. To address similar deficits across other practice domains, the Clinical Nurse Leader (CNL) role has been created. The CNL is a master's degree that prepares a nurse to use a systems perspective to improve outcomes for a cohort of patient, deliver care based on best practices, and coordinate care in a multidisciplinary team. Applying the CNL role to mental health care could help psychiatric mental health nursing be at the forefront in the transformation of mental health care delivery.     

Part 4: Value-informed nursing practice depends on nursing innovation

With the adoption of value-based payments which tie reimbursement to patient outcomes and costs, days when nursing is viewed primarily as a cost to hospitals will soon be over. Already the backbone of high-quality care delivery and patient outcomes, nurses are becoming key drivers of health care organizations' financial outcomes, too. The first three articles published in this 6-part series on value-informed nursing practice—practice that considers both the outcomes and the cost of producing the outcomes—described what value-informed nursing practice means, its economic, policy, and ethical impetuses, and how value-informed nursing practice helps improve environmental sustainability of health systems. Here, in Part 4, we focus on the importance of nursing innovation in implementing value-informed nursing practice. We begin by discussing how innovation is connected to value and then examine the false dichotomy, perceived by many, between innovation and evidence-based care. Following this, we examine how health care organizations and systems can support nursing innovation, before concluding with recommendations for nursing educators.     

Clinical review: International comparisons in critical care - lessons learned

ABSTRACT: Critical care medicine is a global specialty and epidemiologic research among countries provides important data on availability of critical care resources, best practices, and alternative options for delivery of care. Understanding the diversity across healthcare systems allows us to explore that rich variability and understand better the nature of delivery systems and their impact on outcomes. However, because the delivery of ICU services is complex (for example, interplay of bed availability, cultural norms and population case-mix), the diversity among countries also creates challenges when interpreting and applying data. This complexity has profound influences on reported outcomes, often obscuring true differences. Future research should emphasize determination of resource data worldwide in order to understand current practices in different countries; this will permit rational pandemic and disaster planning, allow comparisons of in-ICU processes of care, and facilitate addition of pre- and post-ICU patient data to better interpret outcomes.     

Improving the quality of care and reducing health care costs through a point-of-service health care information system

Health care information systems will become critical to the success of health care providers. These systems must make the process of health care delivery more effective and more efficient, assisting the provider in improving the quality of care while maximizing cost reduction through more appropriate care and reduction in administrative costs. The system must be able to capture accurate encounter data for outcomes analyses and capable of use by multiple health plans for their unique policies or programs such as disease management. The most effective means of achieving all of the above will be to re-empower the physicians through software placed in a mobile computing environment with full integration among all participants.     

Case management and technology: a necessary fit for the future

We now reside in a data-driven health care environment and methods for gathering, presenting, and evaluating relevant data about health care systems are paramount. This article expands on the importance of evaluating the outcomes of case management and how collecting relevant clinical and cost data can provide an infrastructure on which to base future decisions. Data-based decision making in case management is crucial for ensuring quality of care and the appropriate management of patient outcomes, and it underpins the viability of this delivery model of care.     

Health status of populations as a measure of health system performance

This article describes the assessment of self-reported health status as one indicator of the performance of health care delivery systems. This work took place in the context of a larger effort to measure performance in health care. The Consortium Research on Indicators of System Performance (CRISP) project is developing measures of the performance of integrated health care systems, rather than plans or providers. The system focus leads to measurement of the health status of defined populations and an analysis of health care episodes and processes extending beyond the physician's office or hospital that relate directly to patient outcomes and satisfaction. This focus provides opportunities for application of performance measures to quality improvement efforts, since outcomes can be logically linked to identifiable and measurable processes. After a discussion of the purpose and the history of CRISP and how populations were defined within the systems, some preliminary data on the health status of populations are presented.     

Point-of-care testing: an introduction

OBJECTIVE: To review available literature and provide perspective on point-of-care testing, focusing on the impact it has on treatment outcomes in patient care, the impact it has on the costs of patient care, and the role it has in the delivery of pharmaceutical care. DATA SOURCES: Information was retrieved from MEDLINE English literature searches using PubMed (1965-August 2003) and included search terms of point-of-care testing, near patient testing, pharmaceutical care, pharmacists, outcomes, and economics. Additionally, references from retrieved articles were reviewed to identify literature not detected by literature searches. STUDY SELECTION AND DATA EXTRACTION: Comparative studies, demonstration project reports, and systematic reviews were selected. Other related resources, such as government documents, relevant legislation, and government regulations, were included. Emphasis was placed on comparative studies and demonstration project reports. In the absence of these data, other resources were included. DATA SYNTHESIS: Point-of-care testing devices and technology are increasingly used in the delivery of care and therapeutic decision making. No studies have evaluated the impact of point-of-care testing, by itself, on patient care and outcomes. All studies have incorporated point-of-care testing with changes in the way patient care is delivered and have shown significant improvements when this approach is taken. The cost of point-of-care testing is greater than traditional laboratory testing, but the increased cost may be offset by improvements in the management of patient care, improvements in patient outcomes, and decreased utilization of the healthcare system. Point-of-care testing has been used successfully by pharmacists in disease management programs. Various government regulations and legislation impact the use of point-of-care testing. CONCLUSIONS: Limited data indicate that point-of-care testing, when combined with changes in healthcare delivery systems, may improve patient outcomes and decrease the overall cost of health care. Pharmacists have used point-of-care testing in programs designed to improve patient care but must carefully consider regulations and laws that govern the use of these devices. There is a great need for additional investigation into the use of point-of-care testing in patient care.     

Research Priorities for Administrative Challenges of Integrated Networks of Care

In 2006, the Institute of Medicine (IOM) advanced the concept of “coordinated, regionalized, and accountable emergency care systems” to address significant problems with the delivery of emergency medical care in the United States. Achieving this vision requires the thoughtful implementation of well‐aligned, system‐level structures and processes that enhance access to emergency care and improve patient outcomes at a sustainable cost. Currently, the delivery of emergency medical care is supported by numerous administrative systems, including economic; reimbursement; legal and regulatory structures; licensure, credentialing, and accreditation processes; medicolegal systems; and quality reporting mechanisms. In addition, many regionalized systems may not optimize patient outcomes because of current administrative barriers that make it difficult for providers to deliver the best care. However, certain administrative barriers may also threaten the sustainability of integration efforts or prevent them altogether. This article identifies significant administrative challenges to integrating networks of emergency care in four specific areas: reimbursement, medical–legal, quality reporting mechanisms, and regulatory aspects. The authors propose a research agenda for indentifying optimal approaches that support consistent access to quality emergency care with improved outcomes for patients, at a sustainable cost. Researching administrative challenges will involve careful examination of the numerous natural experiments in the recent past and will be crucial to understand the impact as we embark on a new era of health reform. ACADEMIC EMERGENCY MEDICINE 2010; 17:1330–1336 © 2010 by the Society for Academic Emergency Medicine     

The PRISMA Symposium 3: lessons from beyond Europe. why invest in research and service development in palliative care? An Australian perspective

Hospice and palliative care services need to be able to compete with finite health care resources. To compete for such funding, the sector needs to continuously improve the evidence base that demonstrates improved outcomes, or else funding will continue to be at the level of a "social good" rather than as services that deliver improved health outcomes. Three questions need to be answered for policy makers and health funders: 1) Why invest health care spending in hospice and palliative care?, 2) Why invest research monies in hospice and palliative care clinical research and health service development?, and 3) How can emerging evidence be more effectively implemented to improve patient outcomes? No single measure captures the net benefit of hospice and palliative care services. By patient-defined parameters, hospice and palliative care services have demonstrated benefits, including physical symptom control. To meet patients' concerns, greater emphasis needs to be placed on maintaining physical independence for a longer period of time. Targeted investment of research funding can deliver further improvements in patient outcomes and models of service delivery. Rigorous studies are feasible and necessary if each patient is going to receive the best possible support. Benchmarking and service development strategies can deliver improved patient outcomes. With routine point-of-care data collection and feedback loops to individual services, patient-valued outcomes and resourcing can be improved in hospice and palliative care. Public-good investments in hospice and palliative care research are vital to building the evidence base for improving the quality of care offered.     

Nurses' accountability for stroke quality of care: part one: Review of the literature on nursing-sensitive patient outcomes

Over the past decade, an exciting area of research has emerged that demonstrates strong links between specific nursing care activities and patient outcomes. This body of research has resulted in the identification of a set of "nursing-sensitive outcomes"(NSOs). These NSOs may be interpreted with more meaning when they are linked to evidence-based best practice guidelines, which provide a structured means of ensuring care is consistent among all health care team members, across geographic locations, and across care settings. Uptake of evidence-based best practices at the point of care has been shown to have a measurable positive impact on processes of care and patient outcomes. The purpose of this paper is to present a systematic, narrative review of the literature regarding the clinical effectiveness of nursing management strategies on stroke patient outcomes sensitive to nursing interventions. Subsequent investigation will explore current applications of nursing-sensitive outcomes to patients with stroke, and identify and validate measurable NSOs within stroke care delivery.     

Managed care,medical technology,and the well-being of society

The growth of managed care could have widespread effects on the structure and functioning of the health care delivery system, potentially influencing all patients, even those not enrolled in managed care plans. One important mechanism by which managed care could have such broad effects is by influencing technology development and adoption. This article examines available literature on the effects of managed care activity on technology adoption and the implications of any effects on patient care, outcomes, and health care costs. Existing literature supports the view that managed care has contributed to slowing the adoption of new technologies, particularly the high-cost, high-profile technologies that have been the focus of the most attention. The literature outlining the effects of managed-care-induced changes in technology adoption on patient care and outcomes is not large, but what literature there is tends not to find negative effects on patient care and outcomes. Specific evidence about costs also is somewhat sparse, but it suggests that managed care has contributed to some reduction in health care spending, although the extent to which savings will persist over time is unclear. Although evidence thus far does not suggest important detrimental effects of managed care on care or outcomes and even indicates some benefit through savings, it should be noted that existing literature has only explored a small number of the many technologies and services that might have been influenced, and there remain issues for the future that deserve vigilance.     

Building the Information Infrastructure Required for Managed Care

Purpose: To describe the information used by health care purchasers, policymakers, and administrators when making the decisions required in a managed-care environment and what the profession must do to develop an information infrastructure to demonstrate its contribution to patient outcomes.
Scope: Managed care has created a competitive environment for all health care organizations in which they must offer the best value for their dollar. The purchasing processes germane to managed care rely heavily on information for the selection of cost-effective providers and the provision of efficient care. lnformation used in these processes is derived from transaction systems that largely describe physician and other health care worker's services, but not nursing care. Data analysis by computers requires that data be obtained using a standardized language. Currently, nursing lacks a unified approach to the use of a standardized nursing language.
Conclusions: Individual nurses, nurse managers, executives, and educators should strive to develop an information infrastructure that will overcome barriers. Nurses should both adopt a unified approach to a standardized language, and develop a nationwide information infrastructure that will demonstrate nursing's contribution to patient outcomes.     

The clinical nurse leader: a catalyst for improving quality and patient safety

Aim  The clinical nurse leader (CNL^®) is a new nursing role introduced by the American Association of Colleges of Nursing (AACN). This paper describes its potential impact in practice.
Background  Significant pressures are being placed on health care delivery systems to improve patient care outcomes and lower costs in an environment of diminishing resources.
Method  A naturalistic approach is used to evaluate the impact the CNL has had on outcomes of care. Case studies describe the CNL implementation experiences at three different practice settings within the same geographic region.
Results  Cost savings, including improvement on Centers for Medicare and Medicaid Services (CMS) core measures, are realized quickly in settings where the CNL role has been integrated into the care delivery model.
Conclusions  With the growing calls for improved outcomes and more cost-effective care, the CNL role provides an opportunity for nursing to lead innovation by maximizing health care quality while minimizing costs.
Implications for nursing management  Nursing is in a unique position to address problems that plague the nation's health system. The CNL represents an exciting and promising opportunity for nursing to take a leadership role, in collaboration with multiple practice partners, and implement quality improvement and patient safety initiatives across all health care settings.     

Evaluation of a hospital work redesign: patient-focused care

The 1990s have seen a frenzy of work redesign in acute care hospitals/health systems. Much of the redesign work in acute care hospitals has centered on changing how nurses organize and deliver care to patients. But have we really determined that redesigning nursing care delivery does what we want? The author describes the introduction of patient-focused care at one tertiary care university teaching hospital and answers the following question: Is there a change in provider or patient outcomes when the nursing care delivery system is changed from primary/total patient care to patient-focused care?     

Evidence-based practice, step by step: evaluating and disseminating the impact of an evidence-based intervention: show and tell

This is the 11th article in a series from the Arizona State University College of Nursing and Health Innovation's Center for the Advancement of Evidence-Based Practice. Evidence-based practice (EBP) is a problem-solving approach to the delivery of health care that integrates the best evidence from studies and patient care data with clinician expertise and patient preferences and values. When delivered in a context of caring and in a supportive organizational culture, the highest quality of care and best patient outcomes can be achieved.The purpose of this series has been to give nurses the knowledge and skills they need to implement EBP consistently, one step at a time. The final article in the series will be published in the September issue.     

Epidemiologic trends and costs of fragmentation

The data that were reviewed in this article documented that in health systems, which manage behavioral health disorders independently from general medical disorders, the estimated 10% to 30% of patients with behavioral health service needs can expect (1) poor access or barriers to medical or mental health care; (2) when services are available, most provided will not meet minimum standards for expected outcome change; and (3) as a consequence of (1) and (2), medical and behavioral disorders will be more persistent with increased complications, will be associated with greater disability, and will lead to higher total health care and disability costs than will treatment of patients who do not have behavioral health disorders. This article proposes that these health system deficiencies will persist unless behavioral health services become an integral part of medical care (ie, integrated). By doing so, it creates a win-win situation for virtually all parties involved. Complex patients will receive coordinated general medical and behavioral health care that leads to improved outcomes. Clinicians and the hospitals that support integrated programs will be less encumbered by cross-disciplinary roadblocks as they deliver services that augment patient outcomes. Health plans (insurers) will be able to decrease administrative and claims costs because the complex patients who generate more than 80% of service use will have less complicated claims adjudication and better clinical outcomes. As a result, purchaser premiums, whether government programs, employers, or individuals, will decrease and the impact on national budgets will improve. Ongoing research will be important to assure that application of the best clinical and administrative practices are used to achieve these outcomes.     

Skills integration in a simulated and interprofessional environment: an innovative undergraduate applied health curriculum

The objective of our study was to propose an innovative applied health undergraduate curriculum model that uses simulation and interprofessional education to facilitate students' integration of both technical and "humanistic" core skills. The model incorporates assessment of student readiness for clinical education and readiness for professional practice in a collaborative, team-based, patient-centred environment. Improving the education of health care professionals is a critical contributor to ultimately improving patient care and outcomes. A review of the current models in health sciences education reveals a scarcity of clinical placements, concerns over students' preparedness for clinical education, and profession-specific delivery of health care education which fundamentally lacks collaboration and communication amongst professions. These educational shortcomings ultimately impact the delivery and efficacy of health care. Construct validation of clinical readiness will continue through primary research at The Michener Institute for Applied Health Sciences. As the new educational model is implemented, its impact will be assessed and documented using specific outcomes measurements. Appropriate modifications to the model will be made to ensure improvement and further applicability to an undergraduate medical curriculum.     

The role of public insurance and the public delivery system in improving birth outcomes for low-income pregnant women

BACKGROUND: Insurance expansions and service delivery system expansions are alternative policy instruments used to try to improve birth outcomes for low-income women. OBJECTIVES: The objective of this research is to investigate the effect of expansions of public insurance on access and birth outcomes for pregnant women and the role of different delivery systems in these outcomes. MATERIALS AND METHODS: The experience in Florida during the years 1989-1994 is studied. Data are from linked birth certificates, hospital discharge data, Medicaid eligibility and claims files, and county health department records. Use of prenatal care and birthweight for low-income women is compared under different financing for prenatal care and for those using different delivery systems. Several approaches to control for self-selection are adopted, and similar results are obtained with each. RESULTS: Women enrolled in Medicaid have more prenatal care visits than the uninsured. Outcomes for those on Medicaid and the uninsured are significantly better if they receive care in the public health system than if they receive care in the private system-including private offices, clinics, and HMOs. Over time, the gap in outcomes between those in the public system and those receiving prenatal care from private physicians has diminished. CONCLUSIONS: Public insurance improves access to services, but the delivery system is a key factor in improving outcomes.     

Nurse manager opportunities in the new millennium: community-based disease management

Disease state management (DSM) offered in a community-based setting is convenient for the consumer, driven by "best practice" protocols, delivered by nursing specialists, supported by the newest information technology, outcome-driven, and the ultimate in clinically integrated delivery systems. Because the DSM is delivered in the lowest cost setting, the home or workplace, it also offers significant cost savings. Community-based DSM will likely be a central component of 21st century health care and holds many opportunities for entrepreneurial nurse managers. This article describes a community-based DSM that has achieved excellent clinical outcomes, high patient satisfaction, high physician satisfaction, and substantial cost reduction.     

ANA position statement on privatization and for-profit conversion. American Nurses Association

The American Nurses Association (ANA) believes that the health of communities benefits from a mix of health care facilities, including both public and nonprofit private facilities where feasible. ANA is concerned by the rate of conversion of nonprofit facilities and plans to for-profit status. Privatization of public facilities and the conversion of nonprofit facilities and health plans to for-profit status requires careful public oversight to ensure continued access to affordable, quality services, including a maintenance of uncompensated care; a fair accounting of the assets of the entity being privatized or converted; and an assurance that converted assets are used to maintain and improve access to affordable, safe and quality health care services. The rights and benefits of employees must be carefully safe-guarded in any privatization or conversion move. All hospitals, regardless of ownership or tax status, should be held accountable for the delivery of safe, quality services, and should be required to disclose data regarding staffing, patient outcomes, cost and delivery of uncompensated care. Continued data collection will be necessary to guide further development of public policy to address privatization and for-profit conversion.