Outcomes and effectiveness research: capacity building for nurse researchers at the Agency for Healthcare Research and Quality

Several of AHRQ's priority areas including disease prevention, health promotion, primary care, quality of care, service delivery, and patient safety are particularly relevant to nurse researchers. With much national attention focused on nursing-related issues such as staff shortages, training, mandatory overtime, working conditions, and autonomy, it is mandatory that nursing research be conducted to inform healthcare delivery and policy. Nurses also need to contribute to the health services literature so that an even balance of discipline perspective is represented. AHRQ's mandate is represented by the slogan "quality research for quality health care." Although our understanding has expanded of contributors to and determinants of evidence-based practice and the relationship between clinical care and improved outcomes, we have much to learn. Appreciating how and which components of nursing care influence patient outcomes represents an essential area of research in need of development. While clarifying nursing contributions to improved outcomes is not the sole purview of nurse researchers, it is plausible to assume that a clinical background in nursing combined with strong methodological skills can help policy makers and health system leaders understand how nurses can most effectively contribute to outcomes and quality improvement. AHRQ is clearly interested in capacity building of researchers from all relevant disciplines. Nurses, the largest provider of healthcare, need to build capacity and develop a much stronger presence in the health services research community of scholars.     

The Vascular Project: using data to improve processes and outcomes.

Fiscal accountability by health care providers has become a theme in health care delivery systems; however, evaluation of outcomes on the basis of cost alone may minimize the importance of patient needs and the quality of the care delivered. Mechanisms related to resource identification and allocation has to be driven by internal data and information systems that consider clinical, financial, administrative, and patient satisfaction data. This article will define processes, outcomes and outcomes measurement, and management. Various nursing-sensitive outcomes will be presented and their establishment, tracking, interpretation, and effect on the delivery of patient care in a newly opened vascular unit will be highlighted.     

Nurses as practice change facilitators for healthy behaviors

This study used nurses as practice change consultants to help primary care medical practices improve their delivery of health behavior services to patients. Nurse consultants worked with 20 practices from 2 healthcare systems. In each practice, the nurses helped clinicians and staff to develop a practice-specific protocol so that they could identify and intervene with the health behavior of their patients. As a result of the nurse consultant intervention, health behavior delivery was improved. This article describes the specific methods and the lessons learned through this study. We encourage practices to use nurse consultants as one way of improving quality of care.     

Developing standards for an integrated approach to workplace facilitation for interprofessional teams in health and social care contexts: a Delphi study

Integration of health and social care forms part of health and social care policy in many countries worldwide in response to changing health and social care needs. The World Health Organization’s appeal for systems to manage the global epidemiologic transition advocates for provision of care that crosses boundaries between primary, community, hospital, and social care. However, the focus on structural and process changes has not yielded the full benefit of expected advances in care delivery. Facilitating practice in the workplace is a widely recognised cornerstone for developments in the delivery of health and social care as collaborative and inclusive relationships enable frontline staff to develop effective workplace cultures that influence whether transformational change is achieved and maintained. Workplace facilitation embraces a number of different purposes which may not independently lead to better quality of care or improved patient outcomes. Holistic workplace facilitation of learning, development, and improvement supports the integration remit across health and social care systems and avoids duplication of effort and waste of valuable resources. To date, no standards to guide the quality and effectiveness of integrated facilitation have been published. This study aimed to identify key elements constitute standards for an integrated approach to facilitating work-based learning, development, improvement, inquiry, knowledge translation, and innovation in health and social care contexts using a three rounds Delphi survey of facilitation experts from 10 countries. Consensus about priority elements was determined in the final round, following an iteration process that involved modifications to validate content. The findings helped to identify key qualities and skills facilitators need to support interprofessional teams to flourish and optimise performance. Further research could evaluate the impact of skilled integrated facilitation on health and social care outcomes and the well-being of frontline interprofessional teams.     

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     

Nursing case management: application to neuroscience nursing.

The changing health care environment has challenged nurses to develop creative care delivery systems that provide for quality, comprehensive, cost-effective care in a time of restricted reimbursement and diminishing human and material resources. Nursing case management has been identified as one such approach to health care delivery that has resulted in quality, patient-centered care and improved resource utilization. The case management plan, critical path and discharge planning sheet are primary tools in this care delivery model. Because of the diverse case types and variety of patient care settings, neuroscience nursing is an ideal arena for implementing a nursing case management model of care.     

Nurse practitioners and physicians: a collaborative practice

The rapid evolution of health care delivery within the United States has created increased opportunities for nurse practitioners (NPs) to work in a variety of challenging advanced practice roles and to impact the quality of health care. The NP role was originally developed to meet a perceived shortage of primary care physicians, especially for underserved populations. Today, NPs work in various fields, such as geriatrics and women's and family health care, as well as in various systems such as private practice and health maintenance organizations. Effective collaboration with physician colleagues will promote improved communication, health care management, and positive health outcomes. Barriers to effective collaboration are reimbursement, territorialism, and role confusion on part of the health care team and the general public.     

Clinical review: The hospital of the future - building intelligent environments to facilitate safe and effective acute care delivery

ABSTRACT: The translation of knowledge into rational care is as essential and pressing a task as the development of new diagnostic or therapeutic devices, and is arguably more important. The emerging science of health care delivery has identified the central role of human factor ergonomics in the prevention of medical error, omission, and waste. Novel informatics and systems engineering strategies provide an excellent opportunity to improve the design of acute care delivery. In this article, future hospitals are envisioned as organizations built around smart environments that facilitate consistent delivery of effective, equitable, and error-free care focused on patient-centered rather than provider-centered outcomes.     

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.     

Associate degree nursing in a community-based health center network: lessons in collaboration

This exemplar highlights the ability of community experiences to enhance nursing students' understanding of the principles of community-based care: advocating self-care; focusing on prevention, family, culture, and community; providing continuity of care; and collaborating. An innovative teaching-practice model (i.e., a nurse-managed "network" of clinics), incorporating service-learning, was created. The Network's purposes are to provide practice sites in community-based primary care settings for student clinical rotations, increasing the awareness of the civic and social responsibility to provide quality health care for disadvantaged populations; and to reduce health disparities by increasing access to free primary health care, including health promotion and disease prevention, for disadvantaged individuals. Network clients receive free health care, referrals, and guidance to effectively obtain additional health care resources for themselves and their families. The Network is a national pioneer in modeling the delivery of primary care services through a faculty-student practice plan, with leadership emanating from a community college.     

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.     

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?     

Shaping the advanced practice psychiatric-mental health nursing role: a futuristic model

As advanced practice psychiatric-mental health nursing has transitioned from earlier models of practice, elements of clinical specialist and psychiatric nurse practitioner roles are being blended to produce a new type of practitioner. The challenge of preserving mental health expertise while expanding advanced practice primary and primary mental health care competencies is addressed in several nursing education models. At New York University's Division of Nursing, faculty have designed a program around elements identified as essential to the autonomy demanded of the evolving role, knowledge, and skills basic to broad based health care and mental health care delivery with quality patient care outcomes and the competencies necessary for accountability as care providers in a changing health care delivery system. Essential elements, resources to identify them, and strategies to attain them are discussed. Approaches that promote student, clinician, and faculty development and maximize education affirm the specialty's capacity for innovation and the profession's capacity for new direction and futuristic change.     

SHAPING THE ADVANCED PRACTICE PSYCHIATRIC-MENTAL HEALTH NURSING ROLE: A FUTURISTIC MODEL

As advanced practice psychiatric-mental health nursing has transitioned from earlier models of practice, elements of clinical specialist and psychiatric nurse practitioner roles are being blended to produce a new type of practitioner. The challenge of preserving mental health expertise while expanding advanced practice primary and primary mental health care competencies is addressed in several nursing education models. At New York University's Division of Nursing, faculty have designed a program around elements identified as essential to the autonomy demanded of the evolving role, knowledge, and skills basic to broad based health care and mental health care delivery with quality patient care outcomes and the competencies necessary for accountability as care providers in a changing health care delivery system. Essential elements, resources to identify them, and strategies to attain them are discussed. Approaches that promote student, clinician, and faculty development and maximize education affirm the specialty's capacity for innovation and the profession's capacity for new direction and futuristic change.     

Health care information systems. Patient-centered integration is the key

In today's cost-constrained health care delivery environment, hospitals are recognizing the need to optimize their care operations to improve the efficiency, efficacy, and service quality of primary health care providers, particularly the medical staff and nursing services, which comprise about 50% of the hospital's total personnel. Because health care institutions are in the business of caring for patients (not for accounts or departments), and because health care delivery largely is a personnel-intensive information industry, operations optimization is supported best by information systems that fully integrate all information concerning the patient. The goal of this is to simplify the job duties of direct care providers. The benefits of an integrated, patient-centered approach include demonstrable improvements in over-all patient care quality and staff satisfaction as well as a significant reduction in costs.     

Health reform: a community experience using design research as a guide

Meaningful health reform in the United States must improve the health of the population while lowering costs. In an effort to provide a framework for doing so, the Institute of Health Care Improvement created the triple aim, which encompasses the goals of (1) improving individual health and experience with the health care system, (2) improving population health, and (3) decreasing the rate of per capita health care costs. Current reform efforts have focused on the development of Patient-Centered Medical Homes (an innovative team-based model of care that facilitates a partnership between the patient's personal physician coordinating care throughout a patient's lifetime to maximize health outcomes), but these relatively narrow efforts are focused on office practice and payment methods and are not generally oriented toward community needs. We sought to apply design research in assessing a community opportunity to apply the triple aim as a strategy to transform health care delivery. Mixed methodology provides greater insight into the unexpressed health needs of individuals and into the creation of delivery systems more likely to achieve the triple aim. In a small, midwestern town, a mixed methods approach was used to assess community health needs to facilitate design and implementation of care delivery systems. The research findings suggest that health system design concepts should focus on the creation of health, not health care; foster simplicity; create nurturing relationships; eliminate user fear; and contain costs. These observations can be helpful to health care professionals who are developing new methods of care delivery and policymakers and payers contemplating new payment systems to achieve the goals of the triple aim.     

Quality improvement research on late life depression in primary care

BACKGROUND: Two million older Americans suffer from depression annually. Depression causes more functional impairment than many other common medical conditions and older adults have the highest rate of suicide in the United States. Although many of these patients fail to seek or fail to receive care for depression, the majority will be seen in primary care for the treatment of other conditions. OBJECTIVE: To review the health services research on quality improvement for late life depression. METHODS: Qualitative literature review. RESULTS: During the past 30 years, multiple educational and quality improvement interventions have been designed and tested to improve the recognition and treatment of depression in primary care settings. The findings from this large body of health services research suggest that: (1) the outcome of major depression in the usual care of primary care is typically poor; this is particularly true of late life depression; (2) informational support provided to primary care physicians is necessary but insufficient to improve the outcomes of late life depression in primary care; achieving guideline-level therapy requires the substantial participation of an informed and motivated patient working in concert with a health care team and health care system designed to care for chronic conditions; (3) up to 30% of older primary care patients will fail to respond to excellent guideline-level therapy provided in primary care; and (4) the latest quality improvement efforts focus not only on the clinical skills of primary care physicians, but also on patient's self-care and on innovative strategies to improve the system of care. CONCLUSIONS: Late life depression is often a chronic disease and outcomes research demonstrates that quality improvement efforts that focus resources on improving systems of care and the active participation of patients offer the best evidence of improved 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.