Category Archives: Quality of care
Olga Yakusheva, PhD, is an associate professor of economics at Marquette University. Richard C. Lindrooth, PhD, is an associate professor at the University of Colorado Anschutz Medical Campus. Both are grantees of the Robert Wood Johnson Foundation’s Interdisciplinary Nursing Quality Research Initiative.
Technological innovation is rapidly transforming patient care. A new generation of innovations will potentially change the most fundamental aspect of the patient experience – patients’ interactions with physicians and nurses. The FDA recently approved the first autonomous telemedicine robot for use in acute care hospitals. Even more advanced technologies, some capable of processing up to tens of millions of pages of plain medical text per second, are being tested and may soon be used to diagnose conditions and recommend treatment, with limited input from clinicians.
"We suggest that nurses should embrace rather than fear these innovations."
This new technology has the potential to perform several tasks more efficiently than clinicians, albeit with some limitations. It can quickly and effectively sift through large amounts of information and, based on a complex set of guidelines, create a probability-weighted list of diagnoses and recommendations. The result will be purely evidence-based and free of human cognitive decision-making biases. The technology can drastically speed diffusion of new research and guidelines through electronic dissemination, similar to automatic software updates, and make most novel treatment regimens instantly available to patients.
Ying Xue, DNSc, RN, is an associate professor at the University of Rochester School of Nursing and an alumnus of the Robert Wood Johnson Foundation Nurse Faculty Scholars program. This is part of a series of posts for National Nurses Week, highlighting how nurses are driving quality and innovation in patient care.
For the past two decades, supplemental nurses have been about 4 percent of the nursing workforce. These are nurses hired from staffing agencies to temporarily fill vacant nursing positions. The business of supplemental nurse staffing began in the 1970s as a symptom and a response to the nursing shortage. A central concern over the decades has been whether quality of patient care provided by supplemental nurses is the same as that provided by permanent nurses.
On the one hand, some argue that the temporary nature of the position (which varies from per-diem to a few months) might have an adverse effect on patient outcomes due to supplemental nurses’ lack of familiarity with unit policies and health care providers, and disruption in continuity of care. Others contend that supplemental nurses might have a positive effect on patient outcomes because they alleviate deficiencies in nurse staffing.
What’s the answer to this decades’ old question? Surprisingly, relatively little research has been conducted to provide a definitive answer, but several recent studies not only are shedding light on the issue, but helping to reframe the question by challenging some old myths.
Nancy Ryan-Wenger, PhD, RN, CPNP, FAAN, is the director of nursing research and an investigator at the Center for Innovation in Pediatric Practice at Nationwide Children’s Hospital in Columbus, Ohio. As a grantee of the Robert Wood Johnson Foundation Interdisciplinary Nursing Quality Research Initiative (INQRI), she was a lead investigator of the first-ever study to systematically elicit the views of hospitalized children and adolescents on the quality of their nursing care, and also the first to evaluate children’s perceptions of nurses’ behavior for evidence of any disparities across demographic groups. This is part of a series of posts for National Nurses Week, highlighting how nurses are driving quality and innovation in patient care.
Have we asked the children?
That became a pressing question for me when I retired from academia after 30 years and joined the staff of Nationwide Children’s Hospital. I became aware of things that are highly important to hospitals, such as opinions of the quality of care. Yet when I saw the patient surveys at Nationwide, they were almost always completed by parents, and 80 percent of the questions were geared toward parents: Were they kept informed of their child’s condition? Did they have a comfortable place to sleep? Was their child treated kindly by staff member?
Those are important questions, certainly, but if you’re doing a patient survey, don’t you want to know what the patient thinks?
Have we asked the children?
This is part of the May 2013 issue of Sharing Nursing's Knowledge.
Hospitals that have achieved "Magnet" recognition have lower mortality rates, according to new research led by Matthew D. McHugh, PhD, JD, MPH, RN, of the University of Pennsylvania School of Nursing, with support from the Robert Wood Johnson Foundation (RWJF).
McHugh and colleagues examined patient, nurse, and hospital data for 56 hospitals designated as Magnets by the American Nurses Credentialing Center, along with comparable data from 508 non-Magnet hospitals. They found that "Magnet hospitals had significantly better work environments and higher proportions of nurses with bachelor’s degrees and specialty certification," and that "patients treated in Magnet hospitals had 14 percent lower odds of mortality and 12 percent lower odds of failure-to-rescue." They concluded that "lower mortality we find in Magnet hospitals is largely attributable to measured nursing characteristics but there is a mortality advantage above and beyond what we could measure. Magnet recognition identifies existing quality and stimulates further positive organizational behavior that improves patient outcomes."
About 8 percent of hospitals in the United States have achieved Magnet designation. They are recognized for quality patient care, nursing excellence, and innovations in professional nursing practice.
The study was published in the May issue of Medical Care, a journal of the American Public Health Association. McHugh is an RWJF Nurse Faculty Scholar.
Susan B. Hassmiller, PhD, RN, FAAN, is senior adviser for nursing at the Robert Wood Johnson Foundation, and director of the Future of Nursing: Campaign for Action.
National Nurses Week begins today, May 6, and runs through Sunday, May 12, which is Florence Nightingale’s birthday. The theme for the week this year is: delivering quality and innovation in patient care.
It’s a wonderful theme, because nurses do even more than deliver high-quality patient care. Nurses conduct groundbreaking science and discovery, develop innovations that improve the quality of care, provide primary care, help patients and their families avoid and manage illness, teach at community colleges and universities, shape public policies, serve in the military, help when there are disasters, run large health organizations, and much more.
Since it opened its doors 40 years ago, the Robert Wood Johnson Foundation has recognized that, which is why it has invested more than $580 million in nursing over the last four decades. That investment continues today, with support to our programs that prepare the next generation of nurse faculty, support nurse research, promote nursing leaders, and more.
The Institute of Medicine, too, recognized nurses’ many contributions to improving health care in this country in its groundbreaking 2010 report. That is why the report called for a more highly educated nursing workforce, more support for nurse-led research, and more nurses in leadership roles of all kinds, from the front lines to the board room. The Future of Nursing: Campaign for Action is working to implement those and other recommendations from that report.
This week on this blog, you will be able to learn more about it and read about some of the innovative work that nurses around the country are doing. This is one of my favorite weeks of the year, because it provides us an opportunity to really showcase nurses’ work. Enjoy!
In 2011, the Accreditation Council for Graduate Medical Education (ACGME) limited shifts for first-year medical residents, or interns, to 16 hours, in an effort to improve their well-being. But two studies published online this week in the Journal of the American Medical Association (JAMA) find that these regulations may not be improving resident well-being—and that they may be decreasing both the quality of care they provide and their educational opportunities.
Although interns worked fewer hours after implementation of the shift length restriction in 2011, researchers found no change in their sleep duration or symptoms of depression. That study, led by Srijan Sen, MD, PhD, of the University of Michigan in Ann Arbor, also found an increase in self-reported medical errors among interns (from 20% in 2009 to 23% in 2011). The researchers hypothesize that the increase in errors may be due, in part, to interns having to perform more handoffs—where medical errors are known to occur—and to a lack of additional clinical staff that may mean “residents [are] expected to complete the same amount of work as previous cohorts but in less time.”
Another study, led by Sanjay V. Desai, MD, of Johns Hopkins University, also found “unintended consequences” of duty hour regulations. Although that study found more consistent sleep patterns for interns, it also found that nurses, as well as the interns themselves, believed the quality of patient care suffered. Desai’s research team found a concerning balance between the interns’ workload and their time spent on educational activities. “Concerns have been raised about the competency achievable with less hospital experience during any fixed duration of training,” they write. “Opportunities were reduced with restricted shifts, many of which occur solely during evening hours, precluding participation in traditional core educational components of medicine residency programs, such as noontime conference and morning rounds.”
Bonnie Zima, MD, MPH, an alumna of the Robert Wood Johnson Foundation (RWJF) Clinical Scholars program (1989-1991), published a study this month that appeared in a special supplement of Pediatrics with articles by RWJF Clinical Scholars on child health quality. Pediatrics is the official journal of the American Academy of Pediatrics. Zima is a professor-in-residence in child and adolescent psychiatry at the University of California in Los Angeles (UCLA) and associate director of the UCLA Center for Health Services & Society.
Human Capital Blog: Why did you decide to review the new child mental health quality measures?
Bonnie Zima: This paper was written to stimulate discussion about the need for a paradigm shift for quality measurement for children that more closely aligns research with the accelerated pace of quality measure development.
These are exciting times for those who believe that the quality of child health care can be improved through measurement and public reporting. However, this direction also raises questions about how to improve our methods and data infrastructure to monitor the quality of care received in real-time and to link adherence to quality indicators to clinical outcomes that are meaningful to parents, child advocates, providers, agency leaders and policy-makers.
HCB: Why did you focus on child mental health?
Zima: We focused on child mental health care because quality measurement poses additional challenges that can be used as a stimulus to improve future measure development.
Some of the areas for future research include development of a stronger evidence base to support nationally recommended care processes in community-based populations; models of care coordination across multiple care sectors that often have discrete funding streams, such as specialty mental health, public health, education, child welfare, and juvenile justice; and the development of interventions that more flexibly align service delivery with children’s clinical needs, especially for those with co-morbid mental and physical health conditions.
Lori Melichar, PhD, is a senior program officer at the Robert Wood Johnson Foundation (RWJF).
On February 12, the Robert Wood Johnson Foundation launched a new website that can serve as a long-awaited repository for work we have funded over the last 10 years that invests in advancing the science of quality improvement (QI) research and evaluation. We hope the website also provides the opportunity for researchers and other health care professionals engaged in QI work to access resources and to connect with colleagues with mutual interests.
The launch coincided with a virtual meeting on Advancing the Science of QI Research and Evaluation (ASQUIRE). The group convened to hear findings from grantees of the Foundation’s Evaluating QI Training Programs Initiative (PQI).
Meeting participants were tasked with thinking about how the website can best disseminate their work as well as collect, house and spread tools, frameworks, methods and models to assist those doing QI and those evaluating QI efforts. Grantees were joined by experts in QI research, practice and evaluation and a lively discussion (sometimes a debate) ensued.
Lawrence Kleinman, MD, MPH, is vice chair and associate professor of health evidence and policy and associate professor of pediatrics at Mount Sinai Hospital. He is an alumnus of the Robert Wood Johnson Foundation (RWJF) Clinical Scholars program (1990-1992) and helped guide a special supplement of studies by RWJF Clinical Scholars into publication in Pediatrics this month.
Human Capital Blog: How did this special supplement come to be and what impact do you expect and hope it will have?
Kleinman: Des Runyan, MD, DrPH, director of the Robert Wood Johnson Foundation (RWJF) Clinical Scholars program, called to ask me what I thought about the idea and whether I would be willing to shepherd the issue. Des had observed the historical and seminal role of RWJF Clinical Scholars in the emergence of the field of quality of health care, the work of Bob Brook, MD, ScD, chair in health care services at the RAND Corp., a professor of health policy and management, and of medicine, at the University of California at Los Angeles (UCLA), and an RWJF Clinical Scholar alumnus, and of many others, and also the more recent emergence of Clinical Scholars as leaders in the field of children’s health care.
He also recognized that five of seven centers of excellence funded by the Agency for Healthcare Research and Quality (AHRQ) as part of its flagship Pediatric Quality Measures program (PQMP) were led by alumni of the Clinical Scholars program. I think Des viewed that as a seminal moment that showed that Clinical Scholars alumni had achieved similar leadership in child health that they had achieved in the area of adult health. He recognized the opportunity to celebrate that in a collection of work on children’s health quality by RWJF Clinical Scholars and alumni.
HCB: What are the key messages readers should take away from the series?
Kleinman: This supplement demonstrates the capacity and power of using conceptual models to inform quality and quality improvement research, suggests an approach to developing these kinds of conceptual models, and illustrates that a span of approaches—ranging from evidence synthesis to a highly reductionist analysis of existing data to an extremely generative qualitative analysis to the thoughtful integration of ideas by colleagues—may all inform the field in important ways.
Further, the field of pediatric quality of care is blossoming; it truly needs studies that incorporate and extend its range. Finally RWJF Clinical Scholars are still thought leaders and change agents who as a group demonstrate remarkable versatility in their methods and prove notably capable of provoking progress in children’s health and quality research.
Four in 10 physicians say their typical patient load “exceeds safe levels” at least once a month, causing the quality of care they provide to suffer, according to a study by researchers at Johns Hopkins University, published online in the Journal of the American Medical Association (JAMA). More than one-third of physicians (36%) reported their workloads exceeded safe levels at least weekly.
In the survey of more than 500 self-identified hospitalists in an online physician community, respondents said their workloads had caused patient care to suffer. Respondents reported that inadequate time with a patient had caused them to order potentially unnecessary tests or procedures, and that their workloads had “likely contributed” to a host of poor patient outcomes, including morbidity and mortality.
Among the other problems physicians attributed to excessive workloads: inability to fully discuss treatment options; delayed admissions and discharge; increased readmissions; worsened patient satisfaction; and worsened overall quality of care.