Category Archives: Quality of care
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.
The Robert Wood Johnson Foundation Interdisciplinary Nursing Quality Research Initiative (INQRI) will host the next webinar in its “Translating Research Into Practice” series on February 14, 2013.
INQRI investigators Linda Flynn, PhD, RN, FAAN, and Joel Cantor, ScD, will discuss their research and the intervention they designed to increase patient safety by enhancing the leadership and team building skills of nurse managers.
The webinar will be held from 3-4 p.m. EST.
You’re Invited to a Virtual Meeting on Advancing the Science of Quality Improvement Research and Evaluation
Lori Melichar, PhD, is a senior program officer at the Robert Wood Johnson Foundation (RWJF).
The Robert Wood Johnson Foundation’s mission is to improve the health and health care of all Americans. In pursuit of this mission, we seek to improve the quality of care provided in hospitals, ambulatory care centers, public health departments, and other settings where health is enhanced or health care is delivered.
Within the past 15 years, Quality Improvement (QI)—the process-based data-driven approach to improving the quality of a product or service through iterative action-evaluation cycles—has emerged as a promising strategy to accomplish this goal, and RWJF funded several national programs to “demonstrate” the potential of QI to improve health care processes, staff engagement and patient outcomes. The Foundation’s Pursuing Perfection Program, which had as its goal to help hospital and physician organizations improve patient outcomes dramatically by pursuing perfection in major care processes, employed QI tools such as Plan-Do-Study-Act cycles and improvement collaboratives to accomplish this goal. Another program, Transforming Care at the Bedside, taught frontline nurses the skills and methods of QI and empowered these staff to engage in activities to transform hospital care. Paths to Recovery is an RWJF program that used QI processes to improve the systems of care that provided substance abuse treatment. Aligning Forces for Quality is RWJF’s signature effort to lift the overall quality of health care in targeted communities, reduce racial and ethnic disparities, and provide models for national reform.
Robin Newhouse, PhD, RN, is a grantee of the Robert Wood Johnson Foundation Interdisciplinary Nursing Quality Research Initiative. She is professor and chair, Organizations Systems and Adult Health at the University of Maryland School of Nursing. She is also vice-chair of the Methodology Committee for the Patient-Centered Outcomes Research Institute. This post is part of the "Health Care in 2013" series.
My resolution for the U.S. is to begin the transformation of health care systems to enhance high quality patient-centered care. Despite some improvements, the National Healthcare Quality Report 2011 reveals that health care quality in the U.S. often falls short of expectations—demonstrating geographic and population (minority and low-income) variations. In 2011, the U.S. Department of Health and Human Services (HHS) released the National Quality Strategy (NQS), designed to improve the quality of health care in the U.S. My highest priority for action is the first aim: “Better Care: Improve the overall quality of care, by making health care more patient-centered, reliable, accessible, and safe.” Better care is achievable—with two specific strategies in mind: implementation of evidence-based practices and a focused goal to measure and improve patient-centered outcomes.
Implementation of Evidence-Based Practices. We have not gone far enough, fast enough. It is time to focus on implementation of evidence-based practices in health care systems. Research studies have continued to exponentially produce results intended to inform health care practices. Identifying and implementing evidence-based practices known to work—but that are underutilized—can go a long way to improve health care processes and quality. Performance measures are an example of one approach to drive system changes. The 2012 NQS Annual Progress Report describes the achievements of the first year’s work, including a focus on clinical and patient-reported outcomes (as close as possible to patient-centered) and development of new patient-centered outcomes.
Human Capital News Roundup: Nurses' assessment of quality of care, climate change, domestic violence, and more.
Around the country, print, broadcast and online media outlets are covering the groundbreaking work of Robert Wood Johnson Foundation (RWJF) leaders, scholars, fellows and grantees. Some recent examples:
A study led by RWJF Nurse Faculty Scholar Matthew McHugh, PhD, JD, MPH, RN, CRNP, finds that nurses are extremely accurate and reliable assessors of the quality of care in the hospitals in which they work. In the study, nurses’ reports of excellent quality care corresponded with higher levels of patient satisfaction, better scores for processes of care, and better results for patients in the hospital with regard to mortality and failure to rescue. Becker’s Hospital Review and Advance for Nurses are among the outlets to report on the findings. Read more about the study.
New Mexico Business Weekly reports that the RWJF Center for Health Policy at the University of New Mexico has been recognized by the nonprofit Excelencia in Education as one of America’s top programs that is increasing academic opportunities for Latino students.
Jason Farley, PhD, MPH, CRNP, a Nurse Faculty Scholar, spoke to the Baltimore Sun about his research on drug-resistant bacteria and “whether MRSA eradication among people who are HIV positive should focus on the person's entire household, and not just the individual.”
NJ Spotlight reports on the work of the New Jersey Nursing Initiative (NJNI) to help address the state’s nurse and nurse faculty shortage. “The Nursing Initiative’s flagship program, the Faculty Prep Program, comprises 61 nurse scholars (nurses and doctoral-prepared nurses) who have committed to being nurse faculty in New Jersey,” the story reports.