Performance measurement and nursing: How is it changing the profession?
What does the term performance measurement mean within a health care context? Essentially it is an emerging science of measuring care quality against a set of established metrics. The quality being measured can include care protocols, patient satisfaction, patient outcomes and individual staff performance—and sometimes a combination of all three. With quality-based purchasing a bedrock of the recent federal health legislation, performance measurement is becoming ubiquitous across multiple health care strata, and nursing is no exception.
Many hospitals appoint chief nursing officers to oversee performance measurement in their facilities, making it a major priority for nurses at all staff levels. “We look at a whole host of quality indicators that are focused at the patient level,” says Carol Danielson, RN, Senior Vice President and Chief Nursing Officer of Gwinnett Medical Center, located near Atlanta, Ga.
According to Danielson, Gwinnett Medical Center participates in the National Database of Nursing Quality Indicators® (NDNQI®), which tracks data and measures specifically related to quality of nursing care, including pressure ulcers, hospital falls, use of patient restraints and hospital-acquired infections such as ventilator-associated pneumonia, urinary tract infections (acquired from catheters) and bloodstream infections from drug-resistant bacteria such as MRSA.
Danielson reports that her hospital also tracks patient-satisfaction data in accordance with national databases and standards. “We track measures as indicated by such national data-collection instruments such as the Press Ganey survey and the HCAHPS survey,” she says. These two instruments measure criteria such as nursing care professionalism, including such matters as prompt responses to patient calls and keeping patients informed of their care and progress. Danielson emphasizes that patient satisfaction is a crucial determinant of overall care quality. “Some people dispute whether these measures are indicators of quality, but I say they are,” she says.
These issues probably aren’t the first thing a layperson thinks of when it comes to health care quality, but they are very important. “When we talk about patient quality, we aren’t discussing customer satisfaction, but the quality of the care that the patient receives in accordance with evidence-based standards. We collect the data, look at it on the unit level, and use that information to make improvements.”
“We really try to strive for zeroes on all of these measures,” says Danielson. “Things like pressure ulcers, patient falls and hospital-acquired infections should never happen. But they do, and we collect and use data on these issues to get as close to zero as possible. There’s a real accountability that the nurses need to have on these measures, and we take it very seriously.”
While some health care stakeholders view performance measurement as a threat to their professional autonomy and livelihoods, Danielson does not. Indeed, she believes that the rise of performance measures illustrates just how crucial nurses are to quality health care, and raises their prestige accordingly. “We’ve already seen a shift in nurses being more valued as providers,” she says. “I hope that as we become more focused on these measures, we learn more about the link between nursing quality and work force competency—which are both variables that directly affect the patient.”
When it comes to measuring the professional competency of the nurses under her direct supervision, Lesley Hunt, RN, MSN, CCM (and University of Phoenix adjunct nursing instructor) is an expert. As an associate director of a UnitedHealthcare Integrated Care Coordination Team, Hunt supervises a team of nurses who conduct case management of Medicare and Medicaid patients who are served under UnitedHealthcare-administered plans. “I am of the belief that if you don’t tell your staff exactly what you’re measuring about their performance, you can’t measure performance effectively,” says Hunt.
When evaluating her staff nurses, Hunt uses a documentation instrument that measures performance criteria across a wide variety of metrics. “Nurses must score a minimum of 90% on this instrument,” says Hunt, “but we always shoot for higher scores.” The data from this instrument assists Hunt in personnel-related decisionmaking, including when to give raises, when to allow nurses to telecommute from home, and hiring/termination decisions.
In addition, the utilization management nurses Hunt supervises are conducting performance measurement of their own via their job duties, which consist of utilization review of care providers for patients under their management. “Utilization review evaluates the appropriateness of care provided to patients, including the appropriateness of care denials,” Hunt explains. “We’re the insurance company, so a lot of people assume we’re the bad guy. In reality, we closely scrutinize the care the hospitalized patient is receiving and determine the most appropriate level of care based on the patient’s condition and care needed. We want to avoid unsafe discharges. Our most important priority is the patient’s safety.”
Utilization review nurses also evaluate case records to determine if care provided is in accordance with nationally accepted guidelines, such as Milliman and INTERQUAL guidelines. “If we see outliers—care providers who are not operating according to national standards—we step in and investigate,” says Hunt. “Medicare and Medicaid patients are being cared for at taxpayer expense, and my job is to be steward of the public monies. I am a champion of my patient, and that means making sure they are getting the most out of their benefit dollars, as well as getting the right care at the right level.”
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