Seeking to correlate nursing practices with patient outcomes, the National Quality Forum last week proffered the first set of national-standard measures for weighing the impact of nursing care in hospitals.
The 13 measures, proposed after several months of consensus-building discussions among hospital, nursing-group and payer representatives, provide the beginnings of a much-needed framework for evaluating the quality of nursing care, said Lillee Gelinas, who co-chaired the process at the Washington-based NQF.
They also attempt to set up a framework for determining how staffing levels affect clinical outcomes, a contentious issue that was underscored last week in California when the last state agency signed off on a law to require specific nurse-to-patient ratios. The law is scheduled to take effect Jan. 1.
Despite lengthy debate on the relationship of nursing to care quality and the proper ratio of nurses to patients, "we don't clearly link clinical quality and workforce issues," said Gelinas, vice president and chief nursing officer at VHA, the Irving, Texas-based alliance of hospitals and healthcare systems.
The NQF steering committee narrowed more than 150 possible nursing measures down to a list of 57 that deserved further consideration of their relevance, importance in improving care and scientific validity. The chosen measures have "such strength of evidence that you just can't debate them," Gelinas said.
But the NQF will offer a chance for debate and public comment until Oct. 30. The full report on the drafted consensus measures is available until then on the agency's Web site, qualityforum.org. A final version is set for a vote of the group's membership in December.
The NQF, founded as a public-private partnership in 1999, published consensus standards for overall hospital performance earlier this year as a common basis for quality-improvement initiatives among oversight agencies and healthcare coalitions. The CMS, the Joint Commission on Accreditation of Healthcare Organizations and the Leapfrog Group have indicated they plan to incorporate the standards hammered out by the consensus process.
Ten of the drafted nursing-care standards measure prevalence of conditions or events suffered as a result of a hospital stay and considered preventable, such as falls or infections from catheters.
One measure draws a link between mortality and nursing care: the percentage of patients who died after experiencing a complication while hospitalized, such as blood clots, cardiac arrest, pneumonia or sepsis. Another asks for the rate of pneumonia associated with the use of ventilators in the intensive-care unit or the high-risk nursery.
Four of the 10 outcome measures were copied from the list of 39 measures already endorsed by the NQF for evaluating hospital performance.
The remaining measures seek to enable comparisons between the rate of poor outcomes and the nursing workforce marshaled to prevent them. Those measures include the percentage of hours worked by registered nurses compared with total nursing-care hours, and the number of hours per patient day devoted to direct care by registered nurses, licensed practical nurses and other caregivers.
But there are no correct or recommended percentages, Gelinas said. "The point is the correlation; the point is not the hard number." If hospitals have rising rates of infections or complications, for example, the workforce measures would allow researchers to check whether the trends correspond with changes in the size and makeup of the nursing staff, she said.
Several areas important to measuring nursing care, including pain management and the effect of workforce turnover on mortality and complications, were held until more research could be done to prove their worth, she said.