In the climate of health care reform, much attention has been paid to the Triple Aim of improving population health, reducing costs, and improving patient experience. The goals of the Triple Aim framework, which was developed by the Institute for Healthcare Improvement, are complex and challenging, but become less so when broken into smaller goals with clear parameters and measurements. Carefully selecting and measuring performance metrics, therefore, is key to helping organizations achieve the Triple Aim, as well as improving work life for employees. This set of goals has been suggested in recent literature as the “Triple Aim +1,” where ensuring that employees find joy and meaning in their work helps provide the necessary foundation for high-quality and lower-cost care and for an organization to reach its full potential.
“Nursing is very process-oriented in terms of how we develop relationships with patients and families, assess and treat patients, and collaborate with others to assure effectiveness of care and a positive patient experience,” says Patricia Reid Ponte, RN, DNSc, FAAN, NEA-BC, Nurse Scholar in Residence at the Phyllis F. Cantor Center for Research in Nursing and Patient Care Services at the Dana-Farber Cancer Institute and Executive Director of Oncology Nursing and Clinical Services at Brigham and Women’s Hospital. “You can focus on improving pieces of those processes, but if the outcomes you hope to achieve aren’t measured, met, and constantly improved on, none of the process matters.”
A Brief History of Outcomes Measurement
According to Reid Ponte and Richard Siegrist, MS, MBA, CPA, Director of Innovation and Entrepreneurship, Co-Director of the Health Care Management Program, and Lecturer on Health Care Management at the Harvard T.H. Chan School of Public Health, it was a long road to define and create standardized outcomes that measure what they are supposed to. In the early 1990s, though few hospitals and nursing teams regularly collected quality measures, various stakeholders began to advocate for a pay-for-performance system. In addition, some health care organizations began adopting the performance improvement model, which links measurement to the process of improvement and attaining clearly defined goals. This grew partly out of an Institute of Medicine report that highlighted health care errors and called for defining and adhering to performance measures.
Carefully selecting and measuring performance metrics is key to helping organizations achieve the Triple Aim, as well as improving work life for employees.
In response, the federal government created the National Forum for Healthcare Quality Measurement and Reporting, now called the National Quality Forum (NQF), in 1999. The NQF oversees the standardization of health quality measures and the ways in which they are reported, and has identified more than 600 evidence-based measures since its founding. These are considered the gold standard for quality measures and are often used for determining performance-based payments and public reporting.
As the payers and insurers began to focus on measuring outcomes, nursing organizations were an integral part of the process. For example, the American Nurses Association’s set of quality measures make up the National Database of Nursing Quality Indicators, the only national database of nurse-specific quality measures, recently acquired by Press Ganey. These measures and others are also used by the American Nurses Credentialing Center Magnet Recognition Program, which recognizes organizations with nursing and health care delivery excellence.
Since the passage of the Affordable Care Act, Medicare and Medicaid payments have also been linked to quality measures in many areas. As a result, the United States health care system has been moving towards a pay-for-performance model, where hospitals are rewarded or penalized based on their performance on a specific set of measures.
How to Measure and Improve Outcomes
Outcomes can be measured in all areas across an organization, and while patient satisfaction, safety, and mortality ratio are commonly assessed, Reid Ponte and Siegrist caution that less common outcomes shouldn’t be ignored. In particular, they note that measuring financial and cost outcomes are just as important as tracking other results when evaluating a program or process. Workforce outcomes, such as retention, employee engagement, and employee satisfaction, are also less commonly measured, but should be tracked seriously in an organization. Broad categories of quality measures in nursing are as follows: patient-centered such as patient falls or pressure ulcer occurrence, process-related such as patient education and handoffs, and structural-related such as licensure and workforce diversity.
Measuring outcomes is a multi-step and iterative process that should involve interdisciplinary teams at every step. Even when focusing on nursing-specific outcomes, teams can and should involve administrators, clinicians, and others who work closely with nurses. These teams should first come together to determine any gaps or specific ways the organization can improve. They should also set quantifiable goals related to those problems and develop a specific plan to accomplish them. By attaching metrics to the goals, teams can monitor progress and change the plan as necessary.
“The idea is that you create priorities in an organization at the highest level, then bring them down so that they’re system-wide, and create steps and remove barriers to meet those priorities, with input from all levels,” says Reid Ponte. “Define your goals and measures carefully, so you know when you’ve achieved your priorities. As you go through this process, engage, inform, and have administrators and nurses at all levels included in determining your measures. This will help ensure that you are choosing the right measures and that everyone is working towards your goal.”
Reid Ponte points to hand washing as an example of a major priority goal in many hospitals. While it seems basic that everyone washes their hands before or after patient care, hospitals have recognized that they often fall short in this area. The main method of measurement for hand washing rates is observing physicians, nurses, and others in clinical areas. Once hospitals have determined their hand washing rate through observation, they can begin to improve by undertaking an education campaign, such as posting or giving verbal reminders, and new technology is emerging on this front every day.
“Health care delivery is interprofessional and interdisciplinary by definition,” says Reid Ponte. “In the best practice environments, where nurses, clinicians, and staff are really engaged in a culture of respect and where inclusion and transparency exist, everyone who touches the patient both figuratively and literally is as important as anyone else. A culture of inclusion creates the best outcomes.”
The Role of Technology
With the implementation of electronic health records and more refined approaches to big data, hospitals, including nursing teams, are able to capture more information in greater detail and measure results that they might not have been able to previously. Instead of just looking at individual encounters, hospitals and health systems can now link outpatient and inpatient data to create a more robust picture of each patient and to determine trends in outcomes on the practice, program, or system levels.
However, technology can also create challenges. One is that those using the data need to understand analytics and how to use them for improvement. If nursing goals don’t have specific metrics attached to them, it will be nearly impossible to gain useful information from any data collected. Knowing what needs to be measured is an important first step in utilizing data to drive outcome improvements. In addition, because there are numerous tools and techniques to use data for process improvement, it is essential to have a clear understanding of how data can be displayed and analyzed to achieve the desired results.
Hospitals and health systems can now link outpatient and inpatient data to create a more robust picture of each patient and to determine trends in outcomes on the practice, program, or system levels.
Another challenge is that data can only be connected and analyzed if it is input in a standardized way, in a standardized language. In addition, the raw data must be input across clinical settings in order to identify trends and solutions.
“In order to achieve your goals, you need a common language,” says Siegrist. “How do you think about clinical and non-clinical outcomes and make sure people are talking about the same thing when we discuss pay-for-performance? Creating clear goals can help, but it is part of the challenge of using data for process improvement.”
A key future innovation in using data for improvement, according to Reid Ponte and Siegrist, will be in harnessing free-text notes, spaces in electronic medical records in which nurses, physicians, and other clinicians are not limited to checking boxes, to extract their information and compare it against more structured patient data. This will take analytics to a new level for measuring outcomes and improving health care. This, in turn, will help the health care system achieve the Triple Aim and/or Triple Aim +1.
Patricia Reid Ponte and Richard Siegrist direct Strategic Management and Decision Making for Nurse Executives at Harvard T.H. Chan School of Public Health. To learn more about this opportunity, click here.