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MEASURING AND MANAGING OUTCOMES

Outcomes research aims to understand the end results of health care practices and
interventions. These end results include the effects that people experience and care about,
such as health status, ability to function, quality of life, and mortality. Outcomes research
that links the process of care to the outcomes that people experience has become a vital
component to improving quality of care and increasing patient safety.
Nurses have always been focused on patient outcomes. Popular images og Florences
Nightingales enduruing impact on health care and nursing tend to center more on her
caregiving activities and her creation of roles and structures for trained nurses in hospital.
Hoever, perhaps even more important, Nightingale pioneered the systematic use of client
outcomes in the form of mortality data that demonstrated the use of interventions to improve
health care. Collecting and analyzing data specific to nursing care and using to guide process
improvement tehnique, she reduced the mortality rate in a military hospital in the Grimme
from 60 % to 1% Kalisch & Kalisch, 1978). By accomplishing this,Nightingale can be
considered the founder f nursing outcomes measurement and mangement.
In this chapter, some basic ideas about outcomes and outcomes management will be
reviewd, along with what outcomes research is, how it is conducted, and how it can be used
by managers. Particularly important for managers are lessons that can be gleaned from
outcomes research about measurement, design, and analysis of indicator data and an ability to
read and apply the findings outcomes research.

DEFINITIONS
Key terms related to outcomes and their measurement and management include
outcomes, indicators, outcomes management, outcomes research, nursing outcomes research,
and risk adjustment. There are a variety of definitions for these terms from researchers,
theorists, and writers from a variety og disciplines, as well as government regulators and
accreditation bodies. Simply put, an outcomes is the result obtained from the efforts to
accomplish a goal ( Huber & Oermann, 1998). When most nurses consider outcomes, they
think of the consequences of a health care intervention treatment. The term outcomes has also
been defined as end results, or that which results from something (Lang & Marek,1990 p.
158) and as conditions in patients and others that health care delivery aims to achieve (Peters,
1995). Donabedian (1985) described outcomes as changes in the actual or potential health
status of individuals, groups or communities.
Indicators are valid and reliable measures related to performance (Oermann &
Huber. 1999 p. 41). They are the specific tools used to make quality visible to stakeholders in
health care. Outcomes are measured or quantified by observing or describing indicators.
Because quality is so important yet so elusive to define, are variety of accrediting and
regulating bodies and a number of a trade and professional associations (some that have
formed coalitions or alliances), as well as health care quality assesment organizations, have
developed standardized health care performance indicator data sets. For example, the
American Nurses Association(ANA) developed the National Database of Nursing Quality
Indicators (NDNQI) based on their Nursing Quality Indicators initiative (American Nurses
Association [ANA],1996, 2004). According to the ANA, outcomes measures or indicators
measure how nursing care is affecting clients. For example, the ANA includes the
measurement of urinary track infection incidents After 72 hours of hospitalization as an
indicator of nosocomial infection rate.
Indicator are used as measures of all three of Donabedians (1985) aspects of quality:
structure, process, and outcomes. DonabedianS Framework is useful to understand the
relationship between outcomes and the sructure and processes that have produced them. This
suggests that nurse managers and leaders should focus on structure and process factors
because these can be modified to influence patient outcomes (Donabedian, 2005).
Understanding and developingboth the nurse-level and organizational-levelcharacteristics has
the potential then to improve quality and outcomes. For example, structural indicators such
as the mix of registered nurses (RNs). Licensed practical nurses/licensed vocational nurses
(LPNs/ LVNs), and unlicensedassistive personal caring for clients can be important for
assesing organizational impacts on the delivery of nursing care. These can be measured by
the full-time equivalent (FTE) of RNs with direct care responsibilities to LPNs/LVNs and
Unlicensed assistive staff.
Outcomes management, as originally described by Ellwood (1998) is a process used
to assist managers and others make rational patient care-oriented decisions based on what is
known about the effects of the choices on patients outcomes. The care process in outcomes
management is what is being managed to achieve outcomes. To understand outcomes, the
entire care process needs to be carefully examimed and variation in outcomes must be
analyzed. Outcomes management is defined as a multidiciplinary process designed to
provide quality health care, decrease fragmentation, enhance outcomes, and constrain costs.
The core idea of outcomes management is the use of process activities to improve outcomes
(Huber % Oermann, 1998, p.4)
Outcomes research is a field (or subfield) in health services research that examines
what many ultimately believe are the actual goals of health care-improvementsin functional
status and quality of life. What makes outcomes research distinct from the past bodies of
research that examine end points in patients (i.e ., much slinically oriented rsearch) is that
outcomes researchers seek to tease out the effets of patient-level care and systems level
environments from the backround demographic, psychosocial, and clinical characteristic of
patients as influences on endpoints. The purpose is to understand which patients or clients
fare well and which do not in relation to treatments selected and/or the organizational
context of care delivery (Kane,2006a; Mithell et all., 1998). An example of a provider
characteristic that might be investigated as a predictor of patient outcomes might be
professional background (e.g., physicians versus advanced practiced nurses; RNs versus
LPNs/ LVNs).
Nursing Outcomes Research is is a subspecialty within the larger field of health
outcomes research. Nursing outcomes resarch focuses on determining the effect of different
contexts and conditions, related spesifically to nurses and nursing care, on the health status of
patients. Nursing outcomes resaerchers are interested in the structures or management
srategies for nursing care delivery that can achieve optimal outcomes for various clinical
populations, as well as the mix of health care workers best equipped to care for them. Studies
may aim to inform managers decision to recruit specific types of workers, such as RNs (as
opposedto other types of nursing workers) or nurses with specialized experience or training.
Other types of outcomes research are intended to assist manager and clinicians in determining
the types of patients who benefit most from certain nursing intervention.

OUTCOMES MANAGEMENT

The process of managing outcomesincludes the following five steps:


1. Data are collected about outcomes.
2. Trends are identified from data analysis.
3. Variances are investigated.
4. Appropriate service delivery changes are determined.
5. Changes are implemented and reevaluated.
In managing outcomes, the information derived from measuring client outcomes is collected,
trends are identified, variances are examined, and appropri ate care needs are determined to
improve care to an individual, group, or population. Goals of this process include quality
improvement and risk reduction. Variance analysis is one outcomes management tooi. A
variance is adeviation from what is expected. For nurses, this may mean a departure from the
anticipated clinical trajectory. Variances may be possitive or negative but are most useful
trends analysis.
Outcomes research and measurement examines the effectiveness of nursing care in improving
client outcomes. Outcomes data and information about factors or aproaches that promote
favorable outcomes can help nurses assist clients and theur families in meeting health needs
and care needs across the continuum of care. Reading outcomes research can also help nurses
select interventions that are the most useful in accomplishing the desired improvement in the
clients health status. Identifying the most effective interventions can provide invaluable
information to empower clients to self-manage their symptoms and care for them selves
(Oermann & Huber, 1997,1999).
As in any area of clinical care or the management of health services, ideally, practice is at
leas partially guided by research evidence. Although outcomes research has a great deal in
common with other forms of research, it involves some special elements. In particular,
outcomes researchers are especially concerned about understanding real differences
between expected and observed outcomes and between outcomes on different points in time.
There are a least two reasons why managers need to understands how outcomes research is
conducted: firs, the broad concepts can help them analyze and interpret their own data and
second, when correctly interpreted and extrapolated, the findings of outcomes research can
assist managers and clinicians to make better decisions for the populations they care that
favor high quality outcomes.
Increasingly managers are accountable for out comes in clinical care to the point that annual
performance reviews and salary increases arre contingent upon achieving targeted outcomes.
Outcomes research can provide key data for managerial decision making to improve quality
of care. Data derived from outcomes research can be used tpo answer the following types of
questions:
What mix of staffing skill level and education as appropriate to achieve optimal
outcomes for a clinical population with a particular level of patient acuity?
What level of technology and ratio of technology and staff achieve the best outcomes
for high risk patients?
What is the optimal organizational structure to maintain efficiency, safety, and patient
satisfaction at institutions that provide high volumes of services?
Although the answer to each of these questions depends on the specific individual and
institutional contexts and economic considerations at the time, data from outcomes research
can be used to inform decision making.

INFLUENCES ON OUTCOMES

It is that all consumers of outcomes data, including managers, undesrtand how to interpret
outcomes data. Providers interventions are animed at achieving possitive outcomes and
avoiding negative ones. Outcomes are influenced by a number of factors the specific
treatment delivered is only one. A model of factor influencing outcomes is useful as a guide
for managers. Lezzoni (2003a) and Kane (2006b) summarized the factors influencing
outcomes and expressed this in the form of a mathematical function as follows:
Outcomes = (patient clinical characteristics and risk factors, patient demographics,
organizational caracteristics of the setting, treatment, random chance).
Beginning efforts at outcomes measurement tend to focus almost exclusively on the effects of
treathment ( for nurses, usually the process of nursing care on outcomes but that ofthen
encompasses the actions of the entire multidisciplinary health team). Correctly interpreting
health outcomes data across setting or providers (whether in practice or in research) and
attributing differences and outcomes to the to the right causes or sources require attention to
two major challenges. The first lies in ensuring that consistent definitions and data colleection
processes have beenidentified and accurate measures of the phenomena of interest are used.
This includes the outcomes, treatment, and any other risk factors thought to influence
outcomes. The second, shared with all research dealing with dependent variables influenced
by many factors, is that of risk adjustment (lezzoni, 2003a). Risk adjustment involves
accounting for patient factors, the intrinsic risks that a patient brings to the health care
encounter in the form of clinical and/or demographic factors, before drawing conclusions
about the meaning of different values for indicators. Analyses of outcomes across groups are
meaningful only if these analyses account for relevant individual characteristics.

MEASUREMENT OF OUTCOMES

Jennings and colleagues (1999) have presented a framework for classifying outcomes
indicators into there categories: patient-focused, provider-focused, and organization-focused.
Patient-focused outcomes can include such indicators as disease status, symptom experience,
or pain. Other outcomes indicators incorporate a broader impact of disease and its
management on clients lives. These include quality of life, functional status, health status,
and patient satisfaction. There are also provider and organizational outcomes. Provider-
focused outcomes include such phenomena as nurse burnout, turnover, and job satisfaction.
Organizational-focused outcomes may include patient or provider outcomes that are
aggregated to the organizational level such as organizational mortality rates, error rates, or
other rate-based outcomes. Cost indicators are ofthen at the organizational level.

ELEMENTS OF OUTCOMES RESEARCH

Various tyipes of indicators can be used for managerial decision making, highlighting the
improvements in organizational-level factors or nursing care processes and assisting
managers to make various investments in human and material resources in controlled
research examining the factors associated with the quality of care.

Variable Selection
When reading outcomes research, managers should be aware that researchers are ofthen faced
with faced with cinsiderable challenges when sellecting outcome measures. The specific
measured used should influence how managers interpret and apply study findings. For
instance, outcomes can be generic or condition-specific, but they must be described
adequately. An outcomes that is not clearly defined is impossible to measure, and any
conclusions or decision by managers based on the research data my be flawed. Another issue
for managers to consider is the reason or question driving the research and its influence on
the selection of the outcome measure. For example, a study examining the relationship
between the level of nurse expertise and patient outcomes generally would be insufficient to
provide specific guidance on an intervantion to influence the expertise level of nurses on any
one hospital or unit. Managers should also consider whether the data or measurement
instruments that where available to researchers influanced the selection of outcome. For
example, consider the outcome measure in a study examining the influence excessive
workload on nurse injuries. It would be important to know whether the injury data were from
nurse self-reports, an injury data-base, manager reports, insurance recrds, or some other
source and what the potential limitations or biases are of each of these sources.
Risk Adjustment
Analyses of outcomes across groups are meaningful only if those analyses account for
relevant individual differences in the patient populations being served. Returning back to the
outcomes research model, when the interest in determining the effect of a particular
intervention or process of care such as patients to nurse ratio on health status of patients, all
of the other factors that may contribute to variation in the patients health status must be
accounted for. Thus, for example, comparing the effect of a better patients to nurse ratio on
acute myocardial infarction (AMI) outcomes in patients without co-morbidities with those in
older individuals with multiple co-morbidities would be inappropriate because it may be the
patient factors, not the patients to nurse ratio that cause the different outcomes. Risk
adjustment can be an involved and technical pursuit; but if given inadequate attention,
patterns and associations that are found in outcomes research have little credibility because
differences across the units or hospitals on outcomes cannot be interpreted as necessarily
reflecting variations in quality of care. One caution is important. Certain types of outcomes
are so dramatic and so closely tied to failures on the parts of systems for providing care (e.g.,
transfusion errors, severe pressure ulcers) that risk adjustment is unlikely to alter the
interpretation of the relevant indicators. The literature contains some excellent references that
discuss the state of the science in risk adjustment techniques (Elixhauser et al., 1998; Iezzoni,
2003b).

MEASUREMENT OF NURSING INTERVENTION OR TREATMENT

To understand the effect of the nursing treatment, intervention, or process of care being
investigated, that phenomenon must be defined and measured accurately. In instances in
which the intervention is straightforward, such as the implementation of a new technology or
a new program, it may be easier to isolate the effect of treatment. There are times, however,
when measures of the direct process of care are impossible or too labor-intensive to measure
directly because they require intensive monitoring or recording of what nurses are actually
doing. In those instances, proxy measures such as structural or organizational elements may
replace them. For example, nurse staffing is a structural factor indicating the number or
concentration of nurses often in ratio to patients. Nurse staffing measures usually do not
directly asses the process of care, that is, what nurses do in their work with patients.
However, it is seen as a valuable proxy measure for the process of care and quality. Proxy
measures need to be evaluated for how accurately they represent the concept that they
substitute for.

OUTCOMES RESEARCH DESIGN

With all of the factors that may influence outcomes, designing studies aiming to
isolate the effect of nursing interventions or processes of care (or of certain organizational
conditions) on outcomes and eliminating confounding sources is a challenging proposition. A
range of design approaches are possible-selection depends upon the question being studied,
the environment in which the investigation is to be carried out, and the subjects, instruments,
and/or data available for study. The randomized controlled trial (RCT) is often described as
the gold standard, but there is bias in any study and there is some concern that RCTs do not
reflect the world in which managers and other decision makers must operate. One alternative
is the practical clinical trial (PCT), which aims to (1) select clinically relevant alternative
interventions to compare, (2) include a diverse population of study participants, (3) recruit
participants from heterogeneous practice settings, and (4) collect data on a board range of
health outcomes (Tunis et al, 2003). A great deal of nursing outcomes research uses quasi-
experimental designs with either cross-sectional or longitudinal data. There are a variety of
designs, measuring, the outcome in relation to the treatment at any number of points and with
possible control populations, each having its own strengths, weaknesses (Campbell &
Stanley, 1963). In many other cases, however, researchers must turn to the analysis of data
that were collected for different purposes-a practice known as secondary analysis. This
design may save some time and money but requires much caution to avoid drawing erroneous
conclusions (the measures, their reliability and/or validity, and the contexts in which they are
collected may not be ideal). Knowing the potential bias that may arise because of the design
of a study and the methods that a researcher used to address those biases is an invaluable skill
for managers who wish to interpret outcomes data for management decision making. Classic
texts such as Campbell and Stanley (1963) provide background in this area.

LEADERSHIP AND MANAGEMENT IMPLICATIONS


Leader in todays health care delivery system are charged with the responsibility of
producing quality services that achieve desired outcomes. Consumers must perceive that the
outcomes of care justify the cost of services, and the services offered need to be valued by
payers and purchasers of care. Outcomes research can provide nurse managers with an
evidence-based foundation for leadership decisions and for making changes in practice. The
process of determining the appropriate changes that need to be made in service delivery,
making those changes, and reevaluating outcomes based on the changes are hallmarks of
outcomes management.
Managers and executives today have a wealth of information available to them, and
they are challenged with determining which data indicate a need for action in areas or aspects
of care in the settings for which they are responsible. A significant body of literature in
nursing outcomes research that continues to grow is a valuable point of references of
managers. There is, for instance, a large and expanding body of literature suggesting that
lower staffing levels and skill mix in acute care hospitals are associated with increased risk of
negative outcomes (Clarke, 2005). Insufficient nurse staffing, particularly of RNs, has been
associated with a number of unfavorable outcomes including increased surgical mortality,
failure to rescue, and rates of complications due to errors in care such as urinary tract
infections, intravenous line infections, decubitus ulcers, and patient falls (Aiken et al., 2002;
Kane et al., 2007). However, the specific context of the care environment and the patient
population of interest call for continual monitoring of outcomes against internal and external
benchmarks. Several data systems support the monitoring of nursing-sensitive outcomes. For
example, the ANA has developed a system of quality indicators and measurement tolls called
the NDNQI, which are aimed at measuring the quality of nursing care in acute care settings
(Gallagher & Rowell, 2003). The national quality forum (NQF) has also endorsed a set of
voluntary consensus standards for nursing-sensitive care that quantify the contribution of
nursing to patient safety, health care outcomes, and the professional work environment
(National Quality Forum, 2004; Naylor , 2007). Also, agencies such as the centers for
medicare and Medicaid services (CMS) (previously known as the health care financing
administration [HCFA]) and the joint commission (previously the joint commission on
accreditation of healthcare organizations [JCAHO]) incorporate outcomes-based reporting
requirements into their regulatory and accreditation process (Huber & Oermann, 1998).
Managers and executives in practice struggle with decisions around the minimum
number of data elements needed to satisfy payers and regulators versus how to be sufficiently
comprehensive and inclusive in measure selection and what elements are needed in the
dataset. Issues of feasibility, practically, collectability, and comprehensiveness will be part of
his unfolding area of nursing administration. In terms of a guide or framework for selecting
outcomes for tracking purposes, balanced scorecards and dashboard approaches are gaining
popularity. Dashboard approaches seek to identify the key factors for which a nurse manager
needs to frequently monitor data to manage quality and costs. The balanced scorecard uses
four areas for data evaluation-internal business processes, learning and growth, customer, and
financial-and directs managers to select indicators from each of these areas (Park & Huber,
2007). Some research has examined whether this is a feasible approach (Hall et al., 2003).

CURRENT ISSUES AND TRENDS


Leaders and managers in nursing need to track developments in outcomes measures are used.
By feeding observations from the field back to researchers, regulators, and consensus groups,
they can direct the creation of complete sets of clinically and practically important outcomes
for regular use and the design of methods for measuring and managing them. Nurse leaders
also have a crucial role in determining the important outcomes sensitive to nursing care,
acquiring computerized data support for nursing-sensitive outcomes, and then participating in
leading and managing multidisciplinary teams toward comprehensive outcomes management.
More than ever, the consequences of decisions in health care involving nursing services need
to be clarified, investigated, and better matched to outcomes management. The nursing
workforce supply is aging, and nurses report less favorable work environments, low relative
earnings, and more satisfying alternative earnings, and more satisfying alternative job
opportunities. It has become a struggle to keep up the increase in demand for health care
posed by an aging population. This has resulted in an impending workforce crisis that will
require managers to make intelligent decisions regarding how and where to invest resources.
Outcomes research will be vital for understanding the consequences of deploying various
cofigurations of staff in different circumstances, especially when traditional models of care
are no longer viable because the certain types of nursing staff are no longer available in
sufficient numbers. Nurse managers especially need these data to make empirically based
decisions regarding the effective management of their workforce, the maintenance and
improvement of facilities operatious, and the optimization of quality of care within the
systems where they work.
Outcomes research is also shaping the policy environments and constraints in which
managers must operate. For example, according to the ANA, 27 state had some form of nurse
staffing legislation enacted, proposed, or under study as of August 2007 9ANA,2007). The
forms of the staffing proposals vary from public reporting of staffing levels to mandated
staffing ratios. In 1999, then California Governor Gray Davis signed into law Assembly Bill
394 (AB 394) requiring the State department of Health Services to adopt regulations
establishing minimum nurse-to-patient ratios. The legislative intent behind the california
nurse staffing ratios was to improve quality of care, patient safety, and nurse retention
(California Department of Health Services, 2003). A significant, though not entirely
consistent, body of evidence from outcomes research demonstrating the link between
inadequate nurse staffing and unfavorable quality-of-care outcomes informed the intent of the
regulations (California Department of Health Services, 2002, 2003).
Another area receiving growing attention is the trend toward pay-for-performance
reimbursement systems that tie a pre-established portion of payment of services to the
achievement of specific levels of measurable targeted outcomes or being among the highest
scoring organizations on specific measures. Where specifiv nursing services and
interventions are linked to improvements and consistency in achieving outcomes that are
pay0for-performance indicators, managers and institutions will have a tangible incentive for
altering practice or organizational structure to achieve bette outcomes.
As consumers, regulators, and payers increase their focus on outcomes, managers must
proactively engage in outcomes management and participate in the ongoing development and
implementation of nursing-sensitive indicators of quality. Maintaining an awareness of the
advances and developments in outcomes research and the management techniques necessary
to achieve improved outcomes is essential to maximizing system performance.

LEADERSHIP & MANAGEMENT Removes barries to outcomes


BEHAVIORS improvent
Leadership Behaviors Articulates the value of nursing
Inspires outcomes thinking outcomes and practice
Enables the identification and Management Behaviors
use of evidence based knowledge Identifies outcomes of care and
to drive outcomes service
Enable outcomes measurement Measures outcomes
using computerization and large Manages the process of outcomes
nursing databases measurement
Analyzes variances
Takes corrective action when
variances occur
Overlap Areas
Determines outcomes to be
measured and managed
Leads and manages outcomes
evalution