ANA takes aim at downsizings with first nursing report card

Critics question whether outcomes indicators are specific enough

How important are nurses to a patient’s well-being? That’s the question the American Nursing Association (ANA) in Washington, DC, is hoping to answer with the first nursing report card for the acute care setting. The ANA is hoping that the report card, which measures nursing outcomes, will not only improve quality of nursing care, but will become an advocacy tool for the nursing profession by showing hospital administrators that cutting costs by cutting nursing staff is not such a great idea, contend officials at ANA, which has about 180,000 members.

The ANA commissioned a study with Lewin-VHI in Fairfax, VA, in 1995 to look at quality indicators that would be a direct result of nursing care, says ANA spokeswoman Sara Foer, MPH, MSJ. The indicators included:

• nosocomial infection rate;

• patient satisfaction;

• patient injury rate;

• maintenance of skin integrity such as incidence of bed ulcers;

• nurse staff satisfaction;

• staff mix;

• total nursing care hours provided per patient day.

Four state nursing organizations in Arizona, California, North Dakota, and Texas have so far received $10,000 grants to begin planning and data collection for these indicators, and more grants are expected to be given out by the end of the year, says Patricia Rowell, PhD, RN, senior policy fellow in the ANA’s nursing practice department. The state associations have one year to complete the first round of data collection.

Report cards could reverse trend

The report card comes at a time when downsizing is affecting the nursing-staffing mix at most hospitals, Rowell says. Changes in health care have meant mergers and downsizing, often at the expense of nursing staff. "The reality is that the changes in the hospital environment [related to nurses] have been made without any documentation, tracking, or study of their impact on patient care," Rowell says.

One problem is that data proving nursing care has a positive impact on patient outcomes has been absent from traditional report cards, which typically rely on claims, administrative data, and medical chart reviews for outcomes data, the ANA claims. In fact, an ultimate goal of the ANA is to incorporate the nursing outcomes indicators into a major report card initiative, including the Health Plan Employer Data and Information Set (HEDIS) maintained by the National Committee for Quality Assurance in Washington, DC, and the IMSystem proposed by the Joint Commission on Accreditation of Healthcare Organizations.

Yet anecdotal evidence from members shows that understaffing of nurses has negative outcomes on patient care, Rowell contends. For example, many hospitals now use nurses aides or technicians with only a week or two of training to monitor patients, start IVs, perform electrocardiograms, change dressings, and administer medications, says ANA President Virginia Trotter Betts, JD, MSN, RN. As a result, early warning signs of problems that could have been detected by a skilled nurse sometimes go undetected, and complications arise from workers performing tasks above their skill level, Rowell and Betts note.

The report card also is meant to improve public understanding of the role of nursing, ANA officials say.

"We’ve always said that nurses are one of the most important people in the patient environment, but we’ve never been able to prove it," says Nancy Grant, RN, nurse manager of the surgical intensive care unit at MedCentral Health System in Mansfield, OH. Nurse managers at MedCentral began looking for a process to measure patient care outcomes relating to nursing before the ANA launched its report card, and nurses there are pleased with the ANA’s proposal and plan to use its indicators, she adds. "Nursing needs to get out in front and prove they’re needed," Grant emphasizes.

Grant and her staff hope to use the ANA outcomes information they collect to benchmark with other hospitals and improve quality of care at MedCentral, as well as prove their worth to administrators, she says.

The report cards will also provide a useful tool to consumers when selecting health care providers, says Foer.

Definitions will need refining

One complaint about the report card is that the ANA’s definitions of indicators are not specific enough to ensure everyone records the same type of information. The ANA’s definitions are subject to interpretation, Grant says. This could pose a problem when she wants to compare outcomes, she says. "I have people who will say, the patient got weak and I had to lower him to the floor. Is that a fall? If I say it is and hospital B says it isn’t, my numbers will be much higher than theirs," she explains.

The ANA doesn’t plan to refine its definitions for indicators until after data collection has begun in earnest and hospitals begin feeding the ANA data that will help it develop more precise definitions, Rowell says. (See definitions, inserted in this issue.)

Meanwhile, the ANA has published three books on the nursing report card that cover indicators, the methodology of identification, and a guide to implementation, says Rowell. The publications are Nursing Report Card for Acute Care Settings, Nursing Indicators: Definitions — containing the ANA’s current indicator definitions and how they can be used in collecting the data — and Nursing Indicators: A Guide to Implementation. (See editor’s note at the end of article.)

At MedCentral, where data collection is just beginning, data is being extrapolated in a variety of ways. For example, the hospital’s infection control department collects data on nosocomial infections, and the risk manager is keeping statistics on falls. Statistics on skin integrity are being collected at bedside. "We hope to be concurrent," Grant says.

ANA cannot predict what impact the report card will have or when that impact will be felt in the health care community, Rowell adds. "Unfortunately, the financial bottom line is driving health care today. Hopefully, that focus will shift back to quality of care rather than solely financial considerations," she says. "We hope it happens sooner rather than later."

[Editor’s note: To receive the ANA’s nursing report card publications, call (800) 637-0323.]