National Quality Forum Develops First National Performance Standards for Nursing Care
In November 2004, the National Quality Forum endorsed national voluntary consensus standards for nursing-sensitive care. The consensus standards enable assessment of the extent to which nurses in acute care hospitals contribute to health care quality, patient safety, and a professional and safe work environment. The project team also identified priority areas for research.
- The National Quality Forum's 15 national voluntary consensus standards for nursing-sensitive care (on patient outcomes, nursing interventions and system-level measures) are the first national, standardized, and consensus-based performance measures for nursing care. The consensus standards enable consumers to assess the quality of nursing care in hospitals and providers to identify critical outcomes and processes of care for continuous improvement. Purchasers can use the consensus standards to reward hospitals for better performance.
- See Results for a list of the consensus standards. For research recommendations, see Recommendations).
The Robert Wood Johnson Foundation (RWJF) supported this project with an unsolicited grant of $200,000.
Nurses, as the principal caregivers in any health care system, are critical to the quality of care patients receive. Until the National Quality Forum endorsed its set of voluntary consensus standards, there had been no standardized nursing care performance measures, according to the project director, Ellen Kurtzman, representing a major void in health care quality assurance and work system performance efforts.
This grant fits with RWJF's strategic objective in its nursing work: by 2013, reduce the shortage in nurse staffing and improve the quality of nursing-related care by transforming the way care is delivered at the bed side.
The National Quality Forum endorsed a set of national voluntary consensus standards to assess the extent to which nurses in acute care hospitals contribute to health care quality, patient safety, and a professional and safe work environment. Based in Washington, the National Quality Forum is a private, nonprofit membership organization that works to develop and implement a national strategy for health care quality measurement and reporting. Part of its work involves setting voluntary consensus standards through a formal, open, transparent process that encourages the input of a diverse set of stakeholders, in accordance with federal law.
Project staff convened a 22-member steering committee (representing consumers, providers, purchasers, and research and quality improvement organizations), which recommended a set of proposed consensus standards and developed associated research recommendations with the aid of a three-member technical advisory panel that provided additional technical review and advice on scientific and research issues (see Appendix 1 for a list of members). Project staff facilitated the steering committee and advisory panel's work (together referred to as the project team).
Through a literature search, discussions with representatives of nursing, professional and specialty organizations, and a "call for measures" (to National Quality Forum members, and nursing, professional and specialty organizations), the project team identified more than 150 candidate standards. After excluding those that did not meet screening thresholds (e.g., measures that did not apply to hospital inpatient or emergency care), the team evaluated remaining standards for:
- scientific acceptability,
- usability and
The project team then recommended a set of proposed consensus standards to the NQF Membership and public for review and comment. All candidate standards had to be nursing sensitive (measures that nurses affected, provided and/or influenced, but for which they were not exclusively responsible, such as collegiality of nurse-physician relations).
A 30-day public comment period enabled nearly 100 organizations (hospitals, public and private payors, schools of nursing, medical societies and professional organizations, consumer groups, unions and health plans) to comment on the recommended consensus standards. The project team used these comments to refine those recommended for endorsement. National Quality Forum members voted on these recommended standards, and, ultimately, the forum's board of directors endorsed 15 of them as national voluntary consensus standards. The board also endorsed priority areas for research (see Recommendations) and associated recommendations for action (see Appendix 2).
The endorsed consensus standards, and the process by which NQF endorsed them, are presented in a report titled National Voluntary Consensus Standards for Nursing-Sensitive Care: An Initial Performance Measure Set, which the National Quality Forum sent to members and posted online. Team members published an article on the project in Nursing Administration Quarterly and made a presentation at the 2003 Academy Health Annual Meeting. See the Bibliography for details. The federal Department of Veterans Affairs provided $30,500 for the project.
The following results were reported in the report entitled National Voluntary Consensus Standards for Nursing-Sensitive Care: An Initial Performance Measure Set. As stated in this report, the primary purpose of measuring nursing care delivered in U.S. hospitals is to promote the highest level of patient safety and health care outcomes.
- The National Quality Forum-endorsed 15 national voluntary consensus standards for nursing care (on patient outcomes, nursing interventions and system-level measures) are the first national standardized performance measures for nursing care. The consensus standards enable consumers to assess the quality of nursing care in hospitals and providers to identify critical outcomes and processes of care for continuous improvement; purchasers can use the consensus standards to reward hospitals for better performance. The consensus standards are:
Patient-centered Outcome Measures:
- Death among surgical inpatients with treatable serious complications (failure to rescue): The percentage of major surgical inpatients who experience a hospital-acquired complication and die.
- Pressure ulcer prevalence: Percentage of inpatients who have a hospital acquired pressure ulcer.
- Falls prevalence: Number of inpatient falls per inpatient days.
- Falls with injury: Number of inpatient falls with injuries per inpatient days.
- Restraint prevalence: Percentage of inpatients who have a vest or limb restraint.
- Urinary catheter-associated urinary tract infection for intensive care unit (ICU) patients: Rate of urinary track infections associated with use of urinary catheters for ICU patients.
- Central line catheter-associated blood stream infection rate for ICU and high-risk nursery patients: Rate of blood stream infections associated with use of central line catheters for ICU and high-risk nursery patients.
- Ventilator-associated pneumonia for ICU and high-risk nursery patients: Rate of pneumonia associated with use of ventilators for ICU and high-risk nursery patients.
Nursing-centered Intervention Measures:
- Smoking cessation counseling for acute myocardial infarction.
- Smoking cessation counseling for heart failure.
- Smoking cessation counseling for pneumonia.
Each measures the percentage of patients with a history of smoking within the past year who received smoking cessation advice or counseling during hospitalization.
- Skill mix: Percentage of registered nurse, licensed vocational/practical nurse, unlicensed assistive personnel, and contracted nurse care hours to total nursing care hours.
- Nursing care hours per patient day: Number of registered nurses per patient day and number of nursing staff hours (registered nurse, licensed vocational/practical nurse, and unlicensed assistive personnel) per patient day.
- Practice Environment Scale Nursing Work Index: Composite score and scores for five subscales:
- nurse participation in hospital affairs
- nursing foundations for quality of care
- nurse manager ability, leadership and support of nurses
- staffing and resource adequacy
- collegiality of nurse-physician relations.
- Voluntary turnover: Number of voluntary uncontrolled separations during the month by category (RNs, APNs, LVN/LPNs, NAs).
The following research recommendations, summarized from the final report, were endorsed by NQF's board. These areas represent "significant gaps in the initial set of endorsed consensus standards."
- Workforce measures: To understand fully and differentiate the contribution of nursing services to health care, develop workforce measures and the empirical base to support their relationship to quality and patient safety.
- Pain assessment and management measures: Because of the applicability of pain assessment and management measures to all patients and all nursing personnel, research to identify measures that specifically explore nursing's contribution to the assessment and management of pain should be undertaken immediately.
- Nurse-centered intervention process measures: Research should be undertaken to determine the relationship between patient outcomes and nurse-centered intervention process measures, including those that describe the distinctive contributions of nursing (e.g., assessment, problem identification, prevention and patient education) and the dependent, independent and interdependent activities of nurses.
- Measures for other gaps: To address significant gaps in nursing care performance measurement, additional research should be undertaken in a broad range of important areas, including:
- Positive nursing-sensitive measures that promote the highest quality and safety of health care (e.g., symptom management and improved function), rather than measures that address adverse events and negative outcomes.
- Measures that address all six National Quality Forum aims (i.e., care that is safe, beneficial, patient centered, timely, efficient and equitable).
- Measures that address the Institute of Medicine's priority areas for quality improvement.
- Measures that address the role of patient care teams in achieving improved health care outcomes.
- Sufficiency of measures against evaluation criteria: To inform implementation of the National Quality Forum nursing care consensus standards, research should continue to investigate and document each standard's adequacy against the evaluation criteria (e.g., the extent to which each measure is important, scientifically acceptable, usable and feasible).
- Use a standardized process of consensus development to allow health care stakeholders from diverse perspectives to apply uniform criteria to the universe of potential measures and select those that are most important, scientifically acceptable, usable and feasible. The approach to developing these consensus standards, and the parameters for screening and evaluating measures established through this project provide a potential model for other projects that seek agreement on assessing health care quality at the professional versus the health care institution level. (Project Director)
- Include a public comment period as part of a consensus development process to ensure a strong public voice in shaping standards. The National Quality Forum relies on a 30-day period for public comments on the proposed consensus standards before endorsing them. These comments shaped the final consensus standards. For example, while the project team did not initially recommend a measure on voluntary turnover, after comments supported its inclusion, the team included this in the standards recommended for endorsement. (Project Director)
AFTER THE GRANT
Supported by RWJF, the Joint Commission led a collaborative effort to develop specifications for implementing the 15 nursing-senstive performance measures. The resulting document—Implementation Guide for the National Quality Forum Endorsed Nursing-Sensitive Care Performance Measures—was published online by the commission in 2005 for public use. See Grant Results on ID# 051781.
RWJF also funded these related projects:
- In December 2005 RWJF gave the National Quality Forum a one-year, $93,116 grant to develop a system to track implementation of the performance measures in hospitals (Grant ID# 053972). The project staff worked to establish a tracking database and used surveys to identify implementation successes, challenges and technical considerations.
- In January 2007 RWJF provided $299,490 in funding to the Joint Commission to test the National Quality Forum-endorsed measure set for reliability, feasibility and impact on quality of care in a group of volunteer test hospitals (ID# 059409). The Joint Commisson completed analysis of the test results in December 2008 and planned to modify its 2005 implementation guide to incorporate recommendations made by an advisory committee. For more information, see Grant Results.
Meanwhile, the National Quality Forum-endorsed nursing-sensstive measures had an impact on health care improvement efforts, including the following:
- As part of the RWJF national program Transforming Care at the Bedside, program staff at the Institute for Healthcare Improvement used six of the standards to quantify improvements in patient care at the program's participating hospitals. (The six were falls prevalence, falls with injury, pressure ulcer prevalence, failure to rescue, voluntary turnover and nursing care hours per patient day.)
- Hospital Compare, a service that compares the quality of care provided in hospitals, included three of the standards among its publicly reported measures. (The three are smoking cessation measures for acute myocardial infarction, heart failure and pneumonia patients.) Hospital Compare is a product of the Hospital Quality Alliance, a public-private collaborative of hospitals and clinicians, consumer groups, purchasers, accrediting bodies and government agencies.
GRANT DETAILS & CONTACT INFORMATION
Identifying Core Measures for Nursing Care Performance
National Quality Forum (Washington, DC)
Dates: February 2003 to November 2004
Ellen Kurtzman, R.N., M.P.H.
Steering Committee and Technical Advisory Panel
Lillee S. Gelinas, R.N., M.S.N. (Co-Chair)
Vice President, Clinical Performance; Chief Nursing Officer
Mary D. Naylor, Ph.D., R.N. (Co-Chair)
Professor of Gerontology
University of Pennsylvania School of Nursing
G. Rumay Alexander, Ed.D., R.N.
Director of the Office of Multicultural Affairs
University of North Carolina-Chapel Hill
School of Nursing/American Organization of Nurse Executives
Chapel Hill, N.C.
Linda Burnes Bolton, Dr.P.H., R.N.
Vice President and Chief Nursing Officer
Cedars-Sinai Health System
Los Angeles, Calif.
Col. Laura R. Brosch, A.N., Ph.D.
Chief of Nursing Research Service
U.S. Army Medical Research and Materiel Command
Fort Detrick, Md.
Diane Storer Brown, Ph.D., R.N.
Director of Quality & Continuous Readiness Accreditation, Regulation, and Licensing
Kaiser Permanente-Northern California Region
Peter I. Buerhaus, Ph.D., R.N.
Professor of Nursing; Senior Associate Dean for Research
Vanderbilt University School of Nursing
Catholic Healthcare Partners
Gaye J. Fortner, R.N., B.S.N., M.S.N.
Vice President, Operations
HealthCare21 Business Coalition
Carrier Relations and Carrier Performance, Employee Benefits
The Boeing Company
Stephen J. Horner, R.N.
Assistant Vice President, Outcomes Measurement
Jerod M. Loeb, Ph.D.
Executive Vice President, Division of Research
Joint Commission on Accreditation of Healthcare Organizations
Oakbrook Terrace, Ill.
Naomi Naierman, M.P.A.
American Hospice Foundation
Cathy Rick, R.N.
Chief Nursing Officer
Office of Nursing Services
Department of Veterans Affairs
Elmore F. Rigamer, M.D., M.P.A.
Systems Medical Director Medical and Director of Informatics
Bernard Rosof, M.D.
Senior Vice President for Corporate Relations and Health Affairs
North Shore-Long Island Jewish Health System
Great Neck, N.Y.
Diane Sosne, R.N., M.N.
Service Employees International Union
Wanda O. Wilson, Ph.D., M.S.N., C.R.N.A.
Associate Professor of Nursing and Program Director
College of Nursing
University of Cincinnati Medical Center
Steering Committee Liaison Members
Barbara A. Blakeney, M.S., A.P.R.N., B.C., A.N.P.
American Nurses Association
Yvonne Bryan, Ph.D., R.N.
Program Director, Office of Extramural Programs
National Institute of Nursing Research
Judy Goldfarb, M.A., R.N.
Centers for Medicare and Medicaid Services
Barbara J. Hatcher, Ph.D., M.P.H., R.N.
Director, Scientific and Professional Affairs
American Public Health Association
Technical Advisory Panel
Eileen Lake, Ph.D., R.N.
Assistant Professor of Nursing
University of Pennsylvania School of Nursing
Margaret L. McClure, Ed.D., R.N.
Chief Operating Officer
New York University
American Academy of Nursing
New York, N.Y.
Jack Needleman, Ph.D.
UCLA School of Public Health
Los Angeles, Calif.
The following actions related to the use and implementation of the voluntary consensus standards for nursing care were recommended in the report entitled National Voluntary Consensus Standards for Nursing-Sensitive Care: An Initial Performance Measure Set.
- Data issues: There is a pressing need for providers, researchers and information system vendors to develop better data systems to support nursing care monitoring functions and conduct research.
- Use for quality improvement: To be most useful for quality improvement purposes, measures should be collected and analyzed by providers at the hospital unit level, unless the sample size is so small that it would allow for the identification of individual nurses. To avoid a punitive environment, measures should be reported at the institutional level.
- Implementation: The readiness of provider organizations to implement the consensus standards should be used as an overall indication of their commitment to provide quality patient care and an environment that is supportive of nursing.
- Use as a Set: The consensus standards for nursing-sensitive performance should be viewed by health care stakeholders as a set of measures that characterizes the influence of nursing personnel on health care processes and patient outcomes. No individual measure is intended to be a sole or stand-alone indicator of nursing care quality.
- Improving the set: The National Quality Forum should review the initial set of voluntary consensus standards for nursing-sensitive care on a regular basis (at least once every three years) to revise, evaluate and identify improvements.
(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)
Kurtzman ET and Kizer KW. "Evaluating the Performance and Contribution of Nurses to Achieving an Environment of Safety." Nursing Administration Quarterly, 29(1): 1423, 2005. Abstract available online.
National Quality Forum. National Voluntary Consensus Standards for Nursing-Sensitive Care: An Initial Performance Measure Set. Washington: National Quality Forum, 2004. Abstract and Executive Summary available online.
Report prepared by: Robert Crum
Reviewed by: Lori De Milto
Reviewed by: Marian Bass
Program Officer: Lori A. Melichar