Quality of care in nurse-managed health centers.

PURPOSE: The purposes of this article are to: (a) describe the first, national, collection of quality measures for nurse-managed health centers (NMHCs); (b) present the quality findings; (c) compare findings with national ambulatory care benchmarks; and (d) discuss the feasibility of national quality data collection, including NMHCs' experiences with data submission and the utilization of findings. METHODS: Quality outcomes appropriate for aggregated assessment of NMHC quality were proposed by a committee of the National Institute for Nursing Centers. Quality measures related to these outcomes were developed for breast cancer screening, cervical cancer screening, diabetes care, hypertension management, and smoking cessation based on protocols of the Health care Effectiveness Data and Information Set. Nine NMHCs were recruited to participate in retrospective data collection, manually from record audits or electronically from the submission of data files. RESULTS: Overall, quality measure findings compared favorably with national benchmarks, with particularly high quality demonstrated for chronic disease care management. CONCLUSIONS: Good to very good quality of care was documented across NMHCs, and NMHCs compared favorably with national benchmarks. Data were useful to NMHCs in identifying quality strengths and areas for improvement. National data collection proved to be feasible.

Toward a national nurse-managed health center data set: findings and lessons learned over 3 years.

Although primary care nurse-managed health centers (NMHCs) have gained increasing recognition, there are limited standardized clinical and financial data on these centers. The purpose of this paper is to present the process, benefits, and challenges in collecting standardized national data based on a consensus process from NMHCs over 3 consecutive years. The Institute for Nursing Centers (INC) NMHC Survey focuses on demographic, clinical, and financial data. A detailed codebook accompanied the INC NMHC Survey. A total of 42 NMHCs responded in at least 1 of the 3 years. Despite the challenges in collecting some of the data, especially for the first survey year, data quality improved remarkably when the INC NMHC Survey was repeated. Financial data seemed to be more easily reported than demographic or clinical data. NMHCs increase access to care, often for vulnerable populations, yet to date there are limited standardized clinical and financial data on these centers. The INC NHMC Survey and data described in this paper begins to address that gap.

Characteristics of schools of nursing operating academic nurse-managed centers.

Academic nurse-managed centers (ANMCs) can be important sites for addressing the tripartite mission of the academy. Yet, limited information about numbers of ANMCs and the schools sponsoring them is available. This paper presents an update on schools of nursing (SONs) operating ANMCs. A survey was sent to 683 deans and directors of baccalaureate and higher-degree SONs, with 565 responding (response rate: 83%). Ninety-two SONs indicated they had one or more ANMCs. The largest percentage of the SONs with ANMCs were classified as doctoral/research-intensive or extensive universities, a proportion much higher than the national percent of SONs in this category. Schools of Nursing were financially supporting centers at a lower percentage of actual costs than was reported in earlier studies, although grants continue to be a major source of funding. Academic nurse-managed centers are likely to be supported by SONs with substantial research, practice, faculty, and student resources. Overall, the national number of ANMCs seems stationary over the past two decades.

Satisfaction with a school-based teen health center: a report card on care.

Evaluations of the quality of School-Based Health Center (SBHC) care, both satisfaction and outcomes, have been developed by several state SBHC initiatives. However, few of these patient satisfaction surveys have been rigorously evaluated. An adolescent patient satisfaction based on a grading rubric familiar to the adolescents was developed and used to assess care at a nurse-managed teen health center. Satisfaction data on 190 encounters were collected in one SBHC using a report card rubric. The adolescent patients represented grades 6th through 8th, and were almost equally distributed between girls (55.9%) and boys (44.1%). This SBHC was a part of a university consortium of nurse-managed centers. Results demonstrated high satisfaction (approximately 3.7 out of 4) with care using a reliable tool (a = .84) designed for adolescents, which incorporated a grading rubric for the evaluation criteria. The nurse practitioner received high marks for listening to the students and treating the students with respect. Yet, statistical differences by grade level were found. The satisfaction tool was found to be reliable (alpha = .84) and consistent with adolescent's perspectives on satisfaction with health care. The study is the first published report that specifically examined student satisfaction with care in a nurse-managed SBHC. Overall satisfaction with care received high "grades" from both first time and repeat users, and from boys and girls.

Impact of academic nurse-managed centers on communities served.

PURPOSE: This paper presents findings from six community focus groups that addressed the impact of academic nurse-managed centers (ANMCs) on the overall community being served as well as the quality of care provided in the centers. DATA SOURCES: Experts in focus group methodology from a public health institute conducted the six focus groups at ANMCs from four universities in the Midwest. Discussions were guided by nine questions presented to each group. All groups were tape-recorded and transcribed. A total of 37 participants were recruited from the ANMCs and included patients and families, advisory board members, and local community organizations. CONCLUSIONS: Four themes were identified across the six focus groups: valuing patient-centered care, which included two subthemes-continuous specific provider and specific aspects of care; quality of care; increasing access to care/addressing the safety net; and evidence of outreach. IMPLICATIONS FOR PRACTICE: Findings from these focus groups verify that community members do "get it" in terms of the unique aspects of ANMCs. Participants were able to articulate the differences between nurse-managed care and other types of ambulatory primary care. The unique strengths of nurse practitioners were repeatedly articulated as well as the centers' outreach into the community.

Clients served and services provided by academic nurse-managed centers.

Currently, no national database for academic nurse-managed centers (ANMCs) exists. These primary care services remain somewhat invisible in the policy and reimbursement areas of the American primary care system and, consequently, are undersupported. The purpose of this article is to describe client and service data from a national study of ANMCs. A cross-sectional survey design was used to collect data from ANMC directors. Usable data were received from 64 centers. ANMCs in the sample were relatively small in terms of patients and volume. Client and service profiles demonstrated variation, which seemed to be reflective of needs relative to populations and communities served. Nearly half of the ANMCs responding served clients of all ages, with services representing the breadth of primary care (i.e., health maintenance and management of minor acute and common chronic illnesses). Evidence of community-focused care was also noted. The reported use of standardized nursing language was low. Standardized medical taxonomies were more commonly used, with International Classification of Diseases, Ninth Revision being the most common. ANMCs provide a small but substantial amount of primary care services in communities served. Findings indicated a need for ANMCs to improve the documentation of their contributions through the use of standardized taxonomies to provide aggregated reporting for policy and research purposes.

National consensus on data elements for nurse managed health centers.

This report presents a summary of the findings from the National Network for Nurse Managed Health Centers Data Consensus Conference. Nationally, nurse-managed health centers are increasingly offering communities another option for access to high-quality primary care. The lack of agreed upon, standardized data elements for these centers has limited the ability to present clear information about their contributions as well as to inform policy related to their support and development. Fifty-three national invitees came to consensus in Washington, DC on the critical data elements for a national database for nurse-managed health centers. This database includes both clinical and financial/business practices elements. Consensus was not reached around some clinical areas. These areas are briefly discussed as well as the plans for next stages of data collection.

Selecting control interventions for clinical outcome studies.

In the current research environment the design and management of control groups is becoming more complex. The selection of a control group design is dependent on study goals, presence and quality of existing interventions, urgency of the problem or issue being addressed by the intervention, and factors related to the study site. The purpose of the presentation is to identify various approaches to the design of control groups in experimental studies and to identify their strengths, limitations, and applications. A case study exemplifies the issues associated with control group selection and design.

Measuring quality in nurse-managed centers using HEDIS measures.

Nurse-managed centers (NMCs) provide viable options for primary healthcare and contribute substantially to filling access gaps for vulnerable populations. The purposes of this paper are to (a) describe a pilot application and adaptation of eight Health Plan Employer Data and Information Set (HEDIS) measures to six NMCs, (b) report the findings from the quality assessments, and (c) compare findings to national HEDIS data. The eight quality assessment areas are asthma, cervical cancer screening, childhood immunizations, depression, diabetes, hypertension, mammography screening, and smoking cessation. The NMCs achieved or exceeded HEDIS 50th percentile levels in a number of important clinical areas, but did not attain the 50th percentile level in others. Thus, HEDIS measures are relevant for the assessment of care quality and provide useful data for quality improvement in NMCs.

Academic nurse-managed centers: approaches to evaluation.

A comprehensive evaluation plan was developed to assess the outcomes of a multiuniversity project to support the development of academic nurse-managed centers (ANMCs). The evaluation included measuring ANMC impact on the clients and communities served, on students, and on the sponsoring faculties and universities. This article includes a discussion of the processes used in evaluation plan development, the variables measured, the tools developed to measure selected variables, and a summary of evaluation findings. Recommendations for use of selected evaluation components across ANMCs are presented.

The effects of nurse staffing on adverse events, morbidity, mortality, and medical costs.

BACKGROUND: Nurse staffing levels are an important working condition issue for nurses and believed to be a determinant of the quality of nursing care and patient outcomes. OBJECTIVES: To examine the effects of nurse staffing on adverse events, morbidity, mortality, and medical costs. METHODS: Using two existing databases, the study sample included 232 acute care California hospitals and 124,204 patients in 20 surgical diagnosis-related groups. The adverse events included patient fall/injury, pressure ulcer, adverse drug event, pneumonia, urinary tract infection, wound infection, and sepsis. Multilevel analysis was employed to examine, simultaneously, the effects of nurse staffing and patient and hospital characteristics on patient outcomes. RESULTS: Three statistically significant relationships were found between nurse staffing and adverse events. An increase of 1 hour worked by registered nurses (RN) per patient day was associated with an 8.9% decrease in the odds of pneumonia. Similarly, a 10% increase in RN Proportion was associated with a 9.5% decrease in the odds of pneumonia. Providing a greater number of nursing hours per patient day was associated with a higher probability of pressure ulcers. The occurrence of each adverse event was associated with a significantly prolonged length of stay and increased medical costs. Patients who had pneumonia, wound infection or sepsis had a greater probability of death during hospitalization. CONCLUSION: Patients are experiencing adverse events during hospitalization. Care systems to reduce adverse events and their consequences are needed. Having appropriate nurse staffing is a significant consideration in some cases.

Educational implications of nurse practitioner students and medical residents' attitudes toward managed care.

The increasing number of individuals enrolled in managed care organizations is a key consideration when planning effective models of education for future health care professionals. This study compares attitudes toward managed care between medical residents (MRs) (n = 431) and advanced practice nursing students (APNSs) (n = 153) in a Midwestern U.S. state, and it reports the results of a factor analysis of the attitude survey. MRs and APNSs completed a 34-item questionnaire. Results show that MRs were more likely than APNSs to believe that cost has priority over quality of care in a managed care setting and that managed care threatens the autonomy of health care providers. APNS were more likely than MRs to believe that managed care encourages preventive health care. Other comparisons related to Medicaid, capitation, practice guidelines, and success factors are discussed. Findings indicate that MRs were more inclined to see managed care as an economic threat to quality of care than APNSs. At the same time, MRs were somewhat less enthusiastic about practice guidelines and patient outcomes as measures of success in managed care settings than APNSs. Educational implications of findings are discussed.

Health outcomes of incarcerated pregnant women and their infants in a community-based program.

An experimental, community-based, residential program, focused on health promotion, was established in 1990 for incarcerated pregnant women with short-term sentences and histories of drug abuse in a large, midwestern metropolitan area in the United States. Infants resided with mothers after birth. Prenatal care, delivery, postpartum, and family-planning services were initiated and provided by a nurse-midwifery service. Community-based health care, job training, and drug rehabilitation were provided for women during pregnancy through the fourth postpartum month. Program participants' prenatal, delivery, postpartum, and neonatal health outcomes are presented and compared with those of incarcerated women in the same state prison system who experienced usual correctional facility care and support. Program participants represented a group of obstetrically high-risk women. Health outcomes for both groups of incarcerated women and their infants were similar and more optimal than would have been expected given their preexisting health conditions and risk factors.

The HANDS project: studying and refining the automated collection of a cross-setting clinical data set.

The consistent availability of a core set of clinical nursing data is essential to promote quality patient care. Although important work to improve terminology and enhance comparability of data is underway, the efforts do not address the immediate need for useful nursing data sets and valid methods of collection at the point of data entry. The Hands-on Automated Nursing Data System (HANDS) project is dedicated to refining a feasible methodology for gathering, storing, and retrieving a standardized nursing data set. To date the project team has developed and tested a prototype research tool that is automated and contains the structured terminologies (North American Nursing Diagnosis Association, Nursing Outcomes Classification, and Nursing Interventions Classification) to represent nursing diagnoses, outcomes, and interventions, respectively. The Phase I project development activities are reported in this article, along with Phase II and III plans for testing and refining the methodology under actual clinical conditions. Results and lessons learned during Phase I are reported.