Engaging Frontline Staff in Performance Improvement: The American Organization of Nurse Executives Implementation of Transforming Care at the Bedside Collaborative.

BACKGROUND: Process improvement stresses the importance of engaging frontline staff in implementing new processes and methods. Yet questions remain on how to incorporate these activities into the workday of hospital staff or how to create and maintain its commitment. In a 15-month American Organization of Nurse Executives collaborative involving frontline medical/surgical staff from 67 hospitals, Transforming Care at the Bedside (TCAB) was evaluated to assess whether participating units successfully implemented recommended change processes, engaged staff, implemented innovations, and generated support from hospital leadership and staff. METHODS: In a mixed-methods analysis, multiple data sources, including leader surveys, unit staff surveys, administrative data, time study data, and collaborative documents were used. RESULTS: All units reported establishing unit-based teams, of which >90% succeeded in conducting tests of change, with unit staff selecting topics and making decisions on adoption. Fifty-five percent of unit staff reported participating in unit meetings, and 64%, in tests of change. Unit managers reported substantial increase in staff support for the initiative. An average 36 tests of change were conducted per unit, with 46% of tested innovations sustained, and 20% spread to other units. Some 95% of managers and 97% of chief nursing officers believed that the program had made unit staff more likely to initiate change. Among staff, 83% would encourage adoption of the initiative. CONCLUSIONS: Given the strong positive assessment of TCAB, evidence of substantial engagement of staff in the work, and the high volume of innovations tested, implemented, and sustained, TCAB appears to be a productive model for organizing and implementing a program of frontline-led improvement.

Facilitating Nurses' Engagement in Hospital Quality Improvement: The New Jersey Hospital Association's Implementation of Transforming Care at the Bedside.

Transforming Care at the Bedside (TCAB) is a program designed by the Robert Wood Johnson Foundation and the Institute for Healthcare Improvement to engage frontline staff in change processes to improve the work environment and patient care on nursing units. Originally designed and piloted in a small number of hospitals, TCAB is being disseminated through large-scale quality improvement (QI) collaboratives facilitated by professional organizations, such the New Jersey Hospital Association's Institute for Quality and Patient Safety (NJHA). This article presents the results of an evaluation of the NJHA dissemination effort. The evaluation team used an observational mixed-method evaluation design and multiple data sources to assess implementation of TCAB by nursing units in these facilities. The results show that most of the participating units successfully implemented the TCAB improvement processes. Nursing teamwork and three nursing-sensitive outcomes improved significantly over the course of TCAB, and TCAB unit managers attributed important improvements to their unit's participation. These findings suggest that TCAB is a viable mechanism for engaging frontline nursing staff in valuable QI activities. Other hospitals interested in furthering the culture and capacity for QI among frontline nursing unit staff should consider a TCAB collaborative for achieving these goals.

Assessing the impact of academic-practice partnerships on nursing staff.

BACKGROUND: The 'spillover effect' of academic-practice partnerships on hospital nursing staff has received limited attention. In 2007, the Department of Veterans Affairs (VA) created the VA Nursing Academy (VANA) to fund fifteen partnerships between schools of nursing and local VA healthcare facilities. In this paper, we examine the experiences of the VA staff nurses who worked on the units used for VANA clinical training. METHODS: We used survey methods to collect information from staff nurses at all active VANA sites on their characteristics, exposure to the program's clinical training activities, satisfaction with program components, and perspectives of the impact on their work and their own plans for education (N = 314). Our analyses utilized descriptive statistics and bivariate and multivariate regression. RESULTS: Results show that staff nurses working on VANA units had moderately high levels of exposure to the program's clinical education activities, and most reported positive experiences with those activities. The vast majority (80 %) did not perceive the presence of students as making their work more difficult. Among those who were enrolled or considering enrolling in a higher education program, over a quarter (28 %) said that their VA's participation in VANA had an influence on this decision. The majority of staff nurses were generally satisfied with their experience with the students. Their satisfaction with the program was related to the level or dose of their exposure to it. Those who were more involved were more satisfied. Greater interaction with the students, more information on the program, and a preceptor role were all independently associated with greater program satisfaction. CONCLUSIONS: Our study suggests that academic-practice partnerships may have positive spillover effects on staff nurses who work on clinical education units. Further, partnerships may be able to foster positive experiences for their unit nurses by focusing on informing and engaging them in clinical training activities. In particular, our results suggest that academic-practice partnerships should keep unit nurses well informed about program content and learning objectives, encourage frequent interaction with students, involve them in partnership-related unit-based activities, and urge them to become preceptors for the students.

Doctor of nursing practice by 2015: an examination of nursing schools' decisions to offer a doctor of nursing practice degree.

OBJECTIVES: The American Association of Colleges of Nursing recommends that nursing schools transition their advanced practice registered nurse (APRN) programs to doctor of nursing practice (DNP) programs by 2015. However, most schools have not yet made this full transition. The purpose of this study was to understand schools' decisions regarding the full transition to the DNP. METHODS: Key informant interviews and an online survey of nursing school deans and program directors were performed. DISCUSSION: The vast majority of schools value the DNP in preparing APRNs for the future of the health care system. However, other important factors influence many schools to fully transition or not to the postbaccalaureate DNP, including perceived student and employer demand, issues concerning accreditation and certification, and resource constraints. CONCLUSION: Multiple pathways to becoming an APRN are likely to remain until various factors (e.g., student and employer demand, certification and accreditation issues, and resource constraints) yield a more favorable environment for a full transition to the DNP.

The DNP by 2015: A Study of the Institutional, Political, and Professional Issues that Facilitate or Impede Establishing a Post-Baccalaureate Doctor of Nursing Practice Program.

In 2004, members of the American Association of Colleges of Nursing (AACN) voted to endorse a position statement identifying the doctor of nursing practice (DNP) degree as the most appropriate degree for advanced-practice registered nurses (APRNs) to enter practice. At the same time, AACN members voted to approve the position that all master's programs that educate APRNs to enter practice should transition to the DNP by 2015. While the number of DNP programs for APRNs has grown significantly and steadily over this period, at this time, not all nursing schools have made this transition. To better understand why, the AACN contracted with RAND to investigate schools' progress toward this goal and the factors that facilitate or impede this transition. This article describes the results of a mixed-method RAND study undertaken between October 2013 and April 2014 that sought to understand schools' program offerings to prepare APRNs to enter practice and the reasons for those offerings, as well as the barriers or facilitators to nursing schools' full adoption of the DNP.

Examining the value of inpatient nurse staffing: an assessment of quality and patient care costs.

BACKGROUND: Inpatient quality deficits have important implications for the health and well-being of patients. They also have important financial implications for payers and hospitals by leading to longer lengths of stay and higher intensity of treatment. Many of these costly quality deficits are particularly sensitive to nursing care. OBJECTIVE: To assess the effect of nurse staffing on quality of care and inpatient care costs. DESIGN: Longitudinal analysis using hospital nurse staffing data and the Healthcare Cost and Utilization Project State Inpatient Databases from 2008 through 2011. SUBJECTS: Hospital discharges from California, Nevada, and Maryland (n=18,474,860). METHODS: A longitudinal, hospital-fixed effect model was estimated to assess the effect of nurse staffing levels and skill mix on patient care costs, length of stay, and adverse events, adjusting for patient clinical and demographic characteristics. RESULTS: Increases in nurse staffing levels were associated with reductions in nursing-sensitive adverse events and length of stay, but did not lead to increases in patient care costs. Changing skill mix by increasing the number of registered nurses, as a proportion of licensed nursing staff, led to reductions in costs. CONCLUSIONS: The study findings provide support for the value of inpatient nurse staffing as it contributes to improvements in inpatient care; increases in staff number and skill mix can lead to improved quality and reduced length of stay at no additional cost.

The critical elements of effective academic-practice partnerships: a framework derived from the Department of Veterans Affairs Nursing Academy.

BACKGROUND: The nursing profession is exploring how academic-practice partnerships should be structured to maximize the potential benefits for each partner. As part of an evaluation of the U.S. Department of Veterans Affairs Nursing Academy (VANA) program, we sought to identify indicators of successful partnerships during the crucial first year. METHODS: We conducted a qualitative analysis of 142 individual interviews and 23 focus groups with stakeholders from 15 partnerships across the nation. Interview respondents typically included the nursing school Dean, the VA chief nurse, both VANA Program Directors (VA-based and nursing school-based), and select VANA faculty members. The focus groups included a total of 222 VANA students and the nursing unit managers and staff from units where VANA students were placed. An ethnographic approach was utilized to identify emergent themes from these data that underscored indicators of and influences on Launch Year achievement. RESULTS: We emphasize five key themes: the criticality of inter-organizational collaboration; challenges arising from blending different cultures; challenges associated with recruiting nurses to take on faculty roles; the importance of structuring the partnership to promote evidence-based practice and simulation-based learning in the clinical setting; and recognizing that stable relationships must be based on long-term commitments rather than short-term changes in the demand for nursing care. CONCLUSIONS: Developing an academic-clinical partnership requires identifying how organizations with different leadership and management structures, different responsibilities, goals and priorities, different cultures, and different financial models and accountability systems can bridge these differences to develop joint programs integrating activities across the organizations. The experience of the VANA sites in implementing academic-clinical partnerships provides a broad set of experiences from which to learn about how such partnerships can be effectively implemented, the barriers and challenges that will be encountered, and strategies and factors to overcome challenges and build an effective, sustainable partnership. This framework provides actionable guidelines for structuring and implementing effective academic-practice partnerships that support undergraduate nursing education.

CMS Innovation Center Health Care Innovation Awards: Evaluation Plan.

The Center for Medicare and Medicaid Innovation within the Centers for Medicare & Medicaid Services (CMS) has funded 108 Health Care Innovation Awards, funded through the Affordable Care Act, for applicants who proposed compelling new models of service delivery or payment improvements that promise to deliver better health, better health care, and lower costs through improved quality of care for Medicare, Medicaid, and Children's Health Insurance Program enrollees. CMS is also interested in learning how new models would affect subpopulations of beneficiaries (e.g., those eligible for Medicare and Medicaid and complex patients) who have unique characteristics or health care needs that could be related to poor outcomes. In addition, the initiative seeks to identify new models of workforce development and deployment, as well as models that can be rapidly deployed and have the promise of sustainability. This article describes a strategy for evaluating the results. The goal for the evaluation design process is to create standardized approaches for answering key questions that can be customized to similar groups of awardees and that allow for rapid and comparable assessment across awardees. The evaluation plan envisions that data collection and analysis will be carried out on three levels: at the level of the individual awardee, at the level of the awardee grouping, and as a summary evaluation that includes all awardees. Key dimensions for the evaluation framework include implementation effectiveness, program effectiveness, workforce issues, impact on priority populations, and context. The ultimate goal is to identify strategies that can be employed widely to lower cost while improving care.

A dementia care management intervention: which components improve quality?

OBJECTIVES: To analyze whether types of providers and frequency of encounters are associated with higher quality of care within a coordinated dementia care management (CM) program for patients and caregivers. DESIGN: Secondary analysis of intervention-arm data from a dementia CM cluster-randomized trial, where intervention participants interacted with healthcare organization care managers (HOCMs), community agency care managers (CACMs), and/ or healthcare organization primary care providers (HOPCPs) over 18 months. METHODS: Encounters of 238 patient/caregivers (dyads) with HOCMs, CACMs, and HOPCPs were abstracted from care management electronic records. The quality domains of assessment, treatment, education/support, and safety were measured from medical record abstractions and caregiver surveys. Mean percentages of met quality indicators associated with exposures to each provider type and frequency were analyzed using multivariable regression, adjusting for participant characteristics and baseline quality. RESULTS: As anticipated, for all 4 domains, the mean percentage of met dementia quality indicators was 15.5 to 47.2 percentage points higher for dyads with HOCM--only exposure than for dyads with none (all P < .008); not anticipated were higher mean percentages with increasing combinations of provider-type exposure-up to 73.7 percentage points higher for safety (95% confidence interval 65.2%-82.1%) with exposure to all 3 provider types compared with no exposure. While greater frequency of HOCM-dyad encounters was associated with higher quality (P < .04), this was not so for other provider types. CONCLUSIONS: HOCMs' interactions with dyads was essential for dementia care quality improvement. Additional coordinated interactions with primary care and community agency staff yielded even higher quality.

Nurse Practitioners and Sexual and Reproductive Health Services: An Analysis of Supply and Demand.

Use of Sexual and Reproductive Health (SRH) services is projected to grow between 10 and 20 percent from 2006 to 2020. This growth is driven largely by changes in the racial/ethnic make-up of the population of women of reproductive age and an increase in the number of people with insurance coverage because of new health care legislation. Trends in supply and demand for SRH services, particularly for low-income individuals, suggest demand will outstrip supply in the next decade. Nurse Practitioners (NPs) with a women's health focus are key providers of SRH care in Title X-funded clinics, which deliver a significant proportion of U.S. family planning and SRH services to low-income populations. This article looks at why numbers of women's health NPs (WHNPs) have been declining, and are projected to continue to decline, despite significant growth in total numbers of NPs. Barriers to increasing the supply of NPs competent in SRH care-such as reduced funding for WHNP training, increased funding for primary care and geriatric NP training, and a shrinking proportion of WHNPs choosing to work in public health, clinics, and family planning-are identified. From the standpoint that the evolution of the health care delivery system may serve as an opportunity to optimize the delivery of SRH services in the United States, a comprehensive set of options spanning education, federal and state regulations, and emerging models of care delivery are explored to reverse this trend of too few WHNPs, particularly for servicing Title X facilities and their patients.

The relationship between the volume and type of transforming care at the bedside innovations and changes in nurse vitality.

Through an initiative called Transforming Care at the Bedside (TCAB), the Robert Wood Johnson Foundation and the Institute for Healthcare Improvement have created an innovative bottom-up framework for redesigning the work environment on medical-surgical units. The specific purpose of this study, conducted by the University of California Los Angeles/RAND evaluation team, was to examine the number of innovations tested and the association of the volume of tests made and changes in a summary measurement of self-reported vitality at the 13 participating hospitals. The findings of this evaluation yielded several important implications for nurse leaders.

Spreading nursing unit innovation in large hospital systems.

Healthcare administrators increasingly face the challenge of how to spread innovation throughout their organizations. The authors present the results of an evaluation of the efforts of 3 major hospital systems to internally disseminate nursing unit change among medical-surgical units. The findings show that all 3 organizations carefully planned, coordinated, and implemented a spread process; none left dissemination to chance. Although clear differences were evident in the way they engineered their spread, many similarities also were found.

How do teams in quality improvement collaboratives interact?

BACKGROUND: The multi-organizational collaborative is a popular model for quality improvement (QI) initiatives. It assumes organizations will share information and social support. However, there is no comprehensive documentation of the extent to which teams do interact. Considering QI collaboratives as networks, interactions among reams were documented, and the associations between network roles and performance were examined. METHODS: A telephone survey of official team contact persons for 94 site teams in three QI collaborarives was conducted in 2002 and 2003. Four performance measures were used to assess the usefulness of ties to other teams and being considered a leader by peers. RESULTS: Eighty percent of the teams said they would contact another team again if they felt the need. Teams made a change as a direct result of interaction in 86% of reported relationships. Teams typically exchanged tools such as software and interacted outside of planned activities. Having a large number of ties to other teams is strongly related to the number of mentions as a leader. Both of these variables are related to faculty-assessed performance, number of changes the ream made to improve care, and depth of those changes. DISCUSSION: The Findings suggest that collaborative teams do indeed exchange important information, and the social dynamics of the collaborarives contribute to individual and collaborative success.

The effect of a disease management intervention on quality and outcomes of dementia care: a randomized, controlled trial.

BACKGROUND: Adherence to dementia guidelines is poor despite evidence that some guideline recommendations can improve symptoms and delay institutionalization of patients. OBJECTIVE: To test the effectiveness of a dementia guideline-based disease management program on quality of care and outcomes for patients with dementia. DESIGN: Clinic-level, cluster randomized, controlled trial. SETTING: 3 health care organizations collaborating with 3 community agencies in southern California. PARTICIPANTS: 18 primary care clinics and 408 patients with dementia age 65 years or older paired with 408 informal caregivers. INTERVENTION: Disease management program led by care managers and provided to 238 patient-caregiver pairs at 9 intervention clinics for more than 12 months. MEASUREMENTS: Adherence to 23 guideline recommendations (primary outcome) and receipt of community resources and patient and caregiver health and quality-of-care measures (secondary outcomes). RESULTS: The mean percentage of per-patient guideline recommendations to which care was adherent was significantly higher in the intervention group than in the usual care group (63.9% vs. 32.9%, respectively; adjusted difference, 30.1% [95% CI, 25.2% to 34.9%]; P < 0.001). Participants who received the intervention had higher care quality on 21 of 23 guidelines (P < or = 0.013 for all), and higher proportions received community agency assistance (P < or = 0.03) than those who received usual care. Patient health-related quality of life, overall quality of patient care, caregiving quality, social support, and level of unmet caregiving assistance needs were better for participants in the intervention group than for those in the usual care group (P < 0.05 for all). Caregiver health-related quality of life did not differ between the 2 groups. LIMITATIONS: Participants were well-educated, were predominantly white, had a usual source of care, and were not institutionalized. Generalizability to other patients and geographic regions is unknown. Also, costs of a care management program under fee-for-service reimbursement may impede adoption. CONCLUSIONS: A dementia guideline-based disease management program led to substantial improvements in quality of care for patients with dementia. Current Controlled Trials identifier: ISRCTN72577751.

Assessing the implementation of the chronic care model in quality improvement collaboratives.

OBJECTIVE: To measure organizations' implementation of Chronic Care Model (CCM) interventions for chronic care quality improvement (QI). DATA SOURCES/STUDY SETTING: Monthly reports submitted by 42 organizations participating in three QI collaboratives to improve care for congestive heart failure, diabetes, depression, and asthma, and telephone interviews with key informants in the organizations. STUDY DESIGN: We qualitatively analyzed the implementation activities of intervention organizations as part of a larger effectiveness evaluation of yearlong collaboratives. Key study variables included measures of implementation intensity (quantity and depth of implementation activities) as well as fidelity to the CCM. DATA COLLECTION/EXTRACTION METHODS: We developed a CCM-based scheme to code sites' intervention activities and criteria to rate their depth or likelihood of impact. PRINCIPAL FINDINGS: The sites averaged more than 30 different change efforts each to implement the CCM. The depth ratings for these changes, however, were more modest, ranging from 17 percent to 76 percent of the highest rating possible. The participating organizations significantly differed in the intensity of their implementation efforts (p<.001 in both quantity and depth ratings). Fidelity to the CCM was high. CONCLUSIONS: Collaborative participants were able, with some important variation, to implement large numbers of diverse QI change strategies, with high CCM fidelity and modest depth of implementation. QI collaboratives are a useful method to foster change in real world settings.

The role of perceived team effectiveness in improving chronic illness care.

BACKGROUND/OBJECTIVES: The importance of teams for improving quality of care has received increased attention. We examine both the correlates of self-assessed or perceived team effectiveness and its consequences for actually making changes to improve care for people with chronic illness. STUDY SETTING AND METHODS: Data were obtained from 40 teams participating in the national evaluation of the Improving Chronic Illness Care Program. Based on current theory and literature, measures were derived of organizational culture, a focus on patient satisfaction, presence of a team champion, team composition, perceived team effectiveness, and the actual number and depth of changes made to improve chronic illness care. RESULTS: A focus on patient satisfaction, the presence of a team champion, and the involvement of the physicians on the team were each consistently and positively associated with greater perceived team effectiveness. Maintaining a balance among culture values of participation, achievement, openness to innovation, and adherence to rules and accountability also appeared to be important. Perceived team effectiveness, in turn, was consistently associated with both a greater number and depth of changes made to improve chronic illness care. The variables examined explain between 24 and 40% of the variance in different dimensions of perceived team effectiveness; between 13% and 26% in number of changes made; and between 20% and 42% in depth of changes made. CONCLUSIONS: The data suggest the importance of developing effective teams for improving the quality of care for patients with chronic illness.