Psychometric Testing of the Sidani and Doran Therapeutic Self-Care Scale in a Home Health Care Population.

BACKGROUND AND PURPOSE: Self-care is a central goal of home health (HH) nursing care. The study purpose was to assess psychometric performance of the Therapeutic Self-Care Scale (TSCS) in a U.S. HH population. METHODS: TSCS reliability was assessed with Cronbach's alpha and test-retest analyses ( n = 59). Convergent validity testing and principal components analysis (PCA) were performed. RESULTS: After elimination of 2 items, internal consistency reliability was acceptable (α = .804) and test-retest reliability was high (intraclass correlation = .94; p < .001). Convergent validity analyses were inconclusive. PCA found 2 underlying dimensions consistent with a conceptual difference between self-care and self-management. CONCLUSIONS: A valid, reliable measure of self-care/management would be useful for measurement of HH nursing outcomes. The TSCS holds promise but needs further refinement before it can serve this purpose.

Implementation of electronic surveillance of catheter use and catheter-associated urinary tract infection at Nurses Improving Care for Healthsystem Elders (NICHE) hospitals.

BACKGROUND: Manual surveillance of indwelling urinary catheters (IUCs) and catheter-associated urinary tract infections (CAUTIs) is resource intense. METHODS: We implemented electronic surveillance in nonintensive care units of Nurses Improving Care for Healthsystem Elders (NICHE) hospitals. Capacity was created centrally to analyze data collected electronically or manually at each site. We measured the average IUC duration and proportion of patients with IUC duration <3 days. CAUTIs were identified using a validated algorithm based on the Centers for Disease Control and Prevention definition and used to calculate rates and standardized incidence ratios (SIRs). RESULTS: Electronic surveillance was implemented in 25 units at 20 NICHE hospitals. Full automation was achieved at 15 of 16 sites with electronic health records (EHRs). Electronic surveillance challenges included EHR data element formats and IUC documentation. Study units reported on 4,574 patients for 16,105 IUC days over a 6-month period. The mean of the unit-level average IUC duration was 3.2 ± 2.6 days, mean proportion of patients with IUC duration <3 days was 52.4% ± 50%, and mean CAUTI SIR was 0.14 ± 0.31. CONCLUSION: A centralized electronic surveillance strategy for CAUTI is feasible and sustainable. Baseline performance of participating sites was exemplary, with very low SIRs at baseline.

A Trial of electronic surveillance feedback for quality improvement at Nurses Improving Care for Healthsystem Elders (NICHE) hospitals.

BACKGROUND: Catheter-associated urinary tract infection (CAUTI) risk is directly related to duration of indwelling urinary catheters (IUCs), rising beyond 2 days of catheterization. METHODS: We conducted a cluster randomized study in nonintensive care units of Nurses Improving Care for Healthsystem Elders (NICHE) hospitals. Electronic surveillance data were used in an audit and feedback intervention for frontline nurses to reduce IUC duration. Multivariable methods were used to identify the difference in average IUC duration and proportion of patients with IUC duration <3 days between patients in an early intervention group and a delayed intervention group, adjusting for patient, unit, and hospital characteristics. RESULTS: A total of 24 units at 19 NICHE hospitals reported 13,499 adult patients with IUCs over 18 months. Early and delayed intervention groups had important baseline differences in IUC utilization. Use of evidence-based CAUTI prevention measures increased during study participation. In multivariable analysis, the average IUC duration and proportion of patients with IUC duration <3 days were not improved in the early intervention group compared with the delayed intervention group. CONCLUSION: The impact of the audit and feedback intervention was not significant despite the uptake of evidence-based CAUTI prevention practices.

Delineation of self-care and associated concepts.

PURPOSE: The purpose of this paper is to delineate five concepts that are often used synonymously in the nursing and related literature: self-care, self-management, self-monitoring, symptom management, and self-efficacy for self-care. METHOD: Concepts were delineated based on a review of literature, identification of relationships, and examination of commonalities and differences. FINDINGS: More commonalities than differences exist among self-care, self-management, and self-monitoring. Symptom management extends beyond the self-care concepts to include healthcare provider activities. Self-efficacy can mediate or moderate the four other concepts. Relationships among the concepts are depicted in a model. CONCLUSIONS: A clearer understanding of the overlap, differences, and relationships among the five concepts can provide clarity, direction and specificity to nurse researchers, policy makers, and clinicians in addressing their goals for health delivery. CLINICAL RELEVANCE: Concept clarity enables nurses to use evidence that targets specific interventions to individualize care toward achieving the most relevant goals.

Measuring healthcare outcomes to improve quality of care across post--acute care provider settings.

Post-acute care (PAC) occurs in a variety of settings-skilled nursing facilities (nursing homes), rehabilitation facilities, and home health agencies. To evaluate the impact of care processes on clinical outcomes and implement changes designed to improve outcomes, one must begin by measuring outcomes in a valid, reliable manner that allows for comparisons to reference or benchmarking data. Currently, several data sets exist in PAC settings for the purpose of outcome measurement. However, there is a need for comparable information across settings to ensure the quality and continuity of care. This article reviews various existing data sets used in PAC settings, examines ongoing projects to create a single set of measures, and suggests some directions for future research.

A Study of Reliability and Burden of Home Health Assessment Using OASIS.

The Outcome and Assessment Information Set (OASIS) is used for outcome reporting, quality improvement, and case mix adjustment of per-episode payment for home health care. The research described here addresses interrater reliability of OASIS items and compares clinician time required to complete patient assessment with and without OASIS. Interrater reliability for OASIS data items was estimated using independent assessments by two clinicians for a sample of 66 patients. Incremental assessment time due to OASIS was estimated using interview data from two agency-matched groups of clinical care providers-one group who used OASIS in the assessment and a second group whose assessment did not include OASIS items. Interrater reliability is excellent (kappa > .80) for many OASIS items and substantial (kappa > 0.60) for most items. The reported time required to complete an assessment with OASIS did not differ from the time required for a comparable assessment without OASIS. The results of this study are being used to guide developmental efforts to improve OASIS items. They can also be informative to home health care agencies when interpreting OASIS-based outcome and case mix reports.

New tool to use with patient tally reports.

A new tool is available for agencies to use with their patient tally reports derived from OASIS data. By using queries submitted to the outcome and case mix tally reports, agencies can select a group of care episodes for follow-up in the process-of-care investigation portion of their outcome enhancement activities. An example of how an agency used the tool to select care episodes for review is provided.

A study of reliability and burden of home health assessment using OASIS.

The Outcome and Assessment Information Set (OASIS) is used for outcome reporting, quality improvement, and case mix adjustment of per-episode payment for home health care. The research described here addresses interrater reliability of OASIS items and compares clinician time required to complete patient assessment with and without OASIS. Interrater reliability for OASIS data items was estimated using independent assessments by two clinicians for a sample of 66 patients. Incremental assessment time due to OASIS was estimated using interview data from two agency-matched groups of clinical care providers--one group who used OASIS in the assessment and a second group whose assessment did not include OASIS items. Interrater reliability is excellent (kappa > .80) for many OASIS items and substantial (kappa > 0.60) for most items. The reported time required to complete an assessment with OASIS did not differ from the time required for a comparable assessment without OASIS. The results of this study are being used to guide developmental efforts to improve OASIS items. They can also be informative to home health care agencies when interpreting OASIS-based outcome and case mix reports.

The process-of-care investigation. The basics.

The risk-adjusted and descriptive outcome report provides a foundation for Outcome-Based Quality Improvement (OBQI). This article describes the steps of the process-of-care investigation that will begin once target outcomes are selected.

Developing and implementing a plan of action to improve care. The basics.

Once agencies have completed a process-of-care investigation, the next step of OBQI is the development and implementation of a plan of action to improve care. In this article, the authors share strategies for developing, implementing, and monitoring a successful plan of action and describe how pilot agencies developed their own action plan.

A basic and practical overview of the six steps of outcome-based quality improvement. Interpreting outcome reports: the basics.

Analysis of OASIS data produces several types of agency-level (aggregate) reports. This article describes the components of the risk-adjusted and descriptive outcome report.

A basic and practical overview of the six steps of outcome-based quality improvement. Selecting target outcomes: the basics.

After obtaining the risk-adjusted and descriptive outcome report, the first activity of outcome enhancement involves selecting one or two target outcomes. This article outlines the criteria for target outcomes selection and features a suggested timeline.

Improving patient outcomes of home health care: findings from two demonstration trials of outcome-based quality improvement.

OBJECTIVES: To evaluate effects on patient outcomes of Outcome-Based Quality Improvement (OBQI), a continuous quality improvement methodology for home health care (HHC). DESIGN: A quasi-experimental design with prospective pre/post and study/control components within two multiyear demonstration trials (occurring from 1995 to 2000) in which 73 home health agencies implemented OBQI, receiving several annual cycles of outcome reports to evaluate and enhance patient outcomes. SETTING: New York and 27 other states. PARTICIPANTS: The study involved 157,548 predominantly older adult patients admitted over 3 years to 54 OBQI agencies from 27 states in the National Demonstration Trial, 105,917 patients admitted over 4 years to 19 OBQI agencies in the New York State Trial, and 248,621 patients admitted over 3 years to non-OBQI control agencies in the 27 demonstration states. INTERVENTION: As a clinical management and administrative intervention, OBQI involves collecting, encoding, and transmitting patient-level health status data to a central source that provides each OBQI agency with a risk-adjusted outcome report comparing the agency's patient outcomes with those from a reference population and with its own outcomes from the prior period. Target outcomes are selected and focused plans of action implemented to change care behaviors. Outcome changes are evaluated through the next report cycle. MEASUREMENTS: Outcome measures include hospitalization rates and improvement and stabilization outcome rates in functional, physiological, emotional/behavioral, and cognitive health. RESULTS: For the National and New York State Demonstration Trials, the risk-adjusted relative rates of decline in hospitalization of 22% and 26%, respectively, for OBQI patients over the 3-year and 4-year demonstration periods were significant (P <.001) and unparalleled by considerably smaller rates of decline for the non-OBQI patients in the 27 states. The risk-adjusted rates of improvement in OBQI target outcome measures of health status averaged 5% to 7% per year in both demonstration trials and were significantly greater (P <.05) than analogous improvement rates for nontarget comparison outcomes, which averaged about 1% per year. CONCLUSION: It is feasible to integrate the programmatic, data collection, data transmission, and outcome enhancement components of OBQI into the day-to-day operations of home health agencies. The aggregate findings and the agency-level evidence available from site-specific communications suggest that OBQI had a pervasive effect on outcome improvement for home health patients. OBQI appears to warrant expansion and refinement in HHC and experimentation in other healthcare settings.