Satisfaction Patient/family complaints Patient reported communication / dignity / respect Activities of daily living & self care
Process / Structure Use of restraints Smoking cessation counselling Staffing level Skill mix Sickness rates Bank and agency usage Practice environment / perceived quality Voluntary turnover Staff knowledge and expertise
Perception of adequate staffing Staff satisfaction & wellbeing Sickness rates
What makes a good outcome indicator? •Important •Scientifically sound •Useable •Feasible
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Importance
Scientific basis
Useability
Feasability
Mortality
Pressure sores
Impact
High
Medium
Variation in quality
High
Unsure
Evidence of sensitivity to nursing
Strong
Weak
Risk adjustment
Feasible
Problematic
Specification / definition of the outcome
Clear
Problematic
Reliability of data collection
Good
Problematic
Variation attributable to nursing
Low
Unclear
Ownership by nursing
Unclear
High
Knowledge to inform action
Unclear
Clear
Wide applicability
Yes
Yes
Positive behavioural incentives
High
Mixed
Potential for gaming
Low
High
Timely availability of data
Potentially
Challenging
Routinely collected data
Yes
No
‘Nursing-sensitive outcomes are those outcomes arrived at, or significantly impacted by, nursing interventions…’ ‘They represent the consequences or effects of nursing interventions and result in changes in patients’ symptom experience, functional status, safety, psychological distress and/or costs’ ONS Outcomes Project Team July 2004 20
www.ons.org/outcomes/measures/outcomes.shtml
Nurse sensitive outcomes in ambulatory chemotherapy
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NCAT: Quality in Cancer Nursing Phase 1 Develop set of outcome based metrics for care quality Identify a set of nurse sensitive patient outcomes for ambulatory chemotherapy settings
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Methods • Series of scoping reviews to identify nurse sensitive outcomes • Shortlist developed – ranked & verified by experts • Secondary search on shortlist • Grading system used to determine strength of evidence • Results presented to experts to identify outcomes recognised as • Most useful quality measures • Most important for patients
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Most Useful Measure of Quality? (rank of scores)
Most Important to Patients? (rank of scores)
(Rank in literature)
Recommendation/ evidence
Assessment of sensitivity to nursing
Safe Medication Administration
1
3
(2)
1C
Probable
Septicaemia
2
7
(10)
2C
Possible
Education and Communication
4
2
(4)
1B*
Probable
Experience
3
1
(8)
-
Likely
Wellbeing and Function
5
6
(1)
1B/C
Possible
Nausea and Vomiting
6
4
(9)
1A/B
Likely
Pain
7
5
(3)
1A/B
Possible
Diarrhoea
8
9
(5)
1A/B
Possible
Fatigue
9
8
(6)
B/C
Possible
Oral Mucositis
10
10
(7)
1ABC
Probable
Nutrition
11
11
(11)
B/C
Possible
Outcome
Process of development and testing
Stage 1
• Developed patient reported outcome measure
Stage 2
• Pilot at one unit - 1 week Autumn 2010
Stage 3
• Revise and pilot in 10 chemotherapy units • 12 weeks Dec 2010 - Feb 2011
Nature of outcome data • Primarily patient-self report • Patients attending for chemotherapy asked to complete thinking about last time they visited • N=2,466 • Patient characteristics, treatment regimen and cycle
Vomiting Since your last treatment have you experienced vomiting? (n = 2388) Total Centre J Centre K Centre L Centre M
None Mild
Centre N
Moderate Centre P
Severe
Centre Q Centre R Centre S Centre T
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Use of indicators • Indicators, though essential in every improvement process will not by themselves motivate people to change • Good communication bridges the gap between measurement, understanding and improvement • In order to influence people, indicators need to be presented in ways that are easy to understand and in ways that make changes to the system compelling AND possible The Good Indicators Guide (2008) http://www.apho.org.uk/resource/item.aspx?RID=44584 28
Demonstrating nursing’s contribution • Valid and reliable outcomes measures for decision making • Persuasive evidence about the impact of nursing interventions • Presenting evidence to decision makers with easily understandable but compelling information