Posted: May 13th, 2023

Discuss the access, cost, and quality of quality environments, as well as recent quality initiatives (See Chapter 24 and Table 24.1). essay

Chapter 24 •  Measuring Advanced Practice Nurse Performance
INTRODUCTION Performance measurement in the health-care system is ubiquitous and complex. Whomever the provider, whatever the geographic location, whatever the setting, whatever the organization, whomever the stakeholder, whomever the payer, advanced practice nurses (APNs) can expect to have their performance evaluated. APNs, along with other individuals and organizations, must demonstrate that their performance enhances the triple aims of improving care experiences for patients and families, improving the health of populations, and reducing the per capita costs of health care (Berwick, Nolan, & Whittington, 2008 – Affordable Custom Essay Writing Service | Write My Essay from Pro Writers). As Whittington, Nolan, Lewis, and Torres (2015 – Research Paper Writing Help Service) suggest, the triple aims are an integral part of the United States’ strategies to improve health outcomes and health care. These aims provide a framework for state and federal initiatives and the work of credentialing, accrediting, and regulatory agencies at all levels influencing the organization, delivery, and financing of health-care services. To improve care experiences, individual patients and families are encouraged to become more engaged in care and to participate in planning and assuring they receive quality, safe care. To improve outcomes for population health, providers and communities are expected to transform the organization and delivery of services. To reduce health-care costs, care providers and payers are engaged in payment reforms and developing more cost-effective interventions. Reimbursement structures are also being modified. These aims are influenced by several trends related, in part, to the implementation of the Patient Protection and Affordable Care Act (PPACA; Public Law [PL] 111-148) and subsequent policy and administrative changes. Trends and issues include increased access and, thus, more demand for services; drug pricing; mergers of providers, organizations, and insurers; technologies such as telehealth and mobile apps; and data security (Blumenthal, Abrams, & Nuzum, 2015 – Research Paper Writing Help Service; Lorenzetti, 2015 – Research Paper Writing Help Service). Superimposed on all these changes—and influencing them—are political and power issues. Given the demands facing the health-care system, the voice of nurses and the leadership of APNs are essential to meet our professional and societal obligations to improve health and health care. APNs are uniquely positioned to contribute critical knowledge, skills, and attitudes, as well as their values of civic professionalism and compassion, to political and decision-making dialogues. The purpose of the health-care system is to continuously reduce the impact and burden of illness, injury, and disability and to improve the health and functioning of the people of the United States. Although providing direct care and influencing the direct care provided by others are necessary work and contribute to meeting this goal, they are not sufficient to meet growing professional and societal quality and accountability demands. By demonstrating their contributions; continuously improving their performance; and being accountable to the profession, employers, and the public for all components of their role, APNs can make a difference. As the nurse moves from novice to expert, responsibility for and accountability to self and others for the structures, processes, and outcomes of health care increase proportionally. Achieving the status of APN is not a terminal event and the role assumes ongoing and increasing professional and societal obligations. Responsibility for meeting the triple aims means that the APN must serve the profession and society as a primary agent contributing at the level of individual care, in the practice setting, and at the tables where organizational and public policies are made and implemented. In addition, the professional and societal trust afforded to the APN obliges meaningful contributions—beyond individual patient care—to meet the purpose of the health-care system. APNs must not only do good, they must demonstrate their value to society through performance assessment and its documentation and dissemination at every level of care and decision making so their voices are heard. The importance to health outcomes, the profession, and society cannot be underestimated or ignored. The Case for Accountability Why should APNs be concerned about these issues? A Web search of the terms health care AND accountability resulted in more than 130 million hits. This reflects the importance of this issue in our society. The search revealed that accountability for the quality and costs of health care—its value—are of interest to consumers, purchasers/payers, employers, insurers, the government, and professional provider organizations. Although the demand for accountability for the value of health care is not new, growing complexity and changes in the health-care 6044_Ch24_365-386.indd 367 07/09/17 10:12 PM 368 Unit 4 •  Ethical, Legal, and Business Acumen of pay-for-performance determinations. The Institute of Medicine (IOM) (1999, 2001, 2006 – Write a paper; Professional research paper writing service – Best essay writers) identified problems with the quality of care and safety concerns that continue to be reported in the literature. Reports of consumer satisfaction or experience with the health-care system, such as those of the Commonwealth Fund (Commonwealth Fund, 2016: 2024 – Do my homework – Help write my assignment onlineb; Davis et al, 2002), found that patients were not satisfied with the quality of care they were receiving and reported continuing concerns on their summaries of assessment data. Hero, Blendon, Zaslavsky, and Campbell (2016: 2024 – Do my homework – Help write my assignment online) found that concerns about access to preferred care were a major concern. Get research paper samples and course-specific study resources under   homework for you course hero writing service – Manage d care, cost concerns, and the growing consumer movement in health care have increased the demand for information about the value (quality in relation to cost) of health-care services and the performance of health-care providers in delivering quality, cost-effective services across all components of the health-care system. Led by advocacy organizations, consumers are demanding greater accountability from health-care providers and the health-care system. They want quality, cost-effective services delivered from a patient-centered perspective. Federal and state government agencies and other purchasers want to know if the services they pay for are achieving the best possible outcomes at the best price. Organizations that accredit health-care organizations are increasingly seeking evidence that the structures and processes of care produce positive health outcomes. All these demands to demonstrate and be accountable for value- and cost-effective high-quality care require individuals and groups of providers to measure performance and share their assessments with stakeholders. Organizations such as the National Committee for Quality Assurance (NCQA), the National Quality Forum (NQF), The Joint Commission (TJC), and several agencies of the federal government lead efforts to measure and report on the quality of care provided by various health-care system components. Federal and state agencies, independently and in collaboration with private sector organizations, are collecting and disseminating information about the quality of services provided by the health-care system’s various providers. Health-care “report cards” are mechanisms widely employed to address the concerns of consumers, payers, employers, and others about the quality of health care being provided. Report cards are done for hospitals, system raise the issue to a level that cannot be denied or minimized. This demand requires the APN to measure and disseminate information on the value of the role. Nurses in advanced practice, similar to other providers and health-care system components, need knowledge and skills to assess and measure quality and determine the costs of their services if they are to demonstrate value. It is not enough to “do good”; the APN must demonstrate how “doing good” translates into outcomes and costs. Accountability for practice has been and continues to be embedded in APN standards, education, and position descriptions. As Buerhaus and Norman (2001) suggest, the improvement of health-care quality is an “authentic commitment” (p. 68) for all stakeholders and will shape how health-care services are delivered. Given the definition of advanced practice and its role components, APNs must contribute to and lead broad efforts to improve quality. Their actions in defining, measuring, and reporting on their performance will determine their future and that of the health-care system. The advanced practice framework includes patients, health care, nursing, and individual outcomes. Thus, the APN is accountable for performance in all these domains. These concepts and obligations are further reflected for the graduate-level student (American Association of Colleges of Nursing [AACN], 2011). Prepared at this level, the nurse is expected to have advanced role skills, possess refined analytical skills, operate from a broad-based perspective, havethe ability to articulate views and positions, and connect theory and practice. He or she is expected to engage in quality and safety initiatives and collaborate inter-professionally to improve patient and population health outcomes. The Quality Context If the health-care system is to reduce the effect and burden of illnesses, injuries, and disabilities and improve outcomes and functioning, all involved in the system must be responsible for identifying and improving the structures and processes for achieving positive outcomes. Research has shown that consumers and society are not getting what they want or need from the health-caresystem. Errors continue to occur and patient experiences with care continue to be issues with outcomes becoming part 6044_Ch24_365-386.indd 368 07/09/17 10:12 PM Chapter 24 •  Measuring Advanced Practice Nurse Performance 369 health plans, and provider groups with the intent of informing consumers and improving quality. Public reports of health-care quality are done by state and federal governments and private sector organizations. Implementation of the PPACA has resulted in greater reporting at the state and federal levels. Although these reports, especially those related to patient satisfaction and experience with care, remain controversial (Rosen & Chen, 2016: 2024 – Do my homework – Help write my assignment online), they are being widely reported and linked to pay-for-performance initiatives. Quality in service is demanded by anyone seeking that service. This is especially true for health-care services, both by the person receiving services and also for regulating bodies. Nurses must recognize the part they play in quality and safety in an obvious way, measuring, reporting, and articulating their role. The importance of quality and safety is evident in the APN Consensus Document (NCSBN, 2008 – Affordable Custom Essay Writing Service | Write My Essay from Pro Writers) that articulates the parameters and standards for licensure, accreditation, certification, and education (LACE). The APN’s performance will be measured and reported; thus, he or she must be engaged in determining best practices to meet patient and outcome expectations. Values and Value in Health Care To contribute effectively to fulfilling the purpose of the health-care system, the APN needs a clear vision derived from personal and professional values. The APN needs to embrace society’s mandate for health-care value and clarify how the quality and cost issues relate to personal and professional goals. Explicit incorporation of quality and cost values and critical thinking about these issues will result in actions and activities consistent with social demand. Therefore, the APN role can be justified and the needs of society will be better served. APNs will be well positioned to provide leadership in affecting quality and costs, the “bottom line” of health-care system performance. To be effective leaders and advocates for value issues associated with patients and therole, the APN must know and appreciate what other stakeholders want. Thus, it will be easier to understand their behavior and thinking about health and health care and to develop and implement strategies to address value conflicts, thereby resulting in better health-care outcomes. For example, the APN’s employer may valuereducing costs to ensure organizational survival, whereas the APN’s highest value is meeting the diverse needs of patients served by the organization. Negotiation, compromise, and collaboration are necessary to incorporate both values into strategic planning efforts. Awareness of the importance of values, understanding the value equation, and possessing theskills to address value conflicts are critical for APN survival and health-care system improvement. The purposes of this chapter are to introduce APN students to quality frameworks, performance measurement, and accountability and to suggest approaches to current issues and responses to trends. For the graduate APN, this chapter can enhance knowledge and skills that will promote the quality activities, better demonstrate accountability, and foster actions to justify the role of the APN in meeting societal demands for quality, cost-effective health care. The complexity of the quality movement and the value equation are discussed. As the health-care system becomes increasingly complex, as stakeholders’ values and visions clash, and as there is growing dissatisfaction with the health-care system, APN leadership is critical. The challenge to establish value and be accountable at all levels may appear daunting, but it is exciting and potentially rewarding for the APN, the profession, and our society. THE QUALITY ENVIRONMENT Beginning with Florence Nightingale, nursing has always given attention to quality issues. Despite our historical roots as leaders in this area, the profession has drifted to a more internal, narrow perspective. Until recently, this mirrored the attention our society gave to the quality of health care. In the United States especially, the values of individualism and self-determination, science and technology, a disease and medical focus, the free-market economy, and nongovernmental interference shaped both the structures and processes of the health-care system, thus influencing its outcomes. Access and cost issues have, until recently, received more attention than quality, particularly at the societal level. As cost concerns increased and new delivery systems—such as managed care—were implemented, greater attention focused on quality and value. In addition, industry and quality theories and practices in business suggested that lessons learned in these arenas could be applied to the health-care sector. 6044_Ch24_365-386.indd 369 07/09/17 10:12 PM 370 Unit 4 •  Ethical, Legal, and Business Acumen practice behavior, collaboration, and APN satisfaction. The outcomes related to APN structures and processes include mortality, morbidity, patient knowledge, patient satisfaction, service use, and health status. Quality of care can be viewed from a micro or macro perspective. At the micro level, quality is conceptualized and assessed for the patient, the provider, or theinstitution. Clinical and technical care, satisfaction with care, and quality of life represent components of a micro view (Shi & Singh, 2005). Although always an important component of any quality approach, increasing attention is being given to the macro level—looking at outcomes and cost effectiveness for populations and society. Examples include the efforts of private sector organizations such as TJC (formerly the Joint Commission on Accreditation of Healthcare Organizations), NQF, NCQA, and the work supported by private foundations. State and federal legislatures and the agencies implementing public policy decisions are also involved in macro-level quality approaches. Definitions and Frameworks With greater attention being given to quality, long-standing terms and processes were dusted off and a new vocabulary evolved. As shown in Table 24.1, a plethora of terms are used to describe quality concepts. The APN, to operate effectively in the new health-care quality climate, must be fluent in the new language. One of the earliest conceptual frameworks to describe quality was developed by Donabedian (1966). It is widely used by the nursing community and others in the health-care system as a way to identify the structural and process factors that affect outcomes. Hamric (1983, 1989) provided a model for APN patient care evaluation using Donabedian’s framework. Girouard (2000) identified structural elements that include the APN’s education, the time the APN spends in role components, reimbursement levels, and organizational characteristics. Process elements include APN behaviors, referral patterns, prescriptive Table 24.1 The Vocabulary of Quality Access Ability to obtain care or health and related services (also defined as use or insurance coverage) Accountability The demonstration of value (e.g., quality care, patient satisfaction, resource efficiency, and ethical practice); liability for actions Cost To the individual paying for services; to the provider to produce services; for society Outcome The end result of structures and processes of care; the goal or objective of health and health care Performance Assessment of how individual providers behave; measurement assessment of processes of care; may be compared against standards or benchmarks Process Method in which health care is provided; provider behaviors; includes technical and interpersonal elements Quality How well services increase chance for desired outcomes; knowledge based and evidence based Quality assessment Process of defining and measuring quality Quality assurance Process of measurement and quality improvement; may also be defined as the minimum standards approach Quality indicator Trait or characteristic linked with evidence to desirable health outcomes; may serve as proxy for outcome Report cards Collection and reporting of performance and other quality-related data to the public or other targeted groups Structure Tools and resources for care (e.g., facilities, licensing and regulation, staffing, equipment) Total quality Includes – Get research paper samples and course-specific study resources under   homework for you course hero writing service – an environment for quality, involves continuous measurement and improvement activities (often called total quality management or continuous quality improvement) 6044_Ch24_365-386.indd 370 07/09/17 10:12 PM Chapter 24 •  Measuring Advanced Practice Nurse Performance 371 their insurance costs, loss of productive work time, and health-care program administration costs are considered as a percentage of expenditures needed to conduct their business. Individual consumers, although most often focused on their out-of-pocket costs, are also concerned about the costs of insurance, the price of services and goods needed, and pharmaceutical costs. A third approach when considering health-care costs is the perspective of the health-care professional or health-care organization in which the focus is on expenditures, such as costs for personnel, administration, physical plants, and supplies and equipment, to produce services for groups of patients. To adequately assess quality at the individual, societal, or organizational level, the APN must be cognizant of access and cost issues and the role they play in determining outcomes. Access and cost issues reflect structural and process elements, the factors that influence health-care outcomes. In addition, this approach holds opportunities for representing the APN as a solution to access and cost concerns. Thus, the APN can make a strong case for the role’s value in the health-care system. Recent Quality Initiatives A growing number of national quality initiatives reflect the importance of this issue and support the assertion that quality efforts will remain a significant factor in shaping the future of the health-care system. The identification of standards and expected outcomes for access, costs, and quality; their measurement; and public dissemination and discourse are ongoing and expanding. To ensure quality and cost-effective care, quality must be defined; performance expectations specified; and performance and outcomes measured. These are the bases for the quality efforts of national health-care organizations. Quality measurement is needed to understand theeffects of services on individuals and populations and to make improvements in the organization, delivery, and financing of health care. According to the IOM’s National Health Care Quality Roundtable (Donaldson, 1999), still valid today, health-care quality measurement objectives include: • Gathering and analyzing data to inform quality improvement efforts • Assessing facilities and individual performance in relation to established standards One example of such an approach is the Child and Adolescent Health Measurement Initiative (CAHMI), a national initiative based out of the Bloomberg School of Public Health at Johns Hopkins University. In collaboration with consumers, they developed an experience of careframework and measures for children and adults. This framework and the measures developed to date are widely used by such organizations as the NCQA, the NQF, the IOM, and the Robert Wood Johnson Foundation (RWJF) for measuring the quality of care provided to large population groups. In addition, federal government agencies, such as the Agency for Healthcare Research and Quality (AHRQ) and the Centers for Medicare and Medicaid Services (CMS), and state government agencies have adopted the framework and adapted the measures for a macro approach to quality. Access, Cost, and Quality The growing demand for quality requires that attention also be given to access because improved health status and other outcomes of care depend on the individual’s ability to receive needed services across the continuum of care. Although often discussed as an issue of access to insurance for the uninsured and the underinsured, a payment mechanism is not sufficient to improve outcomes. The providers, services, and goods individuals and groups have access to are major factors in achieving desired outcomes and cost efficiencies. Thus, payment levels, what is paid for, and who gets paid are important access considerations in the quality equation. Well-known deficiencies currently exist in mental health-care services, oral health-care services, and care of persons with chronic conditions. The APN should pay particular attention to and justify the needs and benefits resulting from advanced practice nursing services in all health-care settings and for all levels of care. Cost issues are the third component (along with access and quality) of the health-care system triangle and are essential to establish the value of health care. Cost can be considered from the perspective of the society at large—the total costs of health care or the percentage of national dollars for health-care expenditures. Global expenditures include provider services, insurance, goods and supplies, pharmaceuticals, research, education, core public health services, and institutional costs for delivering health-care services. Consumers and employers are concerned about the direct costs of care. For employers, 6044_Ch24_365-386.indd 371 07/09/17 10:12 PM 372 Unit 4 •  Ethical, Legal, and Business Acumen improvement and health services management in managed care organizations (MCOs). To address quality in nursing homes, theCMS is assessing and disseminating information about quality in Medicare- and Medicaid-certified long-term carefacilities.Through the collection and analysis of uniform patient level data (outcome and assessment information set [OASIS]), the CMS is fostering outcome-based quality improvement in home health care. The initiatives described previously reflect only a few of the federal government’s quality-related activities. Other Health and Human Services departments, such as the Centers for Disease Control and Prevention (CDC) and the Maternal and Child Health Bureau (MCHB), are actively engaged in similar activities. State governments are also involved in quality measurement and reporting. For example, New York, Florida, and Washington are measuring provider performance in children’s health care. Private sector organizations representing foundations, purchasers, employers, and professional organizations also measure and report on quality. Accrediting organizations, such as TJC, are moving from assessing only structures and processes of care to outcome evaluation. For example, TJC-accredited organizations, through the ORYX initiative, are required to measure specific patient outcomes and provider performance standards. ORYX isTJC’s performance measurement and improvement initiative, first implemented in 1997. Safety, medicalerrors, and infection rates are also being used byTJC as performanceindicators. Through annual reports on health-care quality, NCQA looks at plan performance related to quality, access, and consumer satisfaction. NCQA’s health plan report cards are shared with employers and purchasing groups and are made available for consumer use in choosing health-care plans. They have played a major rolein accrediting medical homes and advanced medical homes. Three national organizations exemplify the private sector’s role and collaboration with government agencies to address quality: the CAHMI, the American Health Quality Association (AHQA), and the NQF. The CAHMI evaluates health system performance for children covered by Medicaid and private insurance and reports on gaps in care to consumers. It is dedicated to helping parents and children make better decisions and choices by informing them about what to expect from the health-caresystem and by fostering their involvement in holding the health-care system accountable. • Comparing providers to inform purchaser and consumer choice of providers • Informing all stakeholders about decisions and choices • Identifying, rewarding, and sharing best practices • Monitoring and reporting on quality over time • Addressing the health-care needs of communities In response to the demand for quality, performance measurement, and accountability, federal and state governments and the private sector have taken action. Government agencies, with congressional policy direction and as major purchasers of health-care services, need information about the quality of health care to guide policy and program decision making. Two government agencies, the AHRQ and CMS, are worthy of particular attention because quality is a major focus of their activities. The AHRQ, through its internal and external research programs and educational initiatives, is charged to improve the outcomes and quality of health care. In addition, the AHRQ’s goals include addressing patient safety and errors, increasing access to effective services, and reducing costs. As a major purchaser (Medicare and Medicaid), CMS must ensure that its program beneficiaries receive quality, cost-effective care. In addition, through its regulatory functions it sets quality standards for the health-care industry. An example of a recent AHRQ initiative is a synthesis of completed research to answer questions about which prescriptive drugs reduce costs and improve outcomes. AHRQ is also evaluating pilot projects that reward providers for delivering high-quality health-care services. They have disseminated a synthesis of studies so clinicians can make better decisions about treating patients with community-acquired pneumonia. Clinicians will also find AHRQ’s “Child Health Tool Box” and other collections of guidelines and measures useful in establishing their own performance measurement and quality programs. AHRQ’s more than 10 years of reports on health-care quality and disparities (AHRQ, 2015 – Research Paper Writing Help Service) provide the APN with important information to guide thinking about the foci of quality initiatives. Because Medicare and Medicaid beneficiaries use a wide array of health-careservices, theCMS’s quality efforts arefar reaching. Among its initiatives are programs to assess quality and performance in hospitals, home care, and long-term care.The quality improvement system for managed caresets regulatory standards and guidelines for quality assessment and 6044_Ch24_365-386.indd 372 07/09/17 10:12 PM Chapter 24 •  Measuring Advanced Practice Nurse Performance 373 recent years and are a priority in the health-care system. Quality in service is demanded by anyone seeking a service—this is especially true for health-care services. The person receiving service, the organization providing the service, those paying for the service, and those regulating the service (and providers) are demanding performance assessment and accountability. The APN, given the components and core competencies required of the role, is expected to be engaged in all aspects of the quality and safety movement including the development, implementation, and evaluation of the performance measurement and reporting process. As reflected in the LACE discussion in the APRN Consensus Model (2008 – Affordable Custom Essay Writing Service | Write My Essay from Pro Writers), quality and safety activities, assessment, and accountability are essential for all APNs. It is not sufficient for the APN to simply be aware of quality improvement initiatives and requirements; the APN must now be an active participant in the process. The National Quality Strategy, part of the current health-care reform initiatives, is the first policy to set national goals to improve the quality of health care. It serves as a guide for all HHS quality improvement programs and regulations and sets standard criteria to measure the quality of health and health care to align national quality and safety efforts. Most of the tasks APNs will be completing in providing care to patients in this new role intersect with some aspect of the National Quality Strategy. The APN is responsible for meeting the demands of patient care while adhering to requirements that have emerged from this strategy. APNs must also be able to define quality in their own practice. Quality has many definitions, but there is consensus among researchers and policy makers that high-quality care occurs when providers give patients the right care when they need it, such as regularly monitoring chronic conditions to prevent complications. Similarly, quality care is appropriate and cost effective—patients do not receive unnecessary care, such as unnecessary diagnostic tests or treatments. High-quality care is based on the best scientific evidence about what helps people get better and stay well, rather than individual opinions or convenience. High-quality care is tailored to a patient’s preferences and values; it is accessible and reliable for all and does not vary because of race, gender, income, or location. High-quality care means that providers are respectful, communicate clearly, and involve patients in decisions about their care (Geisz, 2014: 2024 – Essay Writing Service. Custom Essay Services Cheap). Several The AHQA represents professionals involved in quality and CMS’s quality improvement organization (formerly the peer review organizations) by implementing best practices and fostering quality improvement. By supplying providers and the public with regular updates on quality-of-care research, standards, and other related issues, they educate a wide audience of health-care system stakeholders. The NQF, created in response to the President’s Commission on Quality in Health Care, states that its role is to develop and implement a national strategy for quality measurement and reporting. It uses its members and other experts to assess research and performance reports and provide guidance for improving health-care quality. For example, it issued a report that identified disparities in health care for minority populations and suggested priority activities to address these disparities. Employers are also involved in health-care quality through their demand for information about quality and performance. Accountability is achieved through the measurement and reporting of performance measures and though incentives for providers. For example, large employers in Massachusetts are offering bonuses to providers who improve the care of patients with diabetes and who use an electronic database to follow chronically ill patients. As these initiatives suggest, the APN’s performance is already being measured—directly as a primary care provider and indirectly as a contributor to the health-care team’s performance. Thus, the APN must be aware of national issues, trends, and approaches in quality measurement and improvement to guide practice and other professional activities. As discussed later in this chapter, there are additional actions to be taken to participate more fully in the quality movement. ADVANCE PRACTICE NURSE PERFORMANCE EXPECTATIONS The transition to the role of APN involves a steep learning curve that recognizes the complexity of health care. The APN will be involved in many aspects of health care that were not often thought of as part of direct, day-to-day practice. Quality improvement and evidence-based practice activities are being given much greater attention in all health-care settings. These, along with quality, safety, and performance measurement, have grown exponentially in 6044_Ch24_365-386.indd 373 07/09/17 10:12 PM 374 Unit 4 •  Ethical, Legal, and Business Acumen Standards for APN master’s and doctoral nursing education programs are found in Health Professions Education: A Bridge to Quality (IOM, 2003). These widely accepted recommendations called for major restructuring of health professionals’ education. All health professionals should be prepared to deliver interprofessional, patient-centered care; practice from an evidence base; engage in quality improvement; and be competent in informatics. Complex practice and delivery system demands create a mandate to expand the clinical education and leadership capacity of APNs. APNs are expected to use advanced communication skills and processes to lead quality improvement and patient safety initiatives in health-care systems (AHRQ, 2015 – Research Paper Writing Help Service). Similar standards and competencies are found in standards for APNs promulgated by the American Nurses Association and most nurse practitioner (NP) and specialty advanced practice nursing professional associations. The drive to measure quality is a concern for payers, regulators, and increasingly consumers. As data systems evolve and payers insist on “paying for performance,” a level of accountability and transparency will be required regardless of provider type or health-care setting.To address the triple aims of the health-care system to improve the care experience, improve population health, and reduce costs, the National Quality Strategy has key foci for the APN: • Making care safer by reducing harm caused in the delivery of care • Ensuring that each person and his or her family is engaged, working as partners in the patient’s care • Promoting effective communication and coordination of care • Promoting the most effective prevention and treatment practices for the leading causes of mortality, starting with cardiovascular disease • Working with communities to promote wide use of best practices to enable healthy living • Making quality care more affordable for individuals, families, employers, governments, and communities by developing and spreading new health-care delivery models Clearly, professional expectations, such as those discussed previously, embody quality and accountability expectations for the APN in direct clinical care and within the health-care system. The APN is expected to do good for patients, measure performance in relationship to best IOM reports are also helpful (as discussed earlier in this chapter) in framing and operationalizing quality definitions. Bunting and Groszkruger (2016: 2024 – Do my homework – Help write my assignment online), for example, offer an approach to using IOM recommendations to improve diagnostic activities. The IOM reports and subsequent quality initiatives of federal and state agencies and privatesector organizations have identified recommendations—most of which are currently in place—and recognized that a collaborative approach was needed to assure health-care quality and safety. These recommendations included establishing agencies to focus on quality and safety; setting clear standards and expectations; peer review; protection of patient data; and adverse event reporting systems.There areseveral activities resulting from thesereports of interest to APNs. Forexample, in 2005 AHRQ launched its Patient Safety Network (PSNet), a national Web-based resource that maintains the latest patient safety news and resources. In 2009, the CMS—within the U.S. Department of Health & Human Services—implemented Medicare PartCplan reporting requirements, which mandated thereporting of serious adverseevents and hospital-acquired conditions. In 2011, theInstitutefor Safe Medication Practices (ISMP), the Food and Drug Administration (FDA), TJC, and other organizations began promoting the use of tall man lettering to reduce confusion among look-alike, sound-alike medications such as busPIRone–buPROPion, and PENTobarbital–PHENobarbital. The IOM identified six aims for quality improvement helpful to the APN developing standards for the practice setting: • Safe: Avoiding injuries to patients from the care that is intended to help them • Timely: Reducing wait times and harmful delays for both those who receive and those who give care • Effective: Providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit • Efficient: Avoiding waste, including waste ofequipment, supplies, ideas, and energy • Equitable: Providing care that does not vary in quality because of personal characteristics • Patient-centered: Providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions 6044_Ch24_365-386.indd 374 07/09/17 10:12 PM Chapter 24 •  Measuring Advanced Practice Nurse Performance 375 By 2022 all master’s nurse anesthesia programs must be transitioned to DNP. Most APNs are probably already involved with directly measuring their individual performance. For example, annual performance reviews are a part of most employer–employee relationships. Generally, this type of evaluation focuses on the processes of care, productivity, and position description expectations. When outcomes, such as effectiveness of care, costs, or patient satisfaction with care, are measured by APNs, they generally apply to the individual’s work or program-specific goals. Recent quality and performance measurement approaches suggest opportunities for the APN to evaluate performance more broadly and in other domains. For example, some state Medicaid programs are assessing their beneficiaries’ experiences with care and providing feedback to individual providers. APNs can use such information to compare their care with other providers and state norms, thus identifying areas for improvement. Although these data are infrequently shared with consumers, it continues to be more widely available. Group Level Evaluation of the structures, processes, and outcomes for groups of providers are a growing component of national initiatives to assess quality and performance. APNs may evaluate their practice as a group of APNs or in groups of diverse health-care providers. Forexample, nurse-midwives can join together to assess the costs, patient satisfaction, and birth outcomes associated with their practice. APNs in a family practice group that includes physicians can determine how their performance compares with that of other group practices. NCQA’s performance health plan measurement data can be abstracted to the provider group level and thus can be compared with national or state norms. The hospital-based APN can participate in evaluating patient outcomes for specific populations of patients and in determining performance in relation to issues such as infection rates, antibiotic use, patient safety, and medication errors. With the advent of setting- and group-specific data collection, analysis, and reporting, opportunities exist for the APN to use findings from these reviews to develop and implement quality improvement in the practice setting. For example, a geriatric NP working with a long-term care practices, and be held accountable for practice. But that is notenough; APN expectations include quality-related issues that extend beyond direct clinical care to the health-care system and its quality and accountability issues. MEASURING QUALITY AND PERFORMANCE The structures, processes, and outcomes associated with APN practice can be evaluated at the individual’s practice level, for groups of providers and organizations, for care systems (such as affordable care organizations), and at the societal level. The APN should be knowledgeable about all these approaches and involved at all levels. He or she will find the literature dealing with research, evidence-based practice, and quality helpful to begin developing a professionally and personally relevant framework to measure quality, evaluate performance, and identify meaningful indicators to justify the role and fulfill the expectations of the role. The intensity of involvement at a given level varies with the position held, employer expectations, level of knowledge, skill in evaluation, and other demands. Individual Level APNs can assess their ability to meet the expectations for advanced practice nursing by using core competencies promulgated by the National Organization of Nurse Practitioner Faculties (NONPF) and the Council on Accreditation of Nurse Anesthesia Educational Programs (COA). The competencies are acquired through mentored patient care experiences with emphasis on independent and interprofessional practice; analytic skills for evaluating and providing evidence-based, patient-centered care across settings; advanced knowledge of the health-care delivery system; patient safety; communication; critical thinking; and leadership. Earlier versions of the NPs’ core competencies authored in 2002 and 2006 – Write a paper; Professional research paper writing service – Best essay writers were applicable for master’s preparation and for the doctor of nursing practice (DNP) graduate as additive to the core competencies for the master’s graduate. As of 2014: 2024 – Essay Writing Service. Custom Essay Services Cheap, there was one set of core competencies for entry into practice on graduation of NPs, regardless of the educational preparation (NONPF, 2014: 2024 – Essay Writing Service. Custom Essay Services Cheap). In June 2016: 2024 – Do my homework – Help write my assignment online, the COA revised both their master’s and DNP program core competencies (COA, 2016: 2024 – Do my homework – Help write my assignment online). 6044_Ch24_365-386.indd 375 07/09/17 10:12 PM 376 Unit 4 •  Ethical, Legal, and Business Acumen these efforts are likely to grow in the future. APNs, as practitioners in most of these settings, should be familiar with the performance assessment measures used in their workplace and regularly review reports to continuously improve quality and meet national performance standards. Societal Level At the societal level, there are several existing and evolving approaches to assess the quality of the nation’s health-care system and its outcomes. Healthy People (ODPHP, 2017) sets health outcome goals, identifies indicators to measure progress in achieving these goals, and lists structures and processes needed to meet the goals. The nation’s health quality is also being assessed by several private sector organizations such as advocacy and consumer groups and foundations. Examples include the Commonwealth Fund; high-need, high-cost patients; access to care and patient care experiences; women’s health coverage; and local health systems rising to the challenge to improve health care (Commonwealth Fund, 2016: 2024 – Do my homework – Help write my assignment onlineb). Congress mandated that AHRQ produce an annual report to the nation on health-care quality. Also, the AHRQ produces a national report on disparities in health care. The National Healthcare Quality Report (AHRQ, 2016: 2024 – Do my homework – Help write my assignment online) includes measures of effectiveness, effective treatment, care coordination, patient safety, person-centered care, healthy living, and care affordability. Disparities in quality, access, use, and costs for low-income groups, minority groups, women, children, older adults, and people with special health-care needs are reported in the National Healthcare Disparities Report (AHRQ, 2016: 2024 – Do my homework – Help write my assignment online). The Institute for Healthcare Improvement (IHI) focus is to promulgate health-care strategies to reduce errors, waste, delay, and escalating costs (IHI, 2016: 2024 – Do my homework – Help write my assignment online). It also focuses on improvement capability, person-family centered care, patient safety, quality, cost, and value. The Anesthesia Patient Safety Foundation (APSF) mission is to continually improve “the safety of patients during anesthesia care” (APSF, 2016: 2024 – Do my homework – Help write my assignment online) through research,education, patient safety programs, and campaigns. APSF provides the platform for exchange of information nationally and internationally about the causes and interventions to prevent anesthetic casualties. AHRQ has a Patient Safety Organization (PSO) program with 12 participating anesthesia groups. Membership facility can usethe nursing home-specific reports generated by CMS to design programs to improve structures and processes of care related to specific outcomes. Findings of TJC can guide the hospital-based APN to identify goals for patient care, develop processes for improvement, and assess the effect of changes made. Systems Level Health-care plans, ACOs, and Medicaid programs are being evaluated and held accountable to consumers and purchasers of care for the quality they provide. As panel or staff members in these health-care delivery systems, APN care is also being assessed. It is assumed that purchasers of care and consumers will use the information increasingly being made available to make purchasing decisions. The Consumer Assessment of Healthcare Providers and Systems (CAHPS) Clinician and Group Surveys (CG-CAHPS) ask patients about their recent experiences with clinicians and their staff. These surveys, used by state Medicaid agencies, Medicare, NCQA, and others, ask consumers to report on their care in several domains. Survey questions ask about timeliness of care, appointment, and information; provider communication; attention to mental and emotional health; support in taking care of own health; discussion of medication decisions; and satisfaction with the provider. NCQA uses these tools and the Healthplan Employer Data and Information Set (HEDIS) to evaluate the quality of care in more than 90% of the nation’s health plans. HEDIS data are obtained from administrative data sources and chart audits to assess effectiveness of care using indicators derived from research and expert opinion (AHRQ, 2016: 2024 – Do my homework – Help write my assignment online). State Medicaid programs use both CAHPS and HEDIS to assess the performance of care provided to beneficiaries. In addition, several states are assessing the quality of children’s health-care services using tools such as those developed and tested by CAHMI. For example, one parent survey asks about providers’ ability to meet expectations related to promoting healthy development (PHD) in young children. CAHPS, HEDIS, and PHD measures, as well as other tools used to assess quality at the systems or health-plan level, areevidence based, psychometrically tested, and widely endorsed by providers, consumers, and other stakeholders. Given the current demand for quality information, 6044_Ch24_365-386.indd 376 07/09/17 10:12 PM Chapter 24 •  Measuring Advanced Practice Nurse Performance 377 and health care in choosing an approach to evaluation. The goals of APN quality measurement are the following: • Develop new and adoptexisting data collection methods relevant to the APN role. • Establish APN competency and practicestandards aligned with facility, systems, and societal quality standards. • Compare APN practice with other providers and groups of providers. • Improve performance based on evidence. • Monitor and report quality over timeto all stakeholders. • Address community and societal health-care needs. Donabedian (1966) provides a basic framework for quality measurement at all levels. Although structures, processes, and outcomes of care can all be examined and used as quality indicators, it is important to provide evidence that measures of specific structures and processes are related to outcomes. In addition, outcomes chosen should be those of importance to health-care stakeholders. Selecting indicators that are of interest only to the APN does not serve to establish the role’s value or its contributions to meeting the purpose of health care and the health-care system. Studies of the relationship of nurse staffing or the APN (a structural measure) to patient outcomes demonstrate how this can be done (Aiken, Clarke, Sloane, Sochalski, & Silber, 2001, 2002; Needleman, Buerhaus, Mattke, Stewart, & Zelevinsky, 2002; Needleman & Minnick, 2008 – Affordable Custom Essay Writing Service | Write My Essay from Pro Writers; Pine, Holt, & Lou, 2003; Simonson, Ahern, & Hendryx, 2007). The researchers provide evidence for selection of the structural variables (nurse staffing and APNs) and for the relationship between nurse staffing and patient outcomes. The importance of their work to a variety of stakeholders, such asTJC (Joint Commission on the Accreditation of Healthcare Organizations, 2016: 2024 – Do my homework – Help write my assignment online) and the American Hospital Association (AHA, 2016: 2024 – Do my homework – Help write my assignment online), is reflected in the media attention given to these studies. Structure, Process, and Outcome Measures Structural measures related to quality and specific to the APN role include characteristics of the APN (education, experience, legal aspects, and roleexpectations), the practice or organizational setting (group resources, organizational structure, and provider relationships), and access to services (referral mechanisms, collaboration, and geographical location). Process measures focus on the nature of the APN’s is voluntary and organizations are required to adhere to the criteria set by the AHRQ regarding the Patient Safety Rule. PSOs serve as a repository for which hospitals and all health-care providers can confidentially and voluntarily provide information that will be used for “the aggregation and analysis of patient safety events (AHRQ-PSO, 2016: 2024 – Do my homework – Help write my assignment online). The quality and performance measurement approaches discussed previously represent a sample of the increasing number of activities in this area. The models section of this chapter includes more detailed descriptions of these efforts and the recommendations section contains specific actions for the APN’s greater involvement at all levels. All are important to the APN to justify the role and to be accountable for meeting the expectations of society for the advanced practice role. All have strengths and weaknesses when considered from the perspective of the APN. Individual-level performance,especially when evaluated using nonstandardized methodologies, provides information of valueto only the APN and theemployer. Without comparative data, the APN’s performance cannot be assessed in relation to other providers; thus, it is more difficult to justify therole and identify APN contributions to outcomes. Individual-level performanceevaluation may be necessary, but it is not sufficient to justify therole or its contributions to quality health care. When performance is assessed at the group, system, or societal level, especially when using standard, tested approaches, the APN is better positioned to justify therole and demonstrate contributions to healthcare outcomes. In addition, quality improvement goals derived from these measurementefforts arethosethat are of greatest social value. However, doing only group-, system-, or societal-level evaluation means that APN-dependent performance may be more difficult to articulate. APPROACHES AND MODELS FOR PERFORMANCE EVALUATION As the APN begins or enhances strategies to evaluate performance, quality, and value, a framework is needed to guide decision making and plan foreffective and meaningful assessments of the role and its contributions. There are many approaches and models for consideration. The APN should assess the approaches and models in relation to their relevance and adaptability to meet the APN’s specific needs, justify the role, and measure APN contributions to health 6044_Ch24_365-386.indd 377 07/09/17 10:12 PM 378 Unit 4 •  Ethical, Legal, and Business Acumen not credentialed by HMOs. Other studies focusing on structure have looked at patient characteristics within APN practices, providing valuable information about the types of patients served (Hamric, Worley, Lindeback, & Jaubert, 1999; Paine et al, 1999). Other APN-related structural variables studied include uses of technology (Borchers & Kee, 1999), identification of activities (Knaus, Felten, Burton, Fobes, & Davis, 1997), and the use of hospital data systems (Bozzo, Carlson, & Diers, 1998). Satisfaction with APN care is a traditional part of APN evaluation. Oermann, Lambert, andTemplin (2000) found that having access to nurse-midwiveswas an important quality of care element for parents. Larrabee, Ferri, and Hartig (1997) found high levels of satisfaction with most aspects of NP care and used those areas with lower ratings to guide quality improvement efforts. Numerous other studies have demonstrated that patients and other providers aresatisfied with the care delivered by APNs(Aquilino, Damiano,Willard, Momony, & Levy, 1999; Garvisan, Grimsey, Littlejohns, Lownes, & Stacks, 1998; McMullen, 1999).Instruments have been developed, and their psychometric properties tested, that can be useful to the APN in determining patient satisfaction with NP care (Cole, Mackey, & Lindenberg, 1999). Assessing the processes of APN carefocuses on the nature of the APN’s activities and interventions for direct patient care and his or her indirect patient care activities such as staff teaching and planning. Examples of instruments developed for this purpose include those of Ingersoll (1988);Tierney, Grant, and Mazique(1990); Kearnes (1992); Houston and Luquire(1991); and Girouard and Spross (1983). Oermann (1999) studied consumer descriptions of quality of care and found that consumers believed quality nursing care meant having nurses who were competent and skilled, communicated effectively, conducted patient teaching, and demonstrated caring behaviors. These elements of quality are consistent with other reports of consumerexpectations and thus should beincluded in the APN’s measurement as indicators of care quality. Evaluation of these processes is important for role justification and theidentification of nursing processes that affect quality outcomes. Several studies have demonstrated APN contributions to process indicators of quality (Bozzo et al, 1998; Diers & Bozzo, 1997; Diers, Bozzo, Blatt, & Roussel, 1998; East & Colditz, 1996; Jacavone, Daniels, & Tyner, 1999; Pelletier-Hibbert, 1998). APNs play a major role in the development, implementation, and evaluation of practice guidelines, clinical interventions and interactions with patients. In current quality terminology, process and performance measures are synonymous. Process measures include the APN’s competence in diagnosis and management of health-care problems, prevention, teaching and counseling, interpersonal aspects of care, and technical care (e.g., errors and medication misuse). Outcomes reflect the results of structures and processes for individual patients, groups of patients, or society.Traditional quality outcome measures are mortality and morbidity. With increasing attention to assessing the quality of health care, patientexperience, or satisfaction with care, costs and access areimportant outcome measures. The framework and evaluation models selected for use by the APN and the purpose and goals of the quality assessment process determine how the APN views patient satisfaction, costs, and access as indicators of quality. A common model for measuring APN effectiveness encompasses structures, processes, and outcomes. Structural variables includelegal issues and funding, organization of care delivery, and use of the APN. Process and performance measures reflect the direct and indirect patient care activities of the APN. The model includes both short- and long-term outcomes. Short-term outcomes include accessibility, satisfaction, patient knowledge and health behaviors, and complications of care. Optimal health status, experience with care, morbidity, mortality, and costs of care are long-term indicators of quality. Individual Level Because APNs are involved in evaluating their performance as a component of their organizational responsibilities, approaches to this level of evaluation are important. In addition, individual-level performance processes can be designed to address evaluation needs at the group and organizational, system, or societal levels. The purpose of the individual evaluation is to assess APN achievement of competencies and to measure performance in meeting position or job description expectations. The APN works with peers, physician collaborators, and supervisors to determine the specific factors to be assessed and to identify or design an evaluation methodology. Approaches to individual-levelevaluation may includestructures, processes, and outcomes. Hansen-Turton, Ware, Bond, Doria, and Cunningham (2013)examined thestructural issue of MCO and HMOs credentialing and found that 25% of NPs are 6044_Ch24_365-386.indd 378 07/09/17 10:12 PM Chapter 24 •  Measuring Advanced Practice Nurse Performance 379 indicators. The models for assessing health-care quality described in the text that follows can be used to shape the APN’s quality and performance assessment goals, especially at the systems and societal levels. Group, System, and Societal Levels During the past several years, there have been several organized efforts to evaluate the quality of health care in the United States. Some are well established as evaluation models, although they are constantly being refined and updated. Other efforts are in earlier stages of development. There is significant consistency and collaboration among all stakeholders to develop approaches and models that will better determine quality, measure performance, demonstrate value, and allow for health-care providers and systems to be held accountable. Nurses, including APNs, and organizations of nurses are increasingly involved in all phases of these activities. Some of the most promising and widely accepted approaches are described to provide the APN with a broad view of current approaches and models. Although the individual’s performance and the APN’s care-related outcomes are important, they take on greater meaning when they can be compared. The APN is encouraged to participate in the development, testing, and use of standardized instruments to measure structures, processes, outcomes, and satisfaction with care to allow for comparisons. In the discussion of group, system, and societal measures that follows, it is clear that group- and system-level assessments will, in the near future, allow for individual provider tracking in relation to performance and outcomes of care. The APN can use these data for individual performance assessments. One of the most widely used frameworks for quality and performance measurement reflects the way consumers think about their care (Foundation for Accountability, 1999). The categories of the framework are the following: • The basics: Satisfaction with the delivery of care by providers, access to care, and receipt of information and services • Staying healthy: Avoiding illness, health promotion through preventive care, reduction of health risks, early detection of illness, and health education • Getting better: Appropriateness of treatment and follow-up care to help recover from illness or injury protocols, and clinical pathways that guide the processes of care. NPs, for example, develop protocols for their collaborative practices with physicians. APNs in hospitals, home care, long-term care, and other settings have leadership opportunities in this area as well. Examples in the literature include the work of Musclow, Sawhney, and Watt-Watson (2002); Morin and colleagues (1999); Sagehorn, Russell, and Ganong (1999); McDaniel (1999); Jacavone and colleagues (1999); Kee and Borchers (1998); and Card and colleagues (1998). APNs have also described and measured processes of care for a variety of patients (Barnason & Rasmussen, 2002; Beal & Philips, 1999; Brooten & Naylor, 1995; Coward, 1998; Strohschein, Schaffer, & Lia-Hoagberg, 1999). Outcomes as the result of the APN’s clinical activities, given their importance in quality improvement and accountability, are the most meaningful components of the APN’s evaluation process. The Bibliography to this text includes several studies that illustrate how APNs evaluated the effectiveness of their practice and outcomes. Additionalstudies described the costs and demonstrated the cost effectiveness of APN practice (Burl, Bonner, Rao, & Khan, 1998; Dahle, Smith, Ingersoll, & Wilson, 1998; Lombness, 1994; Walker, Baker, & Chiverton, 1998). Studies linking structures, processes, and outcomes of APN care are particularly important to document APN effectiveness and to determine best practices for the organization and delivery of patient care services. For example, Rudy and colleagues (1998) examined relationships between staff type, activities of caregiving, and patient outcomes. Other examples of this type of evidence include the work of Mundinger and Kane (2000) comparing NP and physician outcomes in primary care. (Additional examples, including the work of Aiken, Brooten, and others, are included in the Bibliography.) Little information is available to describe the APN’s contributions to achieving broad community- or societal-level health-care goals such as thosein Healthy People (USDHHS, 2014: 2024 – Essay Writing Service. Custom Essay Services Cheap). Although the effect of an individual APN or even a group of APNs may be difficult to measure on such outcomes as health promotion and disease prevention, given the number of contributing factors, APNs should begin to identify how to address these most important societal outcomes. As national assessments of quality and outcomes are developed, the APN has an opportunity to begin to examine practice in relation to these evolving 6044_Ch24_365-386.indd 379 07/09/17 10:12 PM 380 Unit 4 •  Ethical, Legal, and Business Acumen level. HEDIS and CAHPS serve as the measure sets for assessing quality and performance. HEDIS includes more than 60 evidence-based consensus measures ofeffectiveness of care. Measures such as immunization levels, breast and cervical cancer screening, chlamydia screening, antidepressant medication management, postcoronary beta-blocker medication use and cholesterol management, comprehensive diabetes care, hypertension control, follow-up after hospitalization for mental illness, prenatal and postnatal care, and appropriate medication treatment for people with asthma are included in the data set (NCQA, 2011). The HEDIS and CAHPS data are analyzed and reported publicly. Another private sector initiative addressing quality and performance in the health-care system is the NQF (National Forum for Healthcare Quality Measurement and Reporting, 2002). NQF is a membership organization representing a diverse group of public and private sector stakeholders, and its mission is to standardize quality of care performance measurement and reporting mechanisms. NQF has endorsed a list of procedures to promote patient safety; developed a framework for achieving their mission; and identified strategies to reduce health-care disparities. Future plans include developing sets of performance measures for hospitals, nursing homes, cancer care, and diabetes care. The hospital performance measures are created using the IOM’s six domains of quality: safety, effectiveness, equity, patient centeredness, efficacy, and timeliness. Purchasers of care and the business community are adopting existing quality and performance measurement models and assessment methodologies to meet their needs to determine the value of the health care they purchase. For example, a Minnesota coalition of large purchasers, the Buyers Health Care Action Group, assesses quality to increase value, choice, and health-care accountability. The National Business Coalition has strategies to improve patient safety and reduce medical errors by fostering consumer awareness; promoting the use of standardized measurement and reporting; rewarding quality; and supporting and using contract standards for safety. Many business coalitions,employers, and purchasers use data from ¬national organizations such as the NCQA to improve their and their employees’ ability to make better health plan choices and to hold health plans accountable. As the major accrediting organization for hospitals,TJC has a long history of assessing structures and processes of • Living with illness: Self-care guidance, symptom control, avoidance of complications, and maintaining daily activities for people with chronic illness • Changing needs: Comprehensiveness of services, caregiver support, and hospice care that helps individuals and families when needs change dramatically because of a severe disability or terminal illness Evidence-based measures are identified or new measures are developed and field tested foreach of the categories and are used as standards for accountability. FACCT’s framework is widely used by national accrediting organizations such as NCQA and TJC, federal and state agencies, and others, to measure quality and organize quality reporting. For example, the Commonwealth Fund’s score card on health-care quality (2016: 2024 – Do my homework – Help write my assignment onlineb) uses the FACCT framework to organize the information contained in the report. Another framework commonly used for quality and performance measurement is that put forward by the IOM (2001). Experts and a wide variety of health-care system stakeholders, including consumers, developed the framework. It includes six dimensions of quality: safety, effectiveness, equity, patient centeredness, efficacy, and timeliness. It, too, is the conceptual framework that guides other organizations and individuals in quality measurement, improvement, reporting, and research. The Consumer Assessment of Health Plans (CAHPS) (AHRQ, 2014: 2024 – Essay Writing Service. Custom Essay Services Cheapa) is a national quality measurement initiative conducted by AHRQ through several research organizations. It uses elements of the FACCT framework to organize survey questions designed to assess consumer experience with care. There are general surveys and surveys specific to special populations such as children and people with chronic conditions. CAHPS is used by NCQA and others as a standardized approach to provider and health plan quality and performance measurement. The Obama administration established Partnerships for Patients: Better Care, Lower Cost. This public–private partnership focuses on safety and reducing unnecessary hospital admissions (USDHHS, 2011). The NCQA assesses and reports on the performance and quality of MCOs and health plans, including those that serve Medicare and Medicaid beneficiaries in managed-care plans. Both the FACCT and IOM conceptual frameworks are used by NCQA. Data are collected on individual providers and aggregated to the health organization (plan) 6044_Ch24_365-386.indd 380 07/09/17 10:12 PM Chapter 24 •  Measuring Advanced Practice Nurse Performance 381 health centers it supports. The MCHB, in part using CAHMI measures, has sponsored national surveys of children with special health-care needs to determine their health status and the quality of care they are receiving. Thefederal government’s Quality Interagency CoordinationTask Force represents another model of collaboration in the quality arena. The task force is to coordinate efforts across all federal agencies involved in health and health-care quality and its improvement. Task force participants are the Departments of Health and Human Services, Labor, Defense, Veterans Administration, and Commerce; the Office of Get research paper samples and course-specific study resources under   homework for you course hero writing service – Manage ment and Budget; the Coast Guard; the Federal Bureau of Prisons; the National Highway Traffic Safety Administration; the Federal Trade Commission; and the AHRQ. They are to improve safety, improve patient and consumer information on quality, develop the health-care workforce, and improve information systems. The AHRQ’s National Healthcare Quality and National Healthcare Disparities Reports use a framework that includes the IOM’s dimensions of care and FACCT’s patient need frameworks. State governments, advocacy organizations, professional organizations, provider organizations, foundations, and others are undertaking other efforts and using the conceptual frameworks offered by the IOM and FACCT to guide the development of measures or the use of existing measures in their quality strategies. For example, the states of Vermont and California are using the CAHMI performance measurement tools to assess quality of health care for children who are Medicaid beneficiaries. Children NOW, a California advocacy organization, issues report cards on child health status using the CAHMI measures. School-based clinics are using HEDIS-like measures to assess and improve the quality of care in these settings. FACCT, using its adult and child health quality measures, had consumer-centered tools for use by individuals, employers, and purchasers of care. For example, “Compare Your Care” was a computer-based program that helped consumers compare their care experience to national and regional benchmarks derived from evidence-based practice guidelines. One module provides a formulary to help inform consumers about 10 health conditions and what prescription medications are best for them. As the preceding discussion suggests, thereis consistency and collaboration across the health-caresystem in relation to the conceptual frameworks used for measuring health-care care. During the past several years, and with theintroduction of ORYX, TJC has moved toward outcomes assessment. Patient safety, including medication errors and infection rates, are receiving greater attention as quality indicators. Nurses involved in the development and testing of models to improve access quality are also an important consideration. For example, patient satisfaction with hospital care was addressed by Dozier, Kitzman, Ingersoll, Holmberg, and Schultz (2001). They developed and tested a tool, Patient Perception of Hospital Experience With Nursing, to assess whether or not patients’ needs were met by nurses. These tools, and others developed by nurses to assess other nurse-dependent outcomes, are an important alternative to traditional patient care satisfaction tools that focus on amenities of care rather than competencies of nursing practice and to evaluate nurse-dependent outcomes. The federal government’s Medicare, Medicaid, and State Child Health Insurance Program all use and drive quality efforts through the evaluation of care to their beneficiaries in health maintenance organizations and MCOs, long-term care, and home care. HEDIS and CAHPS are used to assess plan quality. As a purchaser of care, CMS is able to demand quality and accountability and does so through contracts that specify quality measures and the identification of specific performance improvement goals. For example, CMS and states are involved in a voluntary performance measurement project using HEDIS measures. CMS’s OASIS uses patient-level home-health agency data to assess and improve quality in Medicare-certified home-health agencies (Shaughnessy, Crisler, Hittle, & Schenkler, 2002). In 2016: 2024 – Do my homework – Help write my assignment online, CMS released the Nursing Home Quality Report for 15,634 nursing homes across the country (CMS, 2015 – Research Paper Writing Help Service). The report includes information about quality, inspection results, and nurse staffing levels that can be compared with state and national norms. The quality measures include ability to perform activities of daily living, numbers of pressure sores, use of physical restraints, infection rates, cognitive impairments, pain management, and ambulation. Other federal agencies such as the Bureau of Primary Health Care (BPHC) and the MCHB are implementing quality assessment and quality improvement initiatives. For example, BPHC’s quality center coordinates quality initiatives and conducts strategic planning to enhance the quality of primary health care,especially for the community 6044_Ch24_365-386.indd 381 07/09/17 10:12 PM 382 Unit 4 •  Ethical, Legal, and Business Acumen other health-care literature should be regularly scanned and the media closely followed to assess trends and keep knowledge up-to-date. Many of the quality-focused and professional organizations (such as the American Nurses Association, nursing specialty organizations, and nursing research societies) provide electronic and paper newsletters and journals that can help the APN stay informed. Melynk, Gallagher-Ford, Long, and Fineout-Overholt (2014: 2024 – Essay Writing Service | Write My Essay For Me Without Delay) identified 13 competencies for RNs and an additional 11 competencies for APNs to improve quality and address costs. The basic evidence-based care competencies for all nurses include identifying questions and problems, seeking evidence, evaluating evidence, and implementing and sustaining change. The APN competencies are at a higher level and include comprehensive searches for and assessment of research and other evidence, integration, collaboration, measurement, mentoring, and leading. Representing the thinking of experts in evidence-based practice, these competencies will help the APN to identify strengths and areas for professional development aimed at enhancing knowledge and skills in this area. Holley (2016: 2024 – Do my homework – Help write my assignment online) calls for APNs to develop a set of competencies specific to APN performance rather than rely on those used for physicians. The importance of APNs and their performance needs to be fully evaluated and their specific contributions to quality and outcomes made explicit (Naylor & Kurtzman, 2010 – Essay Writing Service: Write My Essay by Top-Notch Writer). The skills needed to effect change in the quality arena are the core competencies of advanced practice, direct clinical practice, research skills, clinical and professional leadership, ethical decision-making skills, collaboration, consultation, and expert coaching and guidance. Applying these skills beyond the individual patient practice level increases the APN’s ability to influence quality. Skills grow over time as the APN gets more involved in addressing quality concerns. As others become aware of the APN’s expertise in patient care and quality, and as the APN seeks new opportunities, the sphere of influence will grow. The APN can take action in relation to the practice, education, research, administration, and advocacy roles of advanced practice nursing at all levels. Each role component is discussed and examples of actions are provided. Although challenging, active engagement in the quality movement ensures recognition of the value of the APN role and better outcomes that will improve the health and reduce the burden of illness for U.S. citizens. quality. The FACCT and IOM frameworks guide most of the assessment, research, and reporting related to quality. Similarly, there is a fast-growing consensus for the use of HEDIS, CAHPS, CAHMI, and similar measures to assess quality in the domains suggested by the conceptual frameworks. Another trend is the significant collaboration and cooperation among a wide variety of stakeholders at all levels. The current climate also strongly suggests that health-care quality models and approaches must include the assessment of care in relation to what consumers want from the system, must be evidence based, and must use standardized and tested measurement approaches. The APN will be well positioned to justify the role and operationalize the APN contribution to health and health care if these and related theoretical frameworks are used. In addition, collaboration, the use ofevidencein measure development, rigorous measure testing (or the use of tested measures), and linking structural and process factors to outcomes or quality indicators are vital for APNs to achieve the purposes of their quality and performance assessment activities. RECOMMENDATIONS FOR ACTION To meet the expectations of advanced practice nursing, the APN must transform expert knowledge and skill into actions that contributeto meeting societal health-care goals. One of the most important opportunities for influence is to affect changes that improve outcomes for individual patients, groups of patients, health-care organizations, systems, and society. The APN can and should exert influence to make this change a reality. To improve quality, it must be defined from an evidence base, have outcome standards identified against which to measure quality and performance, have identified best structures and processes linked to outcomes, be tested and articulated, be assessed at all levels, and be shared with all stakeholders. The sixth domain of advanced practice (USDHHS, 2014: 2024 – Essay Writing Service. Custom Essay Services Cheap) is monitoring and ensuring the quality of health-care practice. Competency in this domain is demonstrated when the APN engages in quality monitoring and quality assurance activities. Knowledge and skill for these competencies begin with graduate education, building on the student’s undergraduate education and professional experience, and are continuously enhanced through education and practice experiences. In addition, nursing research and 6044_Ch24_365-386.indd 382 07/09/17 10:12 PM Chapter 24 •  Measuring Advanced Practice Nurse Performance 383 preventive care objectives andCAHPS questions about patient centerednessto determine patientexperienceswith theAPN’s care. Because standardized measures are used, the APN can compare performance to others or to national benchmarks. The collection of data and information to justify theAPN role,measure performance, demonstrate contributionsto quality, and guide quality improvement efforts is critical. Suggested strategiesincludetheregular collection and analysis of data on outcomesexpected fromtheAPN’s practice; the collection of preintervention and postintervention data to track results over time; and assessment of patient experience and satisfaction with care. Possible data sources include administrative data (the data provided to regulators, accreditors, and insurers), chart audits, and clientsurveys. HEDIS,CAHPS, and other standardizedmeasure useisencouraged to enhancethe ability to compare data acrossindividuals, groups, and settings.Data should be analyzed for trends over time: variations among groups of patients(e.g., age, gender,race, and ethnicity); variance from expected outcomes; differences among providers; and variations when compared with regional, state, or national norms. Performance data should besummarized and shared with consumers, other providers, and organizational leaders and used for accountability purposes. Education The APN has responsibility for his or her own, consumers’, and other providers’ education about quality issues and approaches. Consumers need information to be partners in their care, and other members of the health-care team need to better understand the value of APN practice. Sharing clinicalexpertise and participating in collaborative efforts to measure and improve quality best accomplish this. Offering information about best, evidence-based practices is one example of this type of activity. Advanced practice and basic education should include content about and experience with all aspects of the quality process. Buerhaus and Norman (2001) give four reasons for including such information in formal educational programs: 1. Given the current economic climate surrounding health-care delivery, competition will increase and providers will be competing on the basis of quality, using quality indicators to distinguish themselves to purchasers and consumers. Practice In direct clinical care, the APN should practice from an evidence base; deliver patient-centered care; be accessible to the patient; be responsive to patient needs, preferences, and concerns; and avoid missed opportunitiesto deliver preventive and health promotion services.The APN’srole modeling and expertise in delivery system operations can guide others to provide quality patient care and engagein quality improvement activities. Operationalizing Brown’s (2000) characteristics of the clinical role will also result in quality care and quality improvement. Noll and Girard (1993) provide a typology for quality activities related to APN competencies. At the practicelevel, the APN can contributeto the quality movement by collecting accurate and timely data for research and quality assessment purposes.The APN should participate in group practice, organizational efforts, and professional organization quality activities aimed at assessing quality, performance, access, and costs. Partnering with consumers on quality issues is also expected and desirable. Forexample, quality advisory committees that include consumers can be formed at the practice level to identify patients’ quality concerns and approaches to quality improvement. APNs must also participate in formal quality improvement programs and activities at the practice level. Participation and leadership in accrediting and quality reviews by regulators, including TJC, is another action the APN can take to engage in quality measurement and improvement. Professional organizations such as the American Association of Nurse Anesthetists appoint a member to serve on committees such as the Ambulatory Care Professional and Technical Advisory Committee (PTCA). In this position expert advice is given on standards development, environmental trends, education, and other related issues (AANA, 2016: 2024 – Do my homework – Help write my assignment online). Another practice-level set of activities that can be used for quality purposes is use of the position description and annual performance reviews. Position descriptions can be rewritten to reflect the elements of the IOM and FACCT models. Clear articulation of the goals and objectives of the review, and the use of standardized measures derived from these models,will foster more meaningful and relevant APN evaluation. Performancestandardsshould reflectthe purposes, goals, and objectives of the practicesetting andmeetexternal quality demands. Forexample, the APN in primary care can use an immunization benchmark from HEDIS to assess 6044_Ch24_365-386.indd 383 07/09/17 10:12 PM 384 Unit 4 •  Ethical, Legal, and Business Acumen APN can use research knowledge and skills to promote and improve quality. APNs have contributed to building a knowledge base and the methodologies needed to assess quality. Duffy (2002) described the clinical leadership role of the APN in identifying nurse-sensitive and multidisciplinary-quality indicator sets. The author advocates for using a phased, organization-wide process for incorporating these indicators into data collection efforts. Dunbar-Jacob and Schron (2002) suggest using ancillary studies to clinical trials to study questions relevant to nursing practice. Both of these suggestions provide examples of actions the APN can adopt at the practice level. Administration APNs in leadership positions can create a climate that fosters and supports quality and quality improvement. They can also propose structures and processes needed for quality and quality improvement such as available information systems for patient-level data collection. Even if the APN does not have administrative responsibilities, efforts can be made to promote the climate and the structures needed. Cubanski and Kline (2002) suggest several system challenges the APN can help address: • Redesign care to better serve patient needs. • Improve the use of information technology for practice and make it available to clinicians. • Develop systems to coordinate care across conditions, services, and settings. • Promote team effectiveness. • Incorporate process and outcome measures into the delivery of health care. Another administrative opportunity is providing incentives and awards for quality performance or quality improvement. Praise, recognition, promotion, raises, or other monetary contributions can provide incentive to staff. Awards, public acknowledgment, and offering special educational opportunities are other possible actions to foster continuous attention to quality and its improvement. The APN may do these things directly or by promoting their use by leaders in the setting. Rewards and recognition can also be provided through professional nursing organizations. 2. The nursing shortage will result in greater use of unlicensed personnel and foreign-educated nurses, but nurses will still be accountable for nursing care and will need to ensure quality and quality improvement. 3. Nursing is responsible for quality and quality improvement to meet health system goals. 4. Nurses can capitalize on emerging evidence about the relationship of staffing to outcomes to advocate for structures and processes that will improve outcomes. The Council of Accreditation of Nurse Anesthetist Educational Programs (COA) requires the master’s and the doctoral nurse anesthesia curriculum to integrate evidence-based practice throughout the curriculum. Resident nurse anesthetists are expected to use critical thinking and provide nurse anesthesia services based on evidence-based principles (COA, 2016: 2024 – Do my homework – Help write my assignment online). Additionally, the certifying arm, the National Board of Certification and Recertification for Nurse Anesthetists, incorporate evidence-based practice in their recertification program (NBCRNA, 2016: 2024 – Do my homework – Help write my assignment online). The APN may beinvolved in formal classroom or clinical teaching of undergraduate and graduate nursing students and should incorporate quality information and experiences in teaching strategies. The APN is also encouraged to include quality-related content during in-service and continuing education offerings. For example, the pediatric NP giving an in-service on assessing early childhood development should discuss how outcomes will be assessed using the CAHMI PHD measures. As a professional organization, the AANA provides professional practice resources on evidence-based practice for resident nurse anesthetists, CRNAs, and anyone who is interested in gaining knowledge or greater understanding (AANA, 2016: 2024 – Do my homework – Help write my assignment online). Research APN research-related competencies include critically evaluating and applying research to practice, monitoring and evaluating practice, and participating in research. Research knowledge and skills are directly applicable to quality measurement and the interpretation of data. APNs can contribute by building an evidence base for their practice through collaborative research efforts. Using data collected and analyzed to assess performance, the 6044_Ch24_365-386.indd 384 07/09/17 10:12 PM Chapter 24 •  Measuring Advanced Practice Nurse Performance 385 The APN should become an insider in the quality movement by participating in local, state, and national committees that are addressing quality concerns. For example, the author serves on the advisory and executive committees of FACCT’s CAHMI, thus having influence in the development and adoption of child health performance measures. Nurses are also staff at such organizations as TJC and the AHRQ and review quality-related grants for foundations and government agencies. The APN can also become a leader and advocate for quality in the community, in the state, or in the nursing organization. For example, the APN might chair the town health committee or advisory board and develop community health outcome measures for a report card or promote an annual quality conference by the state nurses association. CONCLUSION As the IOM report on the future of the profession (IOM, 2011) recommends, the transformation of the health-care system requires that nurses practice to the full extent of their legal scope and lead change to advance health. The PPACA signals that our society is ready for change in health care. More attention will be directed to primary care, prevention, chronic care, coordination, and other services traditionally provided by nurses. Initiatives to link outcomes to payment will continue. In addition, increasing technology, growing system complexity, and the demands created by an aging population will increase the demands and challenges to ensure the quality and quantity of health-care services. Accountability for performance will be required. APNs cannot escape their responsibility for clearly articulating their value to the health-care system. Because value equals quality and cost, without evidence of quality the case cannot be made for value. Advanced practice nursing cannot be supported and the purposes of the health-care system are not as well met as when the APN is a major player in the quality movement. Although efforts to define, assess, and improve quality have grown significantly in recent years, APN involvement in this arena has been less obvious. To move the health-care system toward quality, the APN, the health-care team, Advocacy As another core competency of APN practice, advocacy can be applied to advancing quality measurement performance and improvement. Clearly, patient advocacy has always been a hallmark of professional nursing practice. The APN can further develop this competency by providing consumers with quality-related information, including what to expect from health care and the health-care system. Advocacy and the development of partnerships with patients can be enhanced when patients havetheir personal health record and information about their condition and treatment options (Davis et al, 2002). Armed with this information, patients can make better informed decisions and participate in all aspects of their care planning. The APN can also advocate for the practice, education, research, and administrative actions described previously. APNs, especially those in direct practice roles, are not often involved with advocacy at the system or policy level. This is a loss to both the APN and society. With their expertise in practice, who better than the APN knows what is needed for quality care to become a reality? As an exception, CRNAs in academia, clinical practice, and resident nurse anesthetists have continually lobbied at the local, state, and national level for patient safety, access to care, title recognition, and workforce development (AANA, 2016: 2024 – Do my homework – Help write my assignment online). Additionally, CRNAs have aggressively lobbied to support full practice authority in the Veterans Hospital. Advocacy is needed at the systems and societal levels to promote more resources for quality measurement and research, improve access for all people, develop better measurement and reporting of quality, support financing of appropriate services, and support government quality efforts. Advocacy with government and private sector organizations means getting involved with the political and policy processes, lobbying, educating consumers and policy makers, and using the media to deliver quality and APN value messages. The APN’sexpert knowledge and skills should be used to influence legislators, regulators, insurers, and private sector organizations involved (or who should be involved). For example, the APN using the influence of a professional nursing organization should use public comment periods to influence new HEDIS measures,TJC standards, and state Medicaid performance measurement approaches. 6044_Ch24_365-386.indd 385 07/09/17 10:12 PM 386 Unit 4 •  Ethical, Legal, and Business Acumen care. The health-care system needs to takefull advantage of this resource. Recent and ongoing quality initiatives offer clear direction for the APN in evaluating performance, measuring quality, and articulating value to a variety of stakeholders. The competencies expected of the APN are explicit to the quality domain. If the profession’s clinical leaders do not get involved, who will fill the gap? The challenges are many, but the potential outcomes for the APN and society are great

Table 24.1 The Vocabulary of Quality
Access . Ability to obtain care or health and related services (also defined as use or insurance coverage)
Accountability . The demonstration of value (e.g., quality care, patient satisfaction, resource efficiency, and ethical practice); liability for actions
Cost .To the individual paying for services; to the provider to produce services; for society
Outcome . The end result of structures and processes of care; the goal or objective of health and health care .
Performance. Assessment of how individual providers behave; measurement assessment of processes of care; may be compared against standards or benchmarks
Process. Method in which health care is provided; provider behaviors; includes technical and interpersonal elements
Quality .How well services increase chance for desired outcomes; knowledge based and evidence based.
Quality assessment. Process of defining and measuring quality Quality assurance Process of measurement and quality improvement; may also be defined as the minimum standards approach
Quality indicator. Trait or characteristic linked with evidence to desirable health outcomes; may serve as proxy for outcome
Report cards. Collection and reporting of performance and other quality-related data to the public or other targeted groups .
Structure. Tools and resources for care (e.g., facilities, licensing and regulation, staffing, equipment)
Total quality.. Includes – Get research paper samples and course-specific study resources under   homework for you course hero writing service – an environment for quality, involves continuous measurement and improvement activities (often called total quality management or continuous quality improvement)

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