Leadership EXAM 1 REVIEW
Is Nursing a Profession?
1. A Profession Has Relevance to Social Values 2. A Profession Has a Training or Educational Period 3. Elements of Self-Motivation Address the Way in Which the Profession Serves the Patient or Family and Larger Social System 4. A Profession Has a Code of Ethics 5. A Professional Has a Commitment to Lifelong Work 6. Members Control Their Profession 7. A Profession Has a Theoretical Framework on Which Professional Practice Is Based 8. Members of a Profession Have a Common Identity and a Distinctive Subculture
PPO and HMO
A PPO is a plan that creates a network of preferred providers, and use of the network providers is at a lower cost to plan participants than using out of network providers (Center for Medicare and Medicaid Services, 2018a). In contrast to a PPO, participants in an HMO are restricted to use of the network providers and will not be covered for out-of-network care except in an emergency
DMAIC
A Six Sigma process for improving existing processes that fall below institutional goals or national norms. DMAIC stands for define, measure, analyze, improve, control.
Budgets
A budget is a tool that helps to make allocation decisions and to plan for expenditures. It is important for staff nurses to understand budget processes, because these decisions directly impact their clinical practice.
Six Stigma
A measurement standard in product variation that began in the 1920s when Shewhart showed that three sigma from the mean is the point where a process requires correction.
metric
A measurement to determine the rate of compliance or noncompliance with an indicator.
Performance Improvement
A plan and documentation method to demonstrate the procedures that have been used in the past and those that will be implemented for changes in the quality of services based on this previously collected data.
Defining your practice context
A practice context entails a blending of all those factors and systems that contribute to the delivery of nursing care. This blend includes the health, social, and cultural characteristics of the patient population served: the type of practice setting, the economic resources of the setting, the type of health care delivery system, the existing policies and procedures, the staffing pattern, and the administrative structure
Proprietary Nursing Schools
A proprietary nursing school is a for-profit school with a nursing program. Many proprietary schools have nursing programs in more than one state. Because not all nursing boards have the same requirements for licensure, it is important to review the requirements in your state to make sure that you will be eligible for licensure once you complete the program. A prospective student should also make sure that the program is accredited and review the pass rates on the NCLEX examination for their graduates.
Sentinel Event
A sentinel event is an unexpected occurrence involving death or loss of limb or function. Such events are called sentinel because they sound a warning of the need for immediate investigation and response (The Joint Commission, 2018a)
Introduction to Economics
A simple definition of economics is the allocation of scarce resources. An analogy might be made to the income that an individual earns. The paycheck is a limited, finite amount of money, and choices must be made about how to spend, or allocate, the money. Such choices might include rent, a car payment, food, clothing, and health insurance payments. Individuals may not be able to pay for all of the goods or services that they wish to have, so decisions must be made and priorities established.
operational definition
A statement detailing the thing or event using specific identifiable and measurable wording with written inclusion and exclusion criteria.
Rapid Cycle Changes
A strategy for process improvement as a part of DMAIC where changes are tried for very short time frames (3-7 days).
What is an accelerated program?
Accelerated programs are offered at both the baccalaureate and master's degree levels; they are designed to build on previous learning to help a person with an undergraduate degree in another discipline make the transition into nursing.
The Aging Population
According to the Administration for Community Living (HHS ACL, 2018, p. 2), by 2040 there will be about 82.3 million older persons, over twice their number in 2000. The population age 65 and older has increased from 37.2 million in 2006 to 49.2 million in 2016 (a 33% increase) in just 10 years and is projected to more than double to 98 million by 2060. The older adult population represented 15.2% of the US population in 2016, but are expected to grow to 21.7% of the US population by 2040. The population age 85 and older is projected to double from 6.4 million in 2016 to 14.6 million in 2040 (a 129% increase!). Nursing educators need to address the provision of health care to the older adult population and continue to ensure its inclusion in nursing curriculum.
A Shortage of Registered Nurses
According to the US Department of Health and Human Services, Health Resources and Services Administration (HRSA, 2017), there were approximately 2.8 million nurses employed in 2014, and it is projected that the number will increase to 3.9 million by 2030, which is a 39% increase nationally. Although these projections indicate that there will not be a nursing shortage nationwide, it is predicted that seven states will still be experiencing a nursing shortage.
Accountable care organizations (ACOs)
Accountable care organizations (ACOs) provide a pathway away from fee-for-service medicine and represent one of the first efforts to make value-based care a reality. ACOs are groups of doctors, hospitals, and other health care providers who come together voluntarily to give coordinated, high-quality care to the Medicare patients they serve. When an ACO succeeds in both delivering high-quality care and spending health care dollars more wisely, it shares in the savings it achieves for the Medicare program
Quality assurance
Activities that are used to monitor, evaluate, and control services to provide some measure of quality to consumers.
What are the other available educational options?
BSN completion programs career ladder or bridge programs external degree programs accelerated programs online university programs
What Is a BSN/MSN Completion Program?
BSN program designed for those who have obtained a diploma or ADN and hold a current RN license to practice Nurse receives transfer credit in basic education courses taken at other institutions 2 yrs in length
barriers to accountable care organizations
Barriers and drawbacks: Legal and regulatory barriers Anticipation of losing autonomy Population base is not large enough Inadequate capital for improvements in information technology Payment structure/financing
Certified Nurse Educator (CNE)
CNEs are registered nurses (RNs) who hold a master's or doctoral degree in nursing with an emphasis in nursing education.The majority of CNEs are nurse educators who facilitate student learning by providing innovative teaching methods in a variety of academic and practice settings, which may include community colleges, universities, hospitals, and technical programs (NLN, 2018).
Clinical nurse specialist (CNS)
CNSs are RNs with advanced nursing degrees—master's or doctoral—who are experts in a specialized area of clinical practice such as psychiatric/mental health, adult/gerontology, pediatric, women's health, and neonatal health. The majority of CNSs specialize in adult health or gerontology (NACNS, 2016).Most CNSs work in the hospital setting, full time, and have responsibility for more than one department. CNSs can also work in clinics, nursing homes, their own offices, and other community-based settings, such as industry, home care, and HMOs. They conduct health assessments, make diagnoses, deliver treatment, lead evidence-based practice projects, and develop quality-control methods. In addition to delivering direct patient care, CNSs work in consultation, research, education, and administration. Some work independently or in private practice and receive reimbursement. Based on state laws where the CNS practices, CNSs are authorized to prescribe medications (NACNS, 2016).
Computerized Provider Order Entry
CPOE is a technology-enabled process that allows providers such as physicians, nurse practitioners, and pharmacists to enter patient care orders directly into a computer system that transmits these orders directly to the receiving department (pharmacy, radiology, dietary, etc.) without intervening steps such as RN review for clarity and completeness. The true benefits of CPOE come with implementing clinical decision support systems (CDSSs) at the same time
Certified registered nurse anesthetist (CRNA)
CRNAs are RNs who complete a graduate program and meet national certification and recertification requirements. There are an estimated 42,260 CRNAs in the United States (Bureau of Labor Statistics, 2017).In this oldest of the advanced nursing specialties, CRNAs safely administer approximately 43 million anesthetics to patients each year in the United States. In some states, CRNAs are the sole anesthesia providers in rural hospitals (AANA, 2016). This enables health care facilities to provide obstetrical, surgical, and trauma stabilization services. CRNAs provide anesthetics to patients in collaboration with surgeons, anesthesiologists, dentists, podiatrists, and other qualified health care professionals.
Benefits to accountable care organizations
Benefits: Improved population health Improved quality of patient care A focus on patients Physician leadership Reduced costs Shared savings
American Nurses Foundation and the American Academy of Nursing
Briefly described, these organizations serve special purposes in support of research and recognition of nursing colleagues. The American Nurses Foundation was established as a tax-exempt corporation to receive money for nursing research. With the establishment of the National Nursing Research Institute, the focus has changed to one of support in the areas of policy making and research or educational activities. The AAN has a membership of more than 1500 nursing leaders and was established as an honorary association for nurses who have made significant contributions to the nursing profession. When a nurse is elected to the AAN, she or he is called a Fellow, and the credential following the nurse's name is FAAN. You may have had instructors who were faculty in the AAN, or you may be working with a nurse who is a FAAN. These nurses can provide valuable mentorship for the new graduate. The official publication of this organization is Nursing Outlook.
What Are the Types of Budgets?
Capital, Operating, Personnel
Clinical decision support (CDS)
Clinical decision support (CDS) is a type of health information technology that provides health care providers, nurses, patients, and other individuals with relevant person-specific information that is presented at the right time for the health care provider to make a clinical decision about the patient's plan of care. Computerized alerts, reminders, diagnostic support, potential drug interactions, and clinical guidelines are a few CDS tools that assist health care providers and nurses with clinical decision-making and improving workflow
What Tools Are Used to Support Care Coordination?
Clinical pathways and disease management protocols are similar strategies that support the work of the coordinator of care to reduce expensive variations in care.
Clinical Pathways
Clinical pathways, also known as care maps, are multidisciplinary plans of "best" clinical practice for groups of patients with a specific medical diagnosis. These pathways support the coordination and delivery of high-quality care. A clinical pathway has the following four essential elements: ▪ A time line outlining when specific care will be given ▪ A statement of the categories of care or activities and their interventions ▪ A list of the intermediate- and long-term outcomes to be achieved ▪ A variance record
Quality improvement methods
Commitment to CQI Empowerment of nurses Collecting data systematically Anticipating risks to prevent them Working groups with sense of collaboration Everyone wins when nurses become involved and invested in being a part of a group willing to make things work well; thus, it is critical to be knowledgeable about current CQI methods
Benefits of a concurrent or dual pathway program
Concurrent enrollment programs are a win/win for all. The student saves time and money, earning a nursing degree often preferred by employers. The community college and the university have engaged, motivated students and the ability to share resources to provide an affordable career ladder, placing competent, practice-ready graduates in the workplace who may then return to school for graduate degrees. The community benefits by having a highly skilled nursing workforce ready to meet the ever-expanding health care needs of a diverse population (Schultz, 2016, p. 1).
What Is a Concurrent Enrollment BSN Completion Program?
Concurrent or dual-enrollment programs layer nursing coursework, blending both the associate and RN to BSN curricula. Students meet all criteria for the community college associate program and then have the opportunity, based on a number of factors, to explore and select a university partner school. The student will complete all prerequisites for both the community college and the university and will make application to both colleges.
Privacy and Confidentiality
Confidentiality agreements should be reviewed and signed when starting employment and yearly thereafter. Breaches of security, confidentiality, or privacy should be addressed and resolved quickly, and the offender should be charged accordingly. Every lapse should be treated openly and used as an example for others to take note of. The IN may be involved in the investigation process and the writing of the policies and procedures.
Plan-Do-Study-Act
Contained within an RCC for planning, doing, studying, and performing actions intended to drive and maintain change.
Core Measures
Core measures include those for patients admitted with a diagnosis of acute myocardial infarction, heart failure, community-acquired pneumonia, surgical infections, pregnancy-related conditions, deep vein thrombosis, and whether specific best practices were implemented within the health care setting. These measures are those that the consumer considers important for choosing one hospital over another.
Define, Measure, Analyze, Improve, Control
DMAIC is pronounced DUH-MAY-ICK which includes: DEFINE: Define the issue, possible causes, and goals MEASURE: Measure the existing system with metrics ANALYZE: Analyze the gap between the existing system and goal IMPROVE: Improve the system with creative strategies CONTROL: Control and sustain the improvement
Quality Indicators
Data that indicate whether high-quality care is being maintained. Items of concern that have arisen because of a nursing practice problem (e.g., Foley catheter securing).
Disease Management Programs
Disease management programs are designed to target individuals with specific costly, chronic conditions such as asthma, diabetes, heart failure, coronary heart disease, end-stage renal disease, depression, high-risk pregnancy, hypertension, and arthritis. Disease management programs usually involve an interprofessional team, including physicians, nurses, pharmacists, dieticians, respiratory therapists, and psychologists. The goal of these programs is to educate individuals to manage and control their condition as a means of receiving better care thus leading to better outcomes and reduced costs. Counseling, home visits, 24-hour call centers, and appointment reminder systems can be used to support patients responsible for their chronic conditions
Disease Management
Disease management refers to multidisciplinary efforts to improve the quality and cost of care for patients suffering from chronic diseases. It involves interventions designed to improve adherence to appropriate scientific guidelines and treatments. The goal is similar to that of case management—to support patients with chronic diseases who may receive services from various levels of care (acute care to home-based care)
EBP and Research
EBP goes beyond nursing research in considering other sources of documentation that may improve nursing care. Research published by other disciplines is included (e.g., medical research and social research), as well as nonresearch data that may contribute to practice (e.g., financial data and clinical experts). This is prudent at a time when the complexity of health problems is increasing and the discovery of new data is more rapid than ever before
Electronic Health Records
EHRs are essential for health care to leverage state-of-the-art technology to deliver the highest-quality, lowest-cost patient care. Two other terms coming into vogue are the comprehensive health record and the connected health record. These terms describe two different visions of the next generation of the EHR. These visions include social determinants of health and more into nontraditional sources of data, including families/caregivers, school clinics, senior centers, and community health facilities. Other experts see the next step in EHR development to include shared care planning, genomics and personalized medicine, population health and public health, and remote monitoring and sensors
Hours per patient day (HPPD)
Each patient-care unit will have a designated number of hours of care per patient day. In an intensive care unit, this might be as high as 22 hours per day; on a general surgical unit, it might be 6 to 8 hours. However, nurses need to be aware that these hours must be spread over three shifts (if the organization uses 8-hour shifts) or two shifts (in the case of 12-hour shifts). Nurse managers typically derive staffing patterns (i.e., combinations of staff [RNs, LPNs, nursing assistants]) that are needed for each shift.
Barriers to Entry to the market
Even if patients had sufficient knowledge to treat their own illnesses, the health care market is fraught with barriers. All providers must pass examinations and be licensed by appropriate boards. Prescriptive authority is heavily regulated and closely controlled
What is evidence based practice?
Evidence-based practice (EBP) "is a problem solving approach to clinical practice that integrates a systematic search for and critical appraisal of the most relevant evidence to answer a burning clinical question, one's own clinical expertise, and patient preferences and values" (Melnyk & Fineout-Overholt, 2005, p. 6). Historically health care—and more specifically, nursing care—was based on tradition. In other words, we simply replicated what had been previously done in nursing, without question to the support of evidence for what we were doing or the impact on patient outcomes. As nursing has evolved and the expectation for continually improving patient outcomes has come to the forefront, a greater emphasis has been placed on implementing nursing care that is supported through the use of the best research available. EBP incorporates many additional sources of data that may contribute to improved nursing care.
Medicare Shared Savings Plan
In 2011, the Centers for Medicare and Medicaid Services (CMS) launched the Medicare Shared Savings Plan as a requirement of the Patient Protection and Affordable Care Act, to assist all health care providers across health care settings (hospitals, doctor's offices, long-term care) in coordinating care for Medicare patients. Under the Medicare Shared Savings Plan, Accountable Care Organizations (ACOs), consisting of health care providers, agree to collaborate in providing patient care versus working independently. This was an effort to control costs and provide quality patient care. In order for an ACO to receive financial compensation for services rendered to a Medicare patient from CMS, the ACO must demonstrate that it has met the performance standards set forth by the CMS (Centers for Medicare & Medicaid Services, 2018a, p. 1).
Few doctors currently communicate with their patients through e-mail Could help to avoid "phone tag" with clients and improve efficiency Drug-refill requests and educational information could be accessed
Fiscal Responsibility
Fiscal responsibility concerns a threefold responsibility: first to the patient, second to the employing institution, and finally to the payer of health care. It is defined as the duty/obligation of the nurse to allocate (1) financial resources of the patient to maximize the patient's health benefit, (2) financial resources of the employer to maximize organizational cost-effectiveness, and (3) financial resources of the payer by using knowledge and efficiency
What is a career ladder program?
Focuses on articulation without loss of credit RN to BSN to MSN or doctoral programs
Forces of Magnetism
Force 1: Quality of nursing leadership Force 2: Organizational structure Force 3: Management style Force 4: Personnel policies and programs Force 5: Professional models of care Force 6: Quality of care Force 7: Quality improvement Force 8: Consultation and resources Force 9: Autonomy Force 10: Relationships between the community and the health care organization Force 11: Nurses as teachers Force 12: Image of nursing Force 13: Interdisciplinary relationships Force 14: Professional development
The 2010 ACA regulations also included regulations to expand Medicaid coverage which included:
In 2014, those under 65 years of age with incomes up to 133% of the federal poverty level, including individuals without children, were eligible for Medicaid. In addition, the State Children Health Insurance Plan (S-CHIP) was made simpler to access. Other requirements of the law included (1) free preventive benefits, such as wellness visits and cholesterol checks; (2) closing the prescription drug "donut hole" coverage gap; (3) investing more resources in efforts to fight health care fraud; and (4) tying payment to quality standards, investing in patient safety, and offering new incentives for providers who delivered high-quality care (HealthCare.gov, 2018a).
Why do Americans go uninsured?
In January 2017, Politifact reported that roughly 28 million Americans were uninsured, down from 41.3 million in 2013, primarily because of the (1) expansion of Medicaid, (2) creation of online health insurance marketplaces, (3) ability of young people to stay on their parents' coverage through age 27, and (4) mandates of the law that require everyone to purchase a health insurance plan (Jacobson, 2017).
Foreign Nurse Licensure
Foreign nurse graduates who want to practice nursing in the United States must contact the board of nursing in the state in which they want to practice to obtain licensure, because each state controls its own requirements for licensure. The state's board of nursing will review the candidate's nursing education and determine the requirements needed to obtain a license in that state. Most states require that foreign nurses take the Commission on Graduates of Foreign Nursing Schools (CGFNS) examination before the NCLEX-RN® examination. This examination determines proficiency in nursing and the English language, thus assisting in the prediction of success on the NCLEX-RN® examination. All foreign nurse graduates, regardless of licensure in their home countries, must successfully complete the NCLEX-RN® examination.
Robotics in Patient Care
From robots who greet and respond to verbal responses, to direct care robots, which can lift patients or lead patients in exercise activities to therapeutic robots—robotics are becoming part of the health care environment. Therapeutic robots built to look like cute animals such as a dog or baby harp seal deliver emotional responses based on sensors and produce the benefits of animal therapy without the problems live animals bring
what does finded research include?
Funded research includes health promotion and disease prevention, quality-of-life issues, health disparities, end-of-life and palliative care, symptom management research, data science, global health, and genomic science.
Further description of EHRs
Further description of EHRs focuses on the total health of the patient—going beyond standard clinical data collected in a single event such as a provider's visit or hospitalization. They provide a broader view on a patient's care. EHRs are designed to reach out beyond the health organization that originally collects and compiles the information. They are built to share information with other health care providers so they contain information from all the clinicians involved in the patient's care
Chapter 16 Conclusion
Given the dire predictions about health care costs being forecast for the next 10 years, it is imperative that nurses consider the economics of clinical practice. Throughout most of nursing history, nurses have not wanted to learn about the costs of care, considering such concerns about as important or as appealing as unnecessary paperwork. Nurses proclaim that they want to be caregivers, not accountants. However, nurses humanize health care institutions. Not only do they bring the values of caring and compassion to the workplace, but they represent the largest health professional group. As representatives of the largest health professional group, nurses can contribute to controlling healthcare costs by incorporating fiscal responsibility into clinical practice.
The Joint Commission's 2019 National Hospital Patient Safety Goals
Goal 1: Use at least two ways to identify patients, such as using the patients' names and dates of birth. Make sure that the correct patient receives the correct blood during a blood transfusion. For newborn patients: Use distinct methods of identification for newborn patients. Goal 2: Improve the effectiveness of communication among caregivers. Get important test results to the right staff person on time. Goal 3: Use medications safely. Before a procedure, label medicines that are not labeled, for example, medicines in syringes, cups, and basins. Do this in the area where medicines and supplies are set up. Take extra care with patients who take medicines to thin their blood. Record and pass along correct information about a patient's medicines. Find out what medicines the patient is taking. Compare those medicines to new medicines given to the patient. Make sure the patient knows which medicines to take when he or she is at home. Tell the patient it is important to bring an updated list of medicines every time he or she visits a provider. Goal 4: Use alarms safely. Make improvements to ensure that alarms on medical equipment are heard and responded to on time. Goal 5: Prevent infection. Use the Centers for Disease Control and Prevention (CDC) hand hygiene guidelines or the current World Health Organization (WHO) hand hygiene guidelines. Set and use the goals for improving hand cleaning. Implement evidence-based practices to prevent health care-associated infections (HAIs) and infections caused by multidrug-resistant organisms that are difficult to treat, infection of the blood from central lines, after surgery, and urinary tract infections. Goal 6: Identify patient safety risks. Find out which patients are most likely to try to commit suicide. Goal 7: Prevent mistakes in surgery. Make sure that the correct surgery is done on the correct patient and at the correct place on the patient's body. Mark the correct place on the patient's body where the surgery is to be done. Pause before the surgery to make sure that a mistake is not being made.
What about graduate school?
Graduate education programs are available on a part-time or a full-time basis. Graduate programs require a good grade point average (GPA) at the undergraduate level. Prerequisites for most graduate programs are satisfactory scores on the Graduate Record Examination (GRE) or the Miller Analogies Test (MAT). Although an increasing number of graduate programs are waiving the entrance examination requirements, it is strongly recommended that all students, whether they plan to pursue graduate studies or not, take the GRE after completing their undergraduate studies.
What is hospital consumer assessment of health care providers and systems?
HCAHPS refers to the Hospital Consumer Assessment of Healthcare Providers and Systems. It is a national program for collecting and providing health care information from the consumer's perspective, and the results are used to improve health care services. The patient survey was developed for public reporting as a way of comparing hospitals across the continuum of patient care and garnering information about the overall quality of care received from the patient's viewpoint. The HCAHPS contains ratings of communication, responsiveness, pain management, discharge information, cleanliness of the hospital environment, quietness of the hospital environment, and if patients would recommend the hospital (HCAHPS, 2017).
Patient Portals
HealthIT.gov (2017) defines a patient portal as a secure online website that gives patients convenient, 24-hour access to personal health information from anywhere with an Internet connection. Using a secure username and password, patients can view health information such as the following: ▪ Recent doctor visits ▪ Discharge summaries ▪ Medications ▪ Immunizations ▪ Allergies ▪ Lab results Some patient portals also allow you to: ▪ Securely message your doctor ▪ Request prescription refills ▪ Schedule non-urgent appointments ▪ Check benefits and coverage ▪ Update contact information ▪ Make payments ▪ Download and complete forms ▪ View educational materials
History and evolution of quality in health care
Historically quality-improvement efforts have focused on controlling processes by inspection, so that errors were prevented. Later, the emphasis changed from inspection to proactive approaches, including the monitoring of processes.
Institute for Health Care Improvement
IHI's work is focused in five key topic areas: ▪ Improvement capability: Ensuring that improvement science drives our work and that we extend the reach and impact of the improvement community ▪ Person- and family-centered care: Putting the patient and the family at the heart of every decision and empowering them to be genuine partners in their care ▪ Patient safety: Making care continually safer by reducing harm and preventable mortality ▪ Quality, cost, and value: Driving affordability and sustainability through quality improvement ▪ Triple aim for populations: Applying integrated approaches to simultaneously improve care, improve population health, and reduce costs per capita (IHI, 2018)
NI education
INs who want to hold leadership roles in NI will need graduate-level preparation. A student who held a leadership role in NI and was enrolled in a NI master's program once said that she thought she knew all about NI, but she learned that she only knew about it at her own organizational level. Her graduate-school education had broadened her perspectives and introduced her to new concepts and ways of thinking (C. Parker, 2011, personal communication).
What Are the Motivators and Barriers for Incorporating Nursing Research into Your Practice?
Identify your bridges (motivators) and roadblocks (barriers) in the practice setting
Consumer knowledge
If an individual is purchasing a coat or a car, the person usually knows a good deal about the item being purchased, or he or she consults Consumer Reports for further data. This is not the case in health care, about which patients tend to have limited knowledge and limited ability to interpret the available knowledge.
What Is Nursing Informatics?
In 1994, the American Nurses Association (ANA) recognized the field of NI. In 2015, the ANA updated the definition of NI as "the specialty that integrates nursing science with multiple information management and analytical sciences to identify, define, manage, and communicate data, information, knowledge, and wisdom in nursing practice" (ANA, 2015, p. 1).
The Certification Process
In 1994, the American Nursing Credentialing Center (ANCC) provided a method for nurses to become certified in this specialty. The baccalaureate degree is the minimum requirement needed to take the certification exam. Nurses can obtain RN-BC certification in informatics nursing through the ANCC.
Nurse Navigator Programs
In 2005, the Patient Navigator Outreach and Chronic Disease Prevention Act authorized federal grants to hire and train patient navigators; their role would be to help patients with cancer and other serious chronic diseases receive access to screening, diagnosis, treatment, and follow-up care. In 2006, the CMS funded six demonstration projects to help minority Medicare patients overcome barriers to screening, diagnosis, and treatment;
In 2008, the TJC published a report titled "Guiding Principles for the Development of the Hospital of the Future." This report outlines principles to
In 2008, the TJC published a report titled "Guiding Principles for the Development of the Hospital of the Future." This report outlines principles to (1) support economic viability, (2) guide technology adoption, (3) guide the achievement of patient-centered care, (4) guide the design of hospitals of the future, and (5) address staffing challenges.
POS
In POS plans, participants will pay less if they use an in-network provider and, in addition, need to have a referral from their primary care provider to see a specialist
Admissions, Discharges, and Transfers within the Operating Budget
In addition to projecting the patient day volume, nurse managers also examine the activity of the unit and the acuity (the intensity of care required) of patients. The activity is usually described as admissions, discharges, and transfers (ADTs). One measure of activity is the average daily census—that is, how many patients are occupying beds on the unit at midnight. However, this measure by itself results in an underestimation of the work of the unit. A more accurate picture is gained by the addition of the ADT data because even though these patients may not be counted in a midnight census, they require many hours of care by registered nurses
Credentials in Nursing
In nursing, the educational credentials that an individual holds indicate not only academic achievement but also the attainment of a minimum level of competency in nursing skills. An ADN, a diploma in nursing, or a baccalaureate degree in nursing (BSN or BS) represents academic achievement. After academic preparation and successful completion of the NCLEX, you will have a legal credential—your nursing license—that permits you to practice as an RN. Additional nursing credentials may reflect practice in special areas, such as critical care registered nurse (CCRN) and certified addictions registered nurse (CARN).
Managed Care
In the early 1900s, patients or their families paid the physician or the hospital directly for the care they received. As health care insurance became an employment benefit after the Second World War, third-party payers became more common. These third-party payers paid the provider an agreed-on fee for each service provided. The more the provider charged, the more the payer paid.
What Is an External Degree Program?
In the early 1970s, the external degree program was a nontraditional program that allowed a student to gain credit, meet external degree requirements, and obtain a degree from a degree-granting institution without attending face-to-face classes. One of the earliest external degree (or distance education) programs was offered through the New York Board of Regents external degree programs (REX), which is now Excelsior College. External degree programs may offer an ADN, a BSN, and a master of science in nursing (MSN). These programs are designed to allow individuals to obtain degrees in nursing without leaving their jobs or their communities.
Capitation
In the most extreme type of managed care, called capitation, employers pay a set fee each month to an insurance company for each covered employee and dependent. This amount does not vary based on the care given. Potential patients may never need any health care or they may require extensive hospitalizations. Regardless, the costs of care for all members of a particular employment group must be taken out of the set fee. Under this arrangement, there is incentive for the insurance company and the provider to work aggressively to keep patients healthy, because prevention or early intervention is likely to be less expensive than hospitalization. Conversely, if patients do not stay healthy or if they overuse hospitalization, the health care provider may actually lose money.
The following is an excerpt from the 2019 NCLEX-RN Test Plan regarding the content area of Information Technology on the NCLEX-RN exam:
Information Technology • Receive and transcribe health care provider ordersa • Apply knowledge of facility regulations when accessing client records • Access data for client through online databases and journals • Enter computer documentation accurately, completely and in a timely manner • Utilize resources to enhance client care (e.g., evidenced-based research, information technology, policies, and procedures)a Confidentiality/Information Security • Assess staff member and client understanding of confidentiality requirements • Maintain client confidentiality and privacya • Intervene appropriately when confidentiality has been breached by staff members
What Impact Has Managed Care Had on Costs?
Initially, managed care reduced the cost of health care. However, costs subsequently increased sharply in response to the backlash from restrictive managed care policies. Given the complexity of the issues surrounding the costs of health care, it is very difficult to say conclusively that managed care is effective, in part because the definition of "effective" may vary.
The 2 Types of Accreditation
Institutional or regional accreditation refers to an entire university or college being accredited, indicating that all components of the institution contribute toward the institution or college's objectives and mission, whereas program or specialized accreditation refers to a specific discipline, department, or individual program of study within the university or college that is accredited
What are the trends affecting the rising costs of health care?
Intrinsic factors include characteristics of the population, the demand for health care, and health insurance coverage. Extrinsic factors include the availability of technology, prescription drug costs, and workforce costs
The Changing Student Profile
It has previously been stated that there is a growing population of nontraditional students—individuals who are making midlife career changes in part because of job displacement or job dissatisfaction. Minority individuals, foreign-educated students, and disadvantaged students are looking toward nursing education for career opportunities. These changes mean that nurse educators will have to go further in addressing the needs of the adult learner. More programs will be needed that permit part-time study and allow students to work while attending school. One option may be for more night or weekend course and clinical offerings. There will continue to be a need for emphasis on remedial education such as developmental courses in math, English, and English as a second language. The diversity in the student population means increased diversity in the nursing workforce, which will contribute to quality health care for the nation's diverse population
Why would I want a Master's Degree?
Policy statements from the nursing profession reflect the need for more education in preparation for the changing role of nursing, a result of health care reform. As care delivery moves increasingly from the acute care center to the community setting, there will be an increased need for advanced clinical practice nurses. Nursing programs are already responding to this changing need.
Cost of Nurse-Sensitive Adverse Events
Practice Issue In a time of increasing health care costs and an emphasis on providing safe, high-quality care to patients, nurses need to understand the cost of complications that are related to nursing care. Implications for Nursing Practice • Pappas (2008) studied five adverse events: medication errors, falls, urinary tract infections, pneumonia, and pressure ulcers. • For patients with health failure, the cost of an adverse event was $1029. • For surgical patients, the cost of an adverse event was $903. • The odds of pneumonia occurring in surgical patients decreased with additional registered nurse hours per patient day.
Preventing Pressure Ulcers on the Heel: A Canadian Cost Study
Practice Issue The heel is an area that is especially at risk for the development of pressure ulcers. Implications for Nursing Practice In a study conducted by Bou et al. (2009), two methods of preventing pressure ulcers on the heel were compared: • Method A involved protective bandaging plus usual care. • Method B provided a hydrocellular dressing for protection of the heel in addition to usual care. 44% of patients in the Method A group developed pressure ulcers on the heel compared with 3.3% in the Method B group. The Method B group cost $11.67 more per patient to provide than the Method A group.
Step 3: Design a Practice Change Based on the Data While Incorporating the Clinical Expertise of the Nurse and Patient Preferences
Prepare a written plan for the new nursing practice. The plan needs to be consistent with your practice context to be effective. For maximum benefit, the plan will also require the consensus of those who will implement it.
key indicators
Selected data based on TJC mandates or on specific problem areas that may show the need for more extensive data collection or remedial action to resolve an identified problem (e.g., fall rates, medication error rates).
monitor
Similar to auditing; checking or verifying that an established practice has been retained.
What is Six Stigma?
Six Sigma (SS) quality improvement methods are one approach taken to create a culture of safety management at the institutional level. Sigma is a measurement standard that reflects how well a product or process is performing
Pareto Principle
Some 80% of the problems are caused by 20% of sources, people, or things. If you can fix the 20%, you can fix the system.
QI Departments
Some hospital QI departments have combined newer strategies with PDSA, including define, measure, analyze, improve, control (DMAIC) and rapid cycle changes (RCCs), which further incorporate a team focus. These are components of CQI, but more discussion of these methods will come later. TJC has also mandated specific quality outcome measures for all hospitals. Outcome measures involve looking for real patient results to determine whether an organization's goals are being achieved. TJC wants to know if the care that patients receive is meeting standards or is improving.
Efforts to help reduce hospital costs
Specific efforts to reduce hospital costs that affect the delivery of nursing care include case management, evidence-based practice (EBP), appropriate staffing, improving retention of staff, use of the electronic health record (EHR), and the reduction of patient care errors.
Staff Nurses and Personnel Budget
Staff nurses need to understand how a nurse manager determines the number of nurses required for patient care. As discussed, beginning considerations are acuity of patients and the volume or number of patients. The nurse manager must also consider the clinical expertise of the nursing staff. If a unit has a high percentage of new graduates, there will be a decreased ability to safely care for a higher volume of acutely ill patients on the unit. Next, the nurse manager engages in a series of calculations, all of which are easily understood by staff nurses.
Working Overtime
It was found that that 14% of nurses in the study reported working shifts of 16 hours or longer in the previous 4 weeks and that 81% of shifts ran beyond their scheduled limits. This work pattern results in fatigue, which can produce a level of performance similar to that of someone who is drunk. Fatigue can also produce physical performance effects that inhibit critical cognitive functions, including lapses of attention, irritability, memory lapses, decreased ability to detect and react to subtle changes, slowed information processing, difficulties in handling unexpected situations, and communication difficulties.
Evidence Based Nursing Center
Joanna Briggs Institute (JBI), an international not-for-profit research and development arm of the School of Translational Science based within the Faculty of Health Sciences at the University of Adelaide, South Australia. It collaborates internationally with more than 70 entities across the world (http://joannabriggs.org/)
Stakeholders
Key people who will be affected by change and who can either positively or negatively influence the improvement.
Registration and Licensure
Licensure affords protection for the public by requiring an individual to demonstrate minimum competency by examination before practicing certain trades. By 1923, 48 states (Alaska and Hawaii did not become states until much later) had some form of nursing licensure in place. Nursing licensure is a process by which a governmental agency grants "legal" permission to an individual to practice nursing. This accountability is maintained through state boards of nursing, which are responsible for the licensing and registration process. Boards of nursing vary in structure and are based on the design of the nurse practice act within each state
Medicare Part C
MA plans—a plan like an HMO or a PPO plan. Medicare will pay a fixed amount each month to the private insurance company providing the MA Plan.Run by Medicare-approved private insurance plans. The MA Plan covers all of Part A and Part B and usually includes prescription drug coverage as part of the plan. May offer additional benefits such as hearing, vision, and dental coverage, as well as health and wellness programs for an additional cost.Might not cover if an individual goes outside of the selected provider network.The individual must follow plan rules, such as obtaining a referral to see a specialist.The individual may only join a plan at certain times during the year and is expected to stay in the plan for a year.
What About a Master's Degree as a Path to Becoming a RN?
MSN programs are particularly attractive to the growing number of college graduates who decide to enter nursing later in life. Generally, the program is 24 to 36 months long. Upon graduation, these students are expected to demonstrate the same entry-level competencies in nursing as baccalaureate graduates. MSN graduates from these programs are then eligible to take the NCLEX-RN examination. Currently, there are 69 entry-level master's programs in the United States (AACN, 2017a).
negative aspects for pay for performance
May harm and reduces access for socioeconomically disadvantaged population because they perform poorly on P4P surveys Lowered job satisfaction for providers Incentives to "game" the system Costly to implement and verify measurement systems P4P processes may not always support individual care Difficult to accurately attribute performance outcomes given that patients receive care from multiple providers
outcome or core measures
Measures that the public consumer considers important for choosing one hospital instead of another.
Medicare Part D
Medicare drug coverage: Individual must have Part A and/or Part B. Most plans charge a monthly premium that varies depending on the plan chosen.Prescriber must be enrolled in Medicare or have "opted-out" in order for prescriptions to be covered under Part D. There is a yearly deductible before the plan begins to pay.Copay—Amounts the individual pays at the pharmacy after the deductible.Coverage gap—After the individual and the plan have paid a certain amount for covered drugs, the "coverage gap" or "donut hole" is reached. In 2019, once you enter the coverage gap, you pay 25% of the plan's cost for brand name and 37% for generic drugs until you reach the end of the coverage gap. Not everyone will enter the coverage gap because their drug costs will not be high enough.After the yearly out-of-pocket limit is reached, the individual receives "catastrophic" insurance whereby the individual again pays only the copay for covered drugs the rest of the year.Limits on how much medication the individual can obtain at one timeDrugs not on the plan's list of approved drugs ("formulary") are not covered.
Managed Care and Medicare
Medicare introduced the prospective payment system as a way of reimbursing hospitals. This marked the beginning of a movement to control health care costs. Under this system, which insurance companies soon adopted, a fixed fee was paid to the hospital according to a preset reimbursement rate for the diagnosis given at discharge. A hospital could treat a patient so that a shorter length of stay was necessary, thus reducing the consumption of resources. This allowed the hospital to show a greater profit or lower loss for caring for a patient if the care was more efficient than was the prearranged rate for the diagnosis
Organization for Associate Degree Nursing
Membership in the Organization for Associate Degree Nursing (OADN) is open to AD nursing graduates, educators, and students. Individuals, states, agencies, and other organizations may also join. There are state and national chapters. The mission of this organization is to be the advocate for AD nursing education and practice while supporting advanced nursing education through academic progression. OADN strives to maintain eligibility for RN licensure for graduates of AD programs, to promote AD nursing programs in the community, to provide a forum for discussion of issues affecting AD nursing, to develop partnerships and increase communication with other health care professionals, to increase public understanding of the AD nurse, to participate at state and national levels in the formation of health care policies, and to facilitate legislative action supporting the activities of OADN.
Nurse Practitioner (NP)
Most of the approximately 330 NP education programs in the United States today confer a master's degree. The majority of states require NPs to be nationally certified by ANCC, AANP, or a specialty nursing organization. In 2018, more than 248,000 advanced practice nurses were NPs (AANP, 2018).Working in clinics, nursing homes, hospitals, health maintenance organizations (HMOs), private industry or their own offices, NPs are qualified to handle a wide range of basic health problems. Most have a specialty—for example, an adult, family, or pediatric health care degree. At minimum, NPs conduct physical examinations, take medical histories, diagnose and treat common acute minor illnesses or injuries, order and interpret laboratory tests and radiographs, and counsel and educate patients. In all states they may prescribe medication according to state law. Some work as independent practitioners and can be reimbursed by Medicare or Medicaid for services rendered.
Payer Allocation Decisions Preauthorization
Most policies require preauthorization (preapproval) of services before the patient receives care, except in cases of emergency.
Step 4: Implement the Change in Nursing Practice
Move the new plan into nursing practice on a defined schedule. Staff in-services may be required so that those involved can fully understand the change. Monitor and evaluate the implementation process. Moreover, as noted by Melnyk and Fineout-Overholt (2005), EBP must recognize the great experience that nurses bring to the practice setting and patient input and preferences if successful implementation is to be realized (Fig. 24.2).
1988 Social Policy Statement
The 1988 Social Policy Statement document defined nursing practice at both the generalist and specialist levels; this is echoed in the current 2010 Social Policy Statement. The certifying organization of the ANA is the American Nurses Credentialing Center (ANCC), which has certified more than 92,000 RNs in different practice areas at both the generalist and specialist levels, along with more than 125,000 advanced-practice nurses (ANCC, 2017).
American Board of Nursing Specialties
The ABNS was established to create uniformity in nursing certification; it now represents more than 25 specialty nursing organizations that promote specialty practice and address certification issues associated with specialty practice. The ABNS functions as a consumer advocate in promoting nursing certification.
Payer Allocation Decisions
The ACA of 2010 required all health plans to provide coverage for applicants regardless of health status, gender, or any other factors. In addition, the ACA requires plans to cover a range of preventive health services without any patient cost sharing (Kaiser Family Foundation, 2015).
ACA regulations with young adults
The ACA regulations let young adults stay on their parents' plan until age 26, a very popular regulation for many people of all political persuasions. In addition, insurance companies were no longer able to deny coverage, charge more based on health status, or drop coverage when the insured was sick. This meant that there were no more limitations of preexisting conditions.
Accrediting Organizations
The ACEN, the CCNE, and the NLN CNEA are accrediting organizations that accredit nursing programs nationwide. Specifically, the ACEN accredits clinical doctorate/DNP specialist certificate, master's/post-master's certificate, baccalaureate, associate, diploma, and practical nursing programs (ACEN, 2018). The NLN CNEA accredits licensed practical nurse/licensed vocational nurse (LPN/LVN), diploma, associate, bachelor, master's, and clinical doctorate degree nursing programs (NLN CNEA, 2018), and the CCNE accredits baccalaureate and graduate programs, postgraduate APRN certificates, and nurse residency programs (CCNE, 2018).
ANCC
The ANCC, a subsidiary of the ANA since 1991, identifies its mission as improving nursing practice and promoting quality health care service through several types of credentialing programs. The ANCC has created a modular approach to certification that enables the nurse to be recognized for multiple areas of expertise, not simply for competency in a core clinical specialty. There are 12 specialty, 5 nurse practitioner certifications, 1 clinical nurse specialist certifications, and an interprofessional certification (ANCC, 2018).
National Academy of Medicine
National Academy of Medicine (NAM) (2018).1 This organization is responsible for several patient safety publications, including To Err Is Human: Building a Safer Healthcare System; Keeping Patients Safe: Transforming the Work Environment of Nurses; Crossing the Quality Chasm: A New Health System for the 21st Century; and The Future of Nursing: Leading Change, Advancing Health (NAM, 2018). In The Future of Nursing report, the IOM stresses the importance of nursing in ensuring high-quality health care for the nation. The report identifies the barriers that prevent nurses from practicing effectively. In conclusion, the report identifies eight recommendations that will reduce barriers to improving the nation's health care system (Table 22.3). For each recommendation, the research team identifies actions for educators, legislators, administrators, and nurses to ensure that these important changes are made. Most states have established "action coalitions" to support the initiation of these steps.
Fiscal Responsibility to the Employing Organization
Nurses also have a responsibility to the organization or agency where they are employed. The most important way for a nurse to demonstrate fiscal responsibility is by providing quality patient care. For example, thorough hand hygiene and the use of sanitizing gels prevent infections that may increase patient costs. Similarly, the prevention of falls and pressure ulcers is a clinical practice that has significant cost implications (Research for Best Practice Boxes 16.1 and 16.2). Nurses who continually improve their clinical practice by using evidence-based practice or "best practice" guidelines are also engaging in quality practice that is cost-effective.
Prospective Payment System and DRGs
Nurses also need to understand the prospective payment system. Under this system, the hospital is paid a set amount for the care of a patient with a certain condition or surgery. If the hospital engages in efficient clinical care practices, the organization makes a profit. If the hospital is not efficient, it may lose money. Medicare reimburses under this prospective system—called diagnostic-related groups (DRGs)—as do many private insurance companies.
The American Red Cross
Nurses of the American Red Cross pioneered public health nursing in the early 1900s. The American Red Cross is a voluntary agency that is supported by contributions and plays an important role in providing disaster relief and education in first aid and home health and in organizing volunteers to assist in hospitals and nursing homes. Nurse volunteers with the Red Cross play a significant role in assisting those who have been affected by natural disasters.
One of the IOM reports, "Keeping Patients Safe: Transforming the Work Environment of Nurses," suggests that the work environment of nurses must be changed to better protect patients. The report makes recommendations in the areas of
One of the IOM reports, "Keeping Patients Safe: Transforming the Work Environment of Nurses," suggests that the work environment of nurses must be changed to better protect patients. The report makes recommendations in the areas of (1) nursing management, (2) workforce deployment, and (3) work design and organizational culture (IOM, 2004).
Online Nursing Programs (External) Accreditation
Online nursing programs are accredited by the ACEN (formerly the National League for Nursing Accrediting Commission [NLNAC]), the NLN CNEA, or the CCNE, which is an autonomous accrediting agency associated with the AACN. In undergraduate nursing programs, all students are required to pass specific college-level tests and performance examinations in two components: general education and nursing. On completion of the undergraduate external degree programs, students are eligible in most states to take the RN licensure exam.
PICOT
Patient population of interest Intervention of interest Comparison of interest Outcome Time
Pay For Performance
Pay for performance (P4P), a value-based health care approach, is increasingly being used to reduce costs and improve the quality of health care. Although traditional fee-for-service reimbursement still represents a large percentage of income for hospitals, the shift toward payment for value-based health care programs is accelerating rapidly. In P4P programs, hospitals are required to address a large number of factors that they previously, in traditional fee-for-service systems, had no incentive to consider. Two basic types of P4P designs are used in hospital reimbursement. With the first, payers lower the fee-for-service payments and instead use funds to reward hospitals based on how well they perform across process, quality, and efficiency measures. In the second, hospitals are penalized financially for poor-quality performance (NEJM Catalyst, 2018).
What Is Performance Improvement?
Performance improvement (PI) is synonymous with QI, and the terms are used interchangeably. Today, improvement science is the term often used, because the process has become very data driven. PI is a plan and documentation method that demonstrates what the standard procedures will be for nurses and others within the hospital. It includes changes that have been implemented based on previous data collection. PI is similar to the nursing process (assess, diagnose, plan, implement, and evaluate). Often QI nurses are called on to conduct small data collection processes and provide reports.
Philip Crosby
Philip Crosby is considered the father of zero defects. He often proposed simplifying things so that everyone could understand. He also believed in the importance of communicating QI efforts and their results to the entire organization. Thereafter, ideas such as "lean" manufacturing, "just in time" product delivery, and "Six Sigma" methods crossed over into health care.
Employer-Sponsored Health Insurance
Plan types offered by employers include preferred provider organizations (PPOs) at 49% of covered employees, high-deductible health plans with savings option (HDHPs/SO) at 29%, health maintenance organizations (HMO) at 16%, Point of Service (POS) Plan at 6%, and conventional or indemnity plan at less than 1%
Relevant websites and online resources
The Academic Center for Evidence-Based Nursing (ACE) at the University of Texas Health Science Center at San Antonio Retrieved from http://ebp.uthscsa.edu/ Agency for Health Care Research and Quality Retrieved from http://www.ahrq.gov American Association of Colleges of Nursing Retrieved from http://www.aacn.nche.edu American Nurses Association Retrieved from http://www.nursingworld.org Indiana Center for Evidence-Based Nursing Practice, in the Purdue University Calumet's School of Nursing Retrieved from http://www.ebnp.org. Institute for Health Care Improvement Retrieved from http://www.ihi.org Joanna Briggs Institute University of Adelaide, Australia Retrieved from http://joannabriggs.org/ The Joint Commission Retrieved from http://www.jointcommission.org National Academy of Medicine (formerly the Institute of Medicine) Retrieved from https://nam.edu/ The Sara Cole Hirsch Institute for Best Nursing Practice Based on Evidence at Case Western Reserve School of Nursing Retrieved from https://case.edu/nursing/research/centers-of-excellence/sarah-cole-hirsh-institute
Nursing Journals and Literature Available
The American Journal of Nursing Nursing Year RN
ANA and economics
The American Nurses Association (ANA) Principles for Health System Transformation (ANA, 2016) also affirms that the health system must provide universal access to essential health care services for all citizens and residents. In another document, the ANA Code of Ethics for Nurses (ANA, 2015a) states that nurses should practice with respect for the dignity, worth, and unique characteristics of every person.
Case Management
The Case Management Society of America (CMSA) notes that case (or care) managers are advocates who help patients understand their current health status, what they can do about it, and why those treatments are important
HDHP/SO
The HDHP/SO is a high-deductible health plan with a lower premium combined with a savings account to allow participants to pay for health care expenses with money free from federal taxes (CMS, 2018a).
Hospital Compare
The Hospital Compare website is designed so that consumers can compare how well selected hospitals serve to provide the care recommended to their patients. This information is provided through the efforts of Medicare and the Hospital Quality Alliance and enables consumers to make informed decisions about their care. The performance measures that can be compared include information related to heart attack, heart failure, pneumonia, surgery, and other conditions (Centers for Medicare & Medicaid Services, 2018b). Consumers can go to www.hospitalcompare.hhs.gov/and search by zip code to compare hospitals and prescribers.
Magnet Hospitals
The Magnet Recognition Program identifies characteristics or outcomes, known as "forces of magnetism," that exemplify excellence in nursing (Box 15.1). Ten years after the identification of the original magnet hospitals, the American Nurses Credentialing Center (ANCC) established a new magnet hospital designation process, similar to accreditation by The Joint Commission (TJC). Recently the recognition program has been expanded to provide national recognition for excellence in long-term-care nursing facilities and smaller community hospitals. In the current competitive environment, receiving the magnet status may serve as a recruiting and marketing tool for hospitals, attesting to a professional work environment and high-quality nursing
National League for Nursing
The NLN was established in 1952; however, the beginning of NLN can be traced back to the 1893 organization of the American Society of Superintendents of Training Schools for Nurses of the United States and Canada. Between the late 1800s and the early 1900s, seven nursing organizations formed and joined under the collective name and function of the NLN. One of the unique features of the NLN is that both individuals and agencies are members. The NLN adopted a strategic plan in 1995 to place community-based health care education and health care delivery at the center of its focus and activities (NLN, 1995).
National Student Nurses Association
The NSNA is a fully independent organization with a membership of approximately 60,000 nursing students throughout the United States. NSNA mentors the professional development of future nurses and facilitates their entrance into the profession by providing educational resources, leadership opportunities, and career guidance.
The national institute of nursing research What Is Its Function?
The National Institute of Nursing Research (NINR) is a branch of the National Institutes of Health (NIH), which is under the jurisdiction of the U.S. Department of Health and Human Services. Each institute within the NIH focuses on a specific area of health care research; the NINR is a major source of federal funding for nursing research. The NINR also supports education in research methods, research career development, and excellence in nursing science. Other functions of the NINR are to establish a National Nursing Research Agenda.
National Patient Safety Foundation
The National Patient Safety Foundation (NPSF) is a nonprofit organization that for years has demonstrated a commitment to patient safety in health care by providing resources for both health care providers and consumers. Part of their mission is to promote understanding among caregivers and consumers. The NPSF holds an annual conference where patient safety knowledge is shared and research results are presented. The organization also funds research to improve safety and quality care (National Patient Safety Foundation, 2018).
How Do We Monitor Quality?
The QI department is typically the department that receives data, analyzes trends, and recommends actions to facilitate improvement in the organization. However, there should also be a CQI council as a primary decision-making nursing team as well as quality circles (QCs) that function along service lines, collaborating to improve care for a group of patient types.
QSEN
The Quality and Safety Education for Nurses Institute (QSEN) site was developed to help prepare future nurses who will be needed in their health care environments to improve patient safety. The idea is to teach student nurses to always be thinking about how to improve care for patients. It began in 2005 when the American Association of Colleges of Nursing (AACN) emphasized the importance of QI system thinking in nursing education. They took the stance that nurses today ought to begin their nursing careers with knowledge about how to create and continuously improve systems of care.
Government Allocation Decisions
The U.S. government has decided it will pay for inpatient health care and some outpatient care for patients 65 years of age and older and for selected others. Unfortunately, many of the persons covered by Medicare have come to believe that Medicare covers "everything," and this is not so. It is particularly challenging to nurses when elderly patients assume that they "have Medicare" and thus "nursing home care is paid for." This is a frequent misinterpretation of Medicare coverage. There are many limitations to the services reimbursed by Medicare and many requirements that must be met before the government will make payment
How is the us health care system financed?
The U.S. health care system has a complex mix of public and private systems for providing health insurance and financing health care. Health insurance provides a means of financing health care expenses. In 2017, the most common ways to obtain health insurance were employer-based (56%), Medicaid (19.3%), Medicare (17.2%), individual direct purchase coverage (16%), or military coverage (4.8%) (Berchick et al., 2018). In addition, 8.8% of people, or 28.5 million, did not have health insurance during 2017 (Berchick et al., 2018). Medicaid, Medicare, and military coverage are all government or public funding. Medicaid is a public insurance program for low-income persons that is jointly administered by the federal and state governments (Kaiser Family Foundation, 2018b). Medicare is a public program administered by the federal government that is for persons 65 years and older, persons who are permanently disabled, and who have end-stage renal disease (ESRD) (Kaiser Family Foundation, 2017a).
Websites for Health Information
The US National Library of Medicine and National Institutes of Health provides an excellent website on Evaluating Health Information at http://www.nlm.nih.gov/medlineplus/evaluatinghealthinformation.html, including some resources in Spanish. As nurses, we need to have a better understanding of how consumers find health information on the Internet, how to evaluate the quality of this information, and how to help our patients critically evaluate and manage the information
WHO and economics
The World Health Organization (WHO) states in its constitution that the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being (WHO, 2005).
Nursing Research Utilization
The ability to transfer research into clinical practice is essential for ensuring quality in nursing. The process of research utilization involves transferring research findings to clinical nursing practice. In the process of research utilization, the emphasis is on using existing data (findings or evidence) from previous nursing research studies to evaluate a current nursing practice. A major component of the process is reviewing completed nursing research studies that have been published in the literature. In contrast, conducting new research involves the collection of new data to answer a specific clinical practice question.
Certified academic clinical nurse educator (CNEcl)
The academic CNEcl is an RN who holds a BSN degree or higher and is employed by an educational institution to provide clinical instruction to nursing students (NLN, 2018).The academic CNEcl supports the learning of nursing students throughout their clinical experiences in nursing school by serving as a clinical instructor or preceptor during the student's clinical rotation (NLN, 2018).
Capital Budget
The beginning point of a budget cycle is usually the capital budget. Hospital administrators usually ask departments or patient-care units for a list of items that their area will need to purchase in the coming year. These items are usually restricted to equipment costing more than $5000 and lasting more than 1 year. Each manager must rank such requests for the unit and write a justification of the necessity for the item.
Step 1: Preutilization
The first step in the application of nursing research to nursing practice is the recognition that some aspect of nursing practice could be done in a safer, more efficient, more beneficial, or simply a different way. This begins an exploratory phase in which nursing colleagues in the practice setting are consulted regarding their opinions about the need to find a new approach for some aspects of nursing practice A second phase of Step 1 is consensus building, which is used to identify the specific practice to be changed. The third and final phase of Step 1 delineates the aspect of nursing practice that will be changed into a concise statement of the practice problem.
Models Associated with Patient Focused Care
The first, the transitional care model (TCM), provides comprehensive in-hospital and follow-up care plans. The second model, care transitions intervention (CTI), teaches self-management and communication skills to patients and caregivers so they can coordinate care. There is also a follow-up component using a home visit and telephone call. The reengineered discharge (RED) model provides patient education, medication reconciliation and education, instruction about red flags to symptoms, teach-back learning processes, coordination of physician appointment and follow-up tests, and evidence-based written discharge plans
Affordable care act
The goals of the ACA were to do the following: ▪ Make affordable health insurance available to people with family incomes between 100% and 400% of the federal poverty level (2017 FPL = $24,600) for a family of four ▪ Expand the Medicaid Program to cover all adults with income below 138% of the federal poverty level ▪ Support innovative medical care delivery methods designed to lower the cost of health care generally (HealthCare.gov, 2018b)
Lack of Price Competition
The health care market, unlike the market for clothing and automobiles, does not engage in price competition. For example, when have you heard of a sale on appendectomies or "2 for the price of 1" hip replacements? Of course, it does not happen. More problematic is the fact that health care consumers frequently do not know the cost of their care—especially if an insurance provider is paying for it. In fact, many consumers indicate that they "never saw a bill" for their hospitalization. This is considered to be a measure of the quality of their insurance.
The ACA identified essential services that insurance companies must cover, including the following:
ambulatory and emergency care; hospitalizations (surgery and overnight stays); pregnancy, maternity, and newborn care; mental health and substance use disorder treatment; prescription drugs; and birth control. Rehabilitative and habilitative services and devices, lab services, preventive and wellness services, chronic disease management, pediatric dental services, and breast feeding assistance were also included (HealthCare.gov, 2018b).
Employee Retirement Income Security Act (ERISA)
an amendment to the Taft-Hartley Act, allowed professional nursing organizations to be considered labor unions. United American Nurses is the collective bargaining organization representing the ANA. After this significant event, some nursing administrators and managers withdrew their memberships from ANA because of the potential conflict of interest between professional affiliation and the workplace. However, this change generated the development of other major nursing organizations: the Center for the American Nurse (CAN) and the American Association of Nurse Executives (AONE).
Strategies for Fiscally Responsible Clinical Practice
The nurse: • Provides quality nursing care that prevents complications • Makes conscious decisions about the allocation of professional nursing time • Understands Medicare and Medicaid insurance coverage • Engages in evidence-based practice and follows best practice guidelines • Shares information with patients and families about the costs of care and alternatives • Assigns assistive personnel (nurse aides, certified medical assistants) appropriately to help with care and recognizes the nurse is ultimately responsible for the care provided • Works with the members of other health care professions to promote fiscal responsibility for clinical practice • Documents patient condition accurately • Begins discharge planning on or before admission • Completes charge slips for patient supplies, if required • Avoids burnout by taking scheduled breaks, meal times, and vacations • Engages in safe clinical practice that will avoid personal injuries
What does the Operating Budget Include?
The operating budget also includes all of the items necessary for care on the unit. These are called line items in a budget and include such things as supplies, telephones, small equipment (e.g., wheelchairs, nurse pagers, fax machines), postage, and copying costs. Some of these are variable costs (i.e., costs that change with the volume of patients cared for in a year).
Personnel Budget
The personnel budget for a nursing unit is the largest part of unit expenses, and nursing is the largest part of personnel expense. In most hospitals, nursing costs represent at least 50% of hospital expense budgets (Pappas, 2008). This has caused some hospital administrators, who need to reduce expenses, to state: "Follow the dollars, and they will lead to nursing."
PPO Managed Care
The preferred provider organization (PPO) is another type of insurance plan designed to meet the goals of managed care. To avoid out-of-pocket expenses, members must use physicians who have agreed to provide services at a lower price to the insurer. However, members may use an "out-of-network" provider without a referral if they are willing to pay more for that service.
Goal of Six Stigma
The primary goal of SS is to increase profits and reduce problems by improving standard operating procedures, reducing errors, and decreasing misuse of the system.
American Assembly for Men in Nursing (Formerly Known as the National Male Nurses Association)
The purpose of AAMN is to recruit men into the profession of nursing, support men who are nurses in professional growth endeavors, and provide a framework for nurses to influence factors that affect men as nurses. At the time of this publication, the AAMN has chapters in 19 states (AAMN, 2018).
The Role of the Case Manager
The purpose of case managers is to enable their clients to achieve goals effectively and efficiently. This role may take a variety of forms but generally includes coordination of care, communication, collaboration, and attention to the transition between levels of nursing care. Social workers and therapists may also be case managers, although how they perform their roles depends on the scope of practice within their discipline. All case managers must be skilled at communication, critical thinking, negotiation, and collaboration. They must be knowledgeable about the resources available to patients. The case manager collaborates not only with individual patients but also with family and other of the patient's support systems.
Step 2: Assessing
The second step in research utilization is the identification and critical evaluation of published research that is related to the practice problem you have identified. Your task will be to analyze and critically evaluate the research reports to determine which findings are adaptable to your practice problem and context. it is essential that the research reports you are reviewing are peer-reviewed to ensure credibility
What is accreditation?
The term accreditation is often confused with certification. Accreditation in higher education is a process by which a voluntary, nongovernmental agency or organization approves and grants status to institutions or programs (not individuals) that meet predetermined standards and criteria (US Department of Education, 2018). There are two types of accreditation in higher education and they are referred to as institutional or regional accreditation and programmatic or specialized accreditation.
What Constitutes a Profession Controversy?
The trained nurse, then, is no longer to be regarded as a better trained, more useful, higher class servant, but as one who has knowledge and is worthy of respect, consideration, and due recompense.... She is also essentially an instructor; part of her duties have to do with the prevention of disease and sickness, as well as the relief of suffering humanity.... These are some of the essentials in nursing by which it has become to be regarded as a profession, but there still remains much to be desired, much to work for, in order to add to its dignity and usefulness.
The 12 Core Measure Sets
There are 12 core measure sets (acute myocardial infarction, children's asthma care, venous thromboembolism, stroke, emergency department, immunization, hospital-based inpatient psychiatric services, tobacco treatment, substance use, perinatal care, hospital outpatient, early hearing detection and intervention) as defined by TJC (2018b). The goal is to improve the quality of health care by implementing a national standardized performance measurement system. Key actions are listed in each category defining the best research-based care process appropriate for that category. By tracking these core measures, hospitals improve patient care by focusing on the results of that care.
Medicare Part B
There is a monthly Part B premium. Most people will pay the standard premium amount, which was $134 in 2018.For covered services, enrollees must meet the yearly Part B deductible before Medicare begins to pay its share. Then, after the deductible is met, enrollees typically pay 20% of the Medicare-approved amount of the service if the health care provider accepts assignment.Services from doctors and other health care providers, outpatient care, home health care, durable medical equipment, and many preventive services: Routine dental care, dentures, hearing aids, eye examinations for prescribing glasses, or cosmetic surgery
Patient Focused Care
These tasks can be centralized on the unit under the direction of the RN. UAPs are cross-trained to perform more than one function, thus increasing the level of productivity. In this system, the patient comes in contact with fewer people, and the RN, who is familiar with the patient's plan of care, supervises the delivery of care. This model also moves RNs to a higher level of functioning because they are now accountable for a fuller range of services to the patient. Tasks that do not require an RN can be delegated to a UAP under the supervision of the RN
Big Data
Think about all the data we collect on a single patient during a 4-day hospital stay. Now add all the data we collect on all the patients in that hospital during that same 4 days. Now add to that all the data we collect on all the patients in all the hospitals in the United States during those 4 days—that is a lot of data (i.e., Big Data!). All of this data is too much to do anything with using traditional data management. So people working in informatics have developed and continue to develop ways of using the massive amounts of data to look for patterns and trends that may help us identify early warning signs, predisposing factors, and other patterns to improve health and health care.
Operating Budgets
This budget includes a statement of the expected expenses of the unit for a period, usually 1 year. The budget process begins with a statement of volume projections. The nurse manager projects how much patient care will be provided in the coming year. The volume that nurses are concerned with is measured in patient days, and thus the question is "How many patient days of care will be provided in the coming year?" The manager would first look at past data to examine how many days were given in the previous year.
Productive Time
This figure reflects the amount of time the nurse is available to provide care to patients. For example, one work day (8 hours) is usually considered to be 7.5 productive hours.
Functional Nursing
This functional kind of nursing, which broke nursing care into a series of tasks performed by many people, resulted in a fragmented, impersonal kind of care. Fragmentation of care caused patient problems to be overlooked because the problems did not fit into a defined assignment. This assembly-line approach provided little time for the nurse to address a patient's psychosocial or spiritual needs. Fragmentation of care and errors and omissions tended to occur or increase when functional nursing was used. This approach would seem to be cost-efficient because it can be implemented with fewer RNs.
Utilization Review
This is a strategy used by managed care companies to control both costs and quality. The process requires that hospital staff, typically registered nurses, communicate the plan of care for a hospitalized patient to the payer or their representative. The payer then determines whether the care is appropriate, is medically necessary, and is covered under the terms of the policy or the contract with the provider (Murray & Henriques, 2003).
Fiscal Responsibility to the Patient
This means that a nurse uses the most cost-efficient combination of resources to maximize the health benefit to the patient. Nurses need to understand the costs of care and different reimbursement systems, because this will affect the development of a care plan. It is important for nurses to assess the resources that patients have available to dedicate to health care. These may include not only insurance coverage but also the availability of family members or community resources to aid in care.
total patient care or private-duty model
This model is efficient because it (1) decreases communication time between the staff caring for a patient, (2) reduces the need for supervision, and (3) allows one person to perform more than one task simultaneously. Some nurses prefer this model because they can focus on patients' needs without the work of supervising others; others feel that their skills and time are wasted doing patient care activities that could be done by others with less skill and education. Patient satisfaction tends to be high with this model if continuity of care and communication are maintained among nurses
Shortage of Nurses
This ongoing shortage of nurses is driven by the aging of the population, including currently practicing nurses, and work conditions in health care. This potential shortage is likely to continue to affect the cost and quality of health care provided in the United States for the foreseeable future.
American Association of Colleges of Nursing
This organization is the national voice for university and 4-year college educational programs in nursing and has a membership of more than 500 colleges. The mission of the organization is to serve the public interest by assisting deans and directors in improving and advancing nursing education, research, and practice. This organization publishes a newsletter and a bimonthly nursing journal called the Journal of Professional Nursing.
Step 4: Implementing
This step involves the implementation or application of the new approach, along with the collection of the evaluation data. By following the specific plan that you established in Step 3, the new approach will be introduced into practice. It is important that you begin collecting your evaluation data at the same time so that you can clearly determine the effect of the new approach.
Non productive Time
This time reflects the amount of time that is not available for direct care. Some examples of nonproductive time include vacations, days off, holidays, time at educational seminars, time for committee work (e.g., quality improvement), breaks, and lunch.
Ch. 9 Conclusion
Throughout the past century, the image of nursing has undergone many changes. The portrayal of nurses in the media has impacted the public perception of both male and female professional nurses. How will nurses continue to refine, intensify, and manage the image of nursing for the future? Will the self-image of nursing change public perception? Nursing is defined as a profession. Participation in the political side of health care, active involvement in professional organizations, a dedication to furthering academic advancement through progression of all nurses, and a commitment to the improvement of nursing's self-image are all ways to meet the upcoming challenges both in the nursing profession and in this dynamic health care environment. The questions will go on and on, and the answers will come from nurses in clinical practice, education, and research. These issues, which have a significant impact on nursing's professional image, must be resolved so nursing continues to move forward as a profession. As a recent graduate, you are the future of this exciting transition.
Patient Engagement
To be engaged, patients must use the resources available to maximize their health. When we add health information technology to the concept of patient engagement, we get the definition from the Office of the National Coordinator for Health Information Technology, "The ability of individuals to easily and securely access and use their health information electronically serves as one of the cornerstones of nationwide efforts to increase patient and family engagement and advance person-centered health" (HealthIt.gov, 2018b).
What Are the Health, Social, and Cultural Characteristics of the Patient Population Being Served?
To begin defining your practice context, you will need to identify any characteristics that are specific to the group of people who will be receiving nursing care.
How Can Health Care Organizations Retain Nurses?
To combat the need for staff to change jobs frequently, administrators and managers often emphasize attractive compensation packages, focusing on a culture of training that includes mentoring and constructive positive feedback as well recognition for excellence. Offering a variety of scheduling options to meet the needs of a variety of ages is also a popular retention strategy.
Doctoral Degree
Until recently, there were two basic models of doctoral education in nursing: the academic degree, or doctor of philosophy (PhD); and the professional degree, or doctor of nursing science (DNS, DSN, or DNSc). For either of these degrees, you must first have a master's in nursing. Nurses have other doctoral degree options available to them, such as the doctor of education (EdD), the doctor of public health (DrPH), the PhD in a discipline other than nursing, the nontraditional external degree doctorate, and the practice-focused nurse doctorate (ND), which was initiated as an entry-level degree.
Medicare Part A
Usually no premium if the individual or the spouse paid Medicare taxes while working. Copayments, coinsurance, or deductibles may apply for some services. Hospital care, hospice care, home health care, and inpatient care in a skilled nursing facility following a 3-day hospital stay. Custodial or long-term care in a skilled nursing facility
Value Based Care
Value-based health care is a delivery model in which reimbursement to providers—such as hospitals, physicians, and other providers—is based on patient outcomes. In short, by using an evidence-based approach, providers are rewarded financially for helping patients to improve their health and thus to reduce chronic disease. This approach encourages patient safety and quality improvement through the elimination or reduction adverse events, adoption of evidence-based care standards, improved protocols, changes in hospital processes to create better patient care experiences and increasing care transparency for consumers. It is seen as the best method for lowering health care costs while also increasing quality, although moving from a fee-for-service to a fee-for-value system is difficult and will take time (NEJM Catalyst, 2017b).
How to read a nursing research article A research article should answer the following:
What?Read the problem statement, purpose, research question, and results/findings.Is the content of the article related to my question?Why?Read the problem statement or the review of literature.Why was the research done?When?Do more recent findings provide a better answer?When was the study done? Is it classic, current, or outdated?Read the date of publication.How?Read the method and design sections.What research method was used? Is it a quantitative, qualitative, or mixed-methods approach?Who?Read the method section.Who were the subjects? What was the sample?Where?Read the method section.In what setting was the research done?So What?Read the findings and discussion.Are the findings helpful to my problem and me?Do Not:Do not automatically accept what you read; critically evaluate the content. You can only evaluate what is written and reported; do not assume anything about what is not written.
Unpredictability of demand
When a person is well, there is little demand for health care services. There is a great demand for health care when a person is ill, and the timing of illness is, of course, uncertain.
What is the ultimate goal of healthcare organizations?
With the advent of both specialty and integrated clinical information systems (CIS), the longitudinal electronic health record (EHR) has become the goal of health care organizations and is now supported by federal mandate
The Affordable Care Act of 2010
▪ Provides state and federal-based health insurance marketplaces where individuals can purchase private insurance with premium and cost-sharing assistance based on income level. Requires all health plans to provide a standardized, easy-to-read uniform Summary of Benefits and Coverage (SBC), which gives consumers consistent information and allows them to compare what health plans offer when making choices of coverage ▪ Prohibits denial of coverage for children with preexisting conditions beginning in 2010 and for adults with preexisting conditions beginning in 2014 ▪ Allows young adults up to age 26 to stay on their parents' insurance policies ▪ Provides expanded Medicaid coverage for low-income children and adults ▪ Provides coverage for a range of preventive health services without any patient cost sharing (copayments, deductibles, or coinsurance)
Most definitions of patient-centered care have several common elements that affect the way health systems are managed and care is delivered. This include the following characteristics:
▪ The health care system's mission, vision, values, leadership, and quality-improvement drivers are aligned with patient-centered goals. ▪ Care is collaborative, coordinated, and accessible. The right care is provided at the right time and in the right place. ▪ Care focuses on physical comfort as well as emotional well-being. ▪ Patient and family preferences, values, cultural traditions, and socioeconomic conditions are respected. ▪ Patients and their families are an expected part of the care team and play a role in decisions at the patient and system levels. ▪ The presence of family members in the care setting is encouraged and facilitated. ▪ Information is shared fully and in a timely manner so that patients and their family members can make informed decisions (NEJM Catalyst, 2017a).
Cyberthreats include the following:
▪ Unpatched software—out-of-date software, which has not had updates and patches applied ▪ Ransomware—malware that prevents authorized users from accessing data until ransom is paid ▪ Phishing (pronounced "fishing")—using e-mail, telephone, or text message posing as a legitimate institution to lure individuals into providing sensitive and usable data ▪ Loss of data stored on mobile device ▪ Insider fraud and misuse of data
2. A Profession Has a Training or Educational Period
▪ What changes will shape the future of associate degree nursing (ADN) programs? ▪ Will diploma or hospital-based nursing programs remain? ▪ How critical is it to complete a bachelor of science in nursing (BSN) program to handle the challenges of the health care environment, complex patient-family needs, and the expanding community-based settings for clinical work? ▪ Is a "ladder" approach or a concurrent enrollment program (CEP) to advanced education the best pathway for you? ▪ Will the practice doctorate in nursing (DNP) degree clarify or confuse advanced-practice roles in nursing?
In 2018, the ANA updated its position statement on the inclusion of recognized terminologies to support nursing practice within health care information technology (HIT) systems to recommend the following:
▪ When exchanging data with another setting for problems and care plans, Systematized Nomenclature of Medicine—Clinical Terms (SNOMED CT) and Logical Observation Identifiers Names and Codes (LOINC) should be used for exchange. LOINC should be used for coding nursing assessments and outcomes and SNOMED CT for problems, interventions, and observation findings (ONC, 2018). ▪ Health information exchange between providers using the same terminology does not require conversion of the data to SNOMED CT or LOINC codes. ▪ Development of a clinical data repository that includes multiple recognized terminologies should be based on the national recognized terminologies of ICD-10, CPT, RxNorm, SNOMED CT, and LOINC (American Nurses Association, 2018).
The CARS Checklist
✓ Credibility—An authoritative source, which includes author's credentials and evidence of quality control such as peer review. ✓ Accuracy—A source that is correct today (not yesterday) and is comprehensive. ✓ Reasonableness—Look at the information for fairness, objectivity, moderateness, consistency, and worldview. ✓ Support—A source that provides convincing evidence for the claims made and which can be triangulated (find at least two other sources that support it).
Internet Resources
the US Surgeon General's Family History Initiative is a great place to start with promoting the importance of a well-documented family health history. In addition to the Office of the Surgeon General, other US Department of Health and Human Services (USDHHS) agencies involved in this project include the National Human Genome Research Institute (NHGRI), the Centers for Disease Control and Prevention (CDC), the Agency for Healthcare Research and Quality (AHRQ), and the Health Resources and Services Administration (HRSA). A downloadable free tool entitled "My Family Health Portrait" is available at http://www.genome.gov/27527640. This tool helps patients organize their family trees and identify common diseases that may run in their families. After completing the required information, the tool will create and print out a graphic representation of the patient's family generations and the health disorders that may have moved from one generation to the next. This is a powerful tool for predicting illnesses (USDHHS, 2016) and can be brought by the patient to a health care provider appointment.
4 Nurse Informaticist (NI)
the extensive clinical background of the IN/INS is invaluable to the success of the implementation of the hardware and software applications needed to transform health care. Nurses have a unique understanding of workflow, the hospital and clinical environment, and the specific procedures that are necessary for effective health care information infrastructure. Moreover, the IN/INS roles are critical members of the team when translating information into practical models that can be applied to improve the health care systems and patient outcomes.
Relationship-based practice
the new name for primary nursing. The RN—who may be called the care coordinator, the responsible nurse, the principal responsible nurse, the case manager, or the care manager—manages and coordinates a patient's care in the hospital and also coordinates the discharge plan. This nurse develops a relationship and can be identified by the patient, the patient's family, and the health care team as having the responsibility and authority for planning the patient's nursing care.
Barriers to EBP
the respondents indicated that heavy workloads often prevented them from keeping up with new evidence. The responding nurses also felt that EBP training, time availability, and mentoring by nurses with EBP experience would encourage them to implement EBP.
Scheduling Patterns
there are numerous scheduling patterns other than the typical 8-hour shift 5 days a week. From working 10-hour days 4 days a week to the weekend alternative (known as the Baylor plan) of two 12-hour weekend shifts for 36 hours of pay, nurses have tried numerous patterns and combinations of shifts.
Marketplace Allocation Decisions
this type of decision making implies that health care is a normal good, similar to a car or a piece of clothing, where an increase in income leads to an increase in demand for the good, and the rules of supply and demand apply.
Effect of economic Recession of 2008 and 2010
unemployment, decreased health insurance, increased medicaid, increased uninsured people
Qualitative Research
• Acquire understanding of phenomena by observing behaviors, reactions, statements of study participants • Inductive approach • Study typically focuses on central concept or aspect for further exploration • Open-ended questions • Questions ask, "How" or "Why"? • Broad questions that seek to explore perceptions, beliefs, attitudes of a particular phenomenon of interest • Data collected through observing, interviewing, audio/video recording • Small sample size • Study participants are typically selected by researcher • Researcher interprets data by developing themes based on participants' views and observations • Data analyzed is subjective in nature; may include words, artifacts, images, anecdotal statements
How might you handle a situation on your unit where staffing is a concern? What are the unit's census, acuity, and patient-classification systems?
• Does your organization have a float pool within the staff or an agency or outside staff available? • Check whether your part-time staff can work an extra shift. • Will another staff member cover the extra shift in exchange for a day off later in the schedule? • Can you survive with partial-shift coverage during the "peak" shift hours? • Ask a staff member to work a double shift—either stay late or come in early. • Work the shift yourself. • What other solutions can you think of? • What are the advantages and disadvantages of each of these options?
Quantitative Research
• Examination of a cause-and-effect relationship • Deductive approach • Study focuses on supporting or refuting the null hypothesis • The research variables are discussed and examined in detail to determine if a relationship or causality exists • Closed-ended questions • Questions ask, "What differences exist," "What is the effect," "What is the relationship ... ?" • Null hypothesis is either supported or refuted based on study findings • Follows specific sequence • Similar to scientific method; numeric data collected through questionnaires, surveys, established instruments • Large sample size • Statistical analysis; numeric data reported • Data analyzed is unbiased and objective
Questions for the new graduate to consider asking during a job interview
• How are financial concerns of patients handled? For example, if a patient is unable to afford needed medications on discharge, what resources are available to nurses to help the patient? • How is acuity of patients assessed and factored into staffing? • What are the budgeted hours per patient day for the unit? • What is the turnover rate on this unit? Why do nurses stay on/leave this unit? • How do staff nurses have input into capital budget requests for the unit? • How are data about unit financial indicators communicated to the staff? • What percentage of salary is used as an estimate of fringe benefits? • What is the overtime rate on this unit? • Can you tell me about the discharge planning process for patients on this unit? • What is the staff development plan for professional nurses on this unit?
Patient Satisfaction
• Patient satisfaction is related to the patient's direct and indirect experiences in communicating with health care providers. • The nurse's work environment can affect patient satisfaction in positive and negative ways. • A patients' personal experiences may not directly relate to the quality of the care provided but rather is related to their expectations of what they believe should be provided or their expectations of their prognosis, treatment, family interaction, and environment.
QSEN Core Competencies
• Patient-centered care • Teamwork and collaboration • Evidence-based practice • Quality improvement • Safety • Informatics
When the statistical procedures are beyond your level of understanding:
• Read the results section, being alert for specific phrases that will tell you the answer to the research question. For example, "the hypothesis was not supported." • Look at the tables; tables should be understandable without the narrative. • Assume that the appropriate statistical analysis was performed correctly and that the researcher has interpreted the results correctly. • Have someone who understands the statistics read the article and ask his or her opinion, or get a consultant.
The Institute of Medicine's Recommendations for the Future of Nursing
• Remove scope of practice barriers. • Expand opportunities for nurses to lead and diffuse collaborative improvement efforts. • Implement nurse residency programs. • Increase the proportion of nurses with a baccalaureate degree to 80% by 2020. • Double the number of nurses with a doctorate by 2020. • Ensure that nurses engage in lifelong learning. • Prepare and enable nurses to lead change to advance health. • Build an infrastructure for the collection and analysis of interprofessional health care workforce data.
The benefits of belonging to a professional nursing organization
• Representation and influence in the legislature • Continuing education • Develop leadership skills • Participate in research • Resources • Personal benefits • Networking • Playing a part in reshaping the future of nursing
The key messages of The Future of Nursing report (2010) include the following:
▪ Nurses should practice to the full extent of their education and training through an improved education system that promotes seamless academic progression. ▪ Nurses should be full partners with physicians and other health care professionals in redesigning health care in the United States. ▪ Effective workforce planning and policy making require better data collection and an improved information infrastructure. The recommendations that were derived from these key messages were as follows: 1. Remove scope-of-practice barriers 2. Expand opportunities for nurses to lead and diffuse collaborative improvement efforts 3. Implement nurse residency programs 4. Increase the proportion of nurses with baccalaureate degrees to 80% by 2020 5. Double the number of nurses with doctorates by 2020 6. Ensure that nurses engage in lifelong learning 7. Prepare and enable nurses to lead change to advance health 8. Build an infrastructure for the collection and analysis of interprofessional health care workforce data (IOM, 2010)
The ANA has adopted the staffing committee approach to this issue, identifying the following as factors to consider in developing a staffing plan
▪ Patient complexity, acuity, or stability ▪ Number of admissions, discharges, and transfers ▪ Professional nursing and other staff skill level and expertise ▪ Physical space and layout of the nursing unit ▪ Availability of technical support and other resources (ANA, 2015).
Watson is being used in several areas of health care already, including the following:
▪ Managing care of complex patients ▪ Accelerating drug discovery by being able to manage the volume of drug research data far better than humans can ▪ Identifying appropriate cancer treatments in studies ▪ Matching patients with clinical trials (Speights, 2018)
8. Members of a Profession Have a Common Identity and a Distinctive Subculture
"Nurses should choose optimism, making positive strides each day to celebrate who they are and the differences they make. Just a nurse—no, never." Melissa Fitzpatrick, 2001
WHO (2018b) goes on to define mHealth as
"a component of eHealth and involves the provision of health services and information via mobile technologies, such as mobile phones, tablet computers, and Personal Digital Assistants (PDAs)."
HealthIT.gov defines EMR as
"a digital version of the paper charts.... An EMR contains the medical and treatment history of the patients in that office, clinic, or hospital"
Personal Health Record
"is an electronic record of an individual's health information by which the individual controls access to the information and may have the ability to manage, track, and participate in his or her own health care"
Nurses in both IN and INS roles
"support nurses, consumers, patients, the interprofessional health care team, and other stakeholders in their decision-making in all roles and settings to achieve desired outcomes. This support is accomplished through the use of information structures, information processes, and information technology"
Cloud Computing
"the delivery of computing services—servers, storage, databases, networking, software, analytics, and intelligence and more—over the Internet ('the cloud') to offer faster innovation, flexible resources, and economies of scale" (Microsoft Azure, 2018).
The World Health Organization (WHO) provides the following definition for eHealth
"the use of information and communication technologies (ICT) for health"
Nursing Certification
"voluntary process by which a nongovernmental agency or association certifies that an individual licensed to practice a profession has certain predetermined standards specified by that profession for specialty practice" (ANA, 1979, p. 67). Certification is a different credential from licensure and has a variety of interpretations—both for the nursing profession and the public. The nursing license is recognized as indicating minimum competency, whereas the certification credential indicates preparation beyond the minimum level.
we spend approx how much on health care per year?
$4 trillion
seven key factors for achieving patient-centered care at the organizational level
(1) top leadership engagement, (2) involvement of patients and families at multiple levels, (3) staff engagement, (4) focus on innovations, (5) alignment of staff roles and priorities, (6) organizational structures and processes, and (7) the environment of care.
What Are the Barriers to Quality Improvement?
*Cost* (#1) Tradition Institutional Values
Hints for conducting a literature search
1. Do some narrowing before you go to online databases. Think about some key terms or alternative terms for your problem. Be prepared to narrow or expand your search, depending on what you find. 2. Plan to spend time conducting your literature search, but do not waste valuable time. Query the online database "help" menu to assist you with getting started. 3. Begin by identifying the major professional nursing journals that publish nursing research. Determine if those journals are available in the database, and start your literature review with those. If your problem is in a specialty area, review specialty journals. 4. If you find an article related to your problem, look at that author's reference list for other current articles and journals. 5. Read the abstract of the article first; this will give you a quick overview of the article to determine if it is relevant to your topic under study. 6. Know the limitations of the databases where you do your search. 7. Carefully appraise information obtained from the Internet that is not part of an established online database, such as Journals@Ovid; EBSCOhost; ProQuest; Thomson Gale PowerSearch.
The 10 E's in "E-Health"
1. Efficiency leading to decreasing costs by avoiding duplicate or unnecessary diagnostic or therapeutic interventions, through enhanced communication possibilities among health care establishments, and through patient involvement. 2. Enhancing quality of care by allowing comparisons among different providers, involving consumers as additional power for quality assurance, and directing patient streams to the best quality providers. 3. Evidence-based intervention effectiveness and efficiency should not be assumed but proven by rigorous scientific evaluation. 4. Empowerment of consumers and patients by making the knowledge bases of medicine and personal electronic records accessible to consumers over the Internet; e-health opens new avenues for patient-centered medicine and enables evidence-based patient choice. 5. Encouragement of a new relationship between the patient and health professional, toward a true partnership where decisions are made in a shared manner. 6. Education of physicians and health care providers through online sources (continuing education) and consumers (health education, tailored preventive information for consumers). 7. Enabling information exchange and communication in a standardized way among health care establishments. 8. Extending the scope of health care beyond its conventional boundaries. 9. Ethics e-health involves new forms of patient-physician interaction and poses new challenges and threats to ethical issues such as online professional practice, informed consent, privacy, and equity issues. 10. Equity to make health care more equitable is one of the promises of e-health, but at the same time there is a considerable threat that e-health may deepen the gap between the "haves" and "have nots," deepening the "digital divide."
Eight Core Functions of the Electronic Health Record
1. Health information and data 2. Result management 3. Order management 4. Decision support 5. Electronic communication and connectivity 6. Patient support 7. Administrative processes and reporting 8. Reporting and population health
The ANA recognized terminologies/data sets as listed in the 2018 revised position statement continue to include the following:
1. NANDA—Nursing Diagnoses, Definitions, and Classification 2. Nursing Interventions Classification System (NIC) 3. Nursing Outcomes Classification System (NOC) 4. Nursing Management Minimum Data Set (NMMDS) 5. Clinical Care Classification (CCC) (formerly Home Health Care Classification [HHCC]) 6. Omaha System 7. Perioperative Nursing Dataset (PNDS) 8. SNOMED CT 9. Nursing Minimum Data Set (NMDS) 10. International Classification of Nursing Practice (ICNP) 11. ABC Codes for billing 12. LOINC
State laws usually fall into one of three approaches to staffing regulation. They:
1. Require hospitals to have nurse-driven staffing committees to develop staffing plans 2. Call for a legislative mandate for specific nurse/patient ratios 3. Include a regulatory requirement to disclose staffing levels to the public and/or a regulatory body (ANA, 2015)
the 6 aims to improve health care quality
1. Safe 2. Effective 3. Patient-centered 4. Timely 5. Efficient 6. Equitable
Code of Ethics For Nurses
1. The nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth, and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems. 2. The nurse's primary commitment is to the patient, whether an individual, family, group, or community. 3. The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient. 4. The nurse is responsible and accountable for individual nursing practice and determines the appropriate delegation of tasks consistent with the obligation to provide optimum patient care. 5. The nurse owes the same duties to self as to others, including the responsibility to preserve integrity and safety, to maintain competence, and to continue personal and professional growth. 6. The nurse participates in establishing, maintaining, and improving health care environments and conditions of employment conducive to the provision of quality health care and consistent with the values of the profession through individual and collective action. 7. The nurse participates in the advancement of the profession through contributions to practice, education, administration, and knowledge development. 8. The nurse collaborates with other health professionals and the public in promoting community, national, and international efforts to meet health needs. 9. The profession of nursing, as represented by associations and their members, is responsible for articulating nursing values, for maintaining the integrity of the profession and its practice, and for shaping social policy.
Health care experts picked the top 12 ways AI will revolutionize the delivery and science of health care (Bresnick, 2018):
1. Unifying mind and machine through brain-computer interfaces 2. Developing the next generation of radiology tools—without the need for biopsies 3. Expanding access to care in underserved or developing regions 4. Reducing the burdens of electronic health record use 5. Containing the risks of antibiotic resistance 6. Creating more precise analytics for pathology images 7. Bringing intelligence to medical devices and machines 8. Advancing the use of immunotherapy for cancer treatment 9. Turning the electronic health record into a reliable risk predictor 10. Monitoring health through wearables and personal devices 11. Making smartphone selfies into powerful diagnostic tools 12. Revolutionizing clinical decision-making with AI at the bedside
What Is the Educational Preparation of the Associate Degree Graduate?
18 to 21 school calendar months at community college earning 60-72 semester credits attracts more of a diverse population conducive for those who prefer to attend school on a part time basis
Analyzing a research article for potential use of findings in nursing practic
1a. The Purpose of the study is: 1b. The importance of this study to nursing practice is: 2. The Research Question/Hypothesis is: (If the question/hypothesis is not stated, it could be): 3a. The Independent Variable(s) is/are: 3b. The Dependent Variable(s) is/are: (If there are no independent and dependent variables, the Research Variable[s] is/are): 3c. Definition(s) of the variable(s) of interest to me is/are: 4. The Conceptual Model/Theoretical Framework linked with this study is: 5a. The content areas in the Review of Related Literature are: 5b. The review does/does not evaluate both supporting and nonsupporting studies: 6a. The Research Design used for the study is: 6b. The design is/is not appropriate for the research question: 6c. The control(s) used in this study is/are: 6d. The Study Setting is: 7a. The Target Population is: 7b. The Sampling Method is: 7c. The Sampling Method is/is not appropriate for the design: 7d. The criteria for participants are: 7e. The sample included ________ participants. 7f. The sample is/is not representative of the population: 8a. The Study Instrument(s) is/are: 8b. Instrument validity and reliability information is presented and is of adequate levels for confidence in using the results: 9a. The Data Collection Method(s) is/are: 9b. The Data Collection Method(s) is/are (is not/are not) appropriate for this study: 10. Steps were taken to protect the Rights of Human Subjects: 11a. The Data Analysis Procedure(s) is/are: 11b. The Data Analysis Procedure(s) is/are appropriate for the level of data collected and the research question/hypothesis: 11c. The Research Question/Hypothesis is/is not supported: 12. The author(s) major Conclusions and/or Implications for Nursing Practice are:
What Is the Educational Preparation of the Diploma Graduate?
2-3 yrs close relationship between nursing school and hospital easier roll transition for graduates to function in the institution they received training in while in nursing school
What Is the Educational Preparation of the Baccalaureate Graduate?
4 to 5 years in length 120-140 credits student must first meet all of the college's or the university's entrance requirements
What is credentialing?
A credential can be as simple as a written document showing an individual's qualifications. A high school diploma is a credential that indicates a certain level of education has been attained. A credential can also signify a person's performance. The attainment of a title—such as Fellow of the American Academy of Nursing (FAAN)—signifies excellence in performance; a postgraduate degree from an institution of higher learning (PhD or EdD) indicates success in terms of academic achievement and advanced nursing knowledge.
Medicaid
A federal and state assistance program that pays for health care services for people who cannot afford them.
Medicare
A federal program of health insurance for persons 65 years of age and older
42 Code of Federal Regulations (42CFR 482.23(b)
A federal regulation, 42 Code of Federal Regulations (42CFR 482.23(b), requires hospitals certified to participate in Medicare to "have adequate numbers of licensed RNs, licensed practical nurses and other personnel to provide nursing care of all patients as needed"
audit
A formal periodic check on quality measures to verify correctness of actions.
Full Time Equivalent
A full-time equivalent (FTE) represents the number of hours that a nurse employed full time is available to perform all of the employment activities. This is calculated to be 2080 hours (52 weeks times 40 hours), but it is usually split into productive and nonproductive time (Hunt, 2001).
Educational Mobility
A growing number of individuals in health care are seeking more education. The issue is not one of entry into practice but rather of how to best facilitate the return of these individuals to nursing school for educational advancement that fits their professional and personal needs. The growth of dual-enrollment nursing programs and web-based (online) courses may facilitate educational mobility.
How Are Nursing Work Assignments Determined?
A major problem in scheduling nurses is the fact that patient acuity fluctuates dramatically from day to day and from season to season. How work assignments are decided varies with individual organizations and is related to the model of care delivery, condition of the patient, architecture of the unit, and expertise of the staff.
Total Quality Management
A management style where the goal is producing quality services for the customer and where the customer defines what quality means.
What Are the Economics of Caring?
A nurse who understands the budgeting process and the research evidence about nurse staffing and patient outcomes can argue persuasively against reductions in nursing hours per patient day (HPPD). It is also important for staff nurses to be able to evaluate the research that provides the evidence for clinical practice change. Many nurses report that their goal is to provide "cost-effective care." However, they use this term loosely and do not understand the economic analysis strategy of cost-effectiveness analysis (CEA). This strategy provides information about the cost of an intervention and the effectiveness of an intervention.
American Nurses Association
ANA is identified as the professional association for registered nurses. It was through the early efforts of Isabel Hampton Robb and others that the Nurses Associated Alumnae of the United States and Canada was formed. At the World's Fair in 1890, a group of 15 nursing leaders began discussions about forming a professional association. Six years later, alumnae from the training schools organized the professional association now known as the ANA. Canadian members split from the original group in 1911 and formed their own professional association. The organizational structure of the ANA has undergone many changes through the years. Currently, when an individual joins the ANA, he or she joins the national organization along with the constituent associations at the state and local levels. This method geographically groups smaller clusters of members together according to their practice interests.
Indicator and Metric Descriptors
Admission documentation Metric 1—Rate of patients' identified learning needs not documented within 24 h of admission. Metric 2—Rate of skin assessment (Braden scale) not documented within 24 h of admission. Metric 3—Rate of patients' identified spiritual needs not documented within 24 h of admission. Foley securing Metric 1—Rate of Foley catheters not secured in place according to the procedure described in Potter and Perry's textbook. Intravenous tube labeling Metric 1—Rate of continuous flow intravenous tubing that has not been labeled with the date and time it needs to be changed. Metric 2—Rate of intermittent flow tubing (IVPB) that has not been labeled with the date and time it needs to be changed. Skin care Metric 1—Rate of high-risk patients, as defined by the Braden scale (< 17), who have pressure ulcers within 2-4 days of admission. Metric 2—Rate of those patients with pressure ulcers who are • Stage 1 • Stage 2 • Stage 3 • Stage 4 Unstageable Suspected of having deep tissue injury TORAV/VORAV Telephone or verbal orders Metric 1—Rate of telephoned physician's orders that did not contain read-back verification by using telephone order read-back and verified (TORAV) documentation with the signature of person taking the order on the first two charts of each odd-numbered day.
Relevant websites and online resources
Agency for Health Care Research and Quality (AHRQ) www.ahrq.gov. American Nurses Association: Health Care Reform https://www.nursingworld.org/practice-policy/health-policy/health-system-reform/ Centers for Medicare & Medicaid Services (CMS) www.cms.gov. Health Care Reform: Affordable Care Act (ACA) www.healthcare.gov. Kaiser Family Foundation http://kff.org/. Medicare http://www.medicare.gov/. Medicaid http://www.medicaid.gov/. Organization for Economic Co-operation and Development (OECD) http://www.oecd.org/. World Health Organization http://www.who.int.
Risk Management
All efforts designed to preserve assets and earning power associated with a business. the lawyer involved in RCA
Expense
All the costs of producing a product. Nursing care units are typically labeled as cost centers; that is, they do not directly generate revenue. Most hospitals have a fixed room rate that includes nursing care. Nurse leaders have questioned the appropriateness of nursing care being lumped into the room rate, but few have been able to effect a change. Some exceptions to this include nursing care to patients in the recovery room, intensive care unit, or labor and delivery area, where there is a separate charge for nursing care.
Revenue
All the money brought into the unit as payment for a good or a service. Some departments in the hospital are defined as revenue centers. Examples might include radiology or surgery. Typically, these departments generate a great deal of income for the larger organization.
Patient Digital Assistant (PDA)
Allows bedside data collection and charting Conserves time and reduces steps to and from nurses' station Offers easier information transmission between workers Portability and information at your fingertips Can use to monitor: Blood glucose levels Blood pressure Diet Activity Calculate dosages Analyze lab results Access reference materials Check for drug interactions Schedule procedures Order prescriptions "Beam" assignments
Relevant websites and online Resources
American Health Information Management Association (AHIMA) What Is a Personal Health Record (PHR)? http://www.myphr.com/StartaPHR/what_is_a_phr.aspx American Medical Informatics Association (AMIA) AMIA NI Working Group. http://www.amia.org/programs/working-groups/nursing-informatics American Nursing Informatics Association (ANIA) https://www.ania.org/ Centers for Medicare & Medicaid Services (CMS) Promoting Interoperability (PI). http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index.html?redirect=/ehrincentiveprograms/ HealthIT.gov Privacy, Security, and HIPAA. http://www.healthit.gov/providers-professionals/ehr-privacy-security HIMSS Impact of the Informatics Nurse Survey Final Report https://www.himss.org/library/2017-nursing-informatics-workforce-survey-full-results Nursing Informatics https://www.himss.org/library/nursing-informatics/%3FnavItemNumber%3D16520 Medicare.gov Manage Your Health. https://www.medicare.gov/manage-your-health/ Microsoft Microsoft Health Vault. https://www.healthvault.com/en-us/ U.S. Department of Health & Human Services (HHS) Health Information Privacy (2018). http://www.hhs.gov/ocr/privacy/ WebMD WebMD Personal Health Record. http://www.webmd.com/phr Your Mobile Device and Health Information Privacy and Security http://www.healthit.gov/providers-professionals/your-mobile-device-and-health-information-privacy-and-security
Relevant websites and online Resources
American Nurses Association Research toolkit. https://www.nursingworld.org/practice-policy/innovation-evidence/improving-your-practice/research-toolkit/ American Speech-Language Hearing Association Evidence-based practice tutorials and resources. http://www.asha.org/Research/EBP/Evidence-Based-Practice-Tutorials-and-Resources/ California State University, Chico What is a scholarly article? https://www.csuchico.edu/lins/handouts/scholarly.pdf Duke University Medical Center Library & Archives Resources for EBP. http://guides.mclibrary.duke.edu/nursing/ebp Indiana Center for Evidence-Based Nursing Practice http://ebnp.org National Institute of Nursing Research Building the scientific foundation for clinical practice. https://www.ninr.nih.gov/ North Carolina State University Anatomy of a scholarly article. http://www.lib.ncsu.edu/tutorials/scholarly-articles/ Peer review in five minutes. http://www.lib.ncsu.edu/tutorials/pr/ Scholarly vs. popular materials guide. http://www.lib.ncsu.edu/guides/spmaterials/ The Academy of Medical-Surgical Nurses Evidence-based practice. https://www.amsn.org/practice-resources/evidence-based-practice University of North Carolina Evidence-based nursing introduction. http://guides.lib.unc.edu/c.php?g=8362&p=43029
Certified nurse-midwife (CNM)
An average 1.5-2 years of specialized education beyond nursing school, either in an accredited certificate program or at the master's level. In 2017, there were an estimated 11,826 nurses prepared as CNMs in the United States (ACNM, 2018).CNMs are well known for delivering babies in hospitals and homes, and providing well-woman gynecological and low-risk obstetrical care, including prenatal, labor and delivery, and postpartum care. The CNM manages women's health care throughout the lifespan, including primary care, gynecological exams, and family planning. CNMs have prescriptive authority in all 50 states.
Patient Safety Goals
Annual goals established by TJC that highlight problematic areas in health care and describe evidence- and expert-based solutions to these problems. Goals are derived primarily from informal recommendations made in TJC's safety newsletter Sentinel Event Alert.
HMO Managed Care
As a part of the managed care trend, health maintenance organization (HMO) plans became very popular as a form of insurance. In HMOs, an annual payment is made on behalf of the members to a group of providers who deliver all of the health services covered under the plan, including physician and hospital services. HMOs have grown because they provide a strong incentive to avoid hospitalization, which consequently reduces costs. HMO members often appreciate the ease of using health care with an HMO because there are fewer noncovered services and fewer forms to complete. However, the choice of providers is limited; members must use physicians who are part of the HMO network, and they may not see specialty physicians without a referral from their primary care provider.
Step 1: Define the Problem
As nursing professionals who will be responsible for implementing an EBP protocol with the goal of improving patient outcomes, we must first recognize and fully define the problem.
The agency for healthcare research and quality What Is Its Function?
As part of the Omnibus Budget Reconciliation Act of 1989, the Agency for Health Care Policy and Research (later renamed the Agency for Healthcare Research and Quality [AHRQ]) was established to enhance the quality and effectiveness of health care services. The AHRQ conducts and supports general health services research, develops clinical practice guidelines, and disseminates research findings and guidelines to health care providers, policy makers, and the public.
What Are the Health Care Delivery Characteristics of Your Setting?
As you continue to define your practice context, specify the type of practice setting, the economic constraints of the setting, the type of health care delivery system, the existing policies and procedures, the staffing patterns, and the administrative structures.
SS methodology
SS methodology is used with improvement science and involves reducing variation in practice through the application of DMAIC. In other words, after a protocol has been found to be effective, everyone is trained to do it the same way. The SS DMAIC process is used primarily for improving existing processes that do not meet institutional goals or national norms
Fiscal Responsibility to the Payer of Care
At present, the U.S. government is the largest single payer of health care. For government-funded care such as Medicare and Medicaid, the ultimate payer then is the taxpayer. For private insurance, the payer may be the insurance company selected by an employer or by an individual. In all cases, the nurse has the obligation to use resources efficiently and effectively. The nurse needs to provide documentation that the patient requires care in the appropriate setting
Ch. 24 Conclusion
Nursing has a growing body of evidence on which we can support our practice. Moreover, research utilization is a key component of effectively implementing EBP protocols aimed at improving patient outcomes. Whether you are a new graduate or an experienced nurse, there are ample opportunities for you to apply research in your area of clinical practice. When areas of practice need to be changed, it is important to have valid information and data to support the need for change. Check out your hospital resources, establish networking and colleague support, and participate in EBP in your workplace setting.
Professional image of nursing What Do We Mean by the "Image" of Nursing?
Nursing has been identified as an "emerging profession" for at least 150 years The perception of nursing is affected by media and includes women's issues and changing roles, more technological and science driven, nurses are decision makers, more male nurses and a push for minorities, nursing associations promote a more positive image of nursing, restructuring of health care environments
NI Conclusion
Nursing informatics is a specialty grounded in the present while planning for the future. Nursing informatics nurses face many challenges in their daily activities, because they are in a position to wear many hats and bear many responsibilities. The next challenge after EHR implementation will be using the data in a meaningful way to improve patient care and lower costs. Computing devices and applications will continue to evolve and improve point-of-care access. Touch screens and voice input are already beginning to have an impact. Change is the only constant. At the end of this chapter are relevant websites and online resources on the concepts that have been presented. The challenge will be for informatic nurses and informatics nurse specialists to assume leadership roles in informatics, while the nurse educator, manager, and practicing nurse prepare to embrace the generalized applications of working within a computerized environment. No longer will it be sufficient to turn on a computer and complete a simple task. A nurse will need to be able to use technology in all the forms found in health care organizations, access information, as well as access and use data and evaluate the content of the information provided to the patient population. Wishing will not make technology go away, so savvy nurses will focus on the benefits that technology brings to patient care, learn the skills they need, and embrace the future with all the changes it will bring.
What Is the Relationship Between Nursing Theory and Research Utilization?
Nursing theory used as the theoretic framework of a research study is essential for the continued development of nursing theories; new research findings will support theory or will suggest the modification of theory. In contrast, when a specific nursing theory is used as the framework for nursing practice, the focus is on the intervention. The intervention that is designed in the planning phase of research utilization must be consistent with the theory
What Is Quality Improvement?
QI refers to the process or activities that are used to measure, monitor, evaluate, and control services, which will lead to measurable improvement to health care consumers. It includes reports that must be generated to track progress. Incidence reports are sometimes referred to as QI reports or variance reports.
RAND Health Insurance Experiment
Rand Health Insurance Experiment (Keeler & Rolph, 1983) was a controlled research study that examined the effect of different copayments on the use of health care. Participants in the study either received free care or paid copayments of 25%, 50%, or 95%. Economic theory would predict that as price increases, the purchase of goods or services would decline. That is exactly what happened. With a copayment of 25%, there was a decline in the use of health care of 19% compared with a free plan. There were even greater declines in the use of health care services at the higher rates of copayments. This consumer behavior is so predictable that health care economists have a term for it: moral hazard. It refers to a situation in which a person uses more health care services because the presence of insurance has lowered the price to the person.
Key performance indicators (KPIs)
Reflect the things that the team wants to change. These are a part of the DMAIC and RCC process. Typical KPIs are time, costs, distance, numbers of incidents, or items.
Research Utilization: What Is It Not?
Research utilization does not entail simply taking the findings of a single research study and using those findings in nursing practice Research utilization should not be confused with a review of nursing practice.
Important characteristics of patient-centered care
Respect for patients' values, preferences and expressed needs: • Involve patients in decision making • Treat patients with dignity respect and sensitivity to their cultural values and autonomy Coordination and integration of care: • Proper coordination of care to reduce feelings of vulnerability (coordination of clinical care, ancillary services support; and front-live patient care) Information and education: • Information on clinical status, progress, and prognosis, processes of care, to facilitate autonomy, self-care and health promotion Physical comfort: • Pain management • Assistance with activities and daily living needs • Hospital surroundings and environment Emotional support and alleviation of fear and anxiety: • Anxiety over • physical status, treatment and prognosis • impact of illness on themselves and family • financial impact of illness Involvement of family and friends: • Providing accommodations for family and friends • Involving family and close friends in decision-making • Supporting family members as caregivers • Recognizing the needs of family and friends Continuity and transition: • Understandable detailed information regarding medications, physical limitations, etc. • Coordinate and plan ongoing treatment and services after discharge • Provide information regarding access to clinical, social, physical and financial support on a continuing basis Access to care: • Access to the location of hospitals, clinics and physician offices • Availability of transportation • Event of scheduling appointments • Accessibility to specialist or specialty services when a referral is made • Clear instructions provided on when and how to get referrals
Margin/Profit
Revenue minus expenses equals margin or profit. Nurses may cringe at the thought of hospitals making a profit, but every hospital—whether it is defined as a not-for-profit hospital or a for-profit hospital—must make a profit. Profits are needed to replace equipment, purchase new technology, and, in some cases, provide care for indigent patients. In addition, for-profit hospitals must pay stockholders a return on their investment. The necessity of making a profit is so crucial to the continued existence of an organization that there is an old adage that states, "No margin, no mission." This means that if an organization does not make a profit, it is unable to fulfill the purpose or mission of the organization, no matter what it might be. The lay public will often describe hospitals as "for profit" or "not for profit." Often faith-based institutions are included in the latter category. In reality, all hospitals must make a profit. It is more significant how the profit is used.
What Are the Basic Concepts of Budgets?
Revenue, Expense, Margin
What Is Root-Cause Analysis?
Root cause analysis (RCA) is a process designed for use in investigating and categorizing the root causes of events. In the health care setting, there are many factors that can contribute to the cause of errors. Rather than placing blame on any one person or thing, RCA, when conducted appropriately, can identify all factors leading to the error. A hospital's risk management department often conducts an RCA, and the results are presented to the QI department for follow-up action. The role of the QI department is to be proactive at finding ways to prevent similar incidents from occurring.
How to Evaluate Websites
Step 1: Authority Who is/are the author(s)? Describe each author's authority or expertise. Are professional qualifications listed? How can you contact the author(s)? Who is the site's sponsor? What does the URL tell you? What type of domain does it come from (.gov, .mil, .edu, .org)? Is the site copyright protected? If the website is offering medical information, is the website HONcode certified? To learn more about Health on the Net Foundation Code of Conduct (HONcode), visit: https://www.hon.ch/HONcode/Pro/. Step 2: Timeliness and Currency When were the site materials created? When did it become active on the Web? When was it last updated/revised? Are the links up-to-date? Are the links functional? When were data gathered? What version/edition is it? Step 3: Purpose Who is the targeted audience? What is the purpose of the website? Are the goals/aims/objectives clearly stated? Does the website present facts or opinions? Does the website offer an area for consumers and another one for health care professionals? Step 4: Content Accuracy and Objectivity Does the information provided meet the purpose? Who is accountable for accuracy? Are the cited sources verifiable and published within the last 5 years? What is the value of the content of this site related to your topical needs? How complete and accurate are the content information and links? Is the site biased? Does it agree with other expert sources? Does it contain advertisements? Step 5: Structure, Design, and Access What is the appearance of the site? Does the site load quickly? Do multimedia, graphics, and art used on the page serve a purpose, or are they just decorative or fun? Is there an element of creativity? Is there appropriate interactivity? Is the navigation intuitive? Are there icons? Is it a secured site? Is an index with links available?
the steps that will assist nurses to integrate EBP into their practice
Step 1: Define the Problem Step 2: Identify, Review, and Evaluate the Data Applicable to the Problem Step 3: Design a Practice Change Based on the Data While Incorporating the Clinical Expertise of the Nurse and Patient Preferences Step 4: Implement the Change in Nursing Practice
Steps for Conducting Research
Step 1: Identify the Problem Step 2: Establish What Is Already Known About the Problem Step 3: Establish a Plan for Conducting the Research Step 4: Implement the Research Study Step 5: Examine the Data Step 6: Utilize the Findings
What Are the Steps for Nursing Research Utilization?
Step 1: Preutilization Step 2: Assessing Step 3: Planning Step 4: Implementing Step 5: Evaluating
Step 5: Evaluating
Step 5 involves the evaluation of the implementation (Step 4) to determine whether the new approach improved practice outcomes. Whether or not you will continue using the new approach in the practice setting may also be determined based on new technology, economic considerations, or changes in staffing. If there is no change in outcomes, you may want to return to the previous practice, or the evaluation phase may lead to another research utilization project. For example, if the practice problem is significant and the practice outcomes were not improved, another new approach may be tried.
TJC
TJC is an accrediting agency that evaluates care in an organization and then determines whether the overall care meets its standards of quality. TJC requires hospitals to submit error reports identifying key sentinel events that have the potential for great harm, and it publishes a monthly sentinel event alert.
TJC accreditation
TJC is the major accrediting body for health care institutions that are funded by Medicare and Medicaid. The CMS is a part of the U.S. Department of Health and Human Services (HHS). Both organizations set the standards for safe practice and evaluate compliance. Having TJC accreditation symbolizes the organization's commitment to quality. This means that nearly all hospitals must be TJC-accredited to stay in business.
The Joint Commission
TJC wrote the IM standards in the mid-1990s. These 10 standards outline the need for IM regulation. Since then, IM has been woven throughout various standards and the National Patient Safety Goals. An example of this is noted in Standard IM.02.01.03 of the revised requirements for the Laboratory Accreditation Program, where the lab must have a "written policy addressing the integrity of health information against loss, damage, unauthorized alteration, unintentional change, and accidental destruction" (TJC, 2014, p. 1).
Role of the Informatics Nurse/Informatics Nurse Specialist (IN/INS)
The IN/INS must have a basic knowledge of how computers and networks work as well as an understanding of system analysis, design principles, and information management (IM). It is important for the IN/INS to converse with both the clinical staff and the technology staff regarding hardware, software, communications, data representation, and security. An IN/INS will be comfortable with software and hardware implementation, training, testing, presenting, and facilitating knowledge Typical job responsibilities consist of (1) product evaluation; (2) system implementation, including preparing users, training, and providing support; (3) system development and quality initiatives, including system evaluations/problem solving and quality improvement/patient safety; and (4) other duties as assigned It is important to note that not all nurses in IN/INS roles work on implementation of the EMR/EHR. Some work for health care product vendors in both the hardware and software areas. They help inform the next generation of existing products, and they work with engineers/design teams to create new products, always bringing the patient care viewpoint and the needs of the end user to the design process. Others work for consulting firms and specialize in workflow improvement using technology, whereas others still work for government, third-party payers, and educational
Institute for Healthcare improvement
The Institute for Healthcare Improvement (IHI) is another nonprofit organization that is highly involved in patient safety initiatives. Founded in 1991, the IHI works to advance QIs and conducts seminars and conferences on patient safety topics. Their website has free open school courses in quality, and anyone can take these minicourses. The IHI is also involved in helping organizations implement patient safety ideas. They offer learning modules in their "open school," where continuing education units or credits are offered (Institute for Healthcare Improvement, 2018).
The Institute of Medicine
The Institute of Medicine (IOM) was established in 1970 as a nonprofit organization whose goal is to supply unbiased health care information so health care providers could make informed health decisions by providing reliable research evidence.
Primary Nursing
nurse plans and directs the care of a patient during a 24-hour period. This approach is designed to reduce or eliminate the fragmentation of care between shifts and nurses, because one nurse is accountable for planning the care of the patient around the clock. Progress reports, referrals, and discharge planning are usually the responsibility of the primary nurse. When the primary nurse is off duty, an associate nurse continues the plan of care. An RN may be the primary caregiver for some of the assigned patients, whereas an associate nurse is the primary caregiver for others.
"sweeping change" to the HIPAA Privacy, Security, Enforcement, and Breach Notification Rules
The changes in the final rulemaking provide the public with increased protection and control of personal health information. The HIPAA Privacy and Security Rules have focused on health care providers, health plans and other entities that process health insurance claims. The changes announced today expand many of the requirements to business associates of these entities that receive protected health information, such as contractors and subcontractors. Some of the largest breaches reported to HHS have involved business associates. Penalties are increased for noncompliance based on the level of negligence, with a maximum penalty of $1.5 million per violation. The changes also strengthen the Health Information Technology for Economic and Clinical Health (HITECH) Breach Notification requirements by clarifying when breaches of unsecured health information must be reported to HHS. Individual rights are expanded in important ways. Patients can ask for a copy of their electronic medical record in an electronic form. When individuals pay by cash they can instruct their provider not to share information about their treatment with their health plan. The final omnibus rule sets new limits on how information is used and disclosed for marketing and fundraising purposes and prohibits the sale of an individual's health information without their permission.
How does the concurrent or dual pathway program begin?
The concurrent or dual pathway program will often begin with the student taking a university course the semester before beginning the community college nursing program. This is generally an introductory course that reviews nursing theory, the history of nursing, or an introduction to professional nursing practice. Following the initial course, the student will enter the nursing program at the community college, and the RN to BSN courses, which are most often offered online or in a hybrid format, will either be layered with the associate degree courses during traditional semesters or spaced during breaks, summers, and/or intercessions
Cost of Health Care
The costs of most health care services and prescription drugs are higher in the United States than in comparable countries. In contrast, the cost of using some services, including physician consultations and hospital stays, is lower than in other countries. However, the use of other services, such as C-sections and knee replacements, are higher than in other countries. Despite having fewer office visits and shorter average hospital stays, the United States overall spends twice as much per person on health care than do comparable countries (Kamal & Cox, 2018).
Ch. 15 Conclusion
The emphasis on cost control and managed care has changed the way in which nursing care is delivered. New models of health care delivery are being developed in which we look at the desired outcome and "manage backward" to achieve that outcome at the lowest possible cost. Because of some of the unexpected negative consequences of managed care, there is now renewed emphasis on evidence-based care to enhance patient safety (see the Relevant Websites and Online Resources). We are continually challenged to develop more innovative and creative ways to ensure excellence in patient care with limited dollars. Nurses can meet this challenge.
Step 3: Planning
The first phase involves determining the new approach, or innovation, that will be used on the basis of the findings from the review of the literature Phase two of planning is the establishment of a systematic method for implementing the new approach. The third phase of planning involves establishing a method for evaluating the practice outcomes or effects of the new approach.
What About a Doctoral Path to Becoming a RN?
The last and least-common path leading to the RN licensure examination is the doctoral degree in nursing, where the graduate has a non-nursing baccalaureate degree. A doctoral nursing program provides basic nursing courses, along with advanced nursing courses. Upon completion, the graduate is eligible to take the NCLEX-RN examination. Currently, the University of Colorado and Case Western University are the only universities to offer a doctoral nursing program as an entry-level degree or prelicensure option
Questions Involved in Rationing
The major ethical questions (Sulmasy, 2007) involved in rationing decisions include (1) who makes the decision, and (2) using what criteria? However, most Americans find the concept of rationing inherently unacceptable. The counterargument to this position is that rationing occurs every day in the U.S. health care system, but the decision is currently made on the basis of the individual's ability to pay for care.
Health Insurance Portability and Accountability Act of 1996
The major impact from this regulatory legislation is in these areas are as follows: ▪ Health information privacy law ▪ Data security standards ▪ Electronic transaction standards
Types of Master's Programs
The master of science (MS) and the MSN are the most common degrees. The usual requirements for admission include a baccalaureate degree from a program that is accredited in nursing by the ACEN, CCNE, or CNEA (the accrediting body of the NLN since 2013), licensure as an RN, completion of the GRE or MAT, and a minimum undergraduate GPA of 3.0. The majority of programs are at least 18 to 24 months of full-time study. Unlike undergraduate students, master's students usually choose an area of role preparation, such as education or administration, and an area of clinical specialization, such as pediatrics or adult health. Some of the more common areas of role preparation include education, administration, case management, health policy/health care systems, informatics, and the increasingly popular advanced clinical practice roles.
The Joint Commission
The mere mention of a visit by TJC can elicit feelings of fear and anxiety in the minds of nurses and hospital administrators. This is because hospitals must meet certain quality standards to pass TJC's inspections and maintain accreditation, and accreditation is required to receive government funding for the provision of health care. In the 1990s, TJC first began to mandate the use of continuous quality improvement (CQI) and to recommend that organizations adopt a QI model for all process improvement activities. TJC typically endorses use of the plan, do, study, act (PDSA) cycle as a tool for process improvement.
Nurse Navigator Role
The navigator role was conceived to reduce barriers to care faced by vulnerable patients who may be coping with delays in access, diagnosis, and treatment and/or with fragmented and uncoordinated care. An analysis of evaluations of nurse navigator programs from 2000 to 2010 identified improved patient satisfaction, positive changes in patients' attitudes and understanding of disease processes, and patients' perceptions of a timelier and more accessible treatment process
Team Nursing
team nursing evolved as a way to address the problems with the functional approach. In this type of nursing, groups of patients were assigned to a team headed by a team leader, usually an RN, who coordinated the care for a designated group of patients. The following is an example of the components of a team: ▪ An RN who is the team leader ▪ Two licensed vocational nurses/practical nurses assigned to patient care ▪ Two unlicensed assistive personnel (UAP)
To qualify for this tax credit with the ACA
To qualify for this tax credit, taxpayers (1) had to indicate that they could not afford coverage through their employer; (2) could not be eligible for Medicaid, Medicare, CHIP, or Tricare; and (3) had to pay their share of the costs not covered by insurance (Internal Review Service [IRS], 2018).
Telemedicine, Telehealth, and Health Monitoring
Today, the use of telecommunication technologies to provide health care is expanding at a phenomenal rate. Surprisingly, it's not just the under-30 population who is embracing this technology. Long labeled as technology-adverse, the senior population is proving just the opposite, especially since telemedicine visits via two-way video reduces the burden of travel to a provider's office.
Quality Measures
Tools used to measure health care functions, outcomes, patients' overall health care experience, and organizational systems associated with providing quality health care.
Quality Improvement
ecently there has been a real change in how members of the health care team view quality improvement within health care settings. What once was considered work only for the QI department is now brought to the frontline workers, who can best affect the outcomes. By frontline workers, we mean the nurses at the bedside and other workers in direct patient care areas who know the problems that need to be resolved. This is also termed improvement science. An ongoing commitment to improvement strategies supports an atmosphere of teamwork. The focus is on the process and systems rather than on blaming individuals
Joseph M. Juran
emphasized the meaning of the Pareto principle which states that 80% of problems are caused by 20% of sources, people, or things. Therefore, if you can fix the 20%, you can fix almost the entire system. Juran's work marked the beginning of the idea of total quality management (TQM).
Organization for Economic Co-Operation and Development
forum that consists of governments from 30 democracies examines the challenges of globalization by examining several factors: economics, social, environmental
nternational Council of Nurses
he International Council of Nurses (ICN), established in 1899, is the international organization representing professional nurses. The focus of this nursing organization is on worldwide health care and nursing issues; it meets every 4 years and is headquartered in Geneva, Switzerland.
The need for nursing practice based on research
increase in health care costs scrutiny of how health care dollars spent payments based on favorable client outcomes Today's need to base practice on nursing care documented to benefit patients
The Utilization of research
involves the systematic process of integrating the findings of completed nursing research studies into clinical nursing practice.
Edward Deming
is often considered the father of QI, although quality concepts have developed and improved throughout several decades. What once began simply as a method for discovering how to prevent defects has evolved into highly complex methods for tracking and improving quality today. Deming's teachings embraced the philosophy that quality within an organization is everyone's responsibility.
Online (Web-Based) Programs
it is possible to earn ADN, BSN, master's, and doctoral degrees in web-based or web-enhanced formats. At times, it can be confusing and overwhelming to find the right programs. Several sites are available to help users locate specific web-based or web-enhanced courses (and course descriptions). See the Internet resources listed on this book's Evolve website. When considering which program is the best fit for your career goals, it is important to consider the cost of an online program but also if the program is in an enhanced nurse licensure compact (eNLC) state.
Rationing
ne author defines rationing as a decision to "(1) withhold, withdraw, or fail to recommend an intervention; (2) informed by a judgment that the intervention has common sense value to the patient; (3) made with the belief that the limitation of health care resources is acute and seriously threatens some members of the economic community; and (4) motivated by a plan of promoting the health care needs of unidentified others in the economic community to which the patient belongs" (Sulmasy, 2007, p. 219).
A Shortage of Qualified Nursing Faculty
the "average ages of doctorally prepared faculty holding the ranks of professor, associate professor, and assistant professor were 62, 57, and 51 years, respectively" (AACN, 2017d, para 5). There are fewer nurses entering the profession who are choosing a teaching role. Because of decreased numbers of new teachers, along with the number of current faculty retiring, the number of qualified faculty will continue to decline. The ability to earn more in the clinical and private sector is also attracting potential nurse educators to leave academia. The American Association of Nurse Practitioners (AANP) gives the average salary of a nurse practitioner as $97,083 whereas the AACN reported that master's-prepared faculty had an annual income of $77,022.
Standards of high-quality health care management
the American Nurses Association (ANA) Standards of Nursing Care, accrediting group standards such as those of The Joint Commission (TJC), which accredits health care organizations, and the Agency for Healthcare Research and Quality (AHRQ), which has established clinical practice guidelines designed to improve patient outcomes and reduce costs. In addition, another national program to ensure high-quality health care for the country is the Healthy People initiative. The current version of the initiative is called Healthy People 2020.
What Are Regulatory and Accreditation Requirements?
the Health Insurance Portability and Accountability Act (HIPAA) and The Joint Commission (TJC) impact the daily work of every clinician and organization. The nurse must have a clear understanding of HIPAA regulations and of TJC requirements to be able to provide safe nursing care.
two distinct roles in NI:
the IN and the informatics nurse specialist (INS) The IN has experience in NI but does not have an advanced degree in the specialty. The INS has graduate-level education in informatics or a related field
the relationship between nurse staffing levels and adverse patient outcomes
▪ Lower levels of hospital nurse staffing are associated with more adverse outcomes. ▪ Patients in hospitals today are more acutely ill than in the past, but the skill levels of the nursing staff have declined. ▪ Higher-acuity patients have added responsibilities that have increased the nurse workload. ▪ Avoidable adverse outcomes, such as pneumonia, can raise treatment costs by as much as $28,000. ▪ Hiring more RNs does not decrease profit. ▪ Higher levels of nurse staffing could have a positive impact on both quality of care and nurse satisfaction (AHRQ, 2004, 2007).
What Is an Indicator and a Metric?
or example, a quality team may have identified a problem with securing urethral catheters properly. This seems to be a recurrent issue. Perhaps several patients had urethral catheters that were inadvertently pulled out. After some investigation and collecting baseline data, the problem was identified as having to do with not securing the catheters properly. Thus the team will collect data for a specific time and will track the nurses' practices. They would count the number of urethral catheters not secured correctly and divide that by the total number of urethral catheters during a specific time frame to obtain the average rate of compliance. The metric or measure is the actual rate of urethral catheters that are secured properly
How Can nurses change the image of nursing?
patient interaction personal interaction with the public public speaking involvement in community activities active participation in political activities bring awareness
The positive aspects of pay for performance
reduces cost decreases bad outcomes stresses quality over quantity of care Encourages payers to redirect funds to encourage best practices and promote positive outcomes Transparency through the use of metrics Encourages accountability and competition Uses existing fee-for-service payment system to allow an incremental transition to value-based care
Advantages of Electronic Health Records
• Simultaneous, remote access to patient from many locations • Legibility of record—no handwriting • Safer data—backup and disaster recovery system, so less prone to data loss • Patient data confidentiality—authorized use can be restricted and monitored automatically • Flexible data layout—can recall data in any order (chronologically or in reverse chronological order) • Integration with other information resources • Incorporation of electronic data—can automatically capture physiological data from bedside monitors, laboratory analyzers, and imaging devices • Continuous data processing—check and filter the data for errors, summarize and interpret data, and issue alerts and/or reminders • Assisted search—can search free-text or structured data to find a specific data value or to determine whether a particular item has been recorded previously • Greater range of data output modalities—data can be presented to users via computer-generated voice, two-way pagers, e-mail, and smartphones • Tailored paper output—data can be printed using a variety of fonts, colors, and sizes to help focus the clinician's attention on the most important data; images can be included to help see a more complete "picture" of the patient's condition • Always up-to-date
Levenstein's Characteristics of a Profession
• The element of altruismHow do you define caring in your clinical practice? • Code of ethicsAre you familiar with the ANA Code of Ethics? • Collaboration with groups and individuals for the benefit of the patientWhat other groups do you work with in your clinical setting that affect the health needs of the patient and family? • Colleagueship demonstrated byAn organization for licensing• What is the role of the State Board of Nursing in your state?A group that helps ensure quality• Are you aware of the role of national nursing organizations that accredit nursing programs?• There are two national nursing organizations that accredit nursing programs; do you know what they are?Peer evaluations of practitioners• What is the role of job evaluations in terms of professional growth? • Accountability for conduct and responsibility for practice decisionsWho monitors professional conduct issues from a legal and ethical point of view?Does shared governance reflect more control of one's nursing practice? • Strong research programAre you aware that a national center for nursing research is now operating in Washington, DC?
CAFE internet research
▪ Challenge the information and demand accountability. ▪ Adapt and require more credibility and evidence for stronger claims—it is okay to be skeptical of the information. ▪ File new information in your mind rather than immediately believing or disbelieving it. ▪ Evaluate and reevaluate regularly. Recognize the dynamic, fluid nature of the information.
In 2018, the ANA published, for public comment, Principles of Staffing and Workforce Management: The Future of Nursing as Holistic Providers and Advocates of Care. This document aligns the ANA's Principles of Staffing with the IHI's Triple Aim and notes that the staffing process involves the following four components:
▪ Forecasting budgeting and planning based on expected future patient volume and acuity ▪ Scheduling of adequate number of nurses and other nursing personnel to address current needs of patients ▪ Assigning staff based on needs of each patient and balanced workload across the scheduled nurses and nursing personnel ▪ Improving monitoring and analyzing, performance, quality and safety, and outcomes of nursing care (ANA, 2018b)
Although there are multiple theories that are applicable to NI practice, the three most common are as follows:
▪ General systems theory—This theory organizes interdependent parts working together to produce a product that none used alone could produce. Key elements are input, process, output, control, and feedback. ▪ Rogers' diffusion of innovation theory—A five-step process of an individual's decision to adopt an innovation, which includes knowledge, persuasion, decision, implementation, and confirmation (Rogers, 2003). ▪ Change theory—Kurt Lewin's change theory
Patients should be assigned a case manager only if they
▪ Have complicated health care needs ▪ Are receiving care that is expensive as well as complicated ▪ Pose discharge planning problems ▪ Receive care from multiple providers ▪ Are likely to have significant physical or psychosocial problems
The following is a list of some simple precautions to take to help secure patient information that may be stored on a mobile device. These recommendations should be followed as standard practice:
▪ Keep careful physical control of the device at all times. ▪ Use a password or other user authentication and a time-out to reactivate the authentication. ▪ Install and enable encryption. ▪ Install and activate remote wiping and/or remote disabling. ▪ Disable and do not install or use file-sharing applications. ▪ Disable the infrared ports and Wi-Fi except when they are actually being used. ▪ Do not send infrared or Wi-Fi transmissions in public locations. ▪ Keep your security software up-to-date. ▪ Research mobile applications (apps) before downloading. ▪ Use adequate security to send or receive health information using public Wi-Fi networks. ▪ Delete all stored health information before discarding or reusing the mobile device.
There still remain major barriers to the complete integration of health information technology. These barriers include the following:
▪ Lack of standardization across care areas—the need for laboratory data and pharmacy systems to be integrated with the patient's EHR, and the ED systems need to share data with the inpatient systems. ▪ Siloed data—hospital data, provider practice data, and long-term care facility data may all be in separate systems with steep fees for building interfaces to allow for exchange of data. ▪ Cost and funding—information technology is costly, and often the major costs are borne by hospitals rather than shared by other providers, payers, and employers. ▪ Privacy and security concerns—a single set of privacy laws is needed to simplify the task of communicating across facilities, agencies, and local, state, and federal governments. ▪ Lack of a uniform approach (number) to match patients to their record—a single authentication number is needed to reduce safety risks and provide a uniform access to patient data
