Come Oct. 1, when the Centers for Medicare & Medicaid Services (CMS) stops paying for care associated with eight hospital-acquired conditions, including nurse-sensitive pressure ulcers and falls, hospitals will have a financial incentive to deliver safer patient care. The more than 200 California Nursing Outcomes Coalition (CalNOC) database project member hospitals are prepared with information to facilitate practice improvements.
?Hospitals involved early on are going to be well-positioned for the new pay-for-performance regulations and CMS not paying for hospital-acquired decubiti, falls, and other issues,? says Patricia McFarland, RN, MS, FAAN, CalNOC administrative manager and CEO of the Association of California Nurse Leaders (ACNL).
CalNOC data sheds light on vulnerable areas with opportunities for improvement, McFarland explains. Participating hospitals can log in to a virtual dashboard for online access to blinded data from other member facilities to compare their outcomes on key indicators, such as pressure ulcers and falls. Hospitals can judge their performance against similarly sized facilities or by unit type, as well as delve down to the unit level at their own facility to find where the decubiti develop or falls happen.
?[The database] allows [facilities] to create their own meaningful benchmarks and comparison in performance that they can use to steer and drive patient care excellence and performance improvement,? says Nancy E. Donaldson, RN, DNSc, FAAN, CalNOC co-principal investigator and research team coordinator, and clinical professor and director of the UCSF/Stanford Center for Research and Innovation in Patient Care at the UCSF School of Nursing.
In addition to incidence, the data include process measures, which give facilities insight into why numbers are high or low. For instance, if leadership reviews the data and sees that 80% of patients on a certain unit are at risk of falling but only half were placed on protocols, that gives the leaders a place to focus attention. They also can talk with management on units doing well to learn their techniques and then share them with other floors.
CalNOC's origins and growth as an industry leader
CalNOC was started 12 years ago by the ACNL and the American Nurses Association California. Initial funding came from ACNL and California hospitals. CalNOC was one of six recipients of an American Nurses Association (ANA) nursing report card initiative.
Participating hospitals pay an annual fee based on average daily census and gather data following identical criteria, as outlined in a comprehensive code book. CalNOC encourages site coordinators and facility teams to call for guidance.
CalNOC encourages its member hospitals to also participate in the ANA National Database of Nursing Quality Indicators (NDNQI), and forwards data of those taking part in both database projects to the national program. Additionally, CalNOC provides data to the California Hospital Assessment and Reporting Taskforce (CHART) and has collaborated with the Military Nursing Outcomes and VA (Veterans Affairs) Nursing Outcomes databases.
?We have all provided collaborative expertise at the national level related to nursing quality measurement,? says Donaldson, who is not aware of any other state collecting nurse-sensitive outcome data.
Gathering data
In addition to pressure ulcers and falls, CalNOC tracks data about hours of care, percentage of RN hours of care, percentage of contracted hours, restraint prevalence, RN education and certification, and patient and RN work satisfaction. In 2006, CalNOC added medication administration accuracy and catheter-associated blood stream infections in peripherally inserted central catheters. CalNOC continues to add new indicators, such as pain management effectiveness and critical-care ventilator-associated pneumonia.
For pressure ulcers, on a set day, hospitals examine every patient for evidence of a pressure ulcer and send the data to CalNOC. If nurses find a pressure ulcer, they check if it was identified and coded accurately. The report sent to CalNOC includes the patient's age, length of stay, whether the patient has a medical or surgical diagnosis, and whether a nurse completed a risk assessment and implemented protocols.
?It's not just the outcome; it's the process of care they can assess and compare with other people and set targets for improvement,? says Carolyn Aydin, PhD, CalNOC database manager and a research scientist at Cedars-Sinai Medical Center. Aydin adds CalNOC is beginning to see a decrease in pressure ulcers, although it has not been proven with a scientific analysis.
CalNOC obtains falls data from incident reports and tracks the fall type, if the patient was identified as at risk, the risk score, and the unit where the incident occurred. Aydin says the data has not indicated a drop in incidence.
Although the specific data is available to members only, Aydin says CalNOC's effort to improve patient care and advance the science benefits everyone. The organization publishes its findings in peer-reviewed journals.
?This is a truly nursing-generated initiative that has become very successful in improving the care patients are receiving,? McFarland says. ?It's a celebration of nursing.?
