Process Structure Human Resources Environmental Resources Organizational Resources

����� Process Structure • Human Resources • • Environmental Resources • Organizational Resources • Physical Resources • Standards of Practice Activities Interventions Outcome • • • Physical Health Status Mental Health Status Social & Physical Function Health Attitudes/knowledge/b ehavior Utilization of Professional Health resources Patient’s Perception of Quality Care (Donabedian in Hodges et al. , 1994)

* ���������� ������������ / “Safe Staffing Saves Lives” ������� (Glovannetti, 1978; Mc. Gillis (ICN, 2006)Hall, 2005)

Relationship Between Nurse Staffing and Patient Outcomes • Patient mortality increased 7% for every additional patient that is added to the average nurse’s workload. • A hospital with an average patientper-nurse ratio of 8: 1 has a 31% higher mortality rate than a hospital with a ratio of 4: 1. JAMA, October 23/30, 2002, 1987 -1993

Did you know…? Facts of Safe Staffing • Research found that fewer nurses at night was linked to an increased risk for specific postoperative pulmonary complications, higher fall rates and lower patient satisfaction levels with pain management. Health Affairs, May-June, 2001, 43 -53

A richer registered nurse skill mix leads to • lower patient morbidity and mortality , • reduced incidences of adverse events, shorter hospital lengths of stay , • higher patient satisfaction. Health Affairs, May-June, 2001, 43 -53

A cross sectional analysis of medical and surgical patients : a higher proportion of hours of care per day and a greater number of hours of care by RNs per day a shorter length of stay, lower rates of UTI, upper GI bleed, pneumonia, shock and cardiac arrest· Health Affairs, May-June, 2001, 43 -53

Safe Staffing ������������ ������������� (The North Carolina Nurses Association, 2005 Cited in ICN, 2006)

Case Method Primary Nursing Function al Method Team Method

Case Method • Earliest form of nursing care • Develop a sense of trust • One-to-one basis • Response for her shift only • As the vehicle for teaching patient care to student • .

Functional Method • One man for one task • Attention to quantity more than quality • No continuity of care • The whole was fractured into parts. • Dehumanized patient care

Team Method • Start during WW II • Acute nursing shortages • Care is assigned by team leader and provided by one or more team members • Team leader. . super woman

Case Method Functio nal Method Team Method

Nurse’s needs for a sense of success with care, daily growth. Autonomy, Authority &Accountability.

Nursing Goal Holistic Nursing Care

������ (Holistic Nursing) Person-centered Care

Holistic Nursing Approach Providing total biopsycho-social care

Primary Nursing arted at 1970 My nurse-My patient

Primary Nurse A Triple Nurse • Autonomy • Accountability • Authority

Primary Nursing • Person centered care • Accountability of patient care • Continuity of patient care • Comprehensive of patient care • Mobilize resource for patient care • Nursing staff development

Primary Nursing System Improve Quality of Care

APNs (ANA, 1996) • manifest a high level of expertise in the assessment, diagnosis, and treatment of the complex responses of individuals, families, or communities to actual or potential health problems, prevention of illness and injury, maintenance of wellness, and provision of comfort.

APNs (ANA, 1996) • has a master’s education concentrating in a specific area of advanced nursing practice • the difference in practice related to a greater depth and broadth of knowledge, a greater degree of synthesis of data, and complexity of skills and intervention.

APN : CNS & NP

Clinical Nurse Specialist : CNS • specialist in nursing practice • a role of master’s prepare expert nurse • developed in response to a perceived need to improve nursing care during a period of rapid knowledge and technology growth

• practice as expert clinician, educator, consultant, change agent, researcher and as collaborator in the inpatient setting. • traditionally practiced in the acute care setting

Nurse Practitioner : NP • a registered nurse with clinical expertise in …. . . Nursing: (Family NP, Community NP) • received master’s preparation program ,

Nurse Practitioner : NP • is responsible for assessment and management of patients, including diagnostic, treatment and prevention. • typically functioned in the outpatient setting and community

Competencies of APNs • Expert clinical practice • Teaching, coaching, guidance skills adaptable to individuals, families, or groups • Consultation • Clinical leadership • Change agent

Competencies of APNs • Evidence-based practice • Conduct Clinical Research • Collaboration (Intra-Inter -multidisciplinary( • Ethical decision making • Evaluation of outcomes • Quality assurance

Knowledge-Based Society

)Center for Advanced Nursing Practice, 2000( Evidence-Based Practice. 4 Evidence-based. 3 Evidence-observed. 2 Evidence-supported. 1 Evidence-triggered

. 1 Evidence-triggered • Practice triggers • Knowledge triggers Describe problem of practice

. 2 Evidence-supported Evidence summation • guideline , • case exemplars , • best practice , • research findings Synthesis available evidence and desire outcome

. 3 Evidence-observed • Pilot study • Product evaluation/ outcome measurement • Cost/benefit analysis Determine relevance in setting

. 4 Evidence-based • Best practice established • Contribution to advances in professional practice • Outcome improvement • Cost/benefit analysis Evaluate impact on systems improvement

Evidence-Based Practice. 4 Evidence-based. 3 Evidence-observed. 2 Evidence-supported. 1 Evidence-triggered )From Center for Advanced Nursing Practice, 2000(

Nursing Outcomes Evidence-Based Nursing Practice

The seven Domains of Outcomes • Physiologic outcomes • Psychosocial outcomes • Functional status • Knowledge • Symptom control • Patient satisfaction • Cost and resource utilization Lang & Marek, 1992

Identify Improvement Opportunity Measure Outcomes Research-Based Process Implement Assess Contributors Develop Enhancement Continuous Quality Improvement of Clinical Practice.

PHASE II n o i is v e R PHASE IV PHASE III Wo. Jner, 2001 Outcome management model

Phase I. Describing population • • Identify intermediate outcomes Identify long-term outcomes Select instruments for longitudinal study Identify untoward intermediate outcomes Identify variances Identify other significant variables Create population database

Phase II. Practice Standardization for Analytic Research • Review Tradition Practice • Review Literature • Conduct Market Survey • Negotiate Practice Standards • Create or Revise Structured Care Methodologies • Complete Practice Standardization

Phase III: Process Implementation Implement Practice Standards Role Model New Practice Collect Data / Assess Reliability

Phase IV: Interdisciplinary Analysis Conduct Interdisciplinary Data Analysis Identify Opportunities for Revision of Standardized Practices Generate New Research Questions/ Hypotheses

PHASE II n o i is v e R PHASE IV PHASE III Outcome management model

Outcomes Measurement Outcomes Research

Outcome Research • Collection and reporting of data that can be used to compare the quality of care delivered by individual providers, or types of organizations, or systems. ) ศร รตนบลล จ รตม , 2547)

Objectives • Monitoring quality of providers • Providers provide highest quality care at the lowest cost • Identifying of low quality providers to improve quality

The cycle of outcome research • Knowledge generation • Dissemination of findings • Utilize of findings in practice

������ Process Structure • Human Resources • • Environmental Resources • Organizational Resources • Physical Resources • Standards of Practice Activities Interventions Outcome • • • Physical Health Status Mental Health Status Social & Physical Function Health Attitudes/knowledge/b ehavior Utilization of Professional Health resources Patient’s Perception of Quality Care (Donabedian in Hodges et al. , 1994)

Case Management Versus Outcomes Management Quality of Care What are they

Charge Nurse Physician &others Primary nurse Patient Associate nurses Hospital resources

Care Map u��� Clinical Pathway ����������

Case Management • is concerned with the case-bycase delivery of patient care by providers, combined with processes such as utilization review/ management, D/C planning, cost containment

Case Management CM duties……Case managers

Outcome Management • is a research-based process that works in concert with CM • Stimulate the use of sciencebased interventions, and conducting systematic evaluation of over all program effectiveness.

Outcome Management • Outcomes measurement facilitates OM, which is imparted on a patient-by patient basis through CM. • OM duties. ……… Outcomes managers / APNs

The combination of OM-and-CM- driven care enables providers to improve quality of care

Outcomes of Care [Patient-focused outcome [functional status, SCA [health status, mental status [quality of life [patient satisfaction [symptom management [patient’s knowledge

Structure (Inputs) Outcome Process -Staff/skill mix -Nursing system -Positive work environment -Standards of Nursing Care CNPG -Culture of Nursing Unit EBNP (Output) (Throughput) Nursing activity by Nursing Process Qualitative Episode of Patient Care Quantitative Qualitative Quantitative A systematic integrative approach to quality nursing care management