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Accountability and the Advanced Practice Nurse
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  • 1. Module Twenty Nine Accountability and the APN
  • 2. Purpose of Health Care System
    • Reduce impact and burden of illness, injury and disability
    • Improve the health and functioning of the people
    • APNs have individual, professional and societal responsibilities in helping meet this purpose
  • 3. Current Demands of Health-Care Environment
    • APNs must demonstrate their contributions
    • Improve their performance
    • Demonstrate accountability to the profession, employers, and public
  • 4. Social Mandate
    • Be accountable for one’s performance
    • Use professional standards
    • Abide by organizational requirements
    • Respond to private and public-sector demands
    • Respond to the needs of the public
  • 5. End Product
    • It is not enough to “do good”; the APN must demonstrate how “doing good” translates into outcomes and costs.
  • 6. Expectations of APN:
    • Articulate role of APN
    • Work collaboratively
    • Serve as an advocate/change agent
    • Implement roles of teacher, researcher, advocate, clinician, consultant, collaborator, and manager of systems
    • Improve the health care system
  • 7. Quality
    • “ the degree to which health services for individuals and populations increase the likelihood of desired health outcomes” (Lohr, 1997)
  • 8. Characteristics of Quality
    • Performance is a continuum from unacceptable to excellent
    • Assessment focuses on services provided
    • Quality can be evaluated from the perspective of individual or population
    • Evidence is needed to identify what interventions and services enhance outcomes
    • Without scientific evidence, professional consensus is needed
  • 9. Drivers for Accountability
    • Consumer movement
    • Cost concerns
    • Managed Care
    • Consumers want quality, cost-effective care delivered from a patient-centered perspective
  • 10. Quality Focused Organizations
    • National Committee for Quality Assurance
    • National Quality Forum
    • Foundation for Accountability
    • Agency for Healthcare Research and Quality
  • 11. Structural Processes That Affect Outcomes
    • APN’s Education
    • Time APN Spends in Role Components
    • Reimbursement Levels
    • Organizational Characteristics
    • Girouard (l996)
  • 12. Processes That Affect Outcomes
    • APN Behaviors
    • Referral Patterns
    • Prescriptive Practice Behavior
    • Collaboration
    • APN Satisfaction
  • 13. Outcomes Related to Quality
    • Mortality
    • Morbidity
    • Patient Knowledge
    • Patient Satisfaction
    • Service Utilization
    • Health Status
  • 14. Access
    • Access: Ability to obtain care or health and related services (also defined as utilization or insurance coverage)
    • Payment levels, what is paid for, and who gets paid are important access considerations
  • 15. Cost
    • Societal: GNP devoted to health care
    • pharmaceuticals, research,
    • education, core public
    • health services, institutional
    • costs, provider services,
    • insurance, goods and
    • supplies.
  • 16. Cost
    • Individual: Direct Costs
    • Employers: Insurance costs, loss
    • of productive work time,
    • health-care program
    • administration costs
  • 17. Cost
    • Health-care
    • Professional: Expenditures, costs for
    • personnel,
    • administration, physical
    • plants, supplies and
    • equipment
  • 18. Health Care System Triangle Cost Access Quality
  • 19. Quality
    • Quality: How well services increase
    • chance for desired outcomes
    • Quality Assessment: Process of
    • defining and measuring
    • quality
    • Quality Assurance: Process of
    • measurement and quality
    • improvement
    • Quality Indicator: Trait or characteristic
    • linked with evidence to desirable
    • health outcomes
  • 20. Health-Care Quality Measurement Objectives
    • Gather and analyze data to inform quality improvement efforts
    • Assess facilities and individual performance in relation to established standards
    • Compare providers to inform purchaser and consumer choices
    • Inform all stakeholders about decisions and choices
    • Identify and reward best practices
    • Monitor and report on quality over time
    • Address health-care needs of communities
  • 21. Agencies Involved in Quality Care Assessment
    • AHRQ: Improve outcomes/quality of
    • care
    • CMS: Assures beneficiaries of
    • Medicare/Medicaid receive
    • quality care
    • CDC:
    • Maternal Child Health Bureau:
    • JCAHO: Outcome evaluation
    • FACCT: American Health Quality Association - helps consumers to make better decisions and choices
  • 22. American Association of Colleges of Nursing
    • APN education prepares the graduate to: “assume responsibility and accountability for the health promotion, assessment, diagnosis and management of patient problems within a specialty area of clinical practice.”
  • 23. Aspects of APN Clinical Role
    • Use of holistic perspective
    • Formation of patient-APN partnerships
    • Expert clinical thinking and skillful practice
    • Research-based practice
    • Diverse approaches to health and illness management
  • 24. Six Domains of APN Practice
    • Management patient health and illness states
    • Nurse-patient relationship
    • Teaching-coaching function
    • Professional role
    • Managing and negotiating health-care delivery system
    • Monitoring and ensuring quality of health-care practice
  • 25. Managing and Negotiating Health-Care Delivery System
    • Use national guidelines and standards
    • Participate in organizational decision making
    • Manage organizational functions and resources
    • Build business/management strategies
    • Work with others to meet patient needs
    • Provide interdisciplinary team leadership
    • Act as a consultant for community health programs
    • Participate in legislative and policy activities
  • 26. Monitor and Ensure Quality of Health-Care Practice
    • Interpret scope of practice to others
    • Incorporate legal and professional standards into practice
    • Assume accountability for practice
    • Collaborate and consult with team about health outcomes
    • Identify ways to update knowledge
    • Assess and adjust care plans
    • Monitor quality of practice
    • Maintain patient database for assessing outcomes
    • Monitor everyone through quality assurance
    • Monitor research to improve quality
  • 27. APN’s Ability To Meet Process Expectations
    • Provide anticipatory guidance and counseling
    • Use appropriate diagnostic tools and interventions
    • Apply principles of self-efficacy
    • Educate patients about self-management
    • Obtain specialist referral care
    • Assess culturally appropriate resources
  • 28. Steps to Individual Evaluation
    • Select a focus
    • Determine goals
    • Identify structures, processes and outcome variables to be used
    • Determine method to assess goal achievement
    • Analyze, interpret, and report evaluation results
  • 29. Systems Level Evaluation
    • Consumer Assessment of Health Plan Surveys (CAHPs)
    • Healthplan Employer Data and Information Set (HEDIS)
    • Promoting Healthy Development (PHD) in young children
  • 30. Societal Level Assessment
    • Healthy People 2010
  • 31. Issues in Quality Measurement
    • Separation of physical and mental health services
    • Difficulty measuring continuity of care
    • Focus on individuals versus populations
    • Access and availability of services
    • Numbers/types of outcomes to assess
    • Need to examine processes
    • Need for providers to remain current
  • 32. Donabedian’s Framework for Quality Measurement Structures Processes Outcomes
  • 33. Indicators of Quality
    • Short-term: accessibility, satisfaction, patient knowledge and health behaviors and complications of care
    • Long-term: health status, morbidity, mortality, and costs of care
  • 34. Foundation for Accountabilty Framework
    • The basics: satisfaction with care, access to care and receipt of information and services
    • Staying healthy: avoiding illness, health promotion, reduction of health risks, early detection of illness and health education
    • Getting better: appropriateness of treatment and follow-up care
    • Living with illness: self-care guidance, symptom control, avoidance of complications, and maintaining daily activities
    • Changing needs: comprehensiveness of services, care-giver support, hospice care
  • 35. IOM Framework
    • Safety
    • Effectiveness
    • Equity
    • Patient-centeredness
    • Efficacy
    • Timeliness
  • 36. Nursing Home Quality Indicators
    • Ability to perform activities in daily living
    • Pressure sores
    • Use of physical restraints
    • Infection rates
    • Delirium incidence
    • Pain management
    • Ambulation
  • 37. Direct Clinical Care
    • Use evidence based information
    • Deliver patient-centered care
    • Be accessible to patient
    • Be responsive to patient needs, preferences and concerns
    • Avoid missed opportunities to deliver preventitive and health promotion services
  • 38. Why to Include Quality Process Information in APN Education
    • Providers will be competing on basis of quality
    • Nursing shortage will result in use of unlicensed personnel and foreign-educated nurses
    • Nursing is responsible for quality
    • Nurses can capitalize on staffing to outcomes research to restructure health care organizations
  • 39. System Changes
    • APNs can help address need to:
    • Redesign care
    • Improve information technology
    • Develop better coordinated systems
    • Incorporate processes and outcome measures into delivery of health care
  • 40. Value = Quality and Cost
    • APNs cannot afford to ignore quality as they strive to promote their value as health care providers