Accountability and the Advanced Practice Nurse


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Accountability and the Advanced Practice Nurse

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