The Commonwealth Fund (2014) reported that while the United States (US) has the most expensive healthcare system among 11 industrialized countries, it ranked last on “measures of health system quality, efficiency, access to care, equity, and healthy lives” (para.1). While we have a substantial investment in healthcare, there continues to be a deficient in attainable outcomes. The Patient Protection and Affordable Care Act (ACA) (Kaiser Family Foundation, 2013), was signed into law on March 23, 2010 by President Obama as a comprehensive health reform law. It was intended to “expand healthcare coverage, control healthcare costs, and improve healthcare delivery system[s]” (p. 1). Controversy continues regarding whether the outcomes of this law have actually achieved the goals and the original purpose. In this election year, the law has become fodder for considerable debate, with some Republicans pushing for its repeal. The outcome of the Presidential and Congressional elections may well determine the law’s future.
At the same time, total healthcare costs in the US are expected to be $4.8 trillion in 2021. Healthcare spending was nearly $2.6 trillion in 2010 and half of this was to pay the cost of medical services by hospitals and physicians (Aetna, 2016). Many Americans continue to lack health insurance, experience rising healthcare costs, and have difficulty paying for healthcare needs (Consumer Reports, 2014). With healthcare costs rising, accountability and measuring the actual outcomes of care provided has greater emphasis. The ACA includes a provision to “allow providers organized as accountable care organizations (ACOs) that voluntarily meet quality thresholds to share in the cost savings…[and] …must agree to be accountable for the overall care of their Medicare beneficiaries…” (Kaiser Family Foundation, 2013, section 11). This implies that sufficient data must be compiled to document outcomes.
Two other current concerns are the number of preventable adverse events that occur in hospitals and premature deaths associated with preventable harm. James (2013) estimated this number between 210,000 and 400,000 per year, depending on the completeness of medical records and the search technology. Given the ramifications and potential repercussions of these events, it is plausible to assume that some are not reported and hence, accurate outcomes are unknown. Greater involvement in their healthcare decisions by patients and families is indicated, with greater attention to outcomes that they perceive have caused “harm” as well as how nursing care at the individual and team level can impact those outcomes.
Over the past decade, technology has increasingly changed both healthcare delivery and outcome measurement. Electronic medical records, medication distribution systems, online patient record systems, and sophisticated diagnostic technology have grown exponentially. Technology has not only facilitated accuracy but many patients now have full access to their healthcare records. Patients themselves are better able to judge the effectiveness of their care and determine which of many alternatives they wish to pursue. It is the responsibility of healthcare providers to make the information available so patients, and their families, can make informed decisions. Concepts such as telehealth and eHealth will continue to grow; with this growth is the concomitant need to measure the effectiveness of these new approaches and protect privacy while providing quality care. Telemedicine can impact cost effectiveness, reach remote patients, monitor patients in home settings, facilitate physician consultations, reduce travel, and provide rural healthcare providers with access to specialty care (American Telemedicine Association, 2015; California Telehealth Resource Center, n.d.; HRSA, n.d.). Considerable research is still needed on the outcomes of care provided through technology and its impact on quality of life, as well as how new technologies can improve and facilitate healthcare education.
Innovative products have generated new approaches in healthcare interventions. Research on these products and their impact on healthcare delivery are needed to differentiate the effective ones from those that are not. It is no longer enough to say that “an IV connector works”, but rather which IV connector and what are the other variables involved in the use of that connector? Especially needed is comparative effectiveness research involving specific products; however replication studies are nearly impossible if the actual product, including manufacturer is not known. One of the documented approaches for this problem is the Healthcare and Technology Synergy Model (HATS) (Chernecky, Zadinsky, Macklin, & Maeve, 2013). The main variables are: a) patient, b) product, and c) practice. These 3 variables influence outcomes and can be effectively measured to determine the impact of new products on patient care. The five introductory articles in this OJIN topic describe the history and challenges of outcome measurement, and consider the concept of organizational outcomes related to several areas described above, such as use/impact of technology, guiding frameworks, teamwork, and gaps in research.
While outcomes of nursing care require further attention, there is considerable lack of evidence regarding exactly how nurses contribute to the prevention of adverse events. In the introductory article, “Outcome Measurement in Nursing: Imperatives, Ideals, History, & Challenges”, author Jones provides strong evidence for the need to place much greater emphasis on evaluation of the impact of nursing practice on actual patient outcomes in the arenas of health promotion; injury and illness prevention; and the alleviation of suffering. While nurses are the largest contributors in healthcare, empirical evidence that quantifies those contributions continues to be lacking. Nurses are both accountable and obligated to provide this documentation as a part of their practice and commitment to quality care. The author describes the imperatives and associated challenges to measure outcomes. Problems arise in measurement study designs because much of nursing is difficult to isolate and measure. Nursing documentation provides the most valid source of date, but it is frequently incomplete. The contribution of nurses to patient outcomes needs considerably more data and documented causal evidence. This will require both the investment of resources and a commitment to discovery.
As one of the important issues in nursing practice is the impact that nursing has on the overall outcomes of healthcare, how nurse staffing impacts those outcomes is a critical area to consider. Costa and Yakusheva, in “Why Causal Inference Matters to Nurses: The Case of Nurse Staffing and Patient Outcomes”, used the Quality Health Outcome Model to examine cross-sectional, longitudinal, and randomized clinical trial based research studies to illustrate both limitations and potentials for research about associations between nurse staffing and patient outcomes. The question is whether increased nurse staffing actually causes an improvement in patient outcomes or whether research findings are more a result of artifacts and confounding variables. Confounding is a constant issue in cross-sectional studies and could be responsible for inconclusive evidence of the link between nurse staffing and patient outcomes. Longitudinal studies tend to be stronger in that the design can take into account a multiplicity of factors over time. Randomized clinical trials provide the strongest evidence; however, due to financial, logistical, and ethical issues, currently no randomized controlled trials of nurse staffing and patient outcomes were noted by the authors in the literature. Hence, the cause and effect relationship between nurse staffing and patient outcomes is yet unclear and the needs for a stronger evidence base remains.
As the nursing workforce ages, there is an increasing mix of age groups, backgrounds, and educational preparation of those who provide care. Moore, Everly, and Bauer begin their article, “Multigenerational Challenges: Team-Building for Positive Clinical Workforce Outcomes”, with the premise that the current nursing workforce is comprised of four cohorts - veterans, baby boomers, millennials, and generation Xers. Veterans are characterized as respectful, adhering to rules and hard working. Baby boomers are job focused and sacrifice their personal lives for the job. Generation Xers want a work/life balance and millennials want flexible schedules and telecommuting. All of these different groups in the work place presents the potential for incivility and even stereotyping based on age and educational history. Teambuilding is presented as an approach that can create positive organizational outcomes. The authors suggest that organizations that promote team-building can improve problem solving and morale, leading to a healthier work environment. Open communication and inclusivity are essential. Several simulated situations (e.g. the “Toxic Waste” scenario) are presented that both administrators and staff personnel can use to promote team building. The strategies emphasize improving understanding, communication, inclusion, trust, and respect.
The last several years have brought increased focus on health team member collaboration [JO1] in provision of care. While working with diverse groups can be challenging, the outcomes of transprofessional approaches support quality care. Wojciechowski, Pearsall, Murphy & French used crosswalk methodology to facilitate interprofessional collaboration and a model to implement bedside shift reporting. In the article, “A Case Review: Integrating Lewin’s Theory with Lean’s System Approach for Change”, these authors provide the project background, and offer a brief overview of the two common frameworks used in this project, Lewin’s Three-Step Model for Change and the Lean Systems Approach. They demonstrate that interprofessional collaboration among disciplines can utilize a mutually implemented framework for change that supports quality care outcomes, and incorporate multiple views and discipline-specific approaches. The conclusion discusses their project outcomes and implications for nursing practice. The success of this approach has potential for future initiatives.
As technology continually changes, maintaining user competencies in application can be challenging. Authors Kleib, Simpson, and Rhodes, in their article, “Information and Communication Technology: Design, Delivery, and Outcomes from a Nursing Informatics Boot Camp”, recount their work to encourage nurses in Alberta, Canada to consider the role of health information technology in nursing practice and its potential for improving healthcare delivery and patient outcomes. The one day continuing education “boot camp” event consisted of a keynote address and sessions on relevance to nurses’ work; the Canadian Association of Schools of Nursing informatics competencies and associated resources; computer and information literacy healthcare applications; common healthcare information systems, with emphasis on computerized documentation tools and their benefits in capturing nurse contributions to patient care; and a knowledge application session. Although attendance was low, the evaluations demonstrated program success and the need for health information technology education for nurses.
These articles offer a wide perspective about outcomes from the provider and patient perspectives. The journal editors invite you to share your response to this OJIN topic addressing Organizational Outcomes, either by writing a Letter to the Editor or by submitting a manuscript to further the discussion of this topic initiated by any of these introductory articles.
Marlene M. Rosenkoetter, PhD, RN, FAAN
Aetna. (2016). The facts about rising health care costs. Underlying medical costs drive growth. Retrieved from http://www.aetna.com/health-reform-connection/aetnas-vision/facts-about-costs.html
American Telemedicine Association. (2015). Research outcomes. Telemedicine’s impact on healthcare cost and quality. Retrieved from http://www.americantelemed.org/docs/default-source/policy/examples-of-research-outcomes---telemedicine's-impact-on-healthcare-cost-and-quality.pdf
California Telehealth Resource Center. (n.d.). Why are telemedicine and telehealth so important in our healthcare system? Retrieved from http://www.caltrc.org/telehealth/why-are-telemedicine-and-telehealth-so-important-in-our-healthcare-system/
Chernecky, C., Zadinsky, J., Macklin, D., Maeve, M.K. (2013). The healthcare and technology synergy (HATS) model for comparative effectiveness research as part of evidence based practice in vascular access. Journal of the Association of Vascular Access 18(3):169-174. Doi: http://dx.doi.org/10.1016/j.ajic.2014.03.353
Consumer Reports. (2014, September). Why is health care so expensive? Why it’s so high, how it affects your wallet—and yes, what you can do about it. Retrieved from http://www.consumerreports.org/cro/magazine/2014/11/it-is-time-to-get-mad-about-the-outrageous-cost-of-health-care/index.htm
HRSA. (n.d.). Health information technology. What is telehealth? Washington, DC: US Department of Health and Human Services. Retrieved from http://www.hrsa.gov/healthit/toolbox/RuralHealthITtoolbox/Telehealth/whatistelehealth.html
James, J. (2013). A new, evidence-based estimate of patient harms associated with hospital care. Journal of Patient Safety, 9(3), 122-128. doi: 10.1097/PTS.0b013e3182948a69. Retrieved from http://journals.lww.com/journalpatientsafety/pages/articleviewer.aspx?year=2013&issue=09000&article=00002&type=Fulltext
Kaiser Family Foundation. (2013, April 23). Summary of the Affordable Care Act. Retrieved from http://kff.org/health-reform/fact-sheet/summary-of-the-affordable-care-act/
The Commonwealth Fund. (2014, June 16). US health system ranks last among eleven countries on measures of access, equity, quality, efficiency, and healthy lives. Retrieved from http://www.commonwealthfund.org/publications/press-releases/2014/jun/us-health-system-ranks-last