Patient Safety / Quality

Building a compelling business case for nursing and quality indicators

In the past few years, several events have highlighted the value of the nursing profession in helping to achieve higher-quality, lower-cost patient care. For example, in 2011, the U.S. Department of Health & Human Services (HHS) released its National Strategy for Quality Improvement in Health Care. Called the National Quality Strategy (NQS), it has three aims (known as the Triple Aim)—better care, healthier people and communities, and affordable care. Before the NQS, this country lacked a formal strategy for ensuring safe, high-quality, accessible care.

A year earlier, the Institute of Medicine (IOM) report “The Future of Nursing: Leading Change, Advancing Health” stated that healthcare transformation and NQS goals couldn’t be achieved unless nurses functioned to the full extent of their education and training.

While measures to monitor and report on healthcare quality should be patient-centric, many such measures are nursing-sensitive and driven by nursing during care delivery, coordination of the patient’s plan of care, and care coordination with other healthcare team members. We also need meaningful data and analytics to support insights for continuous learning and improvement to achieve the best care, reduce costs, and gain new knowledge. The September 2012 IOM report “Best Care at Lower Cost: The Path to Continuously Learning Healthcare in America” recommended that “data generated in the course of care delivery…be digitally collected, compiled, and protected as a reliable and accessible resource for care management, process improvement, public health, and the generation of new knowledge.”

Achieving the Triple Aim and NQS goals

Various initiatives aim to achieve the goals of the Triple Aim and NQS, including the Medicare and Medicaid Electronic Health Records incentive program. Also, the National Quality Forum, a nonprofit group dedicated to improving the quality of health care, has spearheaded the following initiatives:

  • National Priorities Partnership (NPP), whose vision is to achieve better health and a safe, equitable, and value-driven healthcare system
  • Measure Application Partnership, which provides input to HHS on selecting measures to be used for public reporting requirements and payment incentives.

Also, the Accountable Care initiative of the Centers for Medicare & Medicaid Services (CMS) seeks to achieve better outcomes and quality measures by providing financial incentives to providers and provider organizations that achieve quality benchmarks. CMS published the final rule on accountable care organizations in 2011; it includes 33 quality measures across six domains of care.

Nursing can lead the way

Nursing must play a pivotal role in transforming health care and achieving NQS goals. Nurses must be engaged actively and lead the way in defining, implementing, and reporting on clinical quality measures.


Data and nursing quality measures from the National Database of Nursing Quality Indicators®
(NDNQI®) must be transformed into meaningful information tied to goals of the national quality initiatives as well as government and private-payer reporting programs. So how do NDNQI data support organizations in reporting quality measures to CMS and private payers, which ultimately affects financial reimbursement?

Example: Pressure ulcers

Take, for example, pressure ulcers—a costly problem affecting both quality of life and organizational revenue. According to the Agency for Healthcare Research and Quality, pressure ulcers directly cause 60,000 deaths each year; the costs of caring for patients with pressure ulcers run $9.1 to $11.6 billion per year. For an individual patient, costs range from $20,900 to $151,700 per pressure ulcer. In 2007, Medicare estimated each pressure ulcer adds $43,180 to a patient’s hospital stay. CMS no longer reimburses healthcare facilities for the cost of additional care and increased lengths of stay necessitated by hospital-acquired pressure ulcers.

NDNQI data analytics and measures for pressure-ulcer prevention and occurrence can directly substantiate the business case for pressure-ulcer prevention, identification, monitoring, and reporting—activities that can lead to cost avoidance and optimal reimbursement for patient care. The same measures and data analytics substantiate increased quality of care and outcomes.

Presenting a compelling business case

Nursing quality information can and should be used to develop and justify the business case for developing and using tools and digital infrastructures that support quality goals and business operations, such as staffing and care delivery models. In the book Good to Great: Why Some Companies Make the Leap…and Others Don’t, author Jim Collins outlines five essentials for making a compelling business case:

1. Review the situation and business problem, and outline the project’s benefits.

2. Clearly define and link each benefit’s cause to the effect.

3. Clearly identify the key performance indicator for each forecasted benefit.

4. Assess the economic risk of making no investment to address the issue.

5. Align the proposal with the organization’s strategic goals.

So how can you present the business case for justifying your organization’s participation in NDNQI? Using pressure ulcers as an example, you could use the following approach:

  • State the problem and situational analysis—the current state of costs and quality issues related to pressure ulcers in your organization, the overall problem of pressure ulcers in the healthcare industry, and relevant reimbursement changes (current or forthcoming). For instance, calculate the additional cost per patient episode of a pressure ulcer as well as total costs to your facility each year.
  • Clearly define and link each benefit’s cause to the effect. For example, describe how NDNQI indicators and nursing quality data can help inform nursing practice to decrease pressure ulcers.
  • Define the key performance indicators, and define the solution to include the measurement and data analytics needed. You might set quarterly target goals for the maximum number of pressure ulcers and a percentage in annual cost reduction.
  • Assess the economic and quality-related risks of not participating in NDNQI or implementing an approach to pressure-ulcer prevention. For instance, you might include projected revenue loss that could occur in the next year if the hospital fails to prevent pressure ulcers.
  • Note how NDNQI aligns with the strategic goals of your organization and the goals of the NQS, NPP, and other quality-reporting programs required by the organization.

You might also want to directly tie other NDNQI indicators (such as central line-associated bloodstream infections, falls, and ventilator-associated pneumonia) to national quality initiatives and reporting programs—and justifiably include these in a business case as described above. Essential to monitoring and measuring clinical quality measures are data and analytics from both the unit level and the total patient-population level to support a business case for financial and quality return on investment (ROI). ROI can be shown by highlighting decreased costs, cost avoidance, and improved margins at the unit and hospital aggregate levels as well as by population types.

As nurses, we must ensure that the nursing profession is involved in defining, implementing, and reporting clinical quality measures. Otherwise, individual organizations, the healthcare industry at large, and our patients will suffer the consequences—higher costs, lower quality of care, and reduced patient safety.

Selected references

Agency for Healthcare Research and Quality. Preventing pressure ulcers in hospitals: a toolkit for improving quality of care. www.ahrq.gov/research/ltc/pressureulcertoolkit/putool1.htm#11. Accessed November 9, 2012.

Collins J. Good to Great: Why Some Companies Make the Leap…and Others Don’t. New York: Harper Business; 2001.

KP-VA Nursing Collaborative. White paper: a progress report from the Kaiser Permanente and Department of Veterans Affairs nursing collaborative. July 2011. http://ana.nursingworld.org/DocumentVault/NursingPractice/NCNQ/meeting/white-paper.aspx. Accessed November 9, 2012.

U.S. Department of Health & Human Services. National quality strategy: 2012 annual progress report. April 20, 2012. www.healthcare.gov/news/factsheets/2012/04/national-quality-strategy04302012a.html. Accessed November 9, 2012.

Visit www.AmericanNurseToday.com for a complete list of references.

Dana Alexander is vice president of integrated care delivery and chief nursing officer at Caradigm LLC in Bellevue, Washington.

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