A Community of Exceptional Nurses
Rosemary K. Doble, RN, Martha A.Q. Curley,
RN, PhD, CCNS ,
Eileen Hession-Laband, RN, MBA
, Barbara L. Marino, RN, PhD
, Susan M. Shaw, RN, MS
As we venture into the 21st century, we reflect on the changes
in healthcare. The fee-for-service system has been replaced with managed care, and
today healthcare systems across the United States are trying to maintain quality
while struggling for fiscal survival. Even so, healthcare dollars account for a
growing percentage of the gross domestic product. (1) Because nursing salaries account
for a sizable part of healthcare costs, nurses are challenged to articulate their
value as healthcare professionals in this cost-contained environment. Nursing, however,
has yet to describe the experience of quality care or find a way to succinctly and
reproducibly measure such care. (2) Now is the time to link nursing practice to
patients' needs by using a language that is universally understood across the healthcare
system, especially to payers of nursing services. In this article, we describe a
project in which the Synergy Model was used to link nursing care to diagnosis-related
groups (DRGs), the basis of the established method of reimbursement and the language
used by payers.
Nursing productivity is typically measured for staffing and
budgetary concerns and to describe and quantify nursing practice and the outcomes
of nurses' services. (3) Historically, nursing care has been prospectively measured
by using one of several highly subjective systems for classifying patients. These
tools typically describe the amount of time nurses spend on tasks; for example,
time needed to complete a bed bath or to take vital signs. Not considered is the
amount of time a nurse needs to get to know a patient in order to create a safe
environment and plan the care that eventually becomes visible and thus measurable.
In the late 1980s, researchers at Yale University School of
Nursing evaluated the nursing intensity measures used in 9 hospitals. (4) Daily
classifications of patients and DRG information accumulated over patients' entire
length of stay (LOS) were considered. In cross-hospital comparison, the Yale researchers
found wide variability in the nursing time attached to care of patients, but considerable
consistency was apparent in the nursing intensity within each DRG. (4)
The work of the Yale study was expanded by the Resource Information
Management System / Nursing Acuity Project. (5) Its purpose was to use existing
data to develop a system for classifying patients' severity of illness that could
be used in management decisions, such as resource allocations and staffing decisions.
Diers and Bozzo (5) formed a panel of nurse experts from the varied disciplines
at Yale New Haven Hospital. Because patients in intensive care units (ICUs) usually
require more nursing resources and often experience longer LOS than do patients
in other units, nurse experts were separated into an ICU group and a non-ICU group.
A list of DRGs was compiled from the medical records of patients
discharged the previous year. The nurse experts assigned either a "high" or "not
high" rating to each DRG, depending on nursing care requirements, and then sorted
these 2 categories into 5 intensity clusters, with level 1 being the least intensive
care and level 5 being the most intensive care. A sixth cluster was created for
patients whose needs were extreme. (5) Then, an hour standard was attached to each
level to indicate how much nursing time was required to meet the needs of the patients.
Children's Hospital in Boston went a step further in its Nursing
Resource Measurement project by using the Synergy Model to give nursing experts
a common language to describe patients' needs and the nursing competencies required
by pediatric patients within each DRG. "The fundamental premise of [the Synergy
Model]...is that patients' characteristics drive nurses' competencies. When patients'
characteristics match and synergize, patients' outcomes may be optimized." (2, p64)
The Children's Hospital task force was charged with addressing
the issue of measuring nursing intensity. Because the project would eventually describe
patients' care needs across the healthcare system, broad representation on the task
force was sought. A nurse researcher, several program directors, and advanced practice
nurses brought their expertise in clinical measurement, management, and clinical
practice; a nursing project manager brought database and informatics expertise;
and the finance officer was asked to participate.
Once the task force had developed the framework of the project,
the Nursing Resource Measurement group was formed with clinical experts in specialty
areas: level 3 staff nurses or clinical coordinators. As with the earlier projects,
an ICU group and a non-ICU group were formed. The ICU group included nurses from
the multidisciplinary ICU, newborn ICU, cardiac ICU, and the bone marrow transplant
unit. The non-ICU group consisted of representatives from all specialty inpatient
units, including neurology, orthopedics, cardiology / cardiac surgery, general surgery,
oncology, and general medicine.
The nurse experts used an expanded model of the traditional
DRG system to better include children and infants who require acute care - the All
Patient Refined - DRG (APR-DRG) system - which addressed patients- severity of illness
(the extent of physiological decompensation) and risk of mortality (the likelihood
of dying). The APR-DRG system included 4 severity of illness / risk of mortality
subclass ratings for each DRG: 1, minor; 2, moderate; 3, major; 4, extreme.
Data sheets for each level of each APR-DRG were designed to
provide a profile of the group of patients being categorized (Table 1). Each data
sheet included the number and name of the APR-DRG, levels 1 to 4, numbers of patients
with that DRG over a year's time, percentage of patients who were cared for in the
ICU, percentage who died, associated primary diagnoses and secondary diagnoses,
primary and secondary procedures, age group, and mean and range for LOS.
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