The National Nursing Quality Report – Canadian (NNQR-C)

1. The National Nursing Quality Report – Canadian (NNQR-C) Presenter: Diane Doran, RN, PhD, FCAHS University of Toronto e-Health 2013: Accelerating Change May 26-29, 2013 Ottawa, Ontario

2. CFPC CoI Templates: Slide 1 Faculty/Presenter Disclosure • Faculty: Diane Doran • Relationships with commercial interests: • Grants/Research Support: Canada Health Infoway • Speakers Bureau/Honoraria: NA • Consulting Fees: NA • Other: Employee of University of Toronto

3. CFPC CoI Templates: Slide 2 Disclosure of Commercial Support • This program has received in-kind support from Canadian Nurses Association in the form of administrative support and in-kind personnel support. • Potential for conflict(s) of interest: • No conflict of interest to declare.

4. CFPC CoI Templates: Slide 3 Mitigating Potential Bias • The presenter is independent of the funding agency and co-sponsor.

5. Objectives • Provide overview of the NNQR-C • Background / Context • Purpose • Methodology • Progress and next steps • Potential Benefits • Invite questions and comments

6. NNQR-C project team Project Leads Anne Sutherland Boal,BA, MHSA Susan VanDeVelde-Coke, RN, MBA, PhD, CHE Diane Doran,RN, PhD, FCAHS Lori Lamont, RN,VP & CNO WRHA Team Members Karima Velji, RN, PhD, CHE Elizabeth Borycki, RN, PhD Noreen Frisch, RN, PhD, FAAN Sylvie Jetté, RN, PhD Sean Clarke, RN, PhD, FAAN Linda McGillis Hall, RN, PhD, FAAN, FCAHS • The NNQR-C is an Infoway invested project within the Health System Use Program.

7. Context • In the fall of 2010, ACEN made the decision to focus on nurse sensitive indicators • This priority reflects the trend toward accountability: • Health systems must be able to access reliable data about the care individuals receive and about the outcomes the system achieves. • By linking the care to the outcomes, outcomes measurement initiatives have become key elements in developing better ways to monitor, measure, and improve the quality of care.

8. Aim of the NNQR-C • The NNQR-C will enable nurse leaders in Canada to exercise their accountability over quality of care issues that are sensitive to nursing. • Aim is to build a national database of nursing quality indicators that will make the most meaningful contribution towards timely, effective, and efficient decisions about the organization and delivery of patient care for improved outcomes.

9. NNQR-C Vision & Scope NNQR-C envisioned as a minimum set of input, process and outcome indicators that can be: • Collected nationally across the continuum of care; • Be readily available through dashboard applications in healthcare institutions; and • Be benchmarked and used to influence policy directions for nursing to improve client outcomes in all care settings.

10. NNQR-C Health System Use Demonstration Project • Pilot and evaluate a new outcomes monitoring system with a focus on nurse sensitive indicators, utilizing existing databases (HOBIC/C-HOBIC, RAI, DAD, MIS). • Implement a national nursing quality report that will generate a dashboard of nurse sensitive indicators, • Evaluate the feasibility and costs associated with producing the indicators for health care organizations, • Evaluate the potential of these indicators to impact organizational quality improvement and quality outcomes.

11. Participating Pilot Sites • Nine pilot sites across three provinces representing acute care, long-term care/complex continuing care and mental health • Manitoba – 3 Long-Term Care facilities • Ontario – 7 Mental Health units, 5 Acute Care units, 4 LTC/CCC units • New Brunswick – 4 Acute Care units, 2 LTC units

12. Table 1. NNQR Database Schema for Aggregate Data • Unit Structural/ Contextual Table • % RN hours worked • % total nursing hours worked for direct patient care • % nursing hours as paid Absenteeism • % Voluntary nurse turnover • Total nursing hours worked for weighted inpatient day • Nurse job satisfaction & Practice environment scale (nurse survey) Facility Table -Facility code -Facility type -Facility postal code -Province/territorial code • Process Indicator Unit Table • % Fall risk assessment on admission • % Pressure ulcer risk assessment on admission • % Appropriate Hand Hygiene practice • % Patients with Restraints • % Residents physically restrained daily on the most recent RAI assessment • MedRec- % patients reconciled on admission Unit Table -Unit code -Unit type • Unit Outcome Table • % patients with pain • Incidence of Pressure ulcers • Mean Therapeutic Self-Care score at discharge • Falls rate per 1000 days • % Falls causing injury • % patients with improved Aggressive Behaviour Score (Mental Health) • Mean Self-care index score on discharge or most recent assessment (Mental Health)

13. Expected Benefits • Ability to examine relationships between care processes and patient outcomes (ex. risk assessment & incidence of pressure ulcers). • Unit level data will enable decision-making at the local unit, for example: • Allocation of nurse staffing resources (ex. % nursing care hours for direct patient care) • Professional development strategies for nurses to address specific learning needs. • Nurse job satisfaction and work environment data could inform strategies to reduce nurse absenteeism & turnover. • Evidence to highlight best practices within the unit.

14. NNQR-C Implementation Phase • Quarterly indicator data collected through CPSI Patient Safety Metrics system • Sites selected indicators that are feasible to collect (ex. C-HOBIC/HOBIC, DAD, RAI, MIS sources) • Dedicated loading page on CNA website • Data aggregated by hospital type and unit type. • Quarterly submission retrospectively from April 1, 2012 to March 31, 2013 • PSM system provides dashboard reports • Annual nurse survey • Conducted online from CNA website • Job satisfaction and practice environment survey

15. Login Page

16. Mean Performance National and health region

17. Mean Performance – Organization and National

18. Governance & Leadership • NNQR-C Advisory Board (meet 3x year) • Representation from provincial and territorial policy makers, health councils, professional associations and researchers. • Discuss sustainability planning • NNQR-C Steering Committee (meet 4x year) • Site Leads/Coordinators, Project Co-Leads, research team • Regular communication among research team, project staff and site coordinators, Canada Health Infoway team

19. Project Status and Next Steps • Sites entering indicator data into PSM online system • Refinement and clarification of indicators ongoing • Nurse survey launched on CNA web portal • Four Community of Practice meetings • Enabling Nurses to Take Accountability for the Quality and Safety of Care • Using Indicator Data to Improve Practice • Patient Safety Metrics- Measurement Accelerating Improvement • National Nursing Quality Report: Ontario Shores’ Journey • Feasibility & Benefits evaluation starting in July/August: User Satisfaction survey, System and Use Assessment Survey, Site Interviews

20. Lessons learned / early benefits • Selection of indicators requires extensive consultation with various departments (ex. HR/Decision support) • Current evidence needed to be reviewed in order to determine realistic goals for each indicator (ex. 100% of LTC patients should have falls risk assessment on admission) • Ongoing communication, coordination and liaison between sites, project team and partners is necessary to facilitate organizational change and enable implementation success (ex. partnership with CPSI in development of infrastructure and collaboration with CNA in project leadership) • NNQR-C indicators being used to evaluate organizational change initiatives (ex. early data trends being observed, decision-makers’ perceived value of benefits)

21. Case Example: Ontario Shores’ Approach in NNQR • The initial phase involved readiness work which included identification of indicators which would be included as part of the NNQR. • The readiness phase required evaluation of feasibility of extracting the data elements from the electronic health record and validating internal definition of each data element with the NNQR definition. • This process required collaboration among Professional Practice, Clinical Informatics and Decision Support. • The second phase focused on report development. In this phase Ontario Shores invested resources to create customized reports to optimize automation of extracting data elements from the EHR as much as possible. • Within this phase Decision Support and Professional Practice categorized which data elements were feasible to be built in a report and which would continue to be a manual process.

22. Case Example: Ontario Shores’ Approach in NNQR • The final phase focused on implementation and operationalization of the data elements. • Decision Support provided the data to Professional Practice which enabled the creation of customized unit-based profiles of the data elements within the structure, process and outcome framework. • Benefits: The NNQR project has further enhanced the Professional Practice strategies toward Ontario Shores’ organizational initiative within staff mix review by providing a framework and being the catalyst to producing reports to evaluate each unit.

23. Case Example: Ontario Shores’ Approach in NNQR • Technical: As part of the electronic health record, Ontario Shores has a data repository module which collects the data from the various modules of the EHR. • The data required for the NNQR indicators were filtered into a data warehouse. This involved leveraging the data in a way to also pull all units throughout the hospital so that the potential of expanding the reporting to cover the entire clinical units and also to potentially use these data elements in our own project or hospital reporting needs. • Microsoft SQL Server Reporting Services was used to build the custom web-based metric reports to provide the values required for the NNQR indicators. Granular reports were created for each indicator which provides both the Denominator and Numerator values. A web-based dashboard was also created for all of the indicators to view and to assist in validating the data.

24. Conclusion • Use of evidence-based, meaningful, and actionable quality indicators is critical for quality performance and patient safety as an essential component of accountability for a sustainable health care system. • Standardized nursing data will facilitate comparison of outcomes across healthcare facilities, identification of promising practices to the delivery of care, and will provide more effective tools that will be essential to needs-based healthcare planning across Canada.

25. Questions or comments? Thank-you