United States University MSN560 Access Cost and Quality for APNs Discussion

United States University MSN560 Access Cost and Quality for APNs Discussion ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS ON United States University MSN560 Access Cost and Quality for APNs Discussion I’m studying for my Nursing class and don’t understand how to answer this. Can you help me study? Discuss the access, cost, and quality of quality environments, as well as recent quality initiatives (See Chapter 24 and Table 24.1 Vocabulary of Quality Please see chapter attached). Student is to reflect on the relationship between quality measures and evaluation and role development. In addition, describe this relationship and note how the role of the APN might change without effective quality measures. United States University MSN560 Access Cost and Quality for APNs Discussion Length: 4 pages, double-spaced, excluding title and reference pages (required) Chapter 24 of Joel, L.A., (2018). Advanced practice nursing. Essentials for role development (4th Ed.). Philadelphia, PA: F.A. Davis. [ISBN-13: 978-0-8036-6044-1] Format: APA 6th Edition chapter_24.docx Learning Outcomes Learning outcomes expected as a result of this chapter: Describe the value, quality, and accountability context surrounding advanced practice registered nurse (APRN) practice. Understand APRN performance expectations in general and those specific to specialty practice. Develop quality and performance measures for use in practice at the individual, group, systems, and societal levels. Demonstrate the ability to design a model for assessing structures, processes,United States University MSN560 Access Cost and Quality for APNs Discussion and outcomes within a framework of national standards. Plan actions to enhance the APRN impact in patient care, education, research, administration, and advocacy or policy. Chapter 24 • Measuring Advanced Practice Nurse Performance 367 INTRODUCTION Performance measurement in the health-care system is ubiquitous and complex. Whomever the provider, whatever the geographic location, whatever the setting, whatever the organization, whomever the stakeholder, whomever the payer, advanced practice nurses (APNs) can expect to have their performance evaluated. APNs, along with other individuals and organizations, must demonstrate that their performance enhances the triple aims of improving care experiences for patients and families, improving the health of populations, and reducing the per capita costs of health care (Berwick, Nolan, & Whittington, 2008). As Whittington, Nolan, Lewis, and Torres (2015) suggest, the triple aims are an integral part of the United States’ strategies to improve health outcomes and health care. These aims provide a framework for state and federal initiatives and the work of credentialing, accrediting, and regulatory agencies at all levels influencing the organization, delivery, and financing of health-care services. To improve care experiences, individual patients and families are encouraged to become more engaged in care and to participate in planning and assuring they receive quality, safe care. To improve outcomes for population health, providers and communities are expected to transform the organization and delivery of services. To reduce health-care costs, care providers and payers are engaged in payment reforms and developing more cost-effective interventions. Reimbursement structures are also being modified. These aims are influenced by several trends related, in part, to the implementation of the Patient United States University MSN560 Access Cost and Quality for APNs Discussion Protection and Affordable Care Act (PPACA; Public Law [PL] 111-148) and subsequent policy and administrative changes. Trends and issues include increased access and, thus, more demand for services; drug pricing; mergers of providers, organizations, and insurers; technologies such as telehealth and mobile apps; and data security (Blumenthal, Abrams, & Nuzum, 2015; Lorenzetti, 2015). Superimposed on all these changes—and influencing them—are political and power issues. Given the demands facing the health-care system, the voice of nurses and the leadership of APNs are essential to meet our professional and societal obligations to improve health and health care. APNs are uniquely positioned to contribute critical knowledge, skills, and attitudes, as well as their values of civic professionalism and compassion, to political and decision-making dialogues. The purpose of the health-care system is to continuously reduce the impact and burden of illness, injury, and disability and to improve the health and functioning of the people of the United States. Although providing direct care and influencing the direct care provided by others are necessary work and contribute to meeting this goal, they are not sufficient to meet growing professional and societal quality and accountability demands. By demonstrating their contributions; continuously improving their performance; and being accountable to the profession, employers, and the public for all components of their role, APNs canUnited States University MSN560 Access Cost and Quality for APNs Discussion make a difference. As the nurse moves from novice to expert, responsibility for and accountability to self and others for the structures, processes, and outcomes of health care increase proportionally. Achieving the status of APN is not a terminal event and the role assumes ongoing and increasing professional and societal obligations. Responsibility for meeting the triple aims means that the APN must serve the profession and society as a primary agent contributing at the level of individual care, in the practice setting, and at the tables where organizational and public policies are made and implemented. In addition, the professional and societal trust afforded to the APN obliges meaningful contributions—beyond individual patient care—to meet the purpose of the health-care system. APNs must not only do good, they must demonstrate their value to society through performance assessment and its documentation and dissemination at every level of care and decision making so their voices are heard. The importance to health outcomes, the profession, and society cannot be underestimated or ignored. The Case for Accountability Why should APNs be concerned about these issues? A Web search of the terms health care AND accountability resulted in more than 130 million hits. This reflects the importance of this issue in our society. The search revealed that accountability for the quality and costs of health care—its value—are of interest to consumers, purchasers/payers, employers, insurers, the government, and professional provider organizations. Although the demand for accountability for the value of health care is not new, growing complexity and changes in the health-care 368 Unit 4 • Ethical, Legal, and Business Acumen of pay-for-performance determinations. The Institute of Medicine (IOM) (1999, 2001, 2006) identified problems with the quality of care and safety concerns that continue to be reported in the literature. Reports of consumer satisfaction or experience with the health-care system, such as those of the Commonwealth Fund (Commonwealth Fund, 2016b; Davis et al, 2002), found that patients were not satisfied with the quality of care they were receiving and reported continuing concerns on their summaries of assessment data. Hero, Blendon, Zaslavsky, and Campbell (2016) found that concerns about access to preferred care were a major concern. Managed care, cost concerns, and the growing consumer movement in health care have increased the demand for information about the value (quality in relation to cost) of health-care services and the performance of health-care providers in delivering quality, cost-effective services across all components of the health-care system. Led by advocacy organizations, consumers are demanding greater accountability from health-care providers and the health-care system. They want quality, cost-effective services delivered from a patient-centered perspective. Federal and state government agencies and other purchasers want to know if the services they pay for are achieving the best possible outcomes at the best price. Organizations that accredit health-care organizations are increasingly seeking evidence that the structures and processes of care produce positive health outcomes. All these demands to demonstrate and be accountable for value- and cost-effective high-quality care require individuals and groups of providers to measure performance and share their assessments with stakeholders. Organizations such as the National Committee for Quality Assurance (NCQA), the National Quality Forum (NQF), The Joint Commission (TJC), and several agencies of the federal government lead efforts to measure and report on the quality of care provided by various health-care system components. Federal and state agencies, independently and in collaboration with private sector organizations, are collecting and disseminating information about the quality of services provided by the health-care system’s various providers. Health-care “report cards” are mechanisms widely employed to address the concerns of consumers, payers, employers, and others about the quality of health care being provided. Report cards are done for hospitals, system raise the issue to a level that cannot be denied or minimized. This demand requires the APN to measure and disseminate information on the value of the role. Nurses in advanced practice, similar to other providers and health-care system components, need knowledge and skills to assess and measure quality and determine the costs of their services if they are to demonstrate value. It is not enough to “do good”; the APN must demonstrate how “doing good” translates into outcomes and costs. Accountability for practice has been and continues to be embedded in APN standards, education, and position descriptions. As Buerhaus and Norman (2001) suggest, the improvement of health-care quality is an “authentic commitment” (p. 68) for all stakeholders and will shape how health-care services are delivered. Given the definition of advanced practice and its role components, APNs must contribute to and lead broad efforts to improve quality. Their actions in defining, measuring, and reporting on their performance will determine their future and that of the health-care system. The advanced practice framework includes patients, health care, nursing, and individual outcomes. Thus, the APN is accountable for performance in all these domains. These concepts and obligations are further reflected for the graduate-level student (American Association of Colleges of Nursing [AACN], 2011). Prepared at this level, the nurse is expected to have advanced role skills, possess refined analytical skills, operate from a broad-based perspective, have the ability to articulate views and positions, and connect theory and practice. He or she is expected to engage in quality and safety initiatives and collaborate inter-professionally to improve patient and population health outcomes. The Quality Context If the health-care system is to reduce the effect and burden of illnesses, injuries, and disabilities and improve outcomes and functioning, all involved in the system must be responsible for identifying and improving the structures and processes for achieving positive outcomes. Research has shown that consumers and society are not getting what they want or need from the health-care system. Errors continue to occur and patient experiences with care continue to be issues with outcomes becoming part Chapter 24 • Measuring Advanced Practice Nurse Performance 369 health plans, and provider groups with the intent of United States University MSN560 Access Cost and Quality for APNs DiscussionUnited States University MSN560 Access Cost and Quality for APNs Discussion informing consumers and improving quality. Public reports of health-care quality are done by state and federal governments and private sector organizations. Implementation of the PPACA has resulted in greater reporting at the state and federal levels. Although these reports, especially those related to patient satisfaction and experience with care, remain controversial (Rosen & Chen, 2016), they are being widely reported and linked to pay-for-performance initiatives. Quality in service is demanded by anyone seeking that service. This is especially true for health-care services, both by the person receiving services and also for regulating bodies. Nurses must recognize the part they play in quality and safety in an obvious way, measuring, reporting, and articulating their role. The importance of quality and safety is evident in the APN Consensus Document (NCSBN, 2008) that articulates the parameters and standards for licensure, accreditation, certification, and education (LACE). The APN’s performance will be measured and reported; thus, he or she must be engaged in determining best practices to meet patient and outcome expectations. Values and Value in Health Care To contribute effectively to fulfilling the purpose of the health-care system, the APN needs a clear vision derived from personal and professional values. The APN needs to embrace society’s mandate for health-care value and clarify how the quality and cost issues relate to personal and professional goals. Explicit incorporation of quality and cost values and critical thinking about these issues will result in actions and activities consistent with social demand. Therefore, the APN role can be justified and the needs of society will be better served. APNs will be well positioned to provide leadership in affecting quality and costs, the “bottom line” of health-care system performance. To be effective leaders and advocates for value issues associated with patients and the role, the APN must know and appreciate what other stakeholders want. Thus, it will be easier to understand their behavior and thinking about health and health care and to develop and implement strategies to address value conflicts, thereby resulting in better health-care outcomes. For example, the APN’s employer may value reducing costs to ensure organizational survival, whereas the APN’s highest value is meeting the diverse needs of patients served by the organization. Negotiation, compromise, and collaboration are necessary to incorporate both values into strategic planning efforts. Awareness of the importance of values, understanding the value equation, and possessing the skills to address value conflicts are critical for APN survival and health-care system improvement. The purposes of this chapter are to introduce APN students to quality frameworks, performance measurement, and accountability and to suggest approaches to current issues and responses to trends. For the graduate APN, this chapter can enhance knowledge and skills that will promote the quality activities, better demonstrate accountability, and foster actions to justify the role of the APN in meeting societal demands for quality, cost-effective health care. The complexity of the quality movement and the value equation are discussed. As the health-care system becomes increasingly complex, as stakeholders’ values and visions clash, and as there is growing dissatisfaction with the health-care system, APN leadership is critical. The challenge to establish value and be accountable at all levels may appear daunting, but it is exciting and potentially rewarding for the APN, the profession, and our society. THE QUALITY ENVIRONMENT Beginning with Florence Nightingale, nursing has always given attention to quality issues. Despite our historical roots as leaders in this area, the profession has drifted to a more internal, narrow perspective. Until recently, this mirrored the attention our society gave to the quality of health care. In the United States especially, the values of individualism and self-determination, science and technology, a disease and medical focus, the free-market economy, and nongovernmental interference shaped both the structures and processes of the health-care system, thus influencing its outcomes. Access and cost issues have, until recently, received more attention than quality, particularly at the societal level. As cost concerns increased and new delivery systems—such as managed care—were implemented, greater attention focused on quality and value. In addition, industry and quality theories and practices in business suggested that lessons learned in these arenas could be applied to the health-care sector. 370 Unit 4 • Ethical, Legal, and Business Acumen practice behavior, collaboration, and APN satisfaction. The outcomes related to APN structures and processes include mortality, morbidity, patient knowledge, patient satisfaction, service use, and health status. Quality of care can be viewed from a micro or macro perspective. At the micro level, quality is conceptualized and assessed for the patient, the provider, or the institution. Clinical and technical care, satisfaction with care, and quality of life represent components of a micro view (Shi & Singh, 2005). Although always an important component of any quality approach, increasing attention is being given to the macro level—looking at outcomes and cost effectiveness for populations and society. Examples include the efforts of private sector organizations such as TJC (formerly the Joint Commission on Accreditation of Healthcare Organizations), NQF, NCQA, and the work supported by private foundations. State and federal legislatures and the agencies implementing public policy decisions are also involved in macro-level quality approaches. Definitions and Frameworks With greater attention being given to quality, long-standing terms and processes were dusted off and a new vocabulary evolved. As shown in Table 24.1, a plethora of terms are used to describe quality concepts. The APN, to operate effectively in the new health-care quality climate, must be fluent in the new language. One of the earliest conceptual frameworks to describe quality was developed by Donabedian (1966). It is widely used by the nursing community and others in the health-care system as a way to identify the structural and process factors that affect outcomes. Hamric (1983, 1989) provided a model for APN patient care evaluation using Donabedian’s framework. Girouard (2000) identified structural elements that include the APN’s education, the time the APN spends in role components, reimbursement levels, and organizational characteristics. Process elements include APN behaviors, referral patterns, prescriptive Table 24.1 The Vocabulary of Quality Access Ability to obtain care or health and related services (also defined as use or insurance coverage) Accountability The demonstration of value (e.g., quality care, patient satisfaction, resource efficiency, and ethical practice); liability for actions Cost To the individual paying for services; to the provider to produce services; for society Outcome The end result of structures and processes of care; the goal or objective of health and health care Performance Assessment of how individual providers behave; measurement assessment of processes of care; may be compared against standards or benchmarks Process Method in which health care is provided; provider behaviors; includes technical and interpersonal elements Quality How well services increase chance for desired outcomes; knowledge based and evidence based Quality assessment Process of defining and measuring quality Quality assurance Process of measurement and quality improvement; may also be defined as the minimum standards approach Quality indicator Trait or characteristic linked with evidence to desirable health outcomes; may serve as proxy for outcome Report cards Collection and reporting of performance and other quality-related data to the public or other targeted groups Structure Tools and resources for care (e.g., facilities, licensing and regulation, staffing, equipment) Total quality Includes an environment for quality, involves continuous measurement and improvement activities (often called total quality management or continuous quality improvement) Chapter 24 • Measuring Advanced Practice Nurse Performance 371 their insurance costs, loss of productive work time, and health-care program administration costs are considered as a percentage of expenditures needed to conduct their business. Individual consumers, although most often focused on their out-of-pocket costs, are also concerned about the costs of insurance, the price of services and goods needed, and pharmaceutical costs. A third approach when considering health-care costs is the perspective of the health-care professional or health-care organization in which the focus is on expenditures, such as costs for personnel, administration, physical plants, and supplies and equipment, to produce services for groups of patients. To adequately assess quality at the individual, societal, or organizational level, the APN must be cognizant of access and cost issues and the role they play in determining outcomes. Access and cost issues reflect structural and process elements, the factors that influence health-care outcomes. In addition, this approach holds opportunities for representing the APN as a solution to access and cost concerns. Thus, the APN can make a strong case for the role’s value in the health-care system. Recent Quality Initiatives A growing number of national quality initiatives reflect the importance of this issue and support the assertion that quality efforts will remain a significant factor in shaping the future of the health-care system. The identification of standards and expected outcomes for access, costs, and quality; their measurement; and public dissemination and discourse are ongoing and expanding. To ensure quality and cost-effective care, quality must be defined; performance expectations specified; and performance and outcomes measured. These are the bases for the quality efforts of national health-care organizations. Quality measurement is needed to understand the effects of services on individuals and populations and to make improvements in the organization, delivery, and financing of health care. According to the IOM’s National Health Care Quality Roundtable (Donaldson, 1999), still valid today, health-care quality measurement objectives include: Gathering and analyzing data to inform quality improvement efforts Assessing facilities and individual performance in relation to established standards One example of such an approach is the Child and Adolescent Health Measurement Initiative (CAHMI), a national initiative based out of the Bloomberg School of Public Health at Johns Hopkins University. In collaboration with consumers, they developed an experience of care framework and measures for children and adults. This framework and the measures developed to date are widely used by such organizations as the NCQA, the NQF, the IOM, and the Robert Wood Johnson Foundation (RWJF) for measuring the quality of care provided to large population groups. In addition, federal government agencies, such as the Agency for Healthcare Research and Quality (AHRQ) and the Centers for Medicare and Medicaid Services (CMS), and state government agencies have adopted the framework and adapted the measures for a macro approach to quality. Access, Cost, and Quality The growing demand for quality requires that attention also be given to access because improved health status and other outcomes of care depend on the individual’s ability to receive needed services across the continuum of care. Although often discussed as an issue of access to insurance for the uninsured and the underinsured, a payment mechanism is not sufficient to improve outcomes. The providers, services, and goods individuals and groups have access to are major factors in achieving desired outcomes and cost efficiencies. Thus, payment levels, what is paid for, and who gets paid are important access considerations in the quality equation. Well-known deficiencies currently exist in mental health-care services, oral health-care services, and care of persons with chronic conditions. The APN should pay particular attention to and justify the needs and benefits resulting from advanced practice nursing services in all health-care settings and for all levels of care. Cost issues are the third component (along with access and quality) of the health-care system triangle and are essential to establish the value of health care. Cost can be considered from the perspective of the society at large—the total costs of health care or the percentage of national dollars for health-care expenditures. Global expenditures include provider services, insurance, goods and supplies, pharmaceuticals, research, education, core public health services, and institutional costs for delivering health-care services. Consumers and employers are concerned about the direct costs of care. For employers, 372 Unit 4 • Ethical, Legal, and Business Acumen improvement and health services management in managed care organizations (MCOs). To address quality in nursing homes, the CMS is assessing and disseminating information about quality in Medicare- and Medicaid-certified long-term care facilities. Through the collection and analysis of uniform patient level data (outcome and assessment information set [OASIS]), the CMS is fostering outcome-based quality improvement in home health care. The initiatives described previously reflect only a few of the federal government’s quality-related activities. Other Health and Human Services departments, such as the Centers for Disease Control and Prevention (CDC) and the Maternal and Child Health Bureau (MCHB), are actively engaged in similar activities. State governments are also involved in quality measurement and reporting. For example, New York, Florida, and Washington are measuring provider performance in children’s health care. Private sector organizations representing foundations, purchasers, employers, and professional organizations also measure and report on quality. Accrediting organizations, such as TJC, are moving from assessing only structures and processes of care to outcome evaluation. For example, TJC-accredited organizations, through the ORYX initiative, are required to measure specific patient outcomes and provider performance standards. ORYX is TJC’s performance measurement and improvement initiative, first implemented in 1997. Safety, medical errors, and infection rates are also being used by TJC as performance indicators. Through annual reports on health-care quality, NCQA looks at plan performance related to quality, access, and consumer satisfaction. NCQA’s health plan report cards are shared with employers and purchasing groups and are made available for consumer use in choosing health-care plans. They have played a major role in accrediting medical homes and advanced medical homes. Three national organizations exemplify the private sector’s role and collaboration with government agencies to address quality: the CAHMI, the American Health Quality Association (AHQA), and the NQF. The CAHMI evaluates health system performance for children covered by Medicaid and private insurance and reports on gaps in care to consumers. It is dedicated to helping parents and children make better decisions and choices by informing them about what to expect from the health-care system and by fostering their involvement in holding the health-care system accountable. Comparing providers to inform purchaser and consumer choice of providers Informing all stakeholders about decisions and choices Identifying, rewarding, and sharing best practices Monitoring and reporting on quality over time Addressing the health-care needs of communities In response to the demand for quality, performance measurement, and accountability, federal and state governments and the private sector have taken action. Government agencies, with congressional policy direction and as major purchasers of health-care services, need information about the quality of health care to guide policy and program decision making. Two government agencies, the AHRQ and CMS, are worthy of particular attention because quality is a major focus of their activities. The AHRQ, through its internal and external research programs and educational initiatives, is charged to improve the outcomes and quality of health care. In addition, the AHRQ’s goals include addressing patient safety and errors, increasing access to effective services, and reducing costs. As a major purchaser (Medicare and Medicaid), CMS must ensure that its program beneficiaries receive quality, cost-effective care. In addition, through its regulatory functions it sets quality standards for the health-care industry. An example of a recent AHRQ initiative is a synthesis of completed research to answer questions about which prescriptive drugs reduce costs and improve outcomes. AHRQ is also evaluating pilot projects that reward providers for delivering high-quality health-care services. They have disseminated a synthesis of studies so clinicians can make better decisions about treating patients with community-acquired pneumonia. Clinicians will also find AHRQ’s “Child Health Tool Box” and other collections of guidelines and measures useful in establishing their own performance measurement and quality programs. AHRQ’s more than 10 years of reports on health-care quality and disparities (AHRQ, 2015) provide the APN with important information to guide thinking about the foci of quality initiatives. Because Medicare and Medicaid beneficiaries use a wide array of health-care services, the CMS’s quality efforts are far reaching. Among its initiatives are programs to assess quality and performance in hospitals, home care, and long-termUnited States University MSN560 Access Cost and Quality for APNs Discussion care. The quality improvement system for managed care sets regulatory standards and guidelines for quality assessment and Chapter 24 • Measuring Advanced Practice Nurse Performance 373 recent years and are a priority in the health-care system. Quality in service is demanded by anyone seeking a service— this is especially true for health-care services. The person receiving service, the organization providing the service, those paying for the service, and those regulating the service (and providers) are demanding performance assessment and accountability. The APN, given the components and core competencies required of the role, is expected to be engaged in all aspects of the quality and safety movement including the development, implementation, and evaluation of the performance measurement and reporting process. As reflected in the LACE discussion in the APRN Consensus Model (2008), quality and safety activities, assessment, and accountability are essential for all APNs. It is not sufficient for the APN to simply be aware of quality improvement initiatives and requirements; the APN must now be an active participant in the process. The National Quality Strategy, part of the current health-care reform initiatives, is the first policy to set national goals to improve the quality of health care. It serves as a guide for all HHS quality improvement programs and regulationsUnited States University MSN560 Access Cost and Quality for APNs Discussion and sets standard criteria to measure the quality of health and health care to align national quality and safety efforts. Most of the tasks APNs will be completing in providing care to patients in this new role intersect with some aspect of the National Quality Strategy. The APN is responsible for meeting the demands of patient care while adhering to requirements that have emerged from this strategy. APNs must also be able to define quality in their own practice. Quality has many definitions, but there is consensus among researchers and policy makers that high-quality care occurs when providers give patients the right care when they need it, such as regularly monitoring chronic condition

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