The Center for Research & Innovation in Patient Care

California Nursing Outcomes

Coalition (CalNOC) Director's Report

 

Linking Quality Measurement & Evidence-Based Practice Research for Hospitals and Long Term Care

Presented on Behalf of the CalNOC Steering Committee
By Diane Brown, RN, PhD, CPHQ
CalNOC Co-Principal Investigator

The California Nursing Outcomes Coalition (CalNOC) is an unprecedented collaborative initiative engaging a diverse team of staff nurses, advanced practice clinicians, educators, researchers, administrators and leaders in nursing in attaining the shared vision of designing, systematically implementing, and evaluating a statewide nursing outcomes database. The CalNOC project is the largest ongoing nursing quality measurement research and repository development project in progress in the nation.

CalNOC was established in 1996 when ANA\California, the California affiliate of the American Nurses Association, contacted the Association of California Nurse Leaders (ACNL) (formerly Organization of Nurse Executives) to engage them in collaboratively developing a response to the ANA Nursing Quality Request for Proposals. Concurrently, ACNL had already begun initial work to establish a statewide nursing quality initiative, using ANA's new nursing quality indicators. In January 1996 the partnership between ANA\California and ACNL to launch CalNOC was formalized; the nucleus of a CalNOC Steering Committee (CalNOC-SC) was formed. CalNOC's 1996 proposal to ANA was successful and CalNOC became one of ANA's six original state nursing association sponsored quality indicator research and development projects (AZ, TX, MN, ND, VA) (Donaldson, Brown, Aydin & Burnes Bolton, 2001; Grobe, 1998; Redmond, Riggleman, Sorrell & Zerull, 1999; Sheehy, et. al, 2000). CalNOC is a major contributor of data to the ANA National Database for Nursing Quality Indicators (NDNQI) under the auspices of the Midwest Research Institute. The CalNOC Project has successfully completed the Phase I, Feasibility Study (1995-1996), the Phase II, Pilot Test (1997-1998) and is in the midst of Phase III, Expansion and Research (1999-2002).

The aim of the California Nursing Outcomes Coalition (CalNOC) Project is that CalNOC indicators will become the standard for clinical, administrative, and scientific quality measurement in nursing statewide. In order to realize the vision, CalNOC undertakes the following strategic activities:

• Building and sustaining the CalNOC statewide nursing staffing and quality database repository
• Conducting research to advance evidence-based administrative and clinical decision-making
• Providing data to resolve public policy and clinical dilemmas in the cost and efficacy of patient care delivery, nurse staffing and quality.

CalNOC Database Indicators

CalNOC indicators have been selected from among the first ANA Acute Care Indicators advanced for testing in 1995. Additional indicators have emerged based on recommendations from CalNOC sites and in response to regulatory imperatives (ie. Restraint prevalence). By 2001, over sixty acute care hospitals were collecting CalNOC data statewide. The CalNOC data repository currently contains data representing 2,737,700 patient days, collected from 329 patient care units and eight consecutive quarters of staffing data from these medical, surgical, step down, and critical care units. The repository also contains 8102 patient falls reported by 54 hospitals and 87 pressure ulcer prevalence studies reported by 44 hospitals. The following nursing quality indicators are the focus of CalNOC's data collection efforts: patient days, direct care hours, skill mix and RN education level & certification; patient falls-risk, incidence & consequences; pressure ulcers-risk & prevalence; stage & nosocomial; restraint prevalence-type & clinical justification; and patient satisfaction with pain management, patient education, and overall nursing care.

Indicators under development for pilot testing in Phase III include expanding staffing data collection to maternal-child acute care services, extending core indicator data collection to post-acute care settings, standardizing nursing assessment documentation related to patient activities of daily living (ADL) on admission, and revisiting nurse sensitive medication error measurement strategies.

Data Collection Methods

CalNOC uses a rolling site accrual process and a voluntary, convenience sampling method in an effort to enroll hospitals with a strong strategic commitment to support the requisite data collection and repository growth over a sustained period. CalNOC data is collected at the patient level or patient care unit level by nursing staff, who report direct care staff hours of care/skill mix to hospital information systems (from which CalNOC data is extracted by on-site personnel), who report patient falls to hospital "incidence" databases (from which CalNOC data is extracted by on-site personnel) and who participate in patient risk assessments for falls and pressure ulcers upon admission to the hospital. Clinical staff also work in teams to conduct prevalence studies and record direct patient observations which capture a snap shot of pressure ulcers and restraint use in their hospitals. All CalNOC data are coded by the sites to ensure confidentiality, and submitted electronically, using blinding site identification code numbers, to the CalNOC data management team at Cedars Sinai using Excel files or using TeleForm scannable data capture documents. Only the data manager is able to unblind site identification codes for the purposes of data verification/cleaning and report distribution. All CalNOC sites use the CalNOC Acute Care Codebook to ensure data collection precision. As data are received and cleaned, outlier errors are investigated for accuracy before the database is updated. As sites discover errors revised data are entered ensuring that the database reflects the highest level of data accuracy.

CalNOC Reporting

Hospitals receive quarterly reports with data on each of their indicators. These reports provide graphs for quick reference to understand data compared to all hospitals or to like-sized hospitals (using average-daily-census groups). Hospitals can monitor their own performance quarterly for trends using hospital-level aggregated data or unit-based data to compare like units internally. In addition to hospital quarterly reports, these data have been aggregated (no identifiers) and publicly reported. In January 2000 the first public report was issued with four quarters of data from 1998 and 1999. This report represented findings from 38 hospitals and 257 patient care units, reflecting staffing for 1,253,892 patient days, 3,808 patient falls, and 5,804 patients in prevalence studies. In February 2001, staffing data were published in Policy, Politics, & Nursing Practice (Donaldson, Brown, Aydin & Burnes Bolton, 2001) with nine quarters of data from April 1998 through June 2000 from 52 hospitals representing staffing for over 3-million patient days. These data were released to help understand current staffing hours, ratios and skill mix, to help inform those working on current staffing legislation. These data demonstrated the staffing was stable over this time period, but staffing patterns did vary widely across the state.

Improving Patient Care

CalNOC is helping healthcare professionals improve patient care by using evidence. By building and sustaining the database repository, CalNOC has allowed concurrent state-wide benchmarking to understand practice. These data will help identify best practices in the future and have helped nurses to standardize practice now related to risk assessment procedures for pressure ulcers and falls. CalNOC is also advancing evidence-based administrative and clinical decision-making by providing insight into how the structure and process of care effect outcomes. Research analyses related to the role of staffing and skill mix on outcomes, or risk assessment and prevention related to falls and pressure ulcers, has not been possible with large concurrent, ongoing databases in the past. CalNOC is also providing data to resolve public policy and clinical dilemmas in the delivery of patient care, by publicly releasing quality data related to staffing ratios and relationships to outcomes.

Selected References

American Nurses Association. (1997). Implementing Nursing's report card: A study of RN staffing, length of stay and patient outcomes. (# Q-1). Washington DC: American Nurses Publishing.

American Nurses Association. (1995). Nursing care report card for acute care. (# NP-101). Washington DC: American Nurses Publishing.

American Nurses Association. (1996a). Nursing quality indicators: Definitions and implications. (# NP-108). Washington DC: American Nurses Publishing.

American Nurses Association. (1996b). Nursing quality indicators: Guide for implementation. (# NP-109). Washington DC: American Nurses Publishing.

American Nurses Association. (1999). Nursing-sensitive quality indicators for acute care settings and ANA's Safety and Quality Initiative. (#PR-28) American Nurses Association.

Bolton, L. B., Jones, D., Aydin, C., Donaldson, N., Brown, D., Lowe, M., McFarland, P., & Harms, D. (2001). A response to California's mandated nursing ratios. Image: Journal of Nursing Scholarship, 2nd Quarter: 179-84.

Brown, D., Donaldson, N., Aydin, C. & Carlson, N. (2001). Hospital nursing benchmarks: The California Nursing Outcome Coalition Project. Journal for Healthcare Quality, 23(4): 22-27.

Donaldson NE, Brown D, Aydin C, and Burnes Bolton L. (2001). Nurse staffing in California hospitals 1998-2000: Findings from the California Nursing Outcomes Coalition Database Project. Policy, Politics, & Nursing Practice, 2(1): 19-28.

Grobe, S.J., Becker, H., Calvin, A. Biering, P. Jordan, C., & Tabone, S. (1998). Clinical data for use in assessing quality: Lessons learned from the Texas Nurses' Association Report Card Project. Seminars for Nurse Managers, 6, 3, 126-138.

Redmond, G., Riggleman, J, Sorrell, J.M., & Zerull, L. (1999). Creative winds of change: Nurses collaborating for quality outcomes. Nursing Administration Quarterly, 23(2): 55-64.

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