What if nursing evaluations were outcome based?

[Anoetos, BSN, RN]

For some time now, physicians have been evaluated based on how their patients do: surgeons less on the number of procedures they perform as the success rate post surgery of their patients, other doctors on infection rates, recoveries, etc.

What if this was done for nurses? What if we were evaluated based on how our patients did after we gave them care?

I realize there is a lot to figure out here, for one thing, one patient, during a hospital stay, will have several nurses so standardizing this would be difficult. There are other variables as well.

Is this something that could be done? Should it? Would it improve outcomes?

This comes from a discussion I was having with a fellow nurse about the essential differences between service industry and healthcare in the face of the application of common customer service evaluations for healthcare (press-ganey, HCAHPS, etc). The industries just are too different for the same standards to be effectively applied (which helps explain why a 60% rating is considered excellent for a healthcare system on some questions, but would be horrible for, say, a hotel). It occurred to me that much of what may be driving the movement toward this kind of evaluation can be related back to failures, or, at least, inconsistency in care.

Your opinions are appreciated.

[Indy, LPN, LVN]

I think this would be difficult to do. First of all it would mean chart audits on every patient. Secondly it would change how the audits were done. For example, you might want to do something in stages. Auditing every chart or assigning chart audits for down shifts or instead of low census would be one step. Then you look at preventative stuff before looking at outcomes. Did the nurses do the mrsa swabs, did they send first urine for u/a and possible culture, did they document a thorough skin assessment, did they document turns, peri care and baths? I think that approach might be more useful than looking solely at outcomes. And when you find nurses that do not do these things, first of all see if it is all the nurses, and then fix the documentation so that it is easier or faster or not done in 4 different spots. Then you can re-audit later and see who does and who doesn't do the things. The entire idea of it should be less about evaluations which are tied to raises, and more about finding out how to get the preventative things to happen consistently.

[Anoetos, BSN, RN]

Thanks for your response, Indy.

What about random chart audits of things like this measured against patient recovery and length of stay?

Rather than looking at every chart, pick, say ten for any given nurse...

[Indy, LPN, LVN]

Well I would not want that, especially for my unit. There are so many things that go into length of stay. There are some postops that come to my mind immediately, that would make my hair stand on end if my evaluation were tied to their length of stay. A high output enterocutaneous fistula, for example. I didn't make that. Surgeons made that. How about if the selfsame patient didn't get ventilator associated pneumonia, or if they didn't get bedsores, or their central lines didn't grow new stuff? Now that is stuff right up my alley.

Also problematic with random lengths of stay are the psych patients. Some other facility determines when they leave, not us. We would like them to leave as soon as humanly possible! We had a brouhaha at one time over several patients who all got the same infection in their lungs, and it's not common. Nursing was supposed to be in hot water until they figured out it was a piece of OR equipment and I don't want to give details online. My unit was pretty huffy about the whole deal. And all of those patients wound up with longer stays and complicated stuff. If I remember correctly, not one of them had a bedsore.

I think the things you want to evaluate should be different for different units. ICU gets stuck with some doozies.

[hiddencatRN, BSN, RN]

Thanks for your response, Indy.

What about random chart audits of things like this measured against patient recovery and length of stay?

Rather than looking at every chart, pick, say ten for any given nurse...

Don't most places do some form of chart audits already? My documentation is addressed in my review (how would they know about my documentation if they weren't pulling charts). At my new job, every single chart is reviewed for missing documentation and we're notified about things to clarify or complete.

As far as tracking outcomes with multiple nurses, there's probably some fancy statistical trick that could look at trends over time to see that when Nurse A is involved in patient care, the outcomes are better by X amount and when Nurse B is involved the outcomes are only better by Y amount. But is it worth figuring out in such detail when we're a room charge as far as reimbursement goes?

[LynnLRN]

I think it should be outcome based. I think the easiest way to do it would be by unit outcomes (not single nurses), such as using nurse sensitive indicators, budget, etc. This would also help weed out people who aren't holding up their end of the bargain. If people knew their evaluation would be affected by other people's poor work they wouldn't put up with it. So it would lead to an improved work environment and better patient outcomes. iIf you know your raise depends on patients not developing pressure ulcers or falling you would probably be more likely to work harder at preventing them as a team.

[RNperdiem, RN]

There is some of that already. All units here track rates of ventilator-associated pneumonia, line infections and rates of skin breakdown. Results are published and compared.

The cardiac ICU for example usually comes out on top with the scores. They also have the fasted patient turnover, fewer vented patients and fewer central lines. At the other extreme, burn patients are likely to have a much longer length of stay and have a higher risk for UTI, line infection, and almost any kind of infection.

Are the cardiac nurses better, or does patient population matter?

To improve outcomes, new protocols have been developed. Vented patients have a list of things nurses need to do to prevent pneumonias.

[BrandonLPN, LPN]

I think random chance plays too much a part in outcomes for this to be fair....

[SHGR, MSN, RN, CNS]

The places that I know of that are tracking nursing outcomes do it by unit, as far as I know: MRSA-acquisition, VAP, etc. I know of a WOCN department that periodically goes through the entire hospital to check every patient's skin (like a sweep through eval of all currently admitted patients) and they use the data to justify having committed WOCNs. We do need to be able to prove our worth and our good outcomes.

Sure there is an element of random chance, or the outlier patient, but I think that every hospital, every unit, is going to have some outlier patients, and that should even out? Overall, the quality of nursing care and nursing leadership (or lack thereof, based on some AN posts....) is going to trump chance.

Also, when people know that outcomes matter- and are influenceable- yes, outcomes are better. Some people are internally motivated, but for those more externally motivated, or those motivated by praise or "being noticed" in some important way, this kind of tracking works even better. Also, beliefs like "all vented patients are going to get VAP..." is kind of like the diabetic patient that says "I'm just going to end up on dialysis or lose a foot anyway."

Anoetos, I like your thoughtful posts.

[Caffeine_IV]

I don't think I would like that. What would be evaluated? We don't decide the course of treatment. We are part of a care team.

Would that mean any patients we have that went bad during admission or died within a week after discharge would ruin our eval? Some patients have as many as 4 nurses in a given day.