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ADVERSE EVENTS IN HOSPITALS: CASE STUDY OF INCIDENCE AMONG MEDICARE


BENEFICIARIES IN TWO SELECTED COUNTIES
Daniel R. Levinson Inspector General December 2008 OEI-06-08-00220

EXECUTIVE SUMMARY
OBJECTIVE To estimate the incidence of adverse events for hospitalized Medicare
beneficiaries in two selected counties.
BACKGROUND The term adverse event describes harm to a patient as a result of
medical care, such as infection associated with use of a catheter. The term never
events refers to a specific list of serious events, such as surgery on the wrong
patient, that the National Quality Forum (NQF) deemed should never occur in a
healthcare setting. The Tax Relief and Health Care Act of 2006 (the Act) mandates
that the Office of Inspector General (OIG) report to Congress regarding the
incidence of never events among Medicare beneficiaries, payment by Medicare or
beneficiaries for services in connection with such events, and Centers for Medicare
& Medicaid Services (CMS) processes to identify events and deny payment. This
report is one in a series to fulfill requirements in the Act. OIG work on this topic will
continue through 2009. We reviewed a random sample of 278 hospitalized
Medicare beneficiaries selected from all beneficiaries hospitalized in two selected
counties during a 1-week period in August 2008. Physician reviewers determined
whether an adverse event occurred, whether the event was on NQFs list of Serious
Reportable Events or CMSs list of hospital-acquired conditions, and the level of
harm to the patient based on an established harm scale. To establish an estimated
adverse event incidence rate, we included events on the NQF and CMS lists and also
events resulting in the most serious categories on the harm scale (prolonged
hospital stay, permanent harm, life-sustaining intervention, or death). We also
determined whether events on the NQF and CMS lists caused higher Medicare
reimbursement. Lastly, we identified additional events that resulted in temporary
patient harm but were not comparable to the more serious events in our overall
rate.
FINDINGS Fifteen percent of hospitalized Medicare beneficiaries in two selected
counties experienced an adverse event during their hospital stays. Of the 278
Medicare beneficiaries in our sample, 41 experienced an adverse event during their
hospital stay that met one or more of our three criteria for an estimated adverse
event rate of 15 percent. Six of these forty-one patients experienced multiple
adverse events, for a total of 51 adverse events. Incidence rates for adverse events
that met our three criteria were as follows: fewer than 1 percent of beneficiaries
experienced an adverse event on NQFs list of Serious Reportable Events, 4 percent
experienced an adverse event on CMSs list of hospital-acquired conditions, and 13
percent experienced an adverse event resulting in the four most serious categories
on the patient harm scale. (Some adverse events met more than one criterion.) Of
adverse events on CMSs list of hospital-acquired conditions and NQFs list of
Serious Reportable Events, only one resulted in higher Medicare reimbursement to
the hospital. Identified adverse events illustrate differences in the lists and criteria
that define adverse events. A difficulty in determining adverse events incidence
rates involves differences in the definitions used by various entities. The NQF list of

Serious Reportable Events and the CMS list of hospital-acquired conditions often
address the same adverse event but define the event differently. For example, our
sample included two adverse events involving poor glycemic control, both of which
resulted in serious harm. However, because of differences in the way specific
adverse events are defined, one case met the criteria of NQFs list and the other
met the CMS criteria. An additional 15 percent of Medicare beneficiaries in the two
selected counties experienced events during their hospital stays that resulted in
temporary harm. In addition to the adverse events previously discussed, another
15 percent of Medicare beneficiaries experienced events classified as temporary
harm requiring medical intervention. This category of harm represents a wide array
of events, from swelling at a treatment site to low-level infections. In some cases,
the events resulted from standard medical treatment that caused an undesirable
outcome in the patient, such as an allergic reaction to medication. Because these
temporary events did not prolong the hospital stay or result in permanent harm,
they are not included in our overall rate of adverse events. However, these events
are of interest to hospitals and others seeking to improve patient safety because
they are potential indicators of patient care problems and/or improvement
opportunities. For a number of these patients, physician reviewers indicated that
these temporary harm events could have developed into more serious adverse
events with a greater degree of harm without timely intervention.
CONCLUSION The Act requires that OIG report to Congress regarding harm caused in
health care settings. This study is one of several designed to meet this mandate,
providing an estimate of the incidence of adverse events among hospitalized
Medicare beneficiaries in two selected counties. Although these results are not
nationally representative, the extent of adverse events and temporary harm found
in this case study substantiates concerns about the incidence of adverse events in
hospitals and the importance of safety initiatives to reduce occurrences. Our
analysis also calls attention to the difficulty of determining what events should be
considered in an adverse event incidence rate and how those events should be
identified and defined. The Act also directs OIG to make recommendations for such
legislation and administrative action as OIG determines is appropriate. The Act
specifically authorized funding to continue through calendar year 2009 and OIG will
devote this funding to additional studies involving adverse events. Future reports in
this series will include recommendations as appropriate.
AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL RESPONSE We received
positive comments on a draft of this report from the Agency for Healthcare Research
and Quality and from CMS. CMS reiterated its policies to encourage the prevention
of adverse events, including the provision to deny payment for care associated with
hospital-acquired conditions, and indicated that OIG identification of hospitalacquired conditions and their effect on Medicare payment allowed for a deeper
understanding of the payment policy in practice. CMS also offered clarification
regarding one of the hospital-acquired conditions, catheterassociated urinary tract

infection, and recommended further evaluation of this issue. OIG agrees that
further evaluation is warranted and will address this issue in future work in this
series.

Las Vegas Sun


September 9, 2016
Why patients dont report medical errors
By Marshall Allen, ProPublica
Tuesday, Sept. 25, 2012 | 2:02 p.m.
Prior to become a writer for ProPublica, Marshall Allen was the health care writer for
the Sun and the primary author of the newspaper's award-winning project, "Do No
Harm: Hospital Care in Las Vegas."
I was recently browsing through the nearly 200 stories we've compiled with our
Patient Harm Questionnaire, when I was reminded again of a troubling truth. Many
of the people who suffer harm while undergoing medical care do not file formal
complaints with regulators. The reasons are numerous: They're often traumatized,
disabled, unaware they've been a victim of a medical error or don't understand the
bureaucracy.
That's a problem for those individual patients and for the rest of us. There are many
places to complain: a state licensing agency; a professional licensing board that
monitors doctors or nurses; the Joint Commission, which accredits hospitals or a
Medicare Quality Improvement Organization. But if there are no complaints, there
are no independent investigations, and that means no outside accountability for
providers who may have made mistakes, and no public inspection reports that
documents the case -- assuming an agency makes reports public, which is not
always the case. It's a collective problem because patient safety flaws that remain
hidden, if they are not corrected, may be repeated.
We have staggering estimates of the number of people harmed while undergoing
medical treatment. A review of medical records by the U.S. Health and Human
Services Department's inspector general found that in a single month one in seven
Medicare patients was harmed in the hospital, or roughly 134,000 people. "An
estimated 1.5 percent of Medicare beneficiaries experienced an event that
contributed to their deaths," the IG found, "which projects to 15,000 patients in a
single month."
But there's no central system in place to tally and track these events. There's no
way to know when and where patients are being harmed or to tell if the problem is
worse in one place than another.
It's not like keeping track of patient harm is a new idea. More than a decade ago the
Institute of Medicine's landmark "To Err Is Human" report called for a national
system to capture cases of serious harm to patients or death. The report said

accurate reporting provides accountability and knowledge that leads to learning.


That's information that could save lives.
"You really can't improve what you don't measure," said Dr. Julia Hallisy, president of
the Empowered Patient Coalition. "How do you know where to focus your
improvement efforts if you haven't measured what's happening in the first place?"
Efforts at the state level appear to be falling short, according to federal inspectors.
In many states, hospital are required by law to file a report every time a patient
suffers unexpected harm -- often called "sentinel" or "adverse" events. But a July
report by the HHS inspector general's office found that only 12 percent of harmful
events identified by the office even met state requirements for reporting them.
Compounding the problem: Hospitals themselves only reported 1 percent of the
harmful events.
We found something similar when I was a reporter in Las Vegas. We used hospital
billing records to identify 3,689 cases of patient harm at the city's hospitals in a twoyear period. Each of those cases would fit the state's definition of a "sentinel event,"
meaning the hospitals were required by law to report them. Yet in the same time
period they reported to the state only 402 sentinel events.
The federal Agency for Healthcare Research and Quality is now accepting public
comment about a proposed program to encourage consumers to complain about
harm suffered while undergoing medical care. The goals include collecting
information in a common format, developing prototype methods for gathering
information on the phone and Internet and creating a follow-up questionnaire for
medical providers. Patients will be asked what happened, who was involved and for
permission to follow up with the providers involved in the event.
I recently referred the 1,000 members of the ProPublica Patient Harm Facebook
Group to a story about the proposal in The New York Times. Many members of the
group have suffered harm firsthand and filed complaints, so the article created
lively discussion:
Robin Karr said that based on her experience, she's skeptical about reporting harm
directly to the government "but not without hope" about the proposed program.
Debra Van Putten said she knows many people who have filed complaints about
harm they suffered, but little came of their efforts. Patients want more than mere
acknowledgement, she said. They want accountability for whoever is responsible.
Martha Deed said there are so many barriers to a patient reporting harm -emotional trauma and physical disabilities, feeling intimidated by providers, social
pressure not to complain -- that a passive questionnaire is unlikely to elicit
responses. Instead, the patient harm information should be gathered in a way that's

standardized, she said, like the national survey that's administered to recently
discharged hospital patients that has results publicly reported on Hospital Compare.
That's food for thought for those developing the program. Official public comment is
due Nov. 9 and can be sent to Doris Lefkowitz, the AHRQ reports clearance officer:
doris.lefkowitz@AHRQ.hhs.gov.
We'd also love to hear your comments. How do those of you who work in the
medical field feel about this type of reporting system? Patients, what do you think
about it? And what would you recommend as characteristics that would be essential
to such a program?

Can pay for performance improve the quality of primary care?


BMJ 2016; 354 doi: http://dx.doi.org/10.1136/bmj.i4058 (Published 04 August 2016)
Cite this as: BMJ 2016;354:i4058

1. Martin Roland, professor of health services research1,


2. Frede Olesen, professor2
Author affiliations
1. Correspondence to: M Roland mr108@cam.ac.uk
Martin Roland and Frede Olesen explore what other countries can learn from the
UKs experience with the Quality and Outcomes Framework
For many conditions and in many countries, medical care falls short of what should
be provided. Although high quality care depends crucially on the professionalism of
doctors, this has not proved sufficient to ensure universal high quality care, and as a
consequence payers have looked towards incentives as one way of further
improving quality. In 2004 the UK National Health Service introduced the worlds
largest healthcare related pay-for-performance scheme into primary care, the
Quality and Outcomes Framework (QOF). Primary care doctors were paid up to 25%
more if they met a complex set of clinical and organisational indicators.1 The
scheme was a national one with no opportunity for local variations to tackle
particular local healthcare needs.
Although the scheme was initially popular, general practitioners (GPs) have become
increasingly disenchanted, especially with the substantial administrative workload
at a time of rising clinical demand, and there are concerns about reduced time for
aspects of care that are not readily measured. Parts of England have been allowed

to opt out of the scheme, and Scotland is dropping QOF in favour of quality circles
(groups of GPs working together to improve quality).2 What can other countries
learn from the UKs experience of pay for performance? We set out some principles
and caveats for the development and introduction of pay for performance as a tool
for quality improvement.
How should quality of care be measured?
The first problem in developing any pay-for-performance scheme is to decide how to
measure quality of care. The development of clinical indicators is itself a science.
Considerable skill is needed to develop clear reliable and valid indicators with
clinical relevance that also meet administrative or managerial needs, and there are
hundreds of possible quality indicators (the Brazilian pay-for-performance scheme in
primary care has over 1000). However, if the scheme is too large and cumbersome
it will be complex to administer and difficult for clinicians to understanda factor
which itself can be demotivating.3 In contrast, a scheme with a small number of
indicators may lead doctors to prioritise a limited range of aspects of care. Quality
improvement schemes that depend on measurement will inevitably tend to
prioritise aspects of care that are easy to measure, potentially at the expense of
care which is equally or more important.
The UKs scheme started with a focus on clinical care, organisational aspects of
care, and patient experience (box 1). The clinical indicators developed and
expanded to include more conditions over the years, but the organisational
indicators were dropped in 2012 when virtually all practices scored 100%. The
indicators for patient experience were changed several times but were never really
successfully implemented (see examples in box 2).
Box 1: How the Quality and Outcomes Framework works

The original scheme included 76 clinical indicators covering 10 conditions

Data on clinical quality were extracted automatically from practice electronic


records

Doctors could exclude patients from individual clinical indicators (exception


reporting) for specified reasons including clinical inappropriateness,
intolerance of medication, and patient dissent

Organisational indicators included medical records, information for patients,


education and training, practice management, and medicines management

Patient experience indicators related to conducting and acting on the results


of patient experience surveys and offering booked appointments of at least
10 minutes

Box 2: Examples of QOF indicators

Clinical process indicators

Percentage of patients with chronic obstructive pulmonary disease who have


had a review in the preceding 12 months, including an assessment of
breathlessness using the MRC dyspnoea scale

Percentage of patients on lithium therapy with a record of serum creatinine


and thyroid stimulating hormone in the preceding 9 months

Clinical intermediate outcomes

Percentage of patients with coronary heart disease in whom the last blood
pressure reading (measured in preceding 12 months) is 150/90 mm Hg

Percentage of patients with diabetes whose last measured total cholesterol


(measured within the preceding 12 months) is 5 mmol/L

Organisational indicators

The practice has up-to-date clinical summaries in at least 70% of patient


records

A record of all clinical staff having attended training in basic life support skills
in the preceding 18 months

Patient experience indicators

Percentage of patients who indicate in a national survey that they were able
to obtain a consultation with a GP within two working days (England only)

Practice will have undertaken an approved patient survey each year and,
having reflected on the results, will produce an action plan that sets priorities
for the next two years, describes how the practice will report the findings to
patients, and describes the plans for achieving the priorities

There is no optimum size for a pay-for-performance scheme; it will depend on the


nature and scale of the challenges to be addressed. For example, the UKs first
scheme providing incentives for childhood immunisation and cervical cytology
coverage had just three indicators, was effective in maintaining population
coverage, and ran for over 10 years from 1991 without the introduction of any other
clinical targets.4
Who should decide on the indicators?
Clinicians whose performance is to be assessed should be involved in selecting
indicators, using systematic appraisal of evidence and working with experts in
technical construction of valid and reliable indicators. The indicators themselves
should have strong face validity, either through an evidence base or widespread

professional consensus. The UKs QOF ran into problems in the late 2000s partly as
a result of indicators being introduced that had little professional consensus (eg,
completing a symptom inventory for patients with depression), seemed to have a
managerial rather than a clinical agenda (eg, incentives designed to reduce
emergency admissions), or had poorly constructed formulas linking performance to
pay (eg, data from patient surveys). The result was that GPs lost confidence in the
scheme.
Should doctors be able to exclude patients?
It may be impossible to meet the requirements of quality indicators if some patients
decline treatment or follow-up. Treatments or management suggested by clinical
guidelines may also be clinically inappropriate for individual patients. QOF allows
GPs to exclude (exception report) patients on the basis of their clinical judgment or
because patients fail to attend for follow-up appointments. This was an important
part of getting buy-in from UK family doctors and reduces the risk of doctors being
given incentives to manage the patient in a way they believe to be inappropriate.5
An average of around 5% of patients are excluded from individual QOF indicators by
their GP, though the figure varies widely between indicators.6 If doctors are allowed
to exclude patients, this should be monitored, with doctors being prepared to justify
the decisions made.
Is performance a useful way of paying doctors?
The experience of pay-for-performance schemes across the world is that they have
less effect than payers hope for, and the schemes should therefore be seen as one
part of a wider quality improvement strategy.7 However, no payment system is
perfect and all have advantages and potential disadvantages (table). This fact lies
behind attempts to develop blended payment systems designed to provide
population coverage and good access without compromising quality of care.
Intended and unintended consequences of four methods of paying doctors
View this table:

View popup

View inline

Pay for performance will also not generally be suitable for improving care in patients
with more complex problems, or the wider determinants of personal health and
health in society. For important aspects of care that are not easily measurable (eg,
for patients with mental health problems and those with multimorbidity and
complex conditions), better mechanisms are needed to ensure high quality care.
Potential methods include allowance for the additional time taken to provide good
care for such patients (as occurs in the Australian health service) and encouraging

doctors to engage more widely with the health and social needs of patientsfor
example, through social prescribing schemes.8
The formula linking performance to pay needs to be simple and transparent and
should encourage improvement at all levels up to an agreed maximum threshold,
ensuring that low performing practices have an incentive to improve. Tournament
schemes providing payments for the highest scoring practices or groups (eg, those
performing in the top 10%) should be avoided as they inappropriately penalise
doctors if all practices reach high standards of care (eg, if all practices meet 95% on
a particular quality marker). They also dont provide incentives when all providers
need to improve or allow providers to plan and budget ahead as the reward is
dependent on the performance of other providers.
Good data recording and reporting are essential for any pay-for-performance
scheme, and one positive effect of QOF has been the development of
comprehensive electronic records and explicit collection and use of data for
measuring quality. This can be used to educate doctors and increase public
transparency about quality of care. However, it is not clear how much payments add
to feedback and public reporting of performance in improving quality. Although
small financial rewards are probably less effective than large ones, the UKs
experience is that GPs have tried hard to get maximal points, sometimes expending
effort that was clearly beyond any substantial benefit for themselves or their
patients. Clinical ambitions and reputations are important to doctors, and public
reporting of data on quality of care may itself act as a driver of performance.
How often should schemes be revised or changed?
The UKs QOF was changed around every two years. Some changes were minor (eg,
changing the thresholds of individual indicators) and some major (eg, dropping the
organisational indicators entirely). Experience from the UK suggests that substantial
changes should not occur more frequently than every 2-3 years in order to keep
motivation among doctors. However, there is also an argument for rotating
conditions or indicators to allow a wider spectrum of clinical conditions to be
included. In the UK, there has been constant pressure from patient and professional
groups to include more conditions in QOF as this is seen as an effective way of
gaining the attention of GPs.
A key question is when indicators that have been effective in improving quality
should be dropped. If pay for performance is intended to improve quality, should
payments be stopped when maximum achievement on the indicators has been
sustained for some years? Or will quality then decline? The answer is unclear.9 10
One solution may be to reduce quality payments as indicators are rotated or
withdrawn but require limited ongoing data collection for a reduced set of
indicators, and at the same time require (and maybe incentivise) continued and

transparent data collection, potentially including areas where there are no longer
incentives for quality improvement.
What about unintended consequences?
Any incentive scheme, financial or otherwise, can have unintended consequences.
These can range from neglect of conditions that are not included to gaming or
outright fraud. Policy makers and payers must understand the potential for
unintended or unexpected consequences, anticipate them as far as possible, and be
vigilant for them once a scheme is introduced. Some of the QOF indicators that
produced unintended consequences are described in a linked paper.11 Larger
incentives carry greater risk of perverse outcomes, and the UK decided that deriving
25% of GPs income from QOF was too much; it put too much focus on performance
targets, reduced the importance of the patients agenda, and potentially reduced
patient choices about the treatments they should receive. Remuneration from QOF
was reduced to around 15% of income in 2013 and is likely to be reduced further.
Box 3 sets out good design principles that can help avoid adverse consequences.
Box 3: Design principles for pay for performance schemes

Pay for performance should be seen as part of wider quality improvement


efforts.

Public reporting of information on quality of care may be an effective driver of


change without pay for performance

Alternative strategies should be used to improve quality for aspects of care


not easily measured to avoid them being neglected

Single disease indicators may not be appropriate for important patient groups
such as complex patients with multimorbidity

Clinicians should be strongly represented among those selecting indicators


and designing the programme

Technical expertise in developing and implementing indicators is needed so


that they measure what they are intended to measure and reduce unintended
consequences

Indicators should represent aspects of quality that command wide


professional support and, where available, be based on strong scientific
evidence

Payments should be large enough to change behaviour but not so large as to


divert excessive effort onto incentivised aspects of care

The payment formula should encourage improvement at all levels up to an


agreed maximum, ensuring that low performing providers have an incentive
to improve

Unexpected consequences should be anticipated and continuously monitored

The effect on inequalities in delivery of care should be monitored

Conclusions
There is no perfect system of paying for medical care, nor one without potential
unintended consequences, and there is an argument for including some element of
pay for performance in medical care. However, the risks and unintended
consequences always need to be taken into account, as does the organisational
context into which incentives are introducedfor example, whether to reward the
individual, team, clinic, or groups of practices; how that is likely to affect the
behaviour of individual clinicians; and how it will lead to improved care. Research is
needed on more sophisticated ways of using indicators to improve quality of care
and to evaluate the introduction of pay for performance in different settings.12
Key messages

Pay for performance can be a useful part of wider programmes to improve


quality of care, though quality gains from financial incentives are generally
modest

Clinicians must be closely involved in the development of quality indicators


and pay-for-performance programmes

All incentive schemes (financial and non-financial) have the potential to


produce unexpected or perverse outcomes, and these should be anticipated
and continuously monitored

Footnotes

Analysis, doi: 10.1136/bmj.i4060

Editorial, doi: 10.1136/bmj.i4103

Competing interests: We have read and understood BMJ policy on declaration


of interests and declare that MR advised the BMA and NHS Employers on the
development of the Quality and Outcomes Framework from 2001 to 2003.

Contributors and sources: Both authors contributed to the development and


authorship of this article. MR is the guarantor.

This is an Open Access article distributed in accordance with the Creative Commons
Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to

distribute, remix, adapt, build upon this work non-commercially, and license their
derivative works on different terms, provided the original work is properly cited and
the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ .
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View Abstract
We recommend
1. Quality and Outcomes Framework: what have we learnt?
Martin Roland et al., The BMJ, 2016
2. After 12 years, where next for QOF?
Nicholas Steel et al., The BMJ, 2016
3. Effect of financial incentives on incentivised and non-incentivised clinical
activities: longitudinal analysis of data from the UK Quality and Outcomes
Framework.
Tim Doran et al., The BMJ, 2011
4. Incentives paid to GPs to improve healthcare have no effect on mortality,
study finds
Helen Mooney et al., The BMJ, 2016
5. GP incentive scheme has had little effect on health inequalities in England
Anne Gulland et al., The BMJ, 2011

1. Pay for Performance in Primary Care in England and California: Comparison of


Unintended Consequences
Ruth McDonald, PhD, et al., Medscape, 2009
2. Investigating the Relationship Between Quality of Primary Care and
Premature Mortality in England: A Spatial Whole Population Study
Evangelos Kontopantelis, et al., Medscape, 2015
3. Effect of a UK Pay-for-Performance Program on Ethnic Disparities in Diabetes
Outcomes
Riyadh Alshamsan, MSc, et al., Medscape, 2012
4. Pay-For-Performance: The MedPAC Perspective
Karen Milgate, et al., Medscape, 2006
5. A 2020 Vision of Patient-Centered Primary Care
Karen Davis, PhD, et al., Medscape, 2005

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TheRoleOfNursesIn ImprovingHospitalQuality AndEfficiency:Real-World Results


Nurseshavekeyrolestoplayashospitalscontinuetheirquestfor
higherqualityandbetterpatientsafety.
by Jack Needleman and Susan Hassmiller
ABSTRACT: Discussions of hospital quality, efficiency, and nursing care often taken
place
independentofoneanother.Activitiestoassuretheadequacyandperformanceofhospital
nursing, improve quality, and achieve effective control of hospital costs need to be
harmonized.Nursesarecriticaltothedeliveryofhighquality,efficientcare.LessonsfromMagnet program hospitals and hospitals
implementing front-line staffdriven performance improvement programs such as
Transforming Care at the Bedside illustrate how nurses and staff, supported by
leadership, can be actively involved in improving both the quality and
theefficiencyof hospitalcare.[Health Affairs28,no. 4(2009):w625
w633(publishedonline 12 June 2009; 10.1377/hlthaff.28.4.w625)] The u.s. hospital
system suffers from shortfalls in quality and
fromunsustainablegrowthincosts.The2000InstituteofMedicine(IOM) report
ToErrIsHuman documented major weaknesses in the quality in
hospitalandambulatorysettings;the2001follow-upreport,CrossingtheQualityChasm,
laidoutavisionofahealthsystemthatdeliveredsafe,reliable,timely,andpatientcentered
care.1 Improving the quality of Americas hospitals has become a highly visible
public and private enterprise, as payers, accreditors, and private organizations
attempt to set standards and encourage their achievement. At the same time, there
has been ongoing concern about controlling hospital costs, which have experienced
real growth of approximately 2 percent per year despite decades of efforts at
hospital payment reform and utilization control.2 Efforts by hospitals to control labor
costs have had major effects on nursesthe
largestcomponentofhospitallabor.Lowerratesofentryintothenurseworkforce
Quality&Efficiency
HEALTH AFFAIRS ~ Web Exclusive w625
DOI 10.1377/hlthaff.28.4.w625 2009 Project HOPEThe People-to-People Health
Foundation, Inc.
JackNeedleman(needlema@ucla.edu)isaprofessorintheDepartmentofHealthServices,
SchoolofPublic
Health,UniversityofCalifornia,LosAngeles.SusanHassmillerissenioradviserfornursinga
ttheRobertWood JohnsonFoundationinPrinceton,NewJersey.
on September 9, 2016 by HW TeamHealth Affairs by http://content.healthaffairs.org

At the same time, there has been ongoing concern about controlling hospital costs,
which have experienced real growth of approximately 2 percent per year despite
decades of efforts at hospital payment reform and utilization control. 2 Efforts by
hospitals to control labor costs have had major effects on nursesthe largest
component of hospital labor. Lower rates of entry into the nurse workforce in the
1990s, and the impact on long-term shortages of nurses, have been attributed in
part to the perceptions by potential nurses that the quality of work life as a nurse
was low.3
Discussions of hospital quality, cost control, and hospital nursing care have often
taken place independent of one another. These discussions need to be integrated,
and the goals of assuring the adequacy and performance of hospital nursing,
improving quality, and achieving effective cost control need to be harmonized. In
this paper we argue, first, that the staffing and organization of hospital nursing
affects both quality and cost; second, that nurses must be actively involved in
process improvement directed at both quality and efficiency; and third, that there
are emerging models of how such engagement can be obtained from both the
hospital-level leadership and the front-line staff.
Previous SectionNext Section
The Impact Of Nurses On Hospital Safety, Quality, And Costs
Safety and quality.
The 1996 IOM report Nursing Staff in Hospitals and Nursing Homes: Is It Adequate?
concluded that although nursing services are central to the provision of hospital
care, little empirical evidence is available to support the anecdotal and other
informal information that hospital quality of care is being adversely affected by
hospital restructuring and changes in [nurse] staffing patterns. 4
Since that report, and in part in response to it, the number of studies examining the
association of staffing and quality in hospitals has exploded. Major studies
demonstrating the association of nurse staffing and patient outcomes, including
lengths-of-stay, mortality, pressure ulcers, deep vein thromboses, and hospitalacquired pneumonia have been published in first-tier journals, and several major
literature reviews, syntheses, and meta-analyses have been published confirming
the association of nurse staffing with patient outcomes. 5 When the IOM revisited the
issue of nurse staffing and patient care in 2004, it concluded: Research is now
beginning to document what physicians, patients, other health care providers, and
nurses themselves have long known: how well we are cared for by nurses affects
our health, and sometimes can be a matter of life or death. 6
Research on these issues is continuing. Indeed, its scope has expanded through
programs such as the Robert Wood Johnson Foundation (RWJF) Interdisciplinary
Nursing Quality Research Initiative (INQRI), whose projects are examining how

specific processes of care, such as care coordination, medication administration, or


introduction of evidence-based protocols, are associated with nursing care and
patient outcomes.7
Despite this research, the nature of nurses work in hospitals is not well understood
by the public or policymakers. In a recent survey, 88 percent of the public agreed
that making sure there are enough nurses to monitor patient conditions, coordinate
care, and educate patients should be a part of efforts to improve quality, but focus
groups find that the public is confused about what nurses do, the kind of training
they receive, and what distinguishes them from nurse aides and other less trained
personnel.8 The public understands that nurses work is physically and emotionally
demanding but may view this work as delivering care as ordered and providing
physical and emotional comfort to patients and their families. Nurses do far more,
and the work entails both substantial intellectual and organizational competence.
Among the critical tasks carried out by nurses are (1) ongoing monitoring and
assessment of their patients and, as necessary, initiating interventions to address
complications or reduce risk; (2) coordinating care delivered by other providers; and
(3) educating patients and family members for discharge, which can reduce the risk
of posthospital complications and readmission.
Costs.
Much work has examined the association of nursing and quality; less has examined
nursings impact on costs. A number of studies have assessed whether there is a
business case for increasing nurse staffing in hospitalsthat is, whether simply
increasing staffing would pay for itself in reduced complications and lengths-of-stay. 9
One key finding of this work is that improving nurse staffing does not completely
pay for itself, although recent efforts to reduce hospital payment for poor quality
may change this conclusion.
These analyses also find that the biggest cost savings of increased staffing result
from reduced lengths-of-stay. Shorter stays reflect not just reductions in
complications that extend stays, but the ability of nurses to do their work and
coordinate the work of others in a timely and effective manner. They reflect nurses
ability to affect efficiency as well as quality.
A key limitation of these cross-sectional studies is that they do not consider how
changes in nursing organization, systems, or work environment might improve
outcomes or efficiency without increases in staffing. Other research studying
nurses work environments suggests that such improvements are possible.
For example, in 2005 Armine Kazanjian and colleagues found an association
between work environment and patient safety in nineteen of twenty-seven studies. 10
The theoretical and methodological sophistication of the research needs to be
strengthened before the mechanisms connecting nurse work environments to

patient outcomes can be fully understood, and this research is still evolving;
however, there is sufficient evidence to act. 11
Previous SectionNext Section
Hospital Nursing: Key Issues
Tapping nurses knowledge of the system.
Nurses develop substantial knowledge of the strengths and weaknesses of hospital
systems and how they fail. Their ability to create workarounds to broken or
dysfunctional systems is legendary in health care. 12 As hospitals focus on increasing
safety and reliability, patient-centeredness, and efficiency, nurses knowledge and
commitment to their patients and institutions needs to be effectively mobilized. 13 To
accomplish this, nurses perspectives must be represented at the highest levels of
hospital leadership and integrated into hospital decision making. In addition,
consistent with process-improvement research that identifies the active
involvement of front-line staff as a critical factor in making and sustaining change,
processes for engaging nurses and other front-line staff also need to be expanded.
Increasing the visibility and participation of nursing leadership within
hospitals: Magnet accreditation.
One impetus for hospitals to give increased voice to nursing and nursing leadership
has been the development and expansion of the Magnet accreditation program.
Magnet hospitals are those recognized by the American Nurses Credentialing Center
(ANCC) for recruiting and keeping nurses while providing high-quality care to
patients. The framework for the Magnet appraisal process consists of fourteen
characteristics, including (1) strong nursing representation in the organizational
committee structure; (2) nurse leadership that is part of the hospitals executive
leadership; (3) a functioning system of shared governance in nursing; (4)
empowerment of nurses at all levels of the hospital, with nurses able to effectively
influence system processes; and (5) collegial working relationships among
disciplines.14
There are now 305 Magnet hospitals and, according to the ANCC, more than 150
applicants seeking recognition. In 2004, U.S. News and World Report added Magnet
recognition as a factor in its hospital rankings, providing an additional incentive for
hospitals to seek Magnet status. Although every hospital working toward Magnet
recognition will not succeed, there is a great deal of evidence that many nursing
leaders have found portions of the criteria particularly helpful in their efforts to
improve their own settings.15 Other hospitals that will not seek Magnet status
might nonetheless be inspired by the program.
Magnet hospitals were initially identified based on their ability to attract and retain
nurses, but there has been interest in whether Magnet characteristics are also

associated with better quality and patient experiences. Although a 1994 study
found lower Medicare mortality in magnet hospitals, few studies have directly
examined magnet status and patient outcomes.16 Some studies that have looked at
Magnet status and nurses work environment find persistent differences between
Magnet and other hospitals.17 A growing number of studies find that Magnet
characteristics are associated with patient outcomes. 18 This is an area of continuing
research.
In the field, concerns have been raised about the cost of seeking Magnet status and
whether, as implemented, the accreditation process assures full implementation of
the Magnet vision. A new Magnet model of credentialing, yet to be evaluated, that
focuses on outcomes was introduced in 2008; it will weight more heavily for
organizations demonstrating improved and high-level patient satisfaction, nurse
satisfaction, and clinical outcomes measures. 19
The Magnet accreditation program is not the only vehicle for institutionalizing a
more prominent role for nurse leadership at hospitals. Other accreditation programs
should focus hospital leadership on the need to strengthen their nursing services.
Nurses also need to be recruited to hospital and system boards and to board and
leadership positions in national quality improvement organizations.
Previous SectionNext Section
Engaging Front-Line Staff In Improving Hospital Performance
Process improvement research consistently identifies engagement of front-line staff
as central to achieving and sustaining change. Developing models for achieving this
in health care has proved challenging. 20 One such model is Transforming Care at the
Bedside (TCAB).
Launched in 2003 with three hospitals, TCAB is a national program of the Robert
Wood Johnson Foundation (RWJF) and the Institute for Healthcare Improvement (IHI).
Its goal was to engage front-line staff and hospital leadership to make improvement
in four domains: improving the quality and safety of care; ensuring a high-quality
work environment to attract and retain nurses; improving the experience of care for
patients and their families; and improving the effectiveness of the entire care team.
In 2004, ten additional hospitals joined a two-year TCAB learning and innovation
collaborative. By 2006, additional participation criteria were in place, such as
partnering with schools of nursing, and ten of the thirteen hospitals opted to
continue in the collaborative for two more years.
Participants contributions.
Beyond the initial collaborative, the RWJF has expanded TCAB in several ways. It
funded a sixty-seven-hospital collaborative conducted by the American Organization
of Nurse Executives (AONE); it created a Web site that provides information to

hospitals seeking to implement TCAB independently; and it has incorporated TCAB


as a component of its Aligning Forces for Quality initiative. The IHI supports a TCAB
Learning and Innovation community with eighty-one hospitals in its IMPACT
Network; the program has spread to hospitals in four countries. Hospitals not
formally participating in any collaborative have implemented TCAB-like programs by
drawing on published descriptions and contact with TCAB hospitals. Hospitals
provided a variety of resources to facilitate the work of front-line staff, including
release time for nurses to conduct TCAB work, training in quality improvement
methods, travel to collaborative meetings, and participation by resource personnel
such as nurse educators, clinical nurse leaders, and quality improvement staff. 21
Evaluation of TCAB.
The RWJF-sponsored IHI and AONE initiatives are being evaluated. Details of the
evaluation design, methods, and findings are available elsewhere; here we mention
several findings from the IHI-led initiative that suggest that TCAB might serve as an
effective model for engaging front-line staff.22
One measure of the degree of engagement of staff is the volume of testing of
improvement ideas that was conducted. The thirteen pilot units tested 533
innovations over four yearsan average of 41 per unit. Testing was done across all
four TCAB domains. At the end of the pilot period, unit managers at the hospitals
reported that 71 percent had been sustained and were still in place. Many of the
innovations focused on improving efficiency or increasing the value of care.
Examples include adoption of new end-of-shift reporting methods and work to speed
and better coordinate the discharge process among physicians, nurses,
housekeeping, and other departments.
Impact.
Given the small number of hospitals and units involved and uneven data reporting
by units, the impact of this collaborative cannot yet be definitively assessed. The
limited available data suggest that it has had an impact on both quality and
efficiency; if this is confirmed in the larger AONE initiative, it would reinforce
recommendations to engage front-line staff in process improvement.
At the end of the four years, all unit managers in the pilot hospitals reported
improvement in all TCAB domains and attributed all or some of these improvements
to TCAB. Reporting of outcome measures was uneven, and many units
demonstrated no improvements on the measures tracked. However, between 2005
and 2007, falls with harm declined, on average, 45 percent, and the calling of code
blue (meaning need to resuscitate) for cardiac arrest declined 30 percent. Thirtyday readmissions declined 25 percent between 2006 and 2007. 23 Preliminary results
of a business-case analysis commissioned by the RWJF, using a limited set of
outcomes (costs of avoided falls and low levels of turnover and overtime), suggest
that the cost savings might have exceeded the costs of implementation. 24

At the beginning of TCAB, many hospital leaders were skeptical that the work of
testing and evaluating innovations could be widely spread. They expected that
some high-value innovations would be identified on pilot units and that these would
be widely disseminated, but that TCAB unit processes would not. During the first
year of the program, attitudes changed, and there was increased commitment to
spreading processes. Several things contributed to this change. The volume of tests
convinced some leaders that the innovation work needed to be decentralized to
reduce the burden on the units involved. Implementing some innovations required
coordination across units or departments, and this required engaging staff in those
units or departments in TCAB processes. Most significantly, there was a perception
that the culture on the pilot units had changed and that the changes were desirable
throughout the hospital. If the gains were to be sustained, hospitals believed, TCAB
could not be viewed as a project that was going to end or be replaced by the next
project, but had to be, in the words of a unit manager echoed among participating
hospitals, how we do our work.
At the end of the four years, pilot unit managers, unit managers from the first units
to which TCAB was spread, and hospitals chief nursing officers (CNOs) were
surveyed on their TCAB experiences and expectations. Based on those surveys,
TCAB appears to have been successful in engaging front-line staff. All but two unit
managers believed that TCAB made front-line staff more likely to initiate changes to
improve processes on the unit. Informally, waiting lists for nurses to work on TCAB
units were reported, at a time when the hospital nurse shortage was most acute.
Additionally, solid majorities of CNOs and pilot unit mangers believed that
cooperation with other departments had increased because of TCAB. Commitment
to maintaining and spreading TCAB processes to units well beyond the original units
and innovations in the participating hospitals as the formal collaborative ended was
high.
TCAB is not the only model for engaging front-line staff. Many organizations are
testing or implementing other models, including Kaiser Permanente, with its Nurse
Knowledge Exchange; VHA, with its Return to Care initiative; and the Department of
Veterans Affairs (VA), with an internal version of TCAB. 25
Previous SectionNext Section
Discussion And Policy Implications
Hospitals need to integrate their work to improve quality and patient-centeredness
and to increase the efficiency of care delivery. Nurses and other front-line staff must
play key roles. To benefit from the insight and input of these staff members,
hospitals will need to value their potential contributions, shifting their vision of
nursing from being a cost center to being a critical service line.
But simply changing leaderships view of front-line staff or changing hospital culture
to embrace a culture of improvement will be insufficient. One of the lessons we

draw from the TCAB experience is that improvement must be institutionalized in the
day-to-day work of the front-line staff, with adequate time and resources provided
and with front-line staff participating in decision making. The experience of Magnet
hospitals and of units engaged in TCAB provide concrete models of hospital- and
unit-level organizations and processes to accomplish this. Increasingly, there are
organized vehicles for promoting these models, including the Magnet accreditation
program, IHI and AONE plans to promote TCAB models in their ongoing work, and
the RWJFs ongoing support of this program at the state and national levels.
These specific activities need to be complemented with other changes that
encourage the engagement of front-line staff in process improvement. These should
include changes in reimbursement to increase value of effective, high-quality
nursing to hospitals, such as the recent decision by the Centers for Medicare and
Medicaid Services to not pay for never events. There is a growing literature on
nursing-sensitive payment.26
Looking upstream from the hospital, nursing education will have to change to
prepare new graduates to work in environments where they have responsibility for
process improvement. One model showing promise is that of Clinical Nurse Leaders,
an effort to produce nursing school graduates who can implement outcomes-based
practice and quality improvement strategies and create and manage unit-level
systems for delivering care.27
Getting nurses and other front-line staff actively involved in efforts to
simultaneously improve hospital quality and increase efficiency will require action
both within institutions and by those who measure their quality and pay for their
services. The models for accomplishing this are still evolving, but the broad outlines
for achieving such engagement are clear. The lessons from Magnet accreditation
and TCAB should be used as hospitals take full advantage of nurses knowledge and
commitment to their patients and institutionsto increase the safety and reliability,
patient-centeredness, and efficiency of care.
Previous SectionNext Section
Footnotes
Jack Needleman (needlema@ucla.edu) is a professor in the Department of
Health Services, School of Public Health, University of California, Los Angeles.
Susan Hassmiller is senior adviser for nursing at the Robert Wood Johnson
Foundation in Princeton, New Jersey.
Funding for the evaluation of Transforming Care at the Bedside was provided
by the Robert Wood Johnson Foundation. Evaluation coinvestigators Patricia
H. Parkerton of the University of California, Los Angeles, and Marjorie L.
Pearson of RAND contributed to the analysis reported here.

Previous Section

NOTES
1.
L.T. Kohn, J.M. Corrigan, and M.S. Donaldson, eds., To Err Is Human: Building a Safer
Health System (Washington: National Academies Press, 2000)
; and Institute of Medicine, Crossing the Quality Chasm: A New Health System for
the Twenty-first Century (Washington: National Academies Press, 2001).
2.
Authors calculations based on data from the Centers for Medicare and Medicaid
Services.
3.
P.I. Buerhaus, D.O Staiger, and D.I. Auerbach, The Future of the Nursing Workforce
in the United States: Data, Trends, and Implications (Boston: Jones and Bartlett
Publishers, 2009).
4.
G.S. Wunderlich et al., Nursing Staff in Hospitals and Nursing Homes: Is It
Adequate? (Washington: National Academies Press, 1996) (quote on page 9).
5.
See, for example, L.H. Aiken et al., Hospital Nurse Staffing and Patient Mortality,
Nurse Burnout, and Job Dissatisfaction, Journal of the American Medical Association
288, no. 16 (2002): 19871993
CrossRefMedline
; B.A. Mark et al., A Longitudinal Examination of Hospital Registered Nurse Staffing
and Quality of Care, Health Services Research 39, no. 2 (2004): 279300
CrossRefMedline
; J. Needleman et al., Nurse-Staffing Levels and the Quality of Care in Hospitals,
New England Journal of Medicine 346, no. 22 (2002): 17151722
CrossRefMedline

; J. Seago, Nurse Staffing, Models of Care Delivery, and Interventions, in Making


Health Care Safer: A Critical Analysis of Patient Safety Practices, ed. K.G. Shojania
et al. (Rockville, Md.: Agency for Healthcare Research and Quality, 2001)
; D. Heinz, Hospital Nurse Staffing and Patient Outcomes: A Review of Current
Literature, Dimensions of Critical Care Nursing 23, no. 1 (2004): 4450
CrossRefMedline
; and R.L. Kane et al., The Association of Registered Nurse Staffing Levels and
Patient Outcomes: Systematic Review and Meta-Analysis, Medical Care 45, no. 12
(2007): 11951204.
CrossRefMedline
6.
IOM, Keeping Patients Safe: Transforming the Work Environment of Nurses
(Washington: National Academies Press, 2004), 2.
7.
See the Interdisciplinary Nursing Quality Research Initiative home page,
http://www.inqri.org.
8.
G. Ferguson, National Post-Election Health Care Survey, November 59, 2008,
November 2008, http://www.championnursing.org/uploads/aarpprespe.pdf
(accessed 16 February 2009).
9.
J. Needleman et al., Nurse Staffing in Hospitals: Is There a Business Case for
Quality? Health Affairs 25, no. 1 (2006): 204211
Abstract/FREE Full Text
; J. Needleman, Is Whats Good for the Patient Good for the Hospital? Aligning
Incentives and the Business Case for Nursing, Policy, Politics, and Nursing Practice
9, no. 2 (2008): 8087
Abstract/FREE Full Text
; and T.M. Dall et al., The Economic Value of Professional Nursing, Medical Care
47, no. 1 (2009): 97104.
CrossRefMedline

10.
A. Kazanjian et al., Effect of the Hospital Nursing Environment on Patient Mortality:
A Systematic Review, Journal of Health Services Research and Policy 10, no. 2
(2005): 111117.
CrossRef
11.
For the analysis of research needs, see V.A. Lundmark, Magnet Environments for
Professional Nursing Practice, in Patient Safety and Quality: An Evidence-Based
Handbook for Nurses, ed. R.G. Hughes, Pub. no. 08-0043 (Rockville, Md.: AHRQ,
2008)
; and IOM, Keeping Patients Safe.
12.
P.R. Ebright et al., Understanding the Complexity of Registered Nurse Work in
Acute Care Settings, Journal of Nursing Administration 33, no. 12 (2003): 630638
CrossRefMedline
; and A.L. Tucker and S.J. Spear, Operational Failures and Interruptions in Hospital
Nursing, Health Services Research 41, no. 3, Part 1 (2006): 643662.
CrossRefMedline
13.
A.L. Tucker et al., Front-Line Staff Perspectives on Opportunities for Improving the
Safety and Efficiency of Hospital Work Systems, Health Services Research 43, no.
5, Part 2 (2008): 18071829.
CrossRefMedline
14.
American Nurses Credentialing Center, History of the Magnet Program,
http://www.nursecredentialing.org/Magnet/ProgramOverview/HistoryoftheMagnetPro
gram.aspx (accessed 15 May 2009).
15.
M.L. McClure, Magnet Hospitals: Insights and Issues, Nursing Administration
Quarterly 29, no. 3 (2005): 198201.
Medline

16.
L.H. Aiken, H.L. Smith, and E.T. Lake, Lower Medicare Mortality among a Set of
Hospitals Known for Good Nursing Care, Medical Care 32, no. 8 (1994): 771787.
CrossRefMedline
17.
S.R. Lacey et al., Nursing Support, Workload, and Intent to Stay in Magnet, MagnetAspiring, and Non-Magnet Hospitals, Journal of Nursing Administration 37, no. 4
(2007): 199205
CrossRefMedline
; B.T. Ulrich et al., Magnet Status and Registered Nurse Views of the Work
Environment and Nursing as a Career, Journal of Nursing Administration 37, no. 5
(2007): 212220
CrossRefMedline
; and V.V. Upenieks, Assessing Differences in Job Satisfaction of Nurses in Magnet
and Nonmagnet Hospitals, Journal of Nursing Administration 32, no. 11 (2002):
564576.
CrossRefMedline
18.
See A. Kazanjian et al., Effect of Hospital Nursing Environment
; and L.H. Aiken et al., Effects of Hospital Care Environment on Patient Mortality
and Nurse Outcomes, Journal of Nursing Administration 38, no. 5 (2008): 223229.
CrossRefMedline
19.
ANCC, Announcing a New Model for ANCCs Magnet Recognition Program,
http://www.nursecredentialing.org/MagnetNewsArchive2008/NewMagnetModel.aspx
(accessed 15 May 2009).
20.
T. Greenhalgh et al.. Diffusion of Innovations in Service Organizations: Systematic
Review and Recommendations, Milbank Quarterly 82, no. 4 (2004): 581629
CrossRefMedline

; and P.J. Pronovost et al. Creating High Reliability in Health Care Organizations,
Health Services Research 41, no. 4, Part 2 (2006): 15991617.
CrossRefMedline
21.
For information on TCAB, see Robert Wood Johnson Foundation, The Transforming
Care at the Bedside (TCAB) Toolkit, http://www.rwjf.org/pr/product.jsp?id=30051
(accessed 15 May 2009)
; and the Institute for Healthcare Improvement Web site, http://www.ihi.org. For
background on the collaborative model, see P. Rutherford et al., Transforming Care
at the Bedside How-to Guide: Engaging Front-Line Staff in Innovation and Quality
Improvement, 2008,
http://www.ihi.org/IHI/Topics/MedicalSurgicalCare/MedicalSurgicalCareGeneral/Tools/
TCABHowToGuideEngagingStaff.htm (accessed 15 May 2009); the Associates in
Process Improvement home page, http://www.apiweb.org/API_home_page.htm; and
the IDEO home page, http://www.ideo.com/to-go.
22.
J. Needleman et al., Impacts on the Learning Community Hospitals of Transforming
Care at the Bedside, American Journal of Nursing (forthcoming)
; P.H. Parkerton et al., Lessons from Nursing Leaders on Implementing Transforming
Care at the Bedside, American Journal of Nursing (forthcoming)
; and M.L. Pearson et al., Nurses as Agents of Hospital Change: Transforming Care
at the Bedside, American Journal of Nursing (forthcoming).
23.
Rates were based on units providing at least six months of data each year on falls,
codes, and readmissions. Ten of thirteen units were included in analysis of falls,
eleven in analysis of codes, and nine in analysis of readmissions. The falls reduction
is significant at the 0.05 level; the readmissions reduction, at the 0.001 level.
24.
Lynn Unruh, associate professor, University of Central Florida, personal
communication, 1 February 2009.
25.
For more about the Kaiser Permanente Nurse Knowledge Exchange, see
http://www.ideo.com/work/item/nurse-knowledge-exchange (accessed 25 May
2009); for VHA, Return to Care, see E. Ondash, Back to the Bedside with

Relationship-Based Care, http://www.nursezone.com/nursing-news-events/morefeatures/Back-to-the-Bedside-with-Relationship-Based-Care_20314.aspx (accessed


25 May 2009), and the Return to Care Education Series,
https://www.vha.com/portal/server.pt/gateway/PTARGS_0_2_6781_1052_505725_43/
http%3B/contentsrv.vha.com
%3B7087/publishedcontent/publish/vha_public/solutions/clinical_improvement/docs/
clinicaleducreturntocare_fs.pdf (accessed 25 May 2009); for the Veterans Health
Administration internal version of TCAB, see J. Clifford, The Bedside Care
Collaborative, http://abc.eznettools.net/nova/BedsideCareCollaborative.pdf
(accessed 25 May 2009).
26.
See, for example, L.Y. Unruh, S.B. Hassmiller, and S.C. Reinhard, The Importance
and Challenge of Paying for Quality Nursing Care, Policy, Politics, and Nursing
Practice 9, no. 2 (2008): 6872.
Abstract/FREE Full Text
27.
J.L. Harris and K. Ott, Building the Business Case for the Clinical Nurse Leader
Role, Nurse Leader 6, no. 4 (2008): 2528, 37
CrossRef
; R.O. Sherman, Factors Influencing Organizational Participation in the Clinical
Nurse Leader Project, Nursing Economic$ 26, no. 4 (2008): 236241
Medline
; and American Association of Colleges of Nursing, White Paper on the Education
and Role of the Clinical Nurse Leader, May 2007,
http://www.aacn.nche.edu/publications/whitepapers/clinicalnurseleader.htm
(accessed 25 May 2009).

Research
Strategies to prevent falls and fractures in hospitals and care homes and
effect of cognitive impairment: systematic review and meta-analyses
BMJ 2007; 334 doi: http://dx.doi.org/10.1136/bmj.39049.706493.55 (Published 11
January 2007) Cite this as: BMJ 2007;334:82

1. David Oliver, senior lecturer1,


2. James B Connelly, professor1,
3. Christina R Victor, professor1,
4. Fiona E Shaw, honorary clinical senior lecturer2,
5. Anne Whitehead, professor3,
6. Yasemin Genc, lecturer4,
7. Alessandra Vanoli, lecturer5,
8. Finbarr C Martin, consultant geriatrician6,
9. Margot A Gosney, professor1

Accepted 20 October 2006

Abstract
Objectives To evaluate the evidence for strategies to prevent falls or fractures in
residents in care homes and hospital inpatients and to investigate the effect of
dementia and cognitive impairment.
Design Systematic review and meta-analyses of studies grouped by intervention
and setting (hospital or care home). Meta-regression to investigate the effects of
dementia and of study quality and design.
Data sources Medline, CINAHL, Embase, PsychInfo, Cochrane Database, Clinical
Trials Register, and hand searching of references from reviews and guidelines to
January 2005.
Results 1207 references were identified, including 115 systematic reviews, expert
reviews, or guidelines. Of the 92 full papers inspected, 43 were included. Metaanalysis for multifaceted interventions in hospital (13 studies) showed a rate ratio of
0.82 (95% confidence interval 0.68 to 0.997) for falls but no significant effect on the

number of fallers or fractures. For hip protectors in care homes (11 studies) the rate
ratio for hip fractures was 0.67 (0.46 to 0.98), but there was no significant effect on
falls and not enough studies on fallers. For all other interventions (multifaceted
interventions in care homes; removal of physical restraints in either setting; fall
alarm devices in either setting; exercise in care homes; calcium/vitamin D in care
homes; changes in the physical environment in either setting; medication review in
hospital) meta-analysis was either unsuitable because of insufficient studies or
showed no significant effect on falls, fallers, or fractures, despite strongly positive
results in some individual studies. Meta-regression showed no significant
association between effect size and prevalence of dementia or cognitive
impairment.
Conclusion There is some evidence that multifaceted interventions in hospital
reduce the number of falls and that use of hip protectors in care homes prevents hip
fractures. There is insufficient evidence, however, for the effectiveness of other
single interventions in hospitals or care homes or multifaceted interventions in care
homes.

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