System- and Unit-Level Care Quality Outcome Improvements After Integrating Clinical Nurse Leaders Into Frontline Care Delivery

Differences in inpatient performance of public general hospitals following implementation of a points-counting payment based on diagnosis-related group: a robust multiple interrupted time series study in Wenzhou, China

OBJECTIVES

This study measures the differences in inpatient performance after a points-counting payment policy based on diagnosis-related group (DRG) was implemented. The point value is dynamic; its change depends on the annual DRGs' cost settlements and points of the current year, which are calculated at the beginning of the following year.

DESIGN

A longitudinal study using a robust multiple interrupted time series model to evaluate service performance following policy implementation.

SETTING

Twenty-two public general hospitals (8 tertiary institutions and 14 secondary institutions) in Wenzhou, China.

INTERVENTION

The intervention was implemented in January 2020.

OUTCOME MEASURES

The indicators were case mix index (CMI), cost per hospitalisation (CPH), average length of stay (ALOS), cost efficiency index (CEI) and time efficiency index (TEI). The study employed the means of these indicators.

RESULTS

The impact of COVID-19, which reached Zhejiang Province at the end of January 2020, was temporary given rapid containment following strict control measures. After the intervention, except for the ALOS mean, the change-points for the other outcomes (p<0.05) in tertiary and secondary institutions were inconsistent. The CMI mean turned to uptrend in tertiary (p<0.01) and secondary (p<0.0001) institutions compared with before. Although the slope of the CPH mean did not change (p>0.05), the uptrend of the CEI mean in tertiary institutions alleviated (p<0.05) and further increased (p<0.05) in secondary institutions. The slopes of the ALOS and TEI mean in secondary institutions changed (p<0.05), but not in tertiary institutions (p>0.05).

CONCLUSIONS

This study showed a positive effect of the DRG policy in Wenzhou, even during COVID-19. The policy can motivate public general hospitals to improve their comprehensive capacity and mitigate discrepancies in treatment expenses efficiency for similar diseases. Policymakers are interested in whether the reform successfully motivates hospitals to strengthen their internal impetus and improve their performance, and this is supported by this study.

Predictors of Clinical Nurse Leader implementation success across a national sample of settings: A Bayesian multilevel modeling analysis

INTRODUCTION

The Clinical Nurse Leader (CNL) care model is a different way of organizing frontline nursing care delivery in contrast to the traditional "staff nurse" model and is increasingly being adopted by health systems across the United States and abroad. However, variability in implementation and outcomes has been noted across health settings.

AIM

A recently validated CNL Practice Model provides an explanatory pathway for CNL model integration into practice. The purpose of this study was to identify and compare patterns of empirical correspondence to the CNL Practice Model and predict their influence on implementation success.

METHODS

We conducted a secondary analysis of a 2015 national-level study with clinicians and administrators involved with CNL initiatives in their health system. A psychometrically validated CNL Practice Survey was used to collect data measuring the presence (0%-100%) of the five domains of the CNL Practice Model (organizational readiness, CNL structuring, CNL practices, outcomes, and value) and one measure of CNL implementation success. We modeled the complex hierarchical structure of the data using a Bayesian multilevel regression mixed modeling approach. A zero-one-inflated beta distribution, a mixture of Bernoulli distributions for the minimum and maximum responses and a beta distribution for the responses between the minimum and maximum, was used to fit success ratings in the model.

RESULTS

A total of 920 participants responded, 540 (59%) provided success scores. The model captured ratings skewed toward upper bound, while also adequately modeling data between the minimum and maximum values. The Bayesian model converged and gave estimates for all hierarchical parameters, which would likely have failed to converge in a pure maximum likelihood framework. The variability around success score across CNL Practice Model element ratings was greatest at the component level, 0.29 (0.18-0.48), compared to either the domain level, 0.16 (0.01-0.54), or the item level, 0.09 (0.01-0.17). The components most predictive of implementation success were (a) consensus CNL model can close gaps, (b) organization level implementation strategy, and (c) alignment of empirical CNL microsystem level structuring to the model's conceptualization.

CONCLUSIONS

Findings provide further empirical evidence to support the explanatory pathway proposed by the CNL Practice Model and identified specific organizational readiness and CNL workflow structures that are critical antecedents predictive of CNL practice manifestation and production of expected outcomes. Findings indicate actionable implementation evidence that can be successfully adopted across real-world healthcare settings to achieve safer and higher quality patient care.

CLINICAL RELEVANCE

CNL integrated care delivery is a frontline nursing care model that is being increasingly adopted by health systems across the United States and abroad. However, variability in CNL implementation and outcomes has been noted across health settings, limiting its evidence base. Findings of this study contribute a better understanding about the variability of CNL practice and outcomes found in the literature and contribute empirical and conceptual clarity about the relationships between modes of CNL implementation and successful adoption in healthcare settings.

Factors Influencing Implementation Success of the Clinical Nurse Leader Care Delivery Model: Findings From a National-Level Mixed-Methods Study

BACKGROUND

The clinical nurse leader (CNL) care model has existed since 2007. However, there is limited understanding how the model can best be implemented.

PURPOSE

A validated CNL Practice Survey measuring domains theorized to influence CNL implementation was used to examine the link between CNL domains and CNL implementation success.

METHODS

Mixed methods were used to analyze data from a nationwide 2015 survey administered to clinicians and administrators involved in CNL initiatives.

RESULTS

Of total respondents (n = 920), 543 (59%) provided success scores, with 349 (38%) providing comments. Respondents with negative comments gave significantly lower average CNL success scores. The majority of negative comments mapped onto Readiness and Structuring domains, providing details of barriers to CNL implementation success.

CONCLUSIONS

Findings provide information about structural domains that can be strategically targeted to better prepare settings for CNL implementation and success.

A study protocol to evaluate the implementation and effectiveness of the Clinical Nurse Leader Care Model in improving quality and safety outcomes

Aims

Patients are harmed or die every year because of unsafe, inappropriate or inadequate healthcare delivery. Registered Nurses are a recognized patient safety strategy. However, variability in research findings indicate the relationship is not as simple as “more nurses=better outcomes.” Hence, currently there exists no evidence‐based frontline nursing care model. One emerging model is the Clinical Nurse Leader care model.

Design

This Hybrid Type II Implementation‐Effectiveness study will evaluate the effect of the care model on standardized quality and safety outcomes and identify implementation characteristics that are sufficient and necessary to achieve outcomes.

Methods

This study leverages a natural experiment in 66 clinical care units in nine hospitals across five states in the United States that have implemented the Clinical Nurse Leader care model.

Results

Findings will elucidate Registered Nurse's mechanisms of action as organized into frontline models of care and link actions to improved care quality and safety.

Implementation of the Clinical Nurse Leader Role in the Veterans Health Administration

The Veterans Health Administration (VHA) led implementation of the Clinical Nurse Leader (CNL) role nationally with the goal to meet system needs for strong clinical leadership across all settings. After a decade of CNL role implementation, the VHA supported this evaluation to determine the current state, the successes, the challenges, and the fidelity to the original intent of the role. The team used mixed methods to evaluate the state of the CNL initiative. Ten evaluation activities were undertaken including a facility survey directed toward chief nurse executives at all VHA facilities, and a second survey directed at registered nurses who completed a CNL graduate program, were certified as a CNL, or were currently enrolled in a CNL graduate program. The evaluation results suggest the CNL initiative had not yet accomplished the stated goals to improve cost and financial outcomes, increase patient satisfaction, increase staff satisfaction and retention, improve quality and internal processes, and facilitate practice model transformation including evidence-based practice and collaborative, interdisciplinary practice across the system. Observed CNL practices within the VHA could serve as exemplars for developing a care delivery model that could achieve these goals and offer potential paths to move this role forward.

A clinical nurse leader competency framework: Concept mapping competencies across policy documents

To ensure Clinical Nurse Leaders (CNL) are prepared to function to the full scope of their master's level education, the American Association of Colleges of Nursing published a 2007 White Paper and a 2013 update articulating expected end-of-education and CNL practice competencies. The Commission on Nurse Certification published a CNL job analysis in 2016, which identified a core set of knowledge, skills, and abilities for entry-level practicing CNLs, as the basis for the CNL certification exam. While all share core themes, the language and organization of competencies differs across the three policy documents, resulting in potential ambiguity about expected CNL knowledge and practices, and how they differ from other nursing roles. This effort identified, analyzed and synthesized CNL education and practice concepts listed in each document to refine understanding about CNL competencies and harmonize concepts across documents. The product of this effort is a cohesive CNL competency framework that aligns across the education-to-practice trajectory. The CNL competency framework can be used to guide CNL curriculum and certification review, and may have use in implementing and evaluating CNL practice integration.