IMPLEMENTING A RESEARCH FRAMEWORK - SCIENCE AND POLICY IMPLICATIONS: DEVELOPING A NATIONAL FOCUS IOM Workshop: Future Directions of Credentialing Research in Nursing Washington, DC September 3, 2014 Kenneth W. Kizer, MD, MPH Distinguished Professor, University of California, Davis, School of Medicine and Betty Irene Moore School of Nursing and Director, Institute for Population Health Improvement, UC Davis Health System
Question to Consider How does credentialing research in nursing gain a national focus? Or, said differently, when will credentialing in nursing come to be viewed as a national policy matter that demands and drives sound scientific research? 2
Background and Context As a matter of longstanding policy, health care in the USA is considered to be a market-based good that is largely managed by the private sector. In recent years it has become national policy that the quality of health care must improve and that health care delivery must become more integrated. The questions and issues regarding nurse credentialing are not dissimilar to past and current credentialing issues in other areas of health care. 3
As we go down the path towards nurse credentialing, we must not lose sight of the forest for the trees. 4
Background and Context Perhaps the central policy-related question and research issue is whether credentialing (whether individual, team and/or organizational) facilitates more integrated care that yields superior outcomes and quantifiable value that will be recognized in the health care market. And is nurse credentialing sufficiently standardized that payers will know what they are paying for? 5
Two Priority Research Areas The role of nurse credentialing in achieving integrated care The role of nurse credentialing in driving a culture of quality and excellence 6
Achieving Integrated Care New payment models driving the quest for integrated care What is integrated care? No standardized definition. The converse of fragmented care Kodner, et al (2002) - a coherent set of methods and models on the funding, administrative, organizational, service delivery and clinical levels designed to create connectivity, alignment and collaboration within and between the cure and care sectors. WHO (2008) the organization and management of health services so that people get the care they need, when they need it, in ways that are user-friendly; achieve the desired results and provide value for money Singer, et al (2010) - patient care that is coordinated across professionals, facilities, and support systems; continuous over time and between visits; tailored to the patients needs and preferences; and based on shared responsibility between patient and caregivers for optimizing health. 7
Integrated Care versus Integrated Delivery System Integrated care form versus function Integrated patient care and integrated delivery system are not synonymous Integrated delivery system (IDS) is a generic term for a range of organizational and governance structures having varying degrees of administrative, financial and/or clinical integration; there is no standardized definition of what constitutes IDS Integrated delivery systems do not necessarily produce integrated patient care e.g., VA early 1990s, DOD-MTFs No particular model of integrated care has been shown to be superior to others when certain core functionalities are present 8
Achieving Integrated Care Core Functionalities 1. A common vision of health care service delivery that is reflected in shared and widely understood clinical objectives and goals 2. Information management tools and other infrastructure to monitor, analyze and affect clinical processes and outcomes, including policies and procedures for coordinating care across conditions, providers, settings and time 3. Team-based care 4. Methods of accountability, including a performance management system that consistently measures and monitors clinical performance by use of standardized performance measures 5. Strong clinical leadership 6. Aligned interests across providers, including shared financial risks and rewards for clinical outcomes 7. A patient-centric and population health focus 9
How does nurse credentialing enable or support the core functionalities of integrated care or otherwise facilitate achieving integrated care? 10
Achieving Health Care Excellence What is a World-class Medical Facility? In 2005, Congress directed that the Walter Reed Army Medical Center and National Naval Medical Center be consolidated into a new Walter Reed National Military Medical Center and that a new community hospital be built at Fort Belvoir and that the two new facilities be designed and constructed to be world-class medical facilities, although provided no operational or physical specifications for what world-class should mean Out of concern that the new facilities were not being designed and constructed to be world-class, the National Defense Authorization Act for FY 2009, required an independent review of the design plans for the two new facilities 11
What is a World-class Medical Facility? World-class defined The review committee organized specifications into 18 categories within 6 domains Basic Infrastructure Leadership and Culture Processes of Care Performance Knowledge Management Community and Social Responsibility However, achieving a level of performance that would qualify health care to be world class requires more than just implementing the specifications; these things are necessary but not sufficient 12
What is a World-class Medical Facility? A substantial part of achieving health care excellence that would qualify as being world class derives from a facility's "invisible architecture"- that is, its values, culture, and emotional climate. This invisible architecture constitutes the soul of the organization and is what catalyzes the synergies between and among the physicians, nurses, and other staff and the facility's physical environment and technology that drives it to achieve world-class excellence. The elements of this invisible architecture are not well measured with currently available methods... 13
How does nurse credentialing promote or catalyze synergies between and among caregivers and the facility's physical environment and technology to achieve excellence? 14
Conclusion - Implementing a Research Agenda What can be learned about nurse credentialing from credentialing in other areas of health care? Normalization of team-based, integrated care suggests that research should give priority to the relationship between nurse credentialing and achieving integrated care and creating an invisible architecture that drives excellence in health care delivery. 15
kenneth.kizer@ucdmc.ucdavis.edu 16