The KU School of Nursing is using data to advance team-based care
In 2007, a year after receiving Magnet designation from the American Nurses Association (ANA) for excellence in nursing care, the largest teaching hospital in Maine found that two of its critical care units had rates of pressure ulcers above the national average. Commonly known as bed sores, pressure ulcers typically develop when a bedridden patient is not turned frequently or is positioned incorrectly. In one of the hospital’s units, the rate of pressure ulcers hit 67 percent.
The Maine hospital’s chief nursing officer directed the nurse leaders to develop a series of interventions to lower the number of pressure ulcers in those units. In addition to reducing layers of bed linen under patients, developing an in-house manual for treating these ulcers, and stocking units with barrier sprays and ointments, the nurse leaders also started conducting “skin rounds,” during which they assessed each patient for pressure ulcers while also educating the bedside nurse about how best to prevent and treat them. The result? By the end of the year, the number of bed sores plummeted to nearly zero.
This hospital’s success shows how data can identify a problem in health care and enable a provider to make changes to solve it. It’s also one example of the kind of work that the University of Kansas School of Nursing has been doing for hospitals around the country for 20 years. The Maine hospital was one of 2,000 U.S. hospitals that submits its data to the National Database of Nursing Quality Indicators (NDNQI), which was developed by the KU School of Nursing and the Midwest Research Institute (MRI) for the ANA in 1998. When the MRI changed focus in 2001, the NDNQI, currently the only national nursing quality database in the United States and the largest one in the world, moved exclusively to the KU School of Nursing. There, researchers developed evidence-based quality measures and provided data analysis and reports to help individual hospitals across the country identify their problem areas and address them so they could meet the highest standards for nursing care.
That’s a big deal, both for the KU School of Nursing and for the nursing profession as a whole. And if Teri Kennedy, PhD, MSW, LCSW, has her way, this kind of results-changing, data-driven work led by the KU School of Nursing is going to get even bigger.
“We want to expand the expertise and reach of what we are doing across schools and across disciplines, and work interprofessionally to improve care,” she said.
FROM SILOS TO SYNERGIES
Kennedy, who joined the KU School of Nursing faculty in October 2018 as associate dean of interprofessional practice, education, policy and research (i-PEPR), was invested in June 2019 as the Ida Johnson Feaster Professor of Interprofessional Practice and Education. Before coming to KU, she spent over two decades at Arizona State University, where, in addition to directing the Office of Gerontological and Interprofessional Initiatives with the School of Social Work, she also served as faculty lead for interprofessional clinical partnerships with the Center for Advancing Interprofessional Practice, Education and Research with the Edson College of Nursing and Health Innovation.
Kennedy’s mission is to get health care professionals out of the silos in which they have traditionally both trained and worked. Typically, nurses, physicians, physical and occupational therapists, pharmacists, social workers and other health care professionals barely interacted until after graduation, and by then they had a right-hand, left-hand kind of problem: They didn’t necessarily understand the roles of the other people they were working with or how to work as a team.
“People often think that health care professionals are like a symphony and they know how to work together,” said Kennedy. “But there are human beings behind each of those health professions.”
Care delivered in silos can lead to poorer clinical outcomes for patients, increased medical errors, higher costs, stress and career dissatisfaction for the providers themselves, and costly turnover for health care organizations. High-functioning health care teams composed of professionals from different disciplines who communicate and navigate their values, roles and team process can lead to better outcomes clinically, financially, systemically and emotionally.
The concept of interprofessional practice and education has been around since the 1970s, but interest in it has ebbed and flowed. Interprofessional work has been hard to implement not only because of logistics, fear of change and general inertia, but also because of a lack of evidence that directly tied health care workers’ functioning as teams to better patient outcomes as well as to lower costs. Now, the pendulum has swung back again. “Interprofessional education and practice is famously called the new 40-year-old field,” said Kennedy. “We keep rediscovering it and realizing how important it is.”
In the early 2000s, the Institute of Medicine issued a trilogy of reports recognizing that interprofessional teams can best deliver safe and effective patient-centered care. In 2010, the passage of the Affordable Care Act tied reimbursement to quality measures, efficiency and cost savings, and rejuvenated interest in how interprofessional teams can achieve those aims. The same year, the World Health Organization published the “Framework for Action on Interprofessional Education and Collaborative Practice,” to help policymakers implement interprofessional education and practice into their own organizations.
In 2012, through a cooperative agreement with the Health Resources and Services Administration (HRSA), an agency of the U.S. Department of Health and Human Services, as well as support from private funders, the National Center for Interprofessional Practice and Education was established to accelerate teamwork and collaboration among health professionals and break down the silos within which health professionals learn and work. Located at the University of Minnesota, it serves as a national hub to provide health care institutions across the country with the leadership, evidence and resources to guide the use and implementation of interprofessional practice and education, while also fostering high-quality research that uses consistent, validated measurements and standards to assess the effectiveness of these interprofessional efforts.
CHANGING THE CULTURE
The University of Kansas Medical Center was an early adopter of interprofessional concepts. Since its founding in 2012, the Center for Interprofessional Practice, Education and Research (CIPER) has promoted collaboration between the schools and programs at the KU Medical Center and the campuses in Kansas City, Wichita and Salina, as well as the KU campus in Lawrence, in order to transform the quality of patient care through interprofessional team-based practice, research and education.
The obvious way to implement interprofessional practice is to train new health care professionals to work collaboratively from the get-go. All KU Medical Center students take the Foundations of Interprofessional Collaboration course to learn about each other’s roles and how to work as a team. They also have the opportunity to apply those skills by working at the Department of Family Medicine’s Interprofessional Teaching Clinic, where students from medicine, nursing, pharmacy, occupational and physical therapy, dietetics and social work provide team-based care for patients, as well as at the Geriatric Interprofessional Teaching Clinic at the Landon Center on Aging.
Students can also learn to work interprofessionally at primary care and safety net clinics around the state with whom CIPER has developed partnerships. Safety-net clinics serve high-need patients with health disparities who can especially benefit from team-based care. These clinics offer KU Medical Center faculty an opportunity to help current health professionals learn to work interprofessionally, which can be a challenging transition for health care workers used to practicing in a siloed environment. Once trained to provide interprofessional team-based care, these clinic teams are then able to serve as additional interprofessional training sites for students.
“I think students ‘get it’ quicker than we have,” observed Kristy Johnston, MSW, who co-directs CIPER with Kennedy. “They learn fast how communication between team members is vital when they practice, how anybody can be the leader in any given situation, and that it’s their responsibility to have each other’s backs. I think that’s big.”
Implementing interprofessional programs and initiatives is an enormous achievement, but the work doesn’t end there. Showing that they are effective is critical to their survival. That’s one reason data and analysis are so important.
“If we can’t prove that what we are doing works, the initiatives aren’t going to last,” Kennedy said.
One way for health care organizations to measure their performance and outcomes is through a framework known as the Triple Aim. Developed by the Institute for Healthcare Improvement in 2007, the Triple Aim set three goals: enhancing the experience of care, improving the health of populations and reducing per capita cost.
Because so many care providers suffer from burnout, there is now a Quadruple Aim; the fourth component is improving the experience of the provider. Health care is a stressful job; people’s lives depend on it. And when providers burn out, not only does patient care suffer, but providers sometimes leave professions that often already have shortages,. and turnover leads to higher costs.
The goals of the Quadruple Aim are widely recognized in the health care industry. The issue is that research demonstrating the impact of interprofessional team-based care on Quadruple Aim goals have not been designed well or conducted consistently. Hundreds of studies have measured quality of care and outcomes using these goals, but these studies do not use consistent, validated research instruments that result in comparable, reliable data, a problem recognized by the National Center for Interprofessional Practice and Education.
“The literature says we have not done a good job demonstrating the link between working interprofessionally as teams and the Quadruple Aim outcomes,” said Kennedy. “It’s not that there isn’t data, it’s that we are studying apples and oranges and sometimes pears and watermelons, and we are not using consistent tools.”
This is where Kennedy believes KU Medical Center can really make a difference. She is looking to the Center for Data Science (CDS), which grew out of the NDNQI, and the Center for Health Informatics (CHI) to help evaluate the connection between interprofessional teams and Quadruple Aim outcomes.
“The University of Kansas Medical Center is really poised to carry out this kind of work,” she said. “We’ve got amazing talent here, with expertise in both informatics and data science. The people in these two centers are nationally, and in some cases, internationally known.”
Kennedy’s goal is to foster the work they are already doing, while finding new ways for them to collaborate to advance interprofessional team science and improve care. Meanwhile, in 2016, the National Center for Interprofessional Practice began identifying and posting a list of validated measurement tools — e.g., surveys, rubrics, scales — to evaluate the impact of interprofessional programs and collaborative practice.
“We want to use these validated tools with health care data to demonstrate if what we are doing interprofessionally is actually improving the health of patients and populations, reducing costs and improving value, while also advancing workforce resilience and retention,” said Kennedy.
BETTER DATA, BETTER OUTCOMES
The CDS and CHI represent two sides of one coin. Informatics is primarily concerned with the systems and methods used to gather and manage data, while data science is more concerned with the analysis of it. Although interprofessional by nature, both centers were born and are housed in the KU School of Nursing.
The largest workforce in health care, nurses spend the most time at the bedside and have long been involved in recordkeeping and quality improvement. In the 1850s, Florence Nightingale started collecting data on the deaths of soldiers in British military hospitals with high mortality rates and proved that more men were dying of diseases caused by the hospital’s poor sanitary conditions than of battlefield injuries.
In the 1950s, Harriet Werley became the first nurse researcher at the Walter Reed Army Institute of Research and worked with IBM to identify the potential for computer applications to process health care data. That was the beginning of the shift from paper records to electronic ones. Today, especially as electronic health records have replaced paper charts, the volume of health data has exploded.
Nancy Dunton, Ph.D., FAAN and LaVerne Manos, DNP, RN-BC, FAMIA
Nancy Dunton, Ph.D., FAAN, directed the NDNQI from the time it was born in 1998 until the ANA sold it to Press Ganey Associates, a health care analytics company, in 2014. Three year later, the CDS, which Dunton directs, was founded to produce research out of healthcare data.
The CDS has two main focus areas: one area is “-omics,” which includes biological data from fields such as genomics, proteomics and metabolomics to help clinicians identify molecular characteristics of illness and enable providers to design individualized care for patients, a concept known as precision medicine. The other focus is health services research, which is Dunton’s area.
Although the CDS doesn’t collect NDNQI data and produce performance reports for individual hospitals any more, the CDS uses its data to publish analyses about the nursing workforce in general. In one such study from 2018, they compared rates of falls in urban versus rural hospitals and found that the geographic region matters, in addition to unit type and education and experience level of the nursing staff.
The CDS develops new outcomes measures for the NDNQI, as well as the federal Centers for Medicare and Medicaid Services. These include measures related to pain, depression and flu immunizations. One new survey component is a series of six questions to gauge how nurses perceive their relationships with other professionals, including such areas as respect, conflict management and understanding nurses’ knowledge, roles and skills. Nurses rated their relationships with social workers the highest, and with physicians the lowest. The data showed that the best interprofessional relationships were in ambulatory care. The worst were in the operating room and perioperative units —places where patients would especially want their team to work well together.
“The analysis we do and kinds of studies we do are about quality, the whole experience of care and nurses’ role in that, and now we are beginning to get information on RN interactions with other professionals, including physicians, therapists, social workers and pharmacists,” said Dunton. “We hope to continue that expansion.”
Devising systems to collect, organize and manage data is the purview of health informaticists.
“If a patient comes in with acute myocardial infarction, the system should show an order set including all the labs and tests that need to be ordered for that patient,” said LaVerne Manos, DNP, RN-BC, FAMIA, director of the Center for Health Informatics. “This is based on evidence of what the best treatment for that diagnosis is. Informatics puts all that together to make it easier to treat patients.”
This includes designing collection systems with standardized terminology that eliminates language that can mean different things to different health professionals. Without common language, the data end up in their own silos. It also involves designing systems that don’t facilitate human error, such as not labeling fields in all capital letters.
Health informatics is a growing interprofessional field. In addition to a certificate program, the KU Medical Center offers a master of science degree in health informatics. For the first time, health informatics programs will have their own separate accreditation process, and the KU program is expected to be among the first to be accredited. Manos, a site surveyor for the Commission on Accreditation for Health Informatics and Information Management Education, is one of experts writing the competencies for accreditation.
In 2015, Manos, now a member of the board of the International Network for the Science of Team Science, completed a quality improvement/quality assurance project, funded by HRSA, that showed the value of using informatics and telehealth to deliver interprofessional care. Manos and her collaborators developed an interprofessional care plan for patients in the pediatrics unit of The University of Kansas Hospital. They designed changes to the electronic health record system that enabled different health professionals to view each other’s documentation for patients. When the patients were discharged, they sent them home with an iPad so that the team could meet with them virtually before the patient’s first appointment with their primary care providers.
“Twice a pediatric patient averted re-admission because of the interprofessional collaborative team who continued to care for the patient and family from discharge until the first visit with the primary care provider,” remembered Manos.
TAKING TEAM SCIENCE TO THE NEXT LEVEL
Ellen Harper, DNP, RN-BC, MBA, FAAN, spent 24 years working in informatics at the Cerner Corporation, a health information technology company based in Kansas City, before coming to the KU School of Nursing as a clinical assistant professor in 2017. While she was at Cerner, she worked with well-known KU informaticians Judith Warren, Ph.D., RN, FAAN, FACMI, and Sandra Bergquist-Beringer, Ph.D., RN, CWCN, both now Emerita faculty, to create specifications to pull pressure ulcer data from electronic health records to measure quality.
“That’s how I got to know and respect KU,” said Harper. “I wanted to join the faculty here not just because I live in Kansas City, but because of the national reputation KU health informatics has.”
Working with nurses around the country, Harper has completed a pilot study with Amy Garcia, DNP, RN, CENP, director of the Office of Practice at the KU School of Nursing and a former colleague at Cerner, that used electronic data to study nursing care cost, quality, performance, effectiveness and outcomes in a pediatric hospital for patients experiencing pain.
“Today nurses are measured by bad things not happening: the patient didn’t fall, get an infection, etc. We want to measure the actions of the nurse that resulted in positive outcomes,” said Harper.
To measure the value of nursing care at the individual-nurse-to-patient level, they had to combine millions and millions of patient and nurse-specific data from multiple electronic systems — including electronic health records, human resource records and scheduling data -- and then use big data analysis.
“Nursing is the number one operational cost,” said Garcia. “So it’s easy to look to nursing to make cuts. Ellen and I wanted to look at outcomes as they related to staffing. How many hours of care did that patient get from that nurse? What level of experience and education does that nurse have? And did it make a difference in the outcome for that patient?”
Harper and Garcia are now working with Russ Waitman, Ph.D., director of medical informatics, Center for Medical Informatics and Enterprise Analytics at KU Medical Center, and Neena Sharma, PT, Ph.D., CMPT, associate professor, Department of Physical Therapy and Rehabilitation Science at the KU School of Health Professions, to do an even larger study in which they will partner with the University of Colorado and Columbia University to measure the value of interprofessional teams instead of just nursing for patients who have pain.
”Suppose an 80-year-old patient has surgery and then they have pain. The doctor orders meds for the patient, and the nurses and therapists use inventions like heat and reflexology,” said Harper. “All that data is sitting there. We want to pull it to determine the right mix of different care providers for this patient who is 80 years old and had that surgery. We want to find exactly the right set of interventions,” said Harper. “By identifying effective pain interventions, nonpharmacologic interventions as well as drugs, we can potentially even help address the opioid crisis.”
Kennedy notes that this kind of analysis can bring interprofessional team science to a new level. “Combining electronic health records and human resources records is something that isn’t being done everywhere; usually it’s just looking at EHRs,” she said. “The HR records give us additional information that can really help us home in on what’s going on with teams.”
As important as conducting and publishing research is, Kennedy said success in improving care by working interprofessionally also depends on changing the way people think about their work, about making interprofessional concepts and evaluation part of the DNA of everything they do.
Sarah Shrader, associate professor and director of interprofessional education at the KU School of Pharmacy, is someone who seems to embody that. Along with interprofessional colleagues, Shrader has conducted team training at the Family Medicine interprofessional teaching clinic. She and Kristy Johnston are now bringing that training to community-based clinics and hospitals around the state.
And she’s been measuring the impact of their work. Some clinical outcomes have already been measured at the Family Medicine interprofessional teaching clinic, where analysis of the electronic health records indicated that teams improved the management of diabetes and increased the screening for depression while maintaining high levels of patient satisfaction. Now co-directed by Laurel Witt, M.D., assistant professor, Department of Family Medicine, and Ashley Crowl, Pharm.D., clinical assistant professor, KU School of Pharmacy, the clinic continues to refine the interprofessional model of delivering care.
In the community clinics and hospitals, Shrader and her collaborators have evaluated the clinic’s “teamness” (team dynamics), at baseline and after the team training invention, by using a survey recommended by the National Center for Interprofessional Practice and Education and by interviewing clinicians. She says they have seen success in terms of these clinics learning to work interprofessionally. Gathering data to measure clinical outcomes for these community clinics is the next step.
Shrader said that this is the kind of work that could really benefit from the expertise of the CHI and CDS with mining and analyzing different types of data, especially data from multiple sources, to assess the nuances of the value of interprofessional teams.
“Team science definitely impacts care, but teasing out which factors make the difference gets a little messy,” said Shrader. “What is the right mix of providers for a specific population? And are there some populations that benefit more from team-based care than others? There are still so many questions left to be answered.”
She and Kennedy are collaborating to drill down further in the data and find additional measures to help find those answers, both for inpatient and ambulatory care.
“This is what we have the ability to do with our centers and team members, this is the promise of our data and expertise,” said Kennedy. “And ultimately it’s all about improving the care of human beings, in Kansas and beyond.”