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Journal of Nursing Administration:
doi: 10.1097/NNA.0b013e31822a7191
Departments: Evidence and the Executive

County and State Quality Data to Inform Expanded Roles for Nursing's Future

Newhouse, Robin P. PhD, RN, NEA-BC

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Author Information

Author Affiliation: Associate Professor and Chair, Organizational Systems and Adult Health, School of Nursing, University of Maryland, Baltimore.

The author declares no conflict of interest.

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Correspondence: Dr Newhouse, School of Nursing, University of Maryland, 655 W Lombard St, Suite 316B, Baltimore, MD 21201(

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In this department, Dr Newhouse highlights hot topics in nursing outcomes, research, and evidence-based practice relevant to the nurse administrator. The goal is to discuss the practical implications for nurse leaders in diverse healthcare settings. Content includes evidence-based projects and decision making, locating measurement tools for quality improvement and safety projects, using outcome measures to evaluate quality, practice implications of administrative research, and exemplars of projects that demonstrate innovative approaches to organizational problems. In this article, the author describes sources to identify major issues in healthcare quality, nursing's role in addressing quality issues, and Web-based resources for county and state quality data to guide nurses' future engagement.

Two forces are aligning that compel our engagement in collaboration with other healthcare providers toward better healthcare. The first is a clear recognition of considerable gaps in healthcare quality.1 The second is the recent Institute of Medicine report, The Future of Nursing: Leading Change, Advancing Health,2 that maps opportunities and actions required for nursing to address these quality gaps. The status quo, with business as usual, is not an option. Nurse leaders are pivotal to ensuring nursing's essential and significant role in providing evidence-based high-quality healthcare.

Nursing needs to target efforts on problem prone processes, interventions, and outcomes important to the people we serve. One does not search long to identify troublesome deficits in care and sometimes harmful processes.

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2010 National Healthcare Quality and Disparities Report

The 2010 National Healthcare Quality and Disparities Report indicates that there are major opportunities for improvement.1 This quality and access gap is particularly relevant for minority and low-income groups. Disparities exist for specific services (ie, cancer screening and management of diabetes), people (ie, rural and inner-city), and locations (ie, central US states). Priority areas for improvement demonstrate differences in quality depending on race, ethnicity, and socioeconomic status. Three priority areas (population health, safety, and access) did not show improvement. For example, less than 20% of disparities have been reduced for blacks, American Indians, Alaska Natives, Hispanics, and poor people.1 In a second example, there was no improvement in 70% of 22 measures of access, with 40% demonstrating lower levels in comparison to baseline data.1

The opportunity to improve health is profound in terms of both quality and cost. If all states performed as well as the best state performers, significant health improvements could result. For example, 10 million children would receive at least 1 annual medical and dental preventive care visit, more than half-million young children would be up to date with 6 key vaccines, and 5.6 million more children would be insured.3 If strategies are implemented to the level of best performers and projected improvements occur, momentous gains in quality would be realized. Because of their close relationship with patients and systems of care, nursing is well placed to lead and partner in these improvements.

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The Future of Nursing: Leading Change, Advancing Health

The Future of Nursing: Leading Change, Advancing Health cites the need for nursing's engagement in innovation of healthcare systems, expansion of the scope of practice, and partnership with other professions to solve major healthcare problems.2 Practicing to the full extent of our education and training and partnerships with other professionals require that we clearly identify significant problems, interpret evidence, apply the evidence to practice, and evaluate results. Identifying significant problems is the first step.

Often, issues are identified in the clinical arena as problem-prone processes (ie, breach in aseptic technique) or adverse patient outcomes (ie, nosocomial infections). As we think about expanding nursing practice across settings and care transitions, publicly reported sources of county and state data can inform populations, settings, and potential strategies to promote population health.

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Examples of County and State-Level Quality Health Data

There are many sources of county- and state-level quality health data. Three examples of sources include County Health Rankings, Agency for Healthcare Research and Quality (AHRQ) State Snapshots, and The Dartmouth Atlas of Health Care. Table 1 includes the Web site for each example.

Table 1
Table 1
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County Health Rankings

County Health Rankings is a result of the Mobilizing Action Toward Community Health project, a collaboration between the Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute.4 Data are available for counties from all 50 US states.4 Overall county health can be compared against other counties as well as national benchmarks.

Summary reports, data, outcomes maps, and health factors maps are available for downloading. Data guides help to navigate the site and describe potential uses for the information provided. For example, instructions guide the viewer to look at the health outcomes ranks in measures and answer the question: How does your county rank, and how do your measures compare with other state and national benchmarks?

An interactive County Health Rankings model of population health frames the rankings that include factors that are amenable to improve health.5 In the framework, programs and policies are created and implemented that then affect modifiable health factors that then affect outcomes. Health outcomes include mortality and morbidity. Health factors include health behaviors (ie, diet and exercise), clinical care (access and quality), social and economic factors (ie, employment, income), family support, and physical environment quality.

Data from these rankings indicate that there are clear differences in unhealthy and healthy counties.6 Unhealthy counties have twice as many people in fair or poor health, lower high school graduation rates, twice as many children in poverty, fewer grocery stores or farmer's markets, and higher rates of unemployment.6

Data from the County Health Ranking can be used by nurse leaders to identify local health-related problems that can be improved through community partnerships. For example, by entering the county where the healthcare facility is located, a nurse leader can review how his/her county compares to others in the state in terms of multiple metrics including premature deaths, preventable hospitals stays, or other important health behaviors (ie, smoking) or health promotion indicators (ie, diabetes or mammography screening). Of 24 counties in Maryland, my county (Anne Arundel) ranks 13th in clinical care measures. For example, diabetic Medicare patients had a glycated hemoglobin (HbA1c) level 81% of the time compared with 89% in the national benchmark.6

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AHRQ State Snapshots

The AHRQ provides State Snapshots based on data from the National Quality Report.7 State Snapshots provide information about healthcare quality at the state level. Comparisons can be assessed between the state's prior reporting period and the current reporting period, as well as comparisons between a specific state and all others.

A state selection map is available to facilitate review of each state compared with other states and baseline data. Strengths and weaknesses aggregated at the state level allow comparisons to best performers. Performance measures include overall health quality, types of care (ie, acute or chronic), settings of care (ie, hospitals or nursing homes), and 5 clinical conditions (ie, diabetes and cancer). Details on the quality dimension, metric, state performance, most recent year data, aggregated all-state data, and regional and baseline year data are available.

Data from the AHRQ State Snapshots can be used by nurse leaders to compare health-related problems in their state with national benchmarks. For example, my state of Maryland is average in comparison to other states, with lower quality scores than reported in the prior report. Specific areas for improvement include our acute care measures for avoidable admissions for patients with diabetes and heart failure and recommended care for heart failure. The reported state rate for avoidable hospitalizations for uncomplicated diabetes is slightly higher than all states (18.4/100,000 compared with 14.3/100,000).7 Evaluation of the local healthcare processes can uncover opportunities leading to targeted action to decrease preventable readmissions and provide reliable, evidence-based care.

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The Dartmouth Atlas of Health Care

The Dartmouth Atlas of Health Care project provides information about hospitals and associated physicians as well as national, regional, and local markets. Data can be reviewed by searching hospital name, zip code, or state categories. Data can also be searched by topic. Examples of topics include care of chronic illness in the last 2 years of life, Medicare reimbursements, medical discharges, surgical procedures, hospital use, end-of-life care, and quality or effective care.8

Options are available to create customized reports, tables, and maps. Maps, graphs, and data can be downloaded to Excel or PowerPoint for presentations. These customized reports can be created by categories such as year, population, or race.

Data from the Dartmouth Atlas of Health Care can be used by nurse leaders to compare health-related problems in their local area with regional and national benchmarks. For example, national comparisons that can be made by state for diabetic Medicare patients who have had an HbA1c vary by state from a low value of 66.6% to a high value 91.4%.8 Nurse leaders can download a US map into PowerPoint, which provides a graphic display of these variations nationally for presentations.

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The worrisome gaps in healthcare quality can be improved with nursing's involvement and leadership. The opportunities for nursing to engage in new and innovative models of care are limitless, transcending a single point of care-extending to care transitions across the life span.

Nurses in all settings will focus on important healthcare improvements with other healthcare providers engaged in public health, acute, ambulatory, rehabilitation, and long-term care. County and state data could be used as a first step to identify important problems and compare local quality metrics to other states or counties. The data can then be used to evaluate organizational processes and outcomes to determine if there is an opportunity to improve the health of the population served (ie, unplanned readmission). A second example is using the data to partner with community organizations (ie, churches, synagogues, nonprofit clubs) to focus on a common quality problem (such as smoking cessation counseling, diabetes screening, or prenatal care) for the local community.

Nursing can be influential by focusing on significant, visible, important population healthcare problems. The 3 Web-based resources described can be used to identify and understand the nature of a significant health problem. Once understood, interventions can be developed, tested, and implemented to improve the quality of healthcare for the people we serve.

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1. Agency for Healthcare Research and Quality (AHRQ). AHRQ Highlights From the National Healthcare Quality and Disparities Reports. Available at Accessed April 30, 2011.

2. Institute of Medicine. Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine's The Future of Nursing: Leading Change, Advancing Health. 2010. Available at Accessed April 30, 2011.

3. How SKH, Kay Fryer AK, McCarthy D, Schoen C, Schor EL. The Commonwealth Fund State Scorecard on Child Health System Performance. 2011. Available at∼/media/Files/Publications/Fund%20Report/2011/Feb/Child%20Health%20Scorecard/1468_How_securing_a_healthy_future_state_scorecard_child_hlt_sys_performance_2011_web_final_v8.pdf. Accessed April 30, 2011.

4. Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute. County Health Rankings: about the project. Available at Accessed April 30, 2011.

5. Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute. County Health Rankings Model. 2010. Available at Accessed April 30, 2011.

6. Robert Wood Johnson Foundation. Annual health check-up highlights healthiest and least healthy counties in every state. March 30, 2011. Available at Accessed April 30, 2011.

7. Agency for Healthcare Research and Quality. 2009 State Snapshots. Available at Updated May 3, 2010. Accessed April 30, 2011.

8. The Trustees of Dartmouth College. The Dartmouth Atlas of Health Care. 2011. Available at Accessed April 30, 2011.

© 2011 Lippincott Williams & Wilkins, Inc.