The National Priorities Partnership (NPP) is an effort initiated by the National Quality Forum (NQF), in response to requests from the Department of Health and Human Services, to provide feedback into plans articulating a National Quality Strategy that will transform healthcare in America. Supported in part by the Robert Wood Johnson Foundation (RWJF), the NPP now involves 48 major national organizations that, collectively, influence all parts of the healthcare system. The American Nurses Association (ANA), represented by the ANA chief executive officer, is one of the 48 partners, as is the more recently formed Nursing Alliance for Quality Care.
Nurses have the opportunity to play an integral role in achieving the aims of the NPP: better care, affordable care, and healthy people in healthy communities. Recognizing this opportunity and the importance of the NPP, a group of leaders in the nursing community took the initiative to approach the NQF about the possibility of convening a workshop to develop an action plan for nurses to advance and accelerate adoption of the NPP agenda. As a result of their efforts, a 2-day invitational workshop, funded by the RWJF, was held in October 2009. Attendees included nurses representing a wide array of clinical specialties, as well as administration, research, and education, along with experts and stakeholders from across the healthcare system. Physicians and pharmacists joined nurses in the dialogue about nursing's contributions to NPP goals as well as officials representing the Joint Commission, the Center for Medicare & Medicaid Services (CMS), the Health Resource & Services Administration (HRSA), the National Institute of Nursing Research (NINR) and leaders in health services research, healthcare information technology (HIT), and healthcare delivery. This workshop was particularly noteworthy as the NQF chose to start with nursing to identify ways the various healthcare professions could help advance the goals of the NPP.
Member partners of the NPP identified a set of 6 priorities and goals, selected because of their potential to yield substantial improvements in health and healthcare.1 They are as follows:
- engaging patients and families to manage their health and make decisions about their care;
- improving the health of the population by fostering wellness and preventing disease, injury, and disability;
- improving the safety and reliability of America's healthcare system;
- ensuring patients receive care that is well coordinated within and across all healthcare organizations, settings, and levels of care;
- guaranteeing appropriate and compassionate care for patients with life-limiting illnesses; and
- eliminating overuse while ensuring that appropriate care is delivered.
To achieve these priorities, the partners also identified bold actions to bring about transformation, referred to as the "drivers of transformation."1 (p49) The 6 drivers are performance measurement, public reporting, payment systems, research and knowledge dissemination, professional development, and system capacity. System capacity pertains to investing in HIT, designing care processes based on best practices, delivering care with interdisciplinary teams especially for patients with chronic diseases, coordinating care, and developing performance measurement and improvement capabilities.1
The workshop was designed to achieve 3 goals. The first goal was to assess nursing's current and future contributions to the NPP agenda. Recognition of these contributions laid the groundwork for the other 2 goals-identifying opportunities for nursing to advance and accelerate the achievement of the NPP goals, and proposing recommendations that could be used by the nursing community as an action plan to advance the NPP agenda.2
Nursing and the NPP Priorities
A panel of 8 experts provided information to the attendees about current and possible future nursing engagement in each of the 6 NPP priorities. The complete summary of the workshop is available at www.ncnq.org. A glimpse of key ideas related to each of the priorities follows.
- Patient and Family Engagement goals necessitate changing provider education and incentives for engaging patients in their care. Provider education should be interdisciplinary and focused on the skills needed to assess patient beliefs and their readiness to participate in their care. Patients and families need evidence-based resources to help them access health information.
- Population Health goals pose many opportunities for nurses. Those opportunities will be constrained, however, until payment mechanisms are altered to recognize nonphysician providers. There is also a need to restore the public health infrastructure and develop, refine, and fund innovative care models.
- Safety goals were addressed by using the National Database of Nursing Quality Indicators and the California Nursing Outcomes Coalition databases as examples of registries that contain data to support performance measurement and policy decisions. Nursing's contributions to the NPP goals could be accelerated by advancing the use of nursing measures.
- Care Coordination is central to nurses' work; nurse care coordination and transitional care models have demonstrated the ability to reduce the use of health services and lower the costs of care. Priorities for action include advancing policies to pay for well-tested nursing transitional care models and developing and testing performance measures to reflect activities and outcomes related to nurse care coordination.
- Palliative and End-of-Life Care are areas where nurses have a long history of leadership. A key distinction was made-all end-of-life care is palliative, but not all palliative care occurs as life is ending; it may be delivered to improve quality of life while people are being treated for acute or chronic conditions that are not life threatening.
- Overuse of Health Services was viewed, in part, as a response to current payment mechanisms. Prevailing financial incentives contribute to overusing some sectors of the healthcare system, such as invasive procedures, and underusing others, such as educating patients to manage their health. For instance, nursing work associated with reducing hospitalizations in vulnerable populations, such as medication management in the home, is not reimbursed.
Nursing and the Transformational Drivers
The workshop also involved 2 panels-one related to the transformational drivers and the other related to information technology. In the first panel, a group of interdisciplinary experts looked specifically at the role of the transformational drivers in advancing nursing's contributions to the goals of the NPP. The panelists urged the nursing community to be both ambitious and realistic in their use of the drivers. They emphasized the importance of collaborating across nursing practice, education, and research; engaging frontline nurses in every practice setting; and aligning nursing's licensure and credentialing programs with the NPP goals to achieve maximal impact.
In the second panel, 3 nurses with expertise in HIT addressed the role of HIT in advancing the NPP goals and implications for nursing. They referred to HIT as the "steel thread" running through the 6 NPP goals because it can support evidence-based practice, measure quality for the purposes of public reporting, and be used to design work that allows for more efficiency and effectiveness. The panel members were clear in their belief that technology is not the end point, but a means to achieve improved patient care and quality. More nurses are needed to lead the development of a national HIT infrastructure and accelerate the adoption of technology that will improve healthcare without increasing the burden on nurses, and nurses need to be educated about how they can use HIT to its fullest potential.
Recommendations to Nursing From Stakeholder Groups
The workshop participants also heard from 2 panels of key stakeholders who offered their viewpoints about how nursing could advance and accelerate its contributions to the NPP goals. In the first panel, representatives from 4 federal agencies-the Centers for Disease Control and Prevention, CMS, HRSA, and the National Institutes of Health/NINR-emphasized the important role nurses play in the various NPP priorities. They agreed that nurses need to be involved in the design of HIT to ensure that measures are developed that reflect nursing's contribution to the NPP goals. Nursing's contribution to the NPP goals may be accelerated by translating and disseminating findings from nursing research into practice and policy changes.
The second stakeholder panel consisted of 7 people representing a diverse assortment of groups, united by their focus on improving healthcare. This panel included a staff nurse, consumer, pharmacist, physician, purchaser, chief nursing officer, and a healthcare executive. These speakers underscored that, for changes to succeed, they must be driven locally, understood by each level of the organization, and led by clinicians. They also emphasized the need for a standardized HIT platform to support patient care and measure key indicators. The nurse's role as ideal care coordinators was reinforced. Teamwork and collaboration were underscored as essential components of healthcare delivery, especially to guide the appropriate allocation of finite resources. Issues about reimbursement were raised, with particular consideration of funding for advanced practice nurses. Nurses could enhance their visibility to the purchaser community by demonstrating nursing's contribution to the value equation-quality in relation to cost. There was also an emphasis on making sure there were consistencies between how the NPP goals are envisioned and how they are experienced in the practice settings.
Action Steps for the Nurse Executive
The importance of involving frontline staff-clinicians-in transforming care was a theme throughout the workshop. Frontline nurses bear much of the responsibility for many of the transformational drivers, including collecting quality indicators required for performance measurement, using technology to support coordinated and safe care, and implementing evidence in practice. Nurse executives play a critical role in both recognizing the importance of these efforts and ensuring there is a robust infrastructure to support this work, making it more efficient and less time consuming for frontline staff. Nurse executives also have a responsibility to educate and engage staff nurses about the NPP goals so they are able to clearly articulate, champion, and make visible nursing's role to key stakeholder groups.
A number of cross-cutting strategies were recommended by workshop attendees to actualize nursing's contributions to the NPP. These strategies were common across all of the NPP priorities and transformational drivers; they all have relevance for the work of nurse executives. In addition to the strong recommendation to engage frontline staff in all aspects of NPP goals, the nursing community was urged to
- increase nursing's visibility and value to key stakeholder groups, especially consumers and purchasers;
- expand the set of nurse-sensitive measures and their inclusion in public reporting;
- achieve payment for effective nurse-led care delivery models consistent with NPP goals; and
- increase funding for research that links nurse interventions to outcomes for patients and healthcare systems.
Performance measurement was regarded as essential to increase nursing's visibility and value to key stakeholder groups along with being necessary for reforming payment mechanisms. The measurement set needs to be parsimonious, however, and the burden on frontline staff to document and report the measures needs to be reduced. Closely aligned with performance measurement was public reporting, another way to make nursing's contributions visible and achieve progress in payment reform. Likewise, nurse executives could help advocate for nurses to be under the same reimbursement structures as other providers.
Nurse executives have the opportunity to play an important role in developing partnerships involving researchers, educators, and clinicians to accelerate moving evidence into practice. There also are opportunities for nurse executives to take the lead in implementing and evaluating point-of-care technology that supports rapid dissemination of best practices, as well as capturing relevant performance measures that can yield a big return in improving practice and advance care quality.
Last, nurse executives are in an ideal position to advance efforts related to system capacity. Such efforts will require engaging frontline staff in the NPP goals and the larger nursing community in policy changes. Nurse executives also must become actively involved in nominating and appointing nurses with a strong command of the issues coupled with political savvy in key decision-making groups to influence policy change and payment reform.
The nursing discipline was given an extraordinary opportunity when the NQF chose nurses as the first group to identify ways the various professions could advance the goals of the NPP. Transforming the healthcare system will not be easy, but the NPP goals offer a way to focus efforts on areas most likely to yield substantial improvements in health and healthcare. Nurse executives have the opportunity to play a key role in realizing the NPP goals by making recommendations from the workshop into a reality.