AACN Advanced Critical Care Volume 26, Number 1, pp. 43-49 © 2015 AACN
Using a Scorecard to Demonstrate Clinical Nurse Specialists’ Contributions Stacy Jepsen, MS, APRN, ACNS-BC, CCRN
ABSTRACT Clinical nurse specialists (CNSs) have the expertise to influence change at the patient, nurse, and system levels. They are clinical experts who understand the challenges of the current health care environment: decreasing costs, ensuring high-quality care, and achieving outcomes. Evidence has demonstrated CNSs’ influence on improving patient outcomes. Although CNSs often lead the
work, they can be invisible when the outcomes are presented. A scorecard to display this work could be invaluable to the CNS role, as it would bring transparency to the evidencebased work done. This article describes the development of a CNS scorecard in a 627-bed tertiary hospital. Keywords: clinical nurse specialist, outcomes, quality care, scorecard
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nurse (APRN) roles, including leadership and change adaptation. In 1996, the American Association of Colleges of Nursing2 defined the components required in the curriculum of these graduate-level programs. Despite pioneering the APRN role, CNSs have struggled to articulate their role. The National Association of Clinical Nurse Specialists (NACNS) was formed in 19953 and clarified CNS practice and its contribution to patient care and health care at large. The NACNS assisted in protecting the CNS as a unique role after proposals had been made to combine the CNS and CNP roles, because of their similarities and the lack of understanding around the niche each serves in the health care scene. The formation of the NACNS coincided
he 21st century has brought increasing pressures for accountability in health care, from not only patients and families but also payer mechanisms, such as the Centers for Medicare & Medicaid Services and private insurance companies. Changing population demographics, coupled with chronic illness, have resulted in increased demands for resources and access to providers. Many organizations have created comprehensive performance measures, in forms of scorecards and dashboards, to assist in their strategic management processes to meet these health care pressures. Strategies must be developed to support improving quality and reducing costs, all while improving patient outcomes, and the role of the clinical nurse specialist (CNS) is integral in this work. The CNS role was the first nursing specialty to require graduate-level preparation, followed by the certified nurse midwife, certified registered nurse anesthetist, and certified nurse practitioner (CNP).1 Multiple characteristics are common to these 4 advanced practice registered
Stacy Jepsen is Clinical Nurse Specialist, Medical/Surgical/Neuroscience Critical Care, Abbott Northwestern Hospital, 800 East 28th Street, Minneapolis, MN 55407 ([email protected]). The author declares no conflicts of interest. DOI: 10.1097/NCI.0000000000000066
43 Copyright © 2015 American Association of Critical-Care Nurses. Unauthorized reproduction of this article is prohibited.
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adults with cognitive impairment.8 Transitions of care are an essential part of health care reform to reduce hospital length of stay and readmissions. Clinical nurse specialist practice has been shown to influence patient satisfaction, hospital length of stay, hospital costs, readmissions, and patient morbidity and complications, which are high priorities in health care today.4,5,7,9 A 2011 systematic review7 revealed that patients who underwent coronary bypass surgery, radical prostatectomy, or total knee replacement and those receiving end-of-life care had the same or shorter lengths of stay when cared for by a group that included a CNS. Moderate to high levels of evidence also demonstrated lower overall cost of care and complication rates when CNSs were involved in the care.7 This evidence supports the integral role CNSs play in achieving the triple aim: improved patient outcomes, enhanced population health, and reduced health care cost.10 Clinical nurse specialists have played a central role in transforming the health care system to create high-quality, valuable care for patients. This CNS work must continue to be exposed through publishing and transparency of work within organizations. State regulations defining the scope of practice of APRNs vary widely. One of the primary recommendations by the Institute of Medicine’s11 The Future of Nursing report was to ensure that nurses can practice to the full extent of their education and training. Although some states have embraced this recommendation and evolved with health care reform, allowing certain APRNs to practice without a collaborative physician agreement, the bylaws within health care organizations often still limit APRN practice. The Affordable Care Act12 and decreased reimbursement from private and governmental payers, along with a movement toward valuebased purchasing and pay for performance while still in a fee-for-service environment, have put extreme pressure on health care. These changes have been reflected in the number of large hospital systems conducting layoffs to improve operations.13 To achieve health care reform, we must continue the pursuit of achieving the triple aim.10
with the growth of physician specialties, resulting in a need for primary care providers, moving some CNSs into what was once a CNP role.4 Some CNS positions were eliminated or responsibilities moved from clinical to operational at this time as a result of measures taken by hospitals to cut costs.1 The NACNS has successfully promoted the unique practice of CNSs, with approximately 72 000 CNSs nationally in 2013.5 The CNS practice encompasses core competencies including, but not limited to, leadership, collaboration, consultation, and clinical expertise.3 Clinical nurse specialists use these competencies across a broad field of influence, including the patient, nurse, and organization levels. Although specialized clinical practice in patient care has been the foundation of CNS practice, CNSs’ influence at the organizational or system level is what allows them to be prominent leaders in today’s complex health care system. The system leadership core competency states that CNSs have the capacity to “manage change and empower others to influence clinical practice and political processes both within and across systems.”6(p21) However, CNSs must demonstrate their contribution within the health care landscape, from senior leadership in acute care settings to policy makers at the state and national levels. Displaying CNSs’ ability to influence change that improves quality costeffective patient outcomes must be done not only by publishing outcomes but also by bringing transparency to CNSs’ work within organizations. A scorecard specific to CNSs’ work is one way this transparency can be attained. APRN/CNS Contribution Advanced practice nurses, including CNSs, are important providers in health care systems. Studies have demonstrated the positive effects of these roles on patient outcomes. In 2011, a systematic review7 of published literature between 1990 and 2009 was conducted, comparing patient care outcomes delivered by APRNs with other providers. The findings showed that care provided by CNPs and certified nurse midwives in collaboration with physicians resulted in similar or possibly better patient outcomes in certain patient populations than care provided by physicians alone.7 In a study on care transitions, APRNs’ “advanced clinical judgment” and ability to “establish mutually trusting relationships” with patients and their caregivers were shown to lead to successful transitions to home for older
Scorecards Health care organizations often use scorecards to track quality improvement and drive performance excellence.14–18 A scorecard is a tabular 44
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display containing performance measures and their goals, along with visual indicators demonstrating how each measure is performing in a single view.14 Each performance measure shows its current value, goal, and a visual illustration of the status.19 Colors can be used to illustrate the status of the measure: green for meeting the goal, yellow for trending toward the goal, and red for measures below the set goal. A scorecard often contains columns over time that allow trends to be seen. Other columns can be added to reflect operational leads and organizational goals, which allow each measure to link to a contributing person(s) and overarching organizational strategic goal. The terms scorecard and dashboard often are used interchangeably, but dashboards differ from scorecards, as they often have interactive filters allowing for further breakdown in data sets.19 In addition, scorecards should not be confused with a “balanced scorecard,” which is a strategic planning tool that includes finance measures along with the operational measures, such as customer satisfaction, internal process, and organizational growth.18 In the search of the evidence, no information was found on scorecard development and use specific to APRN practice and contribution to care. However, articles were available on scorecards and dashboards specific to nursing services, nurse managers, and nursing-related metrics. The use of scorecards to communicate performance metrics is rapidly growing within health care.
care and to safeguard the provision of quality care.”5(p1) However, CNSs often are not present when the results, both operational and financial, are presented to senior leadership. The CNS group at Abbott Northwestern Hospital, a 627-bed, Magnet-certified tertiary hospital and part of the Allina Health system, often found that they were not included in the presentation of results to senior leadership. The group consisted of both unit-based and population-based CNSs (Table 1), with most reporting to directors of nursing. A monthly meeting allowed them to share and collaborate on work and projects and permitted the spread of Table 1: Clinical Nurse Specialist Team at Abbott Northwestern Hospital
CNS Work Transparency Clinical nurse specialists have a pivotal role in leading organizational quality improvement. They understand the current health care environment of decreasing costs, along with ensuring quality and outcomes. One of the 3 primary areas of influence for CNSs is at the organizational level. Clinical nurse specialists influence the transitions in patient care from admission through discharge, assisting in achieving optimal outcomes and minimizing readmission risk. Clinical nurse specialists often lead the development of novel interprofessional patient care initiatives that address the full continuum of care. Research has demonstrated health care system cost reductions through CNS-led evidence-based quality improvement initiatives.5 A white paper released by the NACNS in 2013 stated, “Clinical nurse specialists are uniquely prepared with advanced nursing education to meet the increased demand for health
CNS Specialty
Population/Unit(s) Supported
Critical care
Two 16-bed cardiovascular intensive care units and support of the extracorporeal membrane oxygenation program
Critical care
One 30-bed medical, surgical, and neurological intensive care unit and support of the neuroscience critical care program
Medical/ surgical
4 units with 147 total beds
Neuroscience/ spine
2 units with 78 total beds and support of the epilepsy, stroke, and spine programs
Women care
3 units with 68 total beds, newborn nursery, and maternal assessment center
Telemetry
3 units with 96 total beds and the clinical monitoring department
Diabetes
Provides care to the diabetic population throughout hospital
Brain tumor
Provides care to patients with brain tumors throughout the hospital and a clinic
Research
Provides consultation to staff nurses throughout hospital on conducting evidence-based practice and research projects
Palliative care
Provides care to patients with palliative care needs throughout hospital
Pain
Provides care to patients with pain management needs throughout hospital
Abbreviation: CNS, clinical nurse specialist.
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improvements across care areas. However, keeping abreast of the primary work of each CNS was challenging, which often led to duplication of efforts. A member of the senior leadership team was invited quarterly to the CNS group meeting for discussion and presentation of work. However, a succinct overview of the CNSs’ work and how that work was tied to hospital and nursing strategic priorities was missing in these meetings. Because Abbott Northwestern Hospital used scorecards throughout the hospital, the CNS group had a vision of what a scorecard pertaining to their key work could resemble.
To keep the scorecard to 1 page, each CNS chose 1 to 2 key measures related to his or her priority work. A goal and benchmark were determined for each measure. The data for many of the measures were already being captured and used in other scorecards maintained by the quality specialists. The CNS(s) leading the work was assigned to each measure. Measures were categorized within the scorecard by the nursing and organization’s strategic goal with which they were aligned (Table 3). The scorecard layout allowed month-to-month data to be populated for each measure, as well as the previous year’s baseline, if present, and any goals set for the current year (see Figure 1).
Scorecard Development The CNS group put in motion the development of a scorecard specific to their priority work, which required key stakeholder support, such as senior leadership and quality specialists. Senior leadership’s support was critical to allow support services, like the quality specialists, to dedicate time to the development and maintenance of the scorecard. Collaboration with a quality specialist was important in the development of the scorecard. The CNSs at Abbott Northwestern Hospital function as clinical experts in evidence-based nursing practice within a specialty area and often lead the quality initiatives, whereas the quality specialists play a supportive role and are instrumental to the data and measurements of success in hospital-wide quality initiatives. To gain senior leadership buy-in, the group sent a communication requesting the support of a CNS scorecard to the vice president of Medical Affairs and director of Patient Safety and Quality, listing the reasons for development of the scorecard (Table 2).
Scorecard Development: Learning and Next Steps Valuable learning occurred during the development of the scorecard, including the importance of tying a team approach to the work represented in the scorecard. Although the scorecard was specific to CNSs, the work entailed a team of interprofessional members to accomplish the goals. We chose to list a collaborative partner, which is either a nursing operational leader, that is, a leader in a director position, or physician lead, next to the CNS lead for each measure. These collaborative partners are key stakeholders leading the work with the CNS(s). We then discussed the importance of speaking to the collaborative partnerships and team work when sharing the scorecard with others. Collaboration is one of the core competencies of CNSs, which contributes to their ability to influence others through “authentic engagement and constructive problem solving.”6(p21) Conveying transparency in the process measures monitored and strategies that assisted in changing behaviors to adopt the best practices in care delivery also was vital. For example, the institution of skin rounds in the intensive care units was discussed in relation to the pressure ulcer measure. Skin rounds include the unit CNS, wound nurse, and bedside nurse assessing the patients’ skin together and are integral in reducing pressure ulcers in intensive care units. Another example of strategies used to change behaviors was hypoglycemia huddles. When a patient has a hypoglycemic event, the bedside nurse, unit charge nurse, and diabetes CNS (when available), along with other key team members, conduct a huddle. Discussion within these huddles helps determine the contributing factors to the hypoglycemic event, identify preventative
Table 2: Reasons for a Clinical Nurse Specialist Scorecard Ability to display performance and quality improvement initiatives that affect outcomes from a hospital-wide perspective Clearly identifies and connects the CNS-focused work to strategic goals of the organization Optimizes CNS resource allocation and reduces duplication of work Communication tool displaying CNS focus areas and associated outcomes Provides shared mental model of CNS work on patient outcomes and quality initiative across hospital continuums Abbreviation: CNS, clinical nurse specialist.
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Table 3: Clinical Nurse Specialist Scorecard Details Measure Hand hygiene
Nursing Strategic Goal
Organization Strategic Goal
Data Element(s)
Clinical competence
Advance safety culture
% compliance
Pressure ulcers
Clinical competence
Advance safety culture
# reportable
Elective induction of labor < 39 wk
Clinical competence
Advance safety culture
%/numerator
Obstetrical hemorrhage with and without transfusion
Clinical competence
Advance safety culture
%/numerator
Hypoglycemia
Clinical competence
Advance safety culture
# of patients/rate
Alarm fatigue
Clinical competence
Advance safety culture
Average ECG alarms per patient/per day
Ketamine use in spine surgery
Clinical competence
Advance safety culture
# of patients/length of stay
Readmission from skilled nursing facility
Coordination of care
Foster stewardship
Actual to expected ratio
Delirium (ICU)
Coordination of care
Foster stewardship
# of patients diagnosed/ICU length of stay
Multidisciplinary rounds program (medical/surgical)
Coordination of care
Foster stewardship
% units/length of stay
Spine surgeries
Coordination of care
Foster stewardship
Volume/length of stay
Pain patient experience score
Patient-centered care
Patient experience
Pain composite score/results of pain questions
Nursing communication patient experience
Patient-centered care
Patient experience
Communication composite score/results of nursing communication questions
Abbreviations: ECG, electrocardiograph; ICU, intensive care unit. Avg indicates average; CNS, clinical nurse specialist; CV BT, cardiovascular breakthrough committee; DRG, diagnosis related group; ECG, electrocardiograph; Gen BT, general breakthrough committee; H4100, cardiovascular surgical intensive care unit; H4200, cardiovascular medical intensive care unit; ICU, intensive care unit; LOS, length of stay; PB2000, medical/surgical/neurological intensive care unit; Pt, patient; PVSR’s, patient visitor safety reports; SNF, skilled nursing facility.
strategies for that patient, and provide learning opportunities for all involved around hypoglycemia prevention. Discussing these strategies when the scorecard is presented assists in highlighting the CNSs’ contribution to outcomes. The development of the CNS scorecard took significant commitment and determination, as each CNS was involved in many other competing initiatives. One CNS drove most of the scorecard creation, which helped keep it at the forefront of the monthly meetings until its completion, along with ongoing maintenance of the scorecard. The discussions around how best to present the work and who to present it too also occurred at the CNS monthly meetings. Many of the measures on the scorecard had substantial financial savings associated with them. Whether the savings were through prevention of hospital-associated events or a reduction in length of stay, the financial impact of the work was significant. However, identifying the
cost avoidance for individual measures was challenging and therefore not displayed on the scorecard. These estimated savings are discussed during scorecard presentations, and work is continuing on how to best display the financial impact on the scorecard itself. Reporting Structure Review of the scorecard occurs on a quarterly basis by the CNS group, and each year the measures are reviewed to ensure that they represent priority work. Each CNS shares the scorecard with his or her director or direct supervisor to ensure transparency across the senior leadership team. The CNS scorecard is now a standard report to the senior management team and Patient Care Executive Committee. Discussions during these presentations include the specific CNS work that contributed to the outcomes displayed on the scorecard, from process measures tracked to key collaborative partnerships 47
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Figure 1. Example of a portion of the clinical nurse specialist scorecard. Avg indicates average; CNS, clinical nurse specialist; CV BT, cardiovascular breakthrough committee; DRG, diagnosis related group; ECG, electrocardiograph; Gen BT, general breakthrough committee; H4100, cardiovascular surgical intensive care unit; H4200, cardiovascular medical intensive care unit; ICU, intensive care unit; LOS, length of stay; PB2000, medical/surgical/neurological intensive care unit; Pt, patient; PVSR’s, patient visitor safety reports; SNF, skilled nursing facility.
group. This awareness assists in the spread of work, which is often challenging in large organizations. Evidence has demonstrated the CNS role’s influence on improving patient outcomes with associated decreases in health care costs. Bringing transparency to this work within organizations is critical to the role of the CNS and can assist in increasing the use of the CNS throughout the health care system.
that channeled success. The value of the CNS is becoming more transparent as evidenced in a senior management team meeting in which the chief nursing officer stated, “let the minutes show the CNSs are worth their weight in gold.” The vice president of Medical Affairs then followed that with “let the minutes reflect I second that.” Conclusion The goal in developing the scorecard was to demonstrate CNSs’ contributions to patient, nursing, and organizational outcomes. The scorecard brings a shared mental model of the priority work being done and assists in prioritization of work by each CNS in the
Acknowledgments Special thanks to Linda Larson, BSN, quality specialist, for scorecard creation and maintenance and Sue Sendelbach, PhD, RN, CCNS, for manuscript review and author mentorship. 48
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10. Institute for Healthcare Improvement. IHI triple aim initiative. http://www.ihi.org/Engage/Initiatives/TripleAim/ pages/default.aspx. Accessed August 20, 2014. 11. Institute of Medicine of The National Academies. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: The National Academies Press; 2011. 12. Medicaid.gov. Keeping America Healthy. Affordable Care Act. http://www.medicaid.gov/affordablecareact/ affordable-care-act.html. Accessed September 9, 2014. 13. Becker’s Hospital Review. 31 hospital, health system layoffs affecting 100+ employees in 2014. http://www .beckershospitalreview.com/leadership-management/ 31-hospital-health-system-layoffs-affecting-10 0employees-in-2014.html. Accessed September 8, 2014. 14. Jeffs L, Merkley J, Richardson S, Eli J, McAllister M. Using a nursing balanced score card approach to measure and optimize nursing performance. Nurs Res. 2011;24(1):47–58. 15. Schalm C. Implementing a balanced scorecard as a strategic management tool in a long-term care organization. Health Serv Res Pol. 2008;13(1):8–14. 16. Barnardo C, Jivanni A. Evaluating the Fraser Health balanced scorecard—a formative evaluation. Health Care Manage Forum. 2009;22(2):49–60. 17. Groene O, Brandt E, Schmidt W, Moeller J. The balanced scorecard of acute settings: development process, definition of 20 strategic objectives and implementation. Int J Qual Health Care. 2009;21(4):259–257. 18. Kaplan RS, Norton DP. The balanced scorecard—measures that drive performance. Harv Bus Rev. 1992;70: 71–79. 19. Chiang A. What is a dashboard? Defining dashboards, visual analysis tools and other data presentation media. http://www.dashboardinsight.com/Article.aspx?id=4387. Accessed July 28, 2014.
REFERENCES 1. Rose S, All A, Gresham D. Role preservation of the clinical nurse specialist and the nurse practitioner. Int J Adv Nurs Pract. 2002;5(2). http://ispub.com/IJANP/5/2/7413. 2. American Association of Colleges of Nursing. The essentials of master’s education for advanced practice nursing. http://www.aacn.nche.edu/education-resources/ masessentials96.pdf. Published 1996. Accessed August 29, 2014. 3. National Association of Clinical Nurse Specialists. Statement on Clinical Nurse Specialist Practice and Education. 2nd ed. Harrisburg, PA: National Association of Clinical Nurse Specialists; 2004. 4. Heitkemper M, Bond E. Clinical nurse specialists: state of the profession and challenges ahead. Clin Nurs Spec. 2004;18(3):135–140. 5. National Association of Clinical Nurse Specialists. Impact of the clinical nurse specialist’s role on cost and quality of health care 2013. http://www.nacns.org/docs/ CNSOutcomes131204.pdf. Accessed August 8, 2014. 6. The National CNS Competency Task Force. Clinical Nurse Specialist Core Competencies Executive Summary 2006–2008. http://www.nacns.org/docs/CNSCore CompetenciesBroch.pdf. Published 2010. Accessed August 10, 2014. 7. Newhouse R, Stanik-Hutt J, White K, et al. Advanced practice nurse outcomes 1990–2009: a systematic review. Nurs Econ. 2011;29(5):1–21. 8. Bradway C, Trotta R, Bixby MB, et al. A qualitative analysis of an advanced practice nurse–directed transitional care model intervention. Gerontologist. 2012;52(3): 394–407. 9. Naylor M, Brooten D, Campbell R, et al.Transitional care of older adults hospitalized with heart failure: a randomized, controlled trial. J Am Geriatr Soc. 2004;52:675–684.
49 Copyright © 2015 American Association of Critical-Care Nurses. Unauthorized reproduction of this article is prohibited.
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Using a Scorecard to Demonstrate Clinical Nurse Specialists’ Contributions Stacy Jepsen, MS, APRN, ACNS-BC, CCRN
ABSTRACT Clinical nurse specialists (CNSs) have the expertise to influence change at the patient, nurse, and system levels. They are clinical experts who understand the challenges of the current health care environment: decreasing costs, ensuring high-quality care, and achieving outcomes. Evidence has demonstrated CNSs’ influence on improving patient outcomes. Although CNSs often lead the
work, they can be invisible when the outcomes are presented. A scorecard to display this work could be invaluable to the CNS role, as it would bring transparency to the evidencebased work done. This article describes the development of a CNS scorecard in a 627-bed tertiary hospital. Keywords: clinical nurse specialist, outcomes, quality care, scorecard
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nurse (APRN) roles, including leadership and change adaptation. In 1996, the American Association of Colleges of Nursing2 defined the components required in the curriculum of these graduate-level programs. Despite pioneering the APRN role, CNSs have struggled to articulate their role. The National Association of Clinical Nurse Specialists (NACNS) was formed in 19953 and clarified CNS practice and its contribution to patient care and health care at large. The NACNS assisted in protecting the CNS as a unique role after proposals had been made to combine the CNS and CNP roles, because of their similarities and the lack of understanding around the niche each serves in the health care scene. The formation of the NACNS coincided
he 21st century has brought increasing pressures for accountability in health care, from not only patients and families but also payer mechanisms, such as the Centers for Medicare & Medicaid Services and private insurance companies. Changing population demographics, coupled with chronic illness, have resulted in increased demands for resources and access to providers. Many organizations have created comprehensive performance measures, in forms of scorecards and dashboards, to assist in their strategic management processes to meet these health care pressures. Strategies must be developed to support improving quality and reducing costs, all while improving patient outcomes, and the role of the clinical nurse specialist (CNS) is integral in this work. The CNS role was the first nursing specialty to require graduate-level preparation, followed by the certified nurse midwife, certified registered nurse anesthetist, and certified nurse practitioner (CNP).1 Multiple characteristics are common to these 4 advanced practice registered
Stacy Jepsen is Clinical Nurse Specialist, Medical/Surgical/Neuroscience Critical Care, Abbott Northwestern Hospital, 800 East 28th Street, Minneapolis, MN 55407 ([email protected]). The author declares no conflicts of interest. DOI: 10.1097/NCI.0000000000000066
43 Copyright © 2015 American Association of Critical-Care Nurses. Unauthorized reproduction of this article is prohibited.
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adults with cognitive impairment.8 Transitions of care are an essential part of health care reform to reduce hospital length of stay and readmissions. Clinical nurse specialist practice has been shown to influence patient satisfaction, hospital length of stay, hospital costs, readmissions, and patient morbidity and complications, which are high priorities in health care today.4,5,7,9 A 2011 systematic review7 revealed that patients who underwent coronary bypass surgery, radical prostatectomy, or total knee replacement and those receiving end-of-life care had the same or shorter lengths of stay when cared for by a group that included a CNS. Moderate to high levels of evidence also demonstrated lower overall cost of care and complication rates when CNSs were involved in the care.7 This evidence supports the integral role CNSs play in achieving the triple aim: improved patient outcomes, enhanced population health, and reduced health care cost.10 Clinical nurse specialists have played a central role in transforming the health care system to create high-quality, valuable care for patients. This CNS work must continue to be exposed through publishing and transparency of work within organizations. State regulations defining the scope of practice of APRNs vary widely. One of the primary recommendations by the Institute of Medicine’s11 The Future of Nursing report was to ensure that nurses can practice to the full extent of their education and training. Although some states have embraced this recommendation and evolved with health care reform, allowing certain APRNs to practice without a collaborative physician agreement, the bylaws within health care organizations often still limit APRN practice. The Affordable Care Act12 and decreased reimbursement from private and governmental payers, along with a movement toward valuebased purchasing and pay for performance while still in a fee-for-service environment, have put extreme pressure on health care. These changes have been reflected in the number of large hospital systems conducting layoffs to improve operations.13 To achieve health care reform, we must continue the pursuit of achieving the triple aim.10
with the growth of physician specialties, resulting in a need for primary care providers, moving some CNSs into what was once a CNP role.4 Some CNS positions were eliminated or responsibilities moved from clinical to operational at this time as a result of measures taken by hospitals to cut costs.1 The NACNS has successfully promoted the unique practice of CNSs, with approximately 72 000 CNSs nationally in 2013.5 The CNS practice encompasses core competencies including, but not limited to, leadership, collaboration, consultation, and clinical expertise.3 Clinical nurse specialists use these competencies across a broad field of influence, including the patient, nurse, and organization levels. Although specialized clinical practice in patient care has been the foundation of CNS practice, CNSs’ influence at the organizational or system level is what allows them to be prominent leaders in today’s complex health care system. The system leadership core competency states that CNSs have the capacity to “manage change and empower others to influence clinical practice and political processes both within and across systems.”6(p21) However, CNSs must demonstrate their contribution within the health care landscape, from senior leadership in acute care settings to policy makers at the state and national levels. Displaying CNSs’ ability to influence change that improves quality costeffective patient outcomes must be done not only by publishing outcomes but also by bringing transparency to CNSs’ work within organizations. A scorecard specific to CNSs’ work is one way this transparency can be attained. APRN/CNS Contribution Advanced practice nurses, including CNSs, are important providers in health care systems. Studies have demonstrated the positive effects of these roles on patient outcomes. In 2011, a systematic review7 of published literature between 1990 and 2009 was conducted, comparing patient care outcomes delivered by APRNs with other providers. The findings showed that care provided by CNPs and certified nurse midwives in collaboration with physicians resulted in similar or possibly better patient outcomes in certain patient populations than care provided by physicians alone.7 In a study on care transitions, APRNs’ “advanced clinical judgment” and ability to “establish mutually trusting relationships” with patients and their caregivers were shown to lead to successful transitions to home for older
Scorecards Health care organizations often use scorecards to track quality improvement and drive performance excellence.14–18 A scorecard is a tabular 44
Copyright © 2015 American Association of Critical-Care Nurses. Unauthorized reproduction of this article is prohibited.
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display containing performance measures and their goals, along with visual indicators demonstrating how each measure is performing in a single view.14 Each performance measure shows its current value, goal, and a visual illustration of the status.19 Colors can be used to illustrate the status of the measure: green for meeting the goal, yellow for trending toward the goal, and red for measures below the set goal. A scorecard often contains columns over time that allow trends to be seen. Other columns can be added to reflect operational leads and organizational goals, which allow each measure to link to a contributing person(s) and overarching organizational strategic goal. The terms scorecard and dashboard often are used interchangeably, but dashboards differ from scorecards, as they often have interactive filters allowing for further breakdown in data sets.19 In addition, scorecards should not be confused with a “balanced scorecard,” which is a strategic planning tool that includes finance measures along with the operational measures, such as customer satisfaction, internal process, and organizational growth.18 In the search of the evidence, no information was found on scorecard development and use specific to APRN practice and contribution to care. However, articles were available on scorecards and dashboards specific to nursing services, nurse managers, and nursing-related metrics. The use of scorecards to communicate performance metrics is rapidly growing within health care.
care and to safeguard the provision of quality care.”5(p1) However, CNSs often are not present when the results, both operational and financial, are presented to senior leadership. The CNS group at Abbott Northwestern Hospital, a 627-bed, Magnet-certified tertiary hospital and part of the Allina Health system, often found that they were not included in the presentation of results to senior leadership. The group consisted of both unit-based and population-based CNSs (Table 1), with most reporting to directors of nursing. A monthly meeting allowed them to share and collaborate on work and projects and permitted the spread of Table 1: Clinical Nurse Specialist Team at Abbott Northwestern Hospital
CNS Work Transparency Clinical nurse specialists have a pivotal role in leading organizational quality improvement. They understand the current health care environment of decreasing costs, along with ensuring quality and outcomes. One of the 3 primary areas of influence for CNSs is at the organizational level. Clinical nurse specialists influence the transitions in patient care from admission through discharge, assisting in achieving optimal outcomes and minimizing readmission risk. Clinical nurse specialists often lead the development of novel interprofessional patient care initiatives that address the full continuum of care. Research has demonstrated health care system cost reductions through CNS-led evidence-based quality improvement initiatives.5 A white paper released by the NACNS in 2013 stated, “Clinical nurse specialists are uniquely prepared with advanced nursing education to meet the increased demand for health
CNS Specialty
Population/Unit(s) Supported
Critical care
Two 16-bed cardiovascular intensive care units and support of the extracorporeal membrane oxygenation program
Critical care
One 30-bed medical, surgical, and neurological intensive care unit and support of the neuroscience critical care program
Medical/ surgical
4 units with 147 total beds
Neuroscience/ spine
2 units with 78 total beds and support of the epilepsy, stroke, and spine programs
Women care
3 units with 68 total beds, newborn nursery, and maternal assessment center
Telemetry
3 units with 96 total beds and the clinical monitoring department
Diabetes
Provides care to the diabetic population throughout hospital
Brain tumor
Provides care to patients with brain tumors throughout the hospital and a clinic
Research
Provides consultation to staff nurses throughout hospital on conducting evidence-based practice and research projects
Palliative care
Provides care to patients with palliative care needs throughout hospital
Pain
Provides care to patients with pain management needs throughout hospital
Abbreviation: CNS, clinical nurse specialist.
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improvements across care areas. However, keeping abreast of the primary work of each CNS was challenging, which often led to duplication of efforts. A member of the senior leadership team was invited quarterly to the CNS group meeting for discussion and presentation of work. However, a succinct overview of the CNSs’ work and how that work was tied to hospital and nursing strategic priorities was missing in these meetings. Because Abbott Northwestern Hospital used scorecards throughout the hospital, the CNS group had a vision of what a scorecard pertaining to their key work could resemble.
To keep the scorecard to 1 page, each CNS chose 1 to 2 key measures related to his or her priority work. A goal and benchmark were determined for each measure. The data for many of the measures were already being captured and used in other scorecards maintained by the quality specialists. The CNS(s) leading the work was assigned to each measure. Measures were categorized within the scorecard by the nursing and organization’s strategic goal with which they were aligned (Table 3). The scorecard layout allowed month-to-month data to be populated for each measure, as well as the previous year’s baseline, if present, and any goals set for the current year (see Figure 1).
Scorecard Development The CNS group put in motion the development of a scorecard specific to their priority work, which required key stakeholder support, such as senior leadership and quality specialists. Senior leadership’s support was critical to allow support services, like the quality specialists, to dedicate time to the development and maintenance of the scorecard. Collaboration with a quality specialist was important in the development of the scorecard. The CNSs at Abbott Northwestern Hospital function as clinical experts in evidence-based nursing practice within a specialty area and often lead the quality initiatives, whereas the quality specialists play a supportive role and are instrumental to the data and measurements of success in hospital-wide quality initiatives. To gain senior leadership buy-in, the group sent a communication requesting the support of a CNS scorecard to the vice president of Medical Affairs and director of Patient Safety and Quality, listing the reasons for development of the scorecard (Table 2).
Scorecard Development: Learning and Next Steps Valuable learning occurred during the development of the scorecard, including the importance of tying a team approach to the work represented in the scorecard. Although the scorecard was specific to CNSs, the work entailed a team of interprofessional members to accomplish the goals. We chose to list a collaborative partner, which is either a nursing operational leader, that is, a leader in a director position, or physician lead, next to the CNS lead for each measure. These collaborative partners are key stakeholders leading the work with the CNS(s). We then discussed the importance of speaking to the collaborative partnerships and team work when sharing the scorecard with others. Collaboration is one of the core competencies of CNSs, which contributes to their ability to influence others through “authentic engagement and constructive problem solving.”6(p21) Conveying transparency in the process measures monitored and strategies that assisted in changing behaviors to adopt the best practices in care delivery also was vital. For example, the institution of skin rounds in the intensive care units was discussed in relation to the pressure ulcer measure. Skin rounds include the unit CNS, wound nurse, and bedside nurse assessing the patients’ skin together and are integral in reducing pressure ulcers in intensive care units. Another example of strategies used to change behaviors was hypoglycemia huddles. When a patient has a hypoglycemic event, the bedside nurse, unit charge nurse, and diabetes CNS (when available), along with other key team members, conduct a huddle. Discussion within these huddles helps determine the contributing factors to the hypoglycemic event, identify preventative
Table 2: Reasons for a Clinical Nurse Specialist Scorecard Ability to display performance and quality improvement initiatives that affect outcomes from a hospital-wide perspective Clearly identifies and connects the CNS-focused work to strategic goals of the organization Optimizes CNS resource allocation and reduces duplication of work Communication tool displaying CNS focus areas and associated outcomes Provides shared mental model of CNS work on patient outcomes and quality initiative across hospital continuums Abbreviation: CNS, clinical nurse specialist.
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Table 3: Clinical Nurse Specialist Scorecard Details Measure Hand hygiene
Nursing Strategic Goal
Organization Strategic Goal
Data Element(s)
Clinical competence
Advance safety culture
% compliance
Pressure ulcers
Clinical competence
Advance safety culture
# reportable
Elective induction of labor < 39 wk
Clinical competence
Advance safety culture
%/numerator
Obstetrical hemorrhage with and without transfusion
Clinical competence
Advance safety culture
%/numerator
Hypoglycemia
Clinical competence
Advance safety culture
# of patients/rate
Alarm fatigue
Clinical competence
Advance safety culture
Average ECG alarms per patient/per day
Ketamine use in spine surgery
Clinical competence
Advance safety culture
# of patients/length of stay
Readmission from skilled nursing facility
Coordination of care
Foster stewardship
Actual to expected ratio
Delirium (ICU)
Coordination of care
Foster stewardship
# of patients diagnosed/ICU length of stay
Multidisciplinary rounds program (medical/surgical)
Coordination of care
Foster stewardship
% units/length of stay
Spine surgeries
Coordination of care
Foster stewardship
Volume/length of stay
Pain patient experience score
Patient-centered care
Patient experience
Pain composite score/results of pain questions
Nursing communication patient experience
Patient-centered care
Patient experience
Communication composite score/results of nursing communication questions
Abbreviations: ECG, electrocardiograph; ICU, intensive care unit. Avg indicates average; CNS, clinical nurse specialist; CV BT, cardiovascular breakthrough committee; DRG, diagnosis related group; ECG, electrocardiograph; Gen BT, general breakthrough committee; H4100, cardiovascular surgical intensive care unit; H4200, cardiovascular medical intensive care unit; ICU, intensive care unit; LOS, length of stay; PB2000, medical/surgical/neurological intensive care unit; Pt, patient; PVSR’s, patient visitor safety reports; SNF, skilled nursing facility.
strategies for that patient, and provide learning opportunities for all involved around hypoglycemia prevention. Discussing these strategies when the scorecard is presented assists in highlighting the CNSs’ contribution to outcomes. The development of the CNS scorecard took significant commitment and determination, as each CNS was involved in many other competing initiatives. One CNS drove most of the scorecard creation, which helped keep it at the forefront of the monthly meetings until its completion, along with ongoing maintenance of the scorecard. The discussions around how best to present the work and who to present it too also occurred at the CNS monthly meetings. Many of the measures on the scorecard had substantial financial savings associated with them. Whether the savings were through prevention of hospital-associated events or a reduction in length of stay, the financial impact of the work was significant. However, identifying the
cost avoidance for individual measures was challenging and therefore not displayed on the scorecard. These estimated savings are discussed during scorecard presentations, and work is continuing on how to best display the financial impact on the scorecard itself. Reporting Structure Review of the scorecard occurs on a quarterly basis by the CNS group, and each year the measures are reviewed to ensure that they represent priority work. Each CNS shares the scorecard with his or her director or direct supervisor to ensure transparency across the senior leadership team. The CNS scorecard is now a standard report to the senior management team and Patient Care Executive Committee. Discussions during these presentations include the specific CNS work that contributed to the outcomes displayed on the scorecard, from process measures tracked to key collaborative partnerships 47
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Figure 1. Example of a portion of the clinical nurse specialist scorecard. Avg indicates average; CNS, clinical nurse specialist; CV BT, cardiovascular breakthrough committee; DRG, diagnosis related group; ECG, electrocardiograph; Gen BT, general breakthrough committee; H4100, cardiovascular surgical intensive care unit; H4200, cardiovascular medical intensive care unit; ICU, intensive care unit; LOS, length of stay; PB2000, medical/surgical/neurological intensive care unit; Pt, patient; PVSR’s, patient visitor safety reports; SNF, skilled nursing facility.
group. This awareness assists in the spread of work, which is often challenging in large organizations. Evidence has demonstrated the CNS role’s influence on improving patient outcomes with associated decreases in health care costs. Bringing transparency to this work within organizations is critical to the role of the CNS and can assist in increasing the use of the CNS throughout the health care system.
that channeled success. The value of the CNS is becoming more transparent as evidenced in a senior management team meeting in which the chief nursing officer stated, “let the minutes show the CNSs are worth their weight in gold.” The vice president of Medical Affairs then followed that with “let the minutes reflect I second that.” Conclusion The goal in developing the scorecard was to demonstrate CNSs’ contributions to patient, nursing, and organizational outcomes. The scorecard brings a shared mental model of the priority work being done and assists in prioritization of work by each CNS in the
Acknowledgments Special thanks to Linda Larson, BSN, quality specialist, for scorecard creation and maintenance and Sue Sendelbach, PhD, RN, CCNS, for manuscript review and author mentorship. 48
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10. Institute for Healthcare Improvement. IHI triple aim initiative. http://www.ihi.org/Engage/Initiatives/TripleAim/ pages/default.aspx. Accessed August 20, 2014. 11. Institute of Medicine of The National Academies. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: The National Academies Press; 2011. 12. Medicaid.gov. Keeping America Healthy. Affordable Care Act. http://www.medicaid.gov/affordablecareact/ affordable-care-act.html. Accessed September 9, 2014. 13. Becker’s Hospital Review. 31 hospital, health system layoffs affecting 100+ employees in 2014. http://www .beckershospitalreview.com/leadership-management/ 31-hospital-health-system-layoffs-affecting-10 0employees-in-2014.html. Accessed September 8, 2014. 14. Jeffs L, Merkley J, Richardson S, Eli J, McAllister M. Using a nursing balanced score card approach to measure and optimize nursing performance. Nurs Res. 2011;24(1):47–58. 15. Schalm C. Implementing a balanced scorecard as a strategic management tool in a long-term care organization. Health Serv Res Pol. 2008;13(1):8–14. 16. Barnardo C, Jivanni A. Evaluating the Fraser Health balanced scorecard—a formative evaluation. Health Care Manage Forum. 2009;22(2):49–60. 17. Groene O, Brandt E, Schmidt W, Moeller J. The balanced scorecard of acute settings: development process, definition of 20 strategic objectives and implementation. Int J Qual Health Care. 2009;21(4):259–257. 18. Kaplan RS, Norton DP. The balanced scorecard—measures that drive performance. Harv Bus Rev. 1992;70: 71–79. 19. Chiang A. What is a dashboard? Defining dashboards, visual analysis tools and other data presentation media. http://www.dashboardinsight.com/Article.aspx?id=4387. Accessed July 28, 2014.
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