Commitment to Excellence in Nursing Regulation Presented at the 2004 CLEAR Annual Conference...

Commitment to Excellence in Nursing

Regulation

Presented at the 2004 CLEAR Annual Conference

September 30 – October 2 Kansas City, Missouri

Kathy Apple, RN, MS, CAEExecutive Director

National Council of State Boards of Nursing

Presented at the 2004 CLEAR Annual ConferenceSeptember 30 – October 2 Kansas City, Missouri

NCSBN Mission

The National Council of State Boards of Nursing (NCSBN), composed of member boards, provides leadership to advance regulatory excellence for public protection.

Presented at the 2004 CLEAR Annual ConferenceSeptember 30 – October 2 Kansas City, Missouri

Need for Study

• Multiple stakeholders were demanding accountability

• Lack of clarity among stakeholders about Board roles and responsibilities

• Trend toward outcome measurement at state level

Presented at the 2004 CLEAR Annual ConferenceSeptember 30 – October 2 Kansas City, Missouri

Purpose of the Study

• Incorporating data from internal and external sources

• Using benchmarking strategies• Identifying best practices

Establishment of a Establishment of a Performance Measurement Performance Measurement

SystemSystem

Presented at the 2004 CLEAR Annual ConferenceSeptember 30 – October 2 Kansas City, Missouri

Phases of the Project

1.1. Validation of Board RolesValidation of Board Roles

Presented at the 2004 CLEAR Annual ConferenceSeptember 30 – October 2 Kansas City, Missouri

Results of Phase 1:

• Roles Identified– Establish scope of practice for

nurses– Issue licenses to qualified nurses– Assure continued competence– Investigate complaints and impose

disciplinary sanctions as appropriate

Presented at the 2004 CLEAR Annual ConferenceSeptember 30 – October 2 Kansas City, Missouri

Phases of the Project

1. Validation of Board Roles

2.2. Identification of Performance Identification of Performance IndicatorsIndicators

Presented at the 2004 CLEAR Annual ConferenceSeptember 30 – October 2 Kansas City, Missouri

Results of Phase 2:

• Technical Work Group developed– Performance indicators– Outcome Indicators– Output Indicators– Efficiency Indicators

Presented at the 2004 CLEAR Annual ConferenceSeptember 30 – October 2 Kansas City, Missouri

Examples

• Performance Indicator– Timeliness of complaint handling

• Outcome Indicator– Average time for complaint

resolution

Presented at the 2004 CLEAR Annual ConferenceSeptember 30 – October 2 Kansas City, Missouri

Examples, cont.

• Output Indicator– Number of complaints resolved in FY

• Efficiency Indicator– Average cost per completed

complaint

Presented at the 2004 CLEAR Annual ConferenceSeptember 30 – October 2 Kansas City, Missouri

Phases of the Project

1. Validation of Board Roles2. Identification of Performance

Indicators

3.3. Tool DevelopmentTool Development

Presented at the 2004 CLEAR Annual ConferenceSeptember 30 – October 2 Kansas City, Missouri

Tool Development Process

• Original tools developed and piloted

• Original tools revised and further tools developed– 6 data collection tools for boards of

nursing– Surveys to collect data from 6

stakeholder groups

Presented at the 2004 CLEAR Annual ConferenceSeptember 30 – October 2 Kansas City, Missouri

Board Surveys

1. Discipline2. Licensure3. Education Program Approval4. Practice5. Governance (Executive Staff)6. Governance (Board President)

Presented at the 2004 CLEAR Annual ConferenceSeptember 30 – October 2 Kansas City, Missouri

Board Surveys Included

• Processes used, e.g.:– Investigator caseloads– Use of site visits or self-reports for

education programs

• Timeliness issues, e.g.:– Days needed to processes license

request

Presented at the 2004 CLEAR Annual ConferenceSeptember 30 – October 2 Kansas City, Missouri

Board Surveys Included

• Outcomes achieved, e.g.:– Number of discipline cases closed

• Opinions, e.g.:– From Executive Staff and Board

President

Presented at the 2004 CLEAR Annual ConferenceSeptember 30 – October 2 Kansas City, Missouri

Stakeholder Groups

1. Licensed nurses2. Health care employers3. Nurses who had been the

subjects of complaints4. Persons who had lodged

complaints5. Nursing associations6. Nursing education programs

Presented at the 2004 CLEAR Annual ConferenceSeptember 30 – October 2 Kansas City, Missouri

Stakeholder Surveys Included

• Perceptions of board’s– Timeliness,– Fairness,– Adequacy of regulation, etc.

• Satisfaction with board’s– Communication with stakeholder

group,– Nursing program approval process,

etc.

Presented at the 2004 CLEAR Annual ConferenceSeptember 30 – October 2 Kansas City, Missouri

Phases of the Project

1. Validation of Board Roles2. Identification of Performance

Indicators3. Tool Development

4.4. Data CollectionData Collection

Presented at the 2004 CLEAR Annual ConferenceSeptember 30 – October 2 Kansas City, Missouri

Data Collection

• Stakeholder contact information submitted by boards– Random samples selected from

those submitted

• 6 data collection tools sent to boards of nursing

Presented at the 2004 CLEAR Annual ConferenceSeptember 30 – October 2 Kansas City, Missouri

Data Collection Wisdom

• Not all boards routinely collected the data asked for– Many boards used this as an

opportunity to improve/modify amount and types of data collected

• Language/definitions (i.e., financial data, board processes) differed among boards

Presented at the 2004 CLEAR Annual ConferenceSeptember 30 – October 2 Kansas City, Missouri

Phases of the Project

1. Validation of Board Roles2. Identification of Performance

Indicators3. Tool development4. Data Collections

5.5. Reports of FindingsReports of Findings

Presented at the 2004 CLEAR Annual ConferenceSeptember 30 – October 2 Kansas City, Missouri

Report Format

I. Aggregate findingsA. Data results

1. From board surveys2. From stakeholder surveys

B. Relationships among variables

II. State-specific findingsA. Comparison of state with all statesB. Comparison of state with “like”

boards

Presented at the 2004 CLEAR Annual ConferenceSeptember 30 – October 2 Kansas City, Missouri

Example of Comparison with Aggregate Data, i.e., Ed. Program Perceptions

Approval Process State Rating

Aggregate Rating

Interval betweenboard visits

2.66 1.40

Preparation time for board visits

2.45 1.41

Feedback/evaluation provided by board

2.16 1.38

Presented at the 2004 CLEAR Annual ConferenceSeptember 30 – October 2 Kansas City, Missouri

Comparisons with Similar Boards

• Boards evidenced a wide variety of resources, structures & processes

• Boards were compared to other boards similar in a number a variables

Presented at the 2004 CLEAR Annual ConferenceSeptember 30 – October 2 Kansas City, Missouri

Comparison Variables

• Size of staff• Staff assigned to specific

functions• Numbers of investigators• Whether or not state mandated

reporting of errors• Processes related to complaint

review

Presented at the 2004 CLEAR Annual ConferenceSeptember 30 – October 2 Kansas City, Missouri

Comparison Variables cont.

• Board structure• Standard of proof• Staff autonomy• Number of board meeting per

year• Timeliness of discipline processes• Timeliness of licensure processes

Presented at the 2004 CLEAR Annual ConferenceSeptember 30 – October 2 Kansas City, Missouri

Comparisons of Sample Board with Other Boards with Similar Numbers of

StaffSample Board

Similar Boards

Number of nursing programs 78 60.53

Rate of complaints resolved 0.78 0.66

Complaints per investigator 116.9 95.78

Nurses' perceptions of courteousness 1.23 1.23

Number of staff involved with investigations 12 7.92Number of board meetings/year 10 6.4

Presented at the 2004 CLEAR Annual ConferenceSeptember 30 – October 2 Kansas City, Missouri

Phases of the Project

1. Validation of Board Roles2. Identification of Performance

Indicators3. Tool development4. Data Collections5. Reports of Findings

6.6. Search for “best practices”Search for “best practices”

Presented at the 2004 CLEAR Annual ConferenceSeptember 30 – October 2 Kansas City, Missouri

The Search for Best Practices

• Data were used to identify boards with consistently high ratings in– Outputs– Effectiveness

• Ratings were explored in 5 functional areas– Discipline, licensure, education

program approval, practice and governance

Presented at the 2004 CLEAR Annual ConferenceSeptember 30 – October 2 Kansas City, Missouri

The Search for Best Practices

• Selected boards were interviewed to discover– Practices common among boards

with consistently high ratings– Differences from boards with lower

ratings

Presented at the 2004 CLEAR Annual ConferenceSeptember 30 – October 2 Kansas City, Missouri

Discipline Best Practices

• Boards with the highest ratings on discipline outcomes– Delegated authority to board staff– Communicated well with stakeholders– Hired investigators and attorneys &

actively managed discipline process– Trained and mentored investigative

staff– Applied discipline sanctions

consistently

Presented at the 2004 CLEAR Annual ConferenceSeptember 30 – October 2 Kansas City, Missouri

Licensure Best Practices

• Boards with the highest ratings on licensure outcomes– Secured essential human and other

resources– Made an aggressive commitment to

customer service

Presented at the 2004 CLEAR Annual ConferenceSeptember 30 – October 2 Kansas City, Missouri

Education Best Practices

• Boards with the highest ratings on education outcomes– Provided consultative, as well as

evaluative services to education programs

– Took a leadership role in establishing congruence between education and regulation

Presented at the 2004 CLEAR Annual ConferenceSeptember 30 – October 2 Kansas City, Missouri

Practice Best Practices

• Boards with the highest ratings on practice outcomes– Facilitated understanding of legal scope of

practice– Made an aggressive commitment to

customer service– Established a high level of involvement

with the statewide nursing community– Delegated authority to board staff

Presented at the 2004 CLEAR Annual ConferenceSeptember 30 – October 2 Kansas City, Missouri

Governance Best Practices

• Boards with the highest ratings on governance outcomes– Promoted an understanding of the

respective roles of staff and board members

– Built an effective working relationship and a high level of trust between board and staff

– Facilitated an effective working relationship among board members

– Demonstrated a commitment to board member development

Presented at the 2004 CLEAR Annual ConferenceSeptember 30 – October 2 Kansas City, Missouri

Phases of the Project

1. Validation of Board Roles2. Identification of Performance

Indicators3. Tool development4. Data Collections5. Reports of Findings6. Search for “best practices”

7.7. Development of Ongoing System of Development of Ongoing System of Performance MeasurementPerformance Measurement

Presented at the 2004 CLEAR Annual ConferenceSeptember 30 – October 2 Kansas City, Missouri

Commitment to Ongoing Regulatory Excellence

(CORE)

Presented at the 2004 CLEAR Annual ConferenceSeptember 30 – October 2 Kansas City, Missouri

CORE

• Nursing Boards educated on CORE– Manuals prepared, distributed and

explained– Ongoing presentations and

publications

• Best Practice “Tool Kit”– Submissions by boards of systems

and processes that have facilitated best practice

Presented at the 2004 CLEAR Annual ConferenceSeptember 30 – October 2 Kansas City, Missouri

CORE

• Ongoing improvement of data collection system– All survey items linked to outcome

and/or best practice– Data collection streamlined– Additional tools created and piloted

• Information Technology• Finance• Board Member

Presented at the 2004 CLEAR Annual ConferenceSeptember 30 – October 2 Kansas City, Missouri

Utilization of Data by Boards of Nursing

Data has been used to:• Support decision-making• Develop mandated reports• Provide information to legislators• Change data management processes• Improve stakeholder satisfaction• Streamline processes• Determine priorities

Presented at the 2004 CLEAR Annual ConferenceSeptember 30 – October 2 Kansas City, Missouri

Next Steps

• Identify and remove barriers to participation

• Support member boards’ adaptations of best practices

Presented at the 2004 CLEAR Annual ConferenceSeptember 30 – October 2 Kansas City, Missouri

Questions?

Presented at the 2004 CLEAR Annual ConferenceSeptember 30 – October 2 Kansas City, Missouri

Kathy Apple, RN, MS, CAENational Council of State Boards of Nursing111 East Wacker Drive, Suite 2900, Chicago, IL 60601Phone: 312-525-3600, Fax: 312-279-1032E-mail: kapple@ncsbn.orgwww.ncsbn.org

PublicationCrawford, L. (2004). Evidenced-Based Regulation: A Regulatory Performance Measurement System, Research Brief Volume 8. National Council of State Boards of Nursing: Chicago.