8: REFLECTIVE RESPONSE ■ 215providers to achieve these goals are front- loaded. This issue is compounded by the
sheer volume of metrics, measures, and groups to whom they are to be reported, which
includes federal and state governments, payers (public and private), and credentialing
organizations such as The Joint Commission, the Leapfrog Group, and numerous spe-
cialty organizations that collect and publish clinical quality and outcome information
benchmarked to peers, many of which are publically reported (Leapfrog Group, 2010).
In many cases, the reporting of these metrics is required either by a licensing entity or by
a payer, and is the price of doing business that is necessary to keep the doors open and
to be able to receive reimbursement for the care provided. Increasingly, those payers are
linking some of that payment to performance in those measures— either incentives for
improved performance or financial penalties for performance that is below the estab-
lished benchmarks (pay for performance).
Participation in the quality reporting programs of some organizations (including
the AHRQ Quality Indicators program described in this chapter) is voluntary and the
benefits to the provider or hospital are not directly financial, but rather consist of self-
improvement, status relative to competitors, and public standing, which may or may
not translate into a competitive advantage in terms of patients choosing their services
over those of another provider or organization. While participation in these programs
can be extremely helpful to the organization in making important improvements in
quality and safety, participation can be costly in terms of the resources and effort that
the collection and reporting of the data require. In many cases, the metrics themselves
and the criteria for collecting them— which patients are included or excluded from the
data collection, how the measures are defined, what constitutes meeting or not meeting
a measure— vary significantly from program to program, even for measures that would
seem to be the same— such as readmissions or complications. Thus, the work required
to fulfill mandatory requirements to state and federal agencies and payers cannot be
leveraged to fulfill the reporting requirements on most of the voluntary programs—
each requires specific resources and staff specialized in understanding the measures
specific to that program so that the data collection and reporting are accurate and appli-
cable to that program.
Further compounding of these issues is the fact that electronic health record (EHR)
systems are still in their infancy, and were designed much more specifically for input-
ting and archiving data on patient encounters than for creating outputs in the form of
reports to meet needs for quality and safety tracking and reporting. The sheer number
of different EHR systems, and the fact that virtually every installation is highly custom-
ized to the provider or organization who implements it, means that creating standard-
ized reports on these measures is very, very challenging. Therefore, much of the data
collection continues to be done through manual chart abstraction, requiring staff time
and resources, none of which directly contributes to revenue, but rather is all overhead
cost for the provider organization.
Where does the DNP fit into all of this? It is clear to see that the collection and
reporting of quality and safety measures are complicated and require oversight by
someone with highly specialized expertise, a role that would seem to describe a nurse
with advanced practice credentials and experience. However, more important than col-
lecting and reporting the data is understanding what it means and what to do about
it. In my opinion, this is the role that the DNP can and should fulfill in the realm of
improving quality, outcomes, and safety for patients. The range of skills required are
part of the DNP’s scope and expertise such as: interpreting the data, discerning trends,
understanding variation in the data and what it means, how to improve, how to build
and work with multidisciplinary teams, using Plan- Do- Study- Act and rapid cycle