Risk Adjustment Analyses of outcomes across groups are meaningful only if those analyses account for relevant individual

differences in the patient populations being served. Returning back to the outcomes research model, when the interest in determining the effect of a particular intervention or process of care such as patients to nurse ratio on health status of patients, all of the other factors that may contribute to variation in the patients health status must be accounted for. Thus, for example, comparing the effect of a better patients to nurse ratio on acute myocardial infarction (AMI) outcomes in patients without co-morbidities with those in older individuals with multiple co-morbidities would be inappropriate because it may be the patient factors, not the patients to nurse ratio that cause the different outcomes. Risk adjustment can be an involved and technical pursuit; but if given inadequate attention, patterns and associations that are found in outcomes research have little credibility because differences across the units or hospitals on outcomes cannot be interpreted as necessarily reflecting variations in quality of care. One caution is important. Certain types of outcomes are so dramatic and so closely tied to failures on the parts of systems for providing care (e.g., transfusion errors, severe pressure ulcers) that risk adjustment is unlikely to alter the interpretation of the relevant indicators. The literature contains some excellent references that discuss the state of the science in risk adjustment techniques (Elixhauser et al., 1998; Iezzoni, 2003b).

MEASUREMENT OF NURSING INTERVENTION OR TREATMENT

To understand the effect of the nursing treatment, intervention, or process of care being investigated, that phenomenon must be defined and measured accurately. In instances in which the intervention is straightforward, such as the implementation of a new technology or a new program, it may be easier to isolate the effect of treatment. There are times, however, when measures of the direct process of care are impossible or too labor-intensive to measure directly because they require intensive monitoring or recording of what nurses are actually doing. In those instances, proxy measures such as structural or organizational elements may replace them. For example, nurse staffing is a structural factor indicating the number or concentration of nurses often in ratio to patients. Nurse staffing measures usually do not directly asses the process of care, that is, what nurses do in their work with patients. However, it is seen as a valuable proxy

measure for the process of care and quality. Proxy measures need to be evaluated for how accurately they represent the concept that they substitute for.

OUTCOMES RESEARCH DESIGN

With all of the factors that may influence outcomes, designing studies aiming to isolate the effect of nursing interventions or processes of care (or of certain organizational conditions) on outcomes and eliminating confounding sources is a challenging proposition. A range of design approaches are possible-selection depends upon the question being studied, the environment in which the investigation is to be carried out, and the subjects, instruments, and/or data available for study. The randomized controlled trial (RCT) is often described as the gold standard, but there is bias in any study and there is some concern that RCTs do not reflect the world in which managers and other decision makers must operate. One alternative is the practical clinical trial (PCT), which aims to (1) select clinically relevant alternative interventions to compare, (2) include a diverse population of study participants, (3) recruit participants from heterogeneous practice settings, and (4) collect data on a board range of health outcomes (Tunis et al, 2003). A great deal of nursing outcomes research uses quasi-experimental designs with either cross-sectional or longitudinal data. There are a variety of designs, measuring, the outcome in relation to the treatment at any number of points and with possible control populations, each having its own strengths, weaknesses (Campbell & Stanley, 1963). In many other cases, however, researchers must turn to the analysis of data that were collected for different purposes-a practice known as secondary analysis. This design may save some time and money but requires much caution to avoid drawing erroneous conclusions (the measures, their reliability and/or validity, and the contexts in which they are collected may not be ideal). Knowing the potential bias that may arise because of the design of a study and the methods that a researcher used to address those biases is an invaluable skill for managers who wish to interpret outcomes data for management decision making. Classic texts such as Campbell and Stanley (1963) provide background in this area.

LEADERSHIP AND MANAGEMENT IMPLICATIONS Leader in todays health care delivery system are charged with the responsibility of producing quality services that achieve desired outcomes. Consumers must perceive that the outcomes of care justify the cost of services, and the services offered need to be valued by payers and purchasers of care. Outcomes research can provide nurse managers with an evidence-based foundation for leadership decisions and for making changes in practice. The process of determining the appropriate changes that need to be made in service delivery, making those changes, and reevaluating outcomes based on the changes are hallmarks of outcomes management. Managers and executives today have a wealth of information available to them, and they are challenged with determining which data indicate a need for action in areas or aspects of care in the settings for which they are responsible. A significant body of literature in nursing outcomes research that continues to grow is a valuable point of references of managers. There is, for instance, a large and expanding body of literature suggesting that lower staffing levels and skill mix in acute care hospitals are associated with increased risk of negative outcomes (Clarke, 2005). Insufficient nurse staffing, particularly of RNs, has been associated with a number of unfavorable outcomes including increased surgical mortality, failure to rescue, and rates of complications due to errors in care such as urinary tract infections, intravenous line infections, decubitus ulcers, and patient falls (Aiken et al., 2002; Kane et al., 2007). However, the specific context of the care environment and the patient population of interest call for continual monitoring of outcomes against internal and external benchmarks. Several data systems support the monitoring of nursing-sensitive outcomes. For example, the ANA has developed a system of quality indicators and measurement tolls called the NDNQI, which are aimed at measuring the quality of nursing care in acute care settings (Gallagher & Rowell, 2003). The national quality forum (NQF) has also endorsed a set of voluntary consensus standards for nursing-sensitive care that quantify the contribution of nursing to patient safety, health care outcomes, and the professional work environment (National Quality Forum, 2004; Naylor , 2007). Also, agencies such as the centers for medicare and Medicaid services (CMS) (previously known as the health care financing administration [HCFA]) and the joint commission (previously the joint

commission on accreditation of healthcare organizations [JCAHO]) incorporate outcomes-based reporting requirements into their regulatory and accreditation process (Huber & Oermann, 1998). Managers and executives in practice struggle with decisions around the minimum number of data elements needed to satisfy payers and regulators versus how to be sufficiently comprehensive and inclusive in measure selection and what elements are needed in the dataset. Issues of feasibility, practically, collectability, and comprehensiveness will be part of his unfolding area of nursing administration. In terms of a guide or framework for selecting outcomes for tracking purposes, balanced scorecards and dashboard approaches are gaining popularity. Dashboard approaches seek to identify the key factors for which a nurse manager needs to frequently monitor data to manage quality and costs. The balanced scorecard uses four areas for data evaluation-internal business processes, learning and growth, customer, and financial-and directs managers to select indicators from each of these areas (Park & Huber, 2007). Some research has examined whether this is a feasible approach (Hall et al., 2003).