Evaluating and Improving Nursing Quality
Nurses have always been instrumental in improving patient safety and the quality of health care. As the nursing profession was born, Florence Nightingale used data she collected from her practice to convince the leaders of her day that sanitation improved survival rates. Today, bedside nurses and nursing leaders use data from the National Database of Nursing Quality Indicators® (NDNQI®) to help them keep patients safe and improve their nursing practice. This book provides an overview of nursing quality measurement and improvement methods, a step-by-step guide to using NDNQI data for quality improvement, and case studies of successful improvement initiatives in 11 U.S. hospitals.
Over the past 15 years, the mandate for improved quality of care has spread through all aspects of the healthcare system. The Institute of Medicine (IOM) defines quality of care as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” (2001). Landmark reports such as IOM’s To Err is Human and Crossing the Quality Chasm brought attention to the many undesirable outcomes experienced by patients and the gap between scientific knowledge and clinical practice (IOM, 2000; 2001). Standardized measures of quality created by pioneers such as the American Nurses Association (ANA) have enabled nurses to begin closing the gap and improving outcomes.
Measures of quality (i.e., quality indicators) have made hospitals increasingly accountable for the nursing care they provide. Government and private insurers now use quality indicators for setting reimbursement rates. In particular, initiatives from the Centers for Medicare and Medicaid Services (CMS) have promoted the reporting and improvement of quality indicators. CMS’s initiatives evolved from public reporting (no incentive offered) to pay-for-reporting (incentive for reporting measure) to pay-for-performance (payment or non-payment based on measure performance). The latter initiative holds healthcare organizations accountable for their quality of care by directly tying reimbursement to performance on standardized measures. Thus, nurses’ work to improve patient safety has a greater financial impact than ever before, giving further value and importance to the profession and to individual nurses.
Multiple indicators are now used to evaluate the quality of nursing care. Each indicator measures one aspect of quality, such as the rate of hospital-acquired infections. To obtain a thorough view of quality, multiple indicators are needed. When an indicator is a direct measure of nursing or is strongly influenced by the care that nurses provide, it is called a nursing-sensitive indicator. Many hospitals report their performance on nursingsensitive indicators to NDNQI.
National Database of Nursing Quality Indicators
NDNQI is the national leader in nursing quality measurement. As of July 2010, 16,579 nursing units in 1,540 hospitals submitted data on nursing-sensitive indicators such as pressure ulcers, patient falls, healthcare-associated infections, number and qualifications of nurses, and more. Every three months, participating nursing units download comparative data reports generated by NDNQI analysts. Reports promote quality improvement by enabling each unit to compare its
staffing levels, nursing practices, and patient outcomes to similar units in similar hospitals. For instance, the quarterly report for a critical care unit in a teaching hospital might reveal its pressure ulcer rate to be above the 75th percentile for critical care units in teaching hospitals nationally. Such a report is intended to trigger a quality improvement effort aimed at lowering pressure ulcer occurrence on that unit.
staffing levels, nursing practices, and patient outcomes to similar units in similar hospitals. For instance, the quarterly report for a critical care unit in a teaching hospital might reveal its pressure ulcer rate to be above the 75th percentile for critical care units in teaching hospitals nationally. Such a report is intended to trigger a quality improvement effort aimed at lowering pressure ulcer occurrence on that unit.
NDNQI was created as part of ANA’s Patient Safety and Quality Initiative to identify the linkages between staffing and patient outcomes. During the mid-1990s, extensive reviews of published evidence and pilot testing by seven state nurses associations led to the definition of reliable and valid nursing quality indicators (Montalvo, 2007). In 1998, ANA established the National Center for Nursing Quality (NCNQ®) and its measurement database, the National Database of Nursing Quality Indicators. The NCNQ advocates for nursing quality and patient safety through research and measurement, collaborative learning, and engagement in the national quality enterprise. The database was originally managed by the Midwest Research Institute and the University of Kansas (KU) School of Nursing under contract to ANA; NDNQI became managed solely by the KU School of Nursing in 2001. When first established, the database consisted of 30 hospitals reporting data on four newly-defined indicators.
Since that time, the database has continually grown in size and content. Hospitals from all 50 states and the District of Columbia now participate in NDNQI, along with seven international hospitals. Virtually all types of hospitals are represented. As of July 2010, 821 non-teaching hospitals, 550 teaching hospitals, and 169 academic medical centers participate in quarterly data reporting. Behavioral health, rehabilitation, oncology, pediatrics, cardiology, and women’s specialty hospitals are included in NDNQI, along with 1,344 general hospitals whose bed sizes range from under 50 to over 900. The American Nurses Credentialing Center (ANCC) has awarded 368 NDNQI-member hospitals (24% of the total in the database) Magnet® recognition for excellence in nursing services. Currently, over 1,700 hospitals participate in NDNQI.
As participation has grown, so have the comparison group options available in NDNQI reports. Nursing units may view comparison data grouped by teaching status, hospital bed size, geographic location (state, census division, and metropolitan status), hospital specialty, unit specialty, Magnet recognition status, or Medicare case mix index category. Comparative reports are also available for multi-hospital health systems. Regardless of comparison group, all reports are stratified by unit type (e.g., adult surgical units are compared to other adult surgical units; pediatric intensive care units [ICUs] are compared to other pediatric ICUs). The combination of unit-level data with a wide selection of comparison groups allows nursing units to draw meaningful conclusions about their performance.
NDNQI collects quarterly data on nurse staffing and patient care indicators and also conducts an annual survey of RNs to evaluate job satisfaction and the nursing work environment. Many indicators collected by NDNQI are endorsed by the National Quality Forum (NQF), a non-profit organization that promotes standardized measures of healthcare quality. Four of the original indicators developed by ANA were selected for NQF’s Nursing-Sensitive Care Performance Measure Set: nursing care hours per patient day, skill mix, patient falls, and falls with injury (NQF, 2004, 2009). NDNQI has incorporated additional NQF-endorsed measures in their data collection, including pressure ulcer prevalence, restraint prevalence, healthcare-associated infections, voluntary nurse turnover, and the Practice Environment Scale. Appendix A lists the quality indicators currently collected by NDNQI. NDNQI continually works to ensure the reliability and validity of their indicators through annual reliability studies of individual indicators and ongoing participant training to promote compliance with precise data collection and entry protocols. Reliable and valid indicators enable public reporting of nursing quality data.
Hospitals that participate in NDNQI benefit substantially from measuring their nursing quality. Benchmarking to peers can spur quality improvement initiatives that reduce costly adverse events and enhance the hospital’s reputation. Additionally, CMS now stipulates
participation in a systematic clinical database registry for nursing-sensitive care as one of the criteria for receiving full Medicare reimbursement rates. Hospitals that do not participate in NDNQI or another qualifying database will experience a 2% reduction in the annual inflation update to Medicare payment rates (CMS, 2010). Participation in NDNQI also fulfills the nursing-sensitive data collection requirements for hospitals seeking to obtain or retain Magnet recognition for nursing excellence.
participation in a systematic clinical database registry for nursing-sensitive care as one of the criteria for receiving full Medicare reimbursement rates. Hospitals that do not participate in NDNQI or another qualifying database will experience a 2% reduction in the annual inflation update to Medicare payment rates (CMS, 2010). Participation in NDNQI also fulfills the nursing-sensitive data collection requirements for hospitals seeking to obtain or retain Magnet recognition for nursing excellence.
NDNQI continually strives to enhance the usefulness of nursing quality indicators. Interactive self-paced online training helps nurses use their NDNQI comparative reports for quality improvement. Researchers at NDNQI are investigating statistical adjustment techniques that would allow mixed acuity units to compare their staffing and patient outcomes to peers. NDNQI’s annual conferences highlight examples of successful quality improvement and promote diffusion of innovations in nursing. With diverse and growing participation, widely accepted indicators, and ongoing development projects, NDNQI is well poised to lead nursing quality measurement in the twenty-first century.
Structure, Process, and Outcomes in Nursing Quality
Comprehensive evaluation of nursing care requires three types of indicators: structure, process, and outcome. Quality theorist Avedis Donabedian (1966, 2003) introduced structure, process, and outcome as distinct yet related approaches to measuring healthcare quality. Using all three gives a complete, balanced view of nursing care. Importantly, the structure of nursing care influences the processes of care, and both affect outcomes (Montalvo & Dunton, 2007). Figure 1 provides an example of the relationship between a few of the structure, process, and outcome indicators collected by NDNQI.
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