Improvements in nursing quality result from evidencebased changes in the structure and processes of care. From unit-specific to system-wide initiatives, in hospitals of various types and sizes, the case studies in Chapter 3 demonstrate the teamwork and persistent effort required to achieve better patient outcomes. This chapter summarizes some of the lessons that can be drawn from the case studies and discusses future directions in nursing quality improvement.

Structural improvements were a hallmark of these case studies. Hospitals hired new staff, especially nurses with advanced specialty training who provided expertise and mentoring for direct-care nurses. Resource nurse programs trained staff nurses as experts for their peers. Getting specialized knowledge to the bedside was a central theme in structural improvement. Depending on the factors contributing to each problem, units were reorganized, nurse-patient ratios were improved, the percent of hours supplied by agency staff was reduced, and nursing skill mix was optimized. Hospitals also purchased new equipment. By providing nurses with the supplies needed to give evidence-based quality care, negative outcomes such as pressure ulcers, falls, and infections were reduced. The costs of new equipment and salaries for additional staff were more than recouped by the savings from fewer adverse events.

Hospitals and units also instituted process improvements, especially more frequent data collection and immediate post-event analysis. Monthly prevalence studies and chart audits were used to identify and correct factors contributing to pressure ulcers or inadequate pain assessment. Similarly, weekly meetings and same-day post-fall reviews allowed leaders and bedside nurses to quickly correct deficiencies and recognize prevention needs. Frequent monitoring and direct one-on-one coaching by peers and leaders promoted cultures of accountability and led to further ideas for improvement.

Other care processes were revised as well. Daily rounds were commonly used to bring increased attention to skin care issues and promote frequent review of device necessity. QI teams designed new prevention protocols based on research literature. Importantly, risk categories were matched to specific interventions. Targeting the right patients with the right techniques not only improves outcomes but uses nursing time and resources efficiently. Daily shift huddles promoted communication and teamwork. New documentation forms streamlined nurses’ work. The process changes used in the case studies brought practice in line with current scientific knowledge and addressed the core issues behind each quality problem.

All of these changes were designed and implemented by teams. Often interprofessional and indicator-specific, the teams were frequently part of a larger quality council empowered by hospital administrators to make the changes needed to improve care. Teams rolled out new procedures using a variety of means, such as online education, in-services, posters, emails, pocket handbooks, and staff meetings. To sustain motivation for improvement, hospitals used real-time feedback on incident-free days and rewarded staff when milestones were reached.