Nurses: Assuring Quality Care

for all Populations

Leonard Davis Institute of Health Economics
University of Pennsylvania

Mary E. Foley, MS, RN

President

Objectives
Identify concerns related to health
care quality.
Define nursings quality indicators
Discuss ways in which nursings
quality indicators can be used to
determine quality of care.

Know the Cost of Everything

but the Value of Nothing
Oscar Wilde

The Outcomes Imperative

Only about 15% of all contemporary
Clinical interventions are supported
by objective scientific evidence that
they do more good than harm.
White, 1994

Environmental Scan
Care continues to move out of the hospital
into the community.
Informed and empowered consumers of
health care are concerned and are
expressing those concerns.
Knowledge is being discovered at an
increasing rate.
Technology continues its rapid
proliferation and diffusion.

Environmental Scan (Cont.)

Measurement of the quality of care
continues to be demanded by all consumers.
Corporatization of health care continues
(product lines, marketing, competition, etc.).
Millions of Americans are under insured.
Costs continue to drive health care.

Millions are Underinsured

Nearly 40 million Americans are uninsured.
More that 8 out of 10 who lack insurance are
in working families.
91% of those who have private insurance get
it at work.
Low-wage workers are less likely to be
offered coverage at work.
Private insurance is very
expensive.

Costs Drive Health Care

Premiums for employment-based insurance
policies increased 11%.
The uninsured are often charged more for care.
Health care spending per privately insured
person increased 7.2% in 2000.
Hospital inpatient spending increased at a rate
of 2.8%.
Health care affordability is
deteriorating.

In most instances, health care

delivered to patients/clients is
provided by an array of health care
providers (occupational therapists,
pharmacists, physicians, registered
nurses, respiratory therapists, etc.).

The procedures and services

currently recorded in
reimbursement and utilization
databases represent only a small
portion of the care received by the
patient/client.

It is vital to prove the

relationship of nursing to
quality care and cost
efficiency in order to secure
any share of future health
care dollars.

Safe and Quality

Patient Care
Linked to
Nursing Interventions

The focus of the health care

system and health care
professionals must be kept on
the client/patient, their family
and their needs.

Requires an interdisciplinary
team consistently using
outcomes information to
make decisions in the best
interest of the patient.

Nursing-Sensitive Indicator
An indicator which is sensitive to
the input of Nursing Care.

Why do it ???
Empirically test indicators
Build collaborative relationships with
hospitals
Develop reliable methods for data collection
Engage nurses in quality-related activities
Build a database for nursing-sensitive
indicators
Educate all consumers of care
about nursing

Definitions of Quality
(as it Relates to Health Care)

192040
Minimum
Standards

19401960
Absence of
Defects

1960
Capacity
to Give
Good Care

1970 80
Adherence
to
Standards

What Quality Is...

Definition of Quality in the 1990s:
Meeting customers expectations;
Doing the right thing and doing it
well (JCAHO, 1994);
Clinically effective, efficient, and
affordable health services that are
delivered satisfactorily.

Dynamic Quality Health Outcomes

Model
System

Outcomes

Interventions

Client
Mitchell,1997

Indicator Selection Criteria

Specificity to nursing
Ability to be tracked
Widely regarded as having strong
link to nursing quality
Subset of indicators identified in
previous work

Indicators
Patient-Focused Outcome
Process of Care
Structure of Care

Structure
Mix of RN, LPN/VN & unlicensed staff
Total Nursing Care Hours Provided
per Patient Day

Process
Maintenance of Skin Integrity
Nurse Staff Satisfaction

Outcome Indicators
Nosocomial Infection Rate
Patient Injury Rate
Patient Satisfaction

Nursing Care

Pain Management

Patient Education

...From Indicators to Information

NCNQ
Purpose
Policies
Database Maintenance

Creating
excellence by
establishing a
culture to build
and support
excellence.

Forces of Magnetism
Quality of Nursing Leadership
Leaders are perceived as knowledgeable, strong, risktakers who follow a meaningful philosophy that is made
explicit in the day-to-day operations of the department &
convey a strong sense of advocacy providing staff with an
overall positive sense of support
The nursing director and managers are pivotal to the
success of the organization
The nursing director is critical to the development of a
positive nursing situation

Forces of Magnetism (cont.)

Organizational Structure
The director of nursing is at the executive level of the
organization, reporting directly to the chief executive
officer
Decentralized departmental structures allow for a
sense of control over the immediate work environment
and strong nursing involvement in the committee
structure across departments
With regard to staffing, quality of the staff is as
important as the quantity

Forces of Magnetism (cont.)

Management Style
Participative management style characterized by
involvement of staff at all levels
Participation is sought, encouraged and valued; nursing
administration is both visible and accessible
Communication is a two way process with active
listening, direct staff input and ongoing information about
what is happening within nursing and the broader
organization

Forces of Magnetism (cont.)

Personnel Policies and Programs

Salaries and benefits competitive

Shift rotation is minimized, if not eliminated, and creative

and flexible staffing arrangements are tailored to meet staff
needs
Significant administrative and clinical promotion
opportunities exist that reward expertise with both title and
salary changes

Elimination of mandatory overtime

Forces of Magnetism (cont.)

Professional Models of Care

The model of care gives the nurse the responsibility

and related authority for patient care

Nurses are accountable for their own practice and

are coordinators of care

Forces of Magnetism (cont.)

Quality of Care
The nurses believe themselves to be providing high
quality of nursing care to their patients

Directors of nursing and nursing management are

viewed as responsible for developing the environment
where such care can flourish

Forces of Magnetism (cont.)

Quality Assurance

Considered a mechanism to improve quality care

Nursing staff involvement in the development of

the plan, implementation and data collection results in
improved nursing care

Forces of Magnetism (cont.)

Consultation and Resources
Knowledgeable experts, particularly Clinical
Nurse Specialist, are available

The magnet climate is one of peer support, both

intra- and interprofessionally, and there is great
awareness and appreciation of agency and community
interchange of resources

Forces of Magnetism (cont.)

Level of Autonomy
The nurses are permitted and expected to exercise
independent judgement

Autonomy is viewed as self-determination in

practicing according to professional nursing
standards

Interdisciplinary decision making is essential

Forces of Magnetism (cont.)

Community and the Hospital

Nurses support active community outreach

Nurses want to view their hospital as a model

corporate citizen

Forces of Magnetism (cont.)

Nurses as Teachers
Nurses place a high value on education and teaching by
nurses, not only their own personal and professional growth,
but they value their roles as teachers
Nurses derive much satisfaction from teaching and it is
viewed as an energizing activity
Teaching is seen as both an expectation in the profession
and as an opportunity to practice as a professional

Forces of Magnetism (cont.)

Image of Nursing

Nurses are professionals

Nurses are essential providers of health care

Forces of Magnetism (cont.)

Collegial Nurse-Physician Relationships
There is a need for mutual respect for each
others knowledge and competence and a mutual
concern for the provision of quality patient care

Nurse-Physician relationships are require

constant attention and nurturing

Forces of Magnetism (cont.)

Orientation, inservice, continuing
education, formal education and career
Magnet development
facilities have a high emphasis on personnel growth

and development; staff development starts w/orientation & is a

strong influence on retention, w/ the gradual introduction of
work viewed as important
Access to inservice & continuing education related to the
area of practice involved is essential; multiple opportunities
exist for clinical advancement that is advancement that is
competency based w/specific requirements

Quality is ballet, not hockey

Crosby, 1996

More Issues to Consider

Risk Adjustment for Indicators
Standardization of data collection training
Determination of the feasibility of using
statistical methods to achieve
comparability among satisfaction
instruments

CommunityBased,
NonAcute Care Indicators
Identification of a core set of
indicators
Pilot testing of the indicators
Integration of the data into a national
database
Development of the risk adjustment
strategy

CommunityBased,
NonAcute Care Indicators
Pain management
Consistency of
communication
Staff mix
Client satisfaction
Prevention of
tobacco use

Cardiovascular
prevention
Care giver activity
Identification of
primary care giver
ADL/IADL
Psychosocial interaction

Using the cost of data collection

as a reason not to collect new data
is inconsistent with our current
understanding of the cost of poor
care and the imperative to
measure quality of care

Sample Size
All Payor - More than 9.1 MILLION
Patients in almost 1,000 hospitals.
Medicare - 3.8 MILLION patients in
more than 1,500 hospitals.
Nurse Staffing Data - From data
sources provided by HCFA.

States Included in Data

Arizona
California
Florida
Massachusetts
Minnesota*
New York
North Dakota*
Texas*
Virginia

Only Medicare data were available for these states

Complications Explored

Adverse drug reactions

Anoxic brain damage

Communication conditions
Immediate post Partum
complications
Diabetic complications
Joint effusion
Metabolic imbalances

Personal care
complications

Psychiatric secondary
diagnosis in nonpsychiatric patients

Transfusion reactions
Trauma in non-trauma
patients
Vascular complications

Study Findings
All analyses of the five original outcome
measures (length of stay (LOS), pneumonia,
post-operative infections, pressure ulcers
and urinary tract infections) show
statistically significant relationships with
nurse staffing. That is, nurse staffing is
related to the rates of the five outcomes.
. Shorter LOS is related to higher levels of
overall staffing per NIWadjusted day.

Study Findings (Cont.)

Lower complication rates are associated
with a higher mix of RNs among licensed
nursing personnel for all four complications.
Pressure ulcers show lower rates where
both staffing per acuity adjusted day and RN
mix are higher.
Lower post-operative infection rates (allpayor data set only) are related to more
licensed hours per NIWadjusted patient day.

Study Findings (Cont.)

Lower rates of bacterial/unspecified
pneumonia complications were
related to a richer staffing mix. [the
one exception being with the
Medicare-only data set].
Longer case-mix adjusted LOS are
found in primary medical school and
other teaching hospitals.

Study Findings (Cont.)

Significantly lower rates of pressure
ulcers and urinary tract infections were
found in primary medical school
hospitals.
Significantly higher rates of postoperative
infections, urinary tract infections and,
especially, pressure ulcers were found in
hospitals located in large urban areas.

Implications
Consistent relationships exist between
nurse staffing, and both LOS and adverse
patient outcomes.
Further evidence is added to a rapidly
growing body of research which
demonstrates the importance of registered
nurses, as well as other nursing
personnel, to the prevention of adverse
patient outcomes.

Implications (Cont.)
Cutting staff to save money may endanger
the patients well-being.
Cutting staff to save money may lengthen
patient stays, increase complication rates
and, thus, increase costs.
Nursing care CAN be quantified as a
critical component of patient care and of
patients well-being.