Nursing-Sensitive Quality

Indicators and Safety Initiatives

by Sheila Lucas, Todd Nickoles, Karrie Pater, Tammy Selleck

NURS541: Quality Improvement and Safety

Ferris State University

Summer 2014

Nursing – Sensitive Indicators (NSI)

• Nursing care specific

• Structure, Process, Outcomes

• The National Database of Nursing Quality Indicators (NDNQI)

(ANA, 2014; Montalvo, 2007)

NSI – Falls

• Description: • A fall is an unplanned descent to the floor during the hospital stay

• Falls Prevalence:• Accidental falls occur in about 2% of hospital stays and vary by unit

• Process and Outcome Indicators

(Montalvo, 2007; NDNQI, 2012)

NSI- Falls

• Evidence:• Structure characteristics had a positive impact on quality of care related to

falls

• Outcomes are affected by both quality and quantity of nursing care

• Magnet Hospitals

(Boltz, Capezuti, Wagner, Rosenbera, Secic, 2013; Everhart et al., 2014 )

NSI – RN Education/Certification

• Description: • Level of education or additional education to enhance knowledge in a

particular area

• A structural indicator of nursing care

(Montalvo, 2007)

NSI – RN Education/Certification (cont.)

• Evidence:• Certifications improved safety outcomes

• Quality nursing outcome

• Magnet Hospitals

(Boltz, Capezuti, Wagner, Rosenbera, & Secic, 2013; Everhart et al., 2014; Montalvo, 2007)

NSI – Nursing Turnover

• Description: Voluntary nursing turnover as a measurement of nursing care

• Evidence: • High Turnover rate within first two years of practice

• Professional Respect, unrealistic expectations, high demand, poor staffing

• Higher rate of patient mortality and failure to rescue

• Increased financial burden on organizations

NSI – Nurse Practice Environment Scale

• Description: Survey completed by nursing staff in acute care settings

• Evidence: • Guide in the development and implementation of Evidenced based nursing

leadership practices

• Links PES scores with patient satisfaction and improved patient care

• Could be modified to be used in outpatient settings

NSI – Nursing Hours per Patient Day

• Description: • Productive hours worked by nursing staff per patient day

• RN and by nursing staff• Focus on in-patient acute care units

• Structure Indicators• Endorsed by the National Quality Forum

(Montalvo, 2007; ANA, 2014)

NSI – Nursing Hours per Patient Day (cont.)

• Evidence:• Kane et al., 2007 – AHRQ-supported review, benefits of higher nurse staffing

ratios

• Lang et al., 2004 – California DHS – no specific ratio, but improved outcomes

• Aiken et al., 2011 – lower ratios improved outcomes in good work environments

• Everhart et al., 2013; Cho et al., 2003; Lang et al., 2004 all supported better financial outcomes for hospitals with higher nurse staffing ratios

(Kane et al., 2007; Lang et al., 2004; Aiken et al., 2011; Everhart et al., 2013; Cho et al., 2003)

NSI – Staff Skill Mix

• Description: • Percentage of total worked hours by each direct patient care

provider

• Structure Indicators• Endorsed by the National Quality Forum

(ANA, 2014)

NSI – Staff Skill Mix (cont.)

• Evidence:• Ridley, 2008 – effects on 30-day mortality, pressure ulcer, pneumonia, UTI

and post-operative infection

• Aiken et al., 2011 – reductions in mortality and failure to rescue

• Esparza et al., 2012 – higher RN proportions associated with reduced LOS and UTI

(Ridley, 2008; Aiken et al., 2011; Esparza et al., 2012)

NSI - Pressure Ulcers/Sores

• Description: Hospital-acquired pressure ulcer growth conveys need for quality nurse education on early detection and intervention to decrease prevalence of complications

• Evidence:• Pressure sores cause financial and health complications

• Costs to facility for treatment is substantial, length of stays increased, and other health complications can ensue as a result

• Nurses lack proper education • Educated nurses lead to decrease prevalence in development

• Shorter length of stays, less money being spent, and less chances of infections being acquired by the patients

(Bergquist-Beringer et al., 2011, Hart et al., 2010; Montalvo, 2009; MHA, 2010; Wurster, 2009)

NSI - Pressure Ulcers/Sores (cont.)

• Data and research: • Issues to educate nurses on:

• Performing risk factor/skin assessments and Braden scale

• Quality nursing care = turning, elevating the head of bed, providing cushions, using turn sheets and performing proper skin care

• Properly treat pressure ulcers once developed

• Bergquist-Beringer et al. (2011) and Hart et al. (2010)• Surveys taken on treatment and prevention before and after NDNQI online

pressure ulcer training program

• Results= Nurses were moderate to near perfect reliability in differentiating and staging pressure ulcers

(Bergquist-Beringer et al., 2011, Hart et al., 2010; Montalvo, 2009; MHA, 2010; Wurster, 2009)

NSI – Pain Management

• Description: Nurses to assess more often and deconstruct barriers to giving medications; thereby, increasing patient comfort and quality

• Evidence: • Moderate prevalence of pain among Americans

• Unrelieved pain = significant consequences

• Pain not being well assessed nor managed due barrier development• Barriers= Lack of education on assessing pain, fear of overly medicating due to

medication side effects, having expectations that pain is apart of having certain disease or heath issues

• Education can deconstruct and minimize barriers• Pain assessment scales are effective

(Hanks-Bell et al., 2010; Idvall, 2010; Zoega, 2014)

NSI – Pain Management (cont.)

• Evidence:• Managing pain =

• Better management of disease symptoms

• Quicker facilitation of the recovery process

• Decreases in patient discomfort, readmissions, prevalence of other pain related disorders

• Nurses need to assess more often, decreasing barriers and understand pain scales

• Idvall et al. (2010) and Zoega et al. (2014)• Joint Commission= Nurses are the key in managing patients’ pain

• After education, nurses had higher patient satisfaction rates• Discomfort was eliminated

• Lead to quicker facilitation of recovery process

• Patients experienced less complications

(Hanks-Bell et al., 2010; Idvall, 2010; Zoega, 2014)

Safety Initiative Introduction

Agency for Healthcare Quality and Research (AHRQ) Patient Surveys(AHRQ, 2013)

Safety Initiative Introduction (cont.)

• Main goal of AHRQ: Support culture of patient safety and quality improvement in nation's health care system • Intent: Positive impact on patient safety

• Providing knowledge and tools

• Creating solutions that alleviate or eliminate harm to patients

• Purpose:

• Eliminating or minimizing hazards that compromise patient safety

• Promoting staff to take the healthcare safety surveys

• Identifies threats to patient safety

• Teaching, disseminating, and implementing effective patient safety practices with evaluation new strategies

(AHRQ, 2013)

Safety Initiative – Nursing Home Surveys

• Description: Designed for nursing home providers and staff • Employee opinions about culture of patient safety in nursing home

• Impact: Creates positive impact on patient safety by providing knowledge and tools • Understand errors to create solutions that alleviate or eliminate harm to patients

• Role of Nursing: • Identifying threats to patient safety in long-term care facilities

• Disseminate data to form teaching strategies

(AHRQ, 2014)

Safety Initiative – Nursing Home Surveys (cont.)

• Evidence:• AHRQ Comparative Database 2011 Report

• 86% believing their residents are safe

• 52% believed poor staffing was an issue

• 51% responded nonpunitive measures were not taken for nursing safety mistakes

• Castle et al. (2010) and Hughes and Lapane (2009)• Created patient safety surveys

• 60% of nursing assistants and 80% of nurses reported a safety problem

• Providing patients safety = means delivering quality care for the residents

(AHRQ, 2014; Castle et al., 2010; Hughes & Lapane, 2009)

Safety Initiative – Medical Office Survey

• Description: Focus on individual medical practices and employee perception of the practices safety culture

• Impact: Provides data to improve the practice safety culture

• Role of Nursing: • Preventing medication errors and falls• Collaborating, coordinating, and integrating care

(U.S. Department of Health and Human Services, 2014; Hughes & Clancy, 2009)

Safety Initiative – Medical Office Survey (cont.)

• Evidence:• Identifying safety concerns and problem solving to improve patient safety

• Benefits of collaboration and coordination to improve patient safety

(Elder, McEwen, Floch, & Gallimore, 2009; Stanton & Dunkin, 2009)

Safety Initiative – Community Pharmacy Survey on Patient Safety Culture

• Description: designed for community pharmacies as a way to measure and improve patient safety

• Impact: Identifies problems or potential problems to improve patient medication safety

• Role of Nursing:• Early identification of problems

• Direct communication

• Active participants in pharmacy patient safety

Safety Initiative – Hospital Survey

• Description: Focus on hospitals and staff perceptions of patient safety culture

• Impact: Provides data and comparisons to improve patient safety culture

• Role of Nursing: • Staffing role supporting domains of patient safety culture• Leadership role driving culture change

(AHRQ, 2014; Blegen, et al., 2009; Sorra et al., 2007; Sorra et al., 2012)

Conclusion

• Nursing-sensitive quality indicators

• Patient safety culture initiatives

References

• Agency for Healthcare Quality and Research [AHRQ]. (2014). Nursing home survey on patient safety culture. Retrieved from http://www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/nursing-home/index.html

• Agency for Healthcare Quality and Research [AHRQ]. (2013). Surveys on patient safety culture. Retrieved from http://www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/index.html

• Aiken, L.H., Cimiotti, J.P., Sloane, D.M., Smith, H.L., Flynn, L., & Neff, D.F. (2011). Effects of nurse staffing and nurse education on patient deaths in hospitals with different nurse work environments. Medical Care, 49(12):1047-1053. doi: 10.1097/MLR.0b013e3182330b6e

• Aiken, L., Clarke, S., Sloane, D., Sochakski, J., & Silber, J. (2002). Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. Journal of the American Medical Association. 288(16)1987-1993. Retrieved from PubMed. PMID: 12387650

• American Nurses Association (n.d.). Safe Staffing: The Registered Nurse Safe Staffing Act HR 1821. Retrieved from http://www.rnaction.org/site/DocServer/RN_Safe_Staffing_Act_2013-One_Pager.pdf?docID=1761

• American Nurses Association [ANA].(2014). About NDNQI. Retrieved from https://www.nursingquality.org/About-NDNQI

• American Nurses Association [ANA].(1999). ANA indicator history. Retrieved from http://www.nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/PatientSafetyQuality/Research-Measurement/The-National-Database/Nursing-Sensitive-Indicators_1/ANA-Indicator-History

• American Nurses Association [ANA].(2014). Nursing- sensitive indicators. Retrieved from http://www.nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/PatientSafetyQuality/Research-Measurement/The-National-Database/Nursing-Sensitive-Indicators_1

• Bergquist-Beringer, S., Gejewski, B., & Klaus, S. (2011). The reliability of the National Database of Nursing Quality Indicators pressure ulcer indicator: A triangulation approach. Journal of Quality Nursing Care, 26(4), 296-301.

• Blegen, M.A., Gearhart, S., O’Brien, R., Sehgal, N.L., & Aldredge, B.K. (2009). AHRQ’s hospital survey on patient safety culture: Psychometric analysis. Journal of Patient Safety, 5(3):139-144. doi: 10.1097/PTS.0b013e3181b53f6e

• Boev, C. (2012). The Relationship between Nurses' Perception of Work Environment and Patient Satisfaction in Adult Critical Care. Journal of Nursing Scholarship, 44(4), 368-375. doi:10.1111/j.1547-5069.2012.01466.x

References (cont.)

• Boltz, M., Capezuti, E., Wagner, L., Rosenber, M., & Secic, M. (2013). Patient safety in medical surgical units: can nurse certification make a difference?MedSurg Nursing, 22 (1), 26-37, 37. Retrieved from https://www.amsn.org/professional.development/periodicals/medsurg-nursingjournal

• Castle, N., Wagner, L., Perara, S., Furguson, J., & Handler, S. (2010). Assessing resident safety culture in nursing homes: Using the nursing home survey on resident safety. Journal of Patient Safety, 6(2), 60-67.

• Cho, S.H., Ketefian, S., Barkauskas, V.H., & Smith, D.G. (2003). The effects of nurse staffing on adverse events, morbidity, mortality, and medical costs. Nursing Research, 52(2):71-79. Retrieved from PubMed Database (PMID:12657982)

• Elder, N.C., McEwen, T.R., Flach, J.M. & Gallimore, J.J. (2009). Management of test results in family medicine. Annals of Family Medicine,7, 343-351. doi:10.1370/afm.961

• Esparza, S.J., Zoller, J.S., White, A.W., & Highfield, M.E. (2012). Nurse staffing and skill mix patterns: Are there differences in outcomes? Journal of Healthcare Risk Management, 31(3):14-23. doi: 10.1002/jhrm.20092

• Everhart, D., Neff, D., Al-Amin, M., Nogle, J., & Weech-Moldonado, R. (2013). The effects of nurse staffing on hospital financial performance: Competitive versus less competitive markets. Health Care Management Review, 38(2): 146-155. doi:10.1097/HMR.0b013e318257292b

• Everhart, D. Schumacher, J.R., Duncan, P.R., Hall, A.G., Neff, D.F.,& Shorr, R.I. (2014). Determinants of hospital fall rate trajectory groups: a longitudinal assessment of nurse staffing and organizational characteristics. Health Care Management (March 2014). doi:10.1097/HMR.00000000000000133

• Friese, C. R., & Manojlovich, M. (2012). Nurse-physician relationships in ambulatory oncology settings. Journal of Nursing Scholarship, 44(3), 258-265. doi:10.1111/j.1547-5069.2012.01458.x

• Hanks-Bell, M., Halvey, K., & Paice, J. (2010). Pain assessment and management in aging. The Online Journal of Issues in Nursing, 9(3), 1-15.

• Hart, S., Berquist, S., Gejewski, B., & Dunston, N. (2010). Reliability testing of the National Database of Quality Nursing Indicators. Journal of Nursing Issues, 12(8), 1-8.

• Hughes, C., & Lapane, K. (2009). Nurses’ and nursing assistants’ perceptions of patient safety culture in nursing homes. Journal of Quality Healthcare, 18(4), 181-186.

• Hughes, R.G., & Clancy, C.M. (2009). Nurses’ role in patient safety. Journal of Nursing Care Quality, 24, 1-4. doi:10.1097/NCQ.0b013e31818f55c7

References (cont.)

• Idvall, E., Hamrin, E., Sjostom, B., & Unosson, M. (2010). Quality indicators in postoperative pain management: A validation study. Nursing Scandinavian Journal of Nursing, 15(4), 331-338.

• Kane, R.L., Shamliyan, T.A., Mueller, C., Duval, S., & Wilt, T.J. (2007). The association of registered nurse staffing levels and patient outcomes: Systematic review and meta-analysis. Medical Care, 45(12):1195-1204. Retrieved from PubMed Database (PMID: 18007170)

• Kovner, C. & Brewer, C. 2011. RN Work Project. Retrieved from http://rnworkproject.org

• Lang, T.A., Hodge, M., Olson, V., Romano, P.S., & Kravitz, R.L. (2004). Nurse-patient ratios: A systematic review on the effects of nurse staffing on patient, nurse employee, and hospital outcomes. Journal of Nursing Administration, 34(7-8): 326-337. Retrieved from PubMed Database (PMID:15303051)

• Minnesota Hospital Association [MHA]. (2010). Preventing pressure ulcers. Retrieved from http://www.mnhospitals.org/patient-safety/current-safety-quality-initiatives/pressure-ulcers

• Montalvo, I. (2007). The national database of Nursing Quality Indicators (NDNQI). Retrieved from http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Volume122007/No3Sept07/NursingQualityIndicators.aspx?%3E

• Montalvo, I. (2009). Nursing Quality Indicator pressure ulcer indicator. Journal of Nursing Administration, 40(10), 256-265.

• Needleman, J., Buerhaus, P., Pankratz, V, Leibson, C., Stevens, S, Harris, M. (2011). Nursing staffing and inpatient hospital mortality. New England Journal of Medicine. 364 (11) 1037-1045. Retrieved from PubMed. PMID: 21410372

• Phipps, D., DeBie, J., Herborg, H., Guerreiro, M., Eickhoff, C., Fernandez-Llimos, F., Bouvy, M., Rossing, C., Mueller, U., Ashcroft D. (2012). Evaluation of the Pharmacy Safety Climate Questionaire in European community pharmacies. International Journal of Quality Health Care. 24 (1): 16-22 doi: 10.1093/intqhc/mzr070

• Ridley, R.T. (2008). The relationship between nurse education level and patient safety: An integrative review. Journal of Nursing Education, 47(4):149-156. Retrieved from PubMed Database (PMID: 18468291)

• Sorra, J., Nieva, V., Famolaro, T., Dyer, N. (2007) Hospital Survey on Patient Safety Culture: 2007 Comparative Database Report. (Prepared by Westat, Rockvlle, MD, under contract No. 233-02-0087, Task Order No. 18). AHRQ Publication No. 07-0025. Rockville, MD: Agency for Healthcare Research and Quality.

References (cont.)

• Sorra, J., Famolaro, T., Dyer, N., et al. (2012). Hospital Survey on Patient Safety Culture 2012 user comparative database report. (Prepared by Westat, Rockville, MD, under Contract No. HHSA 290200710024C). AHRQ Publication No. 12-0017. Rockville, MD: Agency for Healthcare Research and Quality.

• Stanton, M., & Dunkin, J. (2009). A review of case management functions related to transitions of care at a rural nurse managed clinic. Professional Case Management, 14, 321-327. doi:10.1097/NCM.0b013e3181c3d405

• Sullivan Havens, D., Warshawsky, N., & Vasey, J. (2012). The Nursing Practice Environment in Rural Hospitals: Practice Environment Scale of the Nursing Work Index Assessment. Journal of Nursing Administration, 42(11), 519-525. doi:10.1097/NNA.0b013e3182714506

• U.S. Department of Health and Human Services (2014). Medical office survey on patient safety culture. Retrieved from http://www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/medical-office/

• Wurster, J. (2009). What role can nurse leaders play in reducing the incidence of pressure sores? Nursing Economics, 25(5), 267-272.

• Zoega, S., Gunnarsdottir, S., Wilson, M., & Gordon, D. (2014). Quality pain management in adult hospitalized patients: A concept evaluation. Nursing Forum, 16, 1-10.