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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 nursing’s quality indicators

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nurses assuring quality care for all populations

Nurses: Assuring Quality Care for all Populations

Leonard Davis Institute of Health Economics

University of Pennsylvania

Mary E. Foley, MS, RN


  • Identify concerns related to health care quality.
  • Define nursing’s quality indicators
  • Discuss ways in which nursing’s quality indicators can be used to determine quality of care.
the outcomes imperative
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
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
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
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


costs drive health care
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



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.


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 tomake decisions in the best interest of the patient.

nursing sensitive indicator
Nursing-Sensitive Indicator

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

why do it
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
Definitions of Quality(as it Relates to Health Care)

1920‑40 1940‑1960 1960 1970‑80

Minimum Absence of Capacity Adherence

Standards Defects to Give to

Good Care Standards

what quality is
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.

indicator selection criteria
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
  • Patient-Focused Outcome
  • Process of Care
  • Structure of Care
  • Mix of RN, LPN/VN & unlicensed staff
  • Total Nursing Care Hours Provided per Patient Day
  • Maintenance of Skin Integrity
  • Nurse Staff Satisfaction
outcome indicators
Outcome Indicators
  • Nosocomial Infection Rate
  • Patient Injury Rate
  • Patient Satisfaction
  • Nursing Care
  • Pain Management
  • Patient Education
  • ...From Indicators to Information
  • Purpose
  • Policies
  • Database Maintenance

Forces of Magnetism

Quality of Nursing Leadership

  • Leaders are perceived as knowledgeable, strong, risk-takers 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 other’s 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 development

  • Magnet 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
more issues to consider
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
community based non acute care indicators
Community‑Based, Non‑Acute 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
community based non acute care indicators1
Pain management

Consistency of communication

Staff mix

Client satisfaction

Prevention of tobacco use

Cardiovascular prevention

Care giver activity

Identification of primary care giver


Psychosocial inter-action

Community‑Based, Non‑Acute Care Indicators

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
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
States Included in Data
  • Arizona
  • California
  • Florida
  • Massachusetts
  • Minnesota*
  • New York
  • North Dakota*
  • Texas*
  • Virginia
  • Only Medicare data were available for these states
study findings
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 NIW-

adjusted day.

study findings cont
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 (all-payor data set only) are related to more licensed hours per NIW-

adjusted patient day.

study findings cont1
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 cont2
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.
  • 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
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.