In 2004 the National Quality Forum (NQF), a non profit organization of various health care stakeholders, produced a set of national standardized performance measures to establish the relationship between nursing and health care quality.
Why measure nursing care? Here are some reasons why:
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1. Health care quality and safety will be increased.
2. The clinical practice of nursing, nursing and care teams will be enhanced.
3. There will be increased accountability of health care providers to the public.
4. The areas of nursing sensitive research that are top priority will be highlighted addressed and financially supported..
5. There will be acknowledgement of the need to educate and train the nursing workforce now and in the future.
6. Best practices will be shared and benchmarked.
7. There will be a quantifiable answer to the question: To what extent do nursing shortages affect the quality of health care?
NQF initially produced a set of 15 standards. 7 of the standards were patient outcome measures, 3 were nursing intervention measures, and five were system level indicators
The patient outcomes are: death of surgical patients with treatable serious complications (failure to rescue), prevalence of pressure ulcers, frequency of falls and falls with injury, prevalence of use of restraints, UTI associated catheter infections in ICU patients, bloodstream infections related to central line catheters in ICU and high risk nursery patients, and ventilator associated pneumonia, for ICU and high risk nursery patients.
The system level indicators are: Staff skill mix of RNs LVN, LPN, UAP (unlicensed assistive personnel) and contract nurses, nursing care hours per patient day (RN LPN, and UAP), Practice Environment Scale (Nursing Work Index), and voluntary turnover. (1)
Since the production of these standards the three nursing intervention measures (smoking cessation counseling for acute myocardial infarction, heart failure, and pneumonia) have been eliminated
The Interdisciplinary Nursing Quality Research Initiative (INQRI), an organization affiliated with the Robert Woods Johnson Foundation, advocates and facilitates research by nurses to develop new measures to improve nursing performance which in turn increases the quality of health care and decreases costs. Often times to improve nursing performance system changes must take place. Here is a summary of a few of the studies that pursue measurement and quantification of nursing care, all nurse led projects
At the University of Utah a nurse led team developed a survey tool based on quantitative and qualitative data to allow patients to express their opinion on how their pain was being managed during their hospital stay. The Pain CQ survey tool will hopefully be the precursor of a nursing performance measure for management of pain.
At Emory University a team of researchers set out to list the range of activities nurses use to coordinate care, such as mobilizing, exchanging, organizing, assisting and checking. This delineation of what is involved in coordination helped increase the understanding of the extent of care involved in coordination. A NQF Steering Committee was created to further research the topic. So far higher nurse ratings of care coordination have been correlated to reductions in medication errors, falls and increases in patient satisfaction. (2)
In avoiding medication errors nurses are a critical but mostly unknown factor in their prevention. Several research projects are pinpointing and specifying the interventions that nurses use to keep patients safe.
The first study worked to identify the effective nurse practices that prevent medication errors. It also examined the effects of nurse staffing on medication errors. After interviewing RNs in hospitals the research keyed in on several safety practices that nurses use to prevent errors, such as independent medication reconciliation, advocating for the patient and complete assessing of the patient. The processes are associated with strong communication and critical thinking skills within a collaborative environment with doctors. Hospitals that had a supportive practice atmosphere which allowed for nurse involvement in decision making and nurse managers were able to provide high quality patient care. A higher ratio of RNs to patients, and the full use of CPOE (computerized physician order entry) were also a key factors. (3)
A team at University of Wisconsin-Madison is researching how nurse use of medication management health information technology (MMHIT) and bar coding medication administration (BCMA) is affecting the rate of medication error. They hope to develop a set of measures that quantify nurse use of these technologies. The ultimate goal of these technologies would be to support nursing work through increased communication, identification and prevention of adverse events, and better error recovery processes.
Medication errors occur regularly when a patient is admitted or discharged from a medical center. At John Hopkins Hospital, a team is researching nurse pharmacist clinical information coordination teams and how they can increase medication reconciliation. The intervention involves communication between the parties involved to pinpoint discrepancies and resolve them to avoid adverse drug events.(4)
The prevention of medication errors depends on a ongoing commitment to principles of safety by the medical center. For example, Cedars- Sinai Hospital has a dedicated space where nurses can prepare medications. These spaces are no interruption zones. This commitment must involve skilled communication between all involved parties including the patient and their caregivers. Patient involvement as co managers of their care can be achieved if there are tools that can support their participation. A dedication to continual improvement through the testing of new systems and technology is also important.
Health care organizations that adopt nursing performance standards will help advance safer and improved health care for all patients through the acknowledgement of the value of nursing to health care.
Next article: A look into the past to point the way to the future.
(1) http://www.qualityforum.org/Projects/n-r/Nursing_Sensitive_Care_Initial_Measures/Nursing_Sensitive_Care_Initial_Measures.aspx
(2) www.rwjf.org/files/research/20090709chartingissue10.pdf
(3) http://www.inqri.org/CurrProf-2159.html
(4) http://www.inqri.org/uploads/ResearchSynthesisMedication Errors.pdf; http://www.inqri.org/uploads/MeasurementFINAL.pdf
http://books.nap.edu/Reports/2006/Preventing-Medication -Errors-Quality-Chasm-Series.aspx
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