Nursing Quality Indicators

Dr Jothi Clara J Michael,

Director Of Nursing, IHH IN
Vice President ANEI
- CAHO CQE Series - 28th Aug 2021

© All Rights Reserved. This material is confidential and property of IHH Healthcare Berhad. No part of this material should be reproduced or published
in any form by any means, nor should the material be disclosed to third parties without the consent of IHH.
History of Nursing Quality Indicators
(NQI)

• The Beginning of Evaluating the quality of nursing practice

- When Florence Nightingale began to measure patient outcomes.

• Reflection for today: She used statistical methods to generate reports correlating patient outcomes to environmental
conditions (Dossey, 2005; Nightingale, 1859/1946).

• Over the years, quality measurement in health care has evolved – Quality Assurance - Continuous Quality Improvement,
Quality Movement & Campaign, Accreditation Awards and Recognition ………Moving beyond Accreditation ……

• India – QCI, NABH, CAHO, JCI, NABH NE etc.…

• We learn from advanced countries: The work done in the 1970s by the American Nurses Association (ANA), the wide
dissemination of the Quality Assurance (QA) model (Rantz, 1995), and the introduction of Donabedian's structure, process,
and outcomes model (Donabedian, 1988, 1992) have offered a comprehensive method for evaluating health care quality
specifically in Nursing.
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 VAP CLABSI
Rate

Inpatient
Fall Rate

CAUTI SSI QUALITY

INDICATORS –
Familiar NQIs
Hand
Hospital Hygiene
Associated Compliance
Pressure Rate
Ulcer
Nursing
Attrition
Rate

Incidence
Medication of Needle
Errors Stick
Injuries

3
What is Nursing Quality Indicator?
The Nursing Quality Indicators are measures of Nursing care quality that use readily available
hospital inpatient administrative data.

What is Continuous Nursing quality improvement (CNQI)?

Continuous Nursing quality improvement (CNQI) is the key to care excellence to match with the
paradigm shift in roles of health care professionals, expectations from consumers and technological
advancements in Health care. Safety and quality are integral aspects of Nursing Care Continuum.

0 ∞
More than What, Why and How is significant when it comes to NQI 4
Let us Reflect

For patients, what helps make their hospital stay a much better experience & how nursing care
impacts?

………………A smart competent people friendly health care provider at their bedside.

Who else other than Nurses can be fitting into this …

What helps these providers perform better especially “The Nurses”?

..………….. An environment that encourages/ nourishes proactive & predictive

behaviors directed toward prioritizing patient care.

How to evaluate the quality of care? …..………...Right and Appropriate Quality Indicators

Where? How? Who?

Destination Values Team 5
Why NQI ?
• It remains a critical element in the nursing professional tool kit to ensure
accountability, transparency, and quality improvement.
Why monito QI ?
• To carry out interdisciplinary processes to meet organizational QI goals and to
measure, improve, and control nursing-sensitive indicators (NSI) affecting patient
outcomes specific to nursing practices.
• Monitor for early recognition of adverse events, complications and errors.
• Initiating deployment of appropriate and timely nursing care to aid patients in speedy
recovery.
• To ensure TAT in clinical process.
For assessing the provided care & improving the quality of care
For defining strategies to achieve goals & redefining patient care. 6
How do we identify QI for Nursing Service?
– Its Nursing Domain Decision

Scope/ Center Eg: Medication

Depth/Limit
of Excellence Error

No specified size • Incidence of Medication Error

• General Medical and limit for the • Incidence of prescription error
and Surgical number of QI that • Incidence of transcription error
• Superspecialist – can be monitored. • Incidence of dispensing error
Transplantation How ever critical • Incidence of administration error
• Obstetrics NQIs are • Percentage of admissions with ADR
• Orthopedics significant. • Percentage of medication charts
• Neurology with error prone abbreviations
• Pediatrics • Compliance rate to Medication
• Oncology Prescription in capitals
• Percentage of patients receiving
high risk medications developing
Key Principle: adverse drug event.
• Appropriate & Relevant Eg: Initiation of Breast feeding • Percentage of contrast allergic
– Obstetrics Nursing reaction
• Simple to Complex – Eg. Pressure Injury (PI) to PI • Number of patients on NG tube
Healing pattern receiving Non- enteric coated drugs.
• Common / Routine to uncommon/ Rare 7
Nursing Indicator – Safe Staffing For Example

Planned, High levels

Compliance
required and and/or ongoing
Nursing with any
Missed breaks available reliance on
overtime mandatory
nurses for each temporary
training
shift nursing

Nursing staff Nursing staff The number of Temporary- Compliance of

unable to take working planned, required pull in & pull ward nursing
scheduled extra hours and available out nursing staff with any
breaks nursing hours on staff on mandatory
hospital inpatient hospital training in
wards in relation inpatient accordance
to bed utilization. wards. with local policy

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Importance of NQI in NABH & JCI

NABH NE

Ref: NABH NE

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Ref: JCI Standards
Nursing Sensitive Indicators- Structure Process & Outcome Model

• Includes the supply of nursing staff, the skill level of nursing

Structural Indicators staff, equipment, education and certification levels of
nursing staff.

• Measure methods of patient assessment and nursing

Process Indicators interventions and competency assessment. Nurses job
satisfaction is also considered a process indicator.

• Reflect patient outcomes that are determined to be nursing-

sensitive because they depend on the quantity or quality of
Outcome Indicators nursing care outcome. These include pressure ulcers and
falls.

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Ref: https://www.americansentinel.edu/blog/2011/11/02/what-are-nursing-sensitive-quality-indicators-anyway/
Structure Process Outcome Model
Nursing Focused Nurse Focused outcome
Organizational- Focused
Process/Intervention Indicators
Structural Indicators
Indicators
• Nurses Job satisfaction
*Nurse Staffing Characteristics • Nurse reported quality of care
Number of Nursing Staff • Treatment and
Procedures • Nurse burnout
Number Staffing Ratio • Nurse turnover
• Pain Management
Nurse Staffing Levels • Maintenance of skin
Nurse Staffing Qualifications integrity
Nurse Experience • Patient Education
Nurse Education
Patient Focused
*Hospital Characteristics Outcome Indicators
Work Schedule
Patient Safety • Nosocomial Infection
Patient turnover • Mortality
Work environment • Pressure ulcer
Nurse autonomy • Patient Satisfaction
Case Mix • Patient falls
• Patient falls with injury
• LOS
• DVT/Pulmonary Embolism
• Physical restrain use
• Shock/Cardiac arrest

STRUCTURE PROCESS OUTCOME 11

How are Nursing-Sensitive Indicators Developed ?

Nursing Panel
Identification of review’s the Conduct Pilot
Literature Review
potential Indicator validity of the study
Indicator

**Once the potential indicator has been empirically supported to be meaningful

in clinical practice and it has been determined that no undue burden would be
placed on participating facilities/ team. A pilot study is performed in willing
facilities/unit/area. It shall be an inclusive approach.
QI is basis
for BSC
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Nursing Sensitive Indicators - Classification

INDICATOR SUB- INDICATOR MEASURE

• Nursing Hours per Patient Day Registered Nurses (RN) Structure

• Patient Falls with Injury Injury Level Process & Outcome

• Pressure Ulcer Prevalence Community Acquired Process & Outcome

Hospital Acquired
Unit Acquired

• Nosocomial Infections Community Acquired Process & Outcome

a. Urinary catheter-associated urinary tract infection Hospital Acquired
(UTI) Unit Acquired
b. Central line catheter associated blood stream
infection (CABSI)
c. Ventilator-associated pneumonia (VAP)

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This is not enough we need to move to next level
to impact outcome

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Benchmarking QI for Nursing
– Where do we position our Nursing Care

Benchmarking - A continuous process comparing an organization's performance against that of the best
in the industry considering critical consumer needs and determining what should be improved.

Benchmarking Encompasses:

• Regularly comparing indicators (structure, activities, processes and outcomes) against best
practitioners

• Identifying differences in outcomes through inter-organizational visits

• Seeking out new approaches in order to make improvements that will have the greatest impact on
outcomes; and Monitoring Indicators. Here comes Ideation, Innovation & Enovation

Benchmarking can be done at Department level, hospital level, National level or international level.
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Steps of Benchmarking

1. Select the object of the benchmarking (the service or activity to be improved).

2. Identify benchmarking partners (reference points).

3. Collect and organize data internally.

4. Identify the competitive gap by comparing against external data.

5. Set future performance targets (objectives).

6. Communicate the benchmarking results.

7. Develop action plans.

8. Take concrete action (project management).

9. Monitor progress. 16
Ref: Pitarelli and Monnier (2000)
Linking NQI to Performance of an Organization

Better professional
Better outcomes for
development
participant & population
(competence, pride, joy)

Everyone

Better program performance

(Quality & Value)

Change does not necessarily result in improvement, but improvement always brings change 17
Role of Nurse in Quality Improvement

• To carry out interdisciplinary processes to meet organizational QI goals and to measure, improve,
and control nursing-sensitive indicators (NSI) affecting patient outcomes specific to nursing
practices.

• All levels of nurses, from the direct care bedside nurse to the chief nursing officer (CNO), play a
part in promoting QI within the healthcare provider organization.

• Monitor for early recognition of adverse events, complications and errors.

• Initiating deployment of appropriate and timely nursing care to aid patients hastens speedy
recovery.

• Sharpen Nurses EQ/CQ & Empower them to Express without fear while at Bedside or in
Boardroom
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Involvement of Nurses at Various level in monitoring QI

The CNO The nurse manager (NM) The direct care nurse/Bed side RN

• CNOs set the tone for the • The NM is responsible for

nursing department's communicating and • The direct care bedside nurse
participation in QI. operationalizing the is the key to quality patient
organization's QI goals and outcomes, carrying out the
• As a member of processes to the bedside protocols and standards of care
administrative leadership, the nurse, identifying specific shown by evidence to improve
CNO must integrate nursing NSIs that need improvement patient care.
practices into the according to his or her
organizational goals for particular patient population,
excellence in patient and coordinating QI
outcomes through processes to improve these at
communication of strategic the unit level
goals to all levels of staff.

Data Originator? Data Validation?

Not an additional task, but a frame of mind

Creating A Mindset for the Context is very significant 19

Other Factors Related to Quality

Competent nurses

Independent and autonomous practice (micro-management is frowned upon, even in other professions)

Management support (recognitions, team building, and other activities or programs are present)

Patient-centered culture (patients over revenue)

Collaborative working environment (particularly between nurses and doctors)

Availability of continuing education and training options ( engagement of team & newer approaches )

Nurses directly affect the quality of hospital care - All efforts to train them and maintain their value should be
addressed. Nurses will – in turn – pass the same value and care along to their patients.

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The difficulties encountered by RNs while implementing QI

Inadequate number of
Lack of time
professionals

Lack of knowledge on the Lack of understanding of how to

subject. use these instruments

CRITICAL FACTOR -Available

level of nurse staffing

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Relationship between Quality of care and Staff Empowerment

What Builds Staff Empowerment?

Staff
Empowerment
1. Leader support and teams.
2. Communication and information
sharing.
Increased
Job 3. Positive reinforcement.
Satisfaction,
Lower Job 4. Confidence.
Turnover
5. Just Culture
Increased
Patient
satisfaction &
Perception of
care Barriers for Staff Empowerment?

Higher
1. Lack of senior leader support.
Quality of
care
2. Lack of resources.
3. Poor teamwork and support.
Nursing 4. Stagnation and loss of
Quality of momentum for change.
Care-
Measured
through NQI
5. Staff turnover.
6. Punitive response to error. 22
References

• https://www.nice.org.uk/guidance/sg1/chapter/9-safe-nursing-indicators

• https://ojin.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/Tabl
eofContents/Volume122007/No3Sept07/NursingQualityIndicators.aspx

• https://www.hcpro.com/NRS-248978-868/Ask-the-expert-Understanding-nursing-roles-in-
quality-improvement.html

• https://www.americansentinel.edu/blog/2011/11/02/what-are-nursing-sensitive-quality-
indicators-anyway/

• NQI - https://www.qualityindicators.ahrq.gov/

• NABH Standards & JCI Standards Books

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Thank You

Nurse you are a Patient Advocate &

Express without fear while
at Bedside or in Boardroom.

© All Rights Reserved. This material is confidential and property of IHH Healthcare Berhad. No part of this material should be reproduced or published
in any form by any means, nor should the material be disclosed to third parties without the consent of IHH.