The Role of Nurses in Hospital Quality Improvement

Nurses are directly involved in almost all aspects of hospital quality, including patient care, bedside and medication management, assistance with surgeries and other major operations, data collection/reporting, and more.

Furthermore, nurses are directly responsible for monitoring and assessing patients, and performing immediate interventions to reduce risk or prevent medical complications. Nurses also oversee other care providers, i.e. CNAs, LPNs, patient care technicians, caregivers, and more. An attending nurse even helps educate patients and family members regarding post hospital care, before discharge.

These are the reasons nurses play an important role when it comes to improving hospital quality in general.

Demand for Hospital Quality Improvement

The demand for quality improvement in hospitals is ever increasing due to federal government mandates, as well as local requirements, accreditation or regulatory boards, hospital organizations, medical societies, non-profit organizations (NGOs) and and health insurance plans. Core qualities reported may vary in terms of target medical concern or hospital department, but in most cases, employee and patient feedback is included in the measurement.

The Joint Commission aims to standardize measurements used to check hospital quality. Primary factors relate to the hospital as a whole, medical staff (nurses in particular) and patients.

Since the measurements used vary, attempts to standardize the process have been made. While it’s not final, the Joint Commission’s efforts have been the most conclusive. Their measures include the following:

• Failure to rescue
• Falls as well as falls with injury
• Prevalence of pressure ulcer as well as restraint (vest and limb)
• Intensive care unit (ICU) concerns such as urinary catheter-associated urinary tract infections, central line catheter-associated bloodstream infections and ventilator-associated pneumonia
• Smoking related counseling for acute myocardial infarction, heart failure and pneumonia
• Skill mix
• Scheduled hours daily versus number of patients assisted
• Practice Environment Scale of the Nursing Work Index (PES-NWI)
• Voluntary turnover

Magnet Recognition

Among numerous programs demanding or requesting hospital quality improvement, the most relevant for nurses is the Magnet Recognition. It was developed by the American Nurses Credentialing Center (ANCC) – a subsidiary of the American Nurses Association – in order to recognize hospitals which provide nursing excellence.

The Magnet Recognition program is based on an appraisal consisting of 14 characteristics. Foundationally, Magnet looks for a strong presence of nurses in the organizational committee structure of hospitals – including executive functions – empowering nurses in all levels to have a voice in hospital processes. While Magnet was originally focused on recognizing hospitals with higher nurse retention, there are researchers which have proven that Magnet-awarded medical institutions boast of lower mortality rates and higher hospital quality care in general.

The Magnet Recognition by the American Nurses Credentialing Center (ANCC) – a subsidiary of the American Nurses Association – observes hospitals which provide nursing excellence.

Most programs agree that quality improvement is everyone’s responsibility – hospital leaders (executives, board), physicians, nurses, and all other members of the hospital staff. Leaders set the tone, but everyone should be similarly held accountable for success or failure.

Patient Based Quality

Patients have a different definition of quality. In a study conducted by Picker Institute Europe, most people who have been admitted to hospitals agree on the following considerations for quality medical care:

1. Patients (as well as their families) are involved when it comes to making medical decisions. Their preferences, even when against sound medical judgement, are respected.
2. Self-care is supported, in case they prefer this instead of being managed by others (i.e. nurses).
3. Information is effectively communicated at a level they can understand.
4. Empathy and emotional support is provided by medical staff. The latter (including the hospital as a whole) should also be attentive to their physical and environmental needs.
5. Fast and reliable health advice
6. Effective diagnosis, treatment, and medication
7. Continuity of care after discharge

Challenges Involved

Some of the usual hindrances involved revolve around nurses. Problems include inadequate staffing or uneven distribution of schedules, demanding responsibility which covers all aspects of patient care, ineffective nurse training, inefficient administrative tasks, and traditional nursing education, which often clashes with advancing nursing techniques.

Staffing and Patient Care Quality

In relation to staffing and scheduling, research from the Institute of Medicine (IOM) pointed out the direct connection between hospital care quality and nurse staffing.

Staffing is directly related to hospital budget considerations as well as the demand of the local labor market for nurses. Quality of care, on the other hand, is dependent on various factors, such as a nurse’s experience, skills, and education. Another important aspect is the human factor. Fatigue and stress can lead to a decline in patient care quality due to errors in medication, treatment, usage of medical devices, data reporting, and more.

Hospital staffing and quality of care are directly related.

Staffing concerns don’t just involve the total number of nurses employed. They also include other factors, like the ratio of nurses to patients, as well as the experience, skill and education of nurses assigned. Since most hospitals are aware of when human traffic is heaviest, shifts are evenly distributed to cover the influx of patients, with novice nurses scheduled alongside experienced ones. Although there are emergency situations when there are more patients than usual (i.e. major accidents, natural disasters and so on), in most cases, traffic is predictable. This way, nurses aren’t overworked, affecting their performance and the quality of care provided.

Other Factors Related to Quality

Aside from adequate staffing, other factors directly affecting quality include the following:

• 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)
• Collaborative working environment (particularly between nurses and doctors)
• Patient-centered culture (patients over revenue)
• Availability of continuing education and training options

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.

Tine Health

Tine Health resolves one of the major challenges involved when it comes to hospital quality improvement: ineffective nurse training. We provide just-in-time training (JITT), using microlearning videos that are available anytime via a smartphone or tablet. This way, training is available exactly when it’s needed, even while on the go.

Article Sources:

• Health System Change
  http://www.hschange.org/CONTENT/972/
• Health Affairs
  http://content.healthaffairs.org/content/28/4/w625.full
• National Center for Biotechnology Information
  https://www.ncbi.nlm.nih.gov/books/NBK2676/
• BMC Health Services Research
  https://bmchealthservres.biomedcentral.com/articles/10.1186/1472-6963-14-249