Evaluation of the Quality Improvement Initiative Against Standard Benchmarks and Outcomes

Evaluation of the Quality Improvement Initiative Against Standard Benchmarks and Outcomes

A crucial point revealed in the analysis of the QI initiative is that a majority of the nurses in the medical and surgical units felt dissatisfied with their jobs because of overwork. Poor nursing outcomes at TGH are symptomatic of quality issues in the hospital’s nursing workforce. Therefore, prioritizing the quality of nursing is the first step to a successful QI initiative.

The statement is supported by certain assumptions about the value of nursing in achieving better patient outcomes:

• Nurses are the largest workforce in any health care setting and deliver most of the bedside patient care (Stalpers, de Brouwer, Kaljouw, & Schuurmans, 2015)
• Negative nursing outcomes reduce nursing quality, which can be improved by changing the work environment
• Poor nursing outcomes cause similar outcomes in other health care professionals as the latter depend on nurses to a large extent
• Improved nursing quality translates to improved quality of care and patient safety and depends on factors such as strong leadership, adequate staffing and infrastructure, and high standards in nursing education (Huber, 2017).

Guided by these assumptions, TGH evaluated the initiative using the IHI’s plan-do-study- act model (PDSA), which is a simple model that focuses on setting aims and selecting or developing benchmarks, outcomes, and measures that indicate if a new process or product resulted in improvement (Agency for Healthcare Research and Quality, 2017).

The PDSA’s cycle of systematic steps are as follows:

• Plan—involves developing goals and action plan
• Do— involves selecting measures to monitor progress
• Study—involves testing and refining actions on a small scale
• Act—involves expanding implementation to achieve sustainable improvement.

In accordance with the PDSA model, nursing quality was evaluated across three measures—structure, process, and outcomes—to understand neglected patient outcomes. The hospital focused on nurse-sensitive outcomes in patients—delirium, malnutrition, pain, patient falls, and pressure ulcers—that are the benchmarks of nursing quality (Stalpers et al., 2015).

Nurse-sensitive outcomes describe patient outcomes that rely on the quantity and quality of nursing. Additionally, the three measures are made up of nurse-sensitive quality indicators, which are indicators that quantify quality and capture nurse-sensitive outcomes (Heslop & Lu, 2014). These indicators are separate from medical indicators of care quality and are specific to nursing (Montalvo,2007).

The quality indicators were adapted by TGH for internal use in its medical and surgical units from the American Nurse Association’s National Database of Nursing Quality Indicators (NDNQI) and the National Quality Forum’s NQF 15.

Examples of some of the nurse-sensitive quality indicators used in the QI evaluation include

• Total number of nursing hours per day
• Details about nurse staffing—skill mix and staff ratios
• Records of patients’ characteristics
• Documentation of care plans by nurses
• Rate of adverse events
• Patients’ length of stay and level of satisfaction with care
• Average waiting time for nursing care (Heslop & Lu, 2014).

Using these nurse-sensitive indicators in the evaluation allowed TGH to determine the nursing structures and processes that were underperforming and needed improvement.

The evaluation revealed three nurse-sensitive patient outcomes occurring in the units— pain, patient falls, and pressure ulcers—that directly result from a fall in nursing quality and are evidence of an unsuccessful QI initiative. To form a better understanding of quality in nursing and nursing care, certain interprofessional perspectives on initiative functionality and results must be identified. Examining the perspectives will help ascertain the underlying factors in health care that nursing depends on to function well.

Interprofessional Perspective on Initiative Functionality and Outcomes

Various studies have attempted to understand the different processes and systems driving nursing quality and nursing care. These studies have become more relevant in health care becau

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