Learning Objectives
By the end of this section, you will be able to:
- Describe quality assurance programs used in the evaluation phase
- Recognize how quality improvement programs guide patient care
- Identify how patient satisfaction programs influence quality of care
- Recognize how nursing-specific patient safety and quality initiative programs are incorporated into the evaluation phase
In nursing, quality is the cornerstone of effective patient care and positive health outcomes. Quality can be defined as the degree to which nursing services for healthcare consumers, families, groups, communities, and populations increase the likelihood of desirable outcomes and are consistent with evolving nursing knowledge (Agency for Healthcare Research and Quality, 2020). This definition underscores the dynamic nature of nursing, highlighting the necessity for services to achieve desired outcomes and evolve in tandem with expanding knowledge and practices in the field.
Quality in nursing is a multifaceted concept, encompassing patient safety, effectiveness, efficiency, equity, timeliness, and patient-centeredness. More information about quality is provided in Chapter 15 Evidence-Based Research, Quality Improvement, and Collaborative Practice.
This module focuses on the connection between quality and the evaluation phase of the nursing process. As discussed in earlier chapters, evaluation in nursing is not just an endpoint—it’s a vital component of a continuous cycle of improvement. Through evaluation, nurses ensure that their practice is based on the best available evidence and is responsive to the unique needs and preferences of each patient.
Quality Assurance Programs
As a crucial part of many industries and professions, quality assurance (QA) is oversight that ensures current quality standards are met and that staff receive the education and infrastructure support to maintain quality (Selvi, 2018). In nursing, quality encompasses behaviors or processes that result in quality health care. Such actions utilize practices that are consistent with current evidence and knowledge to improve the chances of preferred patient outcomes and decrease the chances of negative outcomes, such as errors.
QA programs in nursing range widely, reflecting the diversity of the healthcare field. Infection control protocols, patient safety measures, staff competency assessments, and performance reviews of clinical procedures are all examples of QA. A common theme among the programs is that they use systematic assessments, audits, and reviews to monitor performance, identify areas for improvement, and implement strategies to enhance the quality of patient care.
By integrating QA programs into the evaluation phase, healthcare organizations can proactively address issues, optimize care-delivery processes, and improve patient outcomes and satisfaction. In an inpatient setting, a QA program might focus on reducing hospital-acquired infections through rigorous hygiene practices and patient monitoring. In a community health setting, QA could involve ensuring home health nurses have up-to-date training in the latest home-care techniques and technologies. Regardless of their particular focus, QA programs typically involve a systematic process of oversight to ensure that all relevant aspects of patient care are continuously monitored and improved. The aim is to maintain quality care and ensure that healthcare staff, including nurses, are equipped with the necessary education, skills, and support infrastructure to uphold these standards.
The Donabedian model is a widely used framework for evaluating the quality of healthcare delivery. It is a well-known model for thinking about QA that identifies three dimensions of care (Figure 14.4) (ACT Academy, n.d.). Each component of the model has an important role:
- Structure: Pertains to the organizational and environmental factors that shape healthcare services, including the physical resources, staffing levels, and policies in place.
- Process: Includes the activities and interactions involved in delivering care, such as clinical procedures and communication among healthcare team members.
- Outcomes: Refers to the results or effects of healthcare services on patient health and satisfaction. It emphasizes the importance of evaluating the technical aspects of care delivery and its influence on patient outcomes and experiences.
Structure Evaluation
A structure evaluation is an assessment of the characteristics of a healthcare system or provider. These include the facilities, equipment, staffing qualifications and levels (e.g., the ratio of providers to patients), and other aspects of the physical and organizational infrastructure (ACT Academy, n.d.). A structure evaluation can provide a foundational understanding of a healthcare entity’s capability to deliver quality care, enabling healthcare providers and administrators to identify areas needing improvement.
For example, hospital leadership might perform a structure evaluation to assess the adequacy and up-to-dateness of medical equipment, the physical layout of patient care areas, and the availability of necessary resources such as intensive care units or specialized labs. Staffing patterns could also be evaluated to determine whether there are enough qualified healthcare professionals to meet patient needs. The evaluation might reveal the need for more specialized nurses in a neonatal unit or for updated magnetic resonance imaging (MRI) machines to enhance diagnostic capabilities.
Process Evaluation
A process evaluation assesses how a system or provider delivers health care. It focuses on the procedures, protocols, and interactions involved in patient care. This type of evaluation sheds light on the actual practices and methods used in patient care, which directly affect patient outcomes. Through process evaluation, healthcare providers can identify inefficiencies or shortcomings in their care-delivery methods and make necessary adjustments to overcome them (ACT Academy, n.d.).
In a hospital setting, a process evaluation might examine how patient care is managed from admission to discharge, including how efficiently patients are triaged in the emergency room, whether best practices and protocols are followed for surgical procedures, and how effectively patient education and follow-up care is conducted. For instance, the evaluation might find that improving communication between different departments, such as surgery and postoperative care, could enhance overall patient care efficiency and outcomes.
Outcome Evaluation
An outcome evaluation is the assessment of healthcare outcomes on patients and populations. It measures the effectiveness of healthcare interventions and services by looking at metrics such as recovery rates, complication rates, and patient satisfaction. This evaluation provides concrete data on the effects of healthcare services, informing decisions on how to improve care quality and patient experiences (ACT Academy, n.d.). By focusing on tangible results, outcome evaluation helps hospitals identify successful practices and areas needing improvement, ultimately guiding strategic decisions to enhance patient care quality and safety.
Within a hospital, outcome evaluations might focus on specific departments or treatments. For example, evaluating the outcomes of a cardiology department might involve analyzing patient recovery rates after cardiac surgeries, the incidence of postoperative complications, and patient satisfaction with the care received. This evaluation could reveal trends such as a higher-than-average readmission rate, prompting a review of discharge procedures and postdischarge follow-up care.
Outcome evaluations can also extend to broader health outcomes, such as assessing the impact of a hospital’s diabetes management program on the overall health and quality of life of patients with diabetes in the community. By examining factors such as blood sugar control, complication rates, and patient adherence to treatment plans, hospitals can gauge the effectiveness of their care protocols and patient education efforts, leading to more tailored and effective patient care strategies.
Quality Improvement Programs
The aim of a QA program is to ensure providers are meeting quality standards. But what happens if evaluations determine they are not or that standards are inadequate? In these cases, the question shifts from how to assess and assure quality to how to improve quality.
In health care, quality improvement (QI) is a systematic framework for enhancing patient care and outcomes (Kelly, 2022). Central to QI is the continuous process of identifying areas for improvement and implementing strategies to achieve better patient outcomes, efficiency, and service quality. Healthcare organizations typically have QI programs in place, and providers, including nurses, can become certified in QI. The certification allows them to showcase their expertise and commitment to improving care quality. A quality improvement nurse plays a pivotal role in QI programs, often leading initiatives and guiding implementation.
Systems and Processes
QI systems and processes vary across healthcare organizations. In a hospital, QI might focus on reducing patient readmission rates or enhancing surgical outcomes. In private practice, QI efforts could center on improving patient wait times and enhancing the patient-provider communication process. Assisted living facilities might implement QI processes to improve resident safety measures and medication management protocols. Each setting requires a unique approach to QI, tailored to its specific patient population and care-delivery model. However, most QI programs include several areas of focus, including the experiences of patients and team members and the usage of data to reveal issues and guide solutions.
Focus on Patients
The patient-focused aspect of QI programs centers on enhancing the patient experience and outcomes. This approach involves tailoring healthcare services to meet the specific needs and preferences of patients, ensuring their involvement in care decisions, and regularly gathering and responding to patient feedback.
In diverse healthcare settings, focusing on patients manifests in different ways. In outpatient clinics, patient-focused QI might involve reducing waiting times and improving systems for scheduling appointments. In hospitals, it could include creating initiatives to improve patient-provider communication and developing more effective pain management protocols. Assisted living facilities may implement QI projects that enhance the personalization of care plans, ensuring that residents’ preferences and life histories are considered in daily care activities. Across all settings, the emphasis is on recognizing and addressing the unique needs and experiences of patients to improve their overall healthcare journey.
Patient Conversations
Addressing Patient Concerns for Quality Improvement
Crucial to patient-centered care is providing patients with an opportunity to give feedback on their experience. This is especially important when the patient is dissatisfied with an aspect of their care, as in the following conversation between a nurse and a patient prior to their discharge.
Nurse: Good afternoon, Ms. Smith. I’m glad to hear your treatment went well. I’m sure you’re looking forward to going home.
Patient: Yes, I can’t wait.
Nurse: We’re continuously working to improve our care, and your feedback is vital. Can you share how you felt about your experience with us?
Patient: Well, the treatment was fine, but I felt rushed whenever I had questions for the staff. It made me a bit uncomfortable.
Nurse: I’m sorry to hear that you felt rushed, Ms. Smith. It’s important to us that our patients feel heard and understood. Can you tell me more about when this happened?
Patient: Mostly during the morning rounds. The staff seemed very busy, and I didn’t want to bother them, but I had questions about my medications and aftercare.
Nurse: Thank you for sharing that. We do have busy moments, but that shouldn’t prevent us from addressing your concerns thoroughly. I’ll bring this up with our team so we can improve our communication, especially during busy times. We might need to adjust our morning routine or provide additional support during peak hours.
Patient: That would be great. I just wanted a bit more time to understand my care plan and what I needed to do after going home.
Nurse: Absolutely, Ms. Smith. Understanding your care plan is crucial for your recovery. Maybe we could explore options such as designated Q&A time during rounds. I’ll also make sure that a member of the team gives you a follow-up call tomorrow. Would that be helpful?
Patient: Yes, a follow-up call sounds like a good idea. I also think having a set time for questions would have eased my concerns.
Nurse: I’m glad to hear that, and I appreciate your feedback. We’ll work on implementing these changes to improve our patients’ experiences. Your insights are invaluable in helping us provide better care. If you have any more suggestions or concerns, please feel free to share them.
Focus on the Team
The team-focused aspect of QI in health care emphasizes the importance of collaboration, communication, and professional development among healthcare workers. This approach recognizes that high-quality patient care results from coordinated efforts among various healthcare professionals, each contributing their expertise to help solve problems.
For example, in hospital settings, team-focused QI might involve interdisciplinary rounds where providers, nurses, and other healthcare professionals collaboratively discuss patient care plans, ensuring comprehensive and coordinated care. In a primary care clinic, QI could be focused on enhancing team communication and coordination, particularly in managing patients with complex care needs and multiple chronic conditions. In home health care, QI initiatives may emphasize training and developing a cohesive team approach, with nurses, therapists, and caregivers working together to provide consistent and effective care in the patient’s home environment. These initiatives foster a culture of teamwork and continuous learning, which are key to improving patient outcomes and staff satisfaction.
Focus on the Use of Data
The data focus in QI programs includes systematically collecting, analyzing, and applying healthcare data to inform and improve care practices. This approach leverages data to identify trends, measure the effectiveness of interventions, and guide decision-making processes.
In hospital environments, data might be used to track patient outcomes and identify patterns in readmissions or hospital-acquired infections, leading to targeted improvement strategies. In a community health center, data analysis could focus on tailoring public health initiatives and outreach programs to health trends in the local population. In a mental health facility, data might be used to evaluate the effectiveness of different therapeutic interventions, guiding improvements in treatment approaches. Across a range of settings, the strategic use of data enables healthcare providers to make evidence-based decisions, enhancing the quality and efficiency of the care they deliver.
Patient Satisfaction Programs
Patient satisfaction programs in health care are designed to gauge and improve the experience of patients during their interaction with healthcare systems. These programs vary in scope and method but aim to collect feedback from patients about their care, which can then be used to improve service delivery.
Satisfaction measurement often uses data collected through patient surveys, suggestion boxes, or direct interviews. These tools capture the patient’s perspective on various aspects of care, such as the quality of communication with healthcare providers, the level of comfort and cleanliness in the facility, the adequacy of information provided about treatments, and overall satisfaction with the care received. Some programs invite patients and families to participate in policy-making and program development. For example, patient advisory councils collaborate with providers to improve the healthcare experience (Boissy & Lloyd, 2024). This approach is increasingly relevant as healthcare institutions aim to enhance patient satisfaction, a key metric under the Affordable Care Act (ACA), which ties patient experience to reimbursement rates.
Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)
The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) is a standardized survey instrument and data collection methodology for measuring patient perspectives on hospital care (Centers for Medicare & Medicaid Services, 2023). HCAHPS (pronounced “H-caps”) was developed by the Centers for Medicare & Medicaid Services (CMS) in partnership with the Agency for Healthcare Research and Quality (AHRQ) to provide a standardized measurement of patient satisfaction across all hospitals in the United States. HCAHPS was implemented in October 2006, and the first results were publicly reported in March 2008.
The rationale behind HCAHPS is to provide objective and comparable information about patients’ perspectives on hospital care, which can be used to improve the quality of healthcare services. The survey consists of twenty-nine questions, nineteen of which cover critical aspects of the hospital experience, such as the communication and responsiveness of the staff, the cleanliness of the facilities, and the usefulness of discharge information; patients are also asked to give the hospital an overall rating and to say whether they would recommend it to others.
The administration of the HCAHPS survey is strictly regulated to ensure consistency and reliability. Hospitals can administer the survey through mail, telephone, or a combination of methods. The survey is given to a random sample of adult patients between forty-eight hours and six weeks after discharge, excluding those with psychiatric diagnoses. The results are publicly reported, allowing for comparison across hospitals and fostering transparency in healthcare quality.
The effect of HCAHPS is significant, leading hospitals to focus more on patient-centered care (PCC), enhance efforts at transparency and accountability, and prioritize improvements in areas directly affecting patient satisfaction. For example, many hospitals have developed specific initiatives to improve communication skills of healthcare providers, enhance the hospital environment for patient comfort, and streamline discharge processes for better patient understanding of posthospital care. These initiatives are not only aimed at improving patient satisfaction scores but also at enhancing the overall quality of care and patient outcomes. HCAHPS has also influenced reimbursement rates under CMS policies. Hospitals with better patient satisfaction scores may receive higher reimbursement, creating a financial incentive to improve patient experience.
Nursing-Specific Patient Safety and Quality Initiatives
Patient safety and quality initiatives are critical components of health care that focus on minimizing risks, errors, and harm to patients during the delivery of care. These initiatives encompass a broad range of practices, from ensuring basic patient safety standards, such as hygiene and infection control, to implementing complex clinical protocols designed to improve the quality of care. Central to these efforts is the commitment to creating a healthcare environment that prioritizes patient well-being, safety, and the delivery of high-standard healthcare services. Modern nurses have important roles in these initiatives, which foster a culture of continuous improvement and accountability within healthcare organizations.
Nursing-Sensitive Quality Indicators
Specific metrics, called nursing-sensitive quality indicators, influence nursing behaviors that reflect the quality of nursing care (Phillips et al., 2021). Nurses who provide quality care can be identified by looking at desirable patient outcomes such as low fall rates, few instances of pressure ulcers and hospital-acquired infections, and high patient satisfaction scores. These indicators also cover structural and process factors such as nurse staffing levels, turnover rates, and care coordination (Table 14.6).
| Nursing-Sensitive Quality Indicator | Structure | Process | Outcome |
|---|---|---|---|
| Nursing hours per patient day | X | ||
| Patient falls | X | X | |
| Patient falls with injury | X | X | |
| Pediatric pain assessment, intervention, and reassessment (AIR) cycle | X | ||
| Pediatric peripheral intravenous infiltration rate | X | ||
| Pressure ulcer prevalence | X | X | |
| Psychiatric physical/sexual assault rate | X | ||
| Restraint prevalence | X | ||
| RN satisfaction survey options | X | X | |
| Nursing education and training | X | ||
| Nurse staffing levels | X | ||
| Availability of nursing supplies | X | ||
| Nurse-to-patient ratio | X | ||
| Nursing certification | X | ||
| Skill mix | X | ||
| Voluntary nurse turnover | X | ||
| Nurse vacancy rate | X | ||
| Nosocomial infections | X |
Nursing-sensitive quality indicators are essential to QA and QI programs. They are vital to highlighting areas where nursing care directly affects patient outcomes. For example, in assessing patient fall rates, hospitals can identify the effectiveness of their fall prevention protocols. By monitoring pressure ulcer prevalence, healthcare facilities can evaluate the adequacy of patient mobility and skin care regimens provided by nurses. These indicators help pinpoint areas for improvement as well as recognize and replicate successful nursing practices across different settings.
National Database of Nursing Quality Indicators (NDNQI)
The National Database of Nursing Quality Indicators (NDNQI) is a comprehensive database that provides standardized monitoring of nursing-sensitive quality indicators (Madaris, 2023). Developed by the ANA, the NDNQI allows healthcare organizations to compare their performance against national and regional benchmarks in key areas of nursing care and patient outcomes. The data collected in NDNQI encompass a range of indicators, such as patient falls, pressure ulcers, nursing care hours, staff turnover, and patient satisfaction levels.
NDNQI is a valuable tool for healthcare organizations that want to identify areas of strength and areas needing improvement. A hospital can use NDNQI data to benchmark its pressure ulcer rates against similar institutions and develop targeted interventions to reduce these incidents. The database also aids with tracking the effectiveness of implemented changes over time, allowing hospitals to see the tangible effects of their quality improvement efforts.
NDNQI also provides insights to guide staffing decisions, which helps hospitals ensure they have the appropriate nurse-to-patient ratios and skill mixes to deliver optimal care. By analyzing trends and patterns from the NDNQI, healthcare administrators and nursing leaders can make evidence-based decisions to enhance patient safety and care quality. The database is also instrumental in supporting research and policy development in nursing care, contributing to advancing the nursing profession and healthcare delivery as a whole.
Link to Learning
The National Database of Nursing Quality Indicators (NDNQI) is managed by Press Ganey, a healthcare company that also distributes a popular survey on outpatient satisfaction. Read this Press Ganey blog to learn more about the purpose, content, and uses of the NDNQI.