Monday September 16th 2019

The quality question: pearls for practice

Mary Jo Assi

It is hard to be in a room with other health care professionals these days and not hear the word quality at least once or twice in any given discussion. So what does it all mean, and what do quality nursing care and quality outcomes mean to you?


In 2000 the Institute of Medicine published the much-referenced To Err Is Human, followed in 2001 by Crossing the Quality Chasm: A New Health System for the 21st Century, and the 2003 report Health Professions Education: A Bridge To Quality. This series of reports identified serious gaps and breaks in our health care system, resulting in poor patient outcomes and an enormous financial impact.

In response, the health care community scrutinized current structures and processes with the aim of improving patient care outcomes by developing and implementing quality improvement tools, including quality indicators and measures, as noted by authors Gwen Sherwood and Jane Barnsteiner in Quality and Safety in Nursing: A Competency Approach to Improving Outcomes.

What are nursing-sensitive indicators?

Nursing-sensitive indicators are measures of the outcomes related to the structures and processes that drive nursing care. Simply put, at the end of the day when providing patient care, it’s not what we did or how we did it, but what difference did we make?

Nurses have participated in the development of a number of clinical quality measures that indicate the quality of nursing care. These measures include restraint use, patient falls with or without injury, pressure ulcers, hospital-acquired infections (HAIs), such as bloodstream infections (BSIs) and catheter-acquired urinary tract infections (CAUTIs), and measures of the nursing work environment, including nurse turnover rates, skill mix and paid hours per patient day, which measures the intensity of nursing care, as identified by the American Nurses Association (ANA).

By nature, we nurses are problem-solvers and are quick to respond when we identify practice-related issues that are barriers to providing the best possible care for our patients. However, while it is important to rapidly identify best practice solutions, before instituting a new or modified practice, we need to select a measure and collect baseline data before making the change. That way when we measure again afterward, we will know whether there was a positive impact on clinical outcomes.

Edward Deming, often referred to as the father of modern quality improvement methods, used tools such as the plan-do-study-act (PDSA) model as a framework for quality improvement activities. This model, or others like it, is often used by health care organizations to approach performance improvement work in a consistent way.

Putting it all together

Elizabeth works on a general surgical unit and recently volunteered to join a unit-based performance improvement workgroup. She learns that the responsibility of this group is to use clinical data collected on a monthly basis to determine whether clinical outcomes are at, above or below targeted goals that were set at the beginning of the year, and to make recommendations about patient care practices, protocols and procedures to her unit’s clinical nurses and leaders based on that review. At the most recent meeting, Elizabeth learns that her unit has exceeded goals for pressure ulcers, falls and BSIs, and that clinical care for CAUTI has not met the targeted goal for the past two months. Workgroup team members recommend that next steps should include a unit-wide celebration to recognize the success achieved in exceeding goals for three indicators, and to develop an action plan aimed at improving CAUTI rates on her unit.

A pearl for practice

A consistent approach to performance improvement of clinical care using standardized tools such as PDSA is critical to the success of clinical improvement activities. By collecting before and after data specific to an established, new or modified practice, nurses will have the information they need to determine whether nursing care is effective at the unit level, and recommend change if it is not. Making clinical practice decisions based on evidence is a true pearl for practice.

— Mary Jo Assi is the director of Nursing Practice and Work Environment at ANA.


American Nurses Association: Nursing-sensitive indicators

Deming Institute: The plan, do, study, act (PDSA) cycle

More from category

Supply and demand
Supply and demand

Health care professionals share information, strategies on drug shortages  It is deeply ingrained in RNs to focus [Read More]

Beyond folding washcloths: An innovation for diversional activity
Beyond folding washcloths: An innovation for diversional activity

Finding ways to keep patients safe in today’s complex hospital settings is an ongoing challenge. RNs experience a [Read More]

Preventing tragedies
Preventing tragedies

New Mexico nurses lead initiative on shaken baby syndrome An initiative — developed and driven by RNs to prevent [Read More]

Gaining momentum: Collaboration for academic progression
Gaining momentum: Collaboration for academic progression

The path to obtaining a Bachelor of Science in nursing can be strewn with challenges. Helping clear the way, the [Read More]

Nurses help shape policy, strengthen the profession
Nurses help shape policy, strengthen the profession

Bias and health disparities affecting the LGBTQ community, substance use disorder in nursing and gun violence – all [Read More]