Question

HOW CAN A CHARGE NURSE USE QSEN OR QUALITY HEALTH CARE TO ENHANCE THEIR ROLE? POWER POINT FORMAT, IF USE REFERENCE PLEASE LIST

Answer 1

Discussions of hospital quality, efficiency, and nursing care often taken place independent of one another. Activities to assure the adequacy and performance of hospital nursing, improve quality, and achieve effective control of hospital costs need to be harmonized. Nurses are critical to the delivery of high-quality, efficient care. Lessons from Magnet program hospitals and hospitals implementing front-line staff–driven performance improvement programs such as Transforming Care at the Bedside illustrate how nurses and staff, supported by leadership, can be actively involved in improving both the quality and the efficiency of hospital care.

Continuous quality improvement is a concept which includes: Quality assurance--the provision of services that meet an appropriate standard. Problem resolution--including all departments involved in the issue at hand. Quality improvement--a continuous process involving all levels of the organization working together across departmental lines to produce better services for health care clients. Deming (1982b) and others have espoused total system reform to achieve quality improvement--not merely altering the current system, but radically changing it. It must be assumed that those who provide services at the staff level are acting in good faith and are not willfully failing to do what is correct (Berwick, 1991). Those who perform direct services are in an excellent position to identify the need for change in service delivery processes. Based on this premise, the staff nurse--who is at the heart of the system--is the best person to assess the status of health care services and to work toward improving the processes by which these services are provided to clients in the health care setting. The nurse manager must structure the work setting to facilitate the staff nurse's ability to undertake constructive action for improving care. The use of quality circles, quality councils, or quality improvement forums to facilitate the coordination of quality improvement efforts is an effective way to achieve success. The QA coordinator assists departments in documenting that the quality improvement efforts are effective across all departments of the organization, and aggregates data to demonstrate that they meet the requirements of external regulatory agencies, insurers, and professional standards. The nurse executive provides the vision and secures the necessary resources to ensure that the organization's quality improvement efforts are successful. By inspiring and empowering the staff in their efforts to improve the process by which health care is provided, nurse managers participate in reshaping the health care environment. The professional nurse plays a vital role in the quality improvement of health care services. However, nurses cannot make these improvements in a vacuum; they must include other professionals and ancillary personnel in their efforts. Total quality commitment must include all levels of an organization's structure. Quality patient care services will be achieved as the result of positive interactions among departments working together to build a dynamic mechanism that continuously improves the processes and outcomes of health care services.

THE IMPACT OF NURSES ON HOSPITAL SAFETY, QUALITY, AND COSTS

SAFETY AND QUALITY.

The 1996 IOM report Nursing Staff in Hospitals and Nursing Homes concluded that although nursing services are central to the provision of hospital care, “little empirical evidence is available to support the anecdotal and other informal information that hospital quality of care is being adversely affected by hospital restructuring and changes in [nurse] staffing patterns.”

Since that report, and in part in response to it, the number of studies examining the association of staffing and quality in hospitals has exploded. Major studies demonstrating the association of nurse staffing and patient outcomes, including lengths-of-stay, mortality, pressure ulcers, deep vein thromboses, and hospital-acquired pneumonia have been published in first-tier journals, and several major literature reviews, syntheses, and meta-analyses have been published confirming the association of nurse staffing with patient outcomes. When the IOM revisited the issue of nurse staffing and patient care in 2004, it concluded: “Research is now beginning to document what physicians, patients, other health care providers, and nurses themselves have long known: how well we are cared for by nurses affects our health, and sometimes can be a matter of life or death.”

Research on these issues is continuing. Indeed, its scope has expanded through programs such as the Robert Wood Johnson Foundation (RWJF) Interdisciplinary Nursing Quality Research Initiative (INQRI), whose projects are examining how specific processes of care, such as care coordination, medication administration, or introduction of evidence-based protocols, are associated with nursing care and patient outcomes.

Despite this research, the nature of nurses' work in hospitals is not well understood by the public or policymakers. In a recent survey, 88 percent of the public agreed that making sure there are enough nurses to monitor patient conditions, coordinate care, and educate patients should be a part of efforts to improve quality, but focus groups find that the public is confused about what nurses do, the kind of training they receive, and what distinguishes them from nurse aides and other less trained personnel.The public understands that nurses' work is physically and emotionally demanding but may view this work as delivering care as ordered and providing physical and emotional comfort to patients and their families. Nurses do far more, and the work entails both substantial intellectual and organizational competence. Among the critical tasks carried out by nurses are

(1) ongoing monitoring and assessment of their patients and, as necessary, initiating interventions to address complications or reduce risk;

(2) coordinating care delivered by other providers; and

(3) educating patients and family members for discharge, which can reduce the risk of posthospital complications and readmission.

“Shorter hospital stays reflect nurses' ability to affect efficiency as well as quality.”

COSTS.

Much work has examined the association of nursing and quality; less has examined nursing's impact on costs. A number of studies have assessed whether there is a business case for increasing nurse staffing in hospitals—that is, whether simply increasing staffing would pay for itself in reduced complications and lengths-of-stay. One key finding of this work is that improving nurse staffing does not completely pay for itself, although recent efforts to reduce hospital payment for poor quality may change this conclusion.

These analyses also find that the biggest cost savings of increased staffing result from reduced lengths-of-stay. Shorter stays reflect not just reductions in complications that extend stays, but the ability of nurses to do their work and coordinate the work of others in a timely and effective manner. They reflect nurses' ability to affect efficiency as well as quality.

A key limitation of these cross-sectional studies is that they do not consider how changes in nursing organization, systems, or work environment might improve outcomes or efficiency without increases in staffing. Other research studying nurses' work environments suggests that such improvements are possible.

HOSPITAL NURSING: KEY ISSUES

TAPPING NURSES' KNOWLEDGE OF THE SYSTEM.

Nurses develop substantial knowledge of the strengths and weaknesses of hospital systems and how they fail. Their ability to create workarounds to broken or dysfunctional systems is legendary in health care. As hospitals focus on increasing safety and reliability, patient-centeredness, and efficiency, nurses' knowledge and commitment to their patients and institutions needs to be effectively mobilized. To accomplish this, nurses' perspectives must be represented at the highest levels of hospital leadership and integrated into hospital decision making. In addition, consistent with process-improvement research that identifies the active involvement of front-line staff as a critical factor in making and sustaining change, processes for engaging nurses and other front-line staff also need to be expanded.

INCREASING THE VISIBILITY AND PARTICIPATION OF NURSING LEADERSHIP WITHIN HOSPITALS: MAGNET ACCREDITATION.

One impetus for hospitals to give increased voice to nursing and nursing leadership has been the development and expansion of the Magnet accreditation program. Magnet hospitals are those recognized by the American Nurses Credentialing Center (ANCC) for recruiting and keeping nurses while providing high-quality care to patients. The framework for the Magnet appraisal process consists of fourteen characteristics, including

(1) strong nursing representation in the organizational committee structure;

(2) nurse leadership that is part of the hospital's executive leadership;

(3) a functioning system of shared governance in nursing;

(4) empowerment of nurses at all levels of the hospital, with nurses able to effectively influence system processes; and

(5) collegial working relationships among disciplines.

ENGAGING FRONT-LINE STAFF IN IMPROVING HOSPITAL PERFORMANCE

Process improvement research consistently identifies engagement of front-line staff as central to achieving and sustaining change. Developing models for achieving this in health care has proved challenging. One such model is Transforming Care at the Bedside (TCAB).

Launched in 2003 with three hospitals, TCAB is a national program of the Robert Wood Johnson Foundation (RWJF) and the Institute for Healthcare Improvement (IHI). Its goal was to engage front-line staff and hospital leadership to make improvement in four domains: improving the quality and safety of care; ensuring a high-quality work environment to attract and retain nurses; improving the experience of care for patients and their families; and improving the effectiveness of the entire care team. In 2004, ten additional hospitals joined a two-year TCAB learning and innovation collaborative. By 2006, additional participation criteria were in place, such as partnering with schools of nursing, and ten of the thirteen hospitals opted to continue in the collaborative for two more years.

PARTICIPANTS' CONTRIBUTIONS.

Beyond the initial collaborative, the RWJF has expanded TCAB in several ways. It funded a sixty-seven-hospital collaborative conducted by the American Organization of Nurse Executives (AONE); it created a Web site that provides information to hospitals seeking to implement TCAB independently; and it has incorporated TCAB as a component of its Aligning Forces for Quality initiative. The IHI supports a TCAB Learning and Innovation community with eighty-one hospitals in its IMPACT Network; the program has spread to hospitals in four countries. Hospitals not formally participating in any collaborative have implemented TCAB-like programs by drawing on published descriptions and contact with TCAB hospitals. Hospitals provided a variety of resources to facilitate the work of front-line staff, including release time for nurses to conduct TCAB work, training in quality improvement methods, travel to collaborative meetings, and participation by resource personnel such as nurse educators, clinical nurse leaders, and quality improvement staff.

EVALUATION OF TCAB.

The RWJF-sponsored IHI and AONE initiatives are being evaluated. Details of the evaluation design, methods, and findings are available elsewhere; here we mention several findings from the IHI-led initiative that suggest that TCAB might serve as an effective model for engaging front-line staff.

One measure of the degree of engagement of staff is the volume of testing of improvement ideas that was conducted. The thirteen pilot units tested 533 innovations over four years—an average of 41 per unit. Testing was done across all four TCAB domains. At the end of the pilot period, unit managers at the hospitals reported that 71 percent had been sustained and were still in place. Many of the innovations focused on improving efficiency or increasing the value of care. Examples include adoption of new end-of-shift reporting methods and work to speed and better coordinate the discharge process among physicians, nurses, housekeeping, and other departments.

DISCUSSION AND POLICY IMPLICATIONS

Hospitals need to integrate their work to improve quality and patient-centeredness and to increase the efficiency of care delivery. Nurses and other front-line staff must play key roles. To benefit from the insight and input of these staff members, hospitals will need to value their potential contributions, shifting their vision of nursing from being a cost center to being a critical service line.

But simply changing leadership's view of front-line staff or changing hospital culture to embrace a culture of improvement will be insufficient. One of the lessons we draw from the TCAB experience is that improvement must be institutionalized in the day-to-day work of the front-line staff, with adequate time and resources provided and with front-line staff participating in decision making. The experience of Magnet hospitals and of units engaged in TCAB provide concrete models of hospital- and unit-level organizations and processes to accomplish this. Increasingly, there are organized vehicles for promoting these models, including the Magnet accreditation program, IHI and AONE plans to promote TCAB models in their ongoing work, and the RWJF's ongoing support of this program at the state and national levels.

These specific activities need to be complemented with other changes that encourage the engagement of front-line staff in process improvement. These should include changes in reimbursement to increase value of effective, high-quality nursing to hospitals, such as the recent decision by the Centers for Medicare and Medicaid Services to not pay for “never events.” There is a growing literature on nursing-sensitive payment.

Looking upstream from the hospital, nursing education will have to change to prepare new graduates to work in environments where they have responsibility for process improvement. One model showing promise is that of Clinical Nurse Leaders, an effort to produce nursing school graduates who can implement outcomes-based practice and quality improvement strategies and create and manage unit-level systems for delivering care.

Getting nurses and other front-line staff actively involved in efforts to simultaneously improve hospital quality and increase efficiency will require action both within institutions and by those who measure their quality and pay for their services. The models for accomplishing this are still evolving, but the broad outlines for achieving such engagement are clear. The lessons from Magnet accreditation and TCAB should be used as hospitals take full advantage of nurses' knowledge and commitment to their patients and institutions—to increase the safety and reliability, patient-centeredness, and efficiency of care.