Applying the Advancing Excellence in America's Nursing Homes Circle of Success to improving and sustaining quality

Looking forward to the Quality Assurance Performance Improvement (QAPI) program to be implemented and required in 2014, and as nursing home staff provide care for residents with increasingly complex health issues, knowledge of how to implement quality improvement (QI) is imperative. The nursing home administrator and director of nursing (DON) provide overall leadership, but it is the primary responsibility of the DON and other registered nurse staff to implement and manage the day to day QI process. This article describes potential roles of nursing leaders and key components of a QI project using a pressure ulcer case study exemplar to illustrate a quality improvement process. The authors suggest specific methods that RN leaders can employ using the Advancing Excellence Campaign Circle of Success as an organizing framework along with evidence-based resources. Nursing home leaders could use this article as a guideline for implementing any clinical quality improvement process.     

Quality improvement engagement and competence: A comparison between frontline nurses and nurse leaders

BackgroundNurses play a pivotal role in improving patient care. To maximize nurses’ impact on quality, nurses must have quality improvement (QI) competence and engage fully in QI initiatives.PurposeTo describe QI competence (knowledge, skills, and attitudes) among frontline nurses and leaders; and compare variations in competence among nursing roles, experience, and specialty areas.MethodsA total of 681 nurses at one heath system fully completed the Nursing Quality Improvement Practice tool electronically.FindingsHalf of the respondents reported QI engagement (53.6%). Mean knowledge scores were 5.08 (SD 1.16, 7 items). Skill proficiency was low (M = 2.82, SD = 1.03; range 1–6) although QI attitudes were favorable (M = 3.76, SD = 0.63; range 1–5). Significant differences in skills and attitudes were identified by role. QI competence among nurses employed in various specialty areas were similar.DiscussionStrategies for increasing QI competence and engagement of nurses must be created and deployed in order to improve quality and safety.     

Research and quality improvement experience and knowledge: a nursing survey

fox j., bagley l., day s., holleran r. & handrahan d. (2011) Journal of Nursing Management 19 , 623–631
Research and quality improvement experience and knowledge: a nursing survey Aim To assess nursing staff’s background and research and quality improvement (QI) experience. Background In this corporation, participation in research and QI is encouraged, but little is known about nurses’ experiences. Methods A web-based survey was distributed. Nursing staffs from an academic/teaching medical centre and other intra-corporation non-academic facilities were compared. Results Respondents included: 148 (52.9%) medical centre and 132 (47.1%) non-medical centre subjects. Medical centre respondents had a higher proportion previously engaged in research, currently engaged in research and previously engaged in QI. Productivity (grant, published and presented) was low for both groups but statistically lower for the non-medical centre group. Medical centre employees used research resources more often than the non-medical centre. Time was the most frequently mentioned barrier to participation in research and QI initiatives. Conclusions A moderate proportion of respondents had research and QI experience, yet productivity and use of resources was low. Nurses at non-academically focused facilities were in most need of assistance. Familiarizing nurses with resources and providing protected time may increase productivity. Implications for nursing management Developing an infrastructure to support nursing research is a worthy goal. Information about interest and experience of nurses can aid management in determining how to focus financial resources.     

Nursing home staff's views on quality improvement interventions: a follow-up study

Ongoing problems with nursing home care mandates understanding nursing home staff's perspectives on innovative quality improvement programs. This follow-up study used focus groups to examine the experiences of staff who participated in a clinical trial that involved Quality Indicator (QI) feedback reports, quality improvement training, and APN consultation. The authors found that QI reports provided staff with a benchmark to judge their care and a means to track problems; APN consultation was essential for staff to learn best practices; and staff questioned the validity of the QI reports, which hindered them from seeking new solutions to problems identified in the QI reports. Findings indicate that innovative QI programs and APN consultation can positively influence nursing home quality improvement efforts and improve care.     

ANA nurse sensitive quality indicators for long-term care facilities

Nurse sensitive quality indicators, developed through the American Nurses Association's (ANA) Safety and Quality Initiative, are key to evaluating the quality of patient care in acute care settings. This study found that the ANA quality indicators were also relevant for long-term care facilities. Long-term care facilities can be part of the ANA Safety and Quality Initiative by collecting and reporting nurse sensitive quality indicators and submitting data to the National Database of Nursing Quality Indicators.     

Nursing home consumer complaints and their potential role in assessing quality of care

BACKGROUND: State survey agencies collect and investigate consumer complaints for care in nursing homes and other health care settings. Complaint investigations play a key role in quality assurance, because they can respond to concerns of consumers and families. OBJECTIVE: This study uses 5 years of nursing home complaints data from Massachusetts (1998-2002) to investigate whether complaints might be used to assess nursing home quality of care. RESEARCH DESIGN: The investigator matches facility-level complaints data with On-Line Survey Certification and Reporting (OSCAR) data and Minimum Data Set Quality Indicator (MDS QI) data to evaluate the association between consumer complaints, facility and resident characteristics, and other nursing home quality measures. RESULTS: Consumer complaints varied across facility characteristics in ways consistent with the nursing home quality literature. Complaints were consistently and significantly associated with survey deficiencies, the presence of a serious survey deficiency, and nurse aide staffing. Complaints were not significantly associated with nurse staffing, and associations with 6 MDS QIs were mixed. The number of complaints was significantly predictive of survey deficiencies identified at the subsequent inspection. CONCLUSION: Nursing home consumer complaints provide a supplemental tool with which to differentiate nursing homes on quality. Despite limitations, complaints data have potential strengths when used in combination with other quality measures. The potential of using consumer complaints to assess nursing home quality of care should be evaluated in states beyond Massachusetts. Evaluating consumer complaints also might be a productive area of inquiry for other health care settings such as hospitals and home health agencies.     

Development of a risk-adjusted urinary incontinence outcome measure of quality for nursing homes

BACKGROUND: Quality of nursing home care is of ongoing concern. The availability of uniform, patient-level information-the Minimum Data Set (MDS)-offers the opportunity to assess quality based on risk-adjusted health outcomes. OBJECTIVE: To develop a risk-adjusted measure of quality based on urinary incontinence (UI) outcomes for nursing homes, derived from the MDS. RESEARCH DESIGN: A retrospective statistical analysis of individual resident level data. SUBJECTS: MDS+ data for 46,453 residents of 671 nursing homes in New York State during the 1995 to 1997 period. MEASURES: Improvement in UI status was defined based on the resident's UI status at 3 months post admission relative to status at admission. Individual risk factors were also defined at admission. Facility level quality indicators were developed. RESULTS: Facility level indicators show substantial variation. An average facility, providing average quality care to a population of average risk, would experience improvement in UI outcomes for 11 of its 25 admissions in a year. The difference between the best and the worst facilities (two standard deviations above and below the average) is eight new residents with improvement in UI outcomes out of 25 annual admissions. CONCLUSIONS: This study demonstrates the feasibility of measuring quality of UI care based on nationally available MDS data. The measures presented can be used to support internal quality improvement efforts. Before such measures can be used externally, either in the survey process or in quality report cards, they should be further validated.     

Stability of nursing home quality indicators over time.

BACKGROUND: Nursing home quality indicators (QIs) provide a way to support quality assurance and improvement activities and to help ensure that cost savings are based on increased efficiency and not on decreased quality of care. OBJECTIVES: QIs values are expected to change over time. However, to be good indicators of quality, they should be reasonably stable over "short" periods. This paper discusses theoretical and measurement issues affecting stability and examines the stability of QIs over each of two 3-month periods and one 6-month period. SUBJECTS: The study sample included 512 nursing facilities from two states, Kansas and South Dakota. QIs were measured for the first 3 quarters of 1996. MEASURES: Facility level QIs were constructed using three different metrics that each provide a unique perspective of facility performance as follows: the proportion of residents in the facility with the QI condition; the facility's percentile rank in its state; and a variable indicating whether the facility's rank exceeded the 90th percentile in its state. QI stability was assessed using Pearson correlation coefficients, Spearman rank order correlation coefficients, and Cohen's Kappa, as appropriate for the metric. RESULTS: Results indicated high levels of stability for most QIs, with lower levels of stability found to be in keeping with theoretical and measurement considerations. CONCLUSIONS: QIs are reasonably stable over short periods of time. Quality improvement efforts may best be focused on facilities that are consistently poor performers over time, and those that show a large decrease in quality from one quarter to the next.     

Performance improvement boot camp

Various regulatory agencies require some form of performance improvement (PI) to be done by each department of the health care facility. Nursing has a vital role in the PI process; this statement holds especially true for radiology nursing.The presenter gave participants some basic information concerning (1) historical growth of quality improvement (QI), (2) development of the performance improvement (PI) process, (3) elements of performance improvement, (4) definitions, and (5) use of QI and PI in radiology.     

Identifying outcomes from the nursing outcomes classification as indicators of quality of care in Korea: a modified delphi study

BACKGROUND: The evaluation of patient outcomes as a measure of quality control of patient care is being adopted in Korean hospitals. Since nursing care contributes to the bulk of patient care, it is important to identify nursing-sensitive patient outcomes, hereafter referred to as 'nursing outcomes', that will be useful in the evaluation of nursing care. OBJECTIVE: This study was conducted to identify nursing outcomes included within the Nursing Outcomes Classification (NOC) that are most sensitive for the evaluation of nursing care in Korean hospitals as well as being observable and measurable. DESIGN: Delphi technique modified for this study was used to gain a consensus from Korean nursing experts. SETTINGS: Participants were recruited from general hospitals in Korea. PARTICIPANTS: Two hundred and thirty nurses working for Quality Improvement (QI) and Continuous Quality Improvement (CQI) programmes were chosen as the nurse experts for this study. METHODS: Three rounds of data collection from all participants was undertaken. In the first data collection, the sensitivity of 260 NOC nursing outcomes (Johnson, et al., 2000. Iowa Outcomes Projects: Nursing Outcomes Classification (NOC). C.V. Mosby, St. Louis) was examined, and more highly nursing sensitive ones were selected. In the second and third data collection phases, nursing outcomes which are most useful for the evaluation of nursing care were selected. RESULTS: Vital Signs Status, Knowledge: Infection Control, Pain Control, Safety Behavior: Fall Prevention, and Infection Status were identified as the five most useful nursing outcomes for the evaluation of nursing care in hospitals. CONCLUSIONS: The nursing outcomes identified highly useful for the evaluation of nursing care in this study can be used effectively for the quality management of nursing care in Korea.     

The gerontological clinical nurse specialist's role in prevention, early recognition, and management of delirium in hospitalized older adults

The purpose of this article is to describe the role of the acute care gerontological clinical nurse specialist (GCNS) and provide an exemplar of using GCNS expertise in the implementation of gerontological nursing best practices in hospitalized patients with delirium.     

Using large data sets in long-term care to measure and improve quality

The authors explore the evolution, potential uses, and limitations of four existing large data sets in long-term care: Minimum Data Set (MDS), Outcome Assessment and Information Set (OASIS), Online Survey and Certification Reporting System (OSCAR), and Consumer Surveys. They also describe the emerging Federal Nursing Home Quality Initiative and its potential for future research. All four existing large data sets have potential to be used to improve quality of care. Their utility is presently diminished because providers are not using the data for formal continuous quality improvement. However, the Center for Medicare and Medicaid Services (CMS) is currently engaged in a series of special studies designed to build and sustain a culture of continuous quality improvement in nursing homes and to make continuous, measurable improvement a growing part of the care of Medicare beneficiaries in those settings. These CMS studies, all of which will draw on the four existing large data sets in long-term care, offer the potential to develop, explicate and test theory about the assumed causal relationships between structure and process variables and related health care outcomes in long-term care.     

Patient information and participation still in need of improvement: evaluation of patients' perceptions of quality of care

Fröjd c ., Swenne c.l ., Rubertsson c ., Gunningberg l . & Wadensten b. (2011) Journal of Nursing Management 19, 226–236
Patient information and participation still in need of improvement: evaluation of patients’ perceptions of quality of care Aims To identify areas in need of quality improvement by investigating inpatients’ perceptions of quality of care, and to identify differences in perceptions of care related to patient gender, age and type of admission. Background Nursing managers play an important role in the development of high-quality care. Methods Quality of care was assessed using the Quality from the Patients’ Perspective (QPP). In all, 2734 inpatients at a Swedish university hospital completed the QPP. Results Inadequate quality was identified for 15 out of 24 items, e.g. information given on treatment and examination results, opportunities to participate in decisions related to care and information on self-care. Patients with emergency admissions reported lower scores for quality of information and doctors’ care than did patients with planned admissions. Conclusion Results from the present survey identified areas in need of quality improvement and differences in perceived care quality between patients. Quality of care must be developed in close collaboration with other healthcare professionals; in this respect, nursing managers could play an important role. Implications for nursing management Nursing managers could play a more active part in measuring quality of care, and in using results from such measurements to develop and improve quality of care.     

The Palliative Care—Promoting Access and Improvement of the Cancer Experience (PC-PAICE) Project in India: A Multisite International Quality Improvement Collaborative

Mentors at seven U.S. and Australian academic institutions initially partnered with seven leading Indian academic palliative care and cancer centers in 2017 to undertake a program combining remote and in-person mentorship, didactic instruction, and project-based learning in quality improvement (QI). From its inception in 2017 to 2020, the Palliative Care—Promoting Accesst and Improvement of the Cancer Experience Program conducted three cohorts for capacity building of 22 Indian palliative care and cancer programs. Indian leadership established a Mumbai QI training hub in 2019 with philanthropic support. In 2020, the project which is now named Enable Quality, Improve Patient care - India (EQuIP-India) focuses on both palliative care and cancer teams. EQuIP-India now leads ongoing Indian national collaboratives and training in QI and is integrated into India's National Cancer Grid. Palliative Care—Promoting Accesst and Improvement of the Cancer Experience demonstrates a feasible model of international collaboration and capacity building in palliative care and cancer QI. It is one of the several networked and blended learning approaches with potential for rapid scaling of evidence-based practices.     

The clinical nurse leader: a catalyst for improving quality and patient safety

Aim  The clinical nurse leader (CNL^®) is a new nursing role introduced by the American Association of Colleges of Nursing (AACN). This paper describes its potential impact in practice.
Background  Significant pressures are being placed on health care delivery systems to improve patient care outcomes and lower costs in an environment of diminishing resources.
Method  A naturalistic approach is used to evaluate the impact the CNL has had on outcomes of care. Case studies describe the CNL implementation experiences at three different practice settings within the same geographic region.
Results  Cost savings, including improvement on Centers for Medicare and Medicaid Services (CMS) core measures, are realized quickly in settings where the CNL role has been integrated into the care delivery model.
Conclusions  With the growing calls for improved outcomes and more cost-effective care, the CNL role provides an opportunity for nursing to lead innovation by maximizing health care quality while minimizing costs.
Implications for nursing management  Nursing is in a unique position to address problems that plague the nation's health system. The CNL represents an exciting and promising opportunity for nursing to take a leadership role, in collaboration with multiple practice partners, and implement quality improvement and patient safety initiatives across all health care settings.     

Evidence-based administrative guideline: quality improvement in nursing homes

Those staff members involved in a quality improvement program for a nursing home play a significant role in ensuring quality care for older adults. Use of the evidence-based administrative guideline "Quality Improvement in Nursing Homes" (Dyck, 2003) can provide a template for the implementation of a research-based quality program.     

Atrial fibrillation ablation: application of nurse methodology

Ablation of pulmonary veins for treatment of atrial fibrillation involves applying radiofrequency energy wave by a catheter that causes a circumferential lesion to achieve electrical isolation and voltage drop in the interior. It is mainly applied when there is resistance to treatment and recurrence of symptoms affecting the quality of life of patients. The nurse is an important part of the multidisciplinary team who care for patients who undergo this procedure. The provision of comprehensive nursing care should include nursing procedures prior to, during, and after treatment to ensure the careful and systematic quality required. The aims of this article are: to provide specialised knowledge on the procedure of atrial fibrillation ablation, to describe the preparation of the electrophysiology laboratory, analyse nursing care and develop a standardized care plan for patients on whom this procedure is performed using the NANDA (North American Nursing Association) taxonomy and NIC (Nursing Intervention Classification).     

Joint commission accreditation and quality measures in U.S. nursing homes

This study examines the association between accreditation and select measures of quality in U.S. nursing homes, both cross-sectionally and over time. Data analyzed in this research originated from a web-based search of The Joint Commission (TJC) accredited facilities and the Nursing Home Compare set of Quality Measures relating to physical restraint use, pain management, urinary catheter use, and pressure sores. Five-Star Nursing Home Quality Rating System information was also used to calculate overall quality measure and health inspection scores. Data were analyzed using negative binomial regression. Comparing quality in the year before accreditation with the 1st year after accreditation, all five Quality Measures and both Five-Star categories demonstrated improvement. In comparing quality after 8 years of accreditation, three of the Quality Measures examined continued to improve. There were no cases where accreditation was associated with decreased quality. These results indicate that TJC accredited nursing homes improve their quality immediately after accreditation but do not continue to improve in all areas over time.