734.3.1Principles of Leadership

The graduate applies principles of leadership to promote high-quality healthcare in a variety of settings through the application of sound leadership principles.

734.3.2Interdisciplinary Collaboration

The graduate applies theoretical principles necessary for effective participation in an interdisciplinary team.

734.3.3Quality and Patient Safety

The graduate applies quality improvement processes intended to achieve optimal healthcare outcomes, contributing to and supporting a culture of safety.

INTRODUCTION

National initiatives driven by the American Nurses Association have determined nursing-quality outcome indicators that are intended to focus plans and programs to increase quality and safety in patient care. The following outcomes are commonly used nursing-quality indicators:

• complications such as urinary tract infections, pressure ulcers, hospital-acquired pneumonia, and DVT

• patient falls

• surgical patient complications, including infection, pulmonary failure, and metabolic derangement

• length of patient hospital stay

• restraint prevalence

• incidence of failure to rescue, which could potentially result in increased morbidity or mortality

• patient satisfaction

• nurse satisfaction and staffing

SCENARIO

Mr. J is a 72-year-old retired rabbi with a diagnosis of mild dementia. He was admitted for treatment of a fractured right hip after falling in his home. He has received pain medication and is drowsy, but he answers simple questions appropriately.

A week after Mr. J was admitted to the hospital, his daughter, who lives eight hours away, came to visit. She found him restrained in bed. While Mr. J was slightly sleepy, he recognized his daughter and was able to ask her to remove the restraints so he could be helped to the bathroom. His daughter went to get a certified nursing assistant (CNA) to remove the restraints and help her father to the bathroom. When the CNA was in the process of helping Mr. J sit up in bed, his daughter noticed a red, depressed area over Mr. J’s lower spine, similar to a severe sunburn. She reported the incident to the CNA who replied, “Oh, that is not anything to worry about. It will go away as soon as he gets up.” The CNA helped Mr. J to the bathroom and then returned him to bed where she had him lie on his back so she could reapply the restraints.

The diet order for Mr. J was “regular, kosher, chopped meat.” The day after his daughter arrived, Mr. J was alone in his room when his meal tray was delivered. The nurse entered the room 30 minutes later and observed that Mr. J had eaten approximately 75% of the meal. The meal served was labeled, “regular, chopped meat.” The tray contained the remains of a chopped pork cutlet.

The nurse notified the supervisor, who said, “Just keep it quiet. It will be okay.” The nursing supervisor then notified the kitchen supervisor of the error. The kitchen supervisor told the staff on duty what had happened.

When the patient’s daughter visited later that night, she was not told of the incident.

The next night, the daughter was present at suppertime when the tray was delivered by a dietary worker. The worker said to the patient’s daughter, “I’m so sorry about the pork cutlet last night.” The daughter asked what had happened and was told that there had been “a mix up in the order.” The daughter then asked the nurse about the incident. The nurse, while confirming the incident, told the daughter, “Half a pork cutlet never killed anyone.”

The daughter then called the physician, who called the hospital administrator. The physician, who is also Jewish, told the administrator that he has had several complaints over the past six months from his hospitalized Jewish patients who felt that their dietary requests were not taken seriously by the hospital employees.

The hospital is a 65-bed rural hospital in a town of few Jewish residents. The town’s few Jewish members usually receive care from a Jewish hospital 20 miles away in a larger city.

REQUIREMENTS

Your submission must be your original work. No more than a combined total of 30% of the submission and no more than a 10% match to any one individual source can be directly quoted or closely paraphrased from sources, even if cited correctly. An originality report is provided when you submit your task that can be used as a guide.

You must use the rubric to direct the creation of your submission because it provides detailed criteria that will be used to evaluate your work. Each requirement below may be evaluated by more than one rubric aspect. The rubric aspect titles may contain hyperlinks to relevant portions of the course.

Analyze the scenario (suggested length of 2–3 pages) by doing the following:

A. Discuss how the application of nursing-quality indicators could assist the nurses in this case in identifying issues that may interfere with patient care.

B. Analyze how hospital data of specific nursing-quality indicators (such as incidence of pressure ulcers and prevalence of restraints) could advance quality patient care throughout the hospital.

C. Analyze the specific system resources, referrals, or colleagues that you, as the nursing shift supervisor, could use to resolve an ethical issue in this scenario.

D. Acknowledge sources, using in-text citations and references, for content that is quoted, paraphrased, or summarized.

E. Demonstrate professional communication in the content and presentation of your submission.

RUBRIC

A
:
UNDERSTANDING OF NURSING QUALITY INDICATORS

B:ADVANCING QUALITY PATIENT CARE

C:RESOLUTION OF ETHICAL ISSUES

D:SOURCES

E:PROFESSIONAL COMMUNICATION

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HomeANA PeriodicalsOJINTable of ContentsVol.12 – 2007No3:Sept’07Nursing Quality Indicators

The National Database of Nursing Quality Indicators® (NDNQI®)^ m d Bookmark and Share

Isis Montalvo, MS, MBA, RN

Abstract

The National Database of Nursing Quality IndicatorsTM (NDNQI®) is the only national nursing database that provides quarterly and annual reporting of structure, process, and outcome indicators to evaluate nursing care at the unit level. Linkages between nurse staffing levels and patient outcomes have already been demonstrated through the use of this database. Currently over 1100 facilities in the United States contribute to this growing database which can now be used to show the economic implications of various levels of nurse staffing. The purpose of this article is to describe the work and accomplishments related to the NDNQI as researchers utilize its nursing-sensitive outcomes measures to demonstrate the value of nurses in promoting quality patient care. After reviewing the history of evaluating nursing care quality, this article will explain the purpose of the NDNQI and describe how the database has been operationalized. Accomplishments and future plans of the NDNQI will also be discussed.

Citation: Montalvo, I., (September 30, 2007) “The National Database of Nursing Quality IndicatorsTM (NDNQI®)” OJIN: The Online Journal of Issues in Nursing. Vol. 12 No. 3, Manuscript 2.

DOI: 10.3912/OJIN.Vol12No03Man02

Key Words: nursing-sensitive indicators, quality, nurse staffing, patient outcomes, nursing outcomes, performance measurement

Quality is a broad term that encompasses various aspects of nursing care. Various health care measures have been identified over the years as indicators of health care quality (American Nurses Association, 1995; Institute of Medicine, 1999, 2001, 2005; Joint Commission, 2007). In 2004, the National Quality Forum (NQF), via its voluntary consensus standards process, endorsed 15 national standards to be used in evaluating nursing-sensitive care. These standards are now known as the NQF 15 (Kurtzman & Corrigan, 2007). The purpose of this article is to describe the work and accomplishments related to the National Database of Nursing Quality IndicatorsTM (NDNQI®) as researchers utilize its nursing-sensitive outcomes measures to demonstrate the value of nurses in promoting quality patient care. After reviewing the history of evaluating nursing care quality, this article will explain the purpose of the NDNQI and describe how the database has been operationalized. Accomplishments and future plans of the NDNQI will also be discussed.

History of Evaluating Nursing Care Quality

Evaluating the quality of nursing practice began when Florence Nightingale identified nursing’s role in health care quality and began to measure patient outcomes. She used statistical methods to generate reports correlating patient outcomes to environmental conditions (Dossey, 2005; Nightingale, 1859/1946). Over the years, quality measurement in health care has evolved. The work done in the 1970s by the American Nurses Association (ANA), the wide dissemination of the Quality Assurance (QA) model (Rantz, 1995), and the introduction of Donabedian’s structure, process, and outcomes model (Donabedian, 1988, 1992) have offered a comprehensive method for evaluating health care quality.

The workforce restructuring and redesign prevalent in the early 1990s demonstrated the need for the ANA to evaluate nurse staffing and identify linkages between nurse staffing and patient outcomes.The workforce restructuring and redesign prevalent in the early 1990s demonstrated the need for the ANA to evaluate nurse staffing and identify linkages between nurse staffing and patient outcomes. In 1994 the ANA Board of Directors asked ANA staff to investigate the impact of these changes on the safety and quality of patient care. In 1994, ANA launched the Patient Safety and Quality Initiative (ANA, 1995). A series of pilot studies across the United States were funded by ANA to evaluate linkages between nurse staffing and quality of care (ANA, 1996a, 1997, 2000a, 2000b, 2000c). Multiple quality indicators were identified initially. Evidence of the effectiveness of these indicators was used to adopt a final set of 10 nursing-sensitive indicators to use in evaluating patient care quality (Gallagher & Rowell, 2003). Implementation guidelines were subsequently published (ANA, 1996b, 1999).

Nursing-sensitive indicators identify structures of care and care processes, both of which in turn influence care outcomes. Nursing-sensitive indicators are distinct and specific to nursing, and differ from medical indicators of care quality. For example, one structural nursing indicator is nursing care hours provided per patient day. Nursing outcome indicators are those outcomes most influenced by nursing care.

Purpose of the NDNQI®

In 1998, the National Database of Nursing Quality Indicators was established by ANA so that ANA could continue to collect and build on data obtained from earlier studies and further develop nursing’s body of knowledge related to factors which influence the quality of nursing care. Linkages between nurse staffing and patient outcomes had already been identified, but continued data collection and reporting was necessary to evaluate nursing care quality at the unit level and thus fulfill nursing’s commitment to evaluating and improving patient care.

Nursing’s foundational principles and guidelines identify that as a profession, nursing has a responsibility to measure, evaluate, and improve practice. This is stated in two of nursing’s guiding documents:

The Code of Ethics for Nurses with Interpretative Statements states: The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient (ANA, 2001, p.12).

Nursing: Scope & Standards of Practice, Standard 7 states: The registered nurse systematically enhances the quality and effectiveness of nursing practice (ANA, 2004. p. 33).

The Utilization Guide for the ANA Principles for Nurse Staffing recognizes that in order to measure sufficiency of staffing on an ongoing basis, at a minimum, unit level nursing-sensitive structure, process, and outcome indicators need to be collected (ANA, 2005). NDNQI’s mission is to aid the nurse in patient safety and quality improvement efforts… NDNQI’s mission is to aid the nurse in patient safety and quality improvement efforts by providing research-based, national, comparative data on nursing care and the relationship of this care to patient outcomes.

Operationalization of the National Database

The NDNQI® database is managed at the University of Kansas Medical Center (KUMC) School of Nursing under contract to ANA with fiscal and legal support provided by KUMC Research Institute (KUMCRI). A health care facility that is interested in joining the NDNQI submits a signed contract and fee, based on hospital size, to KUMCRI, along with information on the person who will be the facility’s NDNQI® primary point of contact. This person is then identified as the NDNQI Site Coordinator. The NDNQI Site Coordinator serves as the interface between the participating facility and the NDNQI liaisons working at the University of Kansas. The NDNQI® liaisons provide ongoing assistance and support to health care facilities at multiple levels. For example they provide help in identifying nursing units appropriately for data entry; offer web-based, data-entry tutorials; conduct pilot testing; and answer questions about definitions and the reading of reports. NDNQI® researchers are also available to answer questions related to the database or the nursing measures.

Education on NDNQI and nursing-sensitive indicators has been ongoing for participating facilities since 1999. Facilities have quarterly conference calls with NDNQI® staff to review any changes or updates to the indicators or database. They also have the opportunity to participate in pilot studies performed when an indicator is being evaluated for implementation.

Once access to the database has been provided, the facility NDNQI® Site Coordinator will work with NDNQI staff from the University of Kansas to correctly classify the nursing units. This is an important step to ensure nursing units are classified appropriately prior to data entry. The facility NDNQI Site Coordinator and other authorized hospital staff also complete web-based tutorials to learn about each indicator prior to initial data submission.The facility NDNQI Site Coordinator has continuous access to the indicator definitions and is responsible for aligning the hospital data collected to NDNQI definitions. The facility NDNQI Site Coordinator has continuous access to the indicator definitions and is responsible for aligning the hospital data collected to NDNQI definitions. On average, it takes three months to join the database and start data submission. The NDNQI is then dependent on hospitals correctly submitting the data on a quarterly basis. All data is submitted electronically via the intranet in a secure website or by XML submission. Data checks and error reports are conducted on an ongoing basis by participating facilities and by NDNQI staff to ensure data integrity.

As of the writing of this article, the NDNQI has implemented six of the ten original ANA-endorsed NDNQI indicators (See Table 1). The initial set of indicators used in establishing the database was selected based on feasibility testing. These indicators included: Falls, Falls with Injury, Nursing Care Hours per Patient Day, Skill Mix, Pressure Ulcer Prevalence, and Hospital-Acquired Pressure Ulcer Prevalence. The RN job satisfaction indicator was pilot tested in 2001 and subsequently implemented in 2002. The RN satisfaction survey is an important indicator to assist nursing leaders and staff in evaluating the work environment so as to facilitate nursing retention and recruiting efforts.

Table 1. NDNQI Indicators

Indicator

Sub-indicator

Measure(s)

1. Nursing Hours per Patient Day1,2

a. Registered Nurses (RN)

b. Licensed Practical/Vocational Nurses (LPN/LVN)

c. Unlicensed Assistive Personnel (UAP)

Structure

2. Patient Falls1,2

Process & Outcome

3. Patient Falls with Injury1,2

a. Injury Level

Process & Outcome

4. Pediatric Pain Assessment, Intervention, Reassessment (AIR) Cycle

Process

5. Pediatric Peripheral Intravenous Infiltration Rate

Outcome

6. Pressure Ulcer Prevalence1

a. Community Acquired

b. Hospital Acquired

c. Unit Acquired

Process & Outcome

7. Psychiatric Physical/Sexual Assault Rate

Outcome

8. Restraint Prevalence2

Outcome

9. RN Education /Certification

Structure

10. RN Satisfaction Survey Options1,3

a. Job Satisfaction Scales

b. Job Satisfaction Scales – Short Form

c. Practice Environment Scale (PES)2

Process & Outcome

11. Skill Mix: Percent of total nursing hours supplied by1,2

a. RN’s

b. LPN/LVN’s

c. UAP

d. % of total nursing hours supplied by Agency Staff

Structure

12. Voluntary Nurse Turnover2

Structure

13. Nurse Vacancy Rate

Structure

14. Nosocomial Infections(Pending for 2007)

a. Urinary catheter-associated urinary tract infection (UTI)2

b. Central line catheter associated blood stream infection (CABSI)1,2

c. Ventilator-associated pneumonia (VAP)2

Outcome

1 Original ANA Nursing-Sensitive Indicator

2 NQF Endorsed Nursing-Sensitive Indicator “NQF-15”

3 The RN Survey is annual, whereas the other indicators are quarterly

Pediatric and psychiatric indicators have been added more recently because participating hospitals requested indicators for these areas. Additional NQF endorsed measures (Table 1) were then added to the database because these represented additional nursing measures available that had already gone through a consensus measure approval process. ANA supported the addition of these measures to the database because they were of interest nationally to the nursing profession and were in concert with ANA’s seminal work and ongoing support of nursing measures.

Implementing an indicator is a multi-step process (Table 2) that includes evaluating the evidence that a specified indicator is nurse sensitive and then pilot testing (Table 3) of the indicator by participating facilities. In addition, …there is ongoing monitoring and testing for validity and reliability per NDNQI standard operating procedure. there is ongoing monitoring and testing for validity and reliability per NDNQI standard operating procedure. An outcome indicator is deemed to be nursing sensitive if there is a correlation or multivariate association between some aspect of the nursing workforce or a nursing process and the outcome. The NDNQI utilizes state-of-the-science methods, such as the hierarchical mixed model, to assess the strength of correlation between nursing workforce characteristics and outcomes (Gajewski et al., 2007; Hart, et al., 2006).

Table 2. Indicator Development Process

Review scientific literature for: (a) evidence that some aspect of nursing case has an effect on a patient outcome; (b) specific definitions of the indicators; and (c) evidence that the indicators can be validly and reliably measured

Collect information from researchers in the field on threats to reliability and validity

Conduct expert review of draft indicator definitions, data collection guidelines, and data collection forms

Distribute revised definitions, guidelines, and forms to clinical experts for comments on face validity and feasibility of reliable data collection

Incorporate clinical expert feedback and develop revised versions of definitions, guidelines, and forms

Conduct a pilot study (Table 3) using the draft data collection materials and review data; also interview hospital study coordinators to identify additional threats to reliability and validity

Finalize definitions, data collection guidelines, and forms

Train database participants in standardized data collection practices

Table 3. Pilot Testing Process

Develop the indicator with draft guidelines and data collection instruments

Recruit pilot testers via e-mail and phone

Select pilot sites from those interested. Sites are selected for hospital/unit diversity

Guide pilot sites in collecting data according to the draft guidelines

Analyze data submitted by pilot sites

Collect written and telephone evaluations to assess for clarity, feasibility, and assessment of threats to validity and reliability

Analyze pilot data for indicator refinement

Finalize guidelines and instruments for dissemination

Quarterly Reports are downloaded electronically from the web by participating facilities. Reports can be downloaded in Adobe PDF, or Microsoft Excel format to facilitate data sharing and dissemination within a given institution. Figure 1 provides a sample of two tables from the report. The reports range from 25-200+ pages based on the number of nursing units and indicators for which hospitals submit data. The reports provide the most current eight quarters worth of data and a rolling average of those eight quarters with national comparisons at the unit level based on patient type, unit type, hospital bed size, and statistical significance of unit performance. For example, patient falls with injury could be reported for each adult medical unit of a 100-199 bed facility. The means for all medical units in a given-size facility can be compared with national standards for a given, nursing-sensitive indicator. The process measures associated with falls are collected and reported as well as the outcome measure of a patient fall.

Figure 1 – Sample Tables from NDNQI Reports

Figure 1

The significance of offering the reports at the unit level is that such reports provide data regarding the specific site where the care occurs and provides a better comparison among like units. The significance of offering the reports at the unit level is that such reports provide data regarding the specific site where the care occurs and provides a better comparison among like units. Nursing leaders at participating facilities have used the information to advocate for more staff or a different mix of staff based on their comparisons of units in comparable facilities nation wide. Staff are also able to identify whether their performance improved after they intervened in an area needing improvement, e.g., a decrease in the fall rate due to implementation of a new protocol.

Some facilities join NDNQI as part of their MagnetTM Journey to report nursing-sensitive indicators. The Magnet facilities represent about 20% of the database. The remaining 80% of NDNQI-participating facilities join because they believe in the value of evaluating the quality of nursing care and improving outcomes, activities which are both basic responsibilities of the profession. NDNQI is also used to aid in the recruitment and retention of nurses by hospitals that use the annual RN Survey data and quarterly data to improve work environments, to staff based on patient outcomes, and to mee

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