Quality Improvement Driving Factors
Quality Improvement Driving Factors
Quality Improvement Driving Factors
To solve system-wide problems causing quality deterioration, the concept of quality improvement (QI) was introduced to healthcare from the manufacturing industry (Lighter, 1999). The QI model adopted in healthcare is based on principles that increase productivity, reduce costs, and make institutions more competitive (Bennett & Slavin, 2002).The model focuses on identifying defects and wastes in the hospital’s service line and streamlining the process to produce better outcomes. The goal of QI in healthcare has focused on improving outcomes such as morbidity, medication errors, re-admission, length of stay, and mortality through streamlining treatment process.
Using the principles of the QI model from manufacturing industry, healthcare QI activities became highly centralized and tightly controlled by standards and regulations. Quality of care is perceived as a property of the system rather than a property of individual care providers. This QI model tends to disregard healthcare workers’ expertise and professional judgment, replacing these instead with rules and protocols intended to streamline the complex system.
Lack of Systematic Quality Evaluation Early on, lack of systematic evaluation tools was identified as a barrier to make measurable improvement on quality. Thus among the IOM QI recommendations (2001), issue of quality evaluation was addressed first, and evaluation tools were rapidly implemented. The evaluation of quality of care is aligned with payment policies and provides strong financial incentives for hospitals. The Joint Commission on Accreditation of Healthcare Organizations started including core quality measures in their accreditation. Hospital associations and health plans such as the Centers for Medicare and Medicaid Services (CMS) began asking hospitals to submit reports about hospital quality measures, and the data have been displayed on the public Hospital Quality Initiative (HQI) Web site (CMS, 2008). Financial incentives are provided for submitting quality evaluation data. Further the public nature of the HQI information pressures hospitals not only to participate in quality evaluation and disclose the data, but also to perform well to remain competitive in the industry (Draper, Felland, Liebhaber, & Melichar, 2008).
To evaluate quality of nursing care separate from overall hospital care, American Nurses Association (ANA) has developed nursing-sensitive indicators including nurse staffing information and patient care outcomes such as pressure ulcers, patient falls, and nosocomial infections (ANA, 1999). This information is currently collected and housed in the National Database of Nursing Quality Indicators® (NDNQI®: 2006). Unlike the HQI, NDNQI® provides hospital unit level national comparative data only to participating hospitals for their internal use in QI activities. Yet, participation to NDNQI® is often driven by administrative interests such as Magnet application, meeting the Joint Commission standards, or nurse retention/recruitment rather than internal motivation to improve quality of care by front-line nurses.
Data collected in the HQI, NDNQI®, and other quality measurements are thoughtful and empirically supported indicators of quality care that make comparison across institutions possible. They also provide benchmarks to hospital and nursing administrators to mark their improvement. However, because they are the measures requested by external QI entities and hospital or nursing administrators, not front-line workers, efforts to collect and use the data
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to evaluate the quality of care has come to be viewed as an administrative mandatory activity.
Insufficient Staffing as a Cause of Quality Deterioration Among nurses, quality of care is thought to be related to an inadequate patient-to-nurse ratio. From their perspectives, the primary cause of poor quality care is the substantial increase in nurses’ workloads that came about with shortened lengths of patients’ hospital stays, increased acuity of hospitalized patients, and insufficient nurse staffing as a result of cost containment and the nursing shortage (ANA, 1999; Erlen, 2004; Gordon, 2005; Ludwick & Silva, 2003; Shindul-Rothchild, et al., 1996). Nurses have been exhausted and dissatisfied, and perceive that they have less time to provide adequate nursing care, and patient safety has been compromised (Aiken, Clarke, Sloane, Sochalski, & Silber, 2002; Ludwick & Silva, 2003; Shindul-Rothchild, Long-Middleton, & Berry, 1997; Vahey, Aiken, Sloane, Clarke, & Vargas, 2004). A number of researchers have found relationships between nurse staffing and patients’ outcomes (Aiken, Clarke, Sloane, Lake, & Cheney, 2008; Aiken, et al., 2002; Needleman et al., 2011; Sochalski, 2004; Vahey, et al., 2004). Aiken et al. (2002), for example, found that a higher patient-to-nurse ratio was associated with not only negative patient outcomes, but increased odds of nurses’ burnout and job dissatisfaction, which leave nurses with feelings of disempowerment and moral distress. The resulting decline in morale leads to further deterioration of the quality of care they provide (Erlen, 2004). From nurses’ perspective, insufficient staffing in today’s healthcare system is a major cause of deterioration in hospital care quality.
Therefore, many quality improvement efforts in nursing have focused on decreasing the patient-to-nurse ratio. ANA worked to educate nurses, consumers, and policy makers about nursing contributions to quality care and the importance of keeping sufficient nurses at the bedside for safe and quality health care (ANA, 1999). Nursing-sensitive indicators, now part of NDNQI®, are developed as a tool to generate national data on the relationships between nurse staffing and patient outcomes.
Threats of Current QI Approaches to Professional Nursing Clearly, significant quality problems exist in the U.S. healthcare system. Both healthcare institutions and the nursing profession have been rigorously trying to change the system to improve the quality of care. These efforts are needed and many nurses welcome the idea of QI. However, by following the rapid movement in recent QI activities without reflecting on the assumptions and the meaning of the activities for nursing professional values and practice, nurses may jeopardize their nursing values, and this can lead to, ultimately, a de- professionalization of nursing. Three particular pitfalls are identified as potential threats to the nursing profession in the QI approaches described above: the focus on quantity of nurses, safety as a quality standard, and QI as a mandatory activity.
The Focus on Quantity of Nurses A number of studies have provided evidence that a higher patient-to-nurse ratio is associated with a higher patient mortality rate and other negative quality outcomes (Aiken, et al., 2008; Aiken, et al., 2002; Needleman et al., 2011; Sochalski, 2004; Vahey, et al., 2004). Yet, the argument that an increased number of nurses will improve quality of care needs careful consideration. Having sufficient number of nurses in a unit is critical to secure the safety and quality of care. But we also have to ask whether it is only the number of nurses that matters. The question is whether quality, competence, and expertise of the nurses should matter too. Although several researchers have found that nurses with more education, more experience, full-time commitment, and better communication skills help to decrease medical error,
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patient fall rate, and mortality (Aiken, Clarke, Cheung, Sloane, & Silber, 2003; Blegen, Vaughn, & Goode, 2001; Estabrooks, Midodzi, Cummings, Ricker, & Giovannetti, 2005), the quality of nurses is rarely discussed in current QI efforts. By simply equating quality of care with the quantity of nurses, we may represent nurses as laborers for whom only the headcount matters, not professionals with expertise and specialty knowledge.
This may be a pitfall of the manufacturing QI model as well. As Jennings noted (2003), QI following a manufacturing model does not count on healthcare workers’ expertise and professional judgment to provide quality care. Instead, it recommends using rules and protocols to navigate the complex system and make clinical judgment to achieve agreed upon quality care. Does it mean that quality care can be achieved if the nurses know how to follow protocols rather than use their own professional knowledge and judgment in their practice?
