Search

Objective This study modeled the predictive power of unit/patient characteristics, nurse workload, nurse expertise, and hospital-acquired pressure ulcer (HAPU) preventive clinical processes of care on unit-level prevalence of HAPUs. Data Sources Seven hundred and eighty-nine medical-surgical units (215 hospitals) in 2009. Study Design Using unit-level data, HAPUs were modeled with Poisson regression with zero-inflation (due to low prevalence of HAPUs) with significant covariates as predictors. Data Collection/Extraction Methods Hospitals submitted data on NQF endorsed ongoing performance measures to CALNOC registry. Principal Findings Fewer HAPUs were predicted by a combination of unit/patient characteristics (shorter length of stay, fewer patients at-risk, fewer male patients), RN workload (more hours of care, greater patient [bed] turnover), RN expertise (more years of experience, fewer contract staff hours), and processes of care (more risk assessment completed). Conclusions Unit/patient characteristics were potent HAPU predictors yet generally are not modifiable. RN workload, nurse expertise, and processes of care (risk assessment/interventions) are significant predictors that can be addressed to reduce HAPU. Support strategies may be needed for units where experienced full-time nurses are not available for HAPU prevention. Further research is warranted to test these finding in the context of higher HAPU prevalence.

Background Quality measurement is central in efforts to improve health care delivery and financing. The Interdisciplinary Nursing Quality Research Initiative supported interdisciplinary research teams to address gaps in measuring the contributions of nursing to quality care. Objective To summarize the research of 4 interdisciplinary teams funded by The Interdisciplinary Nursing Quality Research Initiative and reflect on challenges and future directions to improving quality measurement. Methods Each team summarized their work including the targeted gap in measurement, the methods used, key results, and next steps. The authors discussed key challenges and recommended future directions. Results These exemplar projects addressed cross-cutting issues related to quality; developed measures of patient experience; tested new ways to model the important relationships between structure, process, and outcome; measured care across the continuum; focused on positive aspects of care; examined the relationship of nursing care with outcomes; and measured both nursing and interdisciplinary care. Discussion Challenges include: measuring care delivery from multiple perspectives; determining the dose of care delivered; and measuring the entire care process. Meaningful measures that are simple, feasible, affordable, and integrated into the care delivery system and electronic health record are needed. Advances in health information systems create opportunities to advance quality measurement in innovative ways. Conclusions These findings and products add to the robust set of measures needed to measure nurses' contributions to the care of hospitalized patients. The implementation of these projects has been rich with lessons about the ongoing challenges related to quality measurement.

The objective of this study was to demonstrate the association between nurse staffing and adverse events at the shift level.Despite a growing body of research linking nurse staffing and patient outcomes, the relationship of staffing to patient falls and medication errors remains equivocal, possibly due to dependence on aggregated data.Thirteen military hospitals participated in creating a longitudinal nursing outcomes database to monitor nurse staffing, patient falls and medication errors, and other outcomes. Unit types were analyzed separately to stratify patient and nurse staffing characteristics. Bayesian hierarchical logistic regression modeling was used to examine associations between staffing and adverse events.RN skill mix, total nursing care hours, and experience, measured by a proxy variable, were associated with shift-level adverse events.Consideration must be given to nurse staffing and experience levels on every shift.

Benchmarking is an indispensable tool as hospital leaders face challenges to balance efficiency with safe and effective care. Selection of appropriate "like" hospitals is critical to the benchmarking aim of understanding comparative performance. Based on 10 years of observed outcome differences between small and large hospitals, the Collaborative Alliance for Nursing Outcomes (CALNOC) sought to empirically define small hospitals, and to determine if there were statistical differences between small and large hospitals for selected nursing sensitive outcome indicators. This article reports the examination of hospital size as a proxy characteristic to define "like" hospitals for the purpose of benchmarking outcomes. Findings suggest that optimal classifications into small and large hospital size based on the outcome indicators of falls, falls with injury, and hospital-acquired pressure ulcers stage 2 or worse (HAPU 2+) were not consistent with historical administrative categories based on average daily census and not consistent by outcome. Statistical differences were only found with HAPU 2+ in critical care units, with no differences in the fall outcomes. These data did not support the use of size-based categories to define like hospitals for benchmark comparisons.

This article examines the impact of mandated nursing ratios in California on key measures of nursing quality among adults in acute care hospitals. This study is a follow-up and extension of our first analysis exploring nurse staffing and nursing-sensitive outcomes comparing 2002 pre-ratios regulation data to 2004 postratios regulation data. For the current study we used postregulation ratios data from 2004 and 2006 to assess trends in staffing and outcomes. Findings for nurse staffing affirmed the trends noted in 2005 and indicated that changes in nurse staffing were consistent with expected increases in the proportion of licensed staff per patient. This report includes an exploratory examination of the relationship between staffing and nursing-sensitive patient outcomes. However anticipated improvements in nursing-sensitive patient outcomes were not observed. This report contributes to the growing understanding of the impacts of regulatory staffing mandates on hospital operations and patient outcomes.

The purpose of this article is to present findings from a review of published systematic/integrative reviews and meta-analyses on nursing interventions and patient outcomes in acute care settings. A literature search was conducted for the period 1999-2005, producing 4,000 systematic/integrative reviews and 500 meta-analyses covering seven topics selected by the authors: elder care, caregivers, developmental care of neonates and infants, symptom management, pressure ulcer prevention/treatment, incontinence, and staffing. The association between nursing care interventions/processes and patient outcomes in acute care settings was found to be limited in the articles reviewed. The strongest evidence was for the use of patient risk-assessment tools and interventions implemented by nurses to prevent patient harm. We observed significant variation in methods to measure the effect of independent variables (nursing interventions) on patient outcomes. Results indicate the need for more research measuring the effect of specific nursing interventions that may impact acute care patient outcomes.

This article presents the first analysis of the impact of mandated minimum-staffing ratios on nursing hours of care and skill mix in adult medical and surgical and definitive-observation units in a convenience sample of 68 acute hospitals participating in the California Nursing Outcomes Coalition project. Findings, stratified by unit type and hospital size, reveal expected changes as hospitals made observable efforts toward regulatory compliance. These data cannot affirm compliance with ratios per shift, per unit, at all times; however, they give evidence of overall compliance. Assessment of the impacts of the mandated ratios on two common indicators of patient care quality, the incidence of patient falls and the prevalence of pressure ulcers, did not reveal significant changes despite research linking nurse staffing with these measures. These findings contribute to understanding unit level impacts of regulatory staffing mandates and the preliminary effect of this legislation on core quality of care indicators.

Objective This study tested multivariate models exploring unit-level predictors of medication administration (MA) accuracy. Background During MA, nurses are both the last line of defense from medication-related errors and a potential perpetrator of error. Direct observation reveals safe practices and the accuracy of medication delivery. Methods Using a direct-observation, cross-sectional design, data submitted by 124 adult patient care units for 15600 medication doses, from January 2009 to April 2010, were studied. Results Distractions and interruptions were the most common safe practice deviation. Characteristics of patient care units and RN hours of care affected nurses' safe practices and MA accuracy. Safe practices predict and mediate MA accuracy. A 5% decrease in safe practice deviations would reduce MA errors by 46% without any change in RN hours of care. Conclusion Nurses' adherence to MA safe practices, combined with unit characteristics and staffing factors, has the potential to dramatically improve MA accuracy.

The California Nursing Outcomes Coalition (CalNOC) project is an initiative that has become the largest ongoing nursing quality measurement repository in the nation. Launched in 1996 by California nursing leaders concerned with trends in hospital care, CalNOC has created reliable quality benchmark data to define patient safety thresholds in California. This article describes CalNOC's effort, which aligns with the strategy of the National Quality Forum for measuring and reporting healthcare quality. By tracing the evolution of the CalNOC project and its future potential, we hope to encourage other grassroots efforts to build the database repositories needed for healthcare quality measurement in the 21st century.

Purpose: To explore the need for evidence-based health policy, as illustrated by the mandatory staffing bill passed by the California state legislature in 1999. Design: Prospective data were collected from a voluntary sample of California acute care representatives to describe selected patient safety and clinical outcomes and nurse staffing variables at the patient-care unit level. Methods: Data for descriptive analysis were collected on hospital nurse staffing, patient falls, and pressure ulcers from 257 medical, surgical, medical-surgical combined, step-down, 24-hour observation units, and critical care patient care units in 38 California acute care hospitals from June 1998 to June 1999. Findings: Nursing staffing ratios varied among the 257 units. RNs provided 91% of the nursing care in critical care units. Patients in medical-surgical units received 59% of their care from RNs, 11% from licensed vocational nurses, and 30% from other caregivers. Preliminary data showed no relationships between reported staffing ratios in these hospitals and the incidence of patient falls or hospital-acquired pressure ulcers. Conclusions: California Nursing Outcomes Coalition (CalNOC) data showed wide variations in staffing ratios, patient falls, and hospital-acquired pressure ulcers among nursing units and hospitals. These early findings indicate the need for additional research before determining minimal RN staffing requirements. Analysis of multiple sources of data may be necessary to determine safe staffing ratios and to provide evidence-based data for public policy.

Benchmarking expedites the quest for best practices and is crucial to hospitals' effective, reliable, and superior performance. Comparative performance data are used by accrediting and regulatory bodies to evaluate performance and by consumers in making decisions on where to seek healthcare. Nursing-sensitive quality measures affirmed by the National Quality Forum are now used in public reporting and pay-for-performance in addition to traditional medical outcome metrics. This report provides hospital nursing-sensitive benchmarks from medical/surgical, critical care, and step-down units drawn from 196 hospitals during six quarters in 2007 and 2008. Outcome measures include pressure ulcer prevalence rates and fall/falls with injury rates. Additional indicators that describe nursing care (nurse staffing care hours, skill mix, nurse/patient ratios, workload intensity, voluntary turnover, and use of sitters) and patient descriptors (age, gender, and diagnosis description) were also included. Specific benchmarks are provided using the 10th and the 90th percentiles, as well as quartiles to allow hospitals an opportunity to understand comparative performance with specificity. The purpose of this article is to provide hospitals not currently participating in comparative benchmarking databases with nursing-sensitive data from the Collaborative Alliance for Nursing Outcomes for use in performance improvement processes.

Article-at-a-Glance Background Translating research into practice and policy is a complex process that links the research enterprise and health care delivery system of the United States. The Agency for Healthcare Research and Quality (AHRQ) Partnerships for Quality (PFQ) initiative expanded the scope of research translation beyond clinical practice, highlighting the role of strategic partners. A work group of AHRQ grantees developed a framework for systematic evaluation of the impact of strategic partnerships on research translation. Methods The evaluation framework posits a hierarchy of impacts that cumulatively lead to observable patient outcomes. The evaluation framework captures (1) health care outcomes improvement, (2) clinical practice changes, (3) policies, procedures, and protocols, and (4) research and knowledge. After the framework and tool were subjected to face-validity critique among PFQ investigators, the concept of synergy was added. PFQ investigators pilot-tested the evaluation framework, and the PFQ tool was refined further. Results Early feedback from PFQ grantees suggested that the framework is generalizable and potentially useful to guide investigators in capturing impacts of their work that might otherwise go unrecognized or trivialized. Discussion The PFQ Evaluation Tool, a pragmatic approach for evaluating the impact of partnership-driven translation projects, provides a comprehensive evaluation of impacts, including synergistic outcomes.

Background: The translation and diffusion of findings into health care validate the potential of evidence-based innovation to improve clinical practice and affirm the benefits of society's investment in advancing science. Aims: This article briefly reviews key concepts in the knowledge use process, considers theoretical implications for measuring outcomes and uptake of innovation, discusses issues to consider in planning for measurement of adoption, and provides an example of confronting those challenges from a project now in progress. THEORETICAL PERSPECTIVES AND TRANSLATION OUTCOMES: Four principal conceptual frameworks related to translational science, Lewin, Rogers, Havelock, and Promoting Action on Research Implementation in Health Services (PARIHS), explicate a process that catalyzes new knowledge adoption and use by individuals and systems to solve problems. Each conceptual perspective suggests that translation is not complete until the extent and impact of use is examined and understood. Most perspectives support evaluation of impact of evidence-based practice using process measures that integrate clinician knowledge, actual performance of the practice, and patient/clinician outcomes. Based on the Agency for Healthcare Research and Quality (AHRQ) framework, additional measures might include changes in patterns of care and changes in policies, procedures, or protocols. CASE EXAMPLE: A description of process and outcome measures used in an in-progress quality improvement demonstration project, California Nursing Outcomes Coalition (CalNOC) Partners in Quality Translating Research into Practice to Reduce Patient Falls Project, is presented. IMPLICATION(S) FOR PRACTICE, RESEARCH, AND POLICY: Since the adoption of evidence-based innovation is a process that is often described along a continuum, investigators seeking to measure the impact of an evidence-based innovation must gather evidence that uptake of the innovation has occurred. The theoretical perspective and practical measurement issues of a given project will drive selection of process and outcome measures. Conclusions: Efforts to change practice in order to enhance evidence-based patient care must integrate monitoring and evaluation of specific target outcomes of adoption as the basis for validating the impact of the change.

Using nursing quality benchmarks in operational dashboards and translating those data to drive performance excellence is a strategic imperative. Since access to unit-level, hospital-generated nurse-related benchmarks is an emerging arena, the authors provide an overview of aggregated trends and benchmarks gleaned from the California Nursing Outcome Coalition acute care database for 2 established nurse-related quality indicators-patient falls incidence and hospital-acquired pressure ulcer prevalence. Integrating these acute care benchmarks into clinical dashboards can be invaluable to clinicians, administrators, and policy makers who share a common commitment to expediting evidence-based improvement in patient care safety, outcomes, and excellence.

Healthcare quality professionals in the United States have opportunities to teach healthcare providers in other countries how to measure and monitor quality. Special preparation is required to effectively teach an international audience. This article offers tips for teaching basic quality concepts based upon the authors' experiences in the People's Republic of China. Working with health professionals in other countries is exciting and challenging for everyone involved. Approaching the opportunity with systematic preparation may be the key to success.