Nurse Quality Check

(HealthLeaders) In northeastern Indiana, about 15 miles west of Fort Wayne, sits the 30-bed community hospital Parkview Whitley in Columbia City. Poudre Valley Hospital in Fort Collins, Colo., has 241 beds and more than a dozen patient-care units. And New Jersey’s Robert Wood Johnson University Hospital, a 600-bed academic medical center in New Brunswick, has 32 nursing units that vary in size from eight to 47 beds.

Despite dramatic differences in facility type and community setting, the trio shares one crucial similarity: high-quality nurses. Nursing leadership at each organization takes seriously the notion of holding accountable these caregivers and measuring their success against internal and national standards. The high expectations have paid off, earning them national accolades—Magnet designation from the American Nurses Credentialing Center, American Nurses Association awards, and more—but nurse leaders at all three say the acknowledgment doesn’t change the way they practice. Rather, it reinforces the importance of high-quality nursing care—keeping patients satisfied and out of harm’s path.

“Patient safety and quality are the most important outcomes that we have here,” says Kathy Easter, RN, CCRN, interim director of the Magnet program at Robert Wood Johnson. “Obviously, many of our patients are ill when they’re admitted. But we want to make sure they’re in a better condition upon discharge than they were on admission.”

To make this happen consistently, give nurses a barometer—in the form of metrics and standards—to measure where they stand compared with individuals and units at their hospital and at like institutions. The accountability fosters empowerment, which fosters high-quality care, says Terri Veneziano, MSN, RN, assistant vice president of nursing at Robert Wood Johnson. “We’ve really driven accountability to the nurses at the bedside. They truly are the ones who have the ability … to impact both positive and negative outcomes for patients.”

A go-to metric
All three facilities take part in the National Database of Nurse Quality Indicators, a 14-year-old tool developed as part of the ANA’s Safety and Quality Initiative. As of April, 1,813 hospitals in all 50 states and Washington, D.C., participated. That’s more than 30% of all registered U.S. hospitals.

“It is the nation’s most comprehensive database,” says Bridget Johnson, Parkview Whitley’s vice president of patient services. “We use this to look at performance indicators that measure nursing quality.” In fact, the entire Parkview Health system employs the database, which takes a three-pronged approach to nursing care, looking at structure, process, and patient outcomes. Facilities select which of the 20-plus metrics—they range from patient falls to nurse turnover rates—they want regular reporting on.

Hospitals (and units within) receive comparisons based on bed size or teaching status only. For example, as a regional medical center with 225 staffed beds, Poudre Valley falls into NDNQI’s 200–299 bed range and its teaching hospital status. So its benchmark scores would never be side by side with those of a 20-bed community hospital. “If it’s a medical unit in one place, we’re compared to a medical unit in another place. That’s important,” says Donna D. Poduska, MS, RN, NE-BC, NEA-BC, vice president and chief nursing officer at the Colorado facility. “Different populations of patients will be on the medical unit versus the women’s care unit, so you’re really comparing apples to apples that way.”

Often, it’s the first time these hospitals see how they stack up against similar facilities, and the results tend to motivate change, Johnson adds. When Parkview Whitley’s patient falls spiked in mid-2010—something unknown to hospital leadership before seeing the NDNQI data—an action plan was quickly developed. “We were able to drive that number down and keep that number down,” Johnson says, “based on personal alarms, hourly rounding, bedside shift reports.” In the end, the action plan engaged the nursing staff, which made them accountable to improving the numbers.

Robert Wood Johnson Hospital asks its nurses to complete the annual NDNQI job satisfaction survey. “We look at those metrics to see how satisfied our nurses are with respect to their units,” Easter says. “RN satisfaction is directly related to our other quality outcomes.”

Unique approaches to maintaining quality
All three hospitals aim to exceed national benchmarks, instilling a mind-set that teaches their nurses to go beyond what’s expected. With that comes implementation of unique systems to measure and maintain quality. Robert Wood Johnson, for instance, developed what it calls M and Ms (mistakes and misjudgments). During one of these sessions, a nurse who makes an error or who doesn’t meet a benchmark works with a clinical nurse educator to reflect on the situation. Together they take stock of what happened, look at the metrics, understand how those translate into daily practice, and then implement changes.

The facility also designates one performance improvement analyst for each unit, a registered nurse who takes eight hours every month—a PI day, the nurses call it—to collect data and make recommendations. “Peer to peer, they address the issues if something falls out of alignment,” Easter says. “That’s a unique model, for them to really address it in real time.” She gives the example of catheter-associated urinary tract infections. The PI analyst evaluates how many days a catheter has been in place, where the Foley bag sits compared to the bladder, whether the catheter is attached to the leg—proven infection-prevention methods. “They make sure that that is all in place,” she adds. “If it’s not, they have a real-time conversation with the nurse caring for the patient. They make sure all team members—not only our registered nursing staff, but also our unlicensed assistive personnel—are also on the same page.”

When something doesn’t sit right at Poudre Valley, the hospital has a protocol: “We always like to outperform the mean,” Poduska says. “So if you don’t, you have to develop an action plan [for] how you’re going to improve. Then we monitor those action plans.” The method works from the most granular level to the broadest, with improvement strategies employed for individuals and units, even hospitalwide when necessary. Poudre Valley follows up on the action plans quarterly because that’s how frequently data arrive—except for nurse satisfaction data, that is. Those come annually.

Satisfaction of patients and nurses
Of course, Poudre Valley takes the temperature, so to speak, of its nurses more than just once a year, Poduska says. Nursing leadership performs what she calls spot checks periodically. Then the annual survey digs deeper, looking at nurse-to-nurse communication, nurse-to-physician communication, even job enjoyment.

Veneziano says empowering Robert Wood Johnson’s nurses to effect organizationwide change, for example, or improve bedside care, goes a long way toward fostering contented caregivers. “They realize they have the capability within their own practice to affect patient outcomes so tremendously because of the accountability they have and take on,” she says. And, she adds, there’s a direct correlation between engaged, happy nurses and satisfied patients.

One tactic Veneziano says she believes upped the hospital’s patient-satisfaction scores is a hospitalwide discharge callback system. In theory, the concept is simple. Within 24 hours of a patient’s departure, a nurse calls to ask about pain, follow-up appointments, rounding during the stay, and medication, as well as whether the patient has questions or wants to recognize or reward a caregiver.

In 2011, the hospital called more than 35,000 patients, with second and third attempts made to many patients missed on the initial try. In the first quarter of 2012, the hospital called some 7,800 patients. “It’s taking that relationship from a patient caregiver within the hospital walls here and touching patients when they’re in their homes,” Veneziano says.

Poudre Valley recently implemented two systems, also in an effort to cement a more personal connection with patients. Poduska calls the first system the bedside report. “The oncoming nurse to a new shift and the off-going nurse of that shift go to the patient’s bedside and give a report actively involving the patient,” she says. The Fort Collins regional medical center also instituted hourly rounding or “rounding with a purpose,” as Poduska puts it, to ensure that a patient who needs something never has to wait long for attention. Patients have already started reporting higher satisfaction scores in areas such as involvement in and knowledge of their care plan.

“What we do here is about the patient,” says Johnson of Parkview Whitley. “But we also have to have the right kind of work environment. It’s about putting all of that together.” And, adds Veneziano, it’s about being transparent with nurses and translating the metrics into real situations. “All these numbers and dashboards have meaning to actual care and quality of the patients that we care for,” she says. “We have made the metrics meaningful.”