Group 5

Quality Indicators and Safety

Initiatives
Corinne Bradley, Teri Connors, Mary Hefferan, & Amy
Herrington

Introduction
Discuss the following Nursing Sensitive
Indicators (NSI)
Pediatric pain assessment, intervention, and
reassessment cycle
Nursing turnover
Registered Nursing education/certification
Pressure ulcers
Nursing hours per patient day
Patient falls
Staff mix
Nosocomial infections

Introduction
Source: www.hospitalmedicine.org

Discuss the safety initiative: BOOST

(Better Outcomes for Older adults
through Safe Transitions)
Safe transitions home from hospital
Reduce readmissions
Improving coordination and
communication
Risk assessment

(Society of Hospital Medicine, 2008; Wiliams, M. 2011)

Introduction
Source: www.hospitalmedicine.org

BOOST components
Patient centeredness
Empowerment
Risk adjustment
Team oriented
Bridging

(Society of Hospital Medicine, 2008)

Part 1: Quality Indicators and Safety

Initiatives
Mary Hefferan

NSI: Pediatric Pain Assessment

Assessment, Intervention, and
Reassessment (AIR) cycle
Often undertreated
Barriers to treatment
Myths, improper assessments, fear,
subjective and observational

(Avansino, Peters, Stockfish, & Walco, 2013; Committee on Psychosocial Aspects of Child and Family Health
and Task Force on Pain in Infants, Children and Adolescents, 2001)

NSI: Pediatric Pain Assessment

AIR Cycle
Pediatric pain best managed by cyclical
approach
Assessment: self-report, behavioral
observation tools
Intervention: individualized care
Reassessment: 30-60 minutes after
intervention
Source:http://www.women
shealthsection.com

(Habich, Wilson, Thielk, Melles, Crumlett, Masterson, & McGuire, 2012

NSI: Pediatric Pain Assessment

Why important?
Short term and long term consequences

Quality nursing care

Front-line observers
Select appropriate tools
Reassess post intervention
Leads to regular monitoring, anticipation,
and recording of pain
(Avansino et al., 2013; Baulch, 2010)

Literature Support
Research study
Educated staff
Improved administration of pain
medication, timeliness, and reassessment

Baulch (2010)
Documentation = successful pain
management
Establish trusting relationship
(Baulch, 2010; Corwin, Kessler, Auerbach, Liang, & Kristinsson, 2012)

NSI: Nursing Turnover

Improvement is necessary
Average increased: 11.2% (2012) to
13.1% (2013)
Cost ranges from $36,000 to $48,000
Retention essential to meet new demands

Nursing turnover impacts

Quality care
Patient safety
(American Association of Colleges of Nursing [AACN], 2014; Gilmartin, 2012; Nursing
Solutions Inc., 2013)

Source:
http://mhealthwatch.com

NSI: Nursing Turnover

Quantity
Excessive workloads, stress, burnout
Lower mortality and lower nurse/patient
ratios

Quality
Positive work environment
Authentic leadership
Empowerment
(AACN, 2014; Hayes et. al., 2012; Laschinger,
Wong, & Grau, 2013)

Source:
ultimatesdlc.com

Literature Support
Authentic leadership study
Lower emotional exhaustion
Higher levels of empowerment

Quality nursing preceptor development

Improved retention, cost savings,
improved intradepartmental relationships

Work environments
Collegial leads to less burnout and stress
(Alameda, Carafoli, Flattery, French, & McNamara, 2004; Laschinger, Wong, & Grau,
2013; Oyeleye, Hanson, OConnor, & Dunn, 2013)

Project BOOST: Patient

Centeredness
Identifying the needs, abilities, and
desires of patients and their immediate
caregivers (Society of Hospital Medicine, 2008, para. 3)
Address needs
Health information and education
materials
Within health literacy levels of patients and
care givers
Source: www.dreamstime.com

Patient Centeredness
Healthcare environment
20% of discharged patient may suffer
adverse event
3/4s are medication related
Joint Commission 2012
Reduces barriers to care
Informed patients/caregivers are more
proactive
(Dickens & Piano, 2013; Hearld & Alexander, 2012; Hansen et. al., 2013)

Source:
blog.skylight.
com

Patient Centeredness
Role of nursing
Most opportunity to ensure needs met
Teaching: continual evaluation
Caregiver involvement
Health information tools

(Slatore, Hansen, Ganzini, Press, Osborne, Chesnutt, & Mularski, 2012)

Literature Support
Patient centered intervention
Used nurse transition coach
Significantly lower re-hospitalization rates
at 30 and 90 days

Caregiver involvement
More prepared for role
Better perception of continuity of care

(Bull, Hansen, & Gross, 2000; Coleman, Parry, Chalmers, & Min, 2006)

Literature Support
Patient centeredness
Decreased utilization of health care
services
Lower annual costs

(Bertakis & Azari, 2011)

BOOST & NSI

Patient centeredness & pediatric pain
assessment
Individualized pain score scales
Involvement of parents

(Frank, Oulton, Nderitu, Lim, Fang, & Kaiser, 2011)

Re-hospitalization and Nursing

Turnover
Turnover
Higher rates of infection and infectionrelated hospitalization

Nurse retention
Related to 30 day re-hospitalization rate
Improves quality of organization
Source:capsules.kaiserhealthnews.org

(Thomas, Mor, Tyler, & Hyer, 2012; Zimmerman, Gruber-Baldini, Hebel, Sloane, &
Magaziner, 2002)

End of Part 1

Part 2: Quality Indicators and Safety

Initiatives
Amy Herrington

NSI: RN Education/Certification
Education
ADN/Diploma vs. BSN

Certification
NP, CNS, Specialty

(AACN, 2014).

Literature Review:
RN Education/Certification

Reduction in turnover
Patient & Nurse Satisfaction
Quality of Care
Patient Outcomes
Safety

(Blegen et al., 2013; Cramer et al., 2014; Fleischman, Meyer & Watson, 2011; Kaplow, 2011; Valente, 2010)

NSI: Pressure Ulcer Rate

Community-Acquired
Hospital-Acquired
Unit-Acquired

(Hill-Brown, 2011; Spetz, Brown, Aydin & Donaldson, 2013; Sullivan & Schoelles, 2013).

Literature Review:
Pressure Ulcer Rate

Healthcare Costs
Length of Stay
Staffing/Skill Mix
Liability
Morbidity
Quality of Life

(Park, Boyle, Bergquist-Beringer, Staggs & Dunton, 2014; Shannon, Brown & Chakravarthy, 2012; Spetz et
al., 2013; Sullivan & Schoelles, 2013; Welton, 2008).

BOOST: Empowerment
Empowering patients and caregivers
through the use of education and tools
which will position the patient for a safe
discharge.

(Society of Hospital Medicine, 2008)

Literature Review: Empowerment

More effective disease control

Prevention of complications
Reduced hospitalization costs
Improved quality of life

(Abedi, Salimi, Feizi & Safari, 2013; Dharmarajan, Hsieh & Lin, 2013; Enderlin, McLeskey, Rooker, Steinhauser,
DAvolio, Gusewelle & Ennen, 2013; Royani, Rayyani, Behnampour, Arab & Goleij, 2013; Tuso, Huynh, Garofalo,
Lindsay, Lenaburg, Lau, Florence, Jones, Harvey & Kanter, 2013).

RN Education/Certification &
BOOST
Certified RN can better assess patients
needs and empower patient

Pressure Ulcer Rates & BOOST

Empowerment Decreased
Community Acquired Pressure Ulcers

End of Part 2

Part 3: Quality Indicators and Safety

Initiatives
Teri Connors

NSI: Total Nursing Hours Per Patient Day

Productive Hours
RNs, LPN/LVNs, UAPs
Direct Patient Care
Each Inpatient Unit

(National Quality Forum, 2012)

Calculating Nursing Hours per

Patient Day
(4 RNs + 1 LPN + 1 NA) x 24 hours
22 patients
EQUALS
6.55 Nursing Hours per Patient Day (NPPD)

Effects of Nursing Staffing

Higher nursing staffing levels = better
patient outcomes
Length of Stay
Mortality
Hospital Acquired Infections
Falls
Medication Errors
Pressure Ulcers
(National Quality Forum, 2012)

Research: Economic Benefits

Nursing Sensitive Outcome

Number of Nursing-Sensitive
Outcomes Prevented

Surgical Wound Infection

145

Pulmonary Failure

173

Upper Gastric Ulcers & GI

Bleeds

541

Shock & Cardiac Arrest

343

Failure to Rescue

155

Total

1357

(Twigg, Geelhoed, Bremner & Duffied, 2013)

Higher RN Skill Mix Decreases

Pressure Ulcers
Pneumonia
DVTs
Ulcers
Gastritis & GI
Bleeds

Sepsis
Shock/Cardiac
Arrest
Mortality/Failure to
Rescue

(Twigg, Duffield, Bremner, Rapley & Finn, 2012)

NSI: Falls
Sudden, unintended, uncontrolled
downward displacement of a patients
body to the ground or other object.

(The Agency for Health Care Research and Quality, 2009)

Nurses Impact on Patient Falls

Patients Gatekeeper
Ensures Safe Care
Key Part of Fall Safety
Partner with Patients to Prevent Falls

Research: Magnet Status and

Staffing
Fall rate 5% lower in Magnet hospitals
RN hours per patient day related to 3%
lower fall rate in ICUs
LPNs & UAPs related to 2-4% higher
fall rate in non-ICUs
(Lake, Shang, Klaus, Dunton, 2010)

Research: Hourly Rounding

Fall rate decreased on experimental
unit from 3.37/1,000 patient days to
2.6/1,000 patient days with rounding
Fall rate on control unit increased
Fall rate decrease was not statistically
significant but 23% reduction was
clinically significant
Promising effects of hourly rounding
(Kalman, Nigolian & Olrich, 2012)

Project Boost: Risk Assessment

Identifies dominant patient specific risk
factors
8P Scale
Completed at admission
Mitigate risks

TARGET 8P Scale

Problem Medications
Psychological
Principal Diagnosis
Polypharmacy
Poor Health Literacy
Patient Support
Prior Hospitalization
Palliative Care

Research: Chronic Heart Failure

5.8 million adults

High 3-6 months readmission rates
High nurse to patient ratios affect ability
to provide effective discharge teaching
(Manning, 2011)

Research: Chronic Heart Failure

Risk Assessment Tool

Referral to HF Nurse Educator
Indepth discharge teaching
Follow-up during transition to home

(Manning, 2011)

Results

Decreased readmissions
Decreased length of stay
57% reduction in cost of care
(Manning, 2011)

Research: Adverse Events

Hemorrhage related to dual antiplatlet
therapy (DAT)
1.2 ED visits per 1000 prescriptions for
DAT vs. 2.5 ED visits per 1000
prescriptions for warfarin
Reinforces need for risk mitigation

(Shelhab, Sperling, Kegler, Budnitz, 2010)

Research: Health Literacy

Low health literacy is a risk factor

36% of US adults have limited literacy
skills
$73 billion in additional health
expenditures
(Cloonan, Wood, Riley, 2013)

Research: Health Literacy

Teachback
Jargon-free, slowed down verbal
communication
Understandable written materials
Follow-up phone calls with tailored
messages
Beginning discharge planning early
(Cloonan, Wood, Riley, 2013)

Results of Improved Health Literacy

Nursing Staffing and Readmissions

Nursing Staffing Ratios (NSI) affect
patients
LOS
Fall rates
Pressure Ulcers
Medication Errors
Time & Ability to Teach Patients

Falls & Readmissions

Patient who fall in the hospital are at an
increased risk to fall after discharge
Mitigate risk by teaching, PT, fall
interventions

Part 4: Quality Indicators and Safety

Initiatives
Corinne Bradley

Nursing Sensitive Indicator: Skill Mix

RN
LPN/LVNs
UAP
Percent Agency Staff

(American Nurses Association [ANA], 2014).

Literature Review: Skill Mix

Patient Outcomes
Safety Concerns
Communication
Management Support
Teamwork

(Brown, Donaldson, Bulton, & Aydin, 2010; Brown & Wolosin, 2013; Godden, 2012; Kavanagh,
Cimiotti, Abusalem, & Coty, 2012; Shearer, 2013)

Nursing Sensitive Indicator: Nosocomial

Infections.
Otherwise known has Health Aquired
Infections (HAI).
Defined as an infection received while
being treated in a facility for an
unrelated concern.
Examples: Blood stream infections,
surgical site infections, urinary tract
infections, etc.
(Center for Disease Control, 2014)

Literature Review: HAI

Mortality
Length of Stay
Healthcare Costs
Nurse Staffing
Contaminated Surfaces
Hand Hygiene

(Almaguer-Leyva et al., 2013; Alter & Merlin, 2011; Brown & Wolosin, 2013; Curtis, 2008;
Kavanagh et al., 2012; Kaye et al., 2014; Otter, Yezli, & French, 2011).

Importance of Hand Hygiene

World Health Organization, 2007

BOOST: Team Oriented

The collaboration of multiple disciplines
during hospital admission, pending
discharge, and after discharge to
ensure full understanding and
compliance with discharge instructions
are fully understood to prevent
readmissions.
Care Coordinators could be key to
reducing readmissions
(Society of Hospital Medicine [SHM], 2008).

Literature Review: Team Oriented

Patient Outcomes
Communication
Decrease HAI
Management Support
Safety

(Brown & Wolosin, 2013; Kavanagh et al., 2012).

BOOST: Bridging
Bridging the transition from hospital to
home with sooner interactions with
primary care physicians and/or
specialists.
Care Coordinators key to bridging the
time gap and ensuring well being of
patients.
(SMH, 2008)

Literature Review: Bridging

Patient Outcomes
Decreased Readmission Rates
Telehealth
Nursing Staff Mix

(Burke, Purden, Frasure-Smith, Cossette, McCarthy, & Amsel, 2013; Subirana, Long,
Greenhalgh, & Firth, 2013).

Conclusion

References

Please see attached

reference document