Question

Explore your clinical site and relate one quality improvement (QI) study currently being analyzed. What is benchmarked in the study? What role does the nurse play in the QI study?

Answer 1

Quality improvement (QI) is a systematic, formal approach to the analysis of practice performance and efforts to improve performance. A variety of approaches—or QI models—exist to help you collect and analyze data and test change.

Engaging primary care practices in quality improvement (QI) activities is essential to achieving the triple aim of improving the health of the population, enhancing patient experiences and outcomes, and reducing the per capita cost of care, and to improving provider experience.

All successful quality improvement programs include four key components: the problem, goal, aim, and measures.

The goal of performance improvement and performance improvement studies is to enhance and improve the outcomes of care, to insure client safety, to increase the efficiency of patient care and related processes, to reduce costs and to reduce risks and liability.

Quality assurance (QA) measures compliance against certain necessary standards. Quality improvement is a continuous improvement process. QA is required and normally focuses on individuals, while QI is a proactive approach to improve processes and systems.

As the nation’s hospitals face increasing demands to participate in a wide range of quality improvement activities, the role and influence of nurses in these efforts is also increasing, according to a new study by the Center for Studying Health System Change (HSC). Hospital organizational cultures set the stage for quality improvement and nurses’ roles in those activities. Hospitals with supportive leadership, a philosophy of quality as everyone’s responsibility, individual accountability, physician and nurse champions, and effective feedback reportedly offer greater promise for successful staff engagement in improvement activities.

Yet hospitals confront challenges with regard to nursing involvement, including: scarcity of nursing resources; difficulty engaging nurses at all levels—from bedside to management; growing demands to participate in more, often duplicative, quality improvement activities; the burdensome nature of data collection and reporting; and shortcomings of traditional nursing education in preparing nurses for their evolving role in today’s contemporary hospital setting. Because nurses are the key caregivers in hospitals, they can significantly influence the quality of care provided and, ultimately, treatment and patient outcomes. Consequently, hospitals’ pursuit of high-quality patient care is dependent, at least in part, on their ability to engage and use nursing resources effectively, which will likely become more challenging as these resources become increasingly limited.

Nurses Pivotal to Hospital Quality Initiatives

In recent years, emphasis on improving the quality of care provided by the nation’s hospitals has increased significantly and continues to gain momentum. Because nurses are integral to hospitalized patients’ care, nurses also are pivotal in hospital efforts to improve quality. As hospitals face increasing demands to participate in a wide range of quality improvement activities, they are reliant on nurses to help address these demands.

Gaining a more in-depth understanding of the role that nurses play in quality improvement and the challenges nurses face can provide important insights about how hospitals can optimize resources to improve patient care quality.

Data for this work were collected primarily through interviews with hospital executives in four communities: Detroit, Memphis, Minneapolis-St. Paul and Seattle (see Data Source). Specific domains explored with respondents included:

•     Key quality improvement activities in which the hospital participates;
•     Role of nurses in these activities;
•     Factors affecting nurses’ involvement; and
•     Developments that may change the role of nurses in hospital quality improvement.

Performance measurement involves collecting and reporting data on practices’ clinical processes and outcomes. Measuring clinical performance can create buy-in for improvement work in the practice and enables the practice to track their improvements over time. This information should also be used to identify and prioritize improvement goals and to track progress toward those goals. In addition, these data should be used to monitor maintenance of changes already made.
Selecting Clinical Performance Measures

You will work with your practices to identify the areas of clinical performance they want to assess. The areas of clinical performance should connect to the improvement goals the quality improvement (QI) team has set as well as any mandates from the funder. Common sources for performance measures are the Healthcare Effectiveness Data and Information Set (HEDIS), quality indicators developed by the National Committee for Quality Assurance, and criteria selected by health plans.

In addition to selecting a set of performance measures that the practice wants to track, the QI team will need to decide how frequently to collect data. Data collection timelines should allow sufficient time for change. They also should be generated frequently enough to show progress over time through the use of run charts and other methods of comparing data collected across multiple time periods.

Refining Clinical Measures: Defining the Numerator and Denominator

Many performance measures are rates, with the numerator indicating how many times the measure has been met and the denominator indicating the opportunities to meet the measure. For example, let’s say your practice wants to measure how well it is complying with annual comprehensive foot exam recommendations for its diabetic patients.

In specifying the numerator, the practice will need to define what constitutes the desired performance. Will monofilament testing alone be adequate, or will it need to be combined with visual inspection, testing for sensation, or palpation of pulses? Or will any one of these approaches be deemed adequate? How accurately these events are documented will be important in determining the usefulness of the available data.

In specifying the denominator, the practice will need to establish what constitutes an opportunity to deliver the desired action. For this example, you might define the denominator as the number of diabetic patients who have had a health care encounter in the past 12 months. Or you might define the denominator more broadly from a population health perspective as any diabetic patients in a provider’s panel regardless of the status of their most recent visit.

Denominators in particular are important in understanding and interpreting data so it is very important that you are careful to use the appropriate denominator. For example, if you are working with a practice to determine what percentage of its patients with diabetes have hemoglobin A1c (HbA1c) values of 8 or higher, you would want to use for the denominator only those patients with diabetes who have HbA1c values available in their record. If you use any diabetic patients regardless of whether they have an HbA1c value available, the percentage of patients who have elevated HbA1cs will be artificially depressed.

As you and the practice monitor progress in improving performance on this metric over time, you will need to consider how the denominator may change. For example, a monthly audit of performance on this metric might use diabetic patients receiving care in the previous month as the denominator and the number of these patients who had received a foot exam within the past 12 months as the numerator.

It can be tricky defining an appropriate denominator. If you do not select the correct denominator, you may under- or overstate performance. For example, when calculating the percentage of diabetic patients with low-density lipoprotein (LDL) below 100, you would specify the denominator as the number of diabetic patients with an LDL test, not just the number of diabetic patients. Similarly, if you were tabulating the percentage of patients who gave the most positive response to a question on a survey, you would specify the denominator as the number of patients who answered that question, not the number who were surveyed.

You will also need to help the practice decide which, if any, subgroups they want to evaluate. For example, you may want to measure performance for patients who have had a visit in the past quarter or who have been in treatment for at least 6 months. You will also need to decide whether you want to stratify performance measures for different populations. For example, you might want to compare performance for patients based on age, gender, race or ethnicity, disease severity, or treatment status.