Hello everyone, my name is Rebecca, and I would like to welcome you to RWJBarnabas Health nursing team. Through this tutorial, I am pleased to help you better understand how this facility uses Nursing Sensitive Quality Indicators, also referred to as NSQIs. Our facility utilizes NSQIs in measuring and assessing the quality of nursing care provided. Such indicators are designed to capture elements of nursing care that are directly influenced by nursing interventions and actions and can act as measures of effectiveness and outcomes of nursing care. In our facility, NSQIs are essential since they aid in determining areas where nursing care can be enhanced to improve patient outcomes. According to Afaneh et al. (2021), by measuring indicators like pressure ulcers and patient satisfaction, healthcare organizations can determine areas of concern and therefore implement targeted interventions to enhance patient care. Besides, they can be used in informing evidence-based practice and evaluating the effectiveness of nursing interventions. By measuring and analyzing data on NSQIs, we are able to identify patterns, trends, and relationships that contribute to the advancement of nursing knowledge and the development of best practices.
Briefly, let me explain the National Database of Nursing-Sensitive Quality Indicators (NDNQI)
NDNQI is a program developed by Press Ganey in collaboration with the American Nurses Association (ANA) and is a comprehensive database that gathers and collects data related to NSQIs. NDNQI collects data from participating healthcare facilities in the United States, including our own, on various nursing-sensitive indicators like nursing satisfaction, nursing staffing levels, medication errors, pressure ulcers, and patient falls. It enables healthcare facilities to benchmark their performance against regional and national data and also track their own performance over time. Participating in the NDNQI is voluntary, and organizations that participate submit data regularly, like we do. According to an article by Madaris, Director of Clinical Advisory at Press Ganey (writing in 2023), NDNQI classifies information into three major indicator groups, including structure, process, and outcome, in order to accurately and comprehensively assess nursing performance at organizations in a standardized manner. Examples of structure indicators include patient contracts, patient volume and flow, nurse turnover, workforce characteristics, staffing and skill mix, and RN education/specialty certification. Process indicators include diabetes care, patient falls, care coordination, advanced care planning, and pressure injuries. Further, outcome indicators include ventilator-associated events (VAE), pain impairing function, assaults on nursing personnel, and pediatric peripheral intravenous infiltrations. Educators, policymakers, researchers, and healthcare organizations have widely used NDNQI to foster the delivery of high-quality nursing care and enhance patient outcomes.
Now, let me share an example of how our nursing staff uses NDNQI ratios and an acuity system for staffing. In our facility, the charge nurse uses an acuity system that evaluates the complexity and needs of patients in order to decide suitable staffing levels. Considering the acuity of patients on each shift or unit enables the charge nurse to allocate staff resources effectively. For instance, if there is a high number of patients with high acuity, then the charge nurse can increase the number of nursing staff or may assign more experienced nurses to ensure adequate care. NDNQI include indicators like nurse-to-patient ratios, which measure the number of patients assigned to each nurse. In our facility, the charge nurse regularly reviews and monitors these ratios to ensure they are within recommended guidelines. In situations where the ratios exceed the recommended levels, which indicates inadequate staffing, it is the charge nurse’s responsibility to make adjustments to staffing assignments or advocate for additional resources to maintain effective and safe patient care. Moreover, the charge nurse analyzes NDNQI data over time to determine patterns and trends that may suggest areas of concern. For instance, data may demonstrate a high incidence of pressure ulcers among elderly patients; the charge nurse can proactively adjust staffing levels to the particular unit or implement targeted interventions aimed at addressing the underlying issues that contribute to such indicators. In addition, it is important to note that NDNQI ratios and data are essential for promoting collaborations with the administration. The charge nurse engages in discussions with the hospital administration regarding resource allocation and staffing needs using the ratios and data. Author Paulsen (writing in 2018) points out that presenting evidence-based data on how staffing levels impact NSQIs enables nurse managers to advocate for suitable staffing levels and engage in collaborative decision-making processes to improve patient outcomes and nurse care quality.
In another example, our facility has been experiencing an increase in pressure ulcers among elderly patients, bedbound patients, and those with limited mobility. This issue has affected our quality of care, Medicare reimbursement, and patient satisfaction surveys. You may wonder why this is a problem for our facility. Well, let me explain. According to Smith et al. (2018), pressure ulcers are reported to affect over 2.5 million patients in the United States, costing approximately $9-11 billion and leading to 60,000 deaths due to the consequences of developing pressure ulcers. Pressure ulcers require additional medical attention, like medications, dressings, specialized mattresses, and wound care supplies. The treatment can be costly, particularly in severe cases that may require advanced wound therapies or surgery. Such a financial burden can strain the hospital’s budget. Pressure ulcers can delay patient discharge and recovery as patients may require prolonged hospitalization for wound treatment and management, resulting in bed shortages, increased occupancy rates, as well as longer waiting periods for incoming patients. In addition, there are risks of complications such as osteomyelitis, sepsis, cellulitis, and infections that require additional medical interventions like extended hospitalization, surgery, and antibiotics. Treating such complications strains our resources and increases the nursing staff’s workload. Since pressure ulcers cause distress, discomfort, and pain for patients, it negatively affects the quality of life and patient outcomes. While looking at how this could cost our facility, authors Padula & Delarmente (writing in 2019) stated that the U.S. Centers for Medicare and Medicaid Services (CMS) decreased reimbursement associated with hospital-acquired conditions like hospital-acquired pressure injuries (HAPIs), forcing healthcare facilities to face the entire financial burden of such injuries. A single episode of HAPI could cost healthcare organizations $500 or even more than $70,000.
We have an excellent team of nursing personnel who have taken measures to determine the causes of pressure ulcers and pool efforts to prevent such incidents. Our nurses have a responsibility to provide high-quality patient care and prevent HAPIs. We have monthly training programs and sessions and staff meetings on how to protect patients from pressure ulcers, and I strongly suggest you attend those sessions and meetings. Besides, it is essential for you as nurses to provide reporting of any required data like pressure ulcer incidences in the Press Ganey surveys, as it will significantly contribute to NDNQI.
So, how do we collect and distribute this quality indicator data?
Our facility’s interdisciplinary team, which comprises nurses and other healthcare professionals, plays a key role in ensuring accurate and comprehensive data collection associated with pressure ulcers. They work collaboratively in documenting pressure ulcer incidences, stages, treatments, and outcomes in electronic health record (EHR) systems or patient records. Members of interdisciplinary teams, including wound care specialists, physicians, and nurses, contribute their expertise to effectively capture relevant point data. One of the tools the interdisciplinary team uses is the Braden Scale which helps them identify which patients are at risk of developing pressure ulcers by examining six crucial factors such as nutrition, mobility, activity, moisture, sensory perception, and friction/shear. Using this tool enables the team to separate patients into different risk categories, allowing targeted preventive measures. During patient assessments, the interdisciplinary team documents the score assigned to each Braden Scale category, which enables them to identify the patient’s risk level and identify high-risk patients who require intensified preventive interventions. Data collected from such assessments and interventions are incorporated into EHRs and patients’ records for use in reporting and analysis. Our facility submits pressure ulcer data to NDNQI using online surveys, where the data is aggregated and analyzed at regional and national levels. Press Ganey generates reports and performance benchmarks, hence providing insights into trends, patterns, rates, and comparisons of pressure ulcers among other healthcare organizations.
Let me briefly touch on your role as nurses
Now that you have joined our organization, you have a vital role to play in collecting detailed and accurate data related to pressure ulcers. Nurses are often at the forefront of patient care and are responsible for maintaining updated and accurate patient records, including documentation. As baccalaureate-prepared nurses you should use the Braden Scale to assess patients, document relevant information regarding pressure ulcer stages, development, and treatments, and ensure such information is recorded in appropriate systems. Besides, nurses should also report this data using Press Ganey online surveys for further analysis. Your dedication and expertise in will significantly contribute to enhanced patient safety, improved patient outcomes, and effective monitoring and evaluation of pressure ulcers among our patients.
You may ask…. what do we do with the data?
The data you provide is used for quality improvement initiatives. Our facility uses the data to assess the efficacy of our current preventive strategies and interventions, pinpoint areas of high risk, and identify trends or patterns in pressure ulcer development. This information is useful in creating targeted quality improvement initiatives that aim at minimizing pressure ulcer incidences, enhancing patient outcomes, and improving care processes. With the data supplied to NDNQI using online surveys, our facility can benchmark the quality indicator against regional and national standards and also compare performance with other healthcare providers. This enables the hospital to evaluate its relative performance, recognize gaps, and adopt best practices from high-performing facilities. This data is also helpful in resource allocation decisions. Units that report high incidences of pressure ulcers may require additional staffing, specialized mattresses, or wound care supplies. Hence, we can use this data to prioritize resource allocation and ensure adequate support for effective management and prevention of pressure ulcers. Furthermore, this data is valuable for staff education and training in areas demonstrating suboptimal performance in pressure ulcer management. We can therefore develop targeted education programs on risk assessment, proper positioning, or documentation for nursing staff to address knowledge gaps and promote adherence to best practices, ultimately improving overall care delivery.
As I prepare to conclude this tutorial, I would like to point how your actions impact health care in general
Your actions have a far-reaching impact on healthcare as the data you fill out on those online surveys can be used for research purposes. Our facility can collaborate with research organizations or academic institutions to determine risk factors and trends, hence contributing to the advancement of knowledge in pressure ulcer management and prevention. Research findings generated from the data can inform evidence-based practice and support the development of protocols and guidelines. Our organization can also use NDNQI data to implement targeted interventions, prevent adverse events, and monitor patients closely. Your accurate reporting and documentation, as well as active participation in quality improvement initiatives, is vital in creating a culture of safety and reducing harm to patients. Your actions also have a direct impact on the quality of care provided to patients. By adhering to set protocols and utilizing evidence-based practices, you can ensure patients receive optimal care. Nurses’ accurate documentation of interventions and outcomes fosters effective interdisciplinary team communication and facilitates continuity of care. Furthermore, your actions directly influence patient outcomes. Through your adherence to best practices, diligent data collection, and accurate documentation, you help prevent pressure ulcers and manage safety concerns effectively. This results in improved patient outcomes, including short hospital stays, reduced incidences, and improved overall-patient well-being. Moreover, your efforts in enabling positive patient outcomes can earn our facility higher Medicare reimbursements under the Value-Based Purchasing (VBP) program, which ties a portion of such reimbursements to performance measures and quality indicators. Besides, we can maintain our Medicare reimbursements and avoid financial penalties through the Hospital-Acquired Condition (HAC) Reduction Program, which penalizes facilities with higher rates of particular preventable HACs like pressure ulcers. In 2021, healthcare organizations with high HAC rates, like New York-Presbyterian Weill Cornell Medical Center and Cedars-Sinai Medical Center, suffered substantial revenue losses of $4,043,719 and $3,138,689 respectively, in terms of HAC penalties. As a result, nurses’ contributions to improving care processes, preventing pressure ulcers, and achieving better patient outcomes can help our facility thrive in the evolving healthcare environment.
In conclusion
As nurses, we play a crucial role in collecting data required for the NDNQI related to nursing interventions, patient outcomes, and the nursing practice environment. We contribute to the reliability and robustness of the NDNQI database by accurately documenting and reporting data. Our involvement ensures that the collected data reflects the reality of nursing care and patient outcomes. As front-line caregivers, we can use this data to inform our practice and advocate for evidence-based interventions. Our involvement in the NDNQI ensures that the data is applicable and relevant in real-world nursing care, promoting the implementation of best practices at the bedside. Conclusively, by actively engaging with the NDNQI, we contribute to enhancing nursing practice, improving patient outcomes, and shaping the future of healthcare.
Once again, welcome to this organization, and thank you for the vital role you play in healthcare. I look forward to working with you and witnessing your compassion, expertise, and passion for making a significant difference in patients’ lives and the success of this facility.
References
Afaneh, T., Abu-Moghli, F., & Ahmad, M. (2021). Nursing-sensitive indicators: A concept analysis. Nursing Management (Harrow, London, England: 1994), 28(3), 28–33. https://doi.org/10.7748/nm.2021.e1982
Madaris, S. (2023, January 12). Your comprehensive guide to the press Ganey national database of nursing quality indicators (NDNQI). Press Ganey. https://info.pressganey.com/press-ganey-blog-healthcare-experience-insights/your-comprehensive-guide-to-the-press-ganey-national-database-of-nursing-quality-indicators-ndnqi
Padula, W. V., & Delarmente, B. A. (2019). The national cost of hospital-acquired pressure injuries in the United States. International Wound Journal, 16(3), 634–640. https://doi.org/10.1111/iwj.13071
Paulsen R. A. (2018). Taking nurse staffing research to the unit level. Nursing Management, 49(7), 42–48. https://doi.org/10.1097/01.NUMA.0000538915.53159.b5
Smith, S., Snyder, A., McMahon, L. F., Jr, Petersen, L., & Meddings, J. (2018). Success in hospital-acquired pressure ulcer prevention: A tale in two data sets. Health Affairs (Project Hope), 37(11), 1787–1796. https://doi.org/10.1377/hlthaff.2018.0712
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