The Role of Nurses in Hospital Quality Improvement

HSC Research Brief No. 3

March 2008

Debra A. Draper, Laurie E. Felland, Allison Liebhaber, Lori Melichar

As hospitals throughout the United States encounter mounting pressure to engage in a broad spectrum of quality improvement initiatives, the contribution and influence of nurses within these efforts continues to expand, according to research conducted by the Center for Studying Health System Change (HSC). The organizational culture within hospitals establishes the foundation for quality improvement work and shapes the extent of nurses’ participation in those activities. Hospitals characterized by engaged leadership, a philosophy treating quality as a collective responsibility, personal accountability among staff, dedicated physician and nurse champions, and meaningful feedback systems reportedly have the greatest potential for successfully involving staff in improvement efforts.

Nevertheless, hospitals encounter significant obstacles when it comes to nursing involvement, including: limited nursing resources; the difficulty of engaging nurses across all levels — from the bedside to management; escalating expectations to take part in numerous, frequently overlapping, quality improvement programs; the onerous nature of data collection and reporting requirements; and gaps in traditional nursing education that may not adequately prepare nurses to engage in these activities.

• This research identifies specific cultural factors within hospitals that support nurses’ involvement in quality improvement.
• Hospitals also face significant challenges in leveraging nurses for quality improvement, including a persistent shortage of nursing staff.

Nurses Pivotal to Hospital Quality Initiatives

Over the past several years, the emphasis placed on enhancing the quality of care delivered by American hospitals has grown substantially and shows no signs of slowing. Because nurses are central to the delivery of hospital care, understanding their role in quality improvement is essential.

Developing a deeper understanding of the contributions nurses make to quality improvement — and the difficulties they encounter — can yield valuable insights into how hospitals might better allocate resources to involve nurses in these activities while continuing to maintain adequate staffing for patient care.

The data informing this research were gathered primarily through interviews with hospital leaders in four communities: Detroit, Memphis, Minneapolis-St. Paul, and Seattle (see Data Source). The specific hospitals selected for this study were already participants in quality improvement activities, so the findings reflect the experiences of hospitals that are actively engaged in this work rather than serving as representative of all hospitals in those communities.

• The Joint Commission on Accreditation of Healthcare Organizations (now The Joint Commission)
• The Centers for Medicare and Medicaid Services (CMS) Hospital Quality Initiative (HQI)
• The Magnet Recognition Program of the American Nurses Credentialing Center

Quality Improvement Demands Increasing

Quality improvement is not a novel concept for hospitals. Healthcare facilities have maintained quality improvement departments and employed dedicated staff for many years. What has changed, however, is the growing scope of quality improvement expectations and the increasing number of external entities that hospitals are expected to report to.

Across all four communities studied, hospital respondents described increasing expectations to take part in a wide variety of programs run by diverse organizations, including accreditation and regulatory bodies, health plans, and state hospital associations.

Various Pressures Drive Hospital Participation Decisions

Multiple pressures shape hospital decisions about which quality improvement activities to pursue. In 2002, the Joint Commission on Accreditation of Healthcare Organizations — now simply The Joint Commission — began requiring hospitals to collect and report data on core quality measures for specific clinical conditions, including heart failure, acute myocardial infarction, and pneumonia. Additionally, CMS launched the Hospital Quality Initiative (HQI) in 2003 as a voluntary quality reporting program. Because the HQI's core measures overlapped substantially with The Joint Commission's requirements, many hospitals viewed participating in both programs as relatively efficient.

The public visibility of HQI data puts pressure on hospitals not only to report, but also to perform well compared to competitors and demonstrate improvement over time. The incentive to report to CMS was strengthened through a financial mechanism: hospitals that did not submit quality data faced a reduction in their annual payment update.

Additional entities, such as state hospital associations and health plans, have also expanded their collection and public release of hospital quality data. Health plans are increasingly tying quality performance to financial incentives in their contracts with hospitals.

Hospitals frequently engage in particular quality improvement activities to support the professional interests of their staff. This motivation often lay behind hospitals pursuing Magnet Program recognition from the American Nurses Credentialing Center, which recognizes hospitals for nursing excellence.

As Demands Increase, So Does the Role of Nurses

Nurses represent “the largest deliverer of health care in the U.S.,” as a representative of an accrediting organization noted, and as hospital involvement in quality improvement activities grows, the role of nurses within these efforts has expanded correspondingly.

Respondents observed that nurses are ideally situated to serve on the front lines of quality improvement because they spend the most time at patients’ bedsides and are best positioned to influence the quality and safety of care in real time.

Culture Sets Stage for Quality Improvement

Respondents universally stressed that a supportive organizational culture is fundamental to achieving meaningful progress in quality improvement. They pointed to several key strategies that help cultivate such a culture:

• Visible, consistent support from hospital leadership
• Treating quality as every employee’s responsibility
• Encouraging individual ownership and accountability
• Identifying physician and nurse champions
• Providing ongoing, useful feedback to staff

While respondents acknowledged the importance of these factors, they noted significant variation in how well individual hospitals across the four communities had been able to weave these strategies into their organizational fabric.

Leadership Support

To build a hospital culture that supports quality improvement, respondents highlighted the critical need for hospital leadership to take the lead in engaging nurses and other staff members. A representative of one accrediting organization emphasized that the tone set by the CEO and the chief nursing officer (CNO) is what truly drives nursing participation in quality improvement.

As an illustration, one hospital’s CEO supported the nursing staff in their efforts to more rigorously track and address the prevalence of pressure ulcers among patients, even though doing so required additional resources for more comprehensive data collection. This kind of visible leadership commitment was seen as essential for motivating staff participation.

Hospital respondents emphasized the importance of moving beyond merely “paying lip service” to quality improvement and actually committing resources to these activities. Some hospitals, for instance, invested in dedicated quality improvement staff positions, sent nurses to outside training programs, and allocated time during work hours specifically for quality improvement projects.

Quality as Everyone’s Responsibility

A hospital culture that views quality as the responsibility of every employee is reportedly better positioned to realize significant and lasting improvement. While respondents characterized nurses’ role as central, they also emphasized that quality improvement should be a multidisciplinary effort involving physicians, pharmacists, technicians, and other clinical and non-clinical staff.

At most hospitals, quality improvement efforts cut across departmental boundaries, and nurses participate at some level in virtually all of these activities because of their clinical knowledge and responsibilities.

The degree of broad-based staff involvement in quality improvement varied across hospitals. One hospital CNO noted, “I wish quality improvement could be done in a more multidisciplinary fashion. We tend to silo.”

Individual Ownership and Accountability

Another essential element of a hospital culture that fosters quality improvement is promoting individual ownership and accountability for patient safety and quality, respondents said. At one hospital, the approach was described as shifting from “what happened” to “why it happened” — fostering a culture of learning rather than blame.

Hospitals have adopted various approaches to strengthen staff ownership and accountability. The most frequently reported method was to more explicitly incorporate and specify quality improvement duties within nurses’ job descriptions and performance evaluations.

Hospitals also employ other forms of recognition to foster staff ownership and accountability. Respondents described a variety of reward mechanisms, including public acknowledgment by leadership during staff meetings and award programs recognizing individuals or teams for quality improvement achievements.

Physician and Nurse Champions

Identifying and empowering nurses and physicians to champion quality improvement efforts reportedly helps staff feel engaged and propels quality initiatives forward. One hospital CEO found nurse champions to be especially influential: “If you get the right nurse champion, other nurses will follow.”

Others reported that physician champions on quality improvement projects are valuable because they can leverage peer influence to encourage participation and compliance from fellow physicians. Furthermore, having both a physician and a nurse champion on the same project was viewed as especially effective.

Several respondents observed that hospitals employing physicians directly, rather than depending on voluntary community-based physicians, tend to find it easier not only to secure physician buy-in but also to maintain their sustained engagement in quality improvement activities.

Ongoing Useful Feedback

Hospitals that proactively communicate with staff and deliver timely, meaningful feedback are reportedly more likely to advance quality improvement than those that do not. As one hospital CNO stated, “If you don’t give them the data, they don’t know how they’re doing.”

Hospitals employ a range of feedback tools. One widely adopted mechanism is a periodic scorecard that tracks performance, including quality improvement progress toward established goals. According to respondents, scorecards help staff see where they stand and reinforce organizational priorities.

Bidirectional feedback between hospital leadership and frontline staff is equally important. Several respondents described using patient safety rounds as one mechanism for facilitating this exchange. In these rounds, hospital leaders visit patient care units to listen to staff concerns, observe workflows, and discuss quality improvement.

Challenges Specific to Nurses’ Involvement in Quality Improvement

Hospital respondents identified several challenges related specifically to the participation of nurses in quality improvement, including:

• The scarcity of nurses available for both patient care and quality improvement work
• The difficulty of engaging all nurses — not just nursing leadership — in quality improvement
• Growing and often overlapping demands from external quality reporting entities
• The high administrative burden of data collection and reporting
• A potential mismatch between traditional nursing education and the skills needed for quality improvement

Scarcity of Nurses

The shortage of nurses represents a major challenge for hospitals because it affects not only their capacity to provide adequate nursing coverage for patient care but also their ability to allocate sufficient nursing resources to quality improvement activities.

Respondents acknowledged that there is a ceiling to how much additional work, including quality improvement, can be placed on the shoulders of nurses who are already understaffed. As one quality improvement director noted, “We can’t keep adding more on, or we will break the camel’s back.”

When hospitals cannot employ enough nurses for direct patient care, they often must rely on agency or temporary nurses. As respondents discussed, engaging these nurses in quality improvement is exceedingly difficult because they are typically unfamiliar with the hospital’s specific protocols and culture.

Beyond the challenges posed by agency nurses, the composition of the nursing workforce — specifically the ratio of full-time to part-time nurses — can also affect hospitals’ ability to involve nurses in quality improvement. Part-time nurses may have less opportunity and inclination to participate in improvement activities.

The staffing demands associated with quality improvement frequently require hospitals to weigh these activities against many other competing priorities. Although there is a widespread belief that quality improvement ultimately saves money by reducing errors and improving efficiency, the upfront costs of engaging nursing staff in these activities can be substantial.

Engaging All Nurses, Not Just Nursing Leadership

Another dilemma facing hospitals is that they want their most skilled nurses at the bedside providing direct patient care and simultaneously leading quality improvement activities. This tension is magnified during periods of nursing shortages.

As one hospital respondent observed, “On the one hand, we are saying, ‘Yeah, we are all responsible,’ and then as soon as the rubber hits the road, it’s ‘Don’t add another thing to my nurses’ plate.’”

Although many hospitals aspire to meaningfully involve all nurses in quality improvement activities, there is considerable variation in how well they achieve this goal. Respondents reported that a disproportionate share of quality improvement work tends to fall on nursing management and a relatively small number of dedicated nurses.

Growing Demands

Hospitals also face ever-expanding pressure to engage in additional quality improvement activities, many of which are viewed as redundant. The absence of standardization in quality measurement and reporting across accrediting bodies, government agencies, and health plans compounds this burden.

Many hospital respondents have either scaled back or are considering reducing the number of quality improvement activities they participate in. A hospital CNO said her hospital is “less willing to jump on the bandwagon” and more carefully evaluating which initiatives will yield the greatest benefit.

High Administrative Burden

The administrative workload associated with quality improvement is reportedly so heavy that it often prevents nurses from playing a more substantive role. As a hospital quality improvement director stated, nurses could make far greater contributions to quality improvement if they were not so burdened by manual data collection and chart abstraction.

An additional advantage of enhanced information technology systems, respondents noted, is the ability to provide nurses with more “real-time” data. They believe this would be particularly valuable for quality improvement because it allows nurses to identify and address emerging issues more quickly.

Dissonance with Traditional Nursing Education

Respondents discussed the need for nursing education programs to enhance their curricula with greater emphasis on the concepts and competencies required for participation in quality improvement activities. Traditional nursing education, they noted, has focused primarily on clinical skills and patient care techniques, with relatively less attention to data analysis, process improvement methodologies, and systems thinking.

Respondents also highlighted the importance of effective continuing education programs for nurses in this domain — specifically, to better prepare nurses to translate their bedside observations of problems into actionable quality improvement projects.

Implications

Enhancing health care quality and ensuring patient safety rank high on the national health agenda, and this emphasis is poised to only intensify in the years ahead. The stakes for hospitals to demonstrate measurable improvement in quality continue to rise, both because of increasing public reporting requirements and growing financial incentives tied to performance.

However, determining the optimal allocation of resources — including nurses — is likely to grow more challenging for hospitals. Some regions of the country are already experiencing a nursing shortage, and demographic trends suggest this will worsen. The practical reality for many hospitals is that the very nurses they depend on to implement quality improvement are the same nurses they need at the bedside caring for patients. Finding the right balance will be essential.

Sources and Further Reading

• The Joint Commission: Quality Measures — Accreditation body whose Hospital Quality Initiative (HQI) core measures are discussed as key quality reporting drivers in this research.
• CMS: Hospital Quality Initiative — Federal quality reporting program whose public data on hospital performance created incentives for hospitals to improve.
• American Nurses Credentialing Center: Magnet Recognition Program — The Magnet Program for nursing excellence referenced as a quality improvement activity hospitals pursue.
• Robert Wood Johnson Foundation — Funded this research through its Aligning Forces for Quality initiative.
• Health Affairs — Published the Pham, Coughlan, and O'Malley study on quality-reporting programs' impact on hospital operations cited in the notes.
• AHRQ: Hospital Quality — Agency for Healthcare Research and Quality resources on hospital quality improvement and patient safety.

Notes

1. Pham, Hoangmai H., Jennifer Coughlan and Ann S. O’Malley, “The Impact of Quality-Reporting Programs on Hospital Operations,” Health Affairs, Vol. 25, No. 5 (September/October 2006).

2. Rosenthal, M.B., “Nonpayment for Performance? Medicare’s New Reimbursement Rule,” New England Journal of Medicine, Vol. 357, No. 16 (Oct. 18, 2007).

3. Kuehn, B.M., “No End in Sight to Nursing Shortage: Bottleneck at Nursing Schools a Key Factor,” Journal of the American Medical Association, Vol. 298, No. 14 (Oct. 10, 2007).

Data Source

To investigate the role of nurses in hospital quality improvement activities, data were gathered from hospitals in the four initial communities selected for the Robert Wood Johnson Foundation’s Aligning Forces for Quality (AF4Q) initiative: Detroit, Memphis, Minneapolis-St. Paul, and Seattle.

In each community, two of the larger hospitals were purposefully selected for interviews, yielding a total of eight hospitals. To capture a range of perspectives, the research team interviewed the lead quality improvement person and the chief nursing officer at each hospital.

Acknowledgement: This research was funded by the Robert Wood Johnson Foundation.