Quality Indicators



Quality Indicators

Agency for Healthcare Research and Quality [AHRQ] (2018) defines quality indicators [QI]. As measures of healthcare quality that generate data to be utilized by healthcare leaders and administrators. The QI data is used for decisions on quality improvement. Staffing, operational budget, and innovations. AHRQ develops QI to provide healthcare leaders along with evaluation tools (AHRQ, 2018). Nash et al. (2019) believe that a variety of QI is needed to achieve six areas for improvement identified by the Institute of Medicine [IOM] committee on safety. The six areas of improvement are; effectiveness, patient-centeredness, timeliness, efficiency. And equity (Institute of Medicine, Committee on Quality of Health Care in America [IOM], 2001). Quality improvement is categorized into three areas of quality of care: structural, process, and outcome (Institute for Healthcare Improvement [IHI], 2020).

Two Nurse-Sensitive Indicators of Quality in Ambulatory Care

I currently work in the ambulatory care setting in an integrated academic institution as the Senior Manager for Clinical Services and Operations for Neurosurgery. Stroke Neurology, and Neurology & Sleep. The two indicators chosen for this discussion are; pain assessment and follow-up and unplanned transfers to hospital (Start et al., 2018). These two QI are nursing-sensitive QI that relates to ambulatory care for my current practice. The work setting is the Physician Group Practice [PGP] for each of the three departments, with four neurosurgery clinic locations, one stroke clinic, and two sleep centers. The patient population is approximately 60% neurosurgery, 30% stroke, and 10% sleep therapy.

Early Quality Improvement Theories and Philosophies on the Development of the Two QI

The emphasis on QIs for ambulatory care became actualized in late 1997. With a committee appointed by the American Nurses Association [ANA] to expand nursing-sensitive quality indicators [NSQI] to ambulatory care (Martinez et al., 2015). The ANA committee aimed to show nursing contributions in the ambulatory practice in improving health outcomes and healthcare delivery cost efficiencies. Despite this push by ANA to expand NSQI to ambulatory care, the process was slowed until 2008 with Swan article that called for nurses to act on NSQI in ambulatory care. The American Academy of Ambulatory Care Nursing [AAACN] in 2013 committee started on the challenge for NSQI in ambulatory care. With the first set of NSQI being published in 2014 (Martinez et al., 2015).

The concept of pain assessment and follow-up is embedded in every aspect of patient care. Petiprin (2020) sees the nurse playing the most critical role in assessing and managing the patient’s pain. The evolution of patient pain assessment and management has always had nurses at the forefront. Nursing theories and quality tools have been used over the years by nurses to study and implement pain management (Petiprin, 2020b). Mid-ranged psychological theories such as Kolcaba’s Comfort Theory are used by nursing research in the evolution of pain management in nursing care (Petiprin, 2020a).

Marquet et al. (2015) see unplanned admission transfers to hospital. As the marker for patients’ adverse events [AES]. AEs concerns are international health issues for healthcare leaders, professionals, administrators, patients, and their families. Annually AEs lead to unintended injuries or complications, disabilities, deaths, prolongation of hospital stay, and higher healthcare costs rather than the patient’s disease (Marquet et al., 2015).

     Two Nursing Research Articles that Relate to Two QI Influence on Practice

Article one: Pain Assessment and Follow-up

Meissner et al. (2017) examine the use of QIs in acute postoperative pain management [POPM]. The goal was to use QIs to facilitate caregivers to differentiate between good and poor quality of pain management. The researchers seek to explore the evidence gathered from pain specialists’ experiences in managing patients’ acute pain postoperatively and literature review using QI for acute POPM. The specialist for this study was chosen from Europe and the United States of America [USA]. The inclusion criteria for the participants were a member of a Pain Advisory Board (Meissner et al., 2017). The QIs assessed the healthcare providers’ services and how efficient the interventions were in relieving acute postop pain.

The QI measures used were documentation, timeliness of pain assessment, pain reassessment, and timeliness to giving analgesic medication. Pain assessment was done on day one postop using the numerical rating scale of 0 – 10 was used for pain assessment, with 0 being no pain and 10 being the maximum pain experienced. The review found that patients had poor pain management, with pain levels being moderate to severe, 4 – 10 on the numerical scale (Meissner et al., 2017). The data review found that the barriers to acute POPM were; cost to treat acute pain, lack of knowledge on pain management among staff, lack and unclear instructions, inadequate pain assessments, and sub-optimal care (Meissner et al., 2017).

Article Two: Unplanned Transfers to Hospital

Marquet et al. (2015) view unplanned transfers to the hospital due to preventable adverse patient reactions. The researchers’ research was a three-stage retrospective review on screening, records review, and consensus judgment over six months in Belgium. The study aimed to examine the frequency of preventable adverse reactions and lead to unplanned admission or higher levels of care. A total of 830 medical records were reviewed, 456 of the medical record revealed patient adverse reactions. The review found that 56% of the adverse events were preventable that lead to unplanned hospital admission. This review also revealed that 25% of these adverse reactions required a higher level of care in the intensive care unit. Unplanned transfer to hospital is also a quality standard for The Joint Commission [TJC]. The AHRQ provides a toolkit for healthcare organizations to report and analyze the prevalence and rate of unplanned transfers to hospital (Rahn, 2016).


Agency for Healthcare Research and Quality. (2018). AHRQ quality indicatorshttps://www.ahrq.gov/cpi/about/otherwebsites/qualityindicators.ahrq.gov/qualityindicators.html

Institute for Healthcare Improvement. (2020). How to improve with the model for improvement. chi.org. https://education.ihi.org/topclass/topclass.do?CnTxT-144791570-contentSetup-tc_student_id=144791570-item=967-view=1

Institute of Medicine, Committee on Quality of Health Care in America. (2001). Crossing the quality chasm: A new health system for the 21st century. ProQuest Ebook Central. https://ebookcentral.proquest.com

Marquet, K., Claes, N., De Troy, E., Kox, G., Droogmans, M., Schrooten, W., Weekers, F., Vlayen, A., Vandersteen, M., & Vleugels, A. (2015). One fourth of unplanned transfers to a higher level of care are associated with a highly preventable adverse event. Critical Care Medicine43(5), 1053–1061. https://doi.org/10.1097/ccm.0000000000000932

Martinez, K., Battaglia, R., Start, R., Mastal, M. F., & Matlock, A. M. (2015). Nursing-sensitive indicators in ambulatory care. Nursing Economic$33(1). https://doi.org/https://www.aaacn.org/sites/default/files/documents/news-items/NursingEcARTICLE_NursingSensitiveIndicatorsinAmbulatoryCare.pdf

Meissner, W., Huygen, F., Neugebauer, E. A., Osterbrink, J., Benhamou, D., Betteridge, N., Coluzzi, F., De Andres, J., Fawcett, W., Fletcher, D., Kalso, E., Kehlet, H., Morlion, B., Montes Pérez, A., Pergolizzi, J., & Schäfer, M. (2017). Management of acute pain in the postoperative setting: The importance of quality indicators. Current Medical Research and Opinion34(1), 187–196. https://doi.org/10.1080/03007995.2017.1391081

Nash, D. B., Joshi, M. S., Ransom, E. R., & Ransom, S. B. (Eds.). (2019). The healthcare quality book: Vision, strategy, and tools, fourth edition (4th ed.). Health Administration Press.

Petiprin, A. (2020a). Kolcaba’s theory of comfort. Nursing Theory. https://nursing-theory.org/

Petiprin, A. (2020b). Pain scale 1-10. Nursing Theory. https://nursing-theory.org/articles/pain-scale.php

Rahn, D. J. (2016). Transformational teamwork. Journal of Nursing Care Quality31(3), 262–268. https://doi.org/10.1097/ncq.0000000000000173

Start, R., Matlock, A. M., Brown, D., Aronow, H., & Soban, L. (2018). Realizing momentum and synergy: Benchmarking meaning ambulatory care nurse-sensitive quality indicators. Nursing Economic$36(5), 246–251. https://doi.org/https://www.aaacn.org/sites/default/files/documents/NSI-Measure-Table.pdf



Quality Indicators

Nursing-sensitive indicators (NSIs) can be an essential tool in identifying patient care issues that could arise in the healthcare setting. By analyzing the data on specific NSI, the quality of patient care can be optimized, and patient satisfaction can be improved. As a result, NSIs have become a progressively effective and dependable method to support nursing care quality and performance measurement in the healthcare establishment, including evaluating clinical nursing practice (Heslop et al., 2014). The American Nurses Association (ANA) and the National Database of Nursing Quality Indicators (NDNQI) are two sources of information and guidelines for nurses and nurse managers to use in planning patient care and workloads for each nursing unit. Quality indicators refer to clear, measurable items to outcomes and demonstrate the effect on health and population (Rahn, 2016). The different frameworks and theories appeal to care that concentrates on the patients’ individual needs, wishes, and cultural practices.

Two Nurse-Sensitive Indicators of Quality

Patients with Chronic Kidney Disease (CKD) are at risk for End-Stage Kidney Disease (ESKD), leading to dialysis or transplantation (Manns et al., 2017).  To optimize kidney health, health systems should monitor the quality of care provided to patients suffering from CKD (Manns et al., 2017) with specifics quality indicators (QI) such as nosocomial infections and falls. These NSIs affect other aspects of nursing other than renal care, and as a concept, it is effective in developing nursing care implementation (Heslop et al., 2014). However, the conceptual basis, theoretical role, meaning, use, and interpretation of the concept of NSIs tend to differ. Generally, the studies of indicators of nosocomial infections and falls derive from the NDNQI point to facilitate the ability of health organizations to act in response to patient and staff needs (Montalvo, 2007).

Article One