© All Rights Reserved. This material is confidential and property of IHH Healthcare Berhad. No part of this material should be reproduced or published
in any form by any means, nor should the material be disclosed to third parties without the consent of IHH.
Nursing Quality Indicators
Dr Jothi Clara J Michael,
Director Of Nursing, IHH IN
Vice President ANEI
-CAHO CQE Series -28
th
Aug 2021

2
•TheBeginningofEvaluatingthequalityofnursingpractice
-WhenFlorenceNightingalebegantomeasurepatientoutcomes.
•Reflectionfortoday:Sheusedstatisticalmethodstogeneratereportscorrelatingpatientoutcomestoenvironmental
conditions(Dossey,2005;Nightingale,1859/1946).
•Overtheyears,qualitymeasurementinhealthcarehasevolved–QualityAssurance-ContinuousQualityImprovement,
QualityMovement&Campaign,AccreditationAwardsandRecognition………MovingbeyondAccreditation……
•India–QCI,NABH,CAHO,JCI,NABHNEetc.…
•Welearnfromadvancedcountries:Theworkdoneinthe1970sbytheAmericanNursesAssociation(ANA),thewide
disseminationoftheQualityAssurance(QA)model(Rantz,1995),andtheintroductionofDonabedian'sstructure,process,
andoutcomesmodel(Donabedian,1988,1992)haveofferedacomprehensivemethodforevaluatinghealthcarequality
specificallyinNursing.
History of Nursing Quality Indicators
(NQI)

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QUALITY
INDICATORS –
Familiar NQIs
Medication
Errors
Hospital
Associated
Pressure
Ulcer
CAUTI
VAP
Rate
CLABSI
SSI
Hand
Hygiene
Compliance
Rate
Incidence
of Needle
Stick
Injuries
Inpatient
Fall Rate
Nursing
Attrition
Rate

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WhatisNursingQualityIndicator?
TheNursingQualityIndicatorsaremeasuresofNursingcarequalitythatusereadilyavailable
hospitalinpatientadministrativedata.
WhatisContinuousNursingqualityimprovement(CNQI)?
ContinuousNursingqualityimprovement(CNQI)isthekeytocareexcellencetomatchwiththe
paradigmshiftinrolesofhealthcareprofessionals,expectationsfromconsumersandtechnological
advancementsinHealthcare.SafetyandqualityareintegralaspectsofNursingCareContinuum.
0 ∞
More than What, Why and How is significant when it comes to NQI

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For patients, what helps make their hospital stay a much better experience & how nursing care
impacts?
………………A smart competent people friendly health care provider at their bedside.
Who else other than Nurses can be fitting into this …
What helps these providers perform better especially “The Nurses”?
..………….. An environment that encourages/ nourishes proactive & predictive
behaviors directed toward prioritizing patient care.
How to evaluate the quality of care? …..………...Right and Appropriate Quality Indicators
Where?
Destination
How?
Values
Who?
Team
Let us Reflect

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WhyNQI?
•Itremainsacriticalelementinthenursingprofessionaltoolkittoensure
accountability,transparency,andqualityimprovement.
WhymonitoQI?
•TocarryoutinterdisciplinaryprocessestomeetorganizationalQIgoalsandto
measure,improve,andcontrolnursing-sensitiveindicators(NSI)affectingpatient
outcomesspecifictonursingpractices.
•Monitorforearlyrecognitionofadverseevents,complicationsanderrors.
•Initiatingdeploymentofappropriateandtimelynursingcaretoaidpatientsinspeedy
recovery.
•ToensureTATinclinicalprocess.
Forassessingtheprovidedcare&improvingthequalityofcare
Fordefiningstrategiestoachievegoals&redefiningpatientcare.

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How do we identify QI for Nursing Service?
–Its Nursing Domain Decision
Scope/ Center
of Excellence
•General Medical
and Surgical
•Superspecialist –
Transplantation
•Obstetrics
•Orthopedics
•Neurology
•Pediatrics
•Oncology
Depth/Limit
No specified size
and limit for the
number of QI that
can be monitored.
How ever critical
NQIs are
significant.
Eg: Medication
Error
•Incidence of Medication Error
•Incidence of prescription error
•Incidence of transcription error
•Incidence of dispensing error
•Incidence of administration error
•Percentage of admissions with ADR
•Percentage of medication charts
with error prone abbreviations
•Compliance rate to Medication
Prescription in capitals
•Percentage of patients receiving
high risk medications developing
adverse drug event.
•Percentage of contrast allergic
reaction
•Number of patients on NG tube
receiving Non-enteric coated drugs.
Key Principle:
•Appropriate & Relevant Eg: Initiation of Breast feeding
–Obstetrics Nursing
•Simple to Complex –Eg. Pressure Injury (PI) to PI
Healing pattern
•Common / Routine to uncommon/ Rare

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Nursing Indicator –Safe Staffing For Example
Missed breaks
Nursing
overtime
Planned,
required and
available
nurses for each
shift
High levels
and/or ongoing
reliance on
temporary
nursing
Compliance
with any
mandatory
training
Nursing staff
unable to take
scheduled
breaks
Nursing staff
working
extra hours
The number of
planned, required
and available
nursing hours on
hospital inpatient
wards in relation
to bed utilization.
Temporary-
pull in & pull
out nursing
staff on
hospital
inpatient
wards.
Compliance of
ward nursing
staff with any
mandatory
training in
accordance
with local policy

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Importance of NQI in NABH & JCI
Ref: NABH NE
NABH NE
Ref: JCI Standards

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Nursing Sensitive Indicators-Structure Process & Outcome Model
•Includes the supply of nursing staff, the skill level of nursing
staff, equipment, education and certification levels of
nursing staff.
StructuralIndicators
•Measuremethodsofpatientassessmentandnursing
interventionsandcompetencyassessment.Nursesjob
satisfactionisalsoconsideredaprocessindicator.
ProcessIndicators
•Reflectpatientoutcomesthataredeterminedtobenursing-
sensitivebecausetheydependonthequantityorqualityof
nursingcareoutcome.Theseincludepressureulcersand
falls.
OutcomeIndicators
Ref: https://www.americansentinel.edu/blog/2011/11/02/what-are-nursing-sensitive-quality-indicators-anyway/

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*Nurse Staffing Characteristics
Number of Nursing Staff
Number Staffing Ratio
Nurse Staffing Levels
Nurse Staffing Qualifications
Nurse Experience
Nurse Education
*Hospital Characteristics
Work Schedule
Patient Safety
Patient turnover
Work environment
Nurse autonomy
Case Mix
•Treatment and
Procedures
•Pain Management
•Maintenance of skin
integrity
•Patient Education
•Nurses Job satisfaction
•Nurse reported quality of care
•Nurse burnout
•Nurse turnover
•Nosocomial Infection
•Mortality
•Pressure ulcer
•Patient Satisfaction
•Patient falls
•Patient falls with injury
•LOS
•DVT/Pulmonary Embolism
•Physical restrain use
•Shock/Cardiac arrest
Organizational-Focused
Structural Indicators
Nursing Focused
Process/Intervention
Indicators
Nurse Focused outcome
Indicators
Patient Focused
Outcome Indicators
STRUCTURE PROCESS OUTCOME
Structure Process Outcome Model

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How are Nursing-Sensitive Indicators Developed ?
Identification of
potential Indicator
Literature Review
Nursing Panel
review’s the
validity of the
Indicator
Conduct Pilot
study
**Oncethepotentialindicatorhasbeenempiricallysupportedtobemeaningful
inclinicalpracticeandithasbeendeterminedthatnoundueburdenwouldbe
placedonparticipatingfacilities/team.Apilotstudyisperformedinwilling
facilities/unit/area.Itshallbeaninclusiveapproach.
QI is basis
for BSC

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INDICATOR SUB-INDICATOR MEASURE
•Nursing Hours per Patient Day Registered Nurses (RN)Structure
•Patient Falls with Injury Injury Level Process & Outcome
•Pressure Ulcer Prevalence Community Acquired
Hospital Acquired
Unit Acquired
Process & Outcome
•Nosocomial Infections
a. Urinary catheter-associated urinary tract infection
(UTI)
b. Central line catheter associated blood stream
infection (CABSI)
c. Ventilator-associated pneumonia (VAP)
Community Acquired
Hospital Acquired
Unit Acquired
Process & Outcome
Nursing Sensitive Indicators -Classification

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This is not enough we need to move to next level
to impact outcome

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Benchmarking -A continuous process comparing an organization's performance against that of the best
in the industry considering critical consumer needs and determining what should be improved.
Benchmarking Encompasses:
•Regularly comparing indicators (structure, activities, processes and outcomes) against best
practitioners
•Identifying differences in outcomes through inter-organizational visits
•Seeking out new approaches in order to make improvements that will have the greatest impact on
outcomes; and Monitoring Indicators. Here comes Ideation, Innovation & Enovation
Benchmarking can be done at Department level, hospitallevel, National level orinternational level.
Benchmarking QI for Nursing
–Where do we position our Nursing Care

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1.Select the object of the benchmarking (the service or activity to be improved).
2.Identify benchmarking partners (reference points).
3.Collect and organize data internally.
4.Identify the competitive gap by comparing against external data.
5.Set future performance targets (objectives).
6.Communicate the benchmarking results.
7.Develop action plans.
8.Take concrete action (project management).
9.Monitor progress.
Steps of Benchmarking
Ref: Pitarelli and Monnier (2000)

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Linking NQI to Performance of an Organization
Better outcomes for
participant & population
Better professional
development
(competence, pride, joy)
Everyone
Better program performance
(Quality & Value)
Change does not necessarily result in improvement, but improvement always brings change

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•To carry out interdisciplinary processes to meet organizational QI goals and to measure, improve,
and control nursing-sensitive indicators (NSI) affecting patient outcomes specific to nursing
practices.
•All levels of nurses, from the direct care bedside nurse to the chief nursing officer (CNO), play a
part in promoting QI within the healthcare provider organization.
•Monitor for early recognition of adverse events, complications and errors.
•Initiating deployment of appropriate and timely nursing care to aid patients hastens speedy
recovery.
•Sharpen Nurses EQ/CQ & Empower them to Express without fear while at Bedside or in
Boardroom
Role of Nurse in Quality Improvement

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Involvement of Nurses at Various level in monitoring QI
•CNOs set the tone for the
nursing department's
participation in QI.
•As a member of
administrative leadership, the
CNO must integrate nursing
practices into the
organizational goals for
excellence in patient
outcomes through
communication of strategic
goals to all levels of staff.
•Thedirectcarebedsidenurse
isthekeytoqualitypatient
outcomes,carryingoutthe
protocolsandstandardsofcare
shownbyevidencetoimprove
patientcare.
•The NM is responsible for
communicating and
operationalizing the
organization's QI goals and
processes to the bedside
nurse, identifying specific
NSIs that need improvement
according to his or her
particular patient population,
and coordinating QI
processes to improve these at
the unit level
The nursemanager (NM)The CNO The direct care nurse/Bed side RN
Not an additional task, but a frame of mind
Creating A Mindset for the Context is very significant
Data Originator? Data Validation?

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Other Factors Related to Quality
Competent nurses
Independent and autonomous practice (micro-management is frowned upon, even in other professions)
Management support (recognitions, team building, and other activities or programs are present)
Patient-centered culture (patients over revenue)
Collaborative working environment (particularly between nurses and doctors)
Availability of continuing education and training options ( engagement of team & newer approaches )
Nurses directly affect the quality of hospital care -All efforts to train them and maintain their value should be
addressed. Nurses will –in turn –pass the same value and care along to their patients.

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The difficulties encountered by RNs while implementing QI
Lack of time
Inadequate number of
professionals
Lack of knowledge on the
subject.
Lack of understanding of how to
use these instruments
CRITICAL FACTOR -Available
level of nurse staffing

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Relationship between Quality of care and Staff Empowerment
Staff
Empowerment
Increased
Job
Satisfaction,
Lower Job
Turnover
Increased
Patient
satisfaction &
Perception of
care
Higher
Quality of
care
Nursing
Quality of
Care-
Measured
through NQI
What Builds Staff Empowerment?
1.Leader support and teams.
2.Communication and information
sharing.
3.Positive reinforcement.
4.Confidence.
5.Just Culture
Barriers for Staff Empowerment?
1.Lack of senior leader support.
2.Lack of resources.
3.Poor teamwork and support.
4.Stagnation and loss of
momentum for change.
5.Staff turnover.
6.Punitive response to error.

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•https://www.nice.org.uk/guidance/sg1/chapter/9-safe-nursing-indicators
•https://ojin.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/Tabl
eofContents/Volume122007/No3Sept07/NursingQualityIndicators.aspx
•https://www.hcpro.com/NRS-248978-868/Ask-the-expert-Understanding-nursing-roles-in-
quality-improvement.html
•https://www.americansentinel.edu/blog/2011/11/02/what-are-nursing-sensitive-quality-
indicators-anyway/
•NQI -https://www.qualityindicators.ahrq.gov/
•NABH Standards & JCI Standards Books
References

© All Rights Reserved. This material is confidential and property of IHH Healthcare Berhad. No part of this material should be reproduced or published
in any form by any means, nor should the material be disclosed to third parties without the consent of IHH.
ThankYou
Nurse you are a Patient Advocate &
Express without fear while
at Bedside or in Boardroom.