Nurses Found to Be Accurate Assessors of Care Quality

Patients are making themselves heard in today’s healthcare system, and their perspective matters more than ever before.  They provide valuable insight into their hospital experiences through the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAPS) Survey. And because patient satisfaction results are publicly available and linked with funding through the Centers for Disease Control and Prevention’s (CMS) Hospital Value-based Purchasing (VBP), hospital and health system leaders are paying attention to what patients are saying.

But a new study suggests that leaders should also listen closely to what their nurses are saying.

In “Nurse Reported Quality of Care: A Measure of Hospital Quality,” co-authors Matthew McHugh, PhD, JD, MPH, RN, CRNP, and Amy Witkoski Stimpfel, PhD, RN, found that nurses are an under-tapped resource when it comes to accurately measuring healthcare quality in their workplaces. In fact, they wrote, “nurse reported quality of care can be a valuable indicator of hospital quality.”

The study, which was funded by the Robert Wood Johnson Foundation (RWJF) Nurse Faculty Scholars program and the National Institute of Nursing Research (NINQ), quantified what many have believed all along: if you want to know what’s really happening in the hospital, ask the nurses. They see the good and the bad.

“Our data suggests that their reports are spot on and predictive of outcomes,” said McHugh, an assistant professor of nursing at the University of Pennyslvania and an RWJF Nurse Faculty Scholar.

He added, “People may not like what they have to say, but as it turns out, what they have to say, at least in terms of quality, is a pretty good indicator of actual quality in terms of what’s happening to patients.”

Katie Brewer, MSN, RN, senior policy analyst in the department of nursing practice and policy of  the American Nurses Association, said the study provides evidence that could further boost the influence of nurses. Hospitals have “one of the most potent resources they could ask for working for them, and that is nurses,” she said.

This type of information will be especially useful because the era of value-based purchasing took effect October 1 for acute care hospitals paid under CMS’s Inpatient Prospective Payment System (IPPS), as required by the Affordable Care Act. Hospitals will risk losing funding if they are not meeting quality standards, and this provides “the opportunity for nurses to really shine,” Brewer said.

“This study is so important because hospitals really are now in the Value-based Purchasing world,” said Brewer. “It is validation of what I see as the new paradigm of hospital care.”

McHugh and Stimpfel analyzed data from 396 acute care hospitals in four states: California, Pennsylvania, Florida and New Jersey. The study’s data sources included the Multi-State Nursing Care and Patient Safety Study, a survey of nurses’ work conditions and quality of care from 2006-2007, and HCAPS scores, as well as other data from hospitals reported to CMS as part of the IPPS.

In the models run by the authors, they found that “each 10 percent increment in the proportion of nurses in the hospital reporting that the quality of care on their unit was excellent was associated with 5 percent lower odds of both mortality and failure to rescue for surgical patients.” Additionally, associated with each 10 percent increase was a 3.7 increase in the percentage of patients “who would definitely recommend the hospital.”

Hospitals that are known as good places for nurses to work “have better outcomes, including nurse reported quality of care,” explained McHugh and Stimpfel, noting that hospitals that have received the Magnet designation from the American Nurses Credentialing Center are frequently included in that category. “Our findings suggest that nurse reported quality of care is indeed a valid indicator that reflects differences in quality as measured by standard patient outcomes and process indicators.”

Nurses are also aware of the intangibles, the things that aren’t always formally captured in quality assessments, by virtue of being present for so much of the patient’s experience in the hospital. “Nurses have insight into aspects of care…that are not always documented in the medical record but often make the difference between good and bad outcomes,” McHugh and Stimpfel wrote.

The authors also noted that “the patient’s perspective is the most relevant quality of care indicator” but nurses could provide “complementary benefits” by reporting on quality, too.

“They’re readily available,” said McHugh. “And in some cases, they are already providing data. They’re already giving information about the quality.”

For example, in many hospitals, nurses contribute data about quality to the American Nurses Association’s National Database of Nursing Quality Indicators (NDNQI). And according to Brewer, that can help organizations by figuring out the links between factors such as staffing and patient outcomes and then helping them take steps to address any shortcomings.

With the evidence that nurses are providing reliable assessments of quality of care, hospital leaders can now consider other ways to solicit feedback from their nurses, noted Kelley Ilic, operations manager for the Oregon Center for Nursing.

“Then perhaps they can also solicit help on how processes could be improved,” she said.

The study’s findings add to a large body of evidence of the benefits of having good practice environments, where nurses are able to practice autonomously and are supported by managers and are integrated throughout the hierarchy of the institution, McHugh said.

“Everyone benefits when the nurses are practicing at their best and are supported by the institution,” he said.