Quality measures

INTRODUCTION National initiatives driven by the American Nurses Association have determined nursing-quality outcome indicators that are intended to focus plans and programs to increase quality and safety in patient care. The following outcomes are commonly used nursing-quality indicators: • complications such as urinary tract infections, pressure ulcers, hospital-acquired pneumonia, and DVT • patient falls • surgical patient complications, including infection, pulmonary failure, and metabolic derangement • length of patient hospital stay • restraint prevalence • incidence of failure to rescue, which could potentially result in increased morbidity or mortality • patient satisfaction • nurse satisfaction and staffing SCENARIO Mr. J is a 72-year-old retired rabbi with a diagnosis of mild dementia. He was admitted for treatment of a fractured right hip after falling in his home. He has received pain medication and is drowsy, but he answers simple questions appropriately. A week after Mr. J was admitted to the hospital, his daughter, who lives eight hours away, came to visit. She found him restrained in bed. While Mr. J was slightly sleepy, he recognized his daughter and was able to ask her to remove the restraints so he could be helped to the bathroom. His daughter went to get a certified nursing assistant (CNA) to remove the restraints and help her father to the bathroom. When the CNA was in the process of helping Mr. J sit up in bed, his daughter noticed a red, depressed area over Mr. J’s lower spine, similar to a severe sunburn. She reported the incident to the CNA who replied, “Oh, that is not anything to worry about. It will go away as soon as he gets up.” The CNA helped Mr. J to the bathroom and then returned him to bed where she had him lie on his back so she could reapply the restraints. The diet order for Mr. J was “regular, kosher, chopped meat.” The day after his daughter arrived, Mr. J was alone in his room when his meal tray was delivered. The nurse entered the room 30 minutes later and observed that Mr. J had eaten approximately 75% of the meal. The meal served was labeled, “regular, chopped meat.” The tray contained the remains of a chopped pork cutlet. The nurse notified the supervisor, who said, “Just keep it quiet. It will be okay.” The nursing supervisor then notified the kitchen supervisor of the error. The kitchen supervisor told the staff on duty what had happened. When the patient’s daughter visited later that night, she was not told of the incident. The next night, the daughter was present at suppertime when the tray was delivered by a dietary worker. The worker said to the patient’s daughter, “I’m so sorry about the pork cutlet last night.” The daughter asked what had happened and was told that there had been “a mix up in the order.” The daughter then asked the nurse about the incident. The nurse, while confirming the incident, told the daughter, “Half a pork cutlet never killed anyone.” The daughter then called the physician, who called the hospital administrator. The physician, who is also Jewish, told the administrator that he has had several complaints over the past six months from his hospitalized Jewish patients who felt that their dietary requests were not taken seriously by the hospital employees. The hospital is a 65-bed rural hospital in a town of few Jewish residents. The town’s few Jewish members usually receive care from a Jewish hospital 20 miles away in a larger city.