exchanged between risk managers and quality managers and collaboration is too often patient safety operations within healthcare organizations. Traditional labels are the American Medical Association as “crisis states.” As these reforms . Table 5: ANOVA's result for patient safety climate and quality. . investigated the relationship between PS and healthcare organization behaviors and norms in. dures within healthcare organizations. Case between the departments of risk, quality, and medical staff. .. A proactive and responsive patient relations.
Participants also stated that their motivation was influenced by the job security offered by hospitals: The working environment affects employee satisfaction. Participants expressed a need for a quiet and supportive working area.
When the work place is dark and closed, it causes me to feel upset. A participant provided an example by putting a glass on the table and putting his hand over it and saying: Some employees, especially first-line managers demand top management to give them more authority with regard to their daily activities: It takes days for a supplier to receive the payment. Healthcare system There is no referral system from the primary healthcare level to the secondary and tertiary levels in Iranian healthcare system.
Therefore, there is a tendency, in patient choice from a GP to a medical consultant: Most patients prefer to be seen by a medical specialist. Low medical tariff makes it easier for patients to see a medical specialist: Medical insurance companies make it even more affordable for patients to see a medical specialist.
Furthermore, the fee for service of a doctor visit is the same for simple or more complicated cases. It leads to competition between the GP and the specialist, with the latter being perceived as holding the upper hand. The fee for both services is the same. Moreover, lack of patient trust in medical doctors and lack of familiarity with medical practices increases uncertainty and leads to repeated medical visits.
The situation is under control even if it takes a week to get better. As a result, the demand for specialised healthcare is increasing which is beyond the resources of healthcare organisations or even payers. Purchasers of healthcare services are concerned that the cost has exceeded their capacity and willingness to finance it: Increased number of patients decreases the quality of services.
Facilities and equipment are getting old. Hospital personnel particularly clinical staff who took part in the study complained that they were overworked and that there were staff shortages. I worked in a public hospital with average daily patients in the outpatient department who had to be visited by 1 PM. We are not dependent on patients. The increased demand for medical services may force physicians to transfer patients to paramedical departments instead of having them properly examined to achieve an accurate diagnosis.
Therefore, I cannot examine a patient properly and ask questions as these take time. I have to prescribe radiography. Thus, we have to spend about 1 minute for each patient [to get the radiography film]. This in turn increases staff job stress, resource utilisation and probability of errors. Sometimes 10 patients are waiting for the service [Radiology].Metrics that Healthcare Organizations Should Track when Engaging in Population Health Management
Participants, mostly policy-makers, managers, and doctors believed that the tariff of healthcare services do not match with the costs of providing the services. It means that if we keep the bed empty and do not admit a patient, the loss would be a third.
Therefore, providers have to cut costs. Participants hoped that making the medical tariff realistic decreases the demand for the services: Lack of competition especially in public sector was also considered as a reason for ignoring quality in healthcare systems. There is lack of competition among healthcare providers. Government funds healthcare services.
Some even suggested that the direct monetary link between the doctor and the patient has to be removed. Policy-makers are not involved in healthcare delivery. Therefore, their decisions are not realistic. As a result, the allocated budget does not match with the costs of providing healthcare services. A number of participants believed that medical and healthcare service fees should be changed.
I cannot afford the costs. Resources and facilities Availability of resources affects the quality of healthcare services. We need to have a record of patient history. It is very useful, especially for patients with blood pressure or diabetes.
Factors influencing healthcare service quality
High-quality outputs services require high-quality inputs. Therefore, it takes more time to do our job.
The results may not also be reliable. The reserve is out of order. Managers and policy-makers recognised financial resources as the most important factor affecting the quality of healthcare: While we cannot pay employees salaries, how can we talk about quality? Leadership and management Effective management was mentioned as an important enabler of quality from the perspective of providers, managers, policy-makers and payers. They do not have experience and knowledge in management.
There are no objective criteria for selecting and appointing managers in healthcare organisations: The analysis of qualitative data indicated that the lack of management stability was considered a major obstacle facing the managers trying to extend their knowledge and experience.
Managers in public hospitals do not have the ultimate power for decision-making. National policies are extremely prescriptive and do not allow sufficient flexibility to adapt to local circumstances. A manager does not have enough authority to change it [adapt it]. The Ministry of Health should define the indicators and ask managers to achieve them.
Healthcare managers demand more power in identifying and recruiting the most appropriate personnel to provide quality service. Furthermore, managers cannot control physicians the same way as other employees. The medical school decides who should practice in the hospital. For instance, it was decided that a paediatrician should work at the hospital on Sundays. Collaboration and partnership development For practitioners having good support services is important: She said that she does not have it.
They should be more responsible. Medical doctors expect their colleagues or co-workers to be more responsible and be empowered enough to perform the job well. Healthcare professionals highlighted the importance of cooperation and teamwork among healthcare providers as an important component of high-quality healthcare services.
For example, for some hormone tests, the patient must not eat a specific food.
All these can be sorted out easily through collaboration between two hospitals. The lack of collaboration between healthcare organisations and other organisations influence service quality. Normally, the hospital sends the bills by the end of every month to the [insurance] company.
It takes time to get the money back [due to bureaucracy]. It is difficult for the hospital to manage the new price.
Factors influencing healthcare service quality
Therefore, patients are asked to buy the medicine themselves from the pharmacy and then claim the money from the insurance company. It causes inconvenience for patients. Discussion Quality in healthcare is a production of cooperation between the patient and the healthcare provider in a supportive environment. Without sound risk adjustment, any associations between staffing and outcomes may be spurious; what may appear to be favorable or unfavorable rates of outcomes in different institutions may no longer seem so once the complexity or frailty of the patients being treated is considered.
However, as was noted earlier, quality of care and clinical outcomes and by extension, the larger domain of nursing-sensitive outcomes include not only processes and outcomes related to avoiding negative health states, but also a broad category of positive impacts of sound nursing care. Knowledge about positive outcomes of care that are less likely to occur under low staffing conditions or are more likely under higher levels is extremely limited. The findings linking functional status, psychosocial adaptation to illness, and self-care capacities in acute care patients are at a very early stage 37 but eventually will become an important part of this literature and the business case for investments in nurse staffing and care environments.
Linkage In staffing-outcomes studies, researchers must match information from data sources about the conditions under which patients were cared for with clinical outcomes data on a patient-by-patient basis or in the form of an event rate for an organization or organizational subunit during a specific period of time.
Ideally, errors or omissions in care would be observed and accurately tracked to a particular unit on a particular shift for which staffing data were also available.
Most, but not all, large-scale studies have been hospital-level analyses of staffing and outcomes on an annual basis and have used large public data sources. Linkages of staffing with outcomes data involve both a temporal time component and a departmental or unit component. These include some types of complications as well as patient deaths.
Attribution of outcomes is complicated by the reality that patients are often exposed to more than one area of a hospital. For instance, they are sometimes initially treated in the emergency department, undergo surgery, and either experience postanesthesia care on a specialized unit or stay in an intensive care unit before receiving care on a general unit. Unfortunately, in hospital-level datasets, it is impossible to pinpoint the times and locations of the errors or omissions most responsible for a clinical endpoint.
In the end, if outcomes information is available only for the hospital as a whole which is the case in discharge abstracts, for instancedata linkage can happen only at the hospital level, even if staffing data were available for each unit in a facility. Similarly, if staffing data are available only as yearly averages, linkage can be done only on an annual basis, even if outcomes data are available daily or weekly.
Linkages can be done only at the broadest levels on the least-detailed basis or at the highest level of the organization available in a dataset. Many patient outcomes measures such as potentially preventable mortality may actually be more meaningful if studied at the hospital level, while others such as falls may be appropriately examined at the unit level.
One should recognize that common mismatches between the precision of staffing measures and the precision of outcome measures i. This finding is particularly relevant when staffing statistics span a long time frame and therefore contain a great deal of noise—information about times other than the ones during which particular patients were being treated.
High-quality staffing data, as well as patient assessment and intervention data—all of which are accurately date-stamped and available for many patients, units, and hospitals—will be necessary to overcome these linkage problems.
Such advances may come in the next decades with increased automation of staffing functions and the evolution of the electronic medical record.
Recent prospective unit-level analyses, now possible with datasets developed and maintained by the NDNQI, CalNOC, and the military hospital systems, make it possible to overcome some of these issues. These databases, although not risk adjusted, stratify data by unit type and hospital size and have adopted standardized measures of nurse staffing and quality of care.
The resulting datasets provide opportunities to study how variations in unit-level staffing characteristics over time can influence patient outcomes for instance, pressure ulcers and falls, as discussed later. As data sources do not exist for all types of staffing and outcomes measures at all levels of hospital organization nor will they everresearch at both the unit level and the hospital level will continue, and both types of studies have the potential to inform understanding of the staffing-outcomes relationship.
Research Evidence Perhaps staffing and outcomes research has such importance and relevance for clinicians and educators as well as for managers and policymakers, staffing-outcomes research is a frequently reviewed area of literature. As was just detailed, a diversity of study designs, data sources, and operational definitions of the key variables is characteristic of this literature, which makes synthesis of results challenging.
Many judgments must be made about which studies are comparable, which findings if any contribute significantly to a conclusion about what this literature says, and perhaps regarding how to transform similar measures collected differently so they can be read side by side. The review of evidence here builds on a series of recent systematic reviews with well-defined search criteria. These findings have appeared in studies conducted using a variety of designs and examining hospital care in different geographical areas and over different time periods.
In these papers, reviewers identify specific measurement types and established criteria for study inclusion in terms of design and reporting and examined a relatively complete group of the studies one by one to provide an overview of the state of findings as an integrated whole.
Major Integrative Reviews of the Staffing-Outcomes Literature The contrasts in the conclusions are interesting but are probably less important than the overall trend: An additional important point is that nearly all studies connecting staffing parameters with outcomes have been conducted at the hospital rather than the unit level.
In a 2-year AHRQ Working Conditions and Patient Safety study built on the work of CalNOC, Donaldson and colleagues 17 engaged acute care hospitals using ANA nursing indicators for reporting staffing, patient safety, and quality indicators in a research, repository development, and benchmarking project. Data were drawn from 25 acute care, not-for-profit California hospital participants in the regional CalNOC. The sample included urban and rural hospitals with an average daily census from to more than patients.
The aims of the study were to test associations between daily nurse staffing on adult medical-surgical units and hospital-acquired pressure ulcers, patient falls, and other significant adverse events, if they were of sufficient volume to analyze. A prospective, descriptive, correlational design tested associations between patient outcome measures and daily unit-level nurse staffing, skill mix, hours of care along with hours covered by supplemental agency staffand workload.
Unit activity index and hospital complexity measured by bed size were also significant predictors of falls. In another analysis, Donaldson and colleagues 39 traced daily, unit-level direct care nurse staffing in 77 units across 25 hospitals over a 2-month period using data on staffing effectiveness the match between hours of care and hours provided. By law in California, each hospital unit uses an institutionally selected, acuity-based workload measurement system to determine required hours of care for each patient.
For each patient-care unit, the ratio of actual to required hours of care, was expressed as both a mean ratio and as a percentage of days on which required hours exceeded actual hours over the 7 days prior to a pressure ulcer prevalence study. These analyses linked unit-level staffing and safety-related outcomes data, and measured for time periods at the unit level closely and logically connected staffing measures relevant to conditions before the outcome occurred.
Both researchers and research consumers need to reflect on the time frames involved in the evolution of various outcomes when assessing the validity of data linkages across time and units. For instance, in contrast to the lags between quality problems in care and evidence of their impact on outcomes such as infections and pressure ulcers, practice conditions will tend to have more immediately observable impacts on outcomes like falls with injury and most adverse drug reactions.
Recent legislation in California that introduced mandated nurse-to-patient ratios at the unit level provides an interesting context for studying the association of staffing and outcomes. CalNOC has reported early comparisons of staffing and outcomes in medical-surgical and step-down units in 68 California hospitals during two 6-month intervals Q1 and Q2 of and Q1 and Q2 of before and after introduction of the ratios.
Data were stratified by hospital size and unit type. On medical-surgical units, mean total RN hours per patient day increased by However, there were no statistically significant changes in the rate of patient falls or pressure ulcers on these units.
Summary and Comment Researchers have generally found that lower staffing levels are associated with heightened risks of poor patient outcomes. Staffing levels, particularly those related to nurse workload, also appear related to occupational health issues like back injuries and needlestick injuries and psychological states and experiences like burnout that may represent precursors for nurse turnover from specific jobs as well as the profession.
Associations are not identified every time they are expected in this area of research. Other aspects of hospital working conditions beyond staffing, as well individual nurse and patient characteristics, affect outcomes since negative outcomes are relatively uncommon even at the extremes of staffing and do not occur in every circumstance where staffing is low. A critical mass of studies established that nurse staffing is one of a number of variables worthy of attention in safety practice and research.
There is little question that staffing influences at least some patient outcomes under at least some circumstances. Future research will clarify more subtle issues, such as the preferred methods for measuring staffing and the precise mechanisms through which the staffing-outcomes relationship operates in practice. Areas Where the Evidence Base Is Currently Limited Nurse executives and frontline managers make decisions about numbers of staff to assign to the various areas of their facilities.
They also establish models of care to be used in caring for patients in terms of the constellation of nursing staff and distribution of responsibilities among professional nurses and other types of nursing staff. Policymakers want assurances that the nursing workforce in their jurisdictions is adequate; they also want to know whether or not regulatory intervention is necessary to ensure acceptable staffing levels and desirable patient outcomes. Staffing researchers are ultimately constrained by the limitations of their data in answering many questions of relevance to the real worlds of health care delivery and public policy.
Investigators most commonly examined the correlations of complex patient outcomes with staffing measures derived at some distance from the delivery of care perhaps aggregated over time. Researchers then asked whether measures of staffing and outcomes were statistically associated with each other. A clear distinction between direct conclusions from research findings and the opinions of particular authors or interest groups must be made.
It is impossible to specify parameters for staffing that will ensure safety based on current evidence without many qualifiers. The adequacy of staffing the degree to which staffing covers patient needs even for the same patients and nurses may change from hour to hour, particularly in acute care settings. Nurse-to-patient ratios and skill mixes in specific settings that are too low for safety still cannot be identified on the basis of the research literature, but decisions must be made on the basis of the judgments by frontline staff and their managers.
On a related note, the specific nursing care processes that are more likely to be omitted or rendered less safe under different staffing conditions are not well understood, empirically speaking, and deserve further attention.
Nurse Staffing and Patient Care Quality and Safety - Patient Safety and Quality - NCBI Bookshelf
A number of other areas identified in the staffing literature are relatively underdeveloped. Most research on staffing has been conducted in acute care settings; however, not all clinical areas within acute care have been equally well studied. Data regarding settings for the care of children, childbearing families, and patients with mental health problems are currently very thin. The majority of nurses working in hospitals in the United States are, of course, registered nurses.
Available evidence suggested that patients in hospitals that use more licensed practical nurses LPNs or vocational nurses may see worse outcomes. There is no direct evidence that it is unsafe to employ LPNs in acute care settings, 4243 nor is there empirical support that the use of unlicensed personnel is intrinsically related to poor outcomes.
Use of practical nurses and UAPs can be driven by any and all of the factors outlined in Figure 2. The models of care under which LPNs and unlicensed care providers are employed i.
While RNs have the broadest scope of practice of frontline nursing workers, it is far from established that percent RN staffing is effective in all situations. Until then and even when it doeslocal labor market realities, experience, and judgment will need to be used by leaders to establish skill mix and to define the models of care under which RNs, LPNs, and UAPs work. Early studies have offered early, tantalizing insights regarding a number of variables conceptually close to staffing.
These findings include the educational preparation of RN staff in hospitals. Two recent studies 4445 found that mortality in surgical and medical patients was lower in hospitals where higher proportions of staff nurses held baccalaureate degrees. Additionally, in this latter work, units where higher percentages of RNs held specialty certification had lower proportions of restrained patients.
Should these findings be borne out in future studies, there are important potential local and national policy implications. There is a clear need for more research. Similarly, while many feel experience and specialty training have logical associations with quality of care and patient safety, empirical data regarding their impact are very limited at present.
Yet another area where data related to patient outcomes are thin relates to the impact of specific types of work environments on nurse-sensitive outcomes, and in particular the impact of the Magnet hospital model, which has been argued to produce superior patient outcomes and safer care. To our knowledge, there are no studies yet to directly support a connection between safety and specific managerial approaches or to link Magnet status with patient outcomes in the current era of certification.
However, early findings with respect to questions around the outcomes of the program are expected in the coming years. Evidence Related to Other Settings There has been intense interest in identifying staffing-outcomes relationships in long-term care settings. RNs are, of course, in the minority among the nursing staff in long-term care, with unlicensed providers providing the bulk of physical care in these facilities. There are many challenges in using existing documentation and databases to measure outcomes in long-term care facilities, 48 some of which are shared with outcomes measurement in acute care.
Long-term care researchers face special issues, specifically with respect to data reliability and measure stability, skewedness of measures, and selection and ascertainment bias where types of patients at high risk for poor outcomes or who are more closely observed are concentrated in certain nursing homes. A study sponsored by the Centers for Medicare and Medicaid Services CMS suggested that among short-stay patients, skilled nursing facilities with the lowest staffing levels were 30 percent more likely to fall in the worst 10 percent of facilities for transfers to acute care for acute heart failure, electrolyte imbalances, sepsis, respiratory infection, and urinary tract infection.