Nursing-Sensitive Quality Indicators Nurse Sensitive Quality Indicators

Nursing-Sensitive Quality Indicator: Standard Technique Hand Washing

Reports of incidences of superbug infections in hospitals and highly infectious diseases in underdeveloped countries heightens the importance of standard sanitation techniques. Moreover, increasingly reimbursement rates for hospitals are tied to achievement of specific patient care outcomes, a change that has made healthcare quality more important for all stakeholders. Standard technique in hand washing, skin preparation, and wound dressing is core to quality patient care, yet the literature and the media point to an increasingly pervasive degradation in this area (Szilagy, 2013). Standard sanitation technique is definitely a nursing-sensitive quality indicator as nurses are universally engaged in these processes and procedures in some capacity.

The literature indicates that improper hand hygiene of clinicians is one of the major contributors to healthcare-associated infections (HAIs), and that 7.1% of admissions to the hospital in developed countries involve HAIs. The annual death rate form HAIs is roughly 150,000 people in Europe and 100,000 in the United States. These figures are staggering when one considers that both the European and U.S. standards for hand hygiene in healthcare have been developed according to recommendations from the World Health Organization (WHO). Indeed, the WHO standards include the definition of "5 crucial moments of hand hygiene and 6 practical hand rubbing steps through which alcohol-based hand rub solutions have been proven effective" (Szilagy, 2013).

What Are Nursing-Sensitive Indicators?

The phrase "nursing-sensitive indicators" was first used by Mass, Johnson, and Morehead (1996, as cited in Savitz, et al., n.d.) as a way to make patient outcomes affected by nursing practice salient in the literature and in practice. The literature most frequently seems to associate nursing-sensitive indicators with outcomes that negative -- either less desirable or even adverse (Needleman, et al., 2001, as cited in Savitz, et al., n.d.)). Needleman, et al. (2001) suggests that this is the case because it is considerably more difficult to associate nursing care with positive outcomes since these are rarely documented in medical records or in administrative data sets. Attribution is rarely simple and straightforward and is certainly complicated in the context of healthcare where multiple stakeholders interact and respond to situations that are commonly influx. In an effort to address the dynamic aspect of attribution and simultaneously recognize the potential and actual substantial contributions of nursing in the delivery of clinical care, Needleman, et al. (2001) suggest using the phrase "outcomes potentially sensitive to nursing."

Data Sources for Nursing-Sensitive Quality Indicators

Administrative databases are common sources of data for patient care quality indicators. As with any data source used to assess performance, there are a number of drawbacks to using this type of administrative data to examine the quality of care delivered by health care providers. Consider the variety of uses for aggregated information administrative databases and it is readily apparent that the specificity and focus of the constellation of uses may be entirely different from the focus of when data in the aggregate information and data that will be usedis desirable for informing quality indicators. Administrative databases are foundational to billing and payment for hospital services and typically contain information from the discharge claim. Administrative databases are structured according to a standardized electronic format that is common to all hospitals billing for services. Healthcare quality research, evaluation, public reporting, and quality improvement initiatives all access these forms of aggregated dataadministrative databases.

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In addition, patient information about "race, county or ZIP Code of residence, secondary payer, detailed charges, and identifier of primary physician or surgeon" may be included in the administrative databases (Farquhar, n.d.).
It is significant that the formatting of data collected and the quality of the data differs across the data collection applications and platforms used for collecting information, and among the medical institutions or hospitals. Differences may be seen in the format of data detailing the number and sequencing of the codes for diagnosis and procedures, and different institutions may use diverse methods for audits and edits applied to data both before and after submission, and to the data values that are accepted. TFrom this, the value of the AHRQ quality indicators is evident since the QIs are based on data that is widely available and can readily be used to assess quality. Specifically, the AHRQ quality indicators are uniformly defined and established through standardized algorithms that are adaptable to "virtually any administrative data set" (Farquhar, n.d., p. 8). Because of this, Cocomparisons can be made across hospitals, communities, regions, and even states.

Hand Washing As a Nursing-Sensitive Quality Indicator

Accomplishing adequate and appropriate hand washing by using standard technique is closely associated with positive patient outcomes and has been shown to prevent the spread of disease, reduce the risk of cross-contamination, and contribute to environmental conditions that serve to promote healing and avoid adverse patient outcomes. The hand washing practice of nurses matter: the use of standard technique for hand washing in every relevant situation in a clinical setting and when caring for patients is a quality indicator. Education and training of practitionerclinicians about proper hand washing standard technique is vital to improving hand hygiene compliance and the safeguarding of patients' well-being.

Measuring the Hand Washing Quality Indicator

The identification of typical errors in hand washing technique has been shown to be critically important in to effective training and improvements in the hand washing practices of clinicians. Compliance with hand hygiene is assessed by observing the adherence of clinicians to the five moments (numbers of hand washing opportunities) identified by WHO, and by observing that the WHO six step technique has been followed by clinicians.

Figure 1. WHO - My Five Moments for Hand Hygiene Concept

(Source: Malik, 2008)

The quality of hand washing activity is usually not monitored, and there may or may not be an established methodology for the routine assessment of hand hygiene technique in a clinical setting. It is relatively difficult to objectively assess hand rub coverage of staff through casual observation and without the use of imaging technology to look for missed areas of the hands after the use of WHO's 6 Step technique. This means that From this perspective, the measurements for the hand washing quality indicator may not always be accurate. For example, a research study designed to assess the adequacy of hand hygiene practices in a Singapore hospital found that 72% of the staff adequately washed their hands immediately after completing training in hand washing standard technique. The researchers reported that,

"Failure to adequately clean the dorsal and palmar aspects of the hand occurred in 24% and 18% of the instances, respectively. Fingertips were missed by 3.5% of subjects. The analysis based on 4642 records showed that nurses performed best (77% pass), and women performed better than men (75% vs. 62%, p