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Misplacing Our Focus on Quality Improvement

April 24, 2013

Gold_StarBy Maureen Shawn Kennedy, AJN editor-in-chief

I welcome manuscripts written by nurses in clinical practice, especially comprehensive updates on managing a clinical syndrome or a common problem that readers would find informative and interesting. I call these the “meat and potato” papers—the ones that provide substantial content, the need-to-know information that will help nurses provide quality, evidence-based care. The best ones discuss the physiology and pathology underlying clinical symptoms, practice implications for ongoing monitoring and management, and patient and family teaching and concerns.

The other papers I value are those that describe quality improvement initiatives or processes that improve outcomes and, by following the SQUIRE (Standards for QUality Improvement Reporting Excellence) guidelines, are sufficiently detailed so that others can replicate them. (For information on what we seek to publish, see a recent blog post.)

Lately, though, I’m seeing more and more submissions that are not so much focused on how to use best practices to improve care, but rather on ways to improve scores on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. The authors typically describe the impetus for the improvement as low scores, get administrative support to set benchmarks for improving scores, and define success as improved scores. Often the changes are clinically insignificant but scores increase, so everyone is happy.

While the HCAHPS is a national measure that has been adopted as a measure of quality, it’s important to keep in mind that it measures the patient’s experience and satisfaction with only a few selected aspects of care, such as, according to the official HCAHPS Web site, “communication with nurses, communication with doctors, responsiveness of hospital staff, pain management, communication about medicines, discharge information, cleanliness of the hospital environment, and quietness of the hospital environment.” And because these measures  are tied to reimbursement, they receive a lot of attention.

There are many more aspects of care—treatment based on evidence, thwarting complications, early mobility to prevent pressure ulcers, adequate patient and caregiver teaching to prevent readmissions, to name a few—that are not measured in such a direct way and that may not be visible to patients and families, but may be more critical to a successful hospital experience.

We need to take a balanced approach to assessing quality and to be sure we’re placing emphasis on the right things. And while patients and their families are—or should be—at the center of what we do, our improvement initiatives shouldn’t be focused on getting a “gold star” for customer service.

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One comment

  1. Thank you and keep writing these type of editorials. I no longer practice in acute care settings. I am glad to see that facilities will lose reimbursement when clients are readmitted in short order. What I found was that there was no room for a voice to improve practice, rather it was “treat the sliver of the problem” as presented, discharge and readmit later. I still think quality care goes back to being able to have reasonable debates across disciplines instead of shooting orders and lists at each other.

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