Evidence-Based Geriatric Nursing - Springer Publishing

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Evidence-Based Geriatric Nursing Protocols for Best Practice
to report, record, collect, and manage data. Fourth, data must be analyzed in statistically
appropriate ways. This is not just a matter of using the right statistical methods. More
important, user groups must agree on a framework for analyzing quality data to interpret
the results. Fifth, health care environments are complex and dynamic in nature.
There are differences across health care environments, between types of provider organizations,
and within organizations. Furthermore, changes in health care occur frequently,
such as the movement of care from one setting to another and the introduction of new
technology. Finding common denominators is a major challenge.
Addressing the Challenges
These challenges are not insurmountable. However, making a commitment to quality
care entails a commitment to putting the processes and systems in place to measure
quality through performance measures and to report quality-of-care results. This commitment
applies as much to a quality-improvement initiative on a nursing unit as it
does to a corporate commitment by a large health care system. In other words, once
an organization decides to pursue excellence (i.e., quality), it must accept the need to
overcome the various challenges to measurement and reporting. Let us examine how
this could be done in a clinical setting.
McGlynn and Asch (1998) offer several strategies for addressing the challenges to
measuring quality. First, the various user groups must identify and balance competing
perspectives. This is a process of giving and taking: not only proposing highly clinical
measures (e.g., prevalence pressure ulcers) but also providing more general data (e.g.,
use of restraints). It is a process of asking and responding: not only asking management
for monthly statistics on medication errors but also agreeing to provide management
with the necessary documentation of the reasons stated for restraint use. Second, there
must be an accountability framework. Committing to quality care implies that nurses
assume several responsibilities and are willing to be held accountable for each of them:
(a) providing the best possible care to older patients, (b) examining their own geriatric
nursing knowledge and practice, (c) seeking ways to improve it, (d) agreeing to evaluation
of their practice, and (e) responding to needs for improvement. Third, there must
be objectivity in the evaluation of quality. This requires setting and adopting explicit
criteria for judging performance, then building the evaluation process on these criteria.
Nurses, their colleagues, and their managers need to reach consensus on how performance
will be measured and what will be considered excellent (and good, average, etc.)
performance. Fourth, once these indicators have been identified, nurses need to select a
subset of indicators for routine reporting. Indicators should give a reliable snapshot of
the team’s care to older patients. Fifth, it is critical to separate as much as possible the
use of indicators for evaluating patient care and the use of these indicators for financial
or nonfinancial incentives. Should the team be cost conscious? Yes, but cost should not
influence any clinical judgment as to what is best for patients. Finally, nurses in the
clinical setting must plan how to collect the data. At the institutional level, this may be
facilitated by information systems that allow performance measurement and reporting.
Ideally, point-of-care documentation will also provide the data necessary for a systematic
and goal-directed quality-improvement program, thus, eliminating separate data
abstraction and collection activities.
The success of a quality-improvement program in geriatric nursing care (and the
ability to overcome many of the challenges) hinges on the decision as to what to measure.