Background
Methods
Review of literature
Study selection criteria
Data extraction and synthesis
Stakeholder engagement to adopt/adapt indicators for the Kenyan context
Selection of stakeholders
Results
Overview of the studies included in this review
Author | Title | Sample size | Aim and setting | Study method | Indicator domain (number) | Study location |
---|---|---|---|---|---|---|
Kunaviktikul et al. 2005 | Development of indicators to assess the quality of nursing care in Thailand | Not specified | General clinical nursing | Descriptive observational (FGDs observation sheets, record retrieval forms) | 9 indicators; Structure (2), process (2), outcome (5) | Thailand (Asia) |
McCance et al. 2012 | Identifying key performance indicators for nursing and midwifery care using a consensus approach | 130 | General nursing and midwifery | Consensus (collaborative problem solving) method | 6 process indicators | Ireland (Europe) |
Langemo et al. 2002 | Nursing quality outcome indicators: The North Dakota Study | 217 nurses; 924 patients | Medical and surgical units, intensive care units, transitional care, and swing bed units | Expert/questionnaire | 11 indicators: structure (3), process (3), outcome (5) | North Dakota (United States of America) |
Pazargadi et al. 2008 | Proposing indicators for the development of nursing care quality in Iran | 161 nurses | General clinical nursing | Descriptive-exploratory | 20 indicators: structure (10), process (5), outcome (5) | Iran (Asia) |
La Sala et al. 2017 | The quality of nursing in intensive care: a development of a rating scale | 43 experts | Intensive care unit | Literature review and panel of experts | 21 process indicators. | Italy (Europe) |
Fugaça et al. 2015 | Use of balanced indicators as a management tool in nursing | 200 medical records | Intensive care unit | Case study | 14 indicators: structure (1), process (7), outcome (6) | Brazil (United States of America) |
Burston et al. 2013 | Nurse-sensitive indicators suitable to reflect nursing care quality: a review and discussion of issues | 40 studies | General nursing | Review | 44 outcome indicators | Australia |
Foulkes et al. 2011 | Nursing metrics: measuring quality in patient care | Not specified | General nursing | Expert opinion | 10 indicators: safety (5), effectiveness (3), nurses compassion (2) | United Kingdom (Europe) |
Chen et al. 2016 | Using the Delphi method to develop nurse-sensitive quality indicators for the NICU | 41 experts | Neonatal intensive care units | Modified Delphi technique | 11indicators: structural (1), process (2), outcomes (8) | China |
Seaman et al. 2016 | Abstracting ICU nursing care quality data from the electronic health Record | 1 440 case records | Intensive care unit | Single-blind, randomised crossover cluster (stepped wage) design | 6 indicators | Pennsylvania (United States of America) |
Martha et al. 2006 | The nightingale metrics | Not specified | General nursing | Focused group discussion | Inpatient cardiology unit (4), PICU (7), CICU (6), NICU (8) | Boston (United States of America) |
Twigg et al. 2015 | Foundation of nurse-sensitive outcome indicator suite for monitoring public patient safety in Western Australia | 259 463 patient records | Medical and surgical units | A review of literature and piloting of indicators on an EHR | 8 outcome indicators | Australia |
Maben et al. 2012 | High quality metrics for nursing. | 18 experts | General nursing | Taskforce review | 34 indicators: safety (9), effectiveness (5), patient experience (10), workforce (5), staff experience (5) | United Kingdom (Europe) |
Griffiths et al. 2008 | State of the art metrics for nursing: a rapid appraisal | Not applicable | General nursing | Review | 18 indicators: safety (7), effectiveness (8), compassion (3) | United Kingdom (Europe) |
Koy et al. 2016 | The quantitative measurement of nursing care quality: a systematic review of available instruments | 18 tools | General nursing | Systematic review | Nurses’ perspectives (11), patients’ perspectives (5). Categories and subcategories of nurse-patient perspectives | Cambodia (Asia) |
McCance et al. 2009 | Using the caring dimensions inventory as an indicator of person-centred nursing. | 107 patients; 122 nurses | Medical and surgical, ICU, operating room, sexual health clinic, older people rehabilitation and paediatric infectious disease wards | Quasi-experimental | 40 indicators: nurses’ perspectives (19), patients’ perspective (21) Both nurses and patients (6) | United Kingdom (Europe) |
Montalvo et al. 2007 | The national database of nursing quality indicators | General nursing | Report | 14 indicators: structural (4), process (1), outcome (4), outcome/process (4) | United States of America | |
Zhang et al. 2016 | Assessing nursing quality in paediatric intensive care units; a cross sectional study in China. | 1 385 patients and 274 PICU nurses. | Paediatric intensive care units | Descriptive, cross-sectional | 15 indicators: structural (5), process (3), outcome (7) | China |
Riehle et al. 2007 | Specifying and standardizing performance measures for use at a national level; implications for nurse-sensitive care performance measures. | General nursing | Report | 35 outcome indicators | United States of America | |
Lacey et al. 2006 | Developing measures of paediatric nursing quality | 10 acute care hospitals | Paediatric units | Review of literature, panel of experts and pilot study | 6 outcome indicators | United States of America |
Stratton et al. 2008 | Paediatric | 34 patient care units. | Paediatric units | Descriptive, Correlational, linear mixed model. | 9 indicators | United States of America |
St Pierre et al. 2006 | Staff nurses’ use of report card data for quality improvement | General nursing | Report | 14 indicators | United States of America | |
Lacey et al. 2009 | Nursing; key to quality improvement | General nursing | Review | 15 indicators: patients centred (8), nursing-centred (3), system-centred (4) | United States of America |
Outcome | |
Failure to rescue | Pain presence |
Postoperative respiratory failure | Patient satisfaction with pain management |
Patient complaints | Pain management/controlled |
Patient satisfaction with educational information | Nurse staff satisfaction |
Patient satisfaction with nursing care | Physical well-being |
Patient satisfaction with overall care | Psychological wellbeing |
Patients’ confidence in knowledge and skills of the nurse | Iatrogenic lung collapse |
Patient’s sense of safety whilst under the care of the nurse | Atelectasis |
aPatient involvement in decisions about their nursing care | Fluid overload |
Respect from the nurse for patient’s preference and choice | Falls |
Nurse’s support to patients to care for themselves, where appropriate | Injuries to patient |
Nurse understanding of what is important to the patient | Patient’s falls with injuries in the hospital |
Patient satisfaction with nurse communication | Staff injuries on the job |
Patients experience of care | Knowledge, behaviour, status change scores |
Patient/family complaints satisfaction | Physical and mental health change scores |
Parent/family complaint rate | Follow-up rate to allergy risks |
Patient judgement of hospital quality | Adverse drug reaction rate |
Central line catheter-associated bloodstream infection | Total of prescription mistakes |
Hospital-acquired pneumonia | Total of transfusion reaction |
Respiratory tract infection | Upper GI bleeding |
Nosocomial infection | Mortality |
Ventilator-associated pneumonia (VAP) | Shock/cardiac arrest |
Wounds dressed | Deep vein thrombosis |
Intravenous/vascular access infection | CNS complications |
Thrombophlebitis | Deterioration |
Vascular access infiltration | Complications |
Vascular access thrombosis | Health status |
Peripheral venous extravasation | Symptom management index |
Hospital-acquired urinary tract infection | Symptom resolution |
Urinary catheter-associated UTI | Metabolic derangement |
Wound infection | Functional status |
Surgical wound infection | Rate of accidental endotracheal extubation |
Sepsis | Retinopathy of the preterm child (ROP) |
Intravascular infiltration due to IV therapy | Heavy sedation |
Gastrointestinal infection rate | Average hospital length of stay |
Pressure ulcer prevalence | Vaccination |
Psychiatric physical/sexual assault rate | |
Process | |
Wound care | Smoking cessation counselling |
Skin integrity/pressure ulcer prevention | Smoking cessation counselling for heart failure |
Decubitus prevention care | Smoking cessation counselling for pneumonia |
The risk factors for pressure sores have been documented | Smoking cessation counselling for acute myocardial infarction (AMI) |
Pain assessment with scale and recorded | Nursing care supervision |
Chest-abdomen drain changed as by the protocol | Assessment and record reflex presence (e.g. ocular) |
Chest-abdomen drain insertion area dressed as by guideline | Proper patient positioning in bed |
Mechanical ventilation has been replaced according to protocols | Monitor alarms properly set |
Body temperature values have been updated in the last 24 h | ABG result 1 hour after endotracheal tube removal is available |
The pulse oximetry has been monitored and recorded | Endotracheal suctioning performed as per prescription and recorded |
The ECG and vital signs have been recorded on admission | Hand washing and hand hygiene |
Measuring of patient observations (vital signs) | Documentation of results |
Fluid intake and output have recorded | Number of patient transfers |
Patient washing once a day and recorded | Double-checking of all medication by two nurses |
Patient mouth washing as by ward procedure and recorded | Weight documentation daily |
aAssisting a patient with activities of daily living | Relative/parent notification of patients transfer |
aInstructing patient about self-care | Unplanned admission |
aBeing honest with a patient | Interprofessional relations |
aKeeping relatives informed about a patient | Emergency care |
aProviding privacy for a patient | Discharge and case management |
aGetting to know the patient as a person | Appraisal and induction |
aGiving reassurances about a clinical procedure | Nurses’ compliance in filling of medical records |
Information and involvement of family into the end of life care by nurses | aListening to a patient |
Physical and chemical restraint | aExplaining a clinical procedure to a patient |
aMedication errors | aBeing with a patient during a clinical procedure |
Antithrombotic therapy given and recorded at the correct time | aConsulting with a doctor |
aReporting a patient’s condition to a senior nurse | aObserving the effects of medication on a patient |
Structure | |
Satisfaction questionnaire about work periodically administered to nurses | level of education and work experiences of nurse managers |
Total nursing care hours provided per patient day | Nursing continuing education |
Skill mix (mix of RNs, LPNS and unlicensed staff) | In-service education hours for nursing staff per year |
Number of nurses per patient | Educational materials for nurses in the hospital (library, internet, etc.) |
Working hours of nursing staff | Organisational goal setting |
Proportion of nurses working more than 3 years (nurses experience) | Nursing job description |
Nurse bed care ratio | Organisational budgeting for patient safety |
Voluntary nurse staff turnover rates | Patient waiting time for nursing care |
Patient to nurse ratio | Nursing care standards in hospitals |
Nurse vacancy rate | Safety environment for nurses in hospital |
Overtime | Practice environment scale-Nursing Work Index |
Understaffing as compared to the organisation’s plan | Noise |
On-call or per diem use | Emergency equipment/drugs available |
Sick time | Total volume of laundry per patient |
Agency staff use | Visitation policy |
Staffing level of education | Absenteeism |
Indicators relevant for LMICS
International patient safety goals domain | Indicator definition | Source of indicator | Measurement approach |
---|---|---|---|
Identify patients correctly | |||
Proportion of patients with name tags | Literature (IPSG) | Structure | |
Improve effective communication | |||
Proportion of patients who have a complete assessment (history, head to toe examination, vital signs, weight/height, plan of care) at admission | Literature | Process | |
Proportion of patients who have discharge instructions (follow-up care, education, return date) | Literature | Process | |
Proportion of patients with appropriate vital signs monitoring as per patient acuity documented | Literature | Process | |
Proportion of patients who received at least one session of counselling or communication in 24 hours | Literature | Process | |
Proportion of patients with assessment and planning of care done at least once in 24hours | Literature | Process | |
Proportion of patients with ward round recommendations documented in the cardex | Stakeholders | Process | |
Proportion of patients with surgeons’ instructions transferred to the cardex and with completely filled postoperative forms | Stakeholders | Process | |
Availability of basic nursing forms/charts | Stakeholders (HFA) | Structure | |
Adverse effects reporting system in place to reporting | Stakeholders (HFA) | Structure | |
Improve the safety of high-alert medications | |||
Record of daily stock monitoring/handover and safety of drugs classified under the Dangerous Drugs Act | Stakeholders | Structure | |
Proportion of blood transfusions monitored as per blood transfusion guidelines | Literature | Process | |
Proportion of documented blood transfusions reactions | Literature | Outcome | |
Proportion of patients on anti-coagulation therapy with dose, drug and food interactions, and appropriate nursing care documented | Literature (NPSG) | Process | |
Proportion of patients on drugs with a narrow therapeutic range that are flagged | Literature (NPSG) | Process | |
Ensure correct site, procedure, patient for surgery | |||
Proportion of patients scheduled for surgery with correctly and completely filled preoperative forms/checklist | Stakeholders | Process | |
Proportion of patients with the status of the patient, surgical procedure and surgical site, documented in the cardex | Literature (IPSG) | Process | |
Proportion of patients with filed consent form before surgery | Stakeholders | Process | |
Proportion of patient identifiers before surgery (name tags/other identifying measures) | Literature (IPSG) | Process | |
Proportion of patients with pre-marked sites for procedures that require marking of the incision or insertion site. | Literature (IPSG) | Process | |
Reduce risk of HCA infections | |||
Proportion of surgical patients with post-operative surgical wound infection | Literature | Outcome | |
Proportion of patients on intravenous fluids/treatment whose cannula site was checked and documented (state of cannula site- swollen, SSI, soiled) | Literature | Outcome | |
Proportion of patients on intravenous fluids/treatment whose cannula site was checked and documented vascular access infiltration | Literature | Outcome | |
Proportion of patients requiring wound cleaning with wound cleaned and wound dehiscence (wound characterization-burst wound, septic, granulating, necrotic), exudate and pain documented | Literature | Process | |
Proportion of newborns aged <5 days and born within the hospital who develop septic cords | Stakeholders | Outcome | |
Proportion of newborns on phototherapy with documentation of eyecare done, eyes checked for damages and eye pad changed once in 24 hours | Stakeholders | Process | |
Proportion of patients with UTI in non-genito urinary infection with documentation for input-output monitoring | Literature | Outcome | |
Proportion of patients who develop pressure ulcers while in the ward | Literature | Outcome | |
Proportion of patients with basic activities of daily living (ADL) done. | Literature | Process | |
Compliance with hand hygiene guidelines based on established goals | Literature | Process | |
Patient education on infection prevention practices | Stakeholders | Process | |
Availability of hand hygiene guidelines/training/reminders | Stakeholders (HFA) | Structure | |
Availability and easily accessible clean toilets | Stakeholders | Structure | |
Availability of Waste segregation (3 bins and sharp boxes) | Stakeholders (HFA) | Structure | |
Needle, sharp box more than 3/4 full, or any used needles/sharps outside the box | Stakeholders (HFA) | Structure | |
Bandages/infectious waste lying uncovered | Stakeholders (HFA) | Structure | |
Clean running water (piped, bucket with tap, or pour pitcher) | Stakeholders (HFA) | Structure | |
Functioning hand hygiene stations (that is, alcohol-based hand rub solution or soap and water with a basin/pan and clean single-use towels) | Stakeholders (HFA) | Structure | |
Storage space for sterile and high-level disinfected items (either a room with limited access or a cabinet that can be closed) | Stakeholders (HFA) | Structure | |
Reduce risk of patient harms resulting from falls | |||
Proportion of patients with risk of falling who have harm reduction measures | Literature | Process | |
Use of physical restraint | Literature | Process | |
Proportion of patient falls with injuries | Literature | Process | |
Additional indicators that don’t fall in the IPSG criteria | |||
Other safety related indicator | |||
Proportion of patients at risk of DVT (immobile, obese, on total nursing care etc) who are assessed for DVT at least once in 24 hours | Literature | Process | |
Proportion of diabetic and critically patients with blood sugar monitoring | Stakeholders | Process | |
Proportion of diabetic patients with the following documented: type of feed, medication, frequency, intervention, sugar levels, time of last feed to help interpret the result) | Stakeholders | Process | |
Structure indicators | |||
Patient to nurse ratio | Literature | Structure | |
Nurse skill mix (by education level) | Literature | Structure | |
Staff wearing name tags and on uniform | Stakeholders (HFA) | Structure | |
Outcome indicators | |||
Patient satisfaction with overall care | Literature | Outcome | |
Patient satisfaction with nursing care | Literature | Outcome | |
Proportion of patients who died | Literature | Outcome | |
Average length of stay (by illness acute vs chronic) | Literature | Outcome |
Discussion
Broad indicator definition | Indicators as defined in the literature |
---|---|
Failure to rescue | Failure to rescue |
Postoperative respiratory failure | |
Patient satisfaction | Patient complaints |
Patient satisfaction with educational information | |
Patient satisfaction with nursing care | |
Patient satisfaction with overall care | |
Patients’ confidence in knowledge and skills of the nurse | |
Patient’s sense of safety whilst under the care of the nurse | |
Patient involvement in decisions made about their nursing care | |
Respect from the nurse for patient’s preference and choice | |
Nurse’s support to patients to care for themselves, where appropriate | |
Nurse understanding of what is important to the patient | |
Patient satisfaction with nurse communication | |
Patients experience of care | |
Patient/family complaints satisfaction | |
Parent/family complaint rate | |
Patient judgement of hospital quality | |
Hospital-acquired infection | Central line catheter-associated bloodstream infection (CLABSI) |
Hospital-acquired pneumonia | |
Respiratory tract infection | |
Nosocomial infection | |
Ventilator-associated pneumonia (VAP) | |
Wounds dressed | |
Intravenous/vascular access infection | |
Thrombophlebitis | |
Vascular access infiltration | |
Vascular access thrombosis | |
Peripheral venous extravasation | |
Hospital-acquired urinary tract infection | |
Urinary catheter-associated UTI | |
Wound infection | |
Surgical wound infection | |
Sepsis | |
Intravascular infiltration due to IV therapy | |
Gastrointestinal infection rate | |
Wound care | |
Pressure ulcer | Pressure ulcer prevalence |
Skin integrity/pressure ulcer prevention | |
Decubitus prevention care | |
The risk factors for pressure sores have been documented | |
Pain management | Pain presence |
Patient satisfaction with pain management | |
Pain management/controlled | |
Pain assessment with scale and recorded | |
Job satisfaction and health worker well-being | Nurse staff satisfaction |
Physical well-being | |
Psychological wellbeing | |
Satisfaction questionnaire about work periodically administered to nurses | |
Staffing and skill mix | Total nursing care hours provided per patient day |
Skill mix (mix of RNs, LPNS and unlicensed staff) | |
Number of nurses per patient | |
Working hours of nursing staff | |
Proportion of nurses working more than 3 years (nurses experience) | |
Nurse bed care ratio | |
Voluntary nurse staff turnover rates | |
Patient to nurse ratio | |
Nurse vacancy rate | |
Overtime | |
Understaffing as compared to organisation’s plan | |
On-call or per diem use | |
Sick time | |
Agency staff use | |
Staffing level of education | |
Level of education and work experiences of nurse managers | |
Absenteeism | |
Nursing education | Nursing continuing education |
In-service education hours for nursing staff per year | |
Educational materials for nurses in the hospital (library, internet, etc.) | |
Respiratory support or failure | Iatrogenic lung collapse |
Atelectasis | |
Chest-abdomen drain changed as by the protocol | |
Chest-abdomen drain insertion area dressed as by guideline | |
Mechanical ventilation has been replaced according to protocols | |
Vital signs monitoring | Body temperature values have been updated in the last 24 h |
The pulse oximetry has been monitored and recorded | |
The ECG and vital signs have been recorded on admission | |
Measuring of patient observations (vital signs) | |
Fluid input output monitoring | Fluid overload |
Fluid intake and output have recorded | |
Activities of daily living | Patient washing once a day and recorded |
Patient mouth washing as by ward procedure and recorded | |
Assisting a patient with activities of daily living | |
Self-care | |
Nursing support and communication to patients | Being honest with a patient |
Keeping relatives informed about a patient | |
Providing privacy for a patient | |
Getting to know the patient as a person | |
Giving reassurances about a clinical procedure | |
Information and involvement of family into the end of life care by nurses | |
Falls | Falls |
Injuries to patient | |
Patient’s falls with injuries in the hospital | |
Staff injuries on the job | |
Physical and chemical restraint | |
Medical/nursing errors | Adverse drug reaction rate |
Total of prescription mistakes | |
Total of transfusion reaction | |
Medication errors | |
Counselling | Smoking cessation counselling |
Smoking cessation counselling for heart failure | |
Smoking cessation counselling for pneumonia | |
Smoking cessation counselling for acute myocardial infarction (AMI) |