In a couple past columns we briefly mentioned a study by McHugh and Stimpfel (McHugh 2012) which showed nurses’ ratings of hospital quality and safety correlate well with more formal measures. Now a new study done in Swedish hospitals extends upon that work (Smeds-Alenius 2016). The study used a survey of nurses in 67 Swedish hospitals and covered over 200,000 general, vascular, and orthopedic surgical procedures. The researchers found that hospitals in the highest tertile of nurses reporting excellent quality of care had a 23% lower odds of 30-day inpatient mortality. Similarly, hospitals in the highest tertile of nurses reporting excellent patient safety had a 26% lower odds of 30-day inpatient mortality. The study validates the previous work of McHugh and Stimpfel and suggests that nurses’ assessments could be used as legitimate measures of quality and patient safety. The authors do recognize that inpatient mortality is a crude measure of both safety and quality (Lilford 2010, Girling 2012). Mortality rates may be appropriate indicators for some conditions but not others. Moreover, patient-related factors and patient socioeconomic factors, advance directive issues, plus other factors impact inpatient mortality rates. Even after risk adjustment for patient-related variables, mortality rates may be less than ideal measures of quality or patient safety. The current study was done in Sweden supposedly to minimize some of the confounding factors seen in the US such as variation in insurance status and correlated health status.
So could nurse assessment be used as a formal measure of quality and patient safety? We would have no qualms about using nurse assessments as an informal measure and we do often ask nurses their opinion on quality and patient safety in their hospitals. It might help inform us in our decisions about whether to have a procedure at their hospital. However, what is unknown is what would happen to the observed correlation between nurse assessment and mortality rates if this were to become a formal measure of quality and patient safety. Would nurses continue to provide honest assessments if they knew that the very viability of their hospital might be jeopardized by public disclosure of such assessments? We may never know the answer to that question.
But when we are asked by someone what is the best way to tell whether a hospital has good quality and safety we have no problem telling them “ask a nurse”!
McHugh MD, Stimpfel AW. Nurse reported quality of care: A measure of hospital quality. Research in Nursing & Health 2012; Article first published online: 21 AUG 2012
Smeds-Alenius L, Tishelman C, Lindqvist R, Runesdotter S, McHugh MD. RN assessments of excellent quality of care and patient safety are associated with significantly lower odds of 30-day inpatient mortality: A national cross-sectional study of acute-care hospitals. International Journal of Nursing Studies 2016; 61: 117–124
Lilford R, Pronovost P. Using hospital mortality rates to judge hospital performance: a bad idea that just won't go away. BMJ 2010; 340: c2016
Girling AJ, Hofer TP, Wu J, et al. Case-mix adjusted hospital mortality is a poor proxy for preventable mortality: a modelling study. BMJ Qual Saf 2012; 21(12): 1052-1056 Published Online First: 15 October 2012
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