Essentials of Nursing Leadership and Management, 5th Edition

chapter 10 | Quality and Safety 139

surprises that may delay patient discharge and can
predict lengths of stay more effectively.

Aspects of Health Care to Evaluate

A CQI program can evaluate three aspects of
health care: the structure within which the care is
given, the process of giving care, and the outcome
of that care. A comprehensive evaluation should
include all three aspects (Brook, Davis, &
Kamberg, 1980; Donabedian, 1969, 1977, 1987).
When evaluation focuses on nursing care, the inde-
pendent, dependent, and interdependent functions
of nurses may be added to the model (Irvine, 1998).
Each of these dimensions is described here, and
their interrelationship is illustrated in Table 10-3.

Structure

Structurerefers to the setting in which the care is
given and to the resources (human, financial,
and material) that are available. The following
structural aspects of a health-care organization can
be evaluated:

■Facilities. Comfort, convenience of layout, acces-
sibility of support services, and safety
■Equipment. Adequate supplies, state-of-the-art
equipment, and staff ability to use equipment
■Staff. Credentials, experience, absenteeism,
turnover rate, staff-patient ratios
■Finances. Salaries, adequacy, sources

Although none of these structural factors alone
can guarantee quality care, they make good care
more likely. A higher level of nurses each shift and
a higher proportion of RNs are associated with
shorter lengths of stay; higher proportions of RNs
are also related to fewer adverse patient outcomes
(Lichtig, Knauf, & Milholland, 1999; Rogers
et al., 2004).

Process

Processrefers to the activities carried out by the
health-care providers and all the decisions made
while a patient is interacting with the organization
(Irvine, 1998). Examples include:

■Setting an appointment
■Conducting a physical assessment
■Ordering a radiograph and magnetic resonance
imaging scan
■Administering a blood transfusion
■Completing a home environment assessment

■Preparing the patient for discharge

■Telephoning the patient post discharge

Each of these processes can be evaluated in terms

of timeliness, appropriateness, accuracy, and com-

pleteness (Irvine, 1998). Process variables include

psychosocial interventions, such as teaching and

counseling, and physical care measures. Process also

includes leadership activities, such as interdiscipli-

nary team conferences. When process data are col-

lected, a set of objectives, procedures, or guidelines

is needed to serve as a standard or gauge against

which to compare the activities. This set can be

highly specific, such as listing all the steps in a

catheterization procedure, or it can be a list of

objectives, such as offering information on breast-

feeding to all expectant parents or conducting

weekly staff meetings.

The American Nurses Association (ANA)

Standards of Care are process standards that

answer the question: What should the nurse be

doing, and what process should the nurse follow to

ensure quality care?

Outcome

An outcome is the result of all the health-care

providers’ activities. Outcome measures evaluate

the effectiveness of nursing activities by answering

such questions as: Did the patient recover? Is the

family more independent now? Has team function-

ing improved? Outcome standards address indica-

tors such as physical and mental health; social and

physical function; health attitudes, knowledge,

and behavior; utilization of services; and customer

satisfaction (Huber, 2000).

The outcome questions asked during an evalua-

tion should measure observable behavior, such as

the following:

■Patient: Wound healed; blood pressure within

normal limits; infection absent

■Family: Increased time between visits to the

emergency department; applied for food stamps

■Team: Decisions reached by consensus; atten-

dance at meetings by all team members

Some of these outcomes, such as blood pressure or

time between emergency department visits, are eas-

ier to measure than other, equally important out-

comes, such as increased satisfaction or changes in

attitude. Although the latter cannot be measured as

precisely, it is important to include the full spectrum