Quality Improvement (QI) Proposal: Hiring an Additional Admissions Nurse

Answer

Quality Improvement (QI) Proposal: Hiring an Additional Admissions Nurse

Overview

The healthcare sector at large faces a wide range of ongoing challenges related to or revolving around workforce shortages, cost containment, and an ever-growing burden of chronic illnesses. Driving and compounding these challenges are other factors such as reimbursement constraints, unfunded care regimes, increased service consumption, longer life expectancy, an unfunded (or underfunded) care regime, and a shortage of crucial healthcare providers (like nurses) just to mention but a few. For healthcare organizations to achieve their objectives while maintaining economic viability, it is imperative that they serve as many clients as possible as that also helps in leveraging overhead, meeting state/federal mandates for service provision, and maximizing revenue. A key strategy employed by many healthcare organizations is ensuring optimal nurse staffing levels (hence appropriate nurse-to-patient ratios), either through contracted labor or voluntary and mandatory overtime among other approaches. On overtime, concerns have been raised regarding its negative effects on nurses as well as patients. From fatigue to clinical errors, lack of enough sleep, high turnover rates, and patient dissatisfaction, many factors motivate the reduction of overtime (Bae, 2012). As a quality improvement initiative, hiring an additional admissions nurse will not only help reduce overtime, but will also increase nurse (job) and patient satisfaction. There is no doubt that overall, it will lead to improved patient outcomes.

Indeed, the need for optimal staffing is not limited to the admissions context. Rather, overall nurse-to-patient ratios in all aspects determine economic and clinical outcomes for the organization. In consideration of the negative impacts of overtime and poor nurse-to-patient ratios, a good strategy for addressing this is to hire an additional admissions nurse.

QI Rationale/Purpose

This quality improvement initiative seeks to reduce overtime, minimize clinical errors, improve patient outcomes, and increase patient satisfaction. It will also increase job satisfaction (for nurses), increase retention, and reduce turnover rates. Negative nurse and patient outcomes related to overtime are well-documented in literature. For instance, Bae and Fabry (2014) reviewed several studies that linked overtime to nurse outcomes such as illness, fatigue, turnover intent, job dissatisfaction, absenteeism, and needlestick as well as musculoskeletal injuries. These findings are congruent with what was reported by Stimpfel et al. (2015). Reed (2013) drew attention to the effect of fatigue on nurses, such as the negative impact on morale and an associated turnover intent, which ultimately increases costs to the organization as would result from voluntary turnover and resulting vacancies. Other researchers have investigated the effect of overtime and found a significant association with practice/clinical errors and related unpropitious patient outcomes (Lobo et al., 2015; Olds & Clarke, 2010). In this context, medication errors resulting from fatigue have emerged as the most cited in literature (Bae & Fabry, 2014; Lobo et al., 2015). Low job satisfaction is also mentioned in the same vein (Beckers et al., 2008). Considering these negative effects of overtime, this QI initiative seeks to reduce overtime, thereby addressing related issues. More specifically, it will help increase nurse/job satisfaction and patient satisfaction, reduce fatigue, minimize workplace injuries, minimize clinical errors, increase nurse retention and improve overall patient and nurse outcomes.

Examining the role of the admission stage in clinical settings elevates the need for the proposed quality improvement initiative. Indeed, it is in this stage that initial interaction (between healthcare giver and patient) takes place, so it is imperative that patient experience at this stage is optimized as much as possible. An optimal nurse-patient ratio is one way of improving this experience. At this stage, patient assessment as well as the gathering of data takes place; data that is so crucial in informing and driving collaborative medical/nursing efforts, hence ultimately the quality of care because decisions made by healthcare givers rely on this data (Hayes et al., 2010). Given the nature of their work, admissions nurses must make complex decisions are often faced with dilemmas, aspects that also necessitate optimal staffing at this point. Therefore, the importance of the proposed quality improvement initiative cannot be overemphasized. 

Implementation

Implementation of the proposed quality improvement initiative will begin with planning and budgeting, whereby costs related to advertisement, interview, pre-employment assessment, and orientation will have to be factored in.  Therefore, adequate resources will have to be mobilized and availed for the initiative. After placing an advertisement in the mainstream media, applicants will be invited for interviews which, according to Huffcutt (2011), help in the assessment of various predictor constructs including personality, personal preferences and interests, interpersonal relations, and mental capability among others. Interviewing will also include three types of assessments that are considered necessary and relevant to the proposed quality improvement initiative: situational, behavioral, and clinical assessment(s).  The clinical assessment will be a job knowledge written test that will aim to measure the applicants’ knowledge and competence in clinical informatics and nursing in general. The content of this test will follow relevant professional standards as spelt out by professional nursing certification bodies.  As for situational assessment, it will entail a test meant to measure applicants’ competence in the context of hospital-related situations. Examples of such situations that will have to be captured in the situational assessment include interaction with patients, physicians and fellow nurses in the admissions setting and elsewhere. Last yet important will be the behavioral assessment which will be behavior/personality-based, measuring constructs such as teamwork, stability, extroversion, tough-mindedness, and conscientiousness just to mention but a few. The prospective candidate for the job will be selected based on the highest of these scores vis-à-vis other aspects of the oral interview.

Upon selection, the candidate will be taken through orientation to familiarize him or her with the work setting. Other members of staff will also be introduced and requested to offer their maximum cooperation to the new member.

Evaluation

Evaluation of the proposed quality improvement initiative will be pegged upon what its objective will be. Patient and nurse outcomes will form a good basis for evaluating the initiative. For instance, since one of the objectives will be to reduce overtime, it will be imperative to take note of the frequency and duration of overtime for the admissions nursing staff. Other variables that will also gain relevance in the same respect include turnover rates, absenteeism, nurse complaints (related to dissatisfaction), frequency of medical errors, and patient satisfaction. Periodically analyzing organizational data (from time to time) will a good way of carrying out evaluation, hence the ability to determine if hiring an additional admissions nurse will have had any impact. Measuring job satisfaction using a psychometrically appropriate instrument such as a questionnaire will also be crucial in giving insight into the extent to which the initiative will have worked in as far as contextual quality improvement will be concerned. As to patient satisfaction, surveys will be needed for evaluation, some of which will require the participation and input of family members, friends, or guardians who will have probably accompanied the patients in the course of their treatment and interaction with the healthcare fraternity.

Considering the above points and variables for evaluation, possible hypotheses that will be appropriate include:

Null hypothesis 1: There has been no significant or appreciable increase in patient satisfaction since an additional admissions nurse was hired.

Alternative hypothesis 1: There has been an increase in patient satisfaction since the hiring of an additional admissions nurse.

Null hypothesis 2: Nurse/job satisfaction has not increased since an additional admissions nurse was hired.

Alternative hypothesis 2: Nurse/job satisfaction has increased since an additional admissions nurse was hired.

Null hypothesis 3: There has been no significant reduction in absenteeism since an additional admissions nurse was hired.

Alternative hypothesis 3: Absenteeism has significantly reduced since an additional admissions nurse was hired.

Null hypothesis 4: Turnover rates have not gone down (there has been turnover) since an additional admissions nurse was hired.

Alternative hypothesis 4: Turnover rates have gone down (there has been no turnover) since an additional admissions nurse was hired.

Null hypothesis 5: Hiring an additional admissions nurse has not led to any significant decrease in the number of clinical errors (such as those related to data entry).

Alternative hypothesis 5: Hiring an additional admissions nurse has led to a significant decrease in the number of clinical errors (such as those related to data entry).