In the United States, as early as 1917, the America College of Surgeons developed the first health care indicators. These indicators were the minimum standards that hospitals were expected to meet. Surgeons were the primary inspectors, and during the first surveys only 89 of 652 hospitals met the minimum requirements in the United States . ( www.jc.org )

In 1946, The Centers for Disease Control (CDC) was started. The (CDC) started with population surveys collecting data on malaria. The CDC was the first national organization to develop a plan for prevention of disease. By 1951, multiple health care organizations began collaborating and the Joint Commission was developed ( www.jc.org ). By 1953, the first standards for hospital care were published by the Joint Commission. In 1988, the first measurement systems, or indicators, were implemented into the Joint Commission.

Clinical indicators were designed to assess particular health structure, process and outcomes. The indicators and their classifications are from the Agency for Healthcare Research and Quality, they can be assessed at www.qualityindicators.ahrq.gov Several common Indicator Structures are:

• Rate based - such as a mortality rate
• Mean (average) based - such as the mean rate of vaccinations.
• Generic – Such as vaccinations in general (Example - How many adults are receiving pneumococcal vaccines)
• Specific – Population Specific. (Example – Within the population of patients who had catheters inserted, how many acquired an infection?)

These measurable indicators assist organizations in developing action plans to either prevent deaths, reduce unwarranted events, or prevent other incidents in order to improve the level of patient care. While tracking and measuring indicators, nurses will find that multiple indicators can and will apply to an individual patient.

Inpatient Indicators:
The inpatient quality indicators (IQI) deal with:

• Inpatient mortality for specific procedures and medical conditions. Examples include:
  • Mortality rates for patients with hospital acquired pneumonia.
  • Mortality rates for patients following specific surgical procedures.

The inpatient quality indicators serve as the minimum indicators that facilities can use to benchmark their performance. These types of indicators are publicly reported allowing consumers as well as employees to benchmark themselves and their providers against other organizations.

• Utilization of procedures involve the tracking of procedures specifically where there are questions of overuse, underuse or misuse. Examples include:
  • Examining cesarean delivery rates in organizations
  • Examining the mortality rates for specific procedures, for example: Laparoscopic Cholecystectomy

Utilization indicators are information data point indicators that allow an organization and its providers a method in which to compare their procedure rates against other organizations. This type of information is valuable in comparing provider driven results: for example an Obstetrical provider may have an abnormally high rate of Cesarian Surgical deliveries as compared to other members in his peer group. This type of information can then be used to examine a provider practice, surgical skill. If utilization of one provider is extremely different the organization can determine how it will proceed.

The second type of utilization indicator examines volume of procedures. This indicator examines facilities or providers where higher volumes of specific patient interventions result in lower mortality rates. Examples of this indicator include:

• The mortality rates for Coronary Bypass Surgery
• The mortality rates for Transcatheter Aortic Valve replacement

These indicators may improve facility quality by identifying problem areas that need further investigation and action. For example, an organization that does 50 coronary bypass surgeries a week and has a low mortality rate may be a better place to have a specific surgical procedure, than an organization that does 5 cases of coronary bypass surgery a week and has a higher mortality rate. The sheer volume of cases, experienced personnel may be directly related to the low mortality. By understanding and measuring these indicators health care organizations can continue to improve the quality of patient care. For example: with new transcatheter aortic valve replacements, it has been demonstrated that the higher volume that is preformed the better the outcomes on patients (Thomas, 2010). The old adage holds true here “practice makes perfect”.

Prevention (Preventative) Indicators:

Another group of indicators are known as the prevention indicators. These indicators are measures of avoidable conditions in the health care setting. This indicator structure is commonly rate based. There are over 15 categories of prevention indicators derived from the AHRQ. Examples include:

• Diabetes Short-Term Complications Admission Rates (Hyper glycemia)
• Hypertension Admission Rates
• Congestive Heart Failure Admission Rate

The goal for preventative indicators is to ensure that ambulatory care providers are maintaining patient conditions in order to prevent re-hospitalization. One example may include tracking the number of hyperglycemic patients seeking care through the emergency room. If there were to be a large number of hyperglycemic patient's from one particular provider or ambulatory care center, the question would have to be asked if the provider or center was appropriately treating the Diabetic patient. Appropriate performance improvement could be initiated to investigate if the provider and his staff are teaching patients about adherence to medications, or if patients glucose is not being maintained and managed or if there are other issues the center is not addressing to maintain the Diabetic patient. The preventive indicators are directly related to the Physician Quality Reporting System. This system is from the Centers for Medicare incentive payment program to promote providers to report quality in their respective practices. ( www.cms.gov )

Patient Safety:
The patient safety indicators were developed to assist hospitals in examining potential adverse events and to provide information on patient safety. The indicator structure for Patient Safety Quality Indicators is generally rate based. Examples of patient safety indicators include:

• The rates of Foreign Bodies or materials left during Surgery
• The rates of Iatrogenic Pneumothorax (Iatrogenic meaning hospital acquired)
• The rates of Complications of Anesthesia

Facilities can use this group of indicators to determine safety with high risk procedures. If a facility or surgical team rarely has a surgical object unaccounted for, the facility can be assured its surgical teams are attentive at the time of surgical closing.

Pediatric Indicators:
The pediatric indicators are indicators that can provide information on the quality of care within the pediatric setting. The pediatric indicators are grouped into inpatient quality indicators, preventative quality indicators, and patient safety quality indicators. Simply using adult indicators in the pediatric setting is insufficient. Pediatric indicators require validation through evidence based research for the Pediatric population. The Pediatric inpatient Quality Indicator category consists of:

Indicators regarding the Pediatric Inpatient mortality rate for specific procedures and medical conditions. Examples include:

• Mortality rates for pediatric patients with hospital acquired pneumonia
• Mortality rates for pediatric patients following specific surgical procedures.

The pediatric indicators also include indicators regarding the utilization of procedures where there are questions of overuse, under use or misuse. One example may include: Examining the mortality rates for Pediatric Heart Surgery: again the higher the volume, the less the mortality rate, and the less the complication rate.

Indicators regarding the volume of procedures for which there are cases where higher volumes result in lower mortality rates. An example may include examining the volume of Pediatric Heart Surgery cases.

The Pediatric Preventative Quality Indicators are measures of avoidable conditions in the Pediatric health care setting. The indicator structure is commonly rate based. Examples include, but are not limited to:

• Pediatric Diabetes Short-Term Complications Admission Rates
• Pediatric Asthma Admission Rates
• Gastroenteritis Admission Rates

These indicators were developed to assist hospitals in examining potential adverse events and to provide information on Pediatric patient safety. The indicator structure for Pediatric Patient Safety Quality Indicators is generally rate based. Examples include:

• Accidental puncture or laceration rates
• Postoperative Sepsis rates
• Iatrogenic pneumothorax in neonates

Specific populations and practices have Quality indicator sets that differ slightly from the aforementioned categories. Examples of additional specific populations and practices include:

• Nursing homes
• Federally funded programs for HIV
• Home Health Care

Regardless of the setting, Nursing Quality Indicators are to be used to assist facilities in consistently measuring and improving care. For nurses at all levels, an understanding of the value of specific indicators is important in that they may provide the nurse with basic “rulers” to assist in measuring quality for a specific location or population. Nursing units or departments can develop and implement “Quality Dashboards” displaying particular outcomes for specific patients. For example, if one medical unit has noticed that ypertensive patients are being readmitted, the unit could begin measuring the rate of readmission. Once the readmission rate is measured, an action plan can be developed in order to reduce the readmission rate. An action plan in this example could include (but is not limited to)

• Assign a case manager/Social worker to assess financial need or issues in the population.
• The nursing unit can begin to trend for patterns in provider behavior. For example, one particular provider may have an unusual rate for readmission.

These metrics can be reviewed regularly and can be posted publicly in order for the staff and patient's to view the progress towards specific goals. When used consistently, Nursing Quality Indicators can improve the overall level of patient care within the organization.

Agency for Healthcare Research Quality (2013). http://www.ahrq.gov/research/findings/factsheets/quality/qifactsheet/index.html

Chan, K., Weiner, J. (2006). Electronic Health Record-based Quality Indicators for Ambulatory Care: Findings from a Review of the Literature. http://www.himss.org/files/HIMSSorg/content/files/Code%20161%2

Physician Quality Reporting (2013). http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/index.html?redirect=/PQRI

The Joint Commission (2013). The Joint Commisssion Hisory. http://www.jointcommission.org/about_us/about_the_joint_commission_main.aspx