Magazine article American Nurse Today

Using Data in Nursing Practice: Data and Care Quality Go Hand in Hand

Magazine article American Nurse Today

Using Data in Nursing Practice: Data and Care Quality Go Hand in Hand

Article excerpt

NURSES, as the largest group of healthcare professionals, are key to quality and safety and to ensuring the best patient outcomes. To make informed practice decisions, nurses need access to aggregate data about their patients and the impact of their care, and they need to know how to interpret that data.

This article explores the role data plays in quality and safety and the synergistic relationship between data and nursing practice.

What's the connection between data and quality and safety?

In 2002, the Institute of Medicine held the Health Professions Education Summit to discuss potential reforms, with the goal of improving quality and patient safety. The summit, which included participants from throughout the healthcare disciplines, defined and developed core competencies in patient-centered care, interdisciplinary teams, evidence-based practice, quality improvement, and informatics that should be included in all health profession education.

Nursing led the charge in this effort with the development of the Quality and Safety Education for Nurses (QSEN) Institute, which has defined the essential knowledge, skills, and attitudes that ensure all new RNs and advanced practice RNs (APRNs) are prepared to participate in healthcare teams to improve quality and patient safety. QSEN has developed core competencies that reflect the outcomes of the 2002 summit:

* patient-centered care

* teamwork and collaboration

* evidence-based practice

* quality improvement

* safety

* informatics.

Both the summit and the QSEN included informatics as a competency needed to ensure quality and safety.

Informatics

The informatics competency helps nurses use information and technology to communicate, manage knowledge, mitigate error, and support decision-making at the point of care. Because of the rapid changes in healthcare information and technology, nursing students must know why information and technology skills are essential for safe patient care, understand how to apply information and technology tools, and appreciate the need for lifelong learning on these topics. (See Informatics requirements.)

How do we leverage the electronic health record?

The Health Information Technology for Economic and Clinical Health (HITECH) Act promotes the adoption and meaningful use of health information technology. (See What is meaningful use?)

The goal of HITECH and the original meaningful use legislation is to share electronic health record (EHR) data with patients and engage them in their care. Many hospitals and health systems with mature EHRs have portals for patients to access and record their own health data. Sharing this data, within the parameters of the Health Insurance Portability and Accountability Act, supports the meaningful use of EHRs. Nurses can help encourage public adoption of EHRs by supporting the meaningful use of electronically generated health data.

How do nursing practice and data inform each other?

Nurses, who do most of the EHR documentation (including plans of care, physiological parameters, assessments, interventions, and progress evaluations) in hospitals, are critical to care integration and patient safety. Whether entered into flow sheets or as "smart phrases" or narratives, all data are important to the healthcare team's understanding of the individual patient. Because nurses regularly review individual patient data, they're the essential communicators to providers about any overt or subtle changes in a patient's condition.

EHRs also help nurses understand how to care for populations of patients. To do that, information about individual patients must be extracted and compiled into flow sheet rows. Vital signs and other physiologic measurements lend themselves nicely to flow sheet input. However, the context of the individual patient's story--the narrative that explains why he or she sought health care and what may have led to the problem--doesn't fit neatly into a flow sheet and fragments the story. …

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