Trustees often are asked about their hospital's nursing quality. "Our care is outstanding" tends to be the immediate response. But how can board members be certain?

The primary reason that patients are hospitalized is their need for round-the-clock nursing care. Board members know this. But what most board members don't know, and what is crucial to their fiduciary and quality oversight role, is how to evaluate nursing care quality.

While this sounds daunting, the reality is that there are 10 key nursing department indicators that board members can easily grasp and that will enable them to more confidently and accurately answer that important question. These indicators, derived from hospital management practice, current research and key elements that comprise a nursing department, are listed below, from fundamental to complex.

1. Patient safety. A safe environment is the most crucial element of a patient's stay, and nurses play a vital role. According to the Institute of Medicine, this is "the prevention of harm to patients," which the Agency for Healthcare Research and Quality's Patient Safety Network website further defines as "freedom from accidental or preventable injuries produced by medical care."

To assess the level of patient safety, board members need to ask hospital executives the following questions: How do we ensure a safe environment? Does our culture support patient safety? How is this demonstrated?

To create a culture of safety, the organization must build a care delivery system that prevents errors, learns from the errors that do occur, and recognizes that safety is a partnership among nursing and staff, physicians, patients and family members. Patient Safety Indicators, a free tool from AHRQ, can provide an overview on patient safety events using hospital administrative data. Its 27 measures include decubitus (pressure) ulcer and "failure to rescue."

2. Productivity. Nursing costs can make up 50 percent or more of a hospital's labor budget, so it is critical that those resources are used economically. But how can trustees know when a nursing department is running efficiently?

The main productivity measure for inpatient nursing is the hours per patient day (HPPD), meaning the number of nursing hours provided to each patient per patient day on a specific nursing unit. For example, the medical-surgical HPPD in a 200-bed hospital will average 9.0 hours per patient day. But it is important for board members to understand that those 9.0 hours of care usually encompass all the direct caregivers' hours, including those of the nurse manager, and any hours used for overtime, staff education and meetings.

Benchmarking nursing departments to similar hospitals' nursing departments and using external comparison tools or ratios of nurses to patients is critical when setting productivity targets. Without accurate benchmarks, the productivity target may be inappropriate for the unit and subsequently unachievable. It is the board's responsibility to ensure that the chief nursing officer, and not only the chief financial officer, is involved in setting the target.

Overtime is a cause of increasing HPPD, and high overtime should alert board members that a problem exists. Board members are often told that overtime is just a question of a manager needing to more closely control it, but the issue is more complicated.

A primary reason for overtime is inappropriate HPPD. The targets may be too low, causing nurses to stay longer to finish their work. Patient flow problems can also lead to overtime, such as when patients are admitted toward the end of a shift, which means the nurse must stay later. Finally, staff vacancies cause on-the-job nurses to cover for the absent employees with overtime hours.

Productivity does not guarantee quality patient care; it only indicates that the appropriate number of staff is available to provide patient care.

3. Staffing effectiveness. The Joint Commission evaluates staffing effectiveness in its hospital reviews, taking into account the number, competency and skill mix of nurses as related to the provision of needed services. Three primary components contribute to effective staffing:

  • Staffing mix: Nursing staff is composed mainly of registered nurses, licensed vocational/practical nurses and nursing aides. Board members should note that, according to a 2004 AHRQ report, hospitalized patients receive better care when registered nurses (as opposed to LPNs or NAs) make up the majority of the nursing staff and provide the majority of patient care. The CNO should establish an overall registered nurse percentage target within the hospital to ensure optimal care and develop strategies to recruit additional nurses if the target is not met. Board members should be kept informed of these actions.
  • Scheduling: Two components make up the nursing schedule: core staffing needs and staff scheduling. Core staffing is calculated by the average number of patients by unit and the number of nurses needed to care for those patients by day of the week. Then, a schedule is created that assigns each staff member a work schedule.
  • Turnover and vacancy rates: Vacancies cause employees to work overtime or extra shifts. Overworked staff may then lead to more turnover, creating dissatisfaction among the remaining employees. If schedule gaps cannot be filled, hospitals may be forced to close beds for admissions or cancel elective surgeries. A 2007 meta-analysis released by AHRQ demonstrated that the shortage of registered nurses, in combination with an increased workload, poses a potential threat to the quality of care. The evidence also suggests that increased patient mortality may be the result of high turnover. The monthly turnover rate should be part of the board's dashboard.

4. Regulatory requirements. It is critical that a hospital meet all basic regulatory requirements, including Centers for Medicare & Medicaid Services Conditions of Participation, Joint Commission standards and state licensing regulations. An out-of-compliance hospital can jeopardize patients and staff. For example, it is mandated that the care must be under the direction of a licensed RN, the license is valid and medications are administered under the guidance of nursing. In addition, as this information becomes public, a hospital can become the target of external criticism and scrutiny. These regulations are basic and the hospital should constantly monitor nursing behavior to ensure uninterrupted compliance.

Board members should note that CMS' recent changes to the inpatient prospective payment system mean hospitals won't be reimbursed for patients who develop certain types of nursing-sensitive, health care-associated conditions such as pressure ulcers, falls with injuries or nosocomial infections. Nursing executives have already been monitoring these indicators and, eventually, could help prevent their hospitals from losing revenue.

5. Leadership. In defining its new model for Magnet certification, the American Nurses Credentialing Center noted that today's nurse executive should be a transformational leader who "must lead people to where they need to be in order to meet the demands of the future. This requires vision, influence, clinical knowledge, and a strong expertise relating to professional nursing practice."

Board members should find that the hospital's CNO is an equal and active member of the executive team. He or she should be a credible spokesperson for nursing and patient care.

Additionally, the hospital should provide ways for the nurse managers, who may be promoted to those positions without necessary training, to obtain the requisite executive skills and receive mentoring according to the organization's culture and goals.

6. Education. Education is the key to maintaining a well-functioning nursing staff. There are three facets: nurses' educational preparation level; continuing education and clinical levels of advancement; and new employee orientation.

The first concern is the nurses' basic educational preparation. Registered nurses are not required to earn a baccalaureate degree; however, as health care grows more complex, studies show that a better educated nurse contributes to better patient outcomes. Some hospitals already recognize nurses who have obtained their bachelor's degrees by paying higher salaries and assigning higher job classifications.

Second, as nurses become better educated, many hospitals are establishing clinical "ladders" or levels of advancement that can move the nurse to a higher job classification (for example, from a clinical nurse II to clinical nurse III), bringing additional responsibilities and expectations.

Finally, orientation is critical for introducing newly hired nurses to the unit's policies, procedures and culture. In fact, it can significantly reduce attrition. Board members should ask whether staff members are actively engaged as orientation preceptors and whether they are recognized and compensated for this additional responsibility.

7. Performance improvement. Performance improvement is geared toward advancing practice and sustaining change. There are many business process improvement methodologies for analyzing problems that use data, statistical methods and defined strategies to delineate the problem. It's crucial that the problem is clearly defined and analyzed and that sustainable solutions are created and implemented while measuring the results. Using a uniform methodology for resolving problems ensures that issues are tackled in a consistent manner. Board members should be aware if the hospital uses a specific problem-solving methodology, and they should be provided with monthly status reports on issues currently being addressed.

8. Shared governance. Shared governance means that nurses have control over their practice and influence over decisions that affect it. Nurses gain great satisfaction by being actively involved in decisions concerning the care and management in their unit. Most shared governance models include nurses in decisions regarding education, quality and unit-based activities. Nurse leaders must be open to this practice because their role significantly changes when decision-making is transferred from managers to the nurses. Additionally, the board members' support of management in implementing shared governance is crucial to its success.

9. Patient outcomes. Our understanding of quality has evolved. Nursing units no longer use identical evaluation standards; rather, individual units assess their own patient outcomes. As a result, a culture of investigation and continuous evaluation of care has evolved too. Nurses are engaging in research at the patient's bedside by inquiring about the care and the patient's response to it. They are using evidence-based research to direct the care that is provided. And they are analyzing the care to learn from it, revise it and improve outcomes. Board members should be kept current on these changes through the nursing quality reports.

10. Magnet readiness. The ANCC Magnet Recognition Program recognizes hospitals that provide excellent nursing care, which elevates the nursing profession's reputation and standards. In seeking Magnet status, administrators have involved their nurses in nursing decisions, from staffing to improving patient outcomes. If a nurse executive decides to seek Magnet recognition, it usually indicates that the department is already on a path to excellence. Board members should recognize and support this effort. Most often, board approval is required to apply for Magnet.

Answering the Question

Board members can learn to assess their nursing department by familiarizing themselves with these 10 key elements and by knowing whether they are present and regularly evaluated in their hospital. To achieve this, all new board members should receive a nursing orientation from the chief nursing officer, and the entire board should be presented with ongoing monthly nursing updates.

Ideally, board members can then say with certainty, "Our hospital's nursing department is top-notch. Our nurses are capable and well-trained. They provide excellent patient care, which they continuously evaluate, and they strive to meet the standards of the country's top hospitals."

Ellen Waxenberg Zoschak, M.P.H., M.S., R.N., NEA-BC (, is founder and CEO of The Chabot Group, Oakland, Calif.