Hospital patients' and nurses' perceptions of quality.

Abstract

Hospital quality assurance programs have been provider-oriented, focusing on structure and process elements of care rather than outcomes specific to patient needs and values. This study tested the relationship between quality and value, proposed in Larrabee's model of quality, by developing prediction indices for patient and nurse quality and value. The sample consisted of 199 adult patients. Patient quality was measured by a 100 mm visual analog scale (VAS) (PQUALG) and a modified version of an existing instrument (PQUALT). Patient value was measured as patient goal achievement (PGOAL), the average of three VAS scores for patient defined goals of hospitalization. Nurse quality (NQUAL) was measured as percent agreement between process standards selected for each patient and nursing care documented. Nurse value (NGOAL) was measured as nurse goal achievement, the percent agreement between outcome standards selected for each patient and outcomes documented. Seven patient demographic, seven financial, six illness, and six hospital variables were also measured. PQUALG, PQUALT, PGOAL, and NGOAL were positively skewed and dichotomized for multiple logistic regression analysis. Patient quality was correlated with PGOAL and NGOAL. PQUALG was correlated with PQUALT. NQUAL was not correlated with PQUALG, PQUALT, PGOAL, or NGOAL. PQUALG predictors were pain severity on exit interview (PAINNOW), clinic referral, unit, PGOAL, and being a Medicare recipient. PQUALT predictors were PAINNOW, PGOAL, clinic referral, unit, and worry score on admission. PGOAL predictors included PAINNOW, working part time, being a Blue Cross recipient, being white, being female, and combined household income. NQUAL predictors were being widowed and being a recipient of Medicaid. NGOAL predictors were PAINNOW, being married, and severity of illness score. The results support the relationship between quality and value postulated by Larrabee's model of quality, identify pain management as an important aspect of care for nursing quality improvement programs, and demonstrate that patients and nurses evaluate different dimensions of nursing care. Future research based on Larrabee's model of quality should verify the accuracy of estimates of the odds ratios for predictors of value and quality and should test the relationships among quality and value and the remaining model concepts, beneficence, prudence, and justice.