RUNNING HEAD: QUALITY IMPROVEMENT PROJECT

Quality Improvement Project: Patient Ratios and Safety

Priscilla Ambang
Bon Secours College of Nursing
Barbara Fitzgerald, RN, MSN
Nursing 3207: Quality and Safety in Nursing Practice II
April 30th, 2017
Honor Code: “I Pledge”
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The outpatient infusion setting provides a variety of treatments and care, from wound

care, chemotherapy, injections, hydration, etc. Patient census fluctuates daily, with trends noted

on certain days of the week. Additionally, with many patients seen in outpatient infusion on

active cancer treatment, spontaneous symptom management happens frequently, in the form of

intravenous antiemetics, hydration, treatment for electrolyte imbalances, blood transfusions, etc.

Depending on the day, a staffing challenge may have already been present, with a high census.

By the end of the day, with add on patients and limited staff, an already challenged nurse patient

ratio, can be propelled into a literal, or perceived, unsafe nurse patient ratio by staff and patients.

This frequently occurs in the outpatient infusion setting, with pronounced implications, including

poor nurse retention and decreased patient satisfaction.

The healthcare climate is constantly changing, with new ideas, technology, treatment

protocols, type of care, and staffing ratios. Needless to say, the latter, staffing ratios, affects all of

the former, in one way or another. Nursing staff over the course of numerous years, waxes and

wanes, from superior, to adequate, to short. When staffing ratios are ideal, nurses feel valued and

effective, resulting in excellent care for patients, and positive interactions amongst co-workers

and other team members. If these ratios are inadequate, especially if consistently, nurses feel

undervalued, stressed, and job satisfaction is low, leading to less optimal care for our patients

and poor staff retention. High percentages of positive patient outcomes and/or nurse retention

align with facilities that have adequate, more educated nursing staff. (Aiken, Clarke, Sloan,

Cheney, 2008) Inadequate staffing ratios can also decrease safety and lead to errors, endangering

patients and staff.

Nursing shortages is a problem around the globe, not just in the United States. Facilities

and healthcare leaders understand the correlation between patient safety and inadequate nurse
 RUNNING HEAD: QUALITY IMPROVEMENT PROJECT

staffing ratios. Several states in the US have passed legislation addressing these ratios.

(Rothberg, Abraham, Lindenauer, 2005) Some will argue that the increased ratios have gone

from one extreme to another, resulting in a perceived financial burden on facilities. (Rothberg,

Abraham, Lindenauer, 2005). While this may be the case, research also supports improved

staffing ratios lead to better patient outcomes and decreased financial implications for hospitals.

Per one article, “as a patient safety intervention, patient-to-nurse ratios of 4:1 are reasonably

cost-effective.” (Rothberg, Abraham, Lindenauer, 2005). Certainly ratios are dictated by patient

acuity and the care environment involved. In the outpatient infusion setting, high nurse to patient

ratios are the result of two primary causes, understaffing of nurses and overscheduling of

patients. Our company has a “turn no one away rule.” The physicians who use the outpatient

infusion are very much aware of this, and use it to defend their actions at times, somewhat

disregarding patient safety and the burden on the nursing staff. “Inefficient and ineffective

scheduling leads to delayed appointments and decreased patient and staff satisfaction.” (Riley,

2016) This is in no way intended to minimize our purpose to serve and put patients first. The goal

of addressing these issues, staffing and scheduling, is threefold, patient satisfaction, nurse

retention, and patient safety.

In this quality improvement project, our initial step would be to gather some information

regarding staffing numbers, scheduling trends, and nurse patient ratios. In order to be useful and

demonstrate trends, data collection would need to occur over several weeks. Daily

documentation would be imperative to obtaining accurate information. The number of nurses

scheduled, the census at the beginning of the day and at the end of the day, the number of add on

patients, anticipated nurse patient ratio, and actual nurse patient ratio are all key pieces of

information. After we have obtained and collated data then would need to determine the ideal
 RUNNING HEAD: QUALITY IMPROVEMENT PROJECT

nurse patient ratio, and if proved to be an issue, determine the appropriate schedule for patients

and nurses. Upon completion, we could then conduct several PDSA (Plan-Do-Study-Act) cycles

to implement our changes on a small scale, one each week for one month, if successful increase

and pilot in small phases.(Lloyd and Murray, 2017) If not successful, then we would return to

gather additional information to attempt to address these issues.

The anticipated goal, for example a ratio of 6:1, increasing to a maximum 7:1 with add on

patients, would dictate whether or not our project was successful. The result would be evidenced

by increased patient safety and satisfaction, increased job satisfaction, and staff retention. This

outcome would need to be constantly monitored to ensure ongoing progress.

 RUNNING HEAD: QUALITY IMPROVEMENT PROJECT

Reference List

Aiken, L. H., Clarke, S. P., Sloane, D. M., Lake, E. T., & Cheney, T. (2008). Effects of Hospital

Care Environment on Patient Mortality and Nurse Outcomes. The Journal of Nursing

Administration, 38(5), 223–229. http://doi.org/10.1097/01.NNA.0000312773.42352.d7

Lloyd, R., Murray,S. (2017) QI 103, Lesson 2:How to use data for improvement. Retrieved from

http://app.ihi.org/lms/lessondetailview.aspx?LessonGUID=7ea95efc-454f-44a9-a0d0-

b70a0152e1e8&CourseGUID=7ab177dc-a9cf-4d1d-b870-

f4be6e8d8f67&CatalogGUID=6cb1c614-884b-43ef-9abd-d90849f183d4

Riley, A. (2016). Infusion Center Insights: The ins and outs of infusion center scheduling.

Advisory Board Oncology Rounds. Retrieved from

https://www.advisory.com/research/oncology-roundtable/oncology-

rounds/2016/05/infusion-center-scheduling

Rothberg, M., Abraham, I., Lindenauer, P., Rose, D. (2005). Improving Nurse-to-Patient Staffing

Ratios as a Cost-Effective Safety Intervention. Medical Care, 43(8), 785-791

RUNNING HEAD: QUALITY IMPROVEMENT PROJECT