The National Database of Nursing Quality Indicators: Delivering on a Promise

Abstract

This article chronicles the research and development of the National Database of Nursing Quality Indicators^®. The database was conceptualized by the American Nurses Association during the 1990s to capture the value of nursing care on patient quality outcomes. The goals of the database were to create a longitudinal dataset of nursing structures, processes and patient outcomes sensitive to quality nursing care; in other words, nursing-sensitive indicators. Critical advancements and future directions are discussed.

The National Database of Nursing Quality Indicators^® (NDNQI) was launched in 1998 by the American Nurses Association (ANA) to determine factors that impact nursing care and quality patient outcomes.¹ The database was developed as a quality measurement in the United States, accelerated in the 1990s amidst spiraling health costs and declining quality outcomes.¹ As the industry sought to reduce costs through workforce restructuring, it became imperative to demonstrate nursing’s value to healthcare. One strategy was to identify the nursing structures, processes and outcomes contributing to quality patient outcomes. Through a series of pilot studies, the initial 10 indicators of nursing capacity and patient outcomes were developed. This formed the foundation of the NDNQI, the largest unit-level nursing database to benchmark organizational performance against national, regional, and state standards.

Growth of the NDNQI

Following the initial pilot studies, ANA awarded the further development of the NDNQI to the University of Kansas School of Nursing. Over time, the NDNQI team developed more than 15 additional measures. Participation in the NDNQI grew from ∼30 hospitals to more than 1,700, with data reported for over 20,000 nursing units. Two registered nurse (RN) Job Satisfaction surveys were created, and by 2010, over 300,000 nurses participated annually. NDNQI’s growth aligned with the Magnet Recognition Program^®, which began requiring benchmarked nurse-sensitive indicators in 2008.² More than 90% of Magnet^® hospitals participated in NDNQI, reinforcing NDNQI’s role as the leading national database for empirical outcomes.

The NDNQI was used to produce more than 100 peer-reviewed publications and established critical links between nursing care and patient outcomes. Nurse staffing and skill mix were associated with patient falls³ and pressure injuries.⁴ Screening at admission and risk status was associated with decreased pressure injury rates.⁵ Hourly rounding was associated with decreased fall rates, yet restraint use was not. NDNQI’s fall and pressure injury rate measures were endorsed by the National Quality Program and adopted in major pay-for-performance programs,⁶ making NDNQI a cornerstone in advancing nursing quality and patient safety nationwide.

Acceleration and Advancement

In 2014, the NDNQI transitioned to ownership by Press Ganey. Substantial growth in the scope, reach, and analytic capacity of NDNQI accelerated, with participation expanding to more than 2000 healthcare facilities across the United States and several international regions. This expansion was accompanied by the continued growth of the indicator catalog, surpassing 250 measures of workforce characteristics and patient safety outcomes.

Enhanced dashboards and reporting tools for NDNQI were introduced, allowing organizations to view trends and access integrated snapshots of unit- and system-level performance. The addition of more than 10 comparison groups enabled deeper, more targeted quality improvement insights by situating local performance within relevant national contexts. These enhancements strengthened the ability of organizations to translate NDNQI data into actionable, data-driven insights supporting evidence-informed decision making to improve patient care.

A major advancement was the development of ambulatory care indicators with more than 16,000 ambulatory units contributing data. This expansion was advanced through collaboration with the American Academy of Ambulatory Care Nursing, reflecting the shifting landscape of care delivery outside the hospital. By incorporating ambulatory settings, NDNQI provided organizations with quality insights across the continuum of care, bridging inpatient and outpatient performance measurement.

The Press Ganey research team continued the legacy of the NDNQI as a generator of data-driven and evidence-based insights through peer-reviewed research. For example, NDNQI data were used to illustrate longitudinal trends in nursing-sensitive indicators during the COVID-19 pandemic and recovery period, highlighting the staffing strain and operational disruptions during this time period.⁷ Likewise, a large-scale pressure injury prevention study of more than 350,000 patients investigated patterns of preventive interventions. Through consistently high adherence to nursing practice standards, 95% of high-risk patients avoided the development of pressure injuries.⁸ Together, these studies demonstrate the impact of nurses on patient outcomes.

Future Directions

The NDNQI is delivering on its promise to improve patient care quality. For example, trends in catheter-associated urinary tract infections (CAUTI) and central line-associated bloodstream infection (CLABSI) rates have been well controlled for more than 15 years.⁹ Implicitly, the evidence demonstrates the value of nursing in driving quality gains.⁹ Moving forward, the use of the NDNQI needs to expand beyond those required to support Magnet recognition and federal requirements. To encourage expanded use of the entire catalogue, Press Ganey is focused on improving data submission and report turnaround time. Technology partners are collaborating to facilitate seamless data transfers. A second opportunity is to develop innovative indicators. Virtual nursing care is a recent addition to facilitate the description and evaluation of new models of care related to critical nurse and patient outcomes. Another addition includes nurse manager workload to examine associations between nurse manager span of control and support, and important nurse and patient outcomes. Practice is evolving and the measurement of quality care and patient outcomes must evolve as well.

Conflicts of Interest

The authors declare no conflict of interest.