Elizabeth J. Murray, PhD, RN, CNE
K E Y T E R M S Advocacy
Care coordination Care process
Clinical practice guidelines Communication
Cultural competence Disparity
Diversity Documentation Empowerment
Evidence-based management Evidence-based practice Health literacy
High-reliability organizations Human errors
Human factors engineering Informatics
Information management Interdisciplinary Interprofessional Multidisciplinary Nursing research
Optimal healing environment Outcomes of care
Patient-centered care Quality
Quality improvement Reliability science
L E A R N I N G O B J E C T I V E S
● Describe the impact of the Institute of Medicine (IOM) reports on the qual- ity of health care in the United States.
● Define the IOM competencies, outline the IOM’s six aims for health care, and analyze the IOM’s 10 rules for health care in the 21st century.
● Compare and contrast the IOM competencies and the Quality and Safety Education for Nurses (QSEN) Core competencies.
● Identify and describe fundamental elements for each core competency for nursing.
● Discuss the importance of effective nursing leadership and management in providing safe and quality patient-centered care.
N
urses at all levels are leaders in the patient safety movement. Every nurse must be educated to deliver patient-centered care as a member of an interprofes- sional team, emphasizing evidence-based practice, quality improvement ap- proaches, informatics, and safety (Cronenwett et al., 2007; Greiner & Knebel, 2003).The modern patient safety movement began in 2000 when the Institute of Medicine (IOM) published its landmark report, To Err Is Human: Building a Safer Health System (Kohn, Corrigan, & Donaldson, 2000). With that publication, a quest for quality and safety in health care was launched that continues today. In 2003, the IOM published Health Professions Education: A Bridge to Quality (Greiner & Knebel, 2003), which identified five core competencies for all health-care professions. In response to the IOM report, the Quality and Safety Education for Nurses (QSEN) initiative was launched in 2005 with the primary goal of establishing a set of core competencies specific to the nursing profession.
This chapter provides a foundation for the entire book and discusses the core competencies for health-care professionals identified by the IOM and adapted by the QSEN faculty for nursing to be integrated into basic nursing education.
Because the QSEN core competencies are now being translated into practice, the fundamental elements of each competency are discussed to help nurse leaders and managers operationalize them in their work settings.
INSTITUTE OF MEDICINE REPORTS
Established in 1970 as the health arm of the National Academies, the IOM is an independent nonprofit organization that works outside the federal government to provide unbiased and authoritative advice on health and health care to decision makers and the public. The IOM brings together experts and stakeholders to pro- vide the nation with unbiased, evidence-based guidance on health-related issues.
Since 2000, the IOM has published a number of reports related to the state of quality in the U.S. health-care system. Box 1-1 provides a list of the reports most relevant to the content of this book; select elements of the various reports are discussed here as well as in other chapters.
The IOM’s first report, To Err Is Human, was groundbreaking in that it identified medical errors as the leading cause of injury and unexpected death in health-care settings in the United States. The purpose of the report was to present a strategy to improve health-care quality over the following 10 years. Contending that prevent- able adverse events result in up to 98,000 deaths annually, the IOM identified three domains of quality: patient safety, practice consistent with current medical knowl- edge, and meeting customer-specific values and expectations. Additionally, the Safety
Safety culture Self-management Standardized practice
Standardized protocols Structure or care environment Teamwork and collaboration
IOM determined that patient safety is a critical component of quality. The IOM out- lined the following four-tiered approach to quality improvement (Kohn, Corrigan,
& Donaldson, 2000):
1. “Establishing a national focus to create leadership, research, tools, and protocols to enhance the knowledge base about safety” (p. 3)
2. “Identifying and learning from errors by developing a nationwide public mandatory reporting system and by encouraging health care organizations and practitioners to develop and participate in voluntary reporting systems” (p. 3) 3. “Raising performance standards and expectations for improvements in safety
through the actions of oversight organizations, professional groups, and group purchasers of health care” (p. 4)
4. “Implementing safety systems in health care organizations to ensure safe prac- tices at the delivery level” (p. 4)
Before the publication of To Err Is Human, in 1997, President Bill Clinton ap- pointed the Advisory Commission on Consumer Protection and Quality in the Health Care Industry to advise him on changes occurring in the health-care system and to make recommendations on how to promote and ensure health-care quality as well as protect consumers and professionals in the health-care system. In re- sponse, the Commission drafted a consumer bill of rights, adopting the following eight areas of consumer rights and responsibilities (Advisory Commission on Consumer Protection and Quality in the Health Care Industry, 1997):
1. Information disclosure 2. Choice of providers and plans
3. Choice of health-care providers that is sufficient to ensure access to appropriate high-quality care
4. Access to emergency services BOX 1-1
BOX 1-1 Institute of Medicine ReportsInstitute of Medicine Reports 1990
Medicare: A Strategy for Quality Assurance: Executive Summary, Volume 1
2000
To Err Is Human: Building a Safer Health System
2001
Crossing the Quality Chasm: A New Health System for the 21st Century
2002
Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care
2003
Health Professions Education: A Bridge to Quality Priority Areas for National Action: Transforming Health
Care Quality
2004
Keeping Patients Safe: Transforming the Work Environment of Nurses
Patient Safety: Achieving a New Standard for Care Health Literacy: A Prescription to End Confusion
2011
The Future of Nursing: Leading Change, Advancing Health
5. Participation in treatment decisions
6. Respect and nondiscrimination; confidentiality of health information 7. Complaints and appeals
8. Consumer responsibilities
Endorsing the eight recommendations for consumer rights and responsibilities adopted by the Commission, the IOM (2001) challenged all health-care organiza- tions and professionals to work continually to reduce the burden of illness, injury, and disability of the people of the United States. Although health-care professionals were—and continue to be—dedicated to providing quality care, a gap remained.
Asserting that the U.S. health-care system was in need of major restructuring, the IOM called for an overhaul by outlining six aims for health-care improvement in the 21st century in its 2001 report, Crossing the Quality Chasm: A New Health System for the 21st Century: that health care should be safe, effective, patient-centered, timely, efficient, and equitable. The IOM believed that addressing these perform- ance characteristics would lead to narrowing the quality gap. Table 1-1 lists the descriptions of these six aims.
In addition to the six aims, the IOM (2001) identified 10 rules to redesign and improve health-care delivery in the 21st century. Emphasizing that part of the quality gap reflects a lack of support of well-designed systems and the absence of an environment that fosters innovation and excellence, the IOM contended that these 10 specific rules are necessary to achieve significant improvement in quality (IOM, 2001). These rules were implemented to have an impact on the health-care workforce and, in turn, require change in accountabilities, standards of care, and relationships between patients and health-care professionals (IOM, 2001). Box 1-2 compares the historical approach with the 10 rules for health care in the 21st century.
Building on the six aims for health-care improvement and the rules for health care in the 21st century, the IOM recognized health professions education as the primary tactic to narrow the quality gap. Thus, its report Health Professions
Health Care Should Be: Description
Safe Avoiding injuries to patients from the care that is intended to help them Effective Providing services based on scientific knowledge to all who could benefit and
refraining from providing services to those not likely to benefit; avoiding overuse, underuse, and misuse of care
Patient-centered Providing care that is respectful of and responsive to individual patients’ preferences, needs, and values, and ensuring that patients’ values guide all decisions Timely Reducing waits and sometimes harmful delays for both those who receive and
those who give care
Efficient Avoiding waste, in particular of equipment, supplies, ideas, and energy Equitable Providing care that does not vary in quality because of personal characteristics
such as gender, ethnicity, geographic location, and socioeconomic status Table 1–1 Institute of Medicine’s Six Aims for Health Care
in the 21st Century
Adapted from IOM, 2001, pp. 39–40.
Education: A Bridge to Quality (Greiner & Knebel, 2003) outlined five essential competencies necessary for all future graduates of health professions education programs, regardless of discipline (pp. 45–46):
1. Provide patient-centered care.
2. Work in interdisciplinary teams.
3. Employ evidence-based practice.
4. Apply quality improvement.
5. Use informatics.
The competencies are interrelated and applied together. However, the IOM stresses that skills related to the competencies are not discipline-specific and that each profession may put them into practice differently (Greiner & Knebel, 2003).
In response, the QSEN faculty adapted the IOM competencies for the nursing pro- fession and identified the knowledge, skills, and attitudes for each competency that should be developed in prelicensure nursing education (Cronenwett et al., 2007).
BOX 1-2
BOX 1-2 Ten Rules for Health-care Delivery in the 21st CenturyTen Rules for Health-care Delivery in the 21st Century 1. Care is based on a continuous healing relationship,
rather thanperiodic individual face-to-face visits.
2. Care is based on patients’ values and needs, rather thanvariations of care provided by health-care pro- fessionals based on different local and individual styles of practice and/or training.
3. The patient is the source of control over care, rather thanhealth-care professionals.
4. Knowledge is shared, and information flows freely, rather thanrequiring the patient to obtain permission. The patient has access to information without restriction, delay, or the need to request permission.
5. Decision making is evidence based, rather than based on the education and experience of the health-care professionals.
6.Safety is a system property, in that procedures, job designs, equipment, communication, and information technology should be configured to respect human factors, make errors less com- mon, and make errors less harmful when they do occur, rather than safety being an individual person’s responsibility.
7. There is a need for transparency, rather thana need for secrecy.
8. Health-care professionals predict and anticipate needs, rather thanreacting to problems and underinvesting in prevention.
9. Waste is continuously decreased, rather than resorting to budget cuts and rationing services.
10. Collaboration and teamwork are the norm, rather thanprofessional prerogatives and roles.
Adapted from IOM, 2001, pp. 66–83.
LEARNING ACTIVITY 1-1
Apply the 10 Rules for Health Care
Think about a health-care experience you or your family have encountered. Apply the 10 rules for health care in the 21st century listed in Box 1-2 to various aspects of your experience. Can you identify examples of care that reflect the historical approach? Can you identify examples of care that reflect the 21st-century approach?
QUALITY AND SAFETY EDUCATION FOR NURSES CORE COMPETENCIES
Although all health-care professionals have an obligation to provide safe and qual- ity care, nurses have been directly linked to ensuring patient safety and quality care outcomes (Page, 2004). The national QSEN initiative has been funded by the Robert Wood Johnson Foundation since 2005 and was organized with the purpose of adapting the IOM competencies for nursing specifically to serve as guides for curricular development in formal nursing education, transitions to practice, and continuing education programs (Cronenwett et al., 2007, p.124). In addition, the competencies provide a framework for regulatory bodies that set standards for licensure, certification, and accreditation of nursing education programs (Cronen- wett et al., 2007, p. 124). In collaboration with a national advisory board, QSEN faculty adapted the five competencies outlined in Health Professions Education: A Bridge to Quality (Greiner & Knebel, 2003)—provide patient-centered care, work in interdisciplinary teams, employ evidence-based practice, apply quality improve- ment, use informatics—and added a sixth competency, safety. The overall goal for the QSEN project is to prepare future nurses with the knowledge, skills, and atti- tudes necessary to continuously improve the quality and safety of the health-care systems within which they work (Cronenwett et al., 2007). Definitions of the core nursing competencies and comparisons with the IOM competencies follow.
Patient-Centered Care
Patient-centered care is more than a one-size-fits-all approach to care (Frampton &
Guastello, 2010). Health-care professionals must shift from disease-focused pater- nalistic care to ensuring that the patient is the source of control and facilitating shared decision making (Greiner & Knebel, 2003). The IOM defines patient-centered careas follows: “identify, respect, and care about patients rather than differences, values, preferences, and expressed needs; relieve pain and suffering; coordinate continuous care; listen to, clearly inform, communicate with, and educate patients;
share decision making and management; and continuously advocate disease prevention, wellness, and promotion of healthy lifestyles, including a focus on population health” (Greiner & Knebel, 2003, p. 45).
The skills related to this competency identified by the IOM include the following (Greiner & Knebel, 2003, pp. 52–53):
● Share power and responsibility with patients and caregivers.
● Communicate with patients in a shared and fully open manner.
● Take into account patients’ individuality, emotional needs, values, and life issues.
● Implement strategies for reaching those who do not present for care on their own, including care strategies that support the broader community.
● Enhance prevention and health promotion.
The nurse-patient relationship has changed over the years. Nurses no longer make all the decisions or provide total care for patients. Instead, patients and their families enter into a full partnership with nurses and other health-care professionals.
Today, active involvement of patients and their families in the plan of care and
decision making is considered a precursor to safe, effective, and quality care. Patient safety and quality care require recognizing the patient as the source of control. Care is customized based on patients’ values, needs, and preferences. The nursing core competency of patient-centered care is defined as the recognition of “the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for patients’ preferences, values, and needs”
(Cronenwett et al., 2007, p. 123). Nurses develop healing relationships with patients and families in which they share information and communication flows freely.
The fundamental elements of the patient-centered care core competency include advocacy, empowerment, self-management, cultural competence, health literacy, and an optimal healing environment.
Advocacy
Advocacy is one of the philosophical underpinnings of nursing and encompasses caring, respect for an individual person’s autonomy, and empowerment. Advocacy in nursing is defined as “a process of analyzing, counseling, and responding to patients’ care and self-determination preferences” (Vaartio-Rajalin & Leino-Kilpi, 2011, p. 526). Nurses have an ethical obligation to advocate for patients. The American Nurses Association (ANA) Code of Ethics for Nurses With Interpretive Statements asserts, “the nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient” (2015a, p. 9). Nurses often find themselves representing and/or speaking for patients who cannot speak for themselves. The nurse’s role as advocate is discussed further in Chapter 4.
Empowerment
As part of patient-centered care, nurses are called to empower patients and their families to engage in self-care, decision making, and developing a plan of care.
Empowermentis defined as “patients’ perceptions of access to information, support, resources, and opportunities to learn and grow that enable them to optimize their health and gain a sense of meaningfulness, self-determination, competency, and impact on their lives” (Spence Laschinger, Gilbert, Smith, & Leslie, 2010, p. 5). A sense of empowerment is vital from the nurse’s perception as well as the patient’s perception. To empower patients, nurses must believe that they have the power to accomplish work in a meaningful way. Spence Laschinger and colleagues (2010) contend that empowered nurses empower their patients, with the result being better health-care outcomes.
Self-Management
Self-management is a priority area identified by the IOM as needed for quality health care and in achieving patient-centered care. The major aim of self-management is “to ensure that the sharing of knowledge between clinicians and patients and their families is maximized, that the patient is recognized as the source of con- trol, and that the tools and system supports that make self-management tenable is
available” (Adams & Corrigan, 2003, p. 52). Further, there is strong evidence that support for self-management is critical to the success of chronic illness programs.
Nurses assist patients with self-management by helping them increase skills and confidence in managing their health problems. Health literacy, discussed next, plays a key role in self-management.
Health Literacy
A major barrier to patient-centered care is “the ability to read, understand, and act on healthcare information” or health literacy (Adams & Corrigan, 2003, p. 52). An estimated 90 million Americans have difficulty understanding health information (Finkelman & Kenner, 2016). Poor health literacy affects Americans of all social classes and ethnic groups (Adams & Corrigan, 2003). The IOM defines health literacy as “the degree to which individuals have the capacity to obtain, process, and understand basic information and services needed to make appropriate decisions regarding their health (Nielsen-Bohlman, Panzer, & Kindig, 2004, p. 2). Low literacy skills are most prevalent among the elderly and the low-income population.
Unfortunately, those people most in need of health care are the least able to read and understand information for self-management (Adams & Corrigan, 2003).
Advocating for patients and their families experiencing health literacy problems can make a major difference in their health-care encounters.
LEARNING ACTIVITY 1-2
Assessing Health Literacy
Health literacy should be part of the health assessment performed by nurses as they begin their shift. Is health literacy part of the health assessment document in use in your clinical facility?
Cultural Competence
Patient-centered care requires nurses to provide acceptable cultural care and to re- spect the differences in patients’ values, preferences, and expressed needs (American Association of Colleges of Nursing [AACN], 2008a). Cultural competenceis defined as
“the attitude, knowledge, and skills necessary for providing quality care to diverse populations” (AACN, 2008a, p. 1). Nurses have a moral mandate to provide cultur- ally competent care to all, regardless of gender, age, race, ethnicity, or economic status. Moreover, nurses must provide effective care across diverse population groups congruent with the tenants of social justice and human rights (AACN, 2008b).
Part of cultural competence consists of understanding and respecting diversity.
Not everyone is alike, and nurses must acknowledge and be sensitive to differences in patients and coworkers. Diversityis the “range of human variation, including age, race, gender, disability, ethnicity, nationality, religious and spiritual beliefs, sexual orientation, political beliefs, economic status, native language, and geographical background” (AACN, 2008b, p. 37). Diversity is more than having different