Safety and quality may be the most common areas of discussion and action in health care today. They are critical to individual patient care and for the very survival of healthcare systems. The momentum of attention of the public and professionals began after a series of alarming reports from the IOM (2000, 2001, 2006) that exposed a variety of unfortunate realities of the American healthcare system regarding medical errors and other unaccept- able conditions. Indeed, the American healthcare system was ranked 37th in the world by the World Health Organization (2000b) at its last rating.
Continuous quality improvement is the official jargon for creating an institutional cul- ture that examines processes and systems of care to assure quality of care. Unfortunately, all too often, the focus on measuring quality stops at safety, or the absence of harm, rather than on elevation of standards beyond safety to excellence. Increased public scrutiny has pushed efforts toward improved quality throughout various types of healthcare systems (Advisory Board, 2004; Arnold et al., 2006). Arnold et al., (2006, p. 215) noted that chief nursing executives now spend the majority of their time on issues of quality, compli- ance, and patient safety requirements: “As regulatory requirements become increasingly intense and consumer expectations heighten, quality and compliance-related pressures mount.” They pointed out that it is not unusual in large systems to see entire new struc-
tures created specifically for assurance and monitoring of quality. Indeed, quality ranked highest for chief nursing executives in a study of priorities and challenges among nurse leaders in hospitals (Arnold et al., 2006).
Kurtzman and Jennings (2008; Beecher, 2001) pointed to health policy analysts who found a lack of leadership in quality initiatives. Nursing leaders have begun to fill that leadership gap to make quality one of the most important current issues in all health care situations.
Brooks (2008) outlined a number of official databases or standards directed specifically at quality for nursing practice. These include the National Database for Nursing Qual- ity Indicators, the Veterans Administration Outcomes Database, the National Voluntary Consensus Standards for Nursing Sensitive Care from the Joint Commission on Ac- creditation of Healthcare Organizations, and the standards of Transforming Care at the Bedside from the Institute for Healthcare Improvement (IHI) and Robert Wood Johnson Foundation. Much of the focus among these efforts is on hospital care, but similar issues of quality pervade health care throughout our communities.
The National Quality Forum ([NQF] 2004) outlined 15 “nursing-sensitive” measures now generally used in acute care institutions as indicators of quality. The measures are divided into three areas of patient-centered outcome measures, nursing-centered inter- vention measures, and system-centered measures. Patient-centered measures include failure to rescue (or death among surgical inpatients with treatable serious complica- tions), pressure ulcer prevalence, patient falls prevalence, falls with injury, restraint prevalence, urinary catheter–associated urinary tract infections, central line catheter–
associated infections, and ventilator-associated pneumonias. Nursing-centered measures include counseling patients with acute myocardial infarction, heart failure, or pneumonia regarding smoking cessation. System-centered measures include skill mix among regis- tered nurses, practical nurses, and unlicensed personnel; nursing care hours per patient day; measures of nurse involvement in system governance and professional relation- ships; and voluntary turnover of nurse employees. Obviously, the list reflects important measures for patient survival, but if a stranger from another planet with superior health care visited our system, would that stranger find these measures as minimum for safety or as measures of excellence in healing? We are moving in the right direction with the focus toward improvement of care, and such efforts are making a difference in nursing performance and patient outcomes. But again, the challenge of leaders of the next level is to move performance to higher levels of excellence and healing.
There are several mechanisms by which leaders may engage the organization in pursuit and evaluation of quality. One common way for leaders to confirm, measure, or moni- tor quality is benchmarking. Benchmarking is a method of comparing aspects of perfor- mance with similar organizations. It is usually done to provide information for strategic planning or to improve the processes, productivity, and quality of services. It allows you to make a professional comparison of the quality of your own setting with that of oth- ers anywhere in the world (Hollingsworth, 2008). Indeed, engagement in benchmarking activities in itself is a step toward improvement of quality. There is a difference between benchmarking and adopting industry standards or regulatory guidelines. Benchmark- ing is a voluntary, thoughtful, and selective activity of identifying peer organizations or organizations to which you aspire to emulate on a specific process or outcome. You are then able to set specific goals related to the benchmark findings. The following are some of the steps outlined by Hollingsworth (2008, p. 70) for successful benchmarking:
1. Identify benchmarking partners or.
2. Determine what constitutes the benchmark calculation or data source.
3. Gather information from peer sources.
4. Compare actual data to benchmark data.
5. Identify variances and calculate gaps in performance.
6. Identify ideas for improvement, set goals, and develop and implement an action plan.
7. Measure results and compare with the benchmark.
Benchmarking is most commonly done in hospitals and educational settings, but the principles apply to other settings like primary care or public health.
Magnet designation is another mark of quality. It has been recognized for 25 years as a
“hallmark of excellence” for quality and professional nursing in hospitals (Wolf, Triolo,
& Ponte, 2008). Sponsored by the American Nurses Credentialing Center of the Ameri- can Nurses Association, Magnet status recognizes four major areas:
1. The management, philosophy, and practice of nursing services.
2. Adherence to national standards for improving the quality of patient care services.
3. Leadership of the nurse administrator in supporting professional practice and continued competence of nurses.
4. Understanding and respecting the cultural and ethnic diversity of patients, their significant others, and healthcare providers (Urden, 2006, 25)
Basic criteria, or “forces of magnetism,” include quality of nursing leadership, organi- zational structure, management style, personnel policies and programs, professional models of care, quality improvement, consultation and resources, autonomy, commu- nity supportive partnerships, nurses as teachers, image of nursing, collegial nurse-phy- sician relationships, and professional development. Magnet hospitals have consistently scored high on support to nursing practice, nursing workload, and nurse satisfaction (Lacey et al., 2007). Application of Magnet principles has spread abroad (Aiken, Buchan, Ball, & Rafferty, 2008; Chen & Johantgen, 2010) but has yet to move to practice settings outside hospitals.
Another example of a specific external measure of quality for hospitals is the Malcolm Baldrige National Quality Award, a federal award to healthcare organizations that seek to meet particular standards on leadership; strategic planning; customer and market focus;
measurement, analysis, and knowledge management; human resource focus; process management; and results (American Society for Quality, 2006). The standards include strategic business principles, core values, and role modeling of leaders in principles that ultimately promote quality, such as “planning, communication, coaching, development of future leaders, review of organizational performance, and staff recognition” (Baldrige National Quality Program, 2008; Goonan & Stoltz, 2004; Kurtzman & Jennings, 2008, p. 241).
Also, the NQF is a private, nonprofit organization that develops strategies for quality measurement and reporting in health care. Its mission is to set national priorities and goals for performance improvement, endorse national consensus standards for mea- suring and publicly reporting on performance, and promote the attainment of national goals through education and outreach programs (NQF, 2009). It has exerted consider- able recent influence on performance, influencing initiatives of pay-for-performance,
which is a paradigm that began with the Centers for Medicare and Medicaid Services whereby third parties reimburse healthcare providers based on quality and efficiency rather than on services and procedures only. It requires healthcare agencies to monitor and report data on specific measures with standards that must be met in order to receive payment reimbursement (Gelinas, 2008). Third parties are beginning to withhold pay- ment for conditions related to poor care quality and paying for performance on safety and quality. The movement has begun to change the culture of quality in patient care.
Brooks (2008, p. 146) further proposed four key trends that will shape the future of qual- ity and safety in nursing practice: “(1) transparency; (2) 100K Lives Campaign and stan- dards of care; (3) pay-for-performance/pay-for-reporting; and (4) patient centeredness and coordination of care” (Reinertsen, 2006). Transparency refers to the trend of health- care agencies toward publishing outcome data. Such publication is thought to increase competition on measures of quality. The 100K Lives Campaign refers to an initiative be- gun in 2005 of more than 2,600 healthcare organizations to reduce national hospital deaths by 100,000. It is part of the move toward transparency to improve quality of care. Patient centeredness and coordination of care include accountability for quality processes within entire patient care systems and coordination of patient care across settings.
A variety of individual demonstration movements across the country have begun to make a difference. One example is the Hospital Quality Incentive Demonstration, where hospitals are rewarded financially for top performance on specific outcomes. The Physi- cian Group Practice Demonstration provides for physician groups to be rewarded for innovative proactive patient care and disease management in specific areas to reduce healthcare costs. Also, the Hospital Consumer Assessment of Health Plans Survey is de- signed to measure and standardize data on patient satisfaction. Private healthcare sys- tems and advocate organizations have joined the movement, with a variety of initiatives to change the culture toward incentives for quality and efficiency.
The recent Transforming Care at the Bedside project (IHI, 2010) was a major national effort to address issues of quality, safety, and reliability; vitality of nursing engagement and teamwork; patient-centered care; and value-added care processes in hospitals. It spe- cifically targeted medical-surgical units in a large number of hospitals across the country (Anonymous, 2004, 2005; IHI, 2010; Rutherford, Lee & Greiner, 2004). Specific, broad targets were impressive (Rutherford et al., 2004, p. 4):
1. No unanticipated deaths.
2. No needless pain and suffering.
3. Clinicians, staff, and students will say, “I contribute to an effective care team within a sup- portive environment that nurtures my professional career/growth and continually strives for excellence.”
4. Patients will say, “They give me exactly the help I want (and need) exactly when I want (and need) it.”
5. Unnecessary documentation is eliminated, reducing total documentation by 50%.
6. Clinicians spend 70% of their time in direct patient care.
Measures to monitor achievement of targets include “adverse events, unanticipated deaths, patient falls, unplanned returns to the intensive care unit, pressure ulcer preva- lence, hospital-acquired pneumonia prevalence, care team satisfaction, voluntary turn- over, patient and family satisfaction, percentage of time spent in direct patient care,
percentage of time spent in documentation, percentage of time spend in value-added work, and costs per diagnosis related group for the top three diagnoses of patients”
(Rutherford et al., 2004, p. 4). Results have been highly positive and vary from situations of critical care (Donahue, Rader, & Triolo, 2008) to general medical-surgical patient care (Lorenz, Greenhouse, Miller, Wisniewski, & Frank, 2008; Upenieks, Needleman, et al., 2008; Viney, Batcheller, Houston, & Belcik, 2006), focusing on specific patient choices (Scott-Smith & Greenhouse, 2007) as well as multihospital systems (Martin et al., 2007).
Such trends toward quality offer important opportunities for leadership, particularly in nursing. Similar initiatives need to be tested in settings beyond hospitals. Transforma- tional nurse leaders must have a foundation in understanding the interdisciplinary as- pects of care in continuous quality improvement processes, and in patient-centered care.
The next challenge is to create systems in which quality of care is integrated as second nature into all aspects of health care, including primary care and community health care.
As the leader, remember that tools for quality management are “means, not the end.”
Kibort (2005, p. 54) reminded, “Remember they are just tools. Learn to use a few of them well. And stick to the fundamentals.”
Nearly always, an initiative for quality improvement means leadership in change and change management, whether it is a change of procedure or process, change of prod- uct, or change of culture. Weber and Joshi (2000) noted that understanding change is most critical to successful quality improvement initiatives. It is important for the leader to under- stand the following eight critical strategies to manage change for quality improvement:
1. Develop a vision for change.
2. Focus on the change process.
3. Analyze which individuals in the organization must respond to the proposed change and what barriers exist.
4. Build partnerships between physicians and administration.
5. Create a culture of continuous commitment to . . . [quality].
6. Ensure that . . . [quality] begins with leadership.
7. Ensure that change is well communicated.
8. Build in accountability for change [and quality]. (Weber & Joshi, 2000, p. 388)
As noted in the discussion of patient safety, we must be continually aware in an environ- ment of increased public and regulatory scrutiny and associated reporting requirements to distinguish between competence in compliance and excellence. Every other industry is moving toward customized service. Patients are becoming accustomed to know what they want and to expect care specific to their needs. Nursing leadership, in particular, can create new paradigms and care models that frame productivity as value-added care.
This vision of care “goes beyond direct care activities and includes team collaboration, physician rounding, increased . . . communication, and patient centeredness . . . [in order to] improve efficiency, quality, and service,” for example (Upenieks, Akhaven, & Kotler- man, 2008, p. 394). Excellence in quality represents not only a minimum standard of care but also superb care.
Kurtzman and Jennings (2008, p. 241) suggested the need to develop “quality liter- acy,” calling for leaders to acquire and advance understanding of principles of quality,
“both conceptually and practically.” This includes the development of a business case that includes a set of standard performance measures to highlight nursing’s influence on quality. The business case must provide “clear, unambiguous, quantifiable evidence of
the primacy of nursing’s contribution.” Evidence is the rule of the day. As a leader, you must speak the language and provide the data to support the work that you know leads to excellence.
An innovative study of leaders in 370 hospitals in all 50 states revealed that specific attributes of transformational leadership are related to both quality improvement and knowledge management, resulting in better patient outcomes (Gowen, Henagan, &
McFadden, 2009). Another study in England found that specific leadership activities of training personnel, team working, and appraisal of hospital staff were directly related to patient mortality (West et al., 2002). To lead the charge in authentic quality of care, leaders must create and communicate a specific plan, gather appropriate data, use the data in specific evidence-based decision making, provide training and education to all members of the work team, and reward excellent performance (Kurtzman &
Jennings, 2008).
Knowledge and processes of quality improvement in health care have expanded to become recognized as a science with its own emerging body of knowledge. Cronen- wett (2010) outlined its characteristics. It “considers local context, or what out- comes are achieved in what settings with what roles and processes, and it requires knowledge of [the specific] discipline, local culture, quality improvement methods and measures, and how to manage change.” Furthermore, specific methods for report- ing and publishing work on quality improvement have been proposed (see Davidoff et al., 2009).
In all the efforts to accelerate quality initiatives, we must not forget the viewpoint of patients themselves. Jennings and associates ( Jennings & McClure, 2006; Kurtzman &
Jennings, 2008, p. 241) warned that since most current indicators of quality in all of our lists and recommendations are developed and driven by data needs for compliance to
“payers and purchasers, accreditors, and other policymakers”:
. . . The aspects of care that are most meaningful to clinicians, patients, and family mem- bers may not be reflected in these measures. Consequently, while there may be enormous measurement “activity” taking place, nurse executives must ask themselves, “What are we gaining from this activity and does it reflect the aspects of care that are most vital? How can we use the findings from the measurement efforts to make improvements in the quality of patient care?”
Quality and customized service are the currency of consumers across society today.
People have become accustomed to demanding quality and to have service fit particular individual needs. A service such as health care cannot afford to overlook the personal meaning of that service to those who need it and receive it.
Although most of the published work on quality reflects practice in acute care, in any position or any setting, as a leader, you will devote considerable attention to quality. The public now demands it. There is an amazing array of resources for leaders in standards, structures, and processes to test, evaluate, and improve quality. The vigilance and hard work required to sustain formal activities in quality improvement are enormous. In the midst of all the work, remember that you are the transformational leader. Look beyond the work “activity” to the vision and meaning of improving lives and promoting healing.
Quality “work” can be exhausting if it is not ultimately meaningful to patients and pro- viders and born from passion and inspiration. That reflects the true challenge to leaders.
You must share your own wise energy as leader.