9.2 Quality Care
Open Resources for Nursing (Open RN)
Quality is defined in a variety of ways that impact nursing practice.
ANA Definition of Quality
The American Nurses Association (ANA) defines quality as, “The degree to which nursing services for health care consumers, families, groups, communities, and populations increase the likelihood of desirable outcomes and are consistent with evolving nursing knowledge.”[1] The phrases in this definition focus on three aspects of quality: services (nursing interventions), desirable outcomes, and consistency with evolving nursing knowledge (evidence-based practice). Alignment of nursing interventions with current evidence-based practice is a key component for quality care.[2] Evidence-based practice (EBP) will be further discussed later in this chapter.
Quality of Practice is one of the ANA’s Standards of Professional Performance. ANA Standards of Professional Performance are “authoritative statements of the actions and behaviors that all registered nurses, regardless of role, population, specialty, and setting are expected to perform competently.” See the competencies for the ANA’s Quality of Practice Standard of Professional Performance in the following box.[3]
Competencies of ANA’s Quality of Practice Standard of Professional Performance[4]
- Ensures that nursing practice is safe, effective, efficient, equitable, timely, and person-centered.
- Incorporates evidence into nursing practice to improve outcomes.
- Uses creativity and innovation to enhance nursing care.
- Recommends strategies to improve nursing care quality.
- Collects data to monitor the quality of nursing practice.
- Contributes to efforts to improve health care efficiency.
- Provides critical review and evaluation of policies, procedures, and guidelines to improve the quality of health care.
- Engages in formal and informal peer review processes of the interprofessional team.
- Participates in quality improvement initiatives.
- Collaborates with the interprofessional team to implement quality improvement plans and interventions.
- Documents nursing practice in a manner that supports quality and performance improvement initiatives.
- Recognizes the value of professional and specialty certification.
Reflective Questions
- What Quality of Practice competencies have you already demonstrated during your nursing education?
- What Quality of Practice competencies are you most interested in mastering?
- What questions do you have about the ANA’s Quality of Practice competencies? Where could you find answers to those questions (e.g., instructors, preceptors, health care team members, guidelines, or core measures)?
This chapter will review content related to the competencies of the ANA’s Quality of Practice Standard of Professional Performance. Additional information about peer review is discussed in the “Leadership and Management” chapter, and specialty certification is discussed in the “Preparation for the RN Role” chapter.
Quality and Safety Education for Nurses
The Quality and Safety Education for Nurses (QSEN) project advocates for safe, quality patient care by defining six competencies for prelicensure nursing students: Patient-Centered Care, Teamwork and Collaboration, Evidence-Based Practice, Quality Improvement, Safety, and Informatics. These competencies are further discussed in the “Advocacy” chapter.
Framework of Quality Health Care
A definition of quality that has historically guided the measurement of quality initiatives in health care systems is based on the framework for improvement originally created by the Institute of Medicine (IOM). The IOM name changed to the National Academy of Medicine in 2015. The IOM framework includes the following six criteria for defining quality health care[5],[6]:
- Safe: Avoiding harm 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 (i.e., avoiding underuse and misuse).
- Patient-centered: Providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions.
- Timely: Reducing waits and sometimes harmful delays for both those who receive and those who provide care.
- Efficient: Avoiding waste, including waste 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.
This framework continues to guide quality improvement initiatives across America’s health care system. The evidence-based practice (EBP) movement began with the public acknowledgement of unacceptable patient outcomes resulting from a gap between research findings and actual health care practices. For EBP to be successfully adopted and sustained, it must be adopted by nurses and other health care team members, system leaders, and policy makers. Regulations and recognitions are also necessary to promote the adoption of EBP. For example, the Magnet Recognition Program promotes nursing as a leader in catalyzing adoption of EBP and using it as a marker of excellence.[7]
Magnet Recognition Program
The Magnet Recognition Program is an award from the American Nurses Credentialing Center (ANCC) that recognizes organizational commitment to nursing excellence. The award recognizes organizations worldwide where nursing leaders have successfully aligned their nursing strategic goals to improve the organization’s patient outcomes. To nurses, Magnet Recognition means education and development are available through every stage of their career. To patients, it means quality care is delivered by nurses who are supported to be the best that they can be.[8] See Figure 9.2[9] for an image related to the Magnet Recognition Program.
Reimbursement Models
Quality health care is also defined by value-based reimbursement models used by Medicare, Medicaid, and private insurance companies paying for health services. As discussed in the “Health Care Reimbursement Models” section of the “Health Care Economics” chapter, value-based payment reimbursement models use financial incentives to reward quality health care and positive patient outcomes. For example, Medicare no longer reimburses hospitals to treat patients who acquire certain preventable conditions during their hospital stay, such as pressure injuries or urinary tract infections associated with use of catheters.[10] These reimbursement models directly impact the evidence-based care nurses provide at the bedside and the associated documentation of assessments, interventions, and nursing care plans to ensure quality performance criteria are met.
CMS Quality Initiatives
The Centers for Medicare & Medicaid Services (CMS) establishes quality initiatives that focus on several key quality measures of health care. These quality measures provide a comprehensive understanding and evaluation of the care an organization delivers, as well as patients’ responses to the care provided. These quality measures evaluate many areas of health care, including the following:[11]
- Health outcomes
- Clinical processes
- Patient safety
- Efficient use of health care resources
- Care coordination
- Patient engagement in their own care
- Patient perceptions of their care
These measures of quality focus on providing the care the patient needs when the patient needs it, in an affordable, safe, effective manner. It also means engaging and involving the patient, so they take ownership in managing their care at home.
Visit the CMS What is a Quality Measure web page.
Accreditation
Accreditation is a review process that determines if an agency is meeting the defined standards of quality determined by the accrediting body. The main accrediting organizations for health care are as follows:
- The Joint Commission
- National Committee for Quality Assurance
- American Medical Accreditation Program
- American Accreditation Healthcare Commission
The standards of quality vary depending on the accrediting organization, but they all share common goals to improve efficiency, equity, and delivery of high-quality care. Two terms commonly associated with accreditation that are directly related to quality nursing care are core measures and patient safety goals. Please see Table 9.2 for more information on accrediting organizations.
Table 9.2. Accrediting Organizations [12], [13], [14] [15]
| Organization | Overview | History | Accreditation Process | Standards | Impact |
| The Joint Commission | Non-profit organization accrediting and certifying health care organizations and programs in the U.S. | Founded in 1951, aims to improve public health care quality and safety | Conducts rigorous on-site surveys to assess compliance with standards covering patient care, medication safety, infection control, and overall performance | Developed with input from health care professionals, providers, and consumers and designed to help measure, assess, and improve performance | Recognized as a symbol of quality, reflecting commitment to high performance standards |
| National Committee for Quality Assurance (NCQA) | Private, non-profit organization improving health care quality through evidence-based standards, measures, programs, and accreditation | Established in 1990, provides quality information for health care decision-making | Comprehensive review of policies and procedures, including quality management, utilization management, credentialing, and member rights | Widely regarded standards used by CMS and state governments for quality oversight | Demonstrates commitment to improving health care quality and adhering to high performance standards |
| American Medical Accreditation Program (AMAP) | Program by AMA aimed at improving medical care quality by setting high standards for physicians | Launched in the late 1990s, assesses physicians’ qualifications and ethical standards | Detailed review process, including verification of credentials, practice history assessment, and compliance with CME requirements | Ensures physicians provide high-quality care, maintain competency, and adhere to ethical practices | Recognizes physicians’ commitment to high-quality care and medical practice standards |
| American Accreditation Healthcare Commission (AAHC) / URAC | Independent, non-profit organization promoting health care quality through accreditation, certification, and measurement | Founded in 1990, expanded from utilization review to a wide range of health care services | Thorough review of policies, procedures, and performance, including on-site visits and compliance assessment | Developed by a broad array of stakeholders to promote evidence-based practices, patient safety, and continuous improvement | Recognized as a mark of excellence, demonstrating commitment to quality and accountability |
Core Measures
Core measures are national standards of care and treatment processes for common conditions. These processes are proven to reduce complications and lead to better patient outcomes. Core measure compliance reports show how often a hospital successfully provides recommended treatment for certain medical conditions. In the United States, hospitals must report their compliance with core measures to The Joint Commission, CMS, and other agencies.[16]
In November 2003, The Joint Commission and CMS began work to align common core measures, so they are identical. This work resulted in the creation of one common set of measures known as the Specifications Manual for National Hospital Inpatient Quality Measures. These core measures are used by both organizations to improve the health care delivery process. Examples of core measures include guidelines regarding immunizations, tobacco treatment, substance use, hip and knee replacements, cardiac care, strokes, treatment of high blood pressure, and the use of high-risk medications in the elderly. Nurses must be aware of core measures and ensure the care they provide aligns with these recommendations.[17]
Read more about the National Hospital Inpatient Quality Measures.
Patient Safety Goals
Patient safety goals are guidelines specific to organizations accredited by The Joint Commission that focus on health care safety problems and ways to solve them. The National Patient Safety Goals (NPSG) were first established in 2003 and are updated annually to address areas of national concern related to patient safety, as well as to promote high-quality care. The NPSG provide guidance for specific health care settings, including hospitals, ambulatory clinics, behavioral health, critical access hospitals, home care, laboratory, skilled nursing care, and surgery.
The following goals are some examples of NPSG for hospitals[18]:
- Identify patients correctly
- Improve staff communication
- Use medicines safely
- Use alarms safely
- Prevent infection
- Identify patient safety risks
- Prevent mistakes in surgery
Nurses must be aware of the current NPSG for their health care setting, implement appropriate interventions, and document their assessments and interventions. Documentation in the electronic medical record is primarily used as evidence that an organization is meeting these goals.
Read the current agency-specific National Patient Safety Goals.
- American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵
- Stevens, K. R. (2013). The impact of evidence-based practice in nursing and the next big ideas. OJIN: The Online Journal of Issues in Nursing, 18(2), manuscript 4. https://ojin.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol-18-2013/No2-May-2013/Impact-of-Evidence-Based-Practice.html ↵
- American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵
- American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵
- Agency for Healthcare Research & Quality. (2018, November). Six domains of health care quality. https://www.ahrq.gov/talkingquality/measures/six-domains.html ↵
- Institute of Medicine (US) Committee on Quality of Health Care in America. (2001). Crossing the quality chasm: A new health system for the 21st century. National Academies Press. https://pubmed.ncbi.nlm.nih.gov/25057539/ ↵
- Stevens, K. R. (2013). The impact of evidence-based practice in nursing and the next big ideas. OJIN: The Online Journal of Issues in Nursing, 18(2), manuscript 4. https://ojin.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol-18-2013/No2-May-2013/Impact-of-Evidence-Based-Practice.html ↵
- American Nurses Credentialing Center. (n.d.). ANCC magnet recognition program. https://www.nursingworld.org/organizational-programs/magnet/ ↵
- “Magnet_Recognition_Logo_CMYK_-png-.png” by Mattmitchell37 is licensed under CC BY-SA 4.0 ↵
- James, J. (2012, October 11). Pay-for-performance. Health Affairs. https://www.healthaffairs.org/do/10.1377/hpb20121011.90233/full/ ↵
- CMS.gov. (2020, February 11). Quality measures. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityMeasures ↵
- Joint Commission International. (2024). Who we are. Retrieved from https://www.jointcommission.org/?utm_campaign=tjc_brand__1_core&utm_source=google&utm_medium=cpc&gad_source=1&gclid=CjwKCAjwnK60BhA9EiwAmpHZw55yd91qdT0f3Q6nauq82Oo3uHe5nPJKBwT81CxvmdtkGrjdc26GchoCvz8QAvD_BwE ↵
- NCQA. (2024). About NCQA. Retrieved from https://www.ncqa.org/about-ncqa/ ↵
- AMA Ed Hub. (2024). About the AMA's CME accreditation. https://edhub.ama-assn.org/pages/ama-cme ↵
- ACHC. (2024). About accreditation. Retrieved from https://www.achc.org/ ↵
- John Hopkins Medicine. (n.d.). Core measures. https://www.hopkinsmedicine.org/patient_safety/core_measures.html ↵
- The Joint Commission. (n.d.). Measures. https://www.jointcommission.org/en/measurement/measures/ ↵
- The Joint Commission. (2022). 2022 national patient safety goals. https://www.jointcommission.org/standards/national-patient-safety-goals/ ↵
Admission: Refers to an initial visit or contact with a client.
Brief: A short session to share a plan, discuss team formation, assign roles and responsibilities, establish expectations and climate, and anticipate outcomes and contingencies.
Closed-loop communication: A communication strategy used to ensure that information conveyed by the sender is heard by the receiver and completed.
Communication conflict: Occurs when there is a failure in the exchange of information.
Continuity of care: The use of information on past events and personal circumstances to make current care appropriate for each individual.[1]
Cultural diversity: A term used to describe cultural differences among clients, family members, and health care team members.
Cultural humility: A humble and respectful attitude toward individuals of other cultures that pushes one to challenge their own cultural biases, realize they cannot possibly know everything about other cultures, and approach learning about other cultures as a lifelong goal and process.[2]
CUS statements: Assertive statements that are well-recognized by all staff across a health care agency as implementation of the two-challenge rule. These assertive statements are “I am Concerned - I am Uncomfortable - This is a Safety issue!”[3]
Debrief: An informal information exchange session designed to improve team performance and effectiveness through reinforcement of positive behaviors and reflecting on lessons learned after a significant event occurs.
DESC: A tool used to help resolve conflict. DESC is a mnemonic that stands for Describe the specific situation or behavior and provide concrete data, Express how the situation makes you feel/what your concerns are using “I” messages, Suggest other alternatives and seek agreement, and Consequences are stated in terms of impact on established team goals while striving for consensus.
Discharge: The completion of care and services in a health care facility and the client is sent home (or to another health care facility).
Ethical conflict: Occurs when individuals or groups have fundamentally different beliefs and values.
Feedback: Information is provided to a team member for the purpose of improving team performance. Feedback should be timely, respectful, specific, directed towards improvement, and considerate.[4]
Goal conflict: Happens when the objectives of individuals or groups are incompatible.
Handoff reports: A transfer and acceptance of patient care responsibility achieved through effective communication. It is a real-time process of passing patient specific information from one caregiver to another, or from one team of caregivers to another, for the purpose of ensuring the continuity and safety of the patient’s care.[5]
Horizontal aggression: Hostile behavior among one’s peers.
Huddle: A brief meeting during a shift to reestablish situational awareness, reinforce plans already in place, and adjust the teamwork plan as needed.
I’M SAFE: A tool used to assess one’s own safety status, as well as that of other team members in their ability to provide safe patient care. It is a mnemonic standing for personal safety risks as a result of Illness, Medication, Stress, Alcohol and Drugs, Fatigue, and Eating and Elimination.
Interdisciplinary care conferences: Meetings where interprofessional team members professionally collaborate, share their expertise, and plan collaborative interventions to meet client needs.
Interprofessional collaborative practice: Multiple health workers from different professional backgrounds working together with patients, families, caregivers, and communities to deliver the highest quality of care.
I-PASS: A mnemonic used as a structured communication tool among interprofessional team members. I-PASS stands for Illness severity, Patient summary, Action list, Situation awareness, and Synthesis by the receiver.
ISBARR: A mnemonic for the components of Introduction, Situation, Background, Assessment, Request/Recommendations, and Repeat back.[6],[7]
Mutual support: The ability to anticipate and support team members' needs through accurate knowledge about their responsibilities and workload.
Personality conflict: Arises from differences in individual temperaments, attitudes, and behaviors.
Role conflict: Arises when individuals have multiple, often conflicting, expectations associated with their roles.
Shared mental model: The actions of a team leader that ensure all team members have situation awareness and are "on the same page" as situations evolve on the unit.[8]
Situation awareness: The awareness of a team member knowing what is going on around them.[9]
Situation monitoring: The process of continually scanning and assessing the situation to gain and maintain an understanding of what is going on around you.[10]
STEP tool: A situation monitoring tool used to know what is going on with you, your patients, your team, and your environment. STEP stands for Status of the patients, Team members, Environment, and Progress Toward Goal.[11]
TeamSTEPPS®: An evidence-based framework used to optimize team performance across the health care system. It is a mnemonic standing for Team Strategies and Tools to Enhance Performance and Patient Safety.[12]
Two-challenge rule: A strategy for advocating for patient safety that includes a team member assertively voicing their concern at least two times to ensure that it has been heard by the decision-maker.
Answer Key to Chapter 2 Learning Activities
1. To demonstrate respect for individual culture beliefs, the nurse should use open-ended questions to explore the patient's culture. Demonstrating engagement and interest in learning more about the patient's culture facilitates therapeutic communication and information sharing. Requesting that the patient share cultural background/information that the patient believes is important to their health care demonstrates respect and inclusion for different cultural beliefs and practices.
Answers to interactive elements are given within the interactive element.
Learning Objectives
- Practice and advocate for cost-effective care
- Summarize funding and reimbursement sources for patient-care services
- Explore how political, social, and demographic trends have affected the patient population and delivery of health care
- Analyze the link between economics and quality
- Describe nursing strategies to provide cost-effective care
- Examine economic pressures impacting case management and the management of institutional resources
- Describe the impact of evidence-based practice on health care economics and patient care outcomes
Whether health care is a right or a privilege is a historical ethical question debated around the world that ultimately leads to the question, “Who gets what resources?” Economics is the study of how individuals and societies make decisions about how to use their limited resources. Health care is considered a limited resource because there isn’t enough money or time in the world to purchase and provide care for every individual in every conceivable manner. The ethical question of who pays for that care is referred to as the ethics of rationing health care.
Economics is split into two broad categories called macroeconomics and microeconomics. Macroeconomics looks at decisions that affect the entire society as a whole, whereas microeconomics looks at the financial decisions of businesses and individuals.[13] This chapter will provide an overview of the broad topics of health care funding and reimbursement models at a societal level, as well as staffing and budgeting issues at the institutional level that impact nurses in their day-to-day work. Economics in health care affects an individual’s ability to pay for and receive health care, the ability of an institution to provide health care services, and nurses’ ability to provide safe, quality care to the communities they serve.
