9.2 Quality Care

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]

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.

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]}

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]

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.