Patient safety and quality are 2 of many competing priorities facing health care providers. As safety and quality rise on the agenda of executives, payers, and consumers, competing priorities, such as financial sustainability, patient engagement, regulatory standards, and governmental demands, remain organizational priorities. Nursing represents the largest health care profession in the United States and has the ability to influence the culture of patient safety and quality. It is essential for hospital leadership to provide a culture whereby nurses and staff are actively engaged and feel comfortable speaking up. Transparency is critical in the strategy and implementation of improving quality and safety.
Key points
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Although the environment of health care is continuously transforming, nurses’ steadfast commitment to quality and safety must remain the priority.
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Nurses have significant influence within organizations to drive and elevate patient safety and quality, ultimately resulting in better patient outcomes.
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It is essential for nurse leaders to empower bedside nurses in the processes and initiatives on how organizations will transform their care to a safer, higher-quality delivery system while driving value/efficiency.
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To elevate commitment to patient safety and high quality, it is important for nurses to work collaboratively with other disciplines to build sustainable and uniform care processes that assist them in their delivering quality care.
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Hospital leadership must provide an environment and culture whereby nurses on the front line are actively engaged and participative in the strategy and implementation of work to improve quality and patient safety and ultimately increase transparency to drive the culture of a high-reliability organization (HRO).
Introduction
Patient safety remains a challenge among all health care providers today, including nurses. Despite increased public attention and the rise on the agendas of members of the board and C-suite executives, it is not consistently the top priority in many organizations. Adequate time has not been given to the priority of patient safety.
As organizations are mandated to transform to value-based care, whereby volume is not the driver but rather quality and safety are higher priorities for all providers, nurses are instrumental in redefining care models to create cost efficiency while still providing safe and high-quality care. It is critical that nurses protect patients from preventable harm. In the hospital setting, nurses are with patients 24/7/365, giving them the encouragement to speak up. Nurses are the primary advocates for their patients. For pediatric patients, a nurse may be the sole voice advocating for the child. Although the environment of health care has changed, nurses’ commitment to safety and quality must take precedence.
What does it mean to provide safe and quality nursing care?
The nursing profession, both past and present, has maintained an intense commitment to quality and safety. More than a century ago, Florence Nightingale taught that the first requirement in a hospital is that it should do the sick no harm.
The fundamental principles that Nightingale described are the same principles that nurses are educated in today. She believed hospitals should help patients, not hurt them. She set standards for hospitals to be clean and safe. These efforts are supported by the Institute of Medicine and are held in high regard by national recognition programs, including the Magnet Accreditation Program, Leapfrog Group Hospital Survey, and U.S. News and World Report Honor Roll of Best Hospitals . Nurses have a responsibility to their patients and families to elevate patient safety by eliminating preventable harm and delivering high quality care.
What does it mean to provide safe and quality nursing care?
The nursing profession, both past and present, has maintained an intense commitment to quality and safety. More than a century ago, Florence Nightingale taught that the first requirement in a hospital is that it should do the sick no harm.
The fundamental principles that Nightingale described are the same principles that nurses are educated in today. She believed hospitals should help patients, not hurt them. She set standards for hospitals to be clean and safe. These efforts are supported by the Institute of Medicine and are held in high regard by national recognition programs, including the Magnet Accreditation Program, Leapfrog Group Hospital Survey, and U.S. News and World Report Honor Roll of Best Hospitals . Nurses have a responsibility to their patients and families to elevate patient safety by eliminating preventable harm and delivering high quality care.
Safety and quality are at the core of nursing practice
The impetus for an investment in patient safety gained national attention with the Institute of Medicine’s report, To Err is Human: Building a Safer Health System (1999). The report concluded that as many as 98,000 people die each year as a result of medical errors. The subsequent report, Crossing the Quality Chasm (2001), focused on closing the quality gap. A call for action and improvements, focusing on the six aims of health care: patient safety; effective; patient-centeredness; timeliness; care efficiency; and equity. A consistent theme in both reports was the power of nurses, both at the bedside and within the hospital leadership structure, to identify problems and develop solutions.
As the largest group of health care providers in the United States, nurses have significant influence within organizations to make improvements in each of the 6 aims ( Table 1 ). It is critical for nurses at all levels to be engaged in the processes and initiatives on how organizations transform their care to a safer, higher-quality delivery system while driving value/efficiency.
| Aim | Description by the Institute of Medicine | Implications for Nursing |
|---|---|---|
| Patient safety | Avoiding injuries to patients from the care that is intended to help them | Nurses are advocates – they maintain patient rights and support the ability of each individual to promote well-being, as defined by that individual. Organizations should empower nurses to report errors and to intervene if they perceive that there is impending harm. Similarly, nurses should share this message with patients, and encourage them to take an active role in error prevention. |
| Effective | Providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit | The advancement of evidence-based practice in nursing supports this dimension, because organizations make clinical decisions based on the most relevant evidence and high-quality findings. |
| 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 | The patient-centered care movement has challenged nurses to see health care from the patient’s perspective. Models of patient-centered care include bedside handoff, interdisciplinary patient/family-centered rounds, and hourly rounding. Patient-centered care has been shown to have a positive impact on patients’ optimism, sense of well-being, and trust. |
| Timely | Reducing waits and sometimes harmful delays for both those who receive and those who give care | A systematic review of the impact of nurse staffing on cost and length of stay encourages hospitals to provide higher ratios of registered nurses to nonlicensed staff because some studies have been able to demonstrate a reduction of length of stay with higher nursing ratios. |
| Efficient | Avoiding waste, including waste of equipment, supplies, ideas, and energy | Nurses are well known for their ability to work around obstacles to get their patients access to necessary care and resources. Along with their resourcefulness and willingness to navigate the system, nurses are well positioned to identify shortcomings of current processes. Unmistakably, the involvement of frontline nurses in quality improvement is a key source of evidence for hospitals striving to achieve Magnet Status. |
| Equitable | Providing care that does not vary in quality because of personal characteristics, such as gender, ethnicity, geographic location, and socioeconomic status | The first provision of the Code of Ethics for Nurses as put forth by the American Nurses Association decrees that nurses practice with respect and compassion for each individual. “The nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth, and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems.” This provision is in accordance with the recommendation for patient-centered care because it acknowledges the importance of recognizing each individual, with special consideration to vulnerable populations, so that the clinical decisions made are consistent with what is considered the well-being for that particular individual. |
High cost does not equate to high quality
The United States has the highest cost associated with health care as defined by the percentage of the gross domestic product (GDP) in comparison to other well-developed countries. Despite the persistent increase in national spending for health care, the United States continues to underperform in comparison to other high-income countries when ranked by the Commonwealth Fund on measures of health outcomes, quality, and efficiency ( Fig. 1 ).
Health care spending is projected to continue to increase at an estimated rate of 5.8% per year by 2024. Furthermore, given the expansion of health insurance coverage with the implementation of the Affordable Care Act and the aging population, Centers for Medicare & Medicaid Services estimates that 47% of national health spending will be financed by the government by 2024. The etiologies of health care costs are highly complex and multifactorial.
Advances in health care have dramatically changed the landscape of chronic conditions. Diseases and conditions that were formally untreatable have become chronic conditions as opposed to fatal diseases. This phenomenon is increasingly evident throughout the lifespan ( Fig. 2 ). Chronic conditions account for a majority of hospital admissions, prescriptions, and physician visits.
