Quality and Safety in Nursing. Группа авторов

2 Policy Implications Driving National Quality and Safety Initiatives

       Mary Jean Schumann, DNP, MBA, RN, CPNP‐PC, FAAN

       Even though individual providers and clinicians of every discipline can elect to improve their own practice, strive to provide higher‐quality care, and reduce errors in their own work environments, much of the effort to reach higher levels of quality and safety must also occur through high‐level policy setting and health system reforms. Without policies that focus prioritization of resources on quality health care as a goal, individual efforts will be subsumed by other challenges such as stressful working conditions, short staffing and limited access, and demands for cost containment. This chapter addresses the policy strategies and initiatives that have emerged since 1990, from coalition building, to standard setting, to rule‐making and regulation, to the development of new incentives, to forging of new partnerships with consumer groups, and even legislation. Nurses’ roles in these efforts will also be described, as well as opportunities to influence policy, priorities, outcomes, and implementation today and in the decade that follows. Although quality and safety are distinct, the inclusion of safety is considered in any discussion of health care quality. Because so many measures of health care quality seem rooted in the absence of negative outcomes, such as falls, development of infections, pressure ulcers, misdiagnoses, and harm as a result of medication errors, safety has become synonymous with quality improvement in many discussions. Yet, as the last decade has reinforced, this is not enough. Access to care, cost, social determinants of health, health disparities, and emerging and infectious diseases have confounded incremental efforts to improve quality and safety. Policy‐makers, nurses, and others have had to engage in policy that impacts each of those factors effectively to make a difference.

Policy in the Context of Health Care Quality and Safety

From the outset, this chapter is based on the premise that policy encompasses many strategies and certainly is not limited to or even best achieved in most instances by legislation. Simon (1966) defines policy as “a set of processes, including at least 1) setting the agenda, 2) specifying alternatives from which to choose, 3) an authoritative choice among those specified alternatives, as in a legislative vote or a presidential decision, and 4) implementing the decision.” Although Kingdon (2003) ascribes multiple definitions to the term agenda setting, one is most applicable in the arena of health care quality. He includes as a definition of agenda setting “a coherent set of proposals, each related to the others and forming a series of enactments its proponents would prefer.” In his view, and one which is widely accepted, the policy process begins with agenda setting and continues through formulation of new policy, adoption, policy implementation, evaluation, and reevaluation.

      For purposes of this chapter’s discussion, policy encompasses alternatives that include not only legislative action but also rule‐making, statements of positions, establishment of standards, the adoption of guidelines or principles of best practice, and national consensus strategies. While policy is not confined to federal or national actions, the policy initiatives and opportunities discussed here will be largely at that level, given the scope and nature of the quality issues. Yet, as the most recent US Administration has shown us, the use of executive orders has become a preferred way to make policy change. In addition, the 2020 pandemic has resulted in any number of emergency orders that have allowed the usual process or public comment in emergency rule‐making to be waived. The pandemic and the protests, such as Black Lives Matter, have ushered in significant numbers of state‐level governors’ policy actions that impact health and health care. These cannot be ignored and are replete with opportunities for nurses to play a role.

      Another important concept espoused by Kingdon (2003), useful to understanding not only policy formation but also nursing’s role in shaping it, is that multiple process streams exist. Kingdon describes these as streams of problems, policies, and politics. Indeed, accurate formulation of problems is often a crucial first step to figuring out how to move toward solutions that derive from useful policy. Unless the problem is correctly identified, one can chase many alternative solutions without getting to any that might lead to resolution of the real problem. Kingdon concludes that the greatest policy changes grow out of that coupling of problems, policy proposals, and politics. If we think more broadly about the passage of the still‐controversial health care reform legislation the Affordable Care Act (ACA), policy emerged where there was a convergence of health care delivery challenges, support of stakeholder groups and alliances around policy proposals to improve care, and the political will to enact legislation, modify funding streams, and adjust priorities. A more recent example where science, technology, economics, and politics have needed to converge to create even imperfect policy is the SARS‐CoV‐2 pandemic, better known as COVID‐19. COVID‐19 has tested every aspect of the current health system and health care coverage. What have we discovered? That lack of any of these—political will, adhering to science, use of all available technology, or sufficient economic resources—results in poor or no policy when it comes to achieving common agreement on what is needed to provide safety for patients, families, health care workers, communities, and citizens. What can we use to understand this failing?

      Such an approach to policy‐making portrays a model based upon rational decision‐making, which according to Stone (2012) includes multiple well‐identified steps: identifying objectives, identifying alternative courses of action for achieving objectives, predicting the possible consequences of each alternative, evaluating the possible consequences of each alternative, and selecting the alternative that maximizes the attainment of objectives. This approach is market driven; that is, society comes together because it wants something new or to fix problems. This seems so sensible: why wouldn’t this be effective, whether it results in legislation, standards, guidelines, regulation, or other actions that improve health care quality? As we have seen over the last decade with relation to the ACA, while society wanted to fix health care or the health insurance market, the objectives were in conflict, and neither the objectives nor the solutions were made clear to consumers. Stone, in her book Policy Paradox (2012), pinpoints the need for the Obama Administration to have portrayed the health insurance reform to Americans in a way that spoke to their emotions, in a way that convinced them that it would make their lives and their health care better.

      We have seen in the four years 2016 to 2020, under a different Administration, and particularly in 2020, that the rational decision‐making process has been largely cast aside for an approach that Stone terms “political reasoning”—reasoning by metaphor and analogy. Political reasoning strives to get others to see a situation as one thing rather than another. A protest on Black Lives Matter Square in the Washington District of Columbia could be seen as a forum for public debate or as an emotional assault on vulnerable people. The COVID‐19 pandemic has been termed simultaneously a “health care crisis of enormous proportions” or a situation in which “the country is turning the corner.” The election campaign of 2020 could be another perfect example. Indeed, one voter defended on 60 Minutes her choice of candidate in these terms: “I don’t need my president to be warm and fuzzy and hug babies. My 401K is doing