Quality and Safety in Nursing. Группа авторов
great disparities in health care access or reflected in specific areas of quality. These variations can be documented by using the query process for the Annual Report (https://nhqrnet.ahrq.gov/inhqrdr/data/query). From a nursing perspective, many of these measures can be seen as a reflection of nursing practice, both positive and negative.
Building the Momentum for Quality
The inclusion of such far‐reaching provisions related to quality and safety in the ACA has been made possible largely because of the efforts over several decades of health care industry stakeholders who worked to identify the barriers and build multiple supportive alliances, leading to addressing the issues through policies at every level. As by‐products, professionals in the health care industry became educated about quality principles, and consumer awareness of the complexities of health care systems was raised. The following sections describe how powerful such efforts have become.
National Quality Forum: A Strategic Model
In the early 2000s, following the Institute of Medicine (IOM) reports on medical errors and the quality chasm (Institute of Medicine 2000, 2001), the National Quality Forum (NQF), a new private nonprofit entity, became central to the establishment of standards and policy relative to health care quality. NQF grew out of the Presidential Advisory Commission on Consumer Protection and Quality in the Health Care Industry convened in 1996. The Advisory Commission was one of many ways in which entities concerned about the eroding quality of care began to consider how they might drive improvement. Ultimately, the Commission recommended the creation of a private‐sector entity, which then became the NQF. The expanding role of NQF over the next two decades is an instructive example of the collective efforts of many entities, whether professions, consumers, insurers, or others, working to shape and implement national policy, including the National Quality Strategy.
NQF’s overall purpose is to provide key leadership for a national health care quality measurement and reporting system. Its mission is focused on three themes: (a) build consensus on priorities and goals for health care quality; (b) play a major role in the endorsement of national consensus standards; and (c) use its collective membership to promote attainment of these standards in the delivery of care to consumers. From inception, the CMS, the Office of Personnel Management, and the AHRQ have been part of NQF. In addition, standard‐setting bodies like the Joint Commission, the National Commission for Quality Assurance, the IOM, the National Institutes of Health, and Physician Consortium for Performance Improvement (PCPI)–American Medical Association (AMA) have had key liaison roles as well. Currently, there are nearly 450 NQF organizational members.
The development and expansion of NQF have included input from nurses with representation from organizational membership in NQF from its inception and continuing to the present. The American Nurses Association (ANA) was the first NQF nursing organization member, with others following suit over the next 20 years. As many as 23 entities representing nursing have been NQF members at various times, and nursing has held a seat on the NQF Executive Board in the past.
The NQF employs three strategies to collectively move quality as a national priority as well in driving performance improvement. These three strategies have been used by other coalitions and individual professions as well: (a) convening experts across the industry to define quality by developing standards and measures; (b) gathering information from measurement of performance through data reporting and analysis; and (c) identifying gaps in performance, information about which is then provided back to providers, institutions, and others to initiate performance improvement and public reporting. In addition, NQF, like other collective efforts, places ongoing focus on dissemination of tools and educational activities that promote health care improvement in the United States.
The expansiveness of the NQF structure has provided many touch points for nursing to influence its direction. Calls for endorsement of standards or measures require formal comment and ballot‐type voting. Calls for nominations to work groups based on content expertise or representation allow for formally nominating nursing leaders who can speak on behalf of quality through a nursing lens. Nursing leaders have had opportunities to serve in leadership roles within committees and work groups to react to the work of colleagues from other disciplines, and to inform, persuade, or dissent as needed, in the shaping of policy. And nurses have been instrumental in the development of tools and resources to advance quality at the front lines.
National Priorities Partnership and Implementation of the National Quality Strategy
The National Priorities Partnership is another national collaborative effort, initially including 28 national health care organizations, convened in 2008 as an initiative of the NQF. Its role is to join stakeholders from both public and private sectors to influence policy encompassing every aspect of the health care system. Stakeholder groups include consumer groups, employers, government, health plans, health care organizations, health care professions, scientists, accrediting and certifying bodies, and quality alliances. Today the National Priorities Partnership includes three main areas of collaboration: the Measures Application Partnership (MAP), National Quality Partners (NQP), and the Measure Incubator.
Nursing was represented only by ANA in the initial stakeholder group, but the Nursing Alliance for Quality Care (NAQC) was added as the group expanded. The partnership took the early step of identifying a set of national priorities and goals to coalesce efforts toward achieving performance improvement by stakeholders on high‐leverage areas with the potential to make the most substantial contributions in the near term to the health care delivery systems of the nation and ultimately to consumers. In 2011 the National Priorities Partnership expanded its focus. Significantly, the full list of priorities and goals, consistent with the Quality and Safety Education for Nurses (QSEN) competencies identified in Chapter 1, had substantial impact on the final recommendations of the National Quality Strategy.
Measure Applications Partnership Driving Selection of Measures
The NQF has been named as a consensus endorsement agency, as required by Section 3014 of the ACA. In the habit of convening multistakeholder groups, it is expected to provide input to HHS, through federal government appointment, on the selection of performance measures for public reporting and performance‐based payment programs. In 2010, MAP was designed to service this purpose by an NQF board work group. MAP was designed as a two‐tiered structure that includes a standing multistakeholder coordinating committee to provide direction to and synchronize with the second tier of advisory work groups. The coordinating committee establishes the strategy for the partnership. The work groups identify measurement gaps across settings, prioritize measures, and recommend areas for realignment. NQF through the coordinating committee recommends to HHS measures for use in public reporting, performance‐based payment, and other programs.
MAP reviews standardized performance measures and makes recommendations to HHS for 18 federal programs that use measures for public reporting or payment purposes, including MIPS. NQF reported that in 2018 it updated its measures portfolio by reviewing and endorsing or re‐endorsing 38 measures and removing 40 measures. NQF also worked to remove measures from the portfolio for a variety of reasons, such as measures no longer meeting endorsement criteria; harmonization between similar measures; replacement of outdated measures with improved measures; and lack of continued need for measures where providers consistently perform at the highest level. This continuous refinement of the measures portfolio through the measures maintenance process ensures that quality measures remain aligned with current field practices and health care goals. Measure set refinements also align with HHS initiatives, such as the Meaningful Measures Initiative at CMS (https://www.federalregister.gov/documents/2019/06/26/2019‐13626/secretarial‐review‐and‐publication‐of‐the‐national‐quality‐forum‐2018‐activities‐report‐to‐congress).