Quality and Safety in Nursing. Группа авторов
due to tremendous patient loads. Further, most electronic health record systems do not collect meaningful data that would allow sufficient analysis about social determinants of health, often leading to inequitable care delivery.
The challenge of many electronic systems is that while many data go into the system, particularly in the delivery of nursing care, it can be nearly impossible to extract them for reporting and analysis. Further, decision supports based on data that identify a patient with a stage‐two pressure ulcer, for instance, must also incorporate, in a timely way from the patient perspective, an evidence‐based, appropriate plan of action to both prevent further skin breakdown and begin healing. From a public reporting perspective, is it enough to know that a patient is at risk of experiencing a pressure sore while hospitalized? Engaged consumers and insurers will want to know what the data show about not only the prevention of decubiti, but also the appropriateness of treatment, the speediness of recovery, lost work days, and impact on the quality of life. Policy‐makers are interested in lengths of stay and other factors that drive up the cost of such hospital‐acquired conditions.
Nursing continues to drive forward in the development of electronic measures (eMeasures), particularly data collection on the incidence of pressure ulcers. As of yet, no pressure ulcer eMeasure has been endorsed by NQF, nor is there national‐level public reporting of any nursing measures.
Nursing informatics and the use of nursing terminologies are central to capturing key data elements in a consistent way. Adherence to consensus‐based terminologies, both for the collection of data around the nursing‐sensitive measures but also the processes of care, is necessary to articulate the actual contributions of nurses, their importance in keeping patients safe, and improving the quality of care, as identified in both the IOM reports and the QSEN competencies (Cronenwett et al., 2007, 2009).
A major contributor to this agenda was the Technology Informatics Guiding Education Reform (TIGER) initiative, launched as a result of a 2006 conference convened to create a vision for the future of nursing, bridging the quality chasm with IT, enabling nurses to use informatics in practice and education to provide safer, high‐quality patient care. The development and implementation of the TIGER initiative are described in Chapter 9. Although the EU*US eHealth Work Project has ended, TIGER is currently compiling global case studies to continue bringing the work to life, with a focus on all states within the EU (https://www.himss.org/tiger‐initiative‐international‐competency‐synthesis‐project).
Quality Alliances Influence Policy Actions through a Professional Lens
Various professions have followed a model similar to that of NQF while determining their own efforts to influence the measurement of quality, support quality improvements, and take action at a national policy level. From a positive perspective, these alliances create a pipeline for their profession’s or specialty’s representation at national stakeholder tables, for grooming nominees with the expertise to inform measure development and policy setting, and for providing national leadership for the overall quality agenda. Each faces similar challenges, including that of determining membership and governance structures and dues for long‐term financial sustainability. Each needs to coordinate with other stakeholders and standard setters among its own discipline in order to lead with one voice. Externally, each alliance forms a coherent, coordinated, and consistent approach to quality and measurement that moves the health care system forward as a whole, without becoming counterproductive. Most alliances have some combination of stakeholders among their membership or board that reflects other disciplines, as well as federal agencies such as AHRQ, CMS, or NQF, to provide some level of transparency, consistency, and connectedness. Financial support of each alliance varies, but for most, ongoing sustainability becomes a challenge to the mission of the stakeholders.
Nursing Alliance for Quality Care
Nursing through the NAQC (https://www.nursingworld.org/practice‐policy/naqc) has created its own alliance of national nursing stakeholder organizations in partnership with patient care advocacy organizations representing consumers. NAQC’s membership continues to shift over time, yet remains viable, finding that space where nursing can collectively make the largest contribution to the quality arena. Formed in 2010 from a Robert Wood Johnson Foundation–funded planning grant, NAQC is committed to advancing the highest quality, safety, and value of consumer‐centered health care for patients, their families, and their communities. Governed by an independent board of directors, NAQC first sought long‐range expected outcomes that include the following:
Patients receiving the right care at the right time by the right professional.
Nurses actively advocating and being accountable for consumer‐centered, high‐quality health care.
Policy‐makers recognizing the contributions of nurses in advancing consumer‐centered, high‐quality health care.
NAQC focused on four goals to accomplish these three outcomes: (a) support consumer‐centered health care quality and safety goals to achieve care that is safe, effective, patient‐centered, timely, efficient, and equitable; (b) performance measurement and public reporting that strengthen the role of nursing in transparency and accountability activities; (c) advocacy, by serving as a resource to partners and stimulating policy reform that reflects evidence‐based nursing practice and advances consumer‐centered, high‐quality health care; and (d) building nursing’s capacity to serve in leadership roles that advance consumer‐centered, high‐quality health care. NAQC provided national‐level conferences that supported important policy changes, including nurse‐led medical homes, nurses’ roles in ACOs, and nurses’ roles in fostering patient and family engagement.
In 2013, NAQC determined that its long‐term strategy for sustainability as an alliance required a more permanent home within one of the existing member organizations. It now resides within ANA, maintaining memberships from among the leading national nursing associations. NAQC retains a seat as an alliance at various national tables.
Since 2013, NAQC has continued to embrace work in several areas of quality improvement. It has continued to pursue the transition of QSEN competencies and principles from education to practice. NAQC believes that its various constituencies are knowledgeable regarding the QSEN competencies, but have less comfort in translating them into practice. It also has noted that there is an evident gap with new graduates, who are educated regarding the competencies but are unable to employ them to their satisfaction when they arrive at their first place of employment. After multiple NAQC leadership discussions regarding the education to practice gap, dialogue began among QSEN leadership and NAQC Advisory Board members. From 2017 significant discussion resulted in a new partnership between the two entities. At this time QSEN has incorporated into its nationally searchable database educational exemplars, the first of what is hoped will be many practice exemplars, seeking to reduce the gap between education and practice in a variety of settings from ambulatory, to obstetrics, to acute care, and to the operating room. NAQC believes that it can work with its constituencies to engage them in populating this database.
NAQC’s second enduring initiative continues to be focused on patient and family engagement (patient‐centered care). Given the length of time since its initial White Paper on Nurses' Critical Role in Fostering Patient and Family Engagement in 2013, NAQC has witnessed the explosion of interest in patient involvement, shared decision‐making, and patient advocacy (Sofaer and Schumann, 2013). It is currently engaged in an updated review of literature and the drafting of an updated version of this work, more heavily focused on interdisciplinary efforts.
NAQC is also at the table participating in the National Quality Partnership Leadership Consortium and in both financially supporting and participating in an Action Team to Co‐Design Patient‐Centered Health Systems.
Alliance for Home Health Quality