Authors

  1. Kurtzman, Ellen T. MPH, RN

Article Content

This year, our nation faces 2 important milestones. The first is the 10-year anniversary of the publication entitled To Err is Human: Building A Safer Health System.1 The second is the inauguration of Barack Obama, the 44th president of the United States. Although these events occurred nearly a decade apart, they are connected, at least in part, by a uniting theme-a reexamination of the performance and recommitment to improvements in the quality and safety of our nation's healthcare system.

 

As policy makers examine the "current state" of healthcare quality and safety, they will likely conclude that change has been marginal. Despite the Institute of Medicine's revealing accounts of healthcare quality lapses and patient safety errors and the transformative agenda that was articulated in subsequent reports,2-5 current performance is suboptimal. Recently released studies all point to mediocre performance and ongoing variation, disparities, and inefficiencies.6-11

 

The Transparency and Accountability Agenda

Under the Bush administration, these trends were met with policies intended to improve quality and reduce costs. Referred to as "value-driven healthcare," recent national policy directions have relied on accountability and transparency to drive consumer selection, inspire provider improvement, and align payment with performance. Translated into practice, hospitals, home healthcare agencies, physician practices, dialysis centers, and other providers have had to contend with an ongoing effort to measure and report performance and align incentives with higher quality-with some early successes.12-14 In addition, there is no sign that these policies will be abandoned any time soon.

 

Although the new administration has had less than 60 days to initiate change, policies that promote healthcare transparency and accountability are likely to be sustained and reinforced. A recent Commonwealth Fund report, The 2008 Presidential Candidates' Health Reform Proposals: Choices for America,15 describes President Obama's plans to continue specific policies that reflect this agenda:

 

* public reporting of provider performance and policies that promote healthcare transparency;

 

* alignment of payment with performance and pay-for-performance initiatives;

 

* dissemination of best practices and clinical innovation;

 

* support for chronic disease management and preventative services; and

 

* emphasis on comparative, evidence-based practice.

 

 

Nursing's Influence on Patient Safety and Quality

As the new administration reforms healthcare, solutions that address both skyrocketing costs and low-level performance lie, at least in part, in the nation's nurses. Long-standing and newly emerging evidence supports this point.

 

* A maturing body of evidence links the size and composition of the nursing workforce to patient safety and healthcare quality outcomes. Recent literature reviews exploring the relationships between staffing and outcomes generally find positive and significant associations between staffing and failure to rescue, patient falls, and length of stay.16,17

 

* Nurses continue to hold the trust of the American public. In the annual Gallup Poll's survey, year after year, nurses are rated the most trusted and ethical professionals, outrating clergy, teachers, and public officials.18

 

* In national studies that examine patient safety, findings point to the need for modifications to the nursing work environment to realize dramatic improvements.19

 

* Current and worsening nursing shortages are likely to place patients in harm's way. In a national survey of nurses, hospital executives, and physicians, the shortage was viewed as a major problem in the quality of patient care.20

 

 

Although the body of science continues to grow, in order to accelerate the pace of improvement and use of precious resources, the nation must turn to its nursing workforce.

 

In what ways may nurses, who represent the single largest health profession in the United States,21-23 contribute to today's performance measurement, public reporting, and value-based purchasing directions? What activities should be undertaken by nurses-beyond those that have already been pursued-to shape transparency and accountability policies that will result in measurable improvements in nursing care performance? In what ways are nurses resourced to shape emerging policies? As the United States approaches the 10-year anniversary of the Institute of Medicine's report on patient safety, what further contributions should nurses make to formulate policies that result in improved quality and healthcare outcomes?

 

Strengthening Nursing's "Policy Voice"

With the support of the Robert Wood Johnson Foundation (RWJF) and in collaboration with leaders from selected nursing organizations, a new project housed at The George Washington University's Department of Nursing Education will begin to explore these questions. Over the next few months, national leaders will convene in Washington to examine emerging healthcare policy directions targeted at patient safety and quality, determine opportunities to influence the public policy debate, identify ways to strengthen nursing leadership's influence on the emerging transparency and accountability agenda, and explore the interest in and feasibility of establishing a devoted, unifying policy voice for nursing on these issues. This policy voice is referred to as the national Nursing Quality and Safety Alliance (NQSA).

 

The context in which these nursing leaders will contemplate NQSA is based on an explicit knowledge that the relationship between patients and nurses is intimate, unique, and critical to achieving improved health and well-being. Establishing NQSA holds enormous potential. It recognizes that without nursing engagement, dramatic and sustainable achievements in quality and safety for the American public are unlikely. Should it be pursued, the intent will be for NQSA to do as follows:

 

* inspire continued trust and confidence among the public in the nursing profession,

 

* leverage the single largest healthcare workforce in quality and the national policies that underpin quality, and

 

* motivate policies that accelerate nursing-directed improvements in quality and safety.

 

 

Envisioning NQSA

As the Obama administration gets settled in Washington, our nation's nursing leaders will be envisioning a future in which nursing's influence is more fully reflected in our nation's healthcare policies. Imagine a future with the following:

 

* National policies that influence patient safety and healthcare quality are translated for and disseminated to nurses in all settings. This translation would enable rapid practice change. For example, campaigns on reducing readmission rates and hospital-acquired conditions might be undertaken.

 

* Public reports of healthcare quality including those published by The Joint Commission, National Committee on Quality Assurance, Leapfrog Group, and Centers for Medicare & Medicaid Services include measures that quantify nurses' contributions to safety and patient outcomes. For example, these reports would include nurse staffing measures as well as pressure ulcer and falls rates.

 

* Value-based purchasing programs and financial rewards paid to providers in exchange for high performance reflect nursing's role in quality and safety. For example, Medicare's full annual payment update would be contingent on hospitals' exchanges of quality reporting data that include nursing-sensitive outcomes and staffing measures.

 

* Prompt responses to federal legislation and regulation that impact nursing care and nursing-related quality and safety are crafted and delivered to policy makers. Ongoing advocacy efforts would result in policies that are "friendlier" to nursing.

 

* Goals for high-performing nursing care across settings and healthcare episodes are established, and regular reports on the nation's performance against these goals are published.

 

 

The anniversary of the publication To Err is Human: Building A Safer Health System and last month's inauguration herald significant opportunities for nurses. After a decade-long effort, we know that trying harder will not work. With the assistance and dedication of leaders from the national nursing organizations, involvement by the larger nursing community, and support from RWJF, a clearer understanding of these opportunities and an interest in establishing a unified policy voice will be explored. By reinvesting our collective energies in influencing national healthcare policy directions through NQSA, there is the potential to improve care for patients, avoid unwanted suffering, and sustain the trust of the American public.

 

For more information on the GW project funded by the RWJF, Planning a National NQSA, visit http://www.gwumc.edu/healthsci/departments/nursing/research.cfm or contact the author directly at hspetk@gwumc.edu.

 

References

 

1. Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington, DC: National Academies Press; 2000. [Context Link]

 

2. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press; 2001. [Context Link]

 

3. Institute of Medicine. Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington, DC: National Academies Press; 2004. [Context Link]

 

4. Institute of Medicine. Performance Measurement: Acceleraing Improvement. Washington, DC: National Academies Press; 2006. [Context Link]

 

5. Institute of Medicine. Rewarding Provider Performance: Aligning Incentives in Medicare. Washington, DC: National Academies Press; 2007. [Context Link]

 

6. Agency for Healthcare Research and Quality. 2007 National healthcare quality report. Rockville, MD: US Department of Health and Human Services, Agency for Healthcare Research and Quality. February 2008. AHRQ Pub. No. 08-0040. Available at http://www.ahrq.gov/qual/nhqr07/nhqr07.pdf. Accessed November 14, 2008. [Context Link]

 

7. Agency for Healthcare Research and Quality. 2007 National healthcare disparities report. Rockville, MD: US Department of Health and Human Services, Agency for Healthcare Research and Quality. February 2008. AHRQ Pub. No. 08-0041. Available at http://www.ahrq.gov/qual/nhdr07/nhdr07.pdf. Accessed November 14, 2008. [Context Link]

 

8. The Joint Commission. Improving America's Hospitals: The Joint Commission's Annual Report on Quality and Safety 2007. Oakbrook Terrace, IL: The Joint Commission. November2007. Available at http://www.jointcommissionreport.org/pdf/JC_2007_Annual_Report.pdf. Accessed November 14, 2008. [Context Link]

 

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11. Mangione-Smith R, DiCristofaro AH, Setodji CM, et al. The quality of ambulatory care delivered to children in the United States. N Engl J Med. 2007;357:1515-1523. [Context Link]

 

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15. Collins SR, Nicholson JL, Rustgi SD, David K. The 2008 Presidential Candidates' Health Reform Proposals: Choices for America. New York, NY: The Commonwealth Fund. October 2008. Available at http://www.commonwealthfund.org/usr_doc/Collins_2008presidentialcandidateshltref. Accessed November 14, 2008. [Context Link]

 

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18. Saad L. Nurses shine, bankers slump in ethics ratings. Annual honesty and ethics poll rates nurses best of 21 professions. Princeton, NJ: The Gallup Poll. November 24, 2008. Available at http://www.gallup.com/poll/112264/Nurses-Shine-While-Bankers-Slump-Ethics-Rating. Accessed November 25, 2008. [Context Link]

 

19. Institute of Medicine. Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington, DC: National Academies Press; 2004. [Context Link]

 

20. Buerhaus PI, Staiger DO, Auerbach DI. The Future of the Nursing Workforce in the United States: Data, Trends, and Implications. Salisbury, MA: Jones and Bartlett Publishers; 2008. [Context Link]

 

21. Bureau of Labor Statistics. US Department of Labor. Occupational Outlook Handbook, 2006-07 Edition, Registered Nurses. Available at http://www.bls.gov/oco/ocos083.htm. Accessed July 6, 2007. [Context Link]

 

22. US Department of Health and Human Services. The Registered Nurse Population: Findings From the March 2004 National Sample Survey of Registered Nurses. Washington, DC: US Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Professions, Division of Nursing; February 22, 2002:6. Available at ftp://ftp.hrsa.gov/bhpr/workforce/0306rnss.pdf. Accessed July 6, 2007. [Context Link]

 

23. US Department of Health and Human Services. Supply, Demand, and Use of Licensed Practical Nurses. Washington, DC: US Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Professions, Office of Workforce Evaluation and Quality Assurance. Available at ftp://ftp.hrsa.gov/bhpr/nationalcenter/lpn.pdf. Accessed July 6, 2007. [Context Link]