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What initiatives and/or strategies can the DNP leader employ to build a culture of quality and safety?

Quality and Safety Initiatives in America

What are the driving forces and restraining forces for quality and safety?

What initiatives and/or strategies can the DNP leader employ to build a culture of quality and safety?

How can we combat the restraining forces?

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Strategic Management and Professional Identity (Leadership Role) Formation

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As a DNP-prepared leader, what transformational leadership strategies can you employ to address these issues (i.e. care delivery, payment models, integrated healthcare delivery systems, value-based purchasing)?

What aspects of professional identity (leadership role) formation would you anticipate acquiring to address such issues?

Driving Forces for Quality and SafetyChanging Mindsets to Improve Health Care

Gwen Sherwood, PhD, RN, FAAN, ANEF

Julia stashed her umbrella and looked at the overflowing waiting room of the Emergency Department (ED) where she had worked weekends for the past five years. It was summer and staffing was short even for a Sunday evening in August; several staff were on vacation and one called in sick. A storm had pounded the area, and there was a power outage. The hospital was on the emergency generators, and that meant the electronic chart was slow in response because of the overload. Staff were taking shortcuts due to time pressures. She thought about these breakdowns and remembered the workshop she recently attended on quality improvement. The focus had been on identifying problems and applying quality improvement tools to collect data on the problem, analyze results, and design solutions to close the gap between actual and desired practice. She noted that Ms. Masraf was in the waiting area; she had diabetes, and wounds were difficult to heal. Infection was a constant threat so she had been to the emergency department on several occasions. Julia turned at the sound of a crash and saw that one of the nurse aids had fallen where water had collected from wet umbrellas. Falls were common in the ED as a result of the population served. Patients may be unstable due to their disease condition or influence of alcohol or drug use. She wondered if she could initiate a quality improvement study on any of these continuing problems she saw every time she came to work. Other staff seemed to think this was just a part of how the emergency room functioned.

In 1999, the Institute of Medicine (IOM), a not‐for‐profit organization sponsored by the United States National Academy of Sciences, released To Err Is Human (2000), which estimated there were between 44,000 and 98,000 deaths each year as a result of medical harm. Makary and Daniel (2016) declare this number is both limited and out of date. Their projection released in 2016 cites the deaths due to medical error is more likely 251,454, making this the third leading cause of death in the United States. Since the IOM series of reports focused attention on the issues in health care quality and safety, responses have included regulatory changes, new roles and responsibilities for health care professionals, and calls for a new educational paradigm. Still, health care safety remains a major threat (Balik and Dopkiss, 2010; Cronenwett, 2012; Leape and Berwick, 2005; Wachter, 2004; Wachter, 2010).

The original 1999 report was the first evidence of the gap between the status of health care delivered and the quality of health care that the IOM panel believed Americans were entitled to receive. A number of reports have heralded ways to improve the system of care. The 2001 Crossing the Quality Chasm: A New Health System for the 21st Century issued recommendations for sweeping changes in our systems. This was followed by the 2003 IOM report, Health Professions Education: A Bridge to Quality, which called for a radical redesign of health professions education to achieve six core competencies described as essential to improve twenty‐first century health care: patient‐centered care, teamwork and collaboration, evidence‐based practice, quality improvement, safety, and informatics. The attention from the series of IOM reports over the past 15 years demonstrates that quality and safety are the leading contemporary issues in health care, contributing to costs and poor outcomes. Current health care reform in the United States is based on improving quality outcomes; health care mistakes cost the system between $17 billion and 29 billion each year and costs patients and families economically but also emotionally and physically. Providers who work in flawed systems and deal with inadequate resources experience dissatisfaction and low morale. For all, there is an erosion of trust from the pitfalls experienced.

Health professions education continues to undergo transformation to include preparation in the knowledge, skills, and attitudes (KSA) needed to improve our systems of care (Batalden, Leach, and Ogrinc, 2009; Cronenwett et al., 2007). In 2011, representatives of the major health professions worked together to reach consensus on four domains of interprofessional education competencies that crosswalk these competencies for improving quality and safety: roles and responsibilities, teamwork, communication, and ethics and values (Interprofessional Education Collaborative [IPEC], 2011).

The same questions from 15 years ago continue to need solutions. What are issues in redesigning our systems of care? How do we prepare health professionals with what they need to know and do? How can organizations develop cultures of quality and safety? This chapter will examine the impact of the driving forces for the changes needed, application of quality and safety science to reframe organizational cultures for quality improvement and safety, and a fresh look at how these reframe the education needs for nurses. In a safety culture, the paradigm shifts from individual performance to system initiatives and redesigns to monitor outcomes of care, and situates the patient as a full partner in care.

The Compelling Case for Quality and Safety

When the initial data revealed in the IOM Quality Chasm series of reports became public it, sent shock waves throughout the industry and grabbed the attention of consumers (Textbox 1.1). The evidence reported in this series identified the imperative for changing mindsets to include quality and safety as part of the everyday work of nurses and other health professionals. Prior to release of the first report in 1999, the issues were wrapped in silence; without a reporting system, there was not an evidence base to establish the scope or depth of system issues that contributed to poor quality and safety. There was no national tracking system and little pressure to improve quality and safety outcomes from regulators, health care purchasers, or third‐party payers. And, without just culture emphasis, there was little transparency or accountability in sharing information with patients and families who experienced harm.

Textbox 1.1 Summary: The Institute of Medicine Quality Chasm Series (www.iom.edu)

  • To Err Is Human: Building a Safer Health System (2000)

This first IOM report presented the first aggregate data on the depth and breadth of quality and safety issues in US hospitals. Analysis of outcomes from hospitals in Colorado and Utah concluded that 44,000 people die each year as a result of medical errors and that in New York hospitals, the number is 98,000. Even using the lower number, more people die annually from medical error than from motor vehicle accidents, breast cancer, or AIDS. Medical errors are the leading cause of unexpected deaths in health care settings. Communication is the root cause of 65% of sentinel events. The report presents a strategy for reducing preventable medical errors with a goal of a 50% reduction over five years.

  • Crossing the Quality Chasm: A New Health System for the 21st Century (2001)

The IOM issued a call for sweeping reform of the American health care system. A set of performance expectations for twenty‐first century health care seeks to assure that patient care is STEEEP. These aims provide the measures of quality to align incentives for payment and accountability based on quality improvements. The report includes causes of quality gaps and barriers to improve care. Health care organizations are analyzed as complex systems with recommendations for how system approaches can help implement change.

  • Health Professions Education: A Bridge to Quality (2003)

Education is declared as the bridge to quality based on five competencies identified as essential for health professionals of the twenty‐first century: patient‐centered care, teamwork and collaboration, evidence‐based practice, quality improvement (and safety), and informatics. Recommendations include developing a common language to use across disciplines, integrating learning experiences, developing evidence‐based curricula and teaching approaches, initiating faculty development to model the core competencies, and implementing plans to monitor continued proficiency in the competencies.

  • Keeping Patients Safe: Transforming the Work Environment of Nurses (2004)

The 2004 IOM report links nurses and their work environment with patient safety and quality of care. The findings of this report have helped shape the role of nurses in patient care quality and safety efforts. Key recommendations are creating a satisfying and rewarding work environment for nurses, providing adequate nurse staffing, focusing on patient safety at the level of organizational governing boards, incorporating evidence‐based management in the management of nursing services, building trust between nurses and organizational leaders, giving nurses a voice in patient care delivery through effective nursing leadership and participation in executive decision‐making, providing organizational support to promote learning for both new and experienced nurses, promoting interdisciplinary collaboration, and designing work environments and culture that promote patient safety.

  • Identifying and Preventing Medication Errors (2006)

Medication errors make up the largest category of error with as many as 3–4% of patients experiencing a serious medical error while hospitalized. This report presents a national agenda for reducing medication errors and the huge costs associated with medication errors. Changes across the health care industry require collaboration from doctors, nurses, pharmacists, the Food and Drug Administration and other government agencies, hospitals and other health care organizations, and patients.

The 2001 IOM report, Bridging the Quality Chasm, identified the STEEEP model to improve health care quality and safety. STEEEP outlines performance measures to assure care is safe, timely, effective, efficient, equitable, and patient centered. These aims provide the measures of quality and accountability that continue to elude health care. Although the United States spends more than any other country on health care, the system has significant shortcomings, particularly in efficiency, quality, access, safety, and affordability (Davis, Schoen, and Stremikis, 2010). The fragmentation and decentralization of the health care system is a barrier to quality and safety; for example, patients may see multiple providers who may not be able to share critical patient information due to a lack of technology infrastructure or have a feeling of ownership that precludes sharing and consultation. Although most data are based on acute care in patient settings, errors can occur in physician offices, outpatient settings, nursing homes, patient homes, and so forth. An annotation of the reports with their recommendations is provided in Textbox 1.1.




The data are startling, particularly related to medication errors, one of the most common according to Identifying and Preventing Medication Errors(Aspen et al., 2007). Medication errors particularly impact nurses. Nurses have the primary responsibility for medication administration with patients in a complex environment. Medication errors account for over 7,000 deaths annually. On average, inpatients may experience at least one medication error per day. At least 1.5 million preventable adverse drug events occur each year. Almost 2% of admissions experience a preventable adverse drug event, which increases hospital costs by $4,700 per admission or about $2.8 million annually for a 700‐bed hospital; multiplied, this would account for $2 billion nationally.

The costs associated with quality and safety are complex; accounting includes lost income, health care costs, and other expenses. The national cost for preventable adverse events ranges between $17 billion and $29 billion; additional health care accounts for more than half of these totals because tests and treatments may have to be repeated or others added, and patients may need to extend their hospital stay. In addition to these costs, there are intangible, immeasurable costs, such as patients may suffer or be inconvenienced, have lower satisfaction with care, and lose trust in the system. Most of what is known about the financial and other burdens are hospital related. Data are just beginning to emerge on costs associated with quality and safety across the continuum of care, including ambulatory, home health care, and skilled care.

Health care workers are also affected by the quality of care in the systems in which they work. They may experience loss of morale and lower satisfaction when they are not able to provide the best care possible. Keeping Patients Safe: Transforming the Work Environment of Nurses (Page, 2004) is a comprehensive analysis of the factors influencing nurses’ work. Health care is value based; as professionals we pledge, first, to do no harm. Quality is an essential value. Professionals take pride in doing the right thing, but quality is more than will; it is a mindset of inquiry and the capacity to use appropriate tools to improve systems in which we work. Quality improvement intersects all areas of health care from economic issues to the moral basis undergirding quality for doing our best. It builds on the shared values and moral commitment common to all health professionals. Health professionals have the motivation and ability to improve systems if they have the necessary education and training and work in organizations where quality improvement is integrated as part of daily work.

Consumers have helped motivate changes in health care. Patients and families who experienced adverse events have called for reform in how health care systems identify, investigate, report, and share information related to errors. Patients and families who experience health care mistakes leverage their influence to prevent similar events happening to others. National organizations such as the National Patient Safety Foundation (NPSF) (www.npsf.org) serve both consumers and health professionals. Numerous nonprofit organizations created in response to adverse events focus attention on particular care delivery issues as well as broader issues, establishing patient advocacy with an increasing influence in health care. Many patients or their family members now serve on hospital boards or consumer panels, share their stories in learning situations, and bring growing pressures to have systematic participation in all areas of health care.

The health care industry is applying lessons from other industries, particularly those known as high‐reliability organizations (www.ahrq.gov). A key difference is that most other industries that have had dramatic improvements in quality and safety were supported by a designated agency that sets and communicates goals, brings visibility, and systematically collects and analyzes error reports for root cause analysis; however, health care lacks a single designated agency, as responsibilities are spread among various groups. Although numerous agencies have emerged to promote the safety and quality agenda, none have the purpose of collecting safety or quality data for systematic analysis with broad dissemination to assure that best practice and safety alerts are implemented across all settings. Schumann (2017) offers a summary of these federal, regulatory, professional, and consumer agencies and organizations.

With lack of information on which errors occur and how they occur, and systematic dissemination of the information we do have, health care has lagged behind other high‐risk industries in establishing a safety focus. Aviation has focused on safety for more than 50 years with significant reduction in fatalities. Health care has adopted and adapted principles and approaches from aviation as well as other high‐reliability organizations that have similar characteristics, such as intermittent, intense tasks that demand exacting responses. By systematically collecting data on sentinel events for review through standardized processes, these industries have been able to monitor and improve safety in their systems.

Health care delivery organizations have a significant role in safety. Systems are a set of interdependent components that interact to achieve a common goal. For example, a hospital is a system composed of service lines, nursing care units, ancillary care departments, outpatient care clinics, and so forth. The way in which these separate but united system components interact and work together is a significant factor in delivering high‐quality, safe care. Organizational leadership helps align quality and safety goals with mission and vision so that it is practiced consistently throughout all areas and levels of the system (Triolo, 2012). High‐reliability organizations focus on safety; it is pervasive in their culture to be mindful of where the next error may occur to increase vigilance, establish check lists, or implement other preventions (Barnsteiner, 2012).

Examining Familiar Terms: The Science of Quality and Safety

Quality and safety are intertwined, complex concepts with multiple dimensions. Lack of a comprehensive understanding of the full scope of these terms is but one barrier for implementing quality and safety strategies. It is difficult to reshape the mental model of these broad terms held by health care workers and change attitudes about the necessity of focusing on safety. Overcoming these historic views and overuse of the terms are part of the application of the new KSAs associated with the science of quality and safety.

Though interrelated, quality and safety comprise different concepts. Quality improvement uses data to monitor outcomes of care processes that help guide improvement methods to design and test changes in the system to continuously improve outcomes (Compas, Hopkins, and Townsley, 2008; Johnson, 2017). The goal of quality is to reach for the best practice, and the goal is determined by measuring the reality of the care delivered compared with benchmarks or the ideal outcome. Continuous quality monitoring is the mechanism by which the health care system can be transformed through the collaboration of health care professionals, patients and their families, researchers, payers, planners, and educators. All are working toward a triangle of improvements that lead to better patient outcomes (health), better system performance (care), and better professional development (education) (Bataldan and Davidoff, 2007). All health professionals must know how to assess the scientific evidence to determine what constitutes good care, identify gaps between good care and care delivered in their setting, and implement actions to close gaps (Sherwood and Jones, 2011).

Safety science embraces an organizational framework to minimize risk of harm to patients and providers through both system effectiveness and individual performance by applying human factors as discussed more fully by Barnsteiner in another chapter (2017) and Sammer and colleagues (2010). Safety science builds on Reason’s human error trajectory, which uses the model of lining up a stick through the holes of Swiss cheese; sometimes redundancies in the system fail, and all the holes line up (2000).

Error is the failure of a planned action to be completed as intended or the use of an incorrect plan to achieve an aim. Reason identified two kinds of failure that constitute error:

  1. Error of execution in which the correct action does not proceed as intended
  2. Error of planning in which the original intended action is not correct

An adverse event is the injury that results from care delivered or from care management, not from the underlying patient condition or the reason the patient was seeking care. Preventable adverse events are those attributed to error. There are also various types of errors. Diagnostic errors delay diagnosis, prevent use of appropriate tests, or result in failure to act. Treatment errors can occur while administering treatment, include errors in administering medication, lead to avoidable delay in treatment or response to treatment, or contribute to inappropriate care. Other examples are failure to provide prophylactic treatment, inadequate monitoring or follow‐up, failure to communicate, equipment malfunction, or other system failure.

Errors can be defined in multiple ways with varied components. It is a challenge to develop a unified reporting system that can be used across settings or nationally, in the same way that the aviation industry aggregates reports of airline events. Inconsistent nomenclature of a long list of terms adds to the difficulty of consistently reporting similar events in a central system. Organizations with a culture of safety have implemented processes through risk management to collect error reports for root cause analysis, often classifying them using a tiered system of potential for harm. Carefully detailing all steps and decisions leading to an error or near miss can formulate a system redesign of processes that lessens the chance of future occurrence. The focus is on improving the system to prevent future errors rather than merely blaming individuals. Exploring what happened acknowledges the influence of complex systems and human factors that influence safety. In a just culture, the focus is to determine what went wrong rather than identifying exactly who committed the error to establish blame and punishment. Just culture establishes an environment in which errors and near misses are acknowledged, reported, and analyzed for ways to improve the system. Accountability remains a critical aspect of a culture of safety; recognizing and acknowledging one’s actions is a trademark of professional behavior.

Nurses are in the forefront of examining the work environment to identify quality and safety issues and the influence of human factors, the interrelationship between people, technology, and the environment in which they work (Page, 2004). Human factors consider the ability or inability to perform exacting tasks while attending to multiple tasks at once. For system improvements, organizational leadership must give attention to human factors such as managing workload fluctuations, seeking strategies to minimize interruptions in work, and attending to communication and care coordination across disciplines. Nurses manage care coordination and employ checklists and other strategies to assure safe handoffs between providers and settings. Nurses are challenged by other human factors that impact quality and safety, such as multitasking, distractions, fatigue, task fixation that limits environmental scanning, and hierarchy and authority gradients. Staffing, interpersonal relationships, and the lack of education on quality and safety are among the multiple human factors that impact quality and safety.

Assuring quality and safety involves more than individual accountability; poorly designed protocols and system designs also contribute to quality and safety outcomes (Hughes, 2008). The best way to reduce health care harm is by preventing errors before they happen. Focusing on safety helps eliminate discrepancies in care that result from provider actions in delivering care. Safety huddles or safety briefings are becoming a part of daily routine in many hospitals to identify and focus on high risk situations.

Quality improvement is a critical component of safety—it requires assessing safety issues for prevalence, making comparisons across units or departments, and using benchmark data to help clinicians improve their own practice as well as that of the system. When principles and strategies from quality improvement are applied, the rate of medication errors occurring in a given setting can be measured and compared with a peer unit or industry benchmark. Root cause analysis can determine reasons for errors in medication administration to change the system to prevent or lessen the possibility of errors occurring.

National Organizations for Quality and Safety

Many of the improvements in our health care systems are the result of regulatory mandates from groups such as the Joint Commission (www.jointcommission.org), which grants institutional accreditation and opens the possibility of different aspects of federal funding (Wachter, 2004; Wachter, 2010). The Joint Commission also established the National Patient Safety Goals that are updated annually. The goals provide guidance in key areas of high vulnerability and share evidence for solutions by emphasizing a systematic process for quality improvement, patient safety, and monitoring outcomes. The Joint Commission also established regulations to eliminate disruptive behavior among health care professionals and required organizations to have a code of conduct to define acceptable and inappropriate behavior as well as a process for managing such behaviors.

The Institute for Healthcare Improvement (IHI) (www.ihi.org) is a strong advocate for quality and safety innovations, bringing collaboration among all professions. The IHI’s 100,000 and 5 Million Lives campaigns are just two examples of focused collective efforts for improving outcomes. IHI describes the goals of health care reform in the US as the Triple Aim: improve population health, reduce costs, and improve the quality of care (Berwick, Nolan, and Whittington, 2014). These goals align with the STEEEP model from the IOM (2001) and also place new demands on health care professions education programs to prepare a workforce capable of changing the system (Reeves et al., 2013). New skills for interprofessional care, quality and process improvement, and population health management‐meaning educational institutions must align with practices, health systems and the communities they serve (Brandt et al., 2014). The work of the Affordable Care Act seeks reform and redesign of the systems of care to provide better care, align cost and value, and improve outcomes. Professional nursing organizations have responded to the imperative to improve quality and safety in health care systems (Earnest and Brandt, 2014).

Schumann (2017) provides a comprehensive description of national groups and their goals of quality and safety. The American Nurses Association, following a long history of promoting quality assurance, and the International Council of Nurses (2002) developed a new framework on quality improvement distributed nationally and globally (Doran, 2010). The Magnet recognition program based standards on continuous quality improvement to recognize nursing leadership and organizational quality in nursing care delivery (Triolo, 2012). The standards reinforce conditions in the organization and practice environment that support and facilitate nursing excellence. Recognition is linked to improvement in nurse recruitment, retention, quality outcomes, and patient satisfaction scores. The American Nurses Association also established the National Database of Nursing Quality Indicators in 1998, which maintains data on sustained improvement in a designated nursing‐sensitive indicator such as staffing, hospital‐acquired pressure ulcers, falls and prevention of injury from falls, staff satisfaction, and pediatric and psychiatric mental health data (Montalvo and Dunton, 2007; Schumann, 2017).

Federal programs in Medicare and Medicaid have helped define nurses’ roles and revised the payment structure for health care. Medicare and Medicaid subsequently developed programs to reduce hospital‐acquired conditions, or those conditions that were not present at the time of a patient’s hospital admission (Bodrock and Mion, 2008; Centers for Medicare and Medicaid Services, 2008). Hospitals are no longer reimbursed for 10 preventable hospital‐acquired conditions, many of which were part of nursing care interventions (Hines and Yu, 2009). Other third‐party payers and large employers have “pay for performance” plans in which health systems receive additional economic incentives when specific quality targets are met, many of which are nurse driven.

Comparing Progress to Improve Quality and Safety

The IOM (2001) issued four recommendations to change the system:

  • Create a national focus through leadership, research, tool kits, and protocols to enhance knowledge about safety.
  • Identify and learn from errors by establishing a vigorous error reporting system to assure a safer health care system.
  • Increase standards and expectations for safety improvements through oversight groups, professional organizations, and health care purchasers.
  • Improve the safety system within health care organizations to assure care improves.

Improvements to quality and safety have been slow and uneven. Two progress reports 5 years and 10 years after the release of To Err Is Human (IOM, 2000) examine progress based on these goals. Longo et al. (2005) used a 91‐item survey to assess changes over time between two survey points in 2002 (N = 126) and 2004 (N = 128) in hospitals in Missouri and Utah that had collaborated on a patient safety project funded by the Agency for Healthcare Research and Quality (AHRQ). Assessment included seven variables: computerized physician order entry systems and test results, and assessments of safety procedures; specific safety policies; use of data in patient safety programs; drug handling procedures; manner of handling adverse events reporting; prevention policies; and root cause analysis. Five years after the initial report, hospitals were still not satisfactorily meeting the IOM recommendations. Progress is slow, and technology applications that could improve safety lag.

Another study (Wachter, 2004) measured five areas of patient safety five years after the initial release of the IOM data and also reported slow progress in addressing safety and quality goals. Robust regulations had an initial impact on early improvements, but that impact slowed quickly because regulations alone do not result in lasting change. Progress was noted in information technology applications and workforce organization and training. Still, there was little demonstrable impact from early error reporting systems and only small improvement in accountability. At five years after the initial galvanizing report, Wachter concluded, “we are at the end of the beginning,” meaning much work remains.

In 2010 Wachter assessed10‐year progress following publication of To Err Is Human (2000). Using a report card grading system from A (highest) to D (lowest), he assessed 10 key patient safety domains based on 1999–2004 and 2004–2009. Overall, Wachter graded the progress in safety as a B–, a modest improvement from a C+ based on data in the 2004 report. Leadership engagement from provider organizations and reporting systems were gauged as having made the most progress. There is a stronger business case for hospitals to concentrate on their safety efforts due to stronger accreditation standards and error reporting requirements. Interventions across national and international organizations receive the highest grade, including major campaigns from groups such as IHI, AHRQ, the Joint Commission, the National Quality Forum, and the World Health Organization. Few hospitals have moved to fully implement information technology applications. More systems are implementing a safety culture that balances no blame with accountability. Research is advancing in spite of inadequate funding. Progress in workforce and training is limited as few organizations have robust teamwork or culture change, but some impact has been felt from reducing residents’ duty hours and easing of the nursing shortage. Patient engagement and involvement remains small, with more progress related to disclosure policies and procedures, also addressed by Balik and Dopkiss (2010). Payment system intervention is uncertain, as pay for performance is only beginning. Wachter concludes that our limited ability to measure safety outcomes is a major barrier to progress.

Measuring the impact of quality and safety efforts is challenging, particularly patient deaths due to preventable harm because of its hidden nature; it sometimes depends on providers being willing to share exactly what happened, varying definitions of what is reportable, and fear of punishment. Since the 1999 IOM report, several studies have issued projections of patient deaths due to preventable harm from a health care encounter.

Inpatient deaths between 2000 and 2002 based on AHRQ Patient Safety Indicators in a Medicare population estimated 575,000 deaths extrapolated to 175,000 per year (Health Grades, 2004). A 2008 report from the Inspector General reported 180,000 deaths annually among Medicare inpatients (Department of Health and Human Services [HHS], 2008). Classen et al. (2008) projected roughly 400,000 deaths per year; Landrigan et al. (2010) studied North Carolina inpatients over six years and estimated 134,581 deaths; James (2013) projected a range of 250,000 to 400,000 per year, and, as noted earlier, Makary and Daniel (2016) estimated 251,454. These reports demonstrate the challenges in accurate numbers because of reporting issues, and as Makary and Daniel note, there is no diagnosis for death from medical error on death certificates, which they used for their report. Regardless of the exact number, these reports, like the report cards above, indicate change is coming slowly in trying to reduce patient harm due to error. Still, with any number above zero, work remains to be done.

Other indicators show promise. A focused effort implemented by The Joint Commission (2014) reduced patient falls by 35% in seven hospitals. Between 2010 and 2013, there was a 17% decline in hospital‐acquired conditions, and 50,000 fewer patients died, saving $12 billion in health care costs.

Many nursing organizations have identified and developed programs to improve quality and safety. For example, the American Association of Critical‐Care Nurses (2010) developed multiple approaches including a program on healthy work environments focused on teamwork and collaboration. Competencies were developed for prelicensure and graduate nurses by the Quality and Safety Education for Nurses (QSEN) project (Cronenwett, 2012). The Nursing Alliance for Quality Care (Schumann, 2017) was formed to bring one organized nursing voice to ensure that (a) patients receive the right care at the right time by the right professional; (b) nurses actively advocate and are accountable for consumer‐centered, high‐quality health care; and (c) policymakers recognize the contributions of nurses in advancing consumer‐centered, high‐quality health care.

A Systems Approach to Improve Quality and Safety Outcomes: High Reliability Organizations

High‐reliability organizations (HRO) have effectively applied a systems approach toward quality and safety. Error prevention shifts from the individual to a shared accountability across the system, which assures errors are analyzed through root cause analyses. Understanding how the adverse event trajectory occurred allows the system to reconsider protocols, procedures, or other actions that will reduce the possibility of a repeat error. The National Patient Safety Foundation (NPSF, 2014) has defined health care errors as unintended health care outcomes caused by a defect in care delivery to a patient, therefore a shared system accountability for patient harm. To prevent harm to patients, organizations adopt operational systems and processes that minimize risk and focus on maximizing interception of errors before harm occurs. Safe care, in fact, is preventing harm to patients during the care that is intended to help them; preventable harm involves errors that could have been avoided through reasonable actions and decisions (Sherwood and Armstrong, 2016).

HROs emphasize just culture as a feature of a safety culture (Oster and Braaten). A non‐punitive approach to patient harm is built on the engagement and commitment of everyone from the board



HROs emphasize just culture as a feature of a safety culture (Oster and Braaten). A non‐punitive approach to patient harm is built on the engagement and commitment of everyone from the board room to all staff to accountability, honesty, integrity, and mutual respect in a just culture. Accountability is a critical aspect of a culture of safety; recognizing and acknowledging one’s actions is a trademark of professional behavior. All staff are trained and empowered to participate in an error‐reporting system without fear of punitive action. Near misses are treated as opportunities to improve by examining gaps and correcting design flaws. Safety principles to eliminate hazards guide job design, management of equipment, and working conditions.

Simplifying and standardizing processes are key components of high reliability organizations so that results are predictable, thus improving reliability. Reliability is expecting to get the same result each time an action occurs; therefore, a reliable system seeks to have defect‐free operations in spite of a high risk environment. Health care delivery has intersecting units or microsystems. How these systems function together impacts quality and safety outcomes. For instance, the way patients are assigned beds from the ED to one of the inpatient units, or how the lab responds in urgent situations to the need for blood draws, or how patients are discharged to a skilled nursing facility are opportunities for standardized operational procedures to improve effective outcomes. Five principles guide HROs: sensitivity to operations, preoccupation with failure, reluctance to simplify, deference to expertise, and commitment to resilience. Reliability has economic consequences. Hospital reimbursement is increasingly tied to quality and safety outcomes (Schumann, 2017). Hospitals may not be reimbursed for patient harms such as hospital‐acquired infections, therefore reliable procedures are needed to insure adherence to hand‐washing procedures, evidence‐based catheter insertion and care guidelines, and other evidence‐based best practices.

Nurses on the Frontlines: Changing Mindsets, Improving Quality and Safety

Although quality and safety improvements are goals for practitioners in all levels and areas of health care, nurses have particular roles. The IOM website has the following quote from the 2010 report The Future of Nursing: Leading Change, Advancing Health:

Overcoming challenges in nursing is essential to overcoming the challenges in the health care system as a whole. Nurses are the largest segment of the health care workforce, and their skills and availability can directly affect quality, safety, and efficiency. Most nurses work in hospitals or other acute settings, where they are patients’ primary, professional caregivers and the individuals most likely to intercept medical errors. However, because hospital systems and acute care settings are often complex and chaotic, many nurses spend unnecessary time hunting for supplies, filling out paperwork, and coordinating staff time and patient care, reducing the time they are able to spend with patients and delivering care.

Considering the scope of the recommendations and the limited progress, what are ways that nurses can help lead innovations to achieve the goals of the IOM Quality Chasm series? Wachter’s (2010) review of progress to achieve the IOM recommendations cites moderate progress in addressing workforce and training issues, reporting systems, and research. What does it mean for nursing? Three primary goals can guide nurses in leading change. First, all nurses must develop a mindset of questioning to constantly improve their work and increase their capacity to recognize and acknowledge quality and safety issues in their own work and in the systems in which they work. Second, educational programs must be transformed to address quality and safety competencies to help learners with changes in KSAs. Third, advancing scholarship to determine best practices in education, practice, and systems applications will establish an evidence base to implement effective approaches to transform health care.

Changing Mindset: Inquiry Leading Change

Increasing nurses’ awareness of quality and safety developed within new science applications will help nurses recognize quality and safety concerns in their practice and in their settings. Many remain largely unaware of the scope of the problems and have not been taught how to identify, report, and systematically analyze a near‐miss or sentinel event or lead a quality improvement team (Chenot and Daniel, 2010). Learning the concepts of new safety science refocuses how errors are reported. Rather than using incident reports to establish blame on an individual provider, organizations committed to quality and safety create a culture in which nurses and other professionals are empowered to disclose near misses and mistakes through a reporting system, and to identify areas in which outcomes do not match benchmarks.

A mindset of inquiry, of asking questions is the first step in change for leading improvements in the system. We must be open and receptive to feedback and be able to see the consequences of our actions and be willing to change. Reflective practice is a change process using systematic questions to examine experiences in the context of what one knows and values, other perspectives, and situational context (Horton‐Deutsch and Sherwood, 2008). Asking questions opens the way to innovative approaches, application of evidence‐based practice standards, and various methods of quality improvement.

It is a challenge, however, to build the awareness that empowers nurses to make the first step and acknowledge a near miss or mistake. Nurses then need to know what to report, and how, as well as how to follow the steps in the organization’s safety plan. In a just culture, there is a shift from establishing blame and punishing someone for a mistake to a systematic analysis for the purpose of learning and change. All providers who had any part in the event come together, led by trained professionals, to establish the chain of actions, decisions, and circumstances that may have contributed to an error so there is the opportunity to learn and develop system changes to prevent future occurrences. Patients and their families should be informed and included in the process to achieve transparency in the system, to have full disclosure of the event. Quality improvement teams can collect information to monitor occurrences of the problem in other parts of the system, compare data, and initiate strategies to eliminate variances.

Asking questions can be used in another way. Conducting an annual safety culture survey identifies areas for workplace improvement and determines priorities for improving quality. Scorecards, dashboards, or report cards are strategies to collect and monitor data about services and care provided to track key areas. In academic settings, educators establish a culture of safety and quality for their own educational processes such as a reporting system of learner near misses and errors to assess processes and increase safety awareness.



Transform Education to Integrate Competencies

The second focus area is transforming nursing education to integrate the competencies based on the KSAs developed from the QSEN project (Cronenwett, 2012). The project goal for the QSEN project in the United States (www.qsen.org) is to (a) change the mindset of nurses to a practice based on inquiry in which questions focus on how to continuously improve care, (b) develop and use evidence‐based standards and interventions, (c) investigate outcomes and critical incidents from a system perspective, and (d) work in intra‐ and interprofessional delivery teams(Cronenwett et al., 2007; Cronenwett et al., 2009; Sherwood, 2012). The IOM (Greiner and Knebel, 2003) identified the following competencies as essential for all health professionals if we are to improve health care: patient‐centered care, teamwork and collaboration, evidence‐based practice, quality improvement, safety, and informatics. In the initial report, quality and safety were combined competencies, but subsequent definitions recognize the separate knowledge base for each and have made them distinct competencies, so there is a set of six.

The six competencies are not isolated concepts but are interrelated and apply across all health disciplines. The goal of the competencies is to enable health professionals to deliver patient‐centered care, work as part of interdisciplinary teams, practice evidence‐based health care, implement quality improvement measures and strategies, and use information technology (Cronenwett et al., 2007; Cronenwett et al., 2009; Finkelman and Kenner, 2009; Greiner and Knebel, 2003). Brief descriptions of the competencies are provided in Textbox 1.2, complete definitions and the KSAs can be found in Appendices A and B, and each competency is discussed in separate chapters in Section 2 of this book.

Textbox 1.2 Descriptions of Six Competencies to Improve Quality and Safety*

  • Patient‐centered care

In patient‐centered care, patients and their families are treated with respect and honor, engaged as partners in their care, treated as safety allies, and participate in shared decisions that are made based on knowledge of patient values, beliefs, and preferences (Walton and Barnsteiner, 2017). Sharing knowledge and information with patients and families enable their participation in the team and agreement on their treatment plan. Helping patients and their families know what to report can help prevent errors.

  • Teamwork and collaboration

The degree of how well health care professionals work together accounts for as much as 70% of health care errors (Institute of Medicine, 2000; TJC, 2016), yet nurses and physicians have few educational experiences together. Coordinating complex care requires cross‐disciplinary communication, knowing scope of responsibility, and organizational support for speaking up when safety is compromised (IPEC, 2011). Nurses need skills in problem solving, conflict resolution, and negotiation to be able to coordinate care across interprofessional teams (Dolansky, Luebber, and Singh, 2017). Developing emotional intelligence can help health professionals use their strengths to contribute to effective team functioning. Flexible leadership, effective communication, mutual support, and environmental scanning are effective team behaviors (Disch, 2017).

  • Evidence‐based practice

Evidence‐based practice standards guide patient care, not tradition or trial and error (Tracey and Barnsteiner, 2017). A spirit of inquiry identifies clinical questions that seek best practices. Reflective practice develops a spirit of inquiry by asking questions about the care that was delivered. Skills in informatics are a part of evidence‐based practice to seek current evidence to determine best practices and clarify care decisions. Patient‐centered care considers patient preferences, values, and beliefs within an evidence‐based approach. Nurses use evidence‐based standards and quality improvement tools to measure how care in their own setting compares with benchmark data to determine areas to improve.

  • Quality improvement

A practice attitude of continuously improving care every day with every patient reflects a spirit of inquiry. Quality improvement measures variance in ideal and actual care and implements strategies to close the gap (Johnson, 2017). Nurses use quality improvement tools and informatics to seek evidence and measure care outcomes as well as benchmark data to assess current practice. The ethical responsibility of quality improvement is revealed through the commitment to provide the best practices as well as the ethical conduct of the process itself.

  • Safety

Safety is the effort to minimize the risk of harm to patients and providers through both system effectiveness and individual performance (Barnsteiner, 2017). Competency in safety is based on constantly asking how actions affect patient risk, where the next error is likely to occur, and what actions can prevent near misses. Safety science redirects the examination of errors from the person approach, which blames the individual for forgetfulness, lack of attention, or moral weakness, to one that examines the system in which the error occurred. A systems approach examines the conditions in the environment that may have contributed to the error and designs defenses to prevent errors or mitigate effects.

  • Informatics

Informatics is a thread through all the competencies to help manage care through documentation in electronic health records, decision support tools, and safety alerts (Clancy and Warren, 2017). Providers apply skills in informatics to retrieve information, search for the latest evidence, manage quality improvement data and strategies, and share information across the interprofessional team. Nurses also use informatics knowledge, skills, and attitudes to help guide development of informatics applications, purchases, and ways to use it on the unit.

* Appendices A and B have definitions with the 162 knowledge, skill, and attitude objective statements.

Education transformation cannot happen in isolation. The IOM recommendations demand interprofessional learning experiences for both academic and clinical learning situations. Nursing education most often occurs in silos, or independent departments, with few shared learning opportunities among the many health disciplines with which nurses are expected to work. Knowing what each discipline contributes is crucial to high performance and flexible team leadership that works through authority gradients so all team members have equal opportunity to share information in establishing patient care goals (Disch, 2017). Education transformation applies to all settings—academic and clinical, and all educational entry programs—to prepare nurses in practice as well as those in academic programs.

Resources are available to assist educators in making the transition. The American Association of Colleges of Nursing (AACN) presented a series of QSEN faculty development workshops, and maintains a list of resources on the Association’s web site. The QSEN institute continues to present an annual national forum in which participants share outcomes and strategies for integrating the QSEN competencies in academic and clinical settings. The QSEN web site offers teaching strategies, annotated bibliographies, demonstration projects, videos, learning modules, and a facilitator panel to assist with educator development. Educators and organizations responsible for accreditation, licensing, and certification of health professionals have embedded the competencies into nursing education standards to help lead transformation of how we prepare students and nurses to be proficient in these competencies that are essential to quality and safety (Sherwood, 2012).

Advancing Scholarship


Advancing Scholarship

A third area of focus is advancing scholarship in all areas of quality and safety. Research can help develop the scientific evidence of quality and safety issues to know how and to what extent patients are harmed as well as ways to mitigate. We need evidence‐based educational strategies to determine best practices for teaching and implementing quality and safety concepts in practice. Traditional education methods relying on lecture have not demonstrated the capacity to achieve the KSAs needed to redesign health care across multiple settings (Benner et al., 2010; Day and Sherwood, 2017a; Day and Sherwood, 2017b; Ironside and Cerbie, 2012). To integrate the competencies, educators need evidence‐based curricula and teaching strategies for innovative educational interventions, whether as part of their formal education or as staff in clinical settings (www.qsen.org).

  • Hobgood et al. (2010) compared four pedagogical approaches including high and low fidelity to measure changes in knowledge and attitude of nursing and medical students from an educational intervention for interdisciplinary teamwork.
  • Welsh, Flanagan, and Ebright (2010) compared two methods of end‐of‐shift handoffs to examine communication and potential for adverse events.
  • Hayden et al. (2015) led a national study on the use of simulation in nursing education. Findings indicated learners could achieve the same learning objectives by substituting up to 50% of the usual hours spent in clinical learning assignments with high fidelity simulation.
  • Moughrabi and Wallace (2015) tested the effectiveness of simulation accelerated nursing students in achieving the quality and safety competencies, particularly teamwork and collaboration. Simulation provides a safe place for learners to practice, receive feedback, and apply what they have learned.
  • Riley and Yearwood (2012) used a mixed‐method approach to investigate students’ experiences with infusion of QSEN competencies and their intention to address quality care indicators.

These few examples illustrate opportunities to develop evidence‐based approaches to achieving the IOM recommendations. We have an unparalleled opportunity for nursing leadership and scholarship to help improve our health systems. We need to determine the effectiveness of what we are teaching about quality and safety, measure the long‐term behavior change, and assess the skills needed in the workplace that will drive curricular changes. Benner et al. (2010) call for nurses to claim this opportunity for radical redesign of nursing education that can match the radical changes needed in health care delivery. Scholarly investigation can determine effective pedagogies, outcomes of care interventions, strategies for reporting and investigating errors, system malfunctions that lead to work‐arounds, and communication that promotes interprofessional teamwork.


More than 15 years after the release of To Err is Human, patient safety and quality of care remain major health concerns. Various organizations, including professional and consumer groups, have developed regulations, educational programs, and initiatives for leading change. There is progress in establishing a culture conducive to pursuing health care quality and reporting; clinicians are replacing the fear of a punitive response and cover‐up with a focus on accountability and reporting events so that through analysis the organization can implement improvements and prevention strategies. Nurses have new roles and responsibilities in continuous quality improvement that encourage a culture of inquiry and asking questions, and investigate outcomes and critical incidents from a system perspective. The QSEN institute continues to lead integration of quality and safety competencies in all levels of nursing education. Progress in evidence‐based education approaches and pedagogies will help determine ways to prepare clinicians with new mindsets and lasting changes in behavior based on the six quality and safety competencies.


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The Role of the Clinical Executive

Tukea L. Talbert and Robin Donohoe Dennison


Over the last decade, there has been emerging evidence of the connection between organizational performance and leadership (Frearson, 2002Hallinger & Heck, 1996Muijs, Harris, Lumby, Morrison, & Sood, 2006). The Institute of Medicine (IOM) Committee on the Quality of Health Care in America has issued a mandate to the American health care community to bring “state-of-the-art” health care to all Americans (Fasoli, 2010, p. 25). Fasoli indicates that nursing has reached a point of inflection, a tipping point, and the nursing role must evolve in order to remain fully engaged in health care. Of even greater importance, the nurse leader must be prepared to change and create health care policies, create and implement evidence-based practice guidelines, and embrace and represent quality nursing practice at every level of the organization and of society. Now is the time to ensure that the right people are in key leadership positions, and that those individuals are well prepared to face the dynamic environment and challenges of the health care milieu. Organizational performance during this turbulent time in health care will be contingent on the effectiveness of the leadership team.

The American Association of Colleges of Nursing (AACN) in their position statement (2004) puts forth that the transformation in the health care delivery system will require clinicians to design, evaluate, and constantly improve the context in which care is delivered. The AACN strongly believes that nurses with doctoral preparation that encompasses clinical, organizational, economic, and leadership skills are most likely capable of critiquing scientific findings and subsequently developing programs of care that significantly impact health care and that are economically feasible. The AACN adopted the Doctorate of Nursing Practice (DNP) Position Statement in October of 2004 calling for a transformational change in the education necessary for professional nurses who will practice at an advanced level of nursing practice (Essentials of Doctoral Education for Advanced Nursing Practice Document, 2005). The AACN recognizes the practice demands affiliated with an increasingly complex health care system amid a major health care reform that has gotten new momentum from the President Obama administration. One can conclude that these demands comprise a new strain with a different genotype that is placing new pressure on the preparation of those nurses in senior leadership positions and on their level of preparation.

In this chapter, the following areas will be discussed: an operational definition of the clinical executive; the AACN’s Essentials of Doctoral Education for Advanced Nursing Practice; a comparison of the AACNs Essentials for Master’s Education with the Essentials of Doctoral Education for Advanced Nursing Practice; a comparison of the DNP degree with the MSN and MBA; and the position of the American Organization of Nurse Executives (AONE) regarding the DNP degree requirement for nurse executives. The objectives of this chapter are to give readers the opportunity to have a more in-depth view of the demand for a different level and type of education beyond the master’s degree for clinical executive leadership; the results of a DNP education; and the potential challenges of making the DNP a requirement for nurse executives.


Webster (2000) defines an executive as, “capable of, or concerned with, carrying out duties, functions … or managing affairs in a business or organization; empowered and required to administer” (p. 497). One cannot fully respect the role of the clinical executive without acknowledging the context in which it occurs. The clinical executive must oversee all aspects of clinical practice in health care organizations. The nursing practice within any organization is a “24/7” accountability for processes, structures, and outcomes of care delivery (Fasoli, 2010). The responsibility of the clinical executive is ever changing and growing, and the expectations upon those in the role are greater. For the purposes of this chapter, both authors agree that senior-level nursing leadership (Chief Nursing Officer, Chief Nursing Executive, and VP of Nursing) in a health care setting is a form of advanced nursing practice as evidenced by the differentiation option offered by the DNP degree, which is the eighth option beyond the seven core essentials.


The AACN (2006) identified seven core competencies for the DNP along with two additional differentiated competencies for nurses who choose to focus more on an advanced practice administrative role (i.e., clinical executive role) or an advanced practice-focused role (nurse anesthetist, nurse practitioner, midwife, clinical nurse specialist). The seven core essentials are: (1) scientific underpinnings for practice; (2) organizational and systems leadership for quality improvement and systems thinking; (3) clinical scholarship and analytical methods for evidence-based practice; (4) information systems/technology and patient care technology for the improvement and transformation of health care; (5) health care policy for advocacy in health care; (6) inter professional collaboration for improving patient and population health outcomes; (7) clinical prevention and populations health for improving the nation’s health; (8a—practice-focused) individual, family, and population-focused advanced nursing practice competencies for improving patient care processes and outcomes; and (8b—executive/administrative) systems or organization-focused advanced nursing practice competencies for improving patient care processes and outcomes.

Both authors of this chapter strongly believe that the DNP degree offers an expansive educational experience very different from that of the administrative tract of the Master’s of Science degree. This belief hinges on some of the following benefits from the DNP degree that includes extensive literature on leadership theory that encompasses the process of leadership and more specifically leadership in health care; mentoring opportunities with other leaders in advanced practice roles as part of residency/practicum; the differentiated option to focus more on students’ desired specialization in the program; and the capstone project, which is a work in progress throughout the program. The capstone project serves as the student’s population focus. Throughout the program, the chosen population focus will undergo several analyses that include cost–benefit analyses/return on investment, statistical analyses, utilization focused evaluations, and extensive literature reviews, especially if students have interventional studies as part of their capstone projects.


Although all aspects of the DNP educational experience are important, additional focus will be spent on the practicum experience and the capstone project. The practicum experiences for each student are designed around the student’s choice for specialization (administrative/executive or practice focused). The first author’s (TT) practicum took place at Dartmouth Hitchcock Medical Center in Lebanon, New Hampshire, with the VP of Nursing. During the experience, the VP of Nursing along with other members of the senior leadership team undertook a restructuring of the organizational chart. The change, as you can imagine, was enormous. It not only was going to impact the hospital, but also had implications for change for other hospitals that were part of an alliance with Dartmouth. The VP of Nursing was able to articulate the communication plan at every level of the facility and to those hospitals outside the physical boundaries of Dartmouth. The ability to participate in this monumental event at that hospital was vastly different from any of the clinical experiences in the Master’s of Science in Nursing (MSN) program experienced by this author 10 years prior to the DNP program.

During the practicum at Dartmouth, as a doctoral student I functioned as a consultant and generated questions that might be posed by stakeholders and various team members within and outside the organization. During the residency, students are expected to exhibit critical thinking and participate in scholarly discussions. The key objective during the residency hours (practicum) is that the students drive the learning experience by being active participants who are not simply in an organization solely to shadow their mentors. Each course has course objectives that provide guidelines for students’ practicum experiences; however, the students also create unique objectives for each practicum experience, which results in ownership of the process and outcome of the residency. Although there were other practicum experiences (see Table 6.1.), the Dartmouth experience demonstrated the practice of an effective leader dealing with a very toxic change in a major health care organization. The overall focus of this practicum therefore was on the process of leadership and leadership style, and its effect on organizational culture.


Student’s (TT) Practica Experiences

A second practicum occurred at The University of Texas MD Anderson Cancer Center in Houston, Texas, one of the top oncology health care facilities in the nation. The focus of this residency revolved around my (TT) capstone project, which actually was a quasi-experimental pre- and post-test design study that investigated psychological distress among patients undergoing hematopoietic stem cell transplants. During this time, I was able to examine protocols and isolation practices used by experts in hematopoietic stem cell transplants. This practicum provided insight on current versus traditional practices for isolation and outcomes associated with various isolation interventions. The overall focus of this practicum was to evaluate the impact of leadership on the development of practice policies, standards, processes, and patient outcomes.

Throughout the DNP program, each student works with a patient population for which she must identify an evidence-based health care intervention to implement. Other critical components associated with the intervention and/or practice change includes cost-effective analyses, program evaluation, literature review in search of best practices, and identification of stakeholders that may influence the practice change and/or be affected by the change.

Another key focus of the DNP program is program evaluation. Several options for evaluation are introduced to students that include utilization-focused evaluation, and formative and summative evaluations. In comparison to the MSN administrative track, the detail with evaluation, research, evidence-based interventions, cost-effectiveness analysis, and policy development associated with health care initiatives, interventions, and outcomes was significantly different. Each of the authors believes that with the completion of the DNP program, we acquired a new level of thinking about program development and evaluation; identification and placement of best practices into practice settings; advanced practice in health care; interpretation of patterns from large data sets; and, most importantly, leadership in health care. Overall, the DNP practicum (residency) experiences greatly enhance the learning experience of students and it enables them to view advanced practice from a macroscopic perspective, which is vastly different from the more microscopic approach experienced in the MSN administrative track.


This section highlights some of the key areas of difference between the 1996 Essentials of Master’s Education for Advanced Practice Nursing document (which is currently under revision) from AACN and the 2006 Essentials of Doctoral Education for Advanced Nursing Practice (see Table 6.2). Table 6.2 demonstrates some of the key differences noted between the traditional MSN educational preparation and DNP competences as defined by AACN. There are four critical differences noted: (1) The DNP competencies are more system wide and provide a macroscopic view of health care that combines all the sciences and better prepares graduates to engage in partnerships that will impact change in health care at a higher level. The student’s focus reaches beyond the traditional patient setting within the organization. (2) DNP competencies are geared toward creating graduates who lead to change as opposed to assisting with change, which seems to be more the case with the MSN competencies. This competency is evident through the residency hours and the capstone projects. Students through their residency hours and capstones potentially generate new knowledge, and, in most cases, focus on adapting best practices to the clinical setting. (3) The DNP graduate demonstrates the nursing role to the community at large (even nationally) through both performance and communication, while the MSN graduate competencies focus more on communication of the nursing role on a more narrow scope. (4) The DNP competencies are more population based and prepare a graduate to make change globally, while the MSN competencies are more population and community specific, thus limiting one’s impact on health care to a smaller scale. Table 6.2 illustrates a juxtaposed comparison of each set of competencies, pointing out key differences, which are bolded. Although there is a small amount of overlap with a few of the competencies, the differences stated above clearly indicate the variation in the level of preparation among graduates from the two programs.


Comparison of Essentials of Masters Education and Doctorate of Nursing Practice

Many authors conclude that success at the executive level hinges on being visionary and making decisions on a macroscopic level. Hader (2010a), Senior VP and Chief Nursing Officer (CNO) of Meridian Health System in New Jersey, states that the CNO’s strategic plan must reach beyond the traditional scope of nursing practice. He notes that the CNO’s influence will likely extend to areas outside of nursing. The CNO must engage in collaborative professional relationships with other key stakeholders in the health care organization that include the Chief Medical Officer (CMO), Chief Financial Officer (CFO), Chief Executive Officer (CEO), and Board of Trustee Members. The inability to think and function on a macroscopic level will greatly limit the level of effectiveness of decision making and subsequently the organizational success. Nurse executives exert a great deal of power from the perspective of title and capacity to influence. Nurse executives generally have the majority of the workforce under their span of control, due to their position and the fact that nurses generally are one of the largest sectors of the health care workforce within health care organizations. This opportunity to influence many people who ultimately provide the delivery of care at the bedside is not a position to be understated. It is critical that the individuals in these roles are well prepared for the challenge and are capable of making a difference in health care outcomes.

Our view is that the DNP clinical executive tract is unique in that this degree prepares nurses to be better leaders in a very challenging, dynamic health care arena. Nurses in the role of the clinical executive are no longer invited to the table solely based on their clinical insight, but more so for their ability and capacity to lead organizations based on their leadership competencies. Many of these key competencies are outlined in the AACN Essentials for Doctoral Education for Advanced Nursing Practice document and they include organizational and systems leadership, health care policy for advocacy in health care, and inter professional partnerships for improving patient and population health outcomes.


In terms of reviewing options to prepare the contemporary nurse executive (aside from the DNP or DrNP at one school), the options include: a Masters of Science in Nursing (MSN) degree with an administrative focus and a Masters of Business Administration (MBA); some colleges offer a combination of the MSN/MBA as a concurrent option.

Curriculum and course descriptions were obtained and reviewed from an online search of the following institutions: Indiana Wesleyan University (MBA); University of Texas Tyler (MSN/MBA); and hard copies were obtained from the University of Kentucky (DNP) and Eastern Kentucky University (MSN).1 Through a juxtaposed comparison, some of the following initial conclusions can be made: The MSN with an administrative focus appears to be more focused on a microperspective of leadership development, preparing a novice leader or someone with leadership aspirations; the MBA seems to offer a broader base of courses to better equip the nurse executive, because it includes management concepts, managerial economics, ethics, law, and some leadership courses as well; the MSN/MBA option seems to be the most broad in that it has a good blend of the financial competencies along with some basic entry-level leadership development courses. Overall, any of these three options would be feasible pathways to prepare novice leaders or individuals pursuing a leadership career. In comparison, the post-masters DNP degree with a clinical executive option offers a much more in-depth preparation for advanced leadership roles such as the clinical executive who may serve as the VP of Nursing, Chief Nursing Officer, Chief Operating Officer, and/or the Chief Nurse Executive. With the DNP, one satisfies the requirements of a doctorate, which prepares the individual on a different graduate level (a doctorate) in comparison to the MBA and the MSN options (i.e., a master’s degree). Although being a doctorally prepared nurse executive does not always confer credibility, it does confer the unique competence of the individual who holds the degree (Gerrish, McManus, & Ashworth, 2003).

When further comparing these different degree programs, the DNP degree appears to offer a more in-depth overview of leadership and focus on reaching leadership capacity through self-knowledge and self-mastery. The key benefits revolve around the well-designed, focused residency hours; the extensive overview of leadership literature from diversified author-based sources; the initiation of the capstone project at the inception of the DNP program; the liberty to take elective courses outside the College of Nursing, which included Geriatric Policy and the College of Business courses for this chapter’s first author; research principles and courses required for a doctoral degree; and the exposure to theory on health policy development. In concert with the above benefits, the student is prepared to constantly ask why, always seek new knowledge through research and evidence-based practice, and to design programs and policy with the ability to evaluate these initiatives clinically and financially. DNP graduates demonstrate the importance of always asking the best next question(s). They recognize that while one may not always have the answers, it is the question that may be more important because it highlights an aspect of a complex situation that may have been missed. Students have a sharpened sense of critical thinking outside the scope of nursing which forces the doctoral clinical executive scholar to examine how health care is truly integrated both horizontally and vertically.

The DNP degree is an option that prepares nurse executives to perform at a higher level. We are not suggesting that the other degree options reviewed are inferior, because they are not. The authors believe that they offer a very sound preparation for one interested in leadership, while the DNP offers an advanced level of preparation for someone who desires more knowledge and preparation. The DNP is not more of the same, but a newer version or model of preparation for the nurse executive who functions as the senior nurse leader in organizations with other members of the executive team. The primary difference in the DNP is best described by Hader who states “The curriculum and expectations of academic performance in the clinical doctorate programs are far more extensive than those in a traditional graduate program” (2010b, p. 6). The focus of the DNP program is uniquely different and, in theory, does create a different type of graduate with the ability to think outside traditional boundaries and develop collaborative partnerships to move organizations forward successfully.


At this time, the American Organization of Nurse Executives (AONE) has not endorsed the proposal that the DNP should be a requirement for either the clinical nurse executive or practiced-focused nurse in advanced nursing practice roles. In their position statement, AONE (2007) supports the DNP as a terminal degree option for practice-focused nursing. They believe, however, that master’s nursing degree programs in both generalist and specialty courses of study should remain intact. The Professional Practice Policy Committee of AONE concludes that questions and concerns that have been voiced regarding patient outcomes, salary compensation, and financial impact on organizations have not been fully identified, investigated, or addressed as they relate to the DNP requirement.

Having said the above, AONE considers nurse leadership a subspecialty within nursing practice that requires competence and proficiency unique to the executive role. They believe that there are five core competencies that are common to nurses in executive practice regardless of their educational level or title (AONE Nurse Executive Competencies, 2005). These five competencies are: (1) communication and relationship building; (2) knowledge of the health care environment; (3) leadership; (4) professionalism; and (5) business skills. These core leadership competencies align with specific core essentials of the AACN Essentials of Doctoral Education for Advanced Nursing Practice, such as interprofessional collaboration, organizational and systems leadership, and clinical scholarship. AONE recognizes that their competencies are core competencies and are not exhaustive of all areas of expertise for the nurse executive. They believe that the core competencies establish the standard for executive practice and can be used as a guideline for educational preparation of nurses seeking knowledge in executive practice.

The authors agree with the position of AONE in that there needs to be more evidence to support making the DNP a requirement for those nurses functioning in clinical leadership advanced nursing practice roles. The authors, DNP graduates themselves, aver that this degree is scholarly, uniquely different from a graduate-level preparation for leadership, and is an educational process that prepares the nurse executive to think and function at an advanced level as evidenced by the positions held by these individuals and their accomplishments in these roles. Having said this, it is necessary to address some key questions before concluding that the DNP must be a requirement for any nursing leadership roles. In addition to the questions posed by AONE, other questions need to be addressed as well. First, one must determine for what level of nurse leadership should the doctorate be required. It is the belief of both authors that it would be illogical to require all nurses in leadership to be doctorally prepared. As stated by Jones (2010), this becomes a scope of practice and level of accountability issue. It connects back to the level of preparation offered by the DNP that has been highlighted as producing graduates able to function at a macroscopic level. The nurse executive at the most senior level in the organization needs to see the big picture that often times transcends traditional organizational boundaries. Second, what impact, if any, would such a requirement have on MSN programs? This issue is also raised by AONE in their position statement. Some colleges have or are moving in the direction to eliminate MSN tracks as they create DNP degree options as part of their academic offerings. Third, what impact would the potential elimination of MSN programs have on the supply of nurses? AONE recognizes that nurses may choose other disciplines to acquire a master’s degree, which may result in outward migration from the nursing profession. Overall, the reduction of the number of MSN programs or their elimination may result in some unintended consequences that may have long-term effects on the nursing profession and particularly on providing a steady pool of highly educated clinical nurse executives at a variety of levels.


Future considerations regarding the DNP degree need to include three key components. (1) The profession must find a way to ensure that the degree can withstand the test of time through evidence to support its benefits. Since the inception of the DNP degree, there is growing evidence of its impact as demonstrated by successful graduates of the program functioning as effective clinical executives. Key indicators, as highlighted by AONE, that need to be further investigated include the financial impact of increasing salary expectations of doctorally prepared executives and the corresponding financial impact on organizations, patient satisfaction with holders of this degree, and specific degree-related patient outcomes as evidenced by organizations’ performance with core measures established by the Centers for Medicare and Medicaid (CMS) and Hospital Consumer Assessment of Health-care Providers and Systems (HCAHPS) scores. (2) The profession must carefully examine the scope of practice and level of accountability of nurses who would benefit most from a DNP degree. Jones (2010) indicates that executives at the top level of nursing administration are accountable for the executive level of patient services. She further states that executives will be expected to function at a macrolevel with decision making and actions that impact patients and others within the organization. Mid-level managers have a narrower focus and span of control within organizations and are more likely to function at a microlevel by virtue of the organizational chart and structure of organizations. The nurse executive will work across both microsystem and macrosystem levels that include groups both internal and external to the organization. As stated earlier, one of the unique qualities of the DNP degree is its preparation of the nurse executive to think and function on a macrosystem level. (3) Investigators must continue to monitor the market and demand for DNP graduates. Many authors have noted the turbulence, variability, and increasing complexity of the health care environment (AACN Fact Sheet, 2010Fasoli, 2010New, 2010Schaffner & Shcaffner, 2009). All of these factors continue to add momentum to the demand for preparation beyond a graduate level. The AACN (2010) provides the following statistics with regard to DNP programs: 120 programs are enrolling students nationwide, and an additional 161 DNP programs are in planning stages; DNP programs are present in 36 states and the District of Columbia; from 2008 to 2009, the number of DNP enrollees increased from 3,415 to 5,165; and to date, 18 DNP programs are accredited by the Commission on Collegiate Nursing Education (CCNE) with an additional 70 DNP programs pursuing CCNE accreditation. Coupled with the above, one other significant finding is that employers have quickly recognized the contributions DNP graduates are making in the practice setting (Waxman & Maxworthy, 2010). This last point is further supported by early studies that show the DNP is perceived as a viable advanced education option and enables students to make viable contributions to the nursing profession (Loomis, Willard, & Cohen, 2006). In closing, the supply is present and the demand continues to create a need for clinical executives who are prepared beyond a master’s level. Based on the data above, the DNP is necessary and should continue to be an option for nurses seeking a clinical executive specialty in advanced nursing practice.


As the first author of this chapter (TT) and a member of the first DNP graduating class in the United States (at the University of Kentucky), I recall a moment in time that I shall not forget. One of the members of my Doctoral Capstone Committee asked me what was most beneficial about the DNP program. My response at that time was that I had a better understanding of myself and my personal leadership style. Although this may sound somewhat trivial, it was and continues to be, for me, a profound realization. This realization continues to facilitate my personal leadership journey and development, because I better understand what makes me successful as a leader. It also illuminates and highlights what skill sets are necessary to improve my leadership. Through reflection and my current practice, other responses to that question would include the increased confidence and competence to create a culture of collaboration by navigating through departmental and organizational borders by using focused evaluations, evidence-based practice, and influencing others beyond the traditional boundaries of the nursing component of health care. One could also say that health care today has an entirely different look; it is something that stretches beyond the physical and sometimes human boundaries of the health care facility. Successful clinical executives must be willing and equipped to see the new paradigm and context in which health care is practiced. As a graduate of a DNP program (TT), I am able to see the difference and the shift in the health care paradigm, and understand that it requires one to think and function at a different, more advanced level.


Nurses in the clinical executive role are no longer invited to the table solely based on their clinical insight but more so for their ability and capacity to lead organizations based on their leadership competencies. The nursing profession can lead the “way to knowing” and the capacity to lead by continuing to offer the DNP as a credible degree option for nurses seeking to expand their leadership skill set and knowledge to be better prepared to function in the increasingly turbulent health care environment.

In summary, because there are other strategies necessary to prepare nurses for clinical executive roles, the nursing profession cannot solely depend upon a new degree. They must be proactive in developing a framework that ensures ongoing development of leaders in executive roles that can be incorporated in the context in which they practice. These frameworks must include organizational charts that are aligned with the corporate strategic plan and that create the propensity for nurse leaders to have the capacity to lead and be involved in decision making at every level. The frameworks must provide ongoing opportunities for professional development, mentoring opportunities, and, last but not least, succession planning. Leadership development should not be by default or a second thought, but by design. It must be part of the culture established and supported by the nurse executive in collaboration with the other executive team members. It is too soon to say that a DNP should be required for individuals in clinical executive advanced nursing practice roles. However, it is not too soon to reexamine the process in which nurse executives are prepared for their leadership roles. Because leadership development is a process, it cannot be learned in a day or by completing another degree. The DNP degree offers an innovative educational experience that superbly prepares the nurse executive, but it is only the beginning of the process of leadership development. Nurse executives must be proactive and create organizational cultures that cultivate empowerment, ongoing professional development, and succession planning so that no leader is left behind and organizations advance from good to great.


  1. 1.   Websites for each program are as follows: a) Indiana Wesleyan University MBA: http://www.indwes.edu/Adult-Graduate/MBA/; b) University of Texas Tyler MSN/MBA: http://www.uttyler.edu/nursing/graduate/MSNMBA.html; c) University of Kentucky DNP Clinical Leadership: http://www.mc.uky.edu/Nursing/academic/dnp/default.html; and d) Eastern Kentucky University MSN in Advanced Rural Public Health Nursing with a concentration in Administration: http://www.bsn-gn.eku.edu/docs/ PublicHealthNursingCurriculum.pdf


American Association of Colleges of Nursing. (AACN). (1996) The essentials of master’s education. Retrieved from http://www.aacn.nche.edu/ education/pdf/MasEssentials 96pdf

American Association of Colleges of Nursing (AACN). (2004). AACN position statement on the practice doctorate in nursing October 2004. Retrieved from http://www.aacn.nche.edu/ DNP/pdf/DNP.pdf

American Association of Colleges of Nursing (AACN). (2006). The essentials of doctoral education for advanced nursing practice. Retrieved from http://www.aacn. nche.edu/DNP/pdf/Essentials.pdf

American Association of Colleges of Nursing (AACN). (2010, March). Fact sheet: The doctor of nursing practice (DNP). Retrieved from http://www.aacn.nche. edu/Media/FactSheets/dnp.htm

American Organization of Nurse Executives (AONE). (2005). Nurse executive competencies. Nurse Leader3(1), 50–56.

American Organization of Nurse Executives (AONE). (2007). Consideration of the doctorate of nursing practice. Retrieved from http://www.aone.org/aone/docs/ PositionStatement060607.doc

Fasoli, D. R. (2010). The culture of nursing engagement: A historical perspective. Nursing Administration Quarterly34(1), 18–29.

Frearson, M. (2002). Tomorrow’s learning leaders: Developing leadership and management for post-compulsory learning. 2002 Survey Report. London, UK: LSDA.

Gerrish, K., McManus, M., & Ashworth, P. (2003). Creating what sort of professional? Master’s level nurse education as a professionalizing strategy. Nursing Inquiry10(2), 103–112.

Hader, R. (2010a). Success in the “C-Suite.” Nursing Management41(3), 51–53.

Hader, R. (2010b). Who’s the doctor, anyway? Nursing Management41(5), 6.

Hallinger, P., & Heck, R. H. (1996). Reassessing the principal’s role in school effectiveness: A review of the empirical research. Educational Administration Quarterly32(1), 27–31.

Indiana Wesleyan University College of Adult & Professional Studies—CAPS. (2009). Retrieved from http://www.indwes.edu/Adul-tGraduate/MBA/

Jones, R. A. (2010). Preparing tomorrow’s leaders: A review of the issues. The Journal of Nursing Administration40(4), 154–157.

Loomis, J. A., Willard, B., & Cohen, J. (2006). Difficult professional choices: Deciding between the PhD and the DNP in nursing. Online Journal of Issues in Nursing12(1), 6.

Muijs, D., Harris, A., Lumby, J., Morrison, M., & Sood, K. (2006). Leadership and leadership development in highly effective further education providers: Is there a relationship? Journal of Further and Higher Education30(1), 87–106.

New, N. (2010). Optimizing nurse manager span of control. Nurse Leader7(6), 46–48, 56.

Schaffner, M., & Schaffner, J. (2009). Leadership amid times of economic challenge. Gastroenterology Nursing32(1), 50–51.

Waxman, K. T., & Maxworthy, J. (2010). Doctorate of nursing practice and the nurse executive: The perfect combination. Nurse Leader8(2), 31–33.

Webster’s New World College Dictionary. (2000). Defining the English language for the 21st century (4th ed.). Foster City, CA: IDG Books Worldwide, Inc.



CHAPTER SIX: Reflective Response


Patricia S. Yoder-Wise

Talbert and Dennison pose some questions and insights related to the DNP preparation for clinical nurse executives. They compare master’s preparation (in nursing and in business administration) with the DNP. However, they omit comparison of the DNP with the PhD and how each of those degrees might contribute to the excellence of clinical nurse executives. They also discuss briefly the position of the American Organization of Nurse Executives and address its core competencies for clinical nurse executives. However, they omit addressing the position of the American Nurses Association and its scope and standards document governing nursing administration. Finally, they are clearly enthusiastic supporters of this degree that seems to be so relevant to leading clinical work. Yet, no mention is made of the huge numbers of nurses in administrative positions who are not even prepared with a baccalaureate degree in nursing. This diversity in the educational qualifications for someone who has the ultimate accountability for the nursing care of patients creates an overwhelming challenge to address before the refinement of the question (master’s or doctorate?) can be resolved.

Talbert and Dennison make an excellent case for why clinical executives need solid educational preparation. The idea that nurses in those positions have “24/7 accountability for processes, structures and outcomes” (p. 142) and that these positions often encompass multiple professional groups is an important consideration. The authors point out the value of the practica and the capstone in shaping the contributions the graduate can make. Although these two experiences are similar to clinical intensives and capstone work at the undergraduate level and the practica and thesis options at the master’s level, the richness of the backgrounds learners bring to doctoral level study provides a higher-level experience. In short, every nurse learns through clinical experiences and focused work. If an individual is learning to be a nurse, that level of insight differs greatly from what a nurse, often with multiple years of experience, brings to doctoral-level study.

But what about the difference between the PhD and the DNP? Because I am teaching in both programs, although different courses, I appreciate the distinction in why nurse leaders choose different programs. While I personally tend toward the execution side of leadership, I value those who select a research path. If they did not continue to contribute to our ongoing body of knowledge, we would have less substantive backing in the application of that knowledge. Both of these graduates (the DNP and the PhD) see the macroscopic perspective, but they see it through a different lens.

From my perspective, PhD programs tend to be more similar than varied. The same is not true for DNP programs. The range of what comprises the DNP programs is between high-level application and capstone projects consisting of work we might call intense quality improvement and, at the other end, considerable theoretical perspectives and capstone projects that would be difficult to differentiate from dissertations. As is always true in nursing, our diversity is one of our greatest benefits and one of our greatest liabilities. Until we have some better description of what best comprises a DNP program, it is difficult to compare that type of programming with other degree programs.

One final point about the value or preference for a PhD or a DNP, or for that matter between the DNP and one of the master’s programs: The numbers of nurses prepared at the master’s and doctoral levels continue to be relatively small in comparison to the 3.1 million registered nurses. Rather than worrying about which is better, we should worry about how we move nurses toward graduate education more quickly and consistently. As Talbert and Dennison point out, “Organizational performance during this turbulent time in health care will be contingent on the effectiveness of the leadership team” (p. 141).

Talbert and Dennison pose several excellent questions related to DNP education for nurse leaders. As more DNP graduates emerge from the expanding number of programs, major medical centers and systems will likely expect that the chief nurse executive hold a doctoral degree. In those organizations, many others will likely be prepared at that level. However, we know from past studies about the profile of nurses in clinical leadership positions; they are often prepared at the baccalaureate, or less, level. This fact suggests that we are unlikely to quickly advance a new educational expectation for nurse leaders. That said, we would be remiss if we did not strongly encourage increased education for nurses at every level.

Two key points resonate for me. One is that nurses are not invited to the table based solely on clinical insight; those extending invitations today look for those who are capable leaders. The second point is that ongoing development is critical for anyone in a leadership position. Whether a nurse is prepared with an MSN or a DNP is not the critical question. The question is, “What is the plan for ongoing professional development to remain relevant to the rapidly changing world?” Thus, if we are not learning and improving, we no longer are standing still. We are falling behind.

Programs that produce clinical leaders through strengthening their leadership abilities and through inculcating the skill of continued professional development have the best opportunity to create key leaders for tomorrow’s big challenges.




Nurse Executive Leadership

Al Rundio


Doctor of Nursing Practice (DNP) programs have proliferated the past few years in the United States. The proliferation of such programs demonstrates that nursing is a practice discipline and that clinicians as well as nurse executives can benefit from such a degree as well as contribute to improved patient care outcomes within various health-care systems.

According to Fitzpatrick and Wallace (2009), the DNP is necessary secondary to the complexity of the health-care system, increased diversity of patients and staff, the focus on improved outcomes, enhanced technology and application of such technology, and advanced aging of the U.S. population.

According to Chism (2010), the DNP clinical practice–focused doctorate needs to be grounded in clinical practice and demonstrate how research has an impact on practice. Rather than conducting primary research, the practice doctorate translates research into practice with the ultimate goal of achieving improved patient outcomes. Nurse executives with a DNP are in a pivotal role to affect such change and improvement in care through the reshaping of the health-care delivery system in our nation.

The American Association of Colleges of Nursing (2006) defined eight essentials for DNP programs. Essential II is the following: Organizational and systems leadership for quality improvement and systems thinking leadership is essential to the improvement of health-care delivery systems with a resultant increase in the quality of care that is provided to patients. The following section highlights some key aspects of leadership.


There is no doubt about it—those facilities that have excellent leaders excel. The recent downturn in our economy provides excellent examples of the facilities that embrace change and survive and those that have succumbed to the economy secondary to maintaining the status quo.

There are several leadership theories that one can explore. The reality is that most great leaders embrace various leadership theories. Some leaders are born great. All leaders have essential traits that make them successful as a leader. Yet, others are transformational in nature where they transform the entire culture of an organization as well as the organization itself.

Leadership Is an Art: Leadership Theory and Style

As a former vice president (VP) of nursing in a community hospital, new legislation was passed that recognized advanced practice nurses (APNs). This legislation provided prescriptive practice to APNs. I felt that it was vitally important that APNs be appropriately credentialed on the hospital’s medical staff. This would assure that the medical staff could work collaboratively with these newly credentialed practitioners. I had to convince several people in the organization that this idea of medical staff credentialing for APNs warranted discussion, and we should investigate the possibilities of making this happen. The VP of medical affairs kept stalling the issue, always placing it on a “back burner.”

Finally, I felt that I had had enough of the stall tactics, so 1 day, I advised him that if something was not done, I would have to sue him and the hospital for restraint of trade. I also discussed this with the chief executive officer (CEO) of the organization. The issue was discussed that month at the hospital board meeting with the board of governors voting to appoint an ad hoc committee to study the issue. The VP of medical affairs and I, as well as the other board members, were appointed to this committee. It took nearly 2 years of education and discussion, but finally, this committee unanimously recommended to the full board of governors that APNs should be credentialed on the hospital’s

medical staff. The board of governors unanimously approved this. Several years later, many APNs have and continue to be credentialed on this hospital’s medical staff.

Sometimes, leadership involves stepping out of the box where it is safe. Sometimes, it is where one becomes somewhat aggressive in nature to accomplish what is needed for the organization and nursing. Leadership is also a commitment to one’s value system.

Leadership is integral to the functioning of any organization. It is important to understand that leadership and management are not necessarily the same entity, yet they are implicitly intertwined. The corollary is that if you manage well, you also must be leading well.

There have been many theories studied on the topic of leadership. Today, we recognize how vital good leadership is to the survival of any organization. This is quite evident in health care. With dollars allocated to health care being continually compressed and the nursing shortage escalating, excellent leadership is certainly needed in our health-care delivery systems. As a DNP, the highest educational credential for practicing clinicians and nurse executives, it is essential to embrace the concept of leadership. Only through excellent leadership can nursing move forward in contributing to improved outcomes of care for our patients.

The following describes 10 management/leadership “pearls” to make one successful as a leader. These 10 management/leadership pearls can help you on your journey to successful leadership and management.

At age 26 years, I was offered a supervisory position in an emergency department (ED). I was eager to become a nursing manager: It was a career move that I had worked for, and I was excited that it finally had happened.

Here are some key concepts I have learned in the years since that first job. These 10 pearls can help you on your journey to successful leadership and management.

  1. Build trust.This simple concept is vitally important. When staff members trust their manager, they will move mountains and do almost anything to help accomplish the organization’s goals and objectives.

As a new manager, I wanted to change things overnight. I had come from an ED assistant charge nurse position on the 3 to 11 p.m. shift, and I wanted to make the new hospital a carbon copy of the old one. My rationale was that if it worked at the old hospital, it would work at the new one. I learned differently early on. The patients were different. The cultures of both institutions were different. I should have just observed, and I should have become better acquainted with the staff before implementing many changes. The staff did not even know me. How could they trust me?

  1. Never ask someone to do something that you have not done yourself.I learned this when I was 17 years old and employed after school as a shoe salesman for a major shoe chain. I was the new kid on the block.

One day when I went to work, Sam, the assistant manager, asked me to weed the tarred parking lot. Everyone loved it when Sam was working because he was a great guy who treated everyone fairly, but he was always joking around. So I asked him if he was serious about his request. I was dressed in a suit, and weeding certainly was not a part of my job description. Sam told me that it was my turn. He went on to say that he had done it himself many times before and he would never ask someone to do something

he had not done himself. So, reluctantly, I headed to the parking lot and did the weeding. But from then on, I watched to see if Sam really lived what he told me. I saw Sam shampoo carpets and do many other chores. He did do whatever he asked someone else to do.

Sam’s actions garnered trust and demonstrated to the rest of the employees that he knew what it was like to be in the trenches. One reason I feel that I was so successful as a VP of nursing was that I had started as an orderly in the operating room (OR). I knew what it was like to do a shave preparation, transport a patient, and mop the OR floor.

  1. Delegate.A manager and leader cannot do it all, so it is important to learn delegation skills early on. Delegation frees leaders and managers to do what they should be doing best, that is, leading the organization in the right direction and managing the staff so that organizational goals and objectives are accomplished.
  2. Replenish your cup.I learned this skill when I took a VP of nursing position. I lived and breathed my job and placed family second to it. I had reached my ultimate goal, so I wanted to be successful. A Catholic priest, our hospital chaplain at that time, became a good friend. One day, he came to my office and asked me to go to the community center for a workout and a swim. During our swim, he told me that people cannot give to others if they do not take care of themselves first. “You have to learn how to take time for yourself and replenish and refill your cup before you give to others,” he said.

Other great nursing leaders I know feel the same way. They all say that they work hard, but they play equally as hard. Replenishment for me comes in the form of workouts at the gym, long bike rides, and rock concerts. Replenishment comes to different individuals in different forms, but it is an extremely important concept to embrace and live.

  1. Learn Politics 101.Nurses tend to be apolitical. Most do not even like the word politics; it is necessary to be politically correct to advance your agenda as well as that of nursing. For example, as a VP of nursing, I had to use agency nursing for a short time to stabilize staffing and ultimately contribute to retention of staff by providing safe staffing ratios. Agency nursing costs more than regular staffing. This was the first time that the hospital was using agency nurses, and finance division was really concerned about the additional cost.

So I went out of my way to bond with key individuals in the finance division. When the chief financial officer asked that I play golf with him at the annual hospital golf tournament, I graciously accepted the invitation. Now, I hate golf. It is not a fast enough sport for me. Nevertheless, I had a friend who taught me how to play golf in 10 days so that I would be ready for the tournament and would not look like a total idiot. I played an entire round of golf. Finance became an ally, and I was able to make many positive changes in nursing as a result of this one political move. I will never compromise my value system for politics, but nurses need to become more politically astute to advance nursing.

  1. Master change.There is no doubt about



it, change never stops in health care. A colleague said that managing today is like managing in white water; change is constant. If organizations are going to survive, then change must be a constant, and leaders and managers need to embrace this concept.

  1. Take risks.Nothing ventured, nothing gained. Analyze the situation. If it looks good and your gut tells you to proceed, then take the risk. Do not panic if you fail. You can succeed at everything. If you do not take a risk, you will not grow. Learn from risk taking, and do it whenever you can.
  2. Be a leader.Leaders do the right thing. At times, this may not make them popular. Leaders need to do what needs to be done, and this may mean sticking to their guns. As one colleague told me, if it is lonely at the top, then that is a sign of good leadership.
  3. Be willing to give up things to advance your career.As leaders and managers, we may manage our department or service extremely well and implement many positive changes. If an opportunity comes up, it may involve giving up what we are currently leading and managing for a promotion. Do not hold on; just let go and relish in the fact that you have an opportunity to develop in new and exciting ways. This contributes to our growth and development as leaders and managers.
  4. Practice the piano.Consistently practice the nine management pearls for success. Just as one would ready a piano concerto for a recital, practicing these pearls until they are perfected can lead to true success.

From nurse.com. Copyright 2005 Gannett Healthcare Group. All Rights Reserved.

Through several case studies provided in this chapter, the reader explores different aspects of transformational leadership. The goal is that these case studies will bring some “life” to leadership.




Leading Change: Implementation of a Nursing Informatics System

I was a new VP of nursing at an acute care community hospital. The year after my appointment, the hospital was on a survey by The Joint Commission on Accreditation of Healthcare Organizations.

I had prepared and accomplished a lot for this survey. For example, I had implemented new criterion-based performance descriptions and evaluations for all staff levels; had written a new philosophy statement for the nursing division; and had revised the quality improvement program, including the committee composition.

The country was experiencing a nursing shortage, much like the one that we are currently experiencing.

I will never forget the nurse surveyor from The Joint Commission. She was educationally focused and nursing process-oriented. She was on a mission. For her, the nursing process was a hammer that slammed home the importance of registered nurses (RNs) completing initial patient assessments. She contended, “This is what RNs can use to justify their role. What we do differently from LPNs or other health-care providers is the initial nursing assessment, which must be done by an RN, and the plan of care for the patient.” From this particular nurse surveyor, we received a type I contingency that reflected a deficiency in how we used the nursing process.

The contingency came as no surprise. Back then, everything seemed to be a problem for our education department. For example, the nursing process was not being done because the staff lacked education supporting it. We had discussed the issue at the nursing quality improvement committee. We had implemented a vast education program. We then monitored compliance. We were dismayed when compliance barely improved from the initial survey. That is when it hit me. We were not dealing with a staff education or compliance issue. The problem was much simpler. Nurses in acute care did not value the nursing process because we basically functioned in a medical model. The nurses could not see what the nursing process did to improve patient care. Practicing in the midst of a staffing shortage, why do something if it did not improve care? And was not it my role as VP of nursing to get rid of any work that had no effect on patient care? It became apparent to me that we had a systems problem and what really was needed was a systems change, a new way of thinking that would let the system dictate the process.

I used that negative survey as a catalyst to obtain funding for a nursing informatics system where the documentation was based on standards of nursing practice. The system based the plan of care on the nursing process without the nurses realizing it was a care plan and that it involved the nursing process. Effective informatics systems in nursing become so interwoven into everyday care that they become invisible to the user. They become decision support models for the care delivery system.

Our organization implemented ExcelCare, a system that incorporated 200 medical-surgical standards of nursing care. We formed a committee of staff nurses and clinical nurse specialists who tailored these standards to the nursing practice at our institution. The standards were based on research in the literature. For example, I remember changing the standard for circling cast drainage because a nurse researcher had concluded that neurovascular checks on an extremity were more effective than circling the cast drainage. This system achieved 100% compliance with the nursing process because the documentation system was based on units of care, the nursing practice standards. Selected units of


of care were individualized for each patient and formed an individualized plan of care. In the computer system, nurses documented against the units of care selected for the patient. Care dramatically improved at the organization.

The staff was committed to the system. For instance, when the computer system crashed 1 day, nurses just could not go back to handwritten documentation. We had started with a computer illiterate staff, and now everyone loved the system. The system became so effective that the hospital still uses it today, almost 15 years later. It is one of my legacies at that hospital.

    Discussion Questions

  1. How does your organization implement change?
  2. In assessing your organization, how many problems are directly related to the actions of people compared with a problem in the system?
  3. Can you identify a major issue that requires the change process in your organization?
  4. Can you list two practices that you feel are mundane and should be changed in your organization?


  1. Most change can be explained by current theories. For example, Kurt Lewin, a noted change theorist, describes three steps in the change process: (1) unfreezing, where the organization senses a need for change; (2) movement, where a change agent has been selected and the process of implementing the change begins; and (3) refreezing, where the new change becomes imbedded into the organization’s routine. Occurring daily, change is inherent in today’s management. As one nurse manager recently stated, “Managing change is like rowing in white water. It is constant.”
  2. Most problems in organizations result from variation in a particular system rather than problems with specific individuals. Most problems in organizations require a change in the system, so that human beings can do the correct things.
  3. You should be able to identify a few processes that could be improved by change within your own organization.
  4. Take a look at practices that evolve into rituals over the years. Oftentimes, such practices require change based on current standards of practice.


  1. The nursing process
  2. Systems theory and change theory
  3. Standards of care
  4. Quality improvement
  5. Leadership
  6. Staff involvement
  7. Nursing informatics

Ethical Leadership: Leaders Do the Right Things

On the job, Jane had a special friend who no one else had. She was the assistant director of adolescent services at a residential chemical dependency treatment center, a private, for-profit residential facility with 42 adolescent and 18 adult resident beds—60 inpatient residential beds. Jane was responsible for day-to-day management and operations of the adolescent unit. Jane owed her job to the CEO and owner of the center, with whom she had a personal friendship. This relationship sometimes spilled over into the management arena at the center.

The 42 female and male residents housed in the adolescent unit ranged from ages 13 to 18 years. The average length of stay was 6 to 9 months. Treatment at this facility focused on the 12-step philosophy of Alcoholics Anonymous. Residents attended both individual and group education and counseling sessions. Although treatment also focused on basic life skills, residents attended 2 hours of school each day and enjoyed an active leisure activity program.

John was the director of the leisure activities program at the center. An avid sportsman, he planned many outside and off-site activities for the adolescent residents. Thirty-year-old John reported to Jane, who was 49 years old.

Jane developed a crush on John. He just brightened her day. As for John, he

, he had a lot to gain from his association with Jane, even though he did not like her sometimes quirky pursuit (e.g., 1 day she lifted her blouse up to expose her breasts during a meeting with him). Nevertheless, Jane made sure he had a company credit card. She would authorize hours of overtime for him and just about anything else he wanted for his program. One day, Jane’s behavior deteriorated. Although noted for mood swings, Jane appeared exceptionally depressed. She seemed so distraught at the daily treatment team meeting that the clinical director approached her to see what was wrong. Oddly, she stated, “It’s one of my better days. Everything’s fine.” The clinical director left early that day to attend an outside meeting, but on his return trip home, the human resource (HR) director paged him. She advised him that a serious incident had transpired that day—six staff members had witnessed Jane trying to engage John in heavy petting in the adolescent community room in front of about 15 adolescent residents. When John asked her to stop, she responded, “I bet Mark won’t mind,” pointing to a 15-year-old adolescent resident who had a sexual abuse history. Then Jane went and sat on Mark’s lap.

When Mark started shouting, “Ms. Jane! Ms. Jane!” she whispered in his ear, “The louder you shout, the harder I’ll sit on you.” After a few moments, Jane got off of Mark’s lap and went about her business as if nothing had happened. The clinical director advised the HR director that he would come right in to further address the incident in question.

Later that same day, John went to the HR director, with whom he shared that day’s occurrence. He said he felt that Jane was sexually harassing him. After the clinical director arrived at the office, John was asked to put his story in writing.

The HR director then summoned Jane to her office, where she and the clinical director confronted her with the events of that day. She denied everything, even though the HR director advised her that six staff members had witnessed the occurrence. In light of the large discrepancy between her story and the accounts of the staff members, the clinical director asked, “As a director, how would you determine the truth here?”

Jane advised him to talk to John. “He will tell you the truth about what happened. He will prove my innocence,” she said.

“What would you do if John confirmed the allegations and was even willing to place them in writing?” the clinical director responded. “If that is the case,” Jane replied, “then I should be fired.” And she was. The clinical director terminated her employment, stating that John had not only verbally confirmed the events of the day but had put his allegations in writing. After Jane left, the clinical director notified the Institute of Abuse and Neglect of the Division of Youth and Family Services about what had occurred that day at the center.

    Discussion Questions

  1. Was this situation handled properly or should it have been dealt with differently?
  2. Should the employee have been terminated on the spot, or were there alternative courses of action?
  3. What constitutes sexual harassment in the workplace?
  4. What legal issues could evolve from this case?
  5. When is the right time to report such cases to the appropriate authorities?


  1. This situation was handled properly, as a prompt investigation by the appropriate responsible departments had occurred.
  2. The employee

Leading in Times of Crisis: Disaster Management

It was May in the early 1990s. I was a VP of nursing in a community hospital in southern New Jersey. Sigma Theta Tau was inducting one of my nursing directors in a Sunday afternoon ceremony.

The nursing directors had to rotate day-shift house coverage on weekends. The nursing director, who was joining Sigma Theta Tau, was scheduled to work the weekend day of her induction. She asked other directors to switch weekends with her, but no one could. When she came to me, I volunteered to cover for her. I felt that her participation in the induction ceremony was important.

That weekend was the weekend from hell. Anything and everything happened. On Saturday, a pediatric trauma patient arrived in our ED. His mother had been at a yard sale in a rural area that our hospital serviced. It was raining that day and the 6-year-old ran between parked cars into the street and was struck by an oncoming motor vehicle. The child arrived in our ED comatose. He was going to the OR with a three-member surgical team. Because one of my practice areas was the OR, I went there to assist the team of three surgeons who operated on this child at the same time. Pediatric trauma and such a procedure were rare events at our facility. The case lasted a rather long time, but finally, the child was stabilized, transferred to our critical care unit, and then air lifted to the regional trauma center. The child had initially been brought to our facility because the helicopter was not running at the time of the accident due to inclement weather.

The evening nursing supervisor relieved me that day at 1 p.m., but she never saw me until 7 p.m. that evening.

The next day, Sunday, was a quiet day, quite the opposite of the previous day. I planned to go to lunch that day at 11:45 a.m. and then meet the evening supervisor at 1 p.m. for report. I hoped to be home by about 1:30 p.m. It was a perfect day, that is, until I went on the elevator to the second floor where the cafeteria is located.

As I came off of the elevator, the radiology secretary was running down the hallway. She yelled to me, “Al, get downstairs immediately. There is a terrible smell in radiology.” I hit the “B” key for the basement, where radiology was located. As the elevator door opened, I could smell something like chlorine gas. I proceeded down the hallway where the smell was coming from, but the smell overcame me and I had to exit the area because I felt like I was going to pass out.

The smell was picked up by the air handling system in the new 101-bed patient tower, and bromide gas was quickly being dispersed throughout a major part of the hospital. Although the ink was not yet dry on our internal disaster plan (now crisis management plan), I declared an internal disaster. I was fortunate that I was the one who chaired the committee that had drafted this document so I was familiar with its content and could activate the plan. All of the patients in the tower were moved laterally to the cafeteria within 20 minutes. Every diabetic patient received medications and meals. Every chart was transferred to the holding area. No employees or patients were injured. Pediatric and obstetric patients were wheeled down the street


This became important to them because the annual evaluation process was tied directly to merit raise for nurse managers. My goal was to review all of their statements and then synthesize one philosophy statement for our nursing division. In this way, all nurse managers would have input. An unexpected additional event occurred. The nursing managers decided that they would have their staff submit a philosophy statement appropriate for each nursing unit; for example, the detox unit philosophy statement would be somewhat different than the pediatric unit philosophy statement. One nurse manager went as far as to make the unit philosophy statement competitive. He elected to fund the cost of an annual national conference for the nurse who wrote the winning philosophy statement. He even took the winning philosophy statement and posted it so that the unit’s philosophy statement was shared with all of the staff members.

I complimented the nurse manager on a job well done. He also did an excellent job on the philosophy statement that he had completed for his evaluation, even though at the start of the process, he had said he had no clue about what he was doing. Because he did not understand what a philosophy statement was, he had gone to a library to research the concept. He admitted that he had grown through the process.

    Discussion Questions

  1. Can you think of some ideas on how you can promote transformational leadership in your organization?
  2. Does your organization employ the concepts of transformational leadership? If so, how are these concepts applied? If not, what model of leadership exists in your organization?
  3. How are performance evaluations completed in your facility?
  4. Can you identify a more innovative process for annual employee evaluations?


  1. Transformational leadership can be promoted in an organization in many ways. Using Senge’s approach that all organizations must be learning organizations is one way. Implementing the idea of quality circles, where the employees closest to the work unit use problem-solving techniques to improve work performance, is another way to implement transformational leadership. Encouraging employees to take risks and to transcend normal work performance expectations is another method. Implementation of a shared governance model of nursing care would be another way of encouraging transformational leadership.
  2. This question has to be answered by you. You should try to identify if concepts of transformational leadership exist within your organization. If not, what style of leadership is apparent?
  3. This question has to be answered by you. Most performance evaluations follow a criterion-based method of performance evaluation, that is, the employee is evaluated against predetermined criteria.
  4. There are several ways of being innovative with performance appraisals. One way is to create self-evaluation assignments for the employees being evaluated, where the employees list goals and objectives each year and then evaluate themselves during their annual performance appraisal.


  1. Transformational leadership
  2. Employee evaluation process
  3. Risk taking
  4. Philosophy statements for nursing
  5. Self-actualization of employees

Leading a Renovation: Transforming the Physical Plant of Maternal–Child Health

Empowerment of staff is inherent in the transformational leadership process. However, empowerment and the quality of work life it produces not only relate to the mental environment created by the nursing leader but also the physical workplace. Good architects recognize that those closest to the actual work usually create the best environment for practice.

Some hospital administrators wanted to renovate their pediatric and maternity nursing units into state-of-the-art facilities. They wanted the environment to not only

benefit the patients but also the nurses who worked there. Nurse empowerment was a key philosophy of the nurse executive at this particular organization. So, it is no surprise when he empowered the maternal–child health nurse manager to take on the renovation and construction projects of the pediatric and maternity units.

The first aspect of the project involved the appointment of a project team, which was led by the respective nursing manager. The first charge to the team was to visit different units both within the state of New Jersey and neighboring states to obtain different ideas on how to proceed with a design. They visited hospitals in New Jersey and Pennsylvania.

In keeping with the hospital’s location at the southern New Jersey shore, the nursing manager and her staff came up with the concept of mirroring the Ocean City boardwalk as the main theme for the pediatric unit. The unit design incorporated a lighthouse, built-in aquariums in the nursing stations, and erected rooms that replicated major shops on the Ocean City boardwalk. In fact, designs for the rooms were selected when respective vendors donated money to the pediatric unit. For example, the treatment room even had a friendly carousel horse in it because it was donated by the owner of one of the amusement piers on the boardwalk. This was all the idea of the nursing manager and her staff. The result was an outstanding, functional design. Success was obvious when adults requested that they be placed on this unit when admitted to the hospital (we all do have a child within us). The maternity unit took on a similar design. This unit, with staff involvement, incorporated the labor-delivery-recovery-postpartum (LDRP) concept of care and modeled their theme off of a Victorian bed and breakfast inn from Cape May, New Jersey. Again, the results were astounding. The patient volume doubled the first year that this unit was in operation.

The renovation of these two key nursing units in a community hospital setting just reinforced what nurse empowerment and transformational leaders can accomplish.

    Discussion Questions

  1. What risks did the nursing leader take in this particular organization?
  2. Do you think that the physical environment is important to the practice of nursing?
  3. Does renovation of the physical environment contribute to improved morale and staff retention?


  1. The nursing leader took the risk of empowering a nursing manager who reported to him to take the lead role in a major construction project. Obviously, when delegating such an issue, the nursing leader believed that this nurse was competent and capable of handling such a task. Certainly, such a project could not be delegated to just anyone.
  2. A physical environment that is conducive to both nurses and patients is important in the provision of quality patient care. Such environments not only incorporate aesthetics but also functionality so that nursing performs at its best. Form follows function, so to speak.
  3. Renovation of the physical environment does contribute to improved morale and staff retention as long as nursing staff are involved in the process.


  1. Empowerment of staff
  2. Transformational leadership
  3. Construction codes
  4. New roles for nursing

Leading Oneself: Transforming Oneself for the Future

The future of health care and nursing is not guaranteed. One can never overprepare for evolving roles. Learning is lifelong, and education can come from formal college credit education or continuing education. Peter Senge states that organizations must be learning organizations to survive. He describes successful organizations as those organizations that are in a continuous learning mode.

A key component of any nurse leader’s role is a vision of what the future holds. Some people claim this ability to be “visionary.” Others obtain this vision by being active on state or regional committees and being tuned in to what is occurring in the world around them. This was the case with the nurse executive discussed here.

When looking at statistics of the elderly and where long-term care was heading in this nurse executive’s state, it was apparent that more services for the elderly were in the future of his hospital’s service area. Such services included assisted living, a new concept in his state. Another such service was subacute care within the hospital setting, where units were designed to help ill patients, who required intense therapy, with a quick transition from acute care units to a subacute nursing unit with less intense care provisions. From reviewing other states that had implemented such units, it was apparent that a licensed nursing home administrator had to oversee the operations of such units. Long-term care agencies had been threatened by the location of subacute units in acute care hospital settings. These agencies had lobbied successfully to at least mandate that a licensed nursing home administrator was involved.

The nurse executive believed that all nursing services within a hospital should report to the chief nursing officer within an organization. Recognizing what the future held, he decided to pursue appropriate licensure that would credential him as a licensed nursing home administrator. The process involved 100 continuing education units in long-term care; a 2,000-hour practicum in nursing home administration; and successful completion of a comprehensive national licensing examination in nursing home administration. The nurse executive did successfully accomplish these things before his hospital’s subacute unit became operational. His goal of having hospital nursing units report to nursing was successful.

In transforming an organization, one oftentimes has to continually transform oneself in the process to contribute to the overall good of the entire organization. By doing this, administrators not only acquire talents and skills that will advance them in their current job role but also gain abilities that are transferable to other agencies and future employment.

    Discussion Questions

  1. In what way have you developed in order to transform yourself into a different role?
  2. Had this nurse administrator not pursued continuing education as a licensed nursing home administrator, who would have managed the new subacute unit?
  3. Where do you see the future of health care and nursing going?


  1. Think about ways in which you have added to your own education and preparation for future roles. Where do you see yourself in 5 or 10 years? Are you prepared to take on different roles? Those who have several skill sets will be most employable in the future.
  2. A licensed nursing home administrator would have to have been hired to manage this unit. This administrator may or may not have reported to the chief nursing administrator. By securing a license as a nursing home administrator, the chief nurse administrator
  3. A licensed nursing home administrator would have to have been hired to manage this unit. This administrator may or may not have reported to the chief nursing administrator. By securing a license as a nursing home administrator, the chief nurse administrator assured that this unit would report to nursing.
  4. Take a look into the crystal ball. Review some current literature on the future of health care. Try to identify where you think the future of health care and nursing is headed.


  1. Transformational leadership
  2. Licensure in nursing home administration
  3. Elder care
  4. Future issues in health care




Policy Implications Driving National Quality and Safety Initiatives

Mary Jean Schumann, DNP, MBA, RN, CPNP, 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. 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, 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, and harm as a result of medication errors, safety has become synonymous with quality improvement in many discussions.

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.” There is considerable evidence in this chapter to support the value of that definition.

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.

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 passage of still‐controversial health care reform legislation, the Affordable Care Act, 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.

The Landscape of Formal Stakeholders in the Ongoing Quality Dialogue

Many collective efforts have been initiated over the last 25 years to drive quality and safety improvement through policy channels. This chapter will describe formalized efforts that grew out of a need to address health delivery challenges, using organizational structures or alliances whose missions were substantially focused on quality. The list is necessarily broad and incorporates federal agencies as well as others. Certainly this list is not exhaustive; the intent has been to include those efforts in which nursing has or needs to have a voice in the formal agenda, solutions, and policy formulations. In addition, this chapter will touch on some of the additional opportunities for policy input through regulation and rule making that inevitably emerge from massive policy enactment.

This chapter will begin with a discussion of the result of two decades of effort—the passage and early efforts to implement the Affordable Care Act (ACA) and the many provisions within it that support health care quality and safety. However, the subsequent discussion centers around understanding that other policy efforts have also been required to achieve convergence, successful legislation, and full‐scale implementation.

Affordable Care Act Emerged Where Efforts Converged

In March 2010, the US Congress passed and the president signed into law the ACA. Although the provisions were many and even six years later remain controversial, from the perspective of driving improvements in quality, several key provisions of the law, as they have been phased in, have provided significant opportunity to reshape the future delivery of care. Nurses played a critical role in designing and supporting passage of these provisions and have since had significant opportunity to influence, recommend, and in some cases design innovations in care delivery that are consistent with these provisions and with implementation of various aspects of the law focused on the improvement of quality. The following are some of the key provisions specific to quality and safety.

Improving Health Care Quality and Efficiency

The law established a new Center for Medicare and Medicaid Innovation that conducts pilot demonstrations to test new ways of delivering care to patients. In addition, this center continues to search for existing and promising innovative programs that can be replicated or scaled up to improve the quality and safety of health care delivered, while also reducing the rate of growth in health care spending for Medicare, Medicaid, and the Children’s Health Insurance Program. Included in this provision, the HHS was required to submit a National Strategy for Quality Improvement in Health Care that would include these programs in addition to those of third‐party payers. This National Strategy, a strategic plan for improving the delivery of health care services, achieving better patient outcomes, and improving the health of the US population, continues to be updated yearly. The ACA called for the establishment of an Interagency Working Group on Health Care Quality, composed of senior officials representing 24 federal agencies with major responsibility for health care quality and quality improvement. The working group’s function is to provide a platform for collaboration, cooperation, and consultation among relevant agencies regarding quality initiatives as a means to ensure alignment and coordination across federal efforts and with the private sector. It continues to meet annually to provide guidance and oversight to the collective quality efforts.

Linking Payment to Quality Outcomes

ACA established a Hospital Value‐Based Purchasing program for traditional Medicare participants. No longer do hospitals receive reimbursement for care based exclusively on the quantity of services delivered. This program offers financial incentives to hospitals to improve the quality of care provided to Medicare patients. This method of payment rewards institutions based on how closely they adhere to best clinical practice, as well as on their improvement of the patients’ experiences of care during hospitalization. In keeping with the intent of transparency and accountability, hospital performance is publicly reported using a star rating system in Hospital Compare. Reporting is based on measures relating to events like heart attacks, heart failure, pneumonia, surgical care, health care‐associated infections, and patients’ perception of care. Early in the development of this process stakeholders and quality alliances, including nursing, submitted public comments regarding the proposed rules that would implement the value‐based purchasing provision.

The work of developing and endorsing performance measures that meet the intent of this provision are the result of work in which various entities, alliances, and individual stakeholder organizations engage. Measure development remains some of the more important and most challenging work in policy related to ACA. Measures, if appropriately defined, can quantify the quality of the care delivered for payments, and they also focus attention on issues that are major factors in whether patients survive medical or surgical interventions and hospitalizations. Measure development is challenging because although electronic systems are more efficient methods of data monitoring and capture than manual (paper) documentation that can track institutions’ progress and success, few measures are electronically available in many of these domains, particularly as they might pertain to items that fall most directly into the realm of nurses and nursing care. Equally challenging is the expensive pilot testing and subsequent endorsement process to demonstrate the adequacy and accuracy of such measures for reporting to the public, and for payment. Nurses have great opportunities for influence in the development and adoption of measures that reflect the outcomes and patient experiences of nursing care.

Encouraging Integrated Health Systems

ACA provides incentives for physicians and other providers to join together to form Accountable Care Organizations (ACO), which allow physicians and other providers to better coordinate patient care and improve health care quality, help prevent disease and illness, and reduce unnecessary hospital admissions. When an ACO provides high quality care while reducing costs to the health care system, rules allow the ACO to keep some of the money saved. Key stakeholder groups, including nursing, engaged in public comments in response to controversial ACO rules proposed by the Centers for Medicare and Medicaid Services (CMS) prior to the establishment of most of the ACOs

currently in existence. Although ACOs clearly would benefit from the services of RNs, advanced practice registered nurses (APRN), and other clinicians, certain exclusions in the rules could have negative impact in recognizing their contributions or sharing cost savings.

Paying Providers Based on Value, Not Volume

Provisions in the ACA tie provider payments to the quality of care they provide. Providers are expected to see their payments modified so that those who provide higher value care will receive higher payments than those who provide lower quality care. This provision is taking place in progressive stages. In fiscal years 2013 to 2015, hospitals have become accountable in both reporting and in receipt of payment for specific domains of care that expand to include an additional domain each year. These domains include the following: the clinical process of care domain measures such as venous thromboembolism prophylaxis, appropriate surgical use of postoperative antibiotics, and urinary catheter removal postoperatively; the patient experience of care domain such as nurse communication, doctor communication, hospital staff responsiveness, pain management, medicine communication, and discharge information; the outcome domain measures such as acute myocardial infarction (AMI) 30‐day mortality rate, heart failure (HF) 30‐day mortality rate, pneumonia (PN) 30‐day mortality rate, central line‐associated blood stream infection (CLABSI); and in 2015 the efficiency domain, which focuses on Medicare spending per beneficiary. CMS assesses each hospital’s performance by comparing its scores on achievement and improvement related to each measure of performance (Department Of Health And Human Services Centers for Medicare and Medicaid Services, Hospital Value‐Based Purchasing Program Fact Sheet, accessed at https://www.cms.gov/Outreach‐and‐Education/Medicare‐Learning‐Network‐MLN/MLNProducts/downloads/Hospital_VBPurchasing_Fact_Sheet_ICN907664.pdf).

Partnership for Patients

Partnership for Patients was a national partnership initiated in April 2011 by HHS that projected to save 60,000 lives by preventing injuries and complications in patient care over three years. HHS stated upon its inception that the Partnership for Patients also had the potential to save up to $35 billion in health care costs, including up to $10 billion for Medicare. Over the next 10 years, the Partnership for Patients could reduce costs to Medicare by $50 billion and save billions more in Medicaid. More than 3,500 hospitals, physician and nurse groups, consumer groups, and employers pledged their commitment to the Partnership for Patients. Oversight for this program has been under CMS’s Center for Medicare and Medicaid Innovations.

This public‐private partnership was invested in reforms that help achieve two shared goals:

  • Keeping hospital patients from getting injured or sicker: By the end of 2013, preventable hospital‐acquired conditions were expected to decrease by 40% compared to 2010. Achieving this goal meant approximately 1.8 million fewer injuries to patients, with more than 60,000 lives saved over the next three years.
  • Helping patients heal without complication: By the end of 2013, preventable complications during a transition from one care setting to another were expected to decrease so that all hospital readmissions would be reduced by 20 compared with those of 2010. Achieving this goal would mean that more than 1.6 million patients will recover from illness without suffering a preventable complication requiring re‐hospitalization within 30 days of discharge.
  • The partnership asks hospitals to focus on nine types of medical errors and complications where the potential for dramatic reductions in harm rates has been demonstrated by pioneering hospitals and systems across the country. Examples included preventing adverse drug reactions, pressure ulcers, childbirth complications, and surgical site infections. The CMS Innovation Center had pledged to help hospitals adapt effective, evidence‐based care improvements to target preventable patient injuries on a local level, developing innovative approaches to spreading and sharing strategies among public and private partners in all states. Members of the partnership were to identify specific steps they will take to reduce preventable injuries and complications in patient care.
  • How has the Partnership for Patients done so far in meeting these goals? As reported by Blumenthal in May 2015, 30‐day readmission rates for Medicare enrollees declined nationally from more than 19% to less than 18.5% in 2012 and to 17.5% in 2013; this is equivalent to 150,000 fewer readmissions between January 2012 and December 2013. The first ever decline in hospital composite rates of hospital‐acquired conditions (HAC) nationally decreased from 2010 to 2013. It is estimated that this prevented roughly 50,000 deaths and saved $12 billion. The overall 9% in the decline in the incidence of hospital acquired conditions from 2010–2012 includes 560,000 fewer HACs in just two years, with the prevention of 15,000 deaths due to reductions in adverse events, falls, and infections, and a savings of $3.2 billion in 2012 alone. In addition, through the end of 2013, falls and trauma decreased by nearly 15%, pressure ulcers decreased by 25%, ventilator associated pneumonias decreased by over 50%, and venous blood clotting complications decreased by 13% (Blumenthal, Abrams, and Nuzum, 2015).

National Quality Strategy Is the Future

In compliance with ACA, the National Quality Strategy was released via a report to Congress in March 2011. Consistent with the initiatives of the National Quality Forum and the National Priorities Partners Goals and Priorities, the National Quality Strategy pursued three broad aims—similar to those referenced by the Institute for Health Care Improvement as the Triple Aims—to guide and assess local, state, and national efforts to improve the quality of health care. The aims included the following:

  • Better Care: Improve the overall quality by making health care more patient centered, reliable, accessible, and safe.
  • Healthy People/Healthy Communities: Improve the health of the US population by supporting proven interventions to address behavioral, social, and environmental determinants of health in addition to delivering higher quality care.
  • Affordable Care: Reduce the cost of quality health care for individuals, families, employers, and government.

The National Quality Strategy was based on recognition that in the end, all health care is local, and its intent has been to help assure that these local efforts remain consistent with shared national aims and priorities. The Secretary of HHS developed this initial strategy and plan through a participatory, transparent, and collaborative process that reached out to more than 300 groups, organizations, and individuals who provided comments. The AHRQ was tasked with supporting and coordinating the implementation plan and further development and updating of the strategy, which it has continued to do.

At the federal level, the National Quality Strategy has guided the development of HHS programs, regulations, and strategic plans for new initiatives, in addition to serving as a mechanism for evaluating the full range of federal health efforts. The first year strategy did not include HHS‐specific plans, goals, benchmarks, and standardized quality metrics, but AHRQ developed these through collaboration of the participating agencies and private sector consultations. The 2015 Strategy speaks to the following six evolving priorities that inform the advancement of efforts to keep patients safe:

  • Making care safer by reducing harm caused in the delivery of care
  • Ensuring that each person and family members are engaged as partners in their care
  • Promoting effective communication and coordination of care
  • Promoting the most effective prevention and treatment practices for the leading causes of mortality, starting with cardiovascular disease
  • Working with communities to promote wide use of best practices to enable healthy living
  • Making quality care more affordable for individuals, families, employers, and governments by developing and spreading new health care delivery models (reference AHRQ, Working for Quality web site accessed at http://www.ahrq.gov/workingforquality/nqs/overview.htm

Starting in 2015 annual reports on the progress on the aims and priorities of the National Quality Strategy will be based upon AHRQ’s National Healthcare Quality and Disparities Reports. These reports will include updated measurement data regarding the Nation’s progress on each priority. Current measurement data can be found on the National Health Care Quality and Disparities web site at http://www.ahrq.gov/research/findings/nhqrdr/index.html.

Building the Momentum for Quality

The inclusion of such far‐reaching provisions related to quality and safety in the ACA was made possible largely because of efforts over two decades of health care industry stakeholders to identify the challenges and build multiple supportive allegiances, 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 pages describe how powerful such efforts would be.

National Quality Forum: A Strategic Model

In 2000, following the IOM reports on medical errors and the quality chasm, the National Quality Forum (NQF), a new private not‐for‐profit 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 Health Care Industry convened in 1996. The advisory commission was one of many ways that 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 decade 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: 1) build consensus on priorities and goals for health care quality; 2) play a major role in the endorsement of national consensus standards; and 3) 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. Today, there are nearly 450 NQF organizational members.

The development and expansion of NQF has included input from nurses with representation from organizational membership in NQF from its inception and at the 23‐member board by nursing experts. The American Nurses Association (ANA) was the first NQF nursing organization member, with others following suit over the next decade. As many as 23 entities representing nursing have been NQF members, and nursing continues to hold a seat on the NQF Executive Board.

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: 1) convening experts across the industry to define quality by developing standards and measures; 2) gathering information from measurement of performance through data reporting and analysis; and 3) identifying gaps that are provided back to providers, institutions, and others about performance to initiate performance improvement and public reporting. In addition, NQF, as do 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 allows 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.

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 multi‐stakeholder groups, it is expected to provide input to the US Secretary of Health and Human Services through federal government appointment, on the selection of performance measures for public reporting and performance‐based payment programs. An NQF board work group met in early 2010 to consider the charge and structure for a potential new partnership to serve this purpose, called the Measure Applications Partnership (MAP). MAP has been designed as a two‐tiered structure that includes a standing multi‐stakeholder 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 advise on measures needed for specific uses. NQF through the coordinating committee recommends measures for use in public reporting, performance‐based payment, and other programs to HHS. At least one nursing organization, the ANA, is a member of the coordinating committee, and several nursing organizations have representatives, and individual nursing leaders and content experts have been appointed through a nominations process to the various work groups.

National Database of Nursing Quality Indicators: Capturing the Data

Even before the release of To Err is Human (Institute of Medicine, 2000) and Crossing the Quality Chasm(Institute of Medicine, 2001), the nursing profession had begun to speak up about the eroding of the quality of care patients received. Not surprisingly, this concern surfaced early at the national nursing policy level. In 1994, the ANA House of Delegates at its annual meeting approved a house resolution that urged ANA leadership to address the problem of declining patient care quality experienced in many institutions, perceived by nurses to be due in part to reductions in staffing levels implemented following declining revenue. ANA, when addressing this problem with its interdisciplinary colleagues, was repeatedly asked to show the evidence that reduced nursing staffing led to such declines in quality care. Nurse leaders determined that not only was there a need for education about principles of quality, but that in fact, data were required that would put to rest the criticisms of those claiming that the value of nursing could not be substantiated.

In the mid‐1990s, ANA began a national effort to educate nurses about the value of data and quality through regional conferences. ANA simultaneously convened nurse experts Dr. Norma Lang, Dr. Marilyn Chow, and others to identify structural, process, and outcome measures that would support the relationship between staffing levels, skill mix, and the quality of nursing care. Those initial measure definitions became the basis for the NQF‐endorsed nursing sensitive measures. As a result of recommendations from this group of experts, ANA funded a contract to develop a national database with Dr. Nancy Dunton as principal investigator, that could receive and aggregate data collected via these measures. In 1998, ANA awarded grants to seven state nurses associations to encourage hospitals in those states to collect and submit data to this new database, National Database of Nursing Quality Indicators (NDNQI), a proprietary database of the ANA (Montalvo and Dunton, 2007). Since 1998, the number of acute and specialty hospitals that submit quarterly nursing‐related quality data has grown to more than 2,000, more than one‐third of all US acute care facilities.

The impact of NDNQI on policy conversations at the institutional, state, or national level has been far reaching. Studies published at the national level utilizing the aggregated data support the impact of the quantity and skill mix on the quality of nursing care, the link between nursing satisfaction and improved satisfaction of patients with their care, and the impact of levels of nursing education with the outcomes of care. It has provided comparisons of similar institutions and unit types, both within the state and across the country, to assist chief nursing officers and nurse managers to defend the appropriate levels and skill mix of nurse staffing in their institutions, describe the impact of decreased levels on patient outcomes, and drive performance improvements at unit and institutional levels. NDNQI data reports provided back to the institutions point to opportunities for deeper examination of the processes of care and the need for evidence that supports care decisions.

Data from NDNQI has been used at the state level for public reporting, driving state initiatives, and supporting staffing legislation that defends the hospital and the nursing unit‐level leaderships’ rights to make decisions about safe staffing levels based on the evidence, rather than on state‐mandated ratios. Major insurers provide higher ratings to those institutions that participate in NDNQI, based on their conviction that institutions that care about nursing care quality are more likely to have positive outcomes.

In 2014 ANA made a decision to divest itself of NDNQI and arranged for its purchase by Press Ganey, an established for‐profit business that supports data collection and reporting on the patient experience of care. ANA retains stewardship of certain NDNQI measures and retains an advisory role in the further development of NDNQI.

Institute for Healthcare Improvement Focused on System Improvement

Founded in 1991, IHI has been a major driver of quality care and health care change based on the philosophy that almost any product or service, including health care, can be improved. The IHI encouraged systems thinking with improvement of a systems idea; if one can change the way things


; if one can change the way things are done, one can get better results. IHI aims to improve the lives of patients, the health of communities, and the joy of the health care workforce by focusing on the IOM’s six improvement aims for the health care system: safety, effectiveness, patient‐centeredness, timeliness, efficiency, and equity (Institute of Medicine, 2001). IHI may be best known for its campaigns to Save 100,000 Lives, later to Save Five Million Lives, and currently the Triple Aim initiatives of better care, better health, at lower cost. IHI provides a variety of services and educational programs and tools to assist hospitals and other stakeholders to achieve these aims. IHI’s structure and campaigns have enabled institutions and individual providers of care, including nurses, to share their “near misses” and successes in instructive ways. Nursing organizations have participated in IHI to contribute to discussions and to influence actions that have global and national consequences.

Informatics, Electronic Health Records, and Impact of Technology on Quality and Policy

While also helping align the health care industry with quality expectations in other industries, dialogue about the use of technology, nursing terminologies, and consistent specifications for data capture, including physician order entry, diagnoses, interventions, and decision support, became part of the quality discussion. Harnessing complex technology for quality improvement and reporting purposes has become crucial. Although NDNQI has been able to function successfully in a manual data capture environment to accommodate institutions with insufficient progress toward electronic health records, driving policy changes that impact future quality requires the ability to capture that data electronically according to widely agreed upon specifications. Unless data for measures are able to be gathered as well as submitted electronically, the ability of nurse leaders to drive progress in the policy world of quality will erode.

Data collection burdens, the accuracy of electronic data extractions, the timeliness of the data reporting and analysis, the ability to have timely comparisons to benchmarks, all impact not only the performance improvement process but also the ability to ensure that patients are receiving the care they deserve within a safety culture. The challenge of many electronic systems, as may have already been mentioned, is that while much data go into the system, particularly in the delivery of nursing care, it can be nearly impossible to extract it for reporting and analysis. Further, decision supports based on data that identifies 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 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, are 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; Cronenwett et al., 2009).

A major contributor to this agenda is 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 information technology, enabling nurses to use informatics in practice and education to provide safer, high‐quality patient care (Warren, 2012). Laying the groundwork for an interdisciplinary collaborative, TIGER is implementing Phase 3 to integrate TIGER recommendations for a virtual learning network on health information technology, for the nursing community as well as the larger interdisciplinary health care community. While at first this may seem to be about education and practice, the implications for policy are clear. As national initiatives improve electronic interoperability and the development and implementation of health records, the collection of meaningful data that can be used to influence improvements in care has the potential to revolutionize nurses’ care delivery. At the same time, issues of privacy and confidentiality of data confront every nurse practicing or teaching in such environments, necessitating policies that address these issues and electronic patient data for research and quality improvement.

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 currently include consumer groups, employers, government, health plans, health care organizations, health care professions, scientists, accrediting and certifying bodies, and quality alliances. Since 2008, the number of organizations has expanded to more than 40 stakeholder groups. Nursing was represented only by ANA in the initial stakeholder group, but the newly formed 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 QSEN competencies identified earlier, had substantial impact on the final recommendations of the National Quality Strategy. The list included:

  • Engaging patients and families in managing their health and making decisions about their care
  • Improving the health of the population
  • Improving the safety and reliability of America’s health care system
  • Ensuring patients receive well‐coordinated care within and across all health care organizations, settings, and levels of care
  • Guaranteeing appropriate and compassionate care for patients with life‐limiting illnesses
  • Eliminating overuse while ensuring the delivery of appropriate care
  • Improving access
  • Improving the health care infrastructure



As a second step, the partnership agreed to align the drivers of change and the performance measures around goals for each priority. Each goal reflects those aspects that will most likely lead to achievement of the priority, along with a road map consisting of examples of successful actions and targets for describing success. Taking an important step, the partnership agreed to commit its leadership to support the drivers (below) in order to effect change at the federal, state, and local levels:

  • Performance measurement
  • Public reporting
  • Payment systems
  • Research and knowledge dissemination
  • Professional development: education and certification
  • System capacity

In 2009, the ANA and NQF nursing member organizations, supported by NQF and the Robert Wood Johnson Foundation (RWJF), hosted the Invitational Conference on Nursing and the National Priorities Partnership Goals: Next Steps. Its purpose was to examine each of the priorities, goals, and drivers to 1) identify priorities for nursing quality measurement to align nursing measures with current national quality initiatives, 2) develop specific strategies to fast‐forward achievement of these priorities, and 3) envision new frameworks that would advance performance measurement to improve health and well‐being. As a result of that conference, two American Academy of Nursing (AAN) scholars summarized the proceedings, detailing the nursing opportunities and action plans for each of the priority areas.

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 in each alliance.

Nursing Alliance for Quality Care

Nursing through the 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 grow and to find that space where nursing can collectively make the largest contribution to the quality arena. Although formed only in early 2010 from an earlier RWJF‐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
  • Policymakers recognizing the contributions of nurses in advancing consumer‐centered, high‐quality health care

NAQC focused on four goals to accomplish these three outcomes: 1) support consumer‐centered health care quality and safety goals to achieve care that is safe, effective, patient‐centered, timely, efficient, and equitable; 2) performance measurement and public reporting that strengthens the role of nursing in transparency and accountability activities; 3) 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 4) 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 accountable care organizations, 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 still retains a seat as an alliance at various national tables.

Other similar alliances are included here to provide a perspective on the interdisciplinary reach and nursing’s inclusion in those efforts to improve quality.

The Hospital Quality Alliance

In 2002, the Hospital Quality Alliance (HQA) was formed from organizations representing America’s hospitals, consumer representatives, physician and nursing organizations, employers and payers, oversight organizations, and governmental agencies. It was a national public‐private collaboration committed to making meaningful, relevant, and easily understood information about hospital performance accessible to the public and to informing and encouraging efforts to improve quality. HQA was effective in initiating changes in national policy, perhaps most visibly in terms of quality reporting.

HQA facilitated continuous improvement in patient care through implementation of measures that portray the quality, cost, and value of hospital care; the development and use of measurement reporting in the nation’s hospitals; and sharing of useful hospital performance information with the public through Hospital Compare. Hospital Compare (www.hospitalcompare.hhs.gov) contains performance information about more than 4,000 hospitals, and data are updated quarterly. Hospital Compare is a voluntary national report card of the performance among hospitals, evolved with the support and strong encouragement from HQA, while retaining the right to suppress data it deems not appropriate to share. HQA dissolved as the National Priorities Partnership flourished and the National Quality Strategy took center stage in shaping the quality measures environment.

The Ambulatory Care Quality Alliance

Shortly after the formation of HQA, the American Academy of Family Physicians, the American College of Physicians, America’s Health Insurance Plans, and AHRQ joined together in 2004 to initiate efforts to improve performance measurement, data aggregation, and reporting in the ambulatory care setting. Since then, the mission and membership have grown to a broad‐based collaborative of over 100 organizations, and include all areas of physician practice as well as a variety of other

stakeholders, now known simply as the Ambulatory Care Quality Alliance (AQA). To distinguish itself from the HQA, this collaborative focused initial efforts on physician or other clinician performance. AQA’s most recent strategic plan focuses on being a convener to promote and facilitate alignment among the public and private sector efforts, on promoting best practice quality improvement strategies that address the gap between measurement and improvement, and on advising HHS as it implements health care reform initiatives. While ANA has sent representatives to monitor this alliance’s activities, no nursing organizations are listed among its current membership. Of late, AQA has been actively focused on measure development and on public reporting of outcomes.

Pharmacy Quality Alliance

The Pharmacy Quality Alliance, in place since 2006, focuses on its intersection with the health care system. Its stated mission is to improve the quality of medication use across health care settings through a collaborative process in which key stakeholders agree on a strategy for measuring and reporting performance information related to medications. This alliance, like many of its counterparts, includes representatives from CMS and NQF among its board, as well as at least one consumer representative. Once again, nursing organizations are not listed among its members, yet it has issued an invitation to NAQC to learn more about its structure and work efforts, with the potential for future collaboration.

Alliance for Pediatric Quality

Four national organizations formed the Alliance for Pediatric Quality (APQ) to establish a unified voice for improving the quality of pediatric health care. These organizations are the American Academy of Pediatrics, the American Board of Pediatrics, the Child Health Corporation of America, and the National Association of Children’s Hospitals and Related Institutions (NACHRI). The focus is to improve the quality of care for children by promoting effective, systematic efforts to improve children’s health care and to ensure that health information technology works for children by developing standards that incorporate pediatric requirements and advocating for health information technology that enables systematic improvement. Both NACHRI and the Child Health Corporation of America include nursing in their purview, but neither organization focuses primarily on nursing. There is, however, collaboration on measures that reflect nursing in pediatric quality care, such as pediatric falls and skin breakdown. ANA and NACHRI have worked together to align specifications for pediatric measures and to strengthen opportunities to measure improvements in nursing care for children. The APQ web site states its interest is in recognizing systematic, well‐designed and well‐run improvement initiatives. APQ is currently active in supporting ImproveCareNow as one of its four Improve First projects focused on improved outcomes.

LongTerm Quality Alliance

The Long‐Term Quality Alliance was established in 2010 to respond to increasing demands for long‐term services and support and for expanding the field of providers delivering that care in the United States. It is governed through a broad‐based board of 30 of the nation’s leading experts on long‐term care and related care issues including consumers, family caregivers, health care providers, private and public purchasers, federal agencies, and others. The web site for this alliance states it is focused on facilitating dialogue and partnerships among all provider organizations that serve people needing long‐term services and supports to help break down the provider silos in which quality initiatives have occurred, on bringing consumers and family caregivers together with long‐term care (LTC) providers and government agencies to agree on goals and associated measures of greatest concern, on making stronger links between quality measurement goals and evidence‐based practices to achieve them, and on collaborating with other quality improvement organizations on common priorities and goals. Nursing is well represented and has been a key player in the formation of this alliance.

Kidney Care Quality Alliance

Active since 2006, this alliance was formed by persons committed to kidney care and the health care community at large to involve patients and their advocates, care professionals, providers, suppliers, and purchasers in developing performance measures focused on institutions and physicians. The intent was to also focus on developing data collection and aggregation strategies while promoting transparency by reporting performance measures. The broad membership included two specialty nursing organizations serving that patient population and nurses specializing in nephrology care. Current information reflects four quality measures for managing End Stage Renal Disease (ESRD), which resides on the AHRQ web site but no other Alliance activity. These measures evaluate whether facilities’ and physicians’ patients have had documented discussions of alternate renal replacement therapies during their ESRD management, whether patients receiving dialysis have functional arteriovenous (AV) fistulas, grafts, or cannulas, and whether patients receiving dialysis are appropriately offered or receive influenza vaccine.

Quality Alliance Steering Committee

The Quality Alliance Steering Committee (QASC) was formed in 2006 through a collaboration of HQA and AQA to better coordinate the promotion of quality measurement, transparency, and improvement in care. This alliance included close relationships with CMS and AHRQ, already members of both AQA and HQA. The new steering committee was expected to expand several ongoing pilot projects focused on combining public and private information to measure and report on performance in new ways to enhance the goals of transparency and meaningful information. Nursing organizations and the NAQC have been members of this alliance. No current information is available on QASC’s activities.

Institute of Pediatric Nursing

Gaining status as a private not‐for‐profit entity in early 2011, the Institute of Pediatric Nursing was an alliance of diverse pediatric nursing organizations and major children’s hospitals, acting collaboratively to maximize pediatric nursing’s contribution to child and youth health through unified leadership, knowledge, and expertise. Its goals were to influence 1) nursing education, 2) health care access, 3) child and youth advocacy, 4) care coordination, and 5) safe, quality evidence‐based care. Governed by an independent board that reflects the various major settings of care for children and youth, this alliance served as a catalyst and collaborative voice in addressing key issues in pediatric health care and the pediatric nursing specialty. Early efforts focused on ensuring that Medicaid provisions are actually resulting in high‐quality care by meeting the medical needs of children. The group also helped create new partnerships to support the quality of transitions from acute to school‐based care for many chronically ill children.

Alliance for Home Health Quality Innovation

The Alliance for Home Health Quality Innovation is dedicated to improving the nation’s health care system by supporting research and education to demonstrate the value of home‐based care. Nursing is engaged in this alliance, both through the Visiting Nurse Association of America and the Visiting Nurses Association of New York.

Federal Agencies Engage with Alliances

It becomes clear from studying the configuration of most of the alliances that allegiance and partnerships with federal agencies such as AHRQ and CMS are critical to any strategy driving health care system change that is focused on higher quality. CMS, at the behest of Congress, controls decisions determining reimbursement for services, how to reward for higher quality care, and in making deductions in reimbursement due to preventable negative outcomes of care. NQF has been made the arbiter of measure endorsement and of which measures’ data, gathered by institutions and providers, point to the outcomes that either get rewarded or penalized. And AHRQ plays a major role from a federal perspective in the creation and validation of standards, guidelines for best practice, and research related to quality, safety, and best practice. Any professional alliance looking to develop measures or to suggest that given measures are or are not appropriate for considerations of payment would do well to bring these entities along to the discussion, keep them informed of challenges and lessons learned, and either heed or shape the future they want to see. Some of the alliances that have developed and achieved endorsement of their measures from NQF ensured their measures continued through AHRQ representation.

Centers for Medicare and Medicaid Services

CMS is a federal agency that administers Medicare, Medicaid, and the Children’s Health Insurance Program. CMS reports to HHS. Even though Medicaid services are provided by each state, CMS provides guidance for administering services and can audit services provided to Medicare recipients. CMS has several newly created offices as a result of the ACA, including the Center for Medicare and Medicaid Innovation and the Center for Dual Eligibles. In recent years, CMS has created a Nursing Steering Committee that includes several CMS officials willing to address concerns that arise from external nursing organizations about Medicare and Medicaid reimbursement and service issues for Medicare or Medicaid recipients. This steering committee includes a number of nursing organizations and continues to meet quarterly by conference call.

As policy efforts have shifted from passage of the ACA to defining the rules and regulations that impact implementation of its many provisions, the CMS Nursing Steering Committee has been extremely valuable in identifying opportunities for the profession to weigh in with public comment on proposed rules, and in calling to attention and advocating for changes to language that would disadvantage nursing practice or reduce nursing’s ability to keep patients safe. It continues to serve as a venue for getting timely information about CMS initiatives that potentially affect the profession and consumers.

Agency for Healthcare Research and Quality

AHRQ is the lead federal agency charged with improving the quality, safety, efficiency, and effectiveness of health care for all Americans. AHRQ is one of 12 agencies within the HHS. AHRQ supports research that helps people make more informed decisions and improves the quality of health care services. AHRQ is committed to improving care safety and quality and does this through successful partnerships and the development of knowledge and tools needed for long‐term improvement. AHRQ’s research goals include measurable improvements in health care, with a focus on improved quality of life, improved patient safety and outcomes, and high‐value care for each dollar spent.

Standard Setting by Nonfederal Agencies

Accreditation bodies such as the Joint Commission, the National Commission on Quality Assurance, the Utilization Review Accreditation Commission, and others impact how quality is recognized in practice settings. They drive quality through formal policy mechanisms of setting, monitoring, and evaluating accreditation standards and recognition criteria. Although accreditation is voluntary and paid for by the institution seeking it, accreditation processes wield a great deal of power in shaping expectations of quality and safety. To ensure the reasonableness of standards and evaluation criteria, professional organizations and alliances participate in the development and revision of accreditation and recognition criteria and measures. ANA and others seek to ensure that nurses provide board representation, public comments, or advocacy efforts as a check and balance on the rigor of the accreditation standards and recognition criteria these entities use as the yardstick by which performance is evaluated.

The Joint Commission

The Joint Commission is a 105‐year‐old independent, not‐for‐profit organization that accredits and certifies more than 19,000 health care organizations and programs in the United States, including acute care and long‐term care facilities, ambulatory care services, hospice and home care programs, behavioral health programs, managed care entities, and health care staffing services. The Joint Commission states that these activities are undertaken to continuously improve the safety and quality of care provided to the public. The Joint Commission uses Professional‐Technical Advisory Committees to establish or modify existing standards and determine patient safety goals. Nursing input into these activities occurs through multiple professional nursing organizations with representation on the various advisory committees, through ongoing dialogues and via a separately established Nursing Advisory Council that meets periodically to consider nursing issues where the Joint Commission standards play a role in shaping policy. The Joint Commission has at least one board seat held by a nurse.

The National Committee for Quality Assurance

Founded in 1990, the National Committee for Quality Assurance (NCQA) is a private, not‐for‐profit organization dedicated to improving health care quality and elevating health care quality to the top of the national agenda. NCQA is governed by an independent board composed of multiple stakeholder groups. NCQA develops quality standards and performance measures for a broad range of health care entities. These standards and measure are the tools that organizations and individuals can use to identify opportunities for improvement. Annual reporting of performance against such measures provides direction for improvement. NCQA collects Healthcare Effectiveness Data and Information Set data known as HEDIS (Health Plan Employer Data and Information Set Measures) from more than 700 health plans; conducts accreditation, certification, and state plan surveys; and develops and conducts formal recognition programs including the Primary Care Medical Home Recognition Program. No nursing organizations are included in the governance of NCQA, although nurses have been in key positions at one time or another. However, nursing organizations have actively engaged with NCQA to urge acceptance of APRNs as leaders of medical homes, so that several nurse‐led medical homes are now recognized by NCQA’s programs. Nurse faculty and others have worked with NCQA to mine relevant data regarding APRN practice and the outcomes of patients receiving care by APRNs in practice settings.

Utilization Review Accreditation Commission

The Utilization Review Accreditation Commission (URAC), initiated in 1990, is a not‐for‐profit organization promoting health care quality by accrediting health care organizations, developing measurement, and providing education. URAC’s mission is to protect and empower the consumer. URAC’s first mission was to improve the quality and accountability of utilization review programs. Its spectrum of services has grown to include a larger range of service functions, including the accreditation of integrated health plans. URAC is governed by a board with representatives from multiple constituencies including consumers, providers, employers, regulators, and industry experts. Nursing has a long well‐established presence on URAC’s Board.

“Stand for Quality in Health Care”focused Health Reform Efforts

A driving force for the inclusion of vital principles for quality in health reform legislation emerged from the various quality alliances. This joint effort, formed in 2008 and known as Stand for Quality in Health Care, included more than 200 health care organizations, including nursing organizations. It achieved consensus around the most important features of quality as the health care reform initiatives took shape—consensus that was so strong it evoked bipartisan support. Stand for Quality established recommendations for building a foundation for high‐quality affordable health care that linked performance measurement to health reform. In addition, it linked the investment in health information technology to the improvement of the quality of care and helped drive a quality agenda during the framing of the ACA. It outlined the case for supporting performance measurement, reporting, and improvement through the articulation of Core Principles Linking Performance Measurement, Improvement, and Health Reform; through identification of the Key Functions of the Performance Measurement, Reporting, and Improvement Enterprise; and through the development of deliverables. The key functions included the following:

  • Function 1. Set national priorities and provide coordination.
  • Function 2. Endorse and maintain national standard measures.
  • Function 3. Develop measures to fill gaps in priority areas.
  • Function 4. Use effective consultative processes so stakeholders can inform policymakers on use of measures.
  • Function 5. Collect, analyze, and make performance information available and actionable.
  • Function 6. Support a sustainable infrastructure for quality improvement.

Based on the final provisions of ACA, the above functions are driving the creation of the various commissions and strategies for quality.

Today Stand for Quality states it is engaged in a long‐term strategy to 1) extend current funding for measure endorsement and 2) to secure major funding for further measure development. Specifically, funding will support ongoing endorsement of measures for high‐priority conditions, endorse measures that cross settings and conditions, support new areas of measurement such as value‐based purchasing and registries, and work to facilitate the transition to eMeasures.

Common Strategies Run Through Formalized Initiatives

There are common strategies each collective effort employs to gain political will for change. The various alliances and other collaborative initiatives have several strategies in common, which in and of themselves contribute to a set of tactics around quality that may be applied to other policy discussions. Strategic themes among these initiatives include the following, which are critical when considering quality and safety:

  • Most formal entities include consumers on their governing bodies or among the stakeholder groups they convene to ensure that the needs of the recipients of the care are heard and addressed.
  • The inclusion of a broad base of stakeholders is almost universally applied, acknowledging the complexity of the challenges facing health care.
  • The inclusion of multiple disciplines in most formal collaboratives reinforces that developing policy solutions is a team sport, with no discipline having the political clout to dictate or finalize solutions independently.
  • Most formal collective efforts include one or more federal agencies among its board members in some capacity to ensure federal efforts and other entities are moving in concert.
  • Professional organizations and other stakeholder groups participate in multiple efforts, maximizing their opportunities to influence policy.
  • Participants on the various alliances, agencies, and accrediting bodies often participate with multiple groups. Questions remain whether this is more expeditious or not.
  • Consensus building is the preferred approach to derive proposed solutions.
  • Convergence on proposed solutions occurs among stakeholders and alliances, with the result that while the details might look a bit different, the same conceptual underpinnings run similarly across many collaborative efforts.

Challenges All Collective Efforts Face in Improving the Quality of Care

With approximately 200 national entities, including professional organizations, consumer groups, and thousands of hospitals and other institutions and agencies engaged in the effort to improve quality, there has been substantial investment of financial and other resources, including manpower, over the last 25 years. The timing of many of these efforts in the early 1990s suggests that long before the publication of To Err is Human and Crossing the Quality Chasm, leaders in the health care industry understood that the lack of quality was a significant problem. Nurses were early adopters in hospital efforts to identify opportunities for continuous quality improvement. Many engaged in dialogue with individual physicians who were being challenged by state performance review boards and utilization review committees. Then the focus was primarily on local quality improvement and policy initiatives rather than state or national efforts. Global quality leaders (Deming, 1986; Juran, 1998) stated that 85% of errors in complex organizations were due to system design rather than to inadequate individual job performance. But even their discussions were addressed in departmental, corporate, or institutional policy terms. Twenty‐five years later in 2015, the magnitude of the current efforts to transform the health care system into a high quality system dwarfs all previous efforts. Why has this exploded to such mammoth proportions?

Prior to the implementation of the ACA, looking at any acute care facility, large or small, the number of outpatient procedures and the revenue generated from them had kept pace or overtaken the revenue from acute care services. Numbers of providers in even the smallest facility have increased, including increases in specialists, whether providing virtual or face‐to‐face medicine.


extbox 2.1 Nurses’ engagement in policy at every level of the system

To impact institutional policy, every nurse, regardless of setting or specialty, has expertise to contribute to the discussions focused on health care improvement. Nurses can:

  • Take the opportunity to question practices that lack a base of evidence, or seek literature that informs practice questions.
  • Collect data and utilize National Database of Nursing Quality Indicators to inform and lead better practices that will improve fall assessments or reduce falls, or improve one’s own assessment skills regarding stages of decubiti.
  • Devise local studies with the assistance of more senior experts, to explore or establish the evidence that either supports or disproves care practices.
  • Teach colleagues what has been learned and review institutional or specialty policies about ineffective practices employed.
  • Publish findings, experiential learning, and literature reviews to influence policy changes in others.
  • Engage with others in the institution to review proposed rules and regulations that impact them and offer public comment on professional organizations’ position statements, local or state proposed rules, or CMS‐proposed rules. Proposed rules are published along with the timeline for comment in the Federal Register.

To impact local or community policies, nurses can:

  • Assess community needs or practices that perpetuate risks for falls, whether due to poor sidewalks, potholes in grocery parking lots, or cluttered hallways and aisles in stores, schools, or churches.
  • Advocate for community consensus on policies or regulations to reduce danger to children and elderly pedestrians.
  • Provide education about reducing falls, improving medication adherence, or increasing patient engagement in making care decisions or choices about end‐of‐life care.
  • Volunteer to serve on local YMCA boards, hospital boards, or other local service organizations that may be able to effect changes in services, provide access to better nutrition, or offer safer alternatives for exercise.

To impact state policy nurses can:

  • Demand greater clarity and compliance with CMS guidance regarding Medicaid services for children who are not receiving the supplies they need for their chronic illness, or who lack the services to keep them safe in schools or after school.
  • Engage with local or state chapters of professional nursing associations to coordinate advocacy for change, for modifications to practice acts, or improved services for at‐risk populations.
  • Actively engage in political campaigns around platforms on health care, agree to serve on state licensing boards, or attend state legislative hearings and meetings.

To impact national policy nurses must:

  • First keep themselves and their colleagues informed of the issues.
  • Develop skills and expertise at representing their specialty.
  • Engage in leadership roles within their preferred professional national nursing association.
  • Take action to contact congressmen or senators regarding passage of bills that affect their state and community.
  • Share stories with their representatives that highlight the need for changes in health care.
  • Work with their institutions to invite a congressman or senator to walk a day in the shoes of a nurse, in order to better understand the challenges of short staffing, limited resources, or other needs of the community.


The improvement of nursing and health care quality is the responsibility of every nurse. It can and needs to occur at every level, from the direct one‐on‐one interaction with a patient or family to the advocacy for changes in rules or regulations at every level of government, within an institution or in the local community. It takes many forms, but at its most basic level, it requires being unwilling to accept the status quo, and taking the risk to challenge practice behavior. It requires moral courage to stand up to nursing peers or physician colleagues and dissent when something begins to occur that violates basic principles of quality and safety. Even though many are working on the national level to effect policy change, at the end of the day, all health care is local. It comes back to the individual nurse providing care and living in a community, to articulate when a policy is being crafted, and how its implementation will improve or hinder quality of care or the safety of patients. It comes back to each nurse understanding the intent of that policy and implementing it on behalf of patients. Only then, when every patient is provided the same care we would want for our parent, or sister, or best friend, or child, will high‐quality health care be achieved.


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Rundio, A., & Wilson, V. (2015). The Doctor of Nursing Practice and the Nurse Executive Role. Baltimore, MD: Wolters Kluwer Health.

  • Chapter 9: Strategic Management for the Nurse Executive. pp. 97–103
  • Chapter 10: Defining and Developing Self-Awareness in the Nurse Leader; pp. 104–114
  • Chapter 15: Teambuilding: Insights, Strategies, and Tools. pp. 176–192

Sherwood, G., & Barnsteiner, J. (Eds.). (2017). Quality and safety in nursing: A competency approach to improving outcomes. John Wiley & Sons.

  • Chapter 1: Driving Forces for Quality and Safety: Changing Mindsets to Improve Health Care. pp. 3-20
  • Chapter 2: Policy Implications Driving National Quality and Safety Initiatives. pp. 21-42
  • Chapter 3: A National Initiative: Quality and Safety Education for Nurses (QSEN). pp. 43-58
  • Chapter 17: Global Perspectives on Quality and Safety. pp. 315-330



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