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systems. From these, reports are developed, such as To Err is Human (IOM, 1999); the CDC National Vital Statistics Reports (Martin, Hamilton, Sutton, & Ventura, 2006); and The National Healthcare Disparities Report (NHDR) (Agency for Healthcare Research and Quality (AHRQ), 2005). These reports provide invaluable information, and data is displayed with charts and pictures to emphasize the successes and failures of health care throughout our nation. Evidence of significant disparities and low quality continue to demonstrate the need for significant health care improvement.

Influence of External Forces on Health Care

Recognizing the influence of external forces on care delivery and scope of practice, Nightingale also kept informed of the activities of practitioners and government policy makers (Dossey, Selanders, & Beck, 2005). With health care being the largest sector of our economy, employers, clinicians, managers, and patients all have vested interests in proposed changes to health care financing, organization, and the responsibilities and scope of practice for clinicians. Today, nursing leaders, managers, and staff need to be aware of and involved in the ongoing processes of making health policy.

Organization of Health Care

Health care systems have three main components: structure, process, and outcome. The structure component of health care includes resources or structures needed to deliver quality health care, for example, human and physical resources, such as nurses and nursing and medical practitioners, hospital buildings, medical records, and pharmaceuticals. The process component of health care includes the quality activities, procedures, tasks, and processes performed within the health care structures, such as hospital admissions, surgical operations, and nursing and medical care delivery following standards and guidelines to achieve quality outcomes. The outcome component of health care refers to the results of good care delivery achieved by using quality structures and quality processes and includes the achievement of outcomes such as patient satisfaction, good health and functional ability, and the absence of health care acquired infections and morbidity. See Table 2.1 for examples of structure, process, and outcome performance measures in clinical care, financial management, and human resources management. The American Nurses Association's (ANA) Nursing Care Report Card for Acute Care (1995) also uses the structure, process, outcome framework for its indicators of quality.

Table 2.1 Examples of Performance Measures by Category

	Clinical care	Financial management	Human resources management
Structure	Effectiveness Percent of nurses and physicians who are certified JC (formerly JCAHO) accreditation Presence of council for quality improvement planning Presence of magnet recognition	Effectiveness Qualifications of administrators in finance department Use of preadmission criteria Presence of an integrated financial and clinical information system and clinical decision‐making technology	Effectiveness Ability to attract desired nursing and medical practitioners and other health professionals Size or growth of nursing and medical staff Salary and benefits competitive with competitors Quality of in‐house staff education
Process	Effectiveness Ratio of medication errors Ratio of nurse‐sensitive complications Ratio of health care‐acquired infection Ratio of postsurgical wound infection Ratio of normal tissue removed during surgery	Effectiveness Days in accounts receivable Use of generic drugs and drug formulary Market share Size (or growth) of shared service arrangements	Effectiveness Number and type of staff grievances Number of promotions Organizational climate
	Productivity Ratio of total patient days to total full‐time equivalent (FTE) nurses Ratio of total admissions to total FTE staff Ratio of patient visits to total FTE nursing and medical practitioners	Productivity Ratio of collections to FTE financial staff Ratio of total admissions to FTE in finance department Ratio of new capital acquisitions to fund‐raising staff	Productivity Ratio of front‐line staff to managers
	Efficiency Average cost per admission Average cost per surgery	Efficiency Average cost per debt collection Debt/equity ratio	Efficiency Recruitment costs
Outcome	Effectiveness Case‐severity‐adjusted mortality Patient satisfaction Patient functional health status Number of deaths from medical errors	Effectiveness Return on assets Operating margins Size and growth of federal, state, and local grants for teaching and research Bond rating	Effectiveness Staff turnover rate Number of absenteeism days Staff satisfaction

      Source: Compiled with information from Shortell, S. M., & Kaluzny, A. D. (2006). Health care management (5th ed.). Clifton Park, NY: Delmar Cengage Learning.

      It would be naïve to consider health care in the United States, as it is currently being delivered, as being an effective system of care. If that were true, it would imply that health care is based on shared values and goals; is organized around the patient; utilizes all pertinent information; ensures value‐based and quality‐based care; rewards quality care; is universally standardized and simplified; is available to everyone regardless of income, race, ethnicity, or education; is affordable; and reflects effective collaboration among clinicians and with patients. The World Health Organization (WHO) has put forth primary goals for what good health care should do: improve equity in health, reduce health risks, promote healthy lifestyles and settings, and respond to the underlying determinants of health (World Health Organization (WHO), 2019).

      Consistent with these goals, Healthy People 2020 has also developed overarching goals to increase quality and years of healthy life and eliminate health disparities. These goals are:

       Attain high‐quality, longer lives, free of preventable disease, disability, injury, and premature death.

       Achieve health equity, eliminate disparities, and improve the health of all groups.

       Create social and physical environments that promote good health for all.

       Promote quality of life, healthy development, and healthy behaviors across all life stages (Healthy People 2020, 2010).

      Real World Interview

      What can be said about the United States health care system is that it is not really a system, but rather a hodge‐podge of systems, some great, some not so great, with a “sometimes” desire for universal service, but with also the fierce energy of independent individuals seeking autonomy.

       Ellyn Stecker, MD

      Shipshewana, Indiana

Health Care Rankings

Despite having the most expensive health care, the United States ranks last overall among the 11 countries on measures of health system equity, access, administrative efficiency, care delivery, and health care outcomes. While there is room for improvement in every country, the U.S. has the highest costs and lowest overall performance of the nations

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