Quality and Safety in Nursing - Группа авторов

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the Joint Commission as we know it is almost 70 years old, its history goes back to 1910. It is an independent, nonprofit organization that, through its deemed status from CMS, 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 and professional‐technical 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 had at least one board seat held by a nurse.

      National Committee for Quality Assurance

      Utilization Review Accreditation Commission

      The Utilization Review Accreditation Commission (URAC; www.urac.org),

      initiated in 1990, is a nonprofit 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. Its 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 under its deemed status 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 its board.

      There are common strategies that each collective effort employs to gain political will for quality improvement. 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.

       Many health systems, and those entities seeking to improve quality, are actively seeking patients and families as advocates and representatives, as health systems seek to close the gap between providers and patient satisfaction, in part driven by measures of the patient’s experience of care.

       Increasing emphasis, often less than successful, is focused on seeking broader diversity of patient, family, and consumer representation in order to reduce health care disparities.

       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 collective efforts include one or more federal agencies among their 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 over 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 little different, the same conceptual underpinnings run similarly across many collaborative efforts.

       The cost of health care is a worry that overrides all other efforts to improve quality, increase access to care, and ensure patient safety.

       Social determinants of health are increasingly shown to challenge all efforts to improve health and reduce negative outcomes of care.

      With approximately 200 national entities, including professional organizations and consumer groups, along with thousands of hospitals and other institutions and agencies engaged in the effort to improve quality, there have been substantial investments of financial and other resources, including human resources, over the last 30 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 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.

      Yet, in 2022, the magnitude of the current efforts to transform the health care system into a high‐quality system dwarfs all previous efforts. Health systems were focused on being high‐reliability organizations while at the same time striving to be recognized as safety cultures and just cultures. 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. Now the numbers of providers in even the smallest facility have increased, including increases in specialists, whether providing virtual or face‐to‐face medicine. The enormity and complexity of the systems now needing improvement do not differ all that

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