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the critical access hospital or the largest multihospital system. The systems are complicated and the communications and organizational structures required to ensure efficiency and safety are interrelated, transdisciplinary, and require transparency.

The technology needs of the solo and small group practitioner reflect a similar need for technological capabilities as those required by larger health service plans to which many providers belong. At the same time, fewer and fewer patients see their own primary provider once they entered an acute care facility, regardless of the size of the institution. The hospitalist providing their care may have never seen them previously and will have no connection to their care once they are discharged. Home care and hospice programs are using technology to replace the face‐to‐face time that nurses and others have traditionally relied upon with homebound patients to determine their unspoken needs and vulnerabilities, including electronic profiles on patient caseloads and communication about patients only via electronic records. The latest explosion of telehealth onto the health care scene, whether in transport, in primary care thanks to COVID‐19, or in treating mental and behavioral health disorders, requires greater privacy protections and interoperability than ever before. Yet, due to emergency declarations and easing of certain restrictions to support telehealth visits, many of these same privacy protections, even those under the Health Insurance Portability and Accountability Act (HIPAA), have been eroded.

      What has COVID‐19 shown us? The complexities of providing high‐quality health care that keeps patients, families, and health care workers from harm simply became almost impossible. Our health risks as we know them have gone global in a way that nothing has before. The United States can now see clearly where it has failed its citizens. Health inequities and the challenges of multiple chronic conditions are tough enough when the financial resources are available to make access to care possible. But during this time millions of individuals do not have the luxury of performing jobs from home, or have been unable to work because the business or company they work for has been closed due to quarantine, or the job has been lost because the company has gone out of business, or other restrictions have made it difficult or impossible to keep oneself safe. For many of these people, along with such considerations, the loss of a job means not only loss of income but loss of health care insurance coverage as well. For essential workers, whether first responders, nurses, physicians, maintenance workers, or grocery store clerks, personal protective equipment, something most of us took for granted, disappeared. Even cleaning supplies, hand sanitizer, and hand soap disappeared from store shelves for a time. Each of these shortfalls created additional fears about reaching out to a health care provider for anything short of COVID‐like symptoms.

      The challenges of ensuring effective care transitions, care coordination, and engagement of patients are difficult without effective digital communication systems. But alas, electronic systems in a hospital or system department are still struggling to share information with another department in a timely manner, or more frequently with someone outside the institution. Electronic records and communications are expected to have filled the gap, but they may often collect information that is not meaningful or used. Patients suffer from the lack of effective communication with and among professional staff. COVID‐19 has meant that any support to communicate with professional staff is further hindered by lack of supportive family, who cannot be present when life and death decisions are being made. While theoretically technology exists via iPads and Facetime, those resources are few and far between on the clinical units where they are needed, and due to staffing shortages opportunities to provide these technology‐assisted communications are further limited. The situation is magnified when ineffective communication couples with the payment system and reimbursement that reward undesired outcomes of care, such as continued disease rather than wellness or health, or complications of hospitalization rather than speedy recovery and discharge to another level of care. One begins to see how local policies and regulations have little effect. As the interconnectedness has grown, so have the problems and the solutions required to correct them.

Part of the anticipated effectiveness of ACA was the inclusion of millions of previously uninsured US citizens under Medicaid expansion. The unevenness of implementation across states has impacted services, costs, and meeting chronic health needs, particularly for underserved and minority populations (Long et al., 2014). In addition, despite many efforts to harness the costs of caring for high needs patients and dual eligibles (those whose services are covered by both Medicare and Medicaid), this is a challenge that still needs to be better managed. These are challenges faced by the various collaborations striving to improve upon the policies, regulations, and incentives incorporated in every community hoping to improve the quality of care. Nowhere has this been more evident than in the attempts to manage the resources and knowledge required to effectively control a pandemic.

What Can Every Nurse Do to Influence Policy That Improves Quality?

The QSEN project is an example of nurses taking the responsibility for improving quality and safety outcomes (Cronenwett et al., 2007, 2009). Nurses prepared with the six competencies (patient‐centered care, teamwork and collaboration, evidence‐based practice, quality improvement, safety, and informatics) have the tools and resources to impact policy at the local, state, and national levels (Textbox 2.4; also see Appendices A and B). Improving quality and safety requires the dedicated work of all, and with the work of the QSEN project, nurses will be able to participate in all levels of policy‐making.

Textbox 2.4 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 and inclusive of patient and family advocates 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 and innovative new strategies under study.

       Engage patient and family advisory groups and representatives to co‐design improvements to their health care system, whether big or small.

       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 Centers for Medicare and Medicaid Services (CMS)‐proposed rules. Proposed rules are published along with the timeline for comment in the Federal Register.

       Innovate: necessity is the mother of innovation. Create innovative practices that build from the Quality and Safety Education for Nurses competencies, ensuring that patients and families are at the center of decision‐making and discharge planning.

      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.

       Seek out those who represent health or racial disparities. Seek first to understand their challenges and engage alongside them to look for solutions.

       Advocate for community consensus on policies or regulations to

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