132 unit 2 | Working Within the Organization
History and Overview
You are entering professional nursing at a time
when issues pertaining to quality and safety of the
U.S. health-care system have come to the forefront
in the delivery of health care. Considering the
complexity of the decisions you make every day in
managing patient care at the bedside, it may be easy
to dismiss the theory that you must also consider
quality and safety within the health-care system.
However, each day as a professional registered
nurse (RN), you will participate in activities to sup-
port quality and safety initiatives at the bedside,
within your organization, and as part of the health-
care system. First, this chapter identifies trends
and issues that have brought quality and safety to
the forefront.
Historical Trends and Issues
The rapidly changing health-care delivery system
is driven by many forces (Baldwin, Conger,
Maycock, & Ableggen, 2002; Davis, 2001; Elwood,
2007; Ervin, Bickes, & Schim, 2006; Menix, 2000)
that are influencing the current movement toward
improved quality and safety. Some of these forces
include economics, societal demographics and
diversity, regulation and legislation, technology,
health-care delivery and practice, and environment
and globalization.
Economics. U.S health-care delivery has been
affected by many economic trends and issues.
Businesses, government, and the media decry the
cost of health care within the United States when
compared with that of other developed nations
( Jackson, 2006; Kersbergen, 2000). The cost of
research and the cost to develop new treatments
and technology are rising. Nurses need to be pre-
pared to support consumers with a thorough
knowledge of quality, accountability, and cost-
effectiveness (AACN, 1997). Educated consumers
will expect safe, quality care with associated satis-
faction and health outcomes. Improvements in
quality and safety will reduce costs (Cronenwett et
al., 2007; Institute of Medicine [IOM], 2003a).
Societal demographics and diversity. Increased
numbers of racial and ethnic groups /will influence
health-care delivery (Billings & Halsted, 2005;
Elwood 2007; Heller, Oros, & Durney-Crowley,
2000). Increased numbers of elderly people,
increased lifespan, and improvements in technology
mean an emphasis on specialized geriatric care.
Both the elderly and ethnic minorities are at-risk
populations who suffer disadvantages in access,
payment, and quality of care (U.S. Department of
Health & Human Services, 2001).
Regulation and legislation.The diverse interests
of consumers, insurance companies, government,
and regulation affect health-care legislation. For
health-care leaders and providers of care, unprece-
dented challenges will continue despite the atten-
tion that quality and safety has received during the
evolution of the existing health-care system.
Technology. The use of technology will improve
cost, clinical outcomes, quality, and safety (IOM,
2003a). Nursing practice must accommodate this
health-care delivery trend with the inclusion of
concepts in interdisciplinary collaboration, patient-
focused systems, and information literacy (Booth,
2006). Additionally, nurses must utilize technology
and informatics to incorporate evidenced-based
practices for improved quality and safety in the
health-care delivery system.
Technology also produces advancements in dis-
ease treatments, especially in the areas of genetics
and genomics, and all professionals must integrate
these areas into practice ( Jenkins & Calzone,
2007). Advances in genetics and genomics lead to
breakthroughs in the treatments of a variety of
genetic disorders, QI, and outcomes in clinical
practice often related to pharmacotherapeutics
(Trossman, 2006).
Health-care delivery and practice. Health-care
professionals should be prepared to provide safe,
quality care in all settings, including acute care and
community settings. Nurses and other health-care
professionals need the knowledge, skills, attitudes,
and competencies to function in a variety of set-
tings and the ability to support the needs of the
elderly (Ervin, Bickes, & Schim, 2006; Heller,
Oros, Durney-Crowley, 2000).
The integration of evidenced-based practice will
serve to improve quality and safety for patients, as
it will improve collaboration and interdisciplinary
teamwork (Brady et al., 2001; IOM, 2003a;
O’Neill, 1998). Both the IOM (2003a) and the
Pew Health Professions Commission (O’Neill,
1998) identified the need for the health-care deliv-
ery system and its professionals to improve collab-
oration and to work in an interdisciplinary team to
improve quality and safety.
Environment and globalization. The emergence
of a global economy, the ease of travel, and