chapter 10 | Quality and Safety 135strategy and action plans to redesign the health-care
system. The report stated that the gaps between actu-
al care and high-quality care could be attributed to
four key inter-related areas in the health-care system:
the growing complexity of science and technology, an
increase in chronic conditions, a poorly organized
delivery system of care, and constraints on exploiting
the revolution in information technology. With the
overarching goal of improving the health-care system
by closing identifiable gaps, the report made 13 rec-
ommendations, some of which are in Box 10-4.
Additionally, the report addressed the importance of
aligning and designing health-care payer systems,
professional education, and the health-care environ-
ment for quality enhancements, improved outcomes
in care, and use of best practices.
As a professional nurse, you have a responsibility
to acknowledge the complexity and deficits of the
health-care system. In managing patient care, you
must continually consider the impact of the system
on the care you provide and participate in the qual-
ity and safety initiatives at the bedside, in your unit,
and within your organization to promote quality
and safety within the system.
Quality in the Health-Care System
The IOM defines quality as “the degree to which
health services for individuals and populations
increase the likelihood of desired health outcomes
and are consistent with current and professional
knowledge” (IOM, 2001, p. 232). This definition is
used by U.S. organizations and many international
health-care organizations, and it is the basis for
nursing management of patient care. Box 10-5 elab-
orates on this definition by outlining six primary
aims of health care.
QI
QI activities have been part of nursing care since
Florence Nightingale evaluated the care of soldiers
during the Crimean War (Nightingale & Barnum,
1992). To achieve quality health care, QI activities
use evidence-based methods for gathering data and
achieving desired results.
QI usually involves common characteristics
(McLaughlin & Caluzny, 2006, p 3):
■A link to key elements of the organization’s
strategic plan
■A quality council consisting of the institution’s
top leadership
■Training programs for all levels of personnel
■Mechanisms for selecting improvement oppor-
tunities
■Formation of process improvement teams
■Staff support for process analysis and redesign
■Personnel policies that motivate and support
staff participation in process improvement
QI is called by many names: quality assurance,
FADE, PDSA, total quality management (TQM),
Six Sigma, and CQI. Regardless of the term used, QI
is a structured organizational process for involving
personnel in planning and executing a continuous
flow of improvements to provide quality health care
that meets or exceeds expectations (McLaughlin &
Kaluzny, 2006, p. 3). The following sections focus
on CQI.box 10-4
Ten Rules to Govern Health-Care Reform
for the 21st Century (IOM, 2001, p. 61)- Care is based on a continuous healing relationship
- Care is provided based on patient needs and values
- Patient is source of control of care
- Knowledge is shared and free-flowing
- Decisions are evidence-based
- Safety as a system property
- Transparency is necessary; secrecy is harmful
- Anticipate patient needs
- Waste is continually decreased
- Cooperation between health-care providers
box 10-5
Six Aims for Improving Quality in
Health-Care (IOM, 2001, p. 39).
Health care should be:- Safe:Avoiding injuries to patients from the care that is
intended to help them - Effective:Providing services based on scientific
knowledge to all who could benefit and refraining from
providing services to those not likely to benefit
(avoiding underuse and overuse) - Patient-centered:Providing care that is respectful of
and responsive to individual patient preferences, needs,
and values and ensuring that patient values guide all
clinical decisions - Timely:Reducing waits and sometimes harmful delays
for those who receive and those who give care - Efficient:Avoiding waste, in particular that of
equipment, supplies, ideas, and energy - Equitable:Providing care that does not vary in quality
because of characteristics such as gender, ethnicity,
geographic location, and socioeconomic status