214chapter EIGHT
Refl ective Response
Susan Baseman
The imperative to reform health care delivery and payment in this country is clear— the
trajectory of escalating costs for health care combined with an aging population and
complicated by increasing concerns about quality, safety, access, inefficiency, and varia-
tion in care delivery combined to create a call to action for major delivery system reform
in this country. The Patient Protection and Affordable Care Act (commonly referred to
as the Affordable Care Act or ACA) is designed to address at least some of these issues.
Although better known for its efforts to expand insurance coverage, the ACA includes
a number of provisions that have the goal of improving the quality and efficiency of
American health care.
Dr. Catherine Johnson has thoughtfully described how nurses, specifically nurses
at the level of the professional practice doctorate, can and should be major forces in
improving quality and patient safety in our increasingly complex health care system.
She further describes the challenges of doing so in the context of a system that does not
view nurses as health care reformers capable of influencing or leading work in qual-
ity improvement (QI) and safety. Dr. Johnson notes that one of these challenges is the
lack of sufficient educational preparation and experience in the curriculum of Doctor of
Nursing Practice (DNP) programs, which is compounded by the relative lack of experi-
ence of DNP faculty with QI work.
The description of the National Quality Strategy (NQS) and the work of the
Agency for Healthcare Research and Quality (AHRQ, 2014a, 2014b) and the Institute for
Healthcare Improvement (IHI, 2015) provide a strong foundation for understanding
the goals, strategies, and programs relevant to the discussion of the role of the prac-
tice doctorate in the area of improving quality and safety for patients in the context
of health reform. Areas of this issue that have not been fully addressed in this chapter
are the challenges of translating the goals and best practice standards for quality and
safety as laid out by the NQS, AHRQ, and others into practice, and the role of the DNP
in making that happen (AHRQ, 2014a, 2014b; National Quality Forum, 2014).
The challenge facing health care organizations— whether they are small hospitals,
large academic medical centers, physician practices, urban or rural— is one of shrinking
revenues in the face in increasing requirements for meeting standards of quality and
outcomes. In the current climate of value- based care, the potential rewards in the form
of incentives for improved outcomes and reduced costs are downstream and hard to
predict, while the operational costs of infrastructure and personnel needed to position