18: DNP-PREPARED NURSE’S ROLE ■ 421QUALITY OF CARE
Quality of care is the most elusive and difficult concept to define and measure among
the access, cost, and quality triad. Quality is increasingly linked to achieving successful
outcomes rather than describing and measuring structures, processes, or patient sat-
isfaction (Torgerson & Raftery, 1999). Since the implementation of PPACA, attention
is focused on value- based incentives to improve outcomes by changing providers’
practice patterns and reframing payment strategies (Centers for Medicare & Medicaid
Services [CMS], 2016). If successful, these new payment systems will replace the old
fee for service payment models. Moving away from familiar fee-for-service systems
to value modifiers and meaningful use of payment systems creates management and
political challenges (Miller, 2012). Yet, there is growing traction among policy makers
around strategies that link value- based payments and care management practices to
produce demonstrable patient outcomes (McClellan & Rivlin, 2014). Another popular
fiscal strategy, designed to lower costs and enhance quality of care, is bundled pay-
ments. Bundling provides single payments for a defined treatment, compressing all the
possible charges for an episode of care into a single payment. Because bundling is used
for common and predictable procedures, as knee replacements, providers and insurers
can estimate and manage the risks of accepting bundled payments rather than fees for
service (Delbanco, 2014).
The American health care establishment also relies on technology to deliver
and advance patient care. Initially, the technology was medically oriented. Now, high
technology medicine competes with sophisticated informational technology, as the elec-
tronic medical record (EMR), in institutional and community-based centers and prac-
tices. There is a compelling need to access timely, accurate and secure data by patients,
clinicians, insurance companies, and the government. Competing concerns about pri-
vacy and appropriate access to health data challenge the health care establishment to
rethink where it spends its 3 trillion dollar health care budget. If one aspires leadership
in nursing or health care, competence in health policy is a necessity. Advocacy must be
balanced and informed.
HEALTH POLICY COMPETENCE
When Longest (2016) speaks of policy competence, he notes that anyone who wants
to influence health policy must understand the policy process and comprehend how
health policies are made. This knowledge gives leaders the skill in scanning policy and
political environments, and identifying the threats and opportunities on the horizon.
These insights help leaders shape the policy environment for the benefit of their group’s
interest. Longest is speaking of federal and state health policy, but his advice also applies
to nongovernmental sectors, because U.S. health policy arises from the private as well
as the public sector. Advocacy is ineffective if the person or group desiring change does
not grasp the workings of extant systems and the powerful forces that sustain them.
Longest (2016) also proposes that successful policy advocates possess two skill sets:
the ability to gain access to policy environments and the organizational acumen to build
consensus around an agenda. In this context, access means that nurses know their elected
representatives and can get their attention; they have the power to bring issues of impor-
tance to government. That nurses can have access to political power brokers is not sur-
prising. American nurses (2.8 million RNs and 690,000 licensed practical nurses [LPNs])
are a large, geographically distributed group of health care providers. Approximately