CONTINUING EDUCATION

The Arduous and Challenging Journey of Improving Patient Safety and Quality of Care Esther Lee, MBA, RN The 20th century has seen dramatic improvements in quality, efficiency, and productivity of the industrial, manufacturing, and selected service sectors through the redesign of the management and production processes. Moreover, the health care sector, plagued by overuse, underuse, and misuse of care remained a laggard in adopting needed changes to improve quality, effectiveness, and delivery. The change agent may have been the 2001 report by the Institute of Medicine, which shocked the collective conscience of the industry with the revelation of the alarming statistics of death owing to preventable medical errors. A variety of methodologies have since been adopted by the health care sector with mixed successes. However, scant attention has been given to the historical significance of Florence Nightingale pioneering quality management in nursing care over a century ago with her use of statistics to influence health care decisions, to enhance quality care delivery, and to improve facility design. This article addresses the abstract concept of quality, its illusive nature, and multidimensionality from different perspectives in health utilization and delivery. It presents a survey of the various quality management theories and models and their variance, which have attracted the attention of the health sectors as potential saviors of the beleaguered health industry afflicted by the quality crisis. Keywords: evidence-based practice, quality improvement, quality management, health care quality and delivery. Ó 2013 by American Society of PeriAnesthesia Nurses OBJECTIVES—AFTER READING THIS ARTICLE, the learner will be able to: 1. Describe the principles and theories of quality management. 2. Discuss how out-of-industry quality management practices influence the quality movement in the health care industry.

Esther Lee, MBA, RN, is the Assistant Director of PeriAnesthesia Nursing at the UC San Diego Health System, San Diego, CA. Conflict of interest: No benefits in any form have been received from a commercial party related directly or indirectly to the subject of the article. Address correspondence to Esther Lee, UC San Diego Health System, 200 West Arbor Drive, #8708, San Diego, CA 921038708; e-mail address: [email protected]. Ó 2013 by American Society of PeriAnesthesia Nurses 1089-9472/$36.00 http://dx.doi.org/10.1016/j.jopan.2013.07.004

3. Discuss the multi-dimensional attributes pertaining to quality of care from the perspectives of different stakeholders in the health care industry. To many patients, the mere knowledge that their health conditions require surgical interventions in a hospital sets off a fearful alarm. The news conjures up a sense of mortality and anxiety owing to the unpredictability of the outcomes commonly perceived by patients and their families.1 According to DeWitt and Albert,2 ‘‘Surgery can invoke increased anxiety and other psychologic and physiologic stress for the patient and their visitors.’’ Medical science, a complex and specialized discipline with its unique jargons and practices, creates an asymmetrical knowledge between the patient and care provider. Adding to the fear factor is the proliferation of health information disseminated in an abundance of consumer health Web

Journal of PeriAnesthesia Nursing, Vol 28, No 6 (December), 2013: pp 383-398

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sites and chain e-mails advocating various health maintenance and dubious treatment practices. Health service, unlike the purchase of a piece of merchandise from a retailer, is consumed and cannot be returned or exchanged.

Quality Management in Health Care—A Historical Perspective

‘‘For us who nurse, our nursing is a thing which, unless we are making progress every year, every month, every week, take my word for it, we are going back.’’3 —Florence Nightingale Quality of nursing care can trace its lineage to the days of Florence Nightingale, a trained mathematician who pioneered modern nursing practices. Her pioneering work in quality management has earned scant attention, according to Meyer and Bishop,4 who contend that Florence Nightingale should be accorded the same recognition as Edward Deming, an apostle of quality. Her relentless advocacy of quality in operations function, objectives, and methods compared favorably with the 20th century quality movement. She promoted sanitary reforms of hospitals and, in the process, saved many war wounded during the Crimean War. She advocated the use of mathematics in nursing care

management and gave advice on hospital facility design. Her Coxcomb Diagram represents one of the earliest examples of using statistics as a management tool (Figure 1). She contributed to Army statistics and comparative hospital statistics, secured hospital reform in England, consulted on US army health during the American Civil War, and advised on the Army’s medical care in Canada.5 Her feminist view that nurses should make their independent judgment within the confines of their responsibility, a reversal from an earlier stance that nurses should follow the demands of the doctors unquestionably, was refreshing even in the context of today’s practice environment.6 She laid the groundwork for modern nursing practice. Advances in the knowledge of anatomy and physiology, the discovery of anesthesia, the germ theory, and the formation of nursing schools with the resulting professionalism of nursing laid the foundation of modern health care delivery in a hospital setting. The practice of using pre- and postoperative facilities was introduced in the late 1800s.7 In the 20th century, the Flexner report of 1910 that advocated for the use of medical records provided the model framework for modern medical education. In the 1940s, individual states mandated hospital accreditation, and hospitals were required to submit abstracts to a national center for statistical analysis and benchmarking.7 The concept of

Figure 1. Coxcomb Diagram, 1858 by Florence Nightingale (1820-1910).

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continuous quality improvement (CQI), commonly known as total quality management (TQM) in other industries, was introduced into the health care industry in 1989 by Laffel and Blumenthal,8 physicians associated with the Department of Medicine, Brigham and Women’s Hospital, Boston, MA. They postulated that the traditional model of health care practice relying on performance measurement and conformance to practice standards was insufficient for health care organizations to deliver optimal quality care. They advocated adopting the principles of quality management, well understood in many industrial practices, which focus on problem identification, analysis, and the elimination of variations as a pathway to enhance the quality of care.8 The quality movement has been far reaching and motivates many health care organizations throughout the United States to initiate many quality improvement projects. In the late 1980s and early 1990s, the Joint Commission for the Accreditation of Healthcare Organizations, now known as The Joint Commission (TJC), adopted the CQI theory and practice in their assessment process.9 Meanwhile, other industrial quality management concepts that include Lean Healthcare, Theory of Constraints, and Six Sigma also attracted the attention of the health care industry. Lean Healthcare, an offshoot of lean manufacturing, seeks to minimize or eliminate delay, errors, repeated visits, and inappropriate care; Theory of Constraints targets bottleneck and advocates matching occupancy with overall throughput; and Six Sigma is a data-driven, systematic approach to drive down errors.10 Six Sigma has its root in the manufacturing industry, originated by Motorola, with the aim of producing widgets with only 3.4 defects per million production run (or 0.000034% of defects), which is almost close to production perfection. This practice requires that every department and every person in an organization focus on the ultimate goal of achieving zero defects and total customer satisfaction. Although it may be an achievable ideal in manufacturing with the application of computeraided design and manufacturing and continuous statistical feedback to enable timely corrections of defects and deviations, it remains challenging in the health care industry because it is a people-oriented service industry with many different players and personalities and an ever-changing dynamic service environment.10

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The decades that followed saw many different approaches adopted to improve health care delivery and outcomes. Practice and process redesigns such as evidence-based medicine (EBM), TQM or CQI, Six Sigma, professional development, work environment enhancement and staff empowerment, external control using assessment and accreditation, and patient empowerment have gained popularity as quality management tools in the health care industry.10

The Improvement of Quality The CQI is a management philosophy and methodology which focuses on process and system improvement to add value to the organization and to lessen the need to correct individual mistakes after the fact. It empowers the stakeholders of an organization to analyze and continuously improve the process. The CQI emphasizes teamwork with a multidisciplinary approach in problem solving and is customer driven with the customer’s preference as the determinant of quality. The CQI uses a rational database approach to process analysis and change.8 Among some of the prominent philosophers and early contributors of quality management theories are Dr. Edwards Deming, Dr. Joseph Juran, Philip Crosby, and Dr. Kaoru Ishikawa. Their theories and influences on quality management practices in many industries are briefly discussed. Edward Deming was a member of the core group at the Western Electric Company, an affiliate of the Bell System, who coined the term ‘‘quality assurance.’’11 As a pioneer of TQM, he postulated that business processes could be improved continuously. The correction of system defects and controlling product and service variations determine quality, which would result not only in improved quality but also higher productivity. He argued that the cost of poor quality harms businesses in a variety of ways that include loss of business, increased liability claims, loss of productivity owing to rework, and low morale. Accordingly, the high cost of correction is estimated at about seven times of the initial cost of work.11 Joseph Duran is known for his quality trilogy— quality planning, quality control, and quality improvement. He advocated the use of quality cost accounting and analysis to highlight quality problems and the application of statistical tools for

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analysis to eliminate problems and to ensure conformance to specifications and performance standards.11 Philip Crosby, an executive responsible for quality at International Telephone and Telegraph, theorized that quality is free and doing the job right the first time is always cheaper (zero defect). His emphasis was on behavioral, organizational, and management processes instead of the statistical approach to effect quality change.11 Kaoru Ishikawa was known as the pioneer in the quality revolution in Japan. He advocated for a participatory and bottom-up approach in quality management. He is known for his trademark Cause and Effect diagram (fishbone diagram) and Quality Circles.11 These quality pioneers have a profound impact on the followers of quality improvement across a broad spectrum of industries worldwide, including the health care industry. These pioneers laid a foundation, which has influenced many variations of quality practices and stimulated the formation of quality councils and development of performance standards to guide and encourage improvement in product and service quality in industries and commerce. Among the most salient variation in quality control technique is the ‘‘Six Sigma’’ quality or zero defect (Figure 2), developed by Motorola as a quality goal for all areas of the company.10 This technique defines defects as a failure to meet customers’ requirements and expectations. It uses defects per output of work (unit) as a quality measure and the use of re-engineering

and benchmarking as measures to accomplish the set objectives.11 Today, quality improvement theories and management philosophies such as CQI and Six Sigma are seen as congruent with the health care delivery system. The practice identifies process defects to enable quality improvement using statistical analyses and measures. They are generally viewed favorably as compatible with EBM and evidence-based practice (EBP) in nursing care. The approach is customer focused and aligns with the business model and health care practice of patient-focused and familycentered care. However, Young et al12 contend that all these methods require strong leadership and the need to involve the participation of all people in all parts of the organization. These authors acknowledge the inherent imperfections in process redesign and advocate gradual improvement involving all stakeholders as well as patients in the change process.12 In this regard, Grol10 argues that the challenges to improve patient care are complicated and immense. He advocates using multiple strategies to integrate different approaches (building bridges) to target barriers that obstruct quality improvement and the delivery of optimal care.10

Quality Recognition and Award In 1987, the US Congress acted to establish the Malcolm Baldrige National Quality Award to promote competitiveness, performance, and quality leadership in American businesses. It is the only award of performance excellence for public and private enterprises presented by the president of the United States. The award recognizes the

Figure 2. Six Sigma Quality. From EVANS/LINDSAY. Management and Control of Quality, 3E. Ó1996 SouthWestern, a part of Cengage Learning, Inc. Reproduced by permission. www.cengage.com/permissions.

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recipient’s exemplary management framework, its system attributes that assure the CQI practice, and effective and efficient organizational performance and business processes that are customer and stakeholder focused.13 The attached diagram illustrates the criteria used to evaluate performance excellence for the award (Figure 3). Earlier awards were dominated by the Fortune 500 companies. Education and health care were added to the list of award categories in 1999, and a Missouri health system became the first recipient in this award’s history in 2003.14

Quality Report Card According to Fein,15 the concept of quality has always been ‘‘problematic’’ as quality is difficult to define and to measure, whereas improving quality has historically met with resistance. He points to the fact that Florence Nightingale, who pioneered the quality movement in health care using statistics, was ignored by the medical community. Similarly, Ernest Amory Codman, a Boston surgeon who proposed his ‘‘End Results Ideas’’ to prevent future adverse events was unpopular within the medical community. His staff privileges with the Massachusetts General Hospital were revoked, and he was subsequently expelled from the Massa-

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chusetts Medical Society after he proposed to evaluate the performance of surgeons.15 The year of 1999 marked a major milestone of the quality movement.15 Two landmark publications released by the Institute of Medicine (IOM), To Err is Human and Crossing the Quality Chasm, sounded an urgent alarm to reform the complex American Health system and to deliver safe and quality medical care to all people.16,17 Two separate adverse events studies, one in New York and another in Colorado and Utah, extrapolated from 33.6 million hospital admissions in 1997 that as many as 98,000 patients may have died from preventable medical errors.16 In this report, the IOM urged the building of a safer health system to improve safety and quality, and recommended the establishment of a comprehensive strategy through a collaboration of government, health care providers, industry, and consumers to reduce preventable medical errors.16 The report concluded that ‘‘errors are caused by faulty systems, processes, and conditions that lead people to make mistakes or fail to prevent them.’’ It recommended ‘‘designing the health system at all levels to make it safer—to make it harder for people to do something wrong and easier for them to do it right.’’16

Figure 3. Malcolm Baldrige Quality Award-Criteria for Performance Excellence. Source: http://www.nist.gov/ baldrige/publications/hc_criteria.cfm. Baldridge Performance Excellence Program, Gaitherburg, MD (www.nist. gov/baldridge).

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The March 2001 study Crossing the Quality Chasm reported that the nation’s health care delivery system failed to keep pace with advances in technology and medical science and more extraordinary future advances.17 The report stated that the system is laden with a series of challenges characterized by: a fragmentation of the delivery system; a general lack of rudimentary clinical information capabilities; poorly designed care processes; unnecessary duplication of services; long waiting times and delays; and evidence of overuse of many services, potentially creating greater harm than benefit to patients.17 The report concluded that the nation’s health system with its legacy practice model is unprepared to respond effectively to an aging population with their many chronic conditions. Recommendations included a strategy to innovate and improve the health delivery system to be built around six principles, namely safety, effectiveness, patient-centered care, timeliness, efficiency, and equity.17 The report postulated a redesigned health system that achieves these six goals would benefit patients with improved health and less pain and suffering. Clinicians and other health care workers would also benefit from improved productivity and job satisfaction. To this end, changes to the structure and processes of the practice environment focusing on four areas were advocated, namely health care EBP, information technology, alignment of payment policy with quality improvement, and preparation of the work force for a health care system overhaul.17

Similarly, a report published by the Department of Health and Human Services indicated Medicare adverse events added $4.4 billion to annual health care costs and resulted in 180,000 deaths.19 The report highlighted that in October 2008, 1 in 138,000 patients experienced at least one adverse event; 44% were considered preventable. These scorecards led Brook,20 one of the founders of the modern academic quality movement, to question whether this is the end of the quality improvement movement in health care.

These two IOM reports spurred a growing awareness of the human and financial costs attributed to medical errors and suboptimal care and prompted public and private organizations, accrediting agencies, and hospitals to invest substantially to improve patient safety.15 Moreover, the progress toward reducing avoidable adverse events remains mixed. A retrospective study of admissions to 10 hospitals in North Carolina between 2002 and 2007 showed that there were 25 adverse events per 100 admissions.18 However, Landrigan et al18 illuminated that although North Carolina may not be representative of the nation as a whole, it was chosen as one of the states most engaged in the Institute for Healthcare Improvement’s harm reduction campaigns. Additionally, the state had a reputation for being proactive and known for its effort to improve patient safety.

Perspectives—Quality in Health Care

Questions abound amidst the seeming lack of progress in the quality movement. Social scientists postulate that limited progress may be attributable to the practice environment, the complex organizational cultures, and the cultures of medicine and hospitals. Behavioral scientists theorize that organizational climate, characterized by feelings, attitudes, and behaviors of life within the organization, are measures of an organization’s culture, which can be modified to influence culture. A changed culture can in turn influence climate.15 A study by Sexton et al21 shows an enduring safety culture is attainable by changing the perception of a patient safety climate. This finding holds the promise that the way forward to reverse the slow progress in the quality movement and to instill a durable patient safety culture may reside in an organization’s climate change.

In their research, Stichler and Weiss22 selected patients, physicians, nurses, and payers as subjects to elicit multidimensional perspectives of how the stakeholders of this whole value chain evaluate quality within a health care organization. They contend that quality is in the eyes of the beholder and is ‘‘an illusive concept.’’22 Their findings contradict the general view of a one-size-fits-all interpretation. They contend that quality has become an important trademark among health care organizations in their quest for a unique identity in a competitive health care market place. Three components were presented as measures of health care quality in this research, namely technical care, personal care, and properties of the care environment.22

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Quality—Patients’ Perspective Stichler and Weiss22 noted that patients generally associate quality of care with attributes, such as competent staff as characterized by technical and clinical competence; personalized care as exhibited by staff’s caring and compassionate behaviors; timeliness as characterized by responsiveness and workplace efficiency; facilities’ environment as characterized by cleanliness, comfort, privacy, security, adequate parking, and quality of food; and organizational characteristics as represented by growth, quality, and diversity of health services offerings, and hospital programs.22 Another study by Wilde et al23 substantiated that the patients’ perceptions of quality of care are multifactorial. These perceptions are influenced by the medicotechnical competence of the caregivers, the physical and technical condition of the provider organization, the attitude and performance of the caregivers, and the work culture of the organization. However, culture and communication have been shown to play an important role in the quality of health care outcomes. Studies of cultural competence care demonstrate that ‘‘provider-patient communication’’ correlates to ‘‘patient satisfaction and adherence to medical instructions and positive health outcomes’’ when provider and patient are able to reconcile their sociocultural differences in a therapeutic relationship.24 Research in bioethics has shown that for immigrants from countries in Southern Europe and Asia where communitarianism is valued over individualism, family plays an important role in culturally appropriate care, and contributes to positive health outcomes.25 The breakdown in communications has been tied to cultural misunderstanding and language barrier and the causes of preventable adverse events with serious legal implications. In the United States, a 1984 case illustrated that a misunderstanding of one word led to the misdiagnosis of a cerebral hemorrhage patient. In the 1990s, a Mexican laborer who spoke only Spanish lost his sight because of language barrier, misdiagnosis, an ineffective interpreter system, and wrongful treatment.26

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Two cases in British Columbia, Canada, in the 1990s resulted in severe harm to the patients. In the first case, the physician was found negligent in his ‘‘examination and diagnosis’’ of his patient, resulting in amputation of the patient’s leg, an avoidable error attributed to language barrier. In the second case, the coroner identified that language barriers contributed to the death of a Vietnamese woman with no interpreter service. In 1998, a young Muslim woman was wrongfully sterilized against her beliefs because of ‘‘cultural miscommunication, cultural misunderstanding, and cultural imposition.’’26 In a 2006 study, Seiden and Barach27 estimated between 1,300 and 2,700 wrong-side/wrongsite, wrong-procedure, and wrong-patient adverse events (WSPE) occurred in the United States annually. Despite the estimated high number of cases, WSPE cases were under-reported based on the data they analyzed. These researchers argued that the existing health care system is not ‘‘culturally and structurally organized to prevent WSPE occurrence.’’27 They elucidated that the factors contributing to the WSPE cases include human, patient, and procedure factors. They warned that the continuous occurrence of WSPE undermine the national health care quality goal of improving patient safety and health care quality, perpetuating the cycle that contributes to preventable deaths, disability, suffering, and malpractice and reducing the public’s confidence in the quality of the health care system.27 Quality—Physicians’ Perspective A survey of clinicians on quality in their settings of health care delivery found that physicians consider professional and technical competence of staff; effective communication, team work, and productivity; and quality-of-care outcomes as essential characteristics of quality. Other attributes that influence their perception of quality included organizational culture and values, the care environment, availability of modern diagnostic and treatment technologies, professional development opportunities, and quality assurance practices.22 Two other dimensions that influenced the quality of care were clinical experience and physician leadership. Choudhry et al28 discovered that an inverse relationship exists between the length of time

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a physician is in clinical practice and the quality of care a physician provides based on several outcome measures, adjusted for patient comorbidity, physician volume, or specialization.28 However, they point to the limitations of under-reporting bias, the difficulties of defining physician experience, and other dimensions associating with experience and quality of care that may have escaped noticed in their findings. Despite these limitations, the researchers are troubled by the fact that many experienced physicians in some specialties, who may need quality improvement interventions to keep up to date and to demonstrate continuing competence, are exempted from recertification, a requirement for their recently trained colleagues.28 The study results suggest that more attention is given to this subgroup of physicians who may need quality improvement interventions as more experienced practitioners may ironically be at risk of providing suboptimal care.28 Nevertheless, the findings remain inclusive, and the authors propose more research on this topic is needed.

pinned by robust supports that enable them to execute both academic and operational activities effectively.29 Quality—Nurses’ Perspective Nursing care plays an important role in patient quality outcomes. The Magnet Recognition Award program was established and remains the gold standard in recognition of a health care organization in ‘‘quality nursing care, nursing excellence, and innovation in nursing practice.’’31

On the other hand, Pronovost et al29 attribute the paucity of physician leaders who can advance the science and practice of quality as the cause of the labored and arduous progress in the quality of patient care. This shortage of a talent pool is most acute in the academic medical centers (AMCs).29

In the early 1980s, the National Academy of Nursing established a task force to carry out a study to identify why some of the nation’s hospitals were ‘‘magnets,’’ able to attract and retain nursing talent and consistently produce superior quality in patient health outcomes. The survey uncovered that some of these hospitals possessed unusual attributes that attracted nursing talent.32 The results of the study became the guiding framework and baseline standards of the Magnet Recognition Program. The program was approved by the American Nurses Association Board of Directors in 1990 and is administered by the American Nurses Credentialing Center. A hospital may apply for the award recognition as a stand-alone institution or as a system with unified governance and common practice standards.

Despite the United States’ leadership in biomedical research and a median per capita spending for hospital services and drugs three times that of 29 other countries within the Organization for Economic Cooperation and Development, the United States ranks last among other nations in quality, access, efficiency, equity, and outcomes according to a Commonwealth Fund report.29,30 Pronovost et al29 argue that the challenge is owing to a failure to view the delivery of health care as a science and the inability to translate evidence into practice. They assert that the science of measuring quality and safety and the many quality initiatives in the United States and abroad remain immature. To accelerate the national progress in quality and safety of patient care, these researchers advocate investing in quality and safety science, revising the quality and safety governance in AMCs, combining roles within the hospital and medical school, and investing in physician leadership to be under-

The Magnet Recognition Award serves as a vote of confidence for a hospital’s exemplary care and enhances its image in the community as a quality health care provider. For the nursing division, it is a morale booster validating the value of performance excellence as measured by indicators such as teamwork, EBP, CQI, and excellence in patient outcomes. The award also gives the institution a leading edge in a competitive health care market in retaining and attracting highly qualified physicians and specialists, nursing talent, and other personnel that add value to the organization. The recognition fosters a collaborative culture, encourages teamwork, and advances nursing standards and practice through professional development and continuing education. Additionally, it enhances the organization’s ability to expand its patient pool and health care market share and reinforces its ability to negotiate and contract with payers from a position of strength.32,33

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According to the research by Stichler and Weiss,22 nurses’ perception of quality is influenced by positive patient outcomes, the ability to provide personalized and compassionate patient- and family-focused care with continuity. Compassion in nursing care brings mutual satisfaction to caregivers and patients and contributes to quality health outcomes. Moreover, compassionate care necessitates active listening, educating, comforting, forgiving, and sensitivity in communication and showing respect and understanding of the patients’ background and perspective.34 These attributes align with the principles of patientcentered care noted in the 2001 landmark report Crossing the Quality Chasm and explained as ‘‘respectful and responsive to individual patients’ preference and needs, and ensure that patient’s values guide all clinical decision.’’17,35 Citing Nouwen, Dietze and Orb36 elucidate that compassion is ‘‘intrinsic’’ to nursing care and that its spiritual quality gives it the ‘‘healing power’’ for those who suffer. van der Cingel,37 a bioethicist, elaborates that compassion is neither driven by right or wrong judgments nor should it pose any moral dilemma. Lown et al35 advocate that national quality standards include measures for compassionate care. These researchers concur that compassion promotes patients’ adherence to medication and treatment recommendations resulting in lower readmission rates and reduced health care costs. Compassionate communication is also known to have reduced anxiety, distress, and depression of family members of a dying patient in end-of-life care.35 Similarly, a study on compassionate care in a geriatric care setting revealed that compassion elicits tangible information helpful in reaching the outcome of care. Compassion softens the image of ‘‘the difficult patient;’’37 it helps nurses to understand a patient’s need for attention and the reasons of his/her behaviors. As such, in the nursing care process, compassion encourages patients to share meaningful personal information to enable personalized care and motivates caregivers to provide the best care in an effective and meaningful way that would contribute to positive health outcomes.37 Other measures of quality from a nurse’s perspective include adequate system support, staff empowerment, commitment of quality, adequate nurse-to-patient ratios, professional development,

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appropriate pay and benefits, recognition, and an environment that is sensitive to nurses’ stress level. All these factors motivate high morale, leading to greater job satisfaction and low staff turnover.22 An Australian study by Leggat et al38 on nurse perceptions of the quality of patient care confirms the importance of empowerment and job satisfaction. The study shows the correlation of a high performance work system (HPWS) and the quality of patient outcomes. The HPWS is characterized as ‘‘security, selective hiring, contingent reward, extensive training, autonomy and decision-making latitude, reduced status distinctions, information sharing, transformational leadership, and high quality work.38 Nurses’ job satisfaction is linked to both structural and psychological empowerment. Structural empowerment is perceived by the empowering conditions in the workplace, but psychological empowerment is perceived as the quality of patient care. Feeling empowered increases job satisfaction, a feeling that imparts a sense of competence and freedom and job satisfaction that greatly reduces staff turnover.38 Additionally, the study also confirmed a relationship that exists between nurse satisfaction, quality of patient care provided, and patient satisfaction.38 However, similar to the research by Stichler and Weiss,22 the study by Leggat et al38 focused on one hospital, although the findings generally align with the quality attributes of the US Magnet hospitals. Quality—Payers’ Perspective Large employers, managed care providers, and third-party providers are increasingly interested in TQM as one of the criteria in the selection of providers in health care services.22 The payers who responded to the survey22 listed several categories that would influence their selection of quality hospitals that include: accreditation by regulatory agencies such as TJC; the center of Medicare and Medicaid Services (CMS); image as represented by the health system’s standing in the community; scope of services as measured by the comprehensiveness of its service offerings and the outcomes of care; appropriate care quality management; and organization characteristics as measured by the provider’s quality assurance, improvement, and utilization review programs.

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The concept of pay for performance (P4P) has gained traction in recent years with UnitedHealth Group, Inc. becoming the latest major national health insurer in 2012 to link payments to quality performance. According to this payer, the quality measures may include readmission rates, hospital-acquired infection rates, mortality rates for select conditions, and patients’ satisfaction.39 More than 100 provider organizations have already worked with private health plans using the accountable care organization (ACO) model with ‘‘payment tied to improving patient’s care across the continuum and reducing overall spending growth.’’40 In 2003, the Medicare Payment Advisory Commission41 recommended to Congress to build incentives for quality into the payment systems for providers such as hospital, physicians, home health agencies, dialysis facilities, and Medicare Advantage plans. The Commission advocated embedding into the payment systems measures that would reward providers for attaining or exceeding certain quality benchmarks and improvement at specified levels. The underlying rationale for the P4P incentives was to drive quality in care delivery with the aims of reducing preventable injury and illness, improving patients’ health, and promoting efficiency in resource utilization.41 Consequently, a law was passed in 2006 to accelerate the improvement of patients’ safety by constraining hospitals to bill Medicare for a higher paid diagnostic-related group when hospitalacquired complications were deemed avoidable. The list includes foreign objects left in the body postoperatively, incompatible blood infusion, falls and traumas, catheter-related urinary tract infections, mediastinitis after coronary bypass procedure, and pressure ulcers.42 This practice attracted followers such as the commercial health insurers and state Medicaid plans. In 2008, the list was expanded to include poor glycemic control, deep vein thrombosis, or pulmonary embolism associated with knee/hip surgeries and selected bariatric and orthopaedic surgical site infections. Beginning in 2009, the CMS would stop all payments including physician payments in three flagrant surgical ‘‘never events,’’42 defined as serious complications that should never have happened in a safe hospital. These events include surgery on the wrong patients, wrong surgical procedures,

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and surgery on the wrong parts and wrong sites of the body. The justification of aligning quality performance with payment is to build a path to accountable care.40 The practice aims to promote major changes in physician training, encourage greater collaboration of physicians and teamwork, adoption of electronic information systems, reengineering of clinical work methods, and reduction of errors and waste.42 Meanwhile, across the Atlantic in 2004, the United Kingdom introduced a £1.8 billion (USD $3.2 billion) P4P contract for family practitioners. The payout in the first year was astounding, amounting to 83.4% of the incentive claims, a level of achievement far exceeding the government’s expectation.43 This outcome confounds the researchers who debate whether the high level of quality attained was attributable to the P4P contract or just an accelerated extension of existing trends of improvement from incentive programs initiated in 1990.43 Other arguments point to the improvement as a result of better record keeping as health data were drawn from medical records and not better care provided. Conversely, the proponents of the P4P scheme contend that to provide good care requires the delivery of care, keeping good record of the process, and the intermediate outcomes to enable quality assessment tied to specific benchmarks and indicators.43 Despite the confounding outcomes, the P4P program was seen as an effective change agent to influence professional behaviors. However, the researchers43 contend that continued improvement of quality of care is multifactorial, which requires effective leadership, unambiguous goals, and teamwork. The study results confirm that P4P practice can contribute to the quality of care as an integral part of a comprehensive quality improvement program.43 In general, the underlying concept of P4P is to link payment with the quality of patient outcomes by focusing on financial incentives. The payment practice advocates paying more for evidencebased preventative care, use of information technology, and denial of payment for preventable complications. Additionally, the P4P awards bonuses for efficiency to reduce care and to motivate utilization reduction. This contracting model remains a work in progress with ongoing

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multidisciplinary research to focus on factors that are barriers to success and attributes that would assist program redesign. The P4P remains a promising management tool that could enhance and reinforce medical professionalism and encourages innovations, teamwork, quality patient-centered care practice, and cost reduction.44

The Evidence of Quality If quality is an illusive concept in the eyes of the beholder and it means different things to different people, the study by Berry and Bendapudi1 showed that one North Central health system does not leave the interpretation to chance. This provider has championed patient- and familyfocused care, and the whole organization is structured around the doctrine of the ‘‘patient comes first.’’ They ‘‘offered patients and families concrete and convincing evidence of its strength and values,’’1 recognizing that customers are always looking for clues to explain what they do not understand about purchases of intangible and technically complex products and services. During the whole hospital process, the patients are informed with concrete evidence that patients come first. Employees are dressed to convey respect, competence, professionalism, and expertise in presenting themselves to patients and families.1 The provider also recognized the inseparability of quality of care, the treatment outcomes, the organization’s core values, and the physical facility. In this regard, the provider made sure that the facilities were designed to create a positive and low stress environment that is attractive and airy, to convey respect and a caring environment, facilitate wayfinding, and accommodate family and the physically challenged.1 A well-designed environment

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attracts and keeps talent, and the value of reducing physical and emotional stress benefits both patients and employees. In practicing what the health system called ‘‘evidence management,’’ it turned the whole facility into an animated billboard that advertises its quality, its diverse health care offerings, and professional expertise.1 Through word of mouth and customer loyalty, this health system has established itself as a distinguished local, national, and global brand in the health care industry.

Conclusion The search for quality in health care has been an arduous and labored journey. The quest for health care quality continues among authorities, policymakers, managers of health care organizations, caregivers, payers, and patients. Is P4P, formulated as a form of stick and carrot approach to manage health care quality, an effective tool to improve patient safety and reduce errors and waste? Positive outcomes from such a payment reform have been episodic and ultimate success is not assured. Nevertheless, P4P is seen by authorities in the United States and abroad as an effective substitute for the ‘‘fee for service’’ payment model. Increasingly, insurance payers with growing support from health care providers are attracted to the ACO model as an alternative that offers the potential to modernize care delivery, safeguard patient safety, improve quality, and efficiency, and contain cost. Meanwhile, the progress to overcome the shortcomings in patient safety continues to be labored and challenging. Improving patient safety and health care quality remains a marathon without a finish line.

References 1. Berry LL, Bendapudi N. Best practice—Clueing in customer. Harv Bus Rev 2003;100-106. 2. DeWitt L, Albert NM. Preferences for visitation in the PACU. J Perianesth Nurs. 2010;25:296-301. 3. Ulrich BT. Leadership and Management According to Florence Nightingale, 1st ed. Norwalk, CT: Appleton & Lange; 1992. 4. Meyer BC, Bishop DS. Florence Nightingale: Nineteenth century apostle of quality. J Manag Hist. 2007;13:240-254. 5. Museum FN. Crimean War, Innovations and Improvements. Available at: http://www.florence-nightingale.co.uk/

cms/index.php/crimean-war/innovations. Accessed March 2, 2012. 6. Maindonald J, Richardson AM. This passionate study: A dialogue with Florence Nightingale. J Stat Educ. 2004;12. Available at: www.amstat.org/publications/jse/v12n1/maindo nald.html. Accessed April 13, 2013. 7. Haglund CL, Dowling WL. The Hospital. Introduction to Health Services. Albany, NY: Delmar Publishers; 1993:135-176. 8. Laffel G, Blumenthal D. The case for using industrial quality management science in health care organizations. JAMA. 1989;262:2869-2873.

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9. Blumenthal D, Epstein AM. Quality of health care. Part 6: The role of physicians in the future of quality management. N Engl J Med. 1996;335:1328-1331. 10. Young T, Brailsford S, Connell C, Davies R, Harper P, Klein JH. Using industrial processes to improve patient care. Bmj. 2004;328:162-164. 11. Grol R. Improving the quality of medical care: Building bridges among professional pride, payer profit, and patient satisfaction. JAMA. 2001;286:2578-2585. 12. Evans JR, Lindsay WM. The management and control of quality, 6th ed. Mason, OH: Thomson/South-Western; 2005. 13. Baldrige Excellence Performance Program; Baldrige By Section: Health Care. Date created: February 18, 2010. Available at: http://www.nist.gov/baldrige/enter/health_care.cfm. Accessed February 26, 2012. 14. SSMHC-Malcolm Baldrige Quality Award 2003. 2012. Available at: http://www.stmarysmadison.com/AboutUs/Pages/ MalcomBaldridge.aspx. Accessed February 19, 2012. 15. Fein IA. Quality, patient safety, and culture: ’We have met the enemy and he is us’–Pogo (Walt Kelly, 1971). Crit Care Med. 2011;39:1196-1197. 16. Kohn LT, Corrigan JM, Donaldson MS. To err is human: Building a safer health system. Washington, DC: A report of the Committee on Quality of Health Care in America, Institute of Medicine; 2000. 17. Kohn LT, Corrigan JM, Donaldson MS. Crossing the quality chasm: A new health system for the 21st century. Washington, DC: Committee on Quality of Health Care in America, Institute of Medicine; 2001. 18. Landrigan CP, Parry GJ, Bones CB, Hackbarth AD, Goldmann DA, Sharek PJ. Temporal trends in rates of patient harm resulting from medical care. N Engl J Med. 2010;363:11. 19. Levinson DR. Adverse events in hospitals: National incidence among medicare beneficiaries. Services DoHaH; 2010. 20. Brook RH. The end of the quality improvement movement: Long live improving value. JAMA. 2010;304:1831-1832. 21. Sexton JB, Berenholtz SM, Goeschel CA, et al. Assessing and improving safety climate in a large cohort of intensive care units. Crit Care Med. 2011;39:934-939. 22. Stichler JF, Weiss ME. Through the eye of the beholder: Multiple perspectives on quality in women’s health care. Qual Manag Health Care. 2000;8:1-13. 23. Wilde B, Starrin B, Larsson G, Larsson M. Quality of care from a patient perspective—A grounded theory study. Scand J Caring Sci. 1993;7:113-120. 24. Betancourt JR, Green AR, Carrillo JE, Park ER. Cultural competence and health care disparities: Key perspectives and trends. Health Aff (Millwood). 2005;24:499-505. 25. Johnstone M-J. Bioethics: A Nursing Perspective, 5th ed. Australia: Elsevier; 2009. 26. Johnstone MJ, Kanitsaki O. Culture, language, and patient safety: Making the link. Int J Qual Health Care. 2006;18: 383-388.

ESTHER LEE 27. Seiden SC, Barach P. Wrong-side/wrong-site, wrongprocedure, and wrong-patient adverse events: Are they preventable? Arch Surg. 2006;141:931-939. 28. Choudhry NK, Fletcher RH, Soumerai SB. Systematic review: The relationship between clinical experience and quality of health care. Ann Intern Med. 2005;142:260-273. 29. Pronovost PJ, Miller MR, Wachter RM, Meyer GS. Perspective: Physician leadership in quality. Acad Med. 2009;84: 1651-1656. 30. Davies KA. Prescription for Our Nation’s Ailing Health Care System. New York, NY: The Commonwealth Fund; 2007. 31. UC San Diego Health System. UC San Diego Health System Honored With Magnet Status. UC San Diego HS; 2011. 32. Clark ML. The Magnet Recognition Program and evidence-based practice. J Perianesth Nurs. 2006;21:186-189. 33. Program Overview. Benefits of Magnet Designation 2012. 2012. Available at: http://www.nursecredentialing.org/ Magnet/ProgramOverview.aspx. Accessed February 27, 2012. 34. Lee E. Cultural Incompetent Care, Impacts on Healthcare Outcomes and Patient Safety. Deakin University; 2012:8. 35. Lown BA, Rosen J, Marttila J. An agenda for improving compassionate care: A survey shows about half of patients say such care is missing. Health Aff (Millwood). 2011;30: 1772-1778. 36. von Dietze E, Orb A. Compassion care: A moral dimension of nursing. Nursing Inquiry. 2000;7:166-174. 37. van der Cingel M. Compassion in care: A qualitative study of older people with a chronic disease and nurses. Nurs Ethics. 2011;18:672-685. 38. Leggat SG, Bartram T, Casimir G, Stanton P. Nurse perceptions of the quality of patient care: Confirming the importance of empowerment and job satisfaction. Health Care Manage Rev. 2010;35:355-364. 39. Mathews AW. New Ways to Pay Doctors, UnitedHealth, Nation’s Largest Insurer, Is Latest to Announce Fee Overhaul. Wall Street Journal; 2012. 40. Fisher ES, McClellan MB, Safran DG. Building the path to accountable care. N Engl J Med. 2011;365:2445-2447. 41. Milgate K, Cheng SB. Pay-for-performance: The MedPAC perspective. Health Aff (Millwood). 2006;25:413-419. 42. Milstein A. Ending extra payment for ‘‘never events’’— Stronger incentives for patients’ safety. N Engl J Med. 2009; 360:2388-2390. 43. Campbell S, Reeves D, Kontopantelis E, Middleton E, Sibbald B, Roland M. Quality of primary care in England with the introduction of pay for performance. N Engl J Med. 2007; 357:181-190. 44. Cromell J, Trisolini MG, Pope GC, Mitchell JB, Greenwald LM. Pay for Performance in Health Care: Methods and Approaches, 1st ed. Research Triangle Park, NC: RTI International; 2011. Theoretical Perspectives on Pay for Performance.

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The Arduous and Challenging Journey of Improving Patient Safety and Quality Of Care 1.27 Contact Hours Purpose of the Journal of PeriAnesthesia Nursing: To facilitate communication about and deliver education specific to the body of knowledge unique to the practice of perianesthesia nursing. Purpose of this CNE Activity: To enable the perianesthesia nurse to implement patient safety initiatives to improve the quality of patient care. Target Audience: All perianesthesia nurses. Article Objectives: (1) Describe the principles and theories of quality management. (2) Discuss how outof-industry quality management practices influence the quality movement in the health care industry. (3) Discuss the multi-dimensional attributes pertaining to quality of care from the perspectives of different stakeholders in the health care industry. Accreditation American Society of Perianesthesia Nurses is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. Additional provider numbers: Alabama #ABNP0074, California #CEP5197, Florida 50-114. Registered nurse participants can receive 1.27 contact hours for this activity. Disclosure: All planners and authors of continuing nursing education activities are required to disclose any significant financial relationships with the manufacturer(s) of any commercial products, goods or services. Any conflicts of interest must be resolved prior to the development of the educational activity. Such disclosures are included below. Planner and Author Disclosure: The members of the planning committee for this continuing nursing education activity do not have any financial arrangements, interests or affiliations related to the subject matter of this continuing education activity to disclose. The author for this continuing nursing education activity does not have any financial arrangements, interests or affiliations related to the subject matter of this continuing nursing education activity to disclose. Verification of Participation: Verification of your participation in this educational activity is done by having you complete the registration form and submit the form along with the post test and evaluation form to the ASPAN national office. Requirements for Successful Completion: To receive contact hours for this continuing nursing education activity you must submit the posttest and evaluation form to the ASPAN national office and achieve a minimum grade of 80% on the posttest. Commercial Support: No commercial support has been received for this educational activity.

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Directions: The multiple-choice examination below is designed to test your understanding of The Arduous and Challenging Journey of Improving Patient Safety and Quality Of Care according to the objectives listed. To earn contact hours from the American Society of PeriAnesthesia Nurses (ASPAN) Continuing Education Provider Program: (1) read the article, (2) complete the posttest by indicating the answers in the test

grid provided, and (3) tear out the page (or photocopy) and submit postmarked before December 31, 2015, with check payable to ASPAN (ASPAN member, $12.00 per test; nonmember, $15.00 per test) and return to ASPAN, 90 Frontage Road, Cherry Hill, NJ 08034–1424. Notification of contact hours awarded will be sent to you in 4 to 6 weeks.

Posttest Questions 1. The following statement describes the Flexner report of 1910: A. States that complications should never have happened in a safe hospital B. Determined that the cost of correcting poor quality work is seven times the costs of the initial work C. Advocated the use of medical records and modernized medical education D. Was the beginning of quality management/assurance practices 2. What is continuous quality improvement? A. A management philosophy/methodology focusing on process and system improvement B. Multidisciplinary approach in problem solving C. Emphasis on intuition and feeling in decision making and change D. A and B above 3. Quality management theories and management philosophies are seen as A. Incongruent with modern health care practice B. Compatible with evidence-based medicine and evidence-based practice in nursing intervention C. Aligning with patient-focused and familycentered care D. B and C above 4. Crossing the Quality Chasm, one of the two landmark publications released by the Institute of Medicine, advocated making changes in the health system which include:

A. Deploy evidenced-based health care practice B. Align payment policy with quality improvement C. Design the health systems at all levels to make it safer D. A and B above 5. From the patients perspective, quality of care is generally associated with these attributes: A. Competent staff with technical and clinical competence B. Caring and compassionate behaviors C. Physical and technical conditions of the provider organization D. All of the above 6. From a nursing perspective, measures of quality include all of the following except: A. Positive patient’s outcomes B. An environment sensitive to staff members’ need for a competitive annual cost of living adjustment C. Adequate system support, commitment of quality, and adequate nurse-to-patient ratios D. Staff empowerment 7. Compassion is neither driven by right or wrong judgments nor should it pose any moral dilemma. Compassionate care encompasses all of the following except: A. Active listening and educating B. Sensitivity in communication C. Mutual understanding D. Showing respect and understanding of the patient’s background and perspective

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8. The justification of aligning payment with quality performance is to promote accountable care, this practice include all of the following except: A. Encourage efficiency and greater health care utilization B. Re-engineer clinical work methods C. Reduce errors and waste D. Adopt electronic information system 9. In 2006, a law was passed to keep hospitals from billing Medicare for a higher paid diagnostic-related group when hospitalacquired complications were deemed avoidable. The list includes:

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A. Foreign objects left in the body postoperatively B. Incompatible blood infusion C. Catheter-related urinary tract infections, mediastinitis after coronary bypass procedure, and pressure ulcers D. All of the above 10. Wrong side/wrong site, wrong procedure, and wrong-patient adverse events are caused by: A. Human factors B. Patient factors C. Procedural factors D. All of the above

THE ARDUOUS AND CHALLENGING JOURNEY OF IMPROVING PATIENT SAFETY AND QUALITY OF CARE ANSWERS W011215 Please circle the correct answer 1.

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________________________________________________________________________________________ Please Print Name__________________________________Nursing License No./State____________________________ Address__________________________________________________________________________________ City_______________________________State_______________________Zip_________________________ ASPAN Member #__________________________________________________________________________ E-Mail____________________________________________________________________________________ EVALUATION: The Arduous and Challenging Journey of Improving Patient Safety and Quality Of Care

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Evaluation Form SD5strongly disagree; D5disagree; N5neutral; A5agree; SA5strongly agree

SD

D

N

1. After completion of this educational activity, I am able to 1 2 3 describe the principles and theories of quality management. 2. After completion of this educational activity, I am able to discuss 1 2 3 how out-of-industry quality management practices influence the quality movement in the health care industry. 3. After completion of this educational activity, I am able to discuss 1 2 3 the multi-dimensional attributes pertaining to quality of care from the perspectives of different stakeholders in the health care industry. 4. The program content was relevant to my nursing practice. 1 2 3 5. Learner paced was an appropriate format for the content. 1 2 3 6. This educational activity was free from commercial bias. 1 2 3 7. The planner and presenter disclosure information was included 1 2 3 in this educational activity. 8. Identify the amount of time required to review the on demand video module, take the test and complete the evaluation form: a. Over 120 minutes b. 91-120 minutes c. 61-90 minutes d. 30-60 minutes e. Under 30 minutes 9. Will the knowledge gained through this educational activity change your practice? a. Yes b. No 10. If you answered yes above – please explain: 11. Additional comments

Test answers must be submitted before December 31, 2015 to receive contact hours.

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