Providing evidence of the quality of our service has become an important responsibility for all nursing leaders. Traditionally, quality in health care was judged by reputation, program features, and compliance with policies and procedures.

These traditional methods fall short of providing the level of assurance that society currently demands. In today’s environment, nurses and other health-care leaders are expected to identify evidence-based process and outcome indicators of importance to their patient populations, to measure current performance relative to those indicators, and to continuously improve the care provided to their patients.

An important indicator of quality is meeting customer expectations. Some organizational leaders take that a step further; they are not satisfied until they have exceeded customer expectations. Meeting customer expectations can be a bit more difficult in health care because, unlike in other industries, the purchaser of health-care services is rarely the consumer of those same services.

Nurse leaders play a pivotal role in these efforts and therefore must understand consumer quality expectations.

As patients are exposed to more media attention to health care, advertisements from hospitals and pharmaceuticals, and access to information on health care, they are becoming more discriminating in what they expect and demand from providers.

Patients have a choice about health-care providers. Customer satisfaction surveys are beginning to capture better what patients want and how they are making their choices.

Regulators have been involved in setting minimum standards for quality measurement for many years. In more recent years they have joined forces with other professional organizations and payers to drive public reporting of quality measures.

These preferences are applicable across all settings and patient populations. As you read about the other drivers of quality, you will see that they all tie themselves in some way to the patient. The patient remains the center of all quality efforts.

The Joint Commission on Accreditation of Health-care Organizations (JCAHO) is the primary accreditation organization for health-care institutions.

Through its published standards of care, periodic onsite inspections, and collection of quality data, it helps drive providers to a higher level of care.

JCAHO has also introduced failure mode and effects analysis (FMEA). FMEA, which is explained further in the section on quality tools, is a technique by which process flowcharting and risk categorization are used to prioritize and redesign weak points within care processes in order to reduce vulnerability to committing serious medical errors.

This comprehensive approach to understanding error is required only once a year but can serve as a model for understanding multiple patient care services.

The Centers for Medicare and Medicaid Services (CMS) is the government institution that oversees both Medicare and Medicaid programs, large consumers of health care.

CMS can be considered a driver of quality both from the perspective of a regulator and the perspective of a payer.

Quality indicators monitored by Medicaid programs include patient satisfaction, early prenatal care, childhood immunizations, waiting times, diabetes control, cancer screenings, and the availability of translators.

Beneficiaries in the majority of states are enrolled in managed care plans administered by multiple health plans within each state.

In addition to meeting quality standards set by accreditation and federal agencies, health-care providers are required to meet standards set by state regulators.

Typically, state oversight falls under the state’s department of health, which administers licenses to hospitals, day-care facilities, long-term care, home care, laboratories, behavioral health facilities, and freestanding surgery centers. State departments of health oversee quality in several ways.

Employers constitute a large proportion of the payers of health-care services. Competition in global markets, combined with escalating health-care costs, is driving Fortune 500 companies to join consumers on the quality bandwagon. In fact, 170 of these companies have formed the Leapfrog Group, the largest purchasing group of health care.

The Leapfrog Group wants a system that keeps employees healthy, gets them back to work earlier, and keeps costs down. Some Leapfrog initiatives include support of computerized order entry systems, evidence-based hospital referral, and the use of intensivists in critical care units.

An employers’ group in Indianapolis formed a coalition to put pressure on hospitals and physicians to provide it with outcome data that will be publicly displayed at benefits enrollment fairs.

They are also discussing ways of structuring their benefits programs to have different co-payments, depending on the provider’s outcomes. In this type of a program, employees who choose providers with better outcomes would be responsible for lower co-payments than employees who choose providers with poor outcomes. These types of efforts on the part of employers are putting tremendous pressure on providers to improve outcomes.

The Institute of Medicine (IOM) was chartered in 1970 as an arm of the National Academy of Sciences. Members of the IOM serve as advisors in health, medicine, and biomedical science.

Members are volunteers who are recognized experts in their areas (Institute of Medicine, 2005). The IOM has taken a leadership position in raising national awareness of patient safety issues in hospitals and has therefore spurred the quality movement.

The National Quality Forum (NQF), a nonprofit public-private partnership that works to improve the health-care system through development and dissemination of voluntary consensus standards, recently recommended nursing performance standards).

Member organizations represent health-care providers, educational institutions, consumers, employers, state and federal agencies, and research. Four nursing organizations (American Nurses Association American Academy of Nursing, American Association of Colleges of Nursing, and American Association of Nurse Anesthetists) are represented among NQF member organizations.

In the mid-1990s, the American Nurses Association (ANA) published a report containing process, outcome, and structural measures that have been shown through research to be related to acute care nursing.

These indicators are a subset of the larger set subsequently published by the National Quality Forum. Some of the outcome indicators contained in the report include patient mortality, length of stay, adverse incidents such as medication errors and patient falls, and complications such as nosocomial infections and decubitus ulcers.

The criteria for measurement of excellence in nursing care used by the Magnet Recognition Program are based upon the ANA scope and standards for nurse administrators. The standards also serve as the basis for specialty certification examinations.

Quality models serve as frameworks for diagnosing and finding solutions to performance problems.

The Plan, Do, Study, Act (PDSA) cycle is an improvement model that is still practiced widely. Dr. Deming advocated for this method of continual improvement. Each step of the model contains a distinct improvement phase. The model is meant to be repeated over multiple improvement cycles.

Use of the PDSA cycle assumes that a problem has been identified and analyzed for its most likely causes and that changes have been recommended for eliminating the likely causes.

The model uses a systems framework, which adds three questions to the PDSA cycle. The questions are meant to bring clarity to the improvement process. The three questions are:

1. What are we trying to accomplish? 2. How will we know that a change is an

improvement? 3. What changes can we make that will

result in improvement?

The Quality Health Outcomes Model developed by the Expert Panel on Quality Healthcare of the American Academy of Nursing was proposed to serve as a framework for quality activities as well as nursing systems research.

The model’s four components—intervention, system, client, and outcomes—were built on Donabedian’s structure, process, outcomes paradigm.