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To incorporate quality and safety, improvement must be measurable. By measuring improvement, one is tracking the progress the organization is making in reaching its goals for quality and safety. This can be accomplished by the use of benchmarks. Benchmarks in health care are defined as “the continual and collaborative discipline of measuring and comparing the results of key work processes with those of the best performers in evaluating organizational performance” (Hughes, 2008, para. 6). There are internal benchmarks and external benchmarks. Internal benchmarks can identify and compare best practices. External benchmarks compare data between organizations using “comparative data to judge performance and identify improvements that have proven to be successful in other organizations” (Hughes, 2008, para. 6).

Quality of health care can be measured either by observing the structure, its processes, or its outcomes. To measure the quality of health care through structure, one looks at “the accessibility, availability, and quality of resources, such as health insurance, bed capacity of a hospital, and number of nurses with advanced training” (Hughes, 2008, para. 7). Measuring through processes looks at the delivery of health care, and outcomes are measured by patient satisfaction and mortality.

Continuous quality improvement

 (CQI) is very similar to TQM. CQI is used to develop clinical practice and is based on the notion that there is always opportunity for improvement. Improvements can be made in processes and issues that are discovered by regulatory and accreditation agencies. Identified issues are subsequently brought to a committee where quality improvements are developed. Clinical practice improvements (CPI) are led by hospital committee members and clinicians. Quality improvement teams are organized when data need to be collected and analyzed to find new and innovative ways to make improvements. The findings or quality improvement strategies are then translated into practice changes. It is important that management meets with staff and empowers staff to implement changes. Quality improvement strategies are developed by quality improvement teams for continuous practice improvement.

Quality and Safety Objectives

Quality and safety objectives are important because they help the organization remain focused on the strategies that will help the organization to meet their goals. Objectives are put into place to keep the focus on the organization’s goal. Goals should be measurable and realistic, and reflect the vision the organization projects to the consumer. Strong leadership support and the resources necessary to accomplish organizational change are mandatory for success.

Barriers may exist that hinder organizational improvement, such as poor communication and ineffective relationships between departments. The organization must embrace the need for change to actively pursue institutionalizing a culture of safety and quality improvement (Hughes, 2008). Quality improvement is defined as “systematic, data-guided activities designed to bring about immediate improvement in health care delivery” (Hughes, 2008, para. 11). A quality improvement strategy aims to promote health and health care centered on the needs of patients, families, and communities, and incorporate evidence-based results in clinical medicine, public health, and health care delivery using collaboration to improve care

Organizational Outcomes

“The World Health Organization defines an outcome measure as a ‘change in the health of an individual or group of people that is attributable to one or more interventions.’ Outcome measures (mortality, readmission, patient experience, etc.) are the quality and cost targets healthcare organizations are trying to improve” (Tinker, n.d., para. 3). The triple aim of health care (see Figure 5.6) was developed by the Institute for Healthcare Improvement (IHI). It describes a way to optimize health system performance. It includes improving the patient experience of care, improving the health of populations, and reduces the cost of health care. It is believed that if an organization can attain those outcomes, populations will be healthier. The United States is facing an aging population with chronic health problems—a population that has the potential for a long life, putting increased pressure on medical and social services. The IHI believes there are five components that will help health care organizations achieve the triple aim (Institute for Healthcare Improvement, n.d.a).

Figure 5.6

Triple Aim of Health Care

Note. Adapted from “Initiatives: IHI Triple Aim Initiative,” by Institute for Healthcare Improvement, located on the institute’s website at http://www.ihi.org/Engage/Initiatives/TripleAim/Pages/default.aspx

Organizational Indicators

Organizational 

quality indicators

 can fall into several different categories. There are prevention quality indicators, inpatient quality indicators, patient safety indicators, and pediatric quality indicators. “Quality indicators are standardized, evidence-based measures of health care quality that can be used with readily available hospital inpatient administrative data to measure and track clinical performance and outcomes” (AHRQ, n.d., para. 1). Quality indicators can highlight potential areas for improvement and can also be used to track results from any changes that were implemented. The AHRQ has multiple tools for health care organizations to identify areas for potential improvements.

American Nurses Association Principles for Nurse Staffing

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An association exists between nurse staffing and patient outcomes. The American Nurses Association (ANA) identified elements needed to achieve optimal staffing, which enhances the delivery of safe, quality care. Appropriate staffing matches the expertise of the nurse with the needs of the patient. The ANA found that appropriate staffing is critical to the delivery of cost-effective health care. Nurses should be partners and collaborate with other disciplines. Registered nurses must also have a say in staffing decisions and the environment in which they practice. The ANA also felt that cost effectiveness was important in the delivery of safe, quality care (American Nurses Association, 2012). The National Database for Nursing Quality Indicators (NDNQI) “is the only national nursing database that provides quarterly and annual reporting of structure, process, and outcome indicators to evaluate nursing care at the unit level” (Montalvo, 2007, para. 1).

Information Management

Hospital information management is in essence knowledge management along with data management systems. Hospital information management enables users to share information that meets technical, social, managerial, and economical requirements (Wadwa, Saxena, & Wadhwa, 2007). Information management began in the 1960s when Medicare and Medicaid essentially drove the health care system. At this time, computers were huge, and many times hospitals shared a mainframe to manage hospital accounting systems. In the 1970s, it became evident that computers were the future. Computers were smaller, which made it possible for each department within the hospital to have a computer. Specific departments, such as the lab and radiology, could have their own computers on which to keep information.

The 1980s brought about diagnosis-related groups, which defined a classification system that identified services the patient received directly related to reimbursement. “For the first time, hospitals needed to pull significant information from both clinical and financial systems in order to be reimbursed. At the same time, personal computers, widespread, non-traditional software applications, and networking solutions entered the market” (Grandia, n.d., para. 9). As a result, applications were created to enable financial and clinical systems to talk to each other.

By the 1990s, health care was driven by completion and consolidation. Hospitals had access to broad, distributed computing systems and robust networks, and data and reporting became integrated. The 2000s brought about the beginnings of outcome-based reimbursement. Technological advancements allowed for the installation of bedside clinical applications. As the years passed, everything became more complicated and the amount of data collected was enormous, so that information management is currently driven by accountable care organizations and value-based purchasing initiatives.

 “Knowledge gained from analyzing an organization’s data in search of performance improvement insights will complete the operational systems cycle by refining the rules essential for successful clinical decision support” (Grandia, n.d., para. 15). There is a need for quality control systems. Hospitals must now be actively engaged in strategies that result in the capture and analysis of comprehensive data. This data will enable health care organizations to become organizations that are continuously improving and learning.

Organizational Responsiveness to Change

Organizational responsiveness is a measurement of how well the health care organization is meeting “the legitimate expectations of the population for the non-health enhancing aspects of the health system. It includes seven elements: dignity, confidentiality, autonomy, prompt attention, social support, basic amenities, and choice of provider” (Darby, Valentine, Murray, & deSilva, n.d., p. 1). When change occurs in an organization, health care professionals must use their expertise to manage change. Managing change is a process that begins with evaluation, asking the question: Why is the change needed? The next step in managing change is planning the process of change. After the planning is completed, management must find competent people to undertake the tasks necessary for success. When change is needed, management can either “support it, be indifferent to it, be passive about it or participate in it. Managing change is about handling the complexity of the process. Managing change is a complex, dynamic, and challenging process” (Al-Abri, 2007, para. 2).

With change comes resistance. Health care organizations employ large numbers of professionals who may not perform as well or adapt as well to change. Employees will want to know why the change is happening and how the change will affect them. “Bringing about change requires the manager to challenge the precedent and requires perseverance against the habits and norms of established behaviors. Bringing about change takes time and requires the commitment of time on the part of the manager (Al-Abri, 2007, para. 6).

Managers can use proactive strategies in recognizing resistance to change. Anticipating resistance is important in any change management plan, as well as identification and removal of barriers. Staff need to feel competent in their ability to work with and accept change. Change does not always follow a pattern and is never predictable. Major changes can take many years to transpire. Clinical staff may view their work as a vocation as much as a profession and may be distrusting of upper management. The need for change may be obvious for organizational performance improvement, but staff can view that premise as fundamentally flawed. For change to be successful, employees must feel included on the journey.

Health care systems may require ongoing quality improvement efforts to adopt evidence-based practices that will improve health care delivery. Implementation must take place at several different levels in health care:

· Individual,

· Team,

· Organization, and

· Health care system.

Collaboration across these levels must occur for successful change.

Organizational Readiness for the Multicultural World

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Are health care organizations ready to provide equitable care in a multicultural world? Health equity is has been established when everyone has access to health care regardless of social, economic, or environmental position. In the United States, the burdens of disease and poor health and the benefits of well-being and good health are inequitably distributed (“Summary,” 2017, p. 1). Changes in the health care delivery system are required to reduce health disparities through recognition and the necessity of addressing the health care needs of a diverse population. Health disparities are variations that exist among specific population groups. Disparities can be measured by incidence, prevalence, and mortality. Disparities can also exist across many other dimensions as well, such as gender, sexual orientation, age, disability status, socioeconomic status, and geographic location. Populations that have the least access to health care suffer the greatest impact of disparities (“The State of Health Disparities in the United States,” 2017).

Health care organizations can contribute to the elimination of health disparities, both racial and ethnic, through education. An approach used to achieve cultural competence is aimed at programs that “teach about the attitudes, values, and beliefs of a specific cultural group. This approach to training proposes that cultural competence can be taught through reflective awareness, empathy, active listening techniques, and the cognitive mechanisms” (AHRQ, 2014, para. 3). Changes must occur simultaneously at the provider and organizational level.

Cultural Competency of Staff

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Cultural competence is integral to how health care organizations provide health care. The AHRQ (2014) defines 

culturally competent care

 as “care that respects diversity in the patient population and cultural factors that can affect health and health care, such as language, communication styles, beliefs, attitudes, and behaviors” (para. 1). Staff must be able to relate to a multicultural patient population with cultural and social needs in addition to their need for equitable health care. The nurse leader must seek opportunities to improve the diversity among health care workers and act upon those opportunities to develop diversity among the staff, as well as develop cultural competency among the staff. The nurse leader can take the opportunity to encourage a diverse culture that is knowledgeable about providing health care to an equally diverse population. Greater diversity among health care workers may improve cultural competence through the utilization of training provided by health care organizations. Nurse leaders now ensure that training is provided to improve cultural competence in the health care organization.

It is important that health care workers are informed about their role in providing culturally competent care and it is the responsibility of organizations to provide the tools and education needed by workers to meet the challenges of a diverse patient population.

When patients feel heard and understood by their healthcare providers, they are more likely to participate in preventive healthcare and less likely to miss health appointments. This can reduce medical errors and related legal costs for healthcare facilities, and it can improve health outcomes for patients. Ultimately, a culturally competent organization can help reduce health disparities among patient populations. (Medcom Trainex, 2018, para. 10)

Research has found that the “cultural competence of the healthcare staff was associated with the cultural competence of the leaders” (Dauvrin & Lorant, 2015, p. 200).

Future Organizational Challenges and Opportunities

Quality health care is one of the most important factors in how individuals perceive their quality of life. In some countries, health care is a major political issue, along with the economy. Globally, all health economies are facing similar challenges (CGI, 2014). Because advances in technology are helping people to live longer and health care costs have been rising steadily, there has been an increasing demand for changes to health care delivery in the United States. Organizations face many challenges while learning to adapt to a rapidly changing health care environment.

Health care organizations are employing technologies, such as electronic medical records and databases, to support the collection of voluminous health information. Value-based purchasing requires health care providers to understand the importance of discharge planning and care transition. Leadership must work closely with, and confront the challenges of, population health management, data analytics, and acquiring and implementing the right technologies. Organizations confront challenges posed by a more consumer-driven system in which they “demand greater transparency, better communication, and more information about value” (Appold, 2016).

A culturally competent health care system is one that can acknowledge the importance of culture as it reflects on the dynamics of the organization. This can be demonstrated by the cultural knowledge of the staff. The organization and its leaders must recognize the importance of being culturally diverse in the services and care provided. The organization must also acknowledge that a culturally competent system is “built on an awareness of the integration and interaction of health beliefs and behaviors, disease prevalence and incidence, and treatment outcomes for different patient populations” (Betancourt, Green, Carrillo, & Ananeh-Firempong, 2003, p. 294).

Health care organizations are facing an uncertain future. The journey that began in 2010 with The Patient Protection and Affordable Care Act (ACA) to a value-based health care system will continue. People are now responsible for a larger portion of health care costs and organizations must find new ways to operate. Organizations were used to collecting money from insurance companies and the government, namely Medicare and Medicaid services. With consumers now paying part of the bill, health care is becoming more patient-centered and consumers of health care have higher expectations from providers (Ellis, n.d.). Patients have become more responsible for their own health outcomes.

Innovation

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As health care evolves, so must the providers of health care. The Mayo Clinic in Rochester, Minnesota, has been a revolutionary trendsetter. In 2008, the organization created The Mayo Clinic Center for Innovation, the first innovation center for health care in the United States, which employs teams that are responsible for ensuring “the needs of the patient come first” (Beck, 2000, para. 1). This new innovative health care delivery system employs teams of clinicians, staff members, information technology specialists, and patients that turn innovative ideas into practical solutions. Changes include provider video visits, e-consults, and even a new type of clinical examination room. Mayo Clinic is developing in-home monitoring, patient-driven appointments and online communities (Bhatti, del Castillo, Olson, & Darzi, 2018, para. 6).

Many health care organizations acknowledge the importance of providing culturally competent care to diverse populations across the United States.

Research has shown that when nurses understand the culture and history of a patient’s community, communication and trust are improved. Patients feel more confident in the care they are receiving when their caregiver can relate to them culturally or ethnically. (Hancock, 2017, para. 1)

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In its report on the future of nursing, the IOM (2011) stressed the need for a diverse workforce to achieve health care equality. Nurse leaders can encourage the development of a more culturally diverse and culturally competent staff. “Organizations with an inclusive culture that encourages collaboration, flexibility and fairness as well as equal participation are more successful in employee engagement and retention” (Hancock, 2017, para. 9). Organizations that offer diversity training and seek opportunities to engage underrepresented groups improve organizational performance and culture.

Massachusetts General Hospital Center in 2012 began the Consortium for Affordable Medical Technologies (CAMTech). This innovative design brought together a multidisciplinary team consisting of health care professionals and nonhealth care professions to “co-design novel solutions to US and global health challenges through hackathons, awards programs, and business acceleration activities. CAMTech is an open innovation platform now involving a network of over 4,300 engineers, clinicians, entrepreneurs, and designers from over 700 organizations” (Bhatti et al., 2018, para. 8). A hackathon involves hundreds of specialists working together over a 48-hour period to tackle one problem. In 2016, the hackathon revolved around the “opioid crisis, which resulted in 18 innovation proposals. One hackathon led to the development of the Augmented Infant Resuscitator, an inexpensive add-on to ubiquitous bag valve masks, that dramatically improves how birth attendants provide newborn ventilation” (Bhatti et al., 2018, para. 9). It is innovations such as these that will transform health care.

Role of the Nurse Leader (Synergy Model)

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As organizations evolve, health care leaders must evolve as well. The synergy model for patient care is one that takes the patient’s needs and matches them with the competencies of the nurse. Most patients have similar needs, but at times, specialized nursing care is needed.

The dimensions of a nurse’s practice are driven by the needs of a patient and family. This requires nurses to be proficient in the multiple dimensions of the nursing continuums. When nurse competencies stem from patient needs and the characteristics of the nurse and patient synergize, optimal patient outcomes can result. (American Association of Critical Care Nurses, n.d., p. 1)

There are various assumptions that guide the synergy model. Assumptions are made that nurses care for the whole patient—body, mind, and soul. Each patient has a number of characteristics or “interrelated dimensions,” as does the nurse. The goal of the nurse is to care for the patient; as the patient wishes, either back to a state of wellness or to a peaceful death. Each patient, nurse, provider, or health care organization is unique and brings with it characteristics that span the health care continuum. There are eight characteristics that make up the synergy model (see Table 5.2).

Table 5.2

Synergy Model Characteristics

Note. Adapted from “The AACN Synergy Model for Patient Care,” by the American Association of Critical Care Nurses, p. 1.

Nurses are an integral part of the health care system and possess the skills, knowledge, and attitudes to provide patient-centered care in any setting, whether it be an acute care hospital or the patient’s home. A nurse’s characteristics in the synergy model (see Figure 5.7) are based off of the patient’s needs and the nurse’s expertise, which can range from novice to expert. Under the synergy model, there are five levels of competency from competent to expert in eight different categories.

Figure 5.7

Synergy Model

Note. Adapted from “The AACN Synergy Model for Patient Care,” by the American Association of Critical Care Nurses, pp. 2-3.

Nurse Leader: The Risk Taker

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There are many challenges facing nurse leaders in the current health care environment. To be responsible to the health care organization, nurse leaders must focus on staff providing quality care while meeting productivity and quality indicators. Leaders and managers have always focused on care delivery, but now they must focus on the outcomes of delivery provided. Nurse leaders must recognize the importance of implementing evidence-based practices and evaluating their effectiveness as it relates to patient outcomes and safety. The health care environment has been emphasizing safety and evidence-based decision making, which discourages innovation and risk taking. Having the courage in leadership to take risks can be difficult, but it plays a role in effective management (Sherman, 2014).

There are several key leadership behaviors that foster risk taking and innovation in health care. Leaders should be able to call out bad behavior and have difficult conversations. Staff who are best for the position should be in the position based on competency, not personality. Nurse leaders should do what is right and not what is easy. The organization’s mission and vision should be considered when difficult decisions must be made. Patients should always come before profits, which is difficult in this value-based reimbursement environment.

Fear plays a big role in why leaders are often unwilling to take risks. Risk taking is a learned skill, and stepping out of one’s comfort zone is taking the risk (Sherman, 2014). Innovation in nursing fosters the creation of new knowledge, which begins to elevate nursing practice.

Nursing Leadership

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Transforming the current health care system to meet the demands for safe, quality, and patient-centered care has demanded a shift in the role of nurse leaders. Historically, “nurses could not participate fully due to a variety of cultural, regulatory, and policy barriers that limited the nurse’s ability to effectively contribute to broad, meaningful change are now being called to lead” (Petersen, n.d., p. 40). Presently, the health care system is fragmented and inefficient, pointing to the fact that America spends more on health care than any other country in the world. There exists a lack of insurance, inconsistency in quality, and excessive administrative waste. With the advent of the IOM (2011) report, 
The Future of Nursing: Leading Change, Advancing Health, nurses’ roles and responsibilities have been redefined to meet the needs of an evolving health care system (Petersen, n.d., p. 45).

Nursing leadership emphasizes nursing practice and improvement of health outcomes while ensuring patient safety. The nurse leader as a systems thinker must look beyond the “name, blame, shame
” approach to patient safety and toward focusing on human factors of how care is delivered within a less-threatening environment. Systems thinking looks at large numbers of interactions to gain understanding to help leaders target innovation efforts more effectively (Petersen, n.d., p. 60). Nurse leaders are stepping up and using knowledge and expertise to contribute new innovative strategies to engage in health care reform.

Nurse Leader: Clinical Inquiry

Clinical inquiry is the practice of asking questions about nursing practice. Clinical inquiry can be used for quality improvement, research, and formulating evidence-based practices. Nurse leaders may investigate issues that lead to improved delivery of care or nursing practice. There are many reasons why questions are asked and why answers are needed. “Quality improvement (QI) is a systematic, formal approach to the analysis of practice performance and efforts to improve performance” (American Academy of Family Physicians, n.d., para. 1). Whereas research is a systematic investigation performed to answer a question or investigate a hypothesis, evidence-based practice is the integration of clinical expertise and scientific evidence (results of research) that is implemented into practice to provide medications, treatments, or procedures to care for patients. Clinical inquiry is the combination of quality improvement, research, and evidence-based practices, which nurse leaders use to ensure that patients are receiving quality patient-centered care. Clinical inquiry is not exclusive of nursing but involves interdisciplinary collaboration.

Quality Improvement History

To Err Is Human: Building a Safer Health System

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In 1999, the IOM published a report 
To Err Is Human: Building a Safer Health System. The report found that health care in the United States was not safe. The report stated that as many as “98,000 people die in hospitals each year as a result of medical errors that could have been prevented, according to estimates from two major studies” (IOM, 1999, p. 1). The report also stated that errors that occurred were the result of a failure to safely complete a task, such as “adverse drug events, improper transfusions, surgical injuries and wrong-site surgery, suicides, restraint-related death, falls, burns, pressure ulcers, and mistaken patient identities” (IOM, 1999, p. 1).

Errors were costly to the organization and left patients feeling unsafe. Patients would see multiple providers, have hospitals stays and surgical procedures, but there was no form of communication between providers or between providers and health care organizations. Contributing to the occurrence of errors was the fact that no one had complete information. Taking everything into account, the IOM came up with four strategies it believed would build a healthier health care system:

· Establishing a national focus to create leadership, research, tools, and protocols to enhance the knowledge base about safety.

· Identifying and learning from errors by developing a nationwide public mandatory reporting system and by encouraging health care organizations and practitioners to develop and participate in voluntary reporting systems.

· Raising performance standards and expectations for improvements in safety through the actions of oversight organizations, professional groups, and group purchasers of health care.

· Implementing safety systems in health care organizations to ensure safe practices at the delivery level. (IOM, 1999, pp. 3-4)

So began the quest for continuous quality improvement. President Bill Clinton’s administration issued executive orders instructing government agencies to conduct or oversee health care programs to implement proven techniques for reducing medical errors and creating a task force to find new strategies for reducing errors. Congress soon launched a series of hearings on patient safety and, in December 2000, it appropriated $50 million to the AHRQ to support a variety of efforts targeted at reducing medical errors (IOM, 1999).

Crossing the Quality Chasm: A New Health System for the 21st Century

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In 2001, the IOM published 
Crossing the Quality Chasm: A New Health System for the 21st Century, which discussed “how the health system can be re-invented to foster innovation and improve the delivery of care. Toward this goal, the committee presented a comprehensive strategy and action plan for the coming decade” (IOM, 2001, p. 2). The IOM’s vision included six aims for improvement that defined how health care organizations could change:

· 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.

· 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 both those who receive and those who give care.

· Efficient: avoiding waste, including waste of equipment, supplies, ideas, and energy.

· Equitable: providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status. (IOM, 2001, p. 3)

In order to be able to achieve these aims, the IOM put together a set of 10 rules to use in order to redesign the health care system:

1. Care is based on continuous healing relationships. Patients should receive care whenever they need it and in many forms, not just face-to-face visits. This implies that the health care system must be responsive at all times, and access to care should be provided over the Internet, by telephone, and by other means in addition to in-person visits.

2. Care is customized according to patient needs and values. The system should be designed to meet the most common types of needs, but should have the capability to respond to individual patient choices and preferences.

3. The patient is the source of control. Patients should be given the necessary information and opportunity to exercise the degree of control they choose over health care decisions that affect them. The system should be able to accommodate differences in patient preferences and encourage shared decision making.

4. Knowledge is shared and information flows freely. Patients should have unfettered access to their own medical information and to clinical knowledge. Clinicians and patients should communicate effectively and share information.

5. Decision making is evidence-based. Patients should receive care based on the best available scientific knowledge. Care should not vary illogically from clinician to clinician or from place to place.

6. Safety is a system property. Patients should be safe from injury caused by the care system. Reducing risk and ensuring safety require greater attention to systems that help prevent and mitigate errors.

7. Transparency is necessary. The system should make available to patients and their families information that enables them to make informed decisions when selecting a health plan, hospital, or clinical practice, or when choosing among alternative treatments. This should include information describing the system’s performance on safety, evidence-based practice, and patient satisfaction.

8. Needs are anticipated. The system should anticipate patient needs, rather than simply react to events.

9. Waste is continuously decreased. The system should not waste resources or patient time.

10. Cooperation among clinicians is a priority. Clinicians and institutions should actively collaborate and communicate to ensure an appropriate exchange of information and coordination of care. (IOM, 2001, pp. 3-4)

The IOM has been instrumental in reinventing and redesigning the health care system. Much of what is done today was foreseen in the IOM’s papers from 1999 and 2001. The information found in 
To Err Is Human and 
Crossing the Quality Chasm is still being followed today to fix a broken health care system. Nurse leaders are tasked with the important role of reengineering health care, as well as implementing change and innovation.

Deming’s Total Quality Management

After World War II, William Edwards Deming, an engineer, statistician, and professor, developed 14 key principles for management called total quality management (TQM). TQM is an “organizational approach involving organizational management, teamwork, defined processes, systems thinking, and change to create an environment for improvement. This approach incorporated the view that the entire organization must be committed to quality and improvement to achieve the best results” (Hughes, 2008, para. 8). “Dr. Deming offered 14 key principles for management to follow to significantly improve the effectiveness of a business or organization. Many of the principles are philosophical. Others are more pragmatic. All are transformative in nature” (“Dr. Deming’s 14 Points for Management,” n.d., para. 1). Deming’s 14 principles are as follows:

1. Create constancy of purpose toward improvement of product and service, with the aim to become competitive and to stay in business, and to provide jobs.

2. Adopt the new philosophy. We are in a new economic age. Western management must awaken to the challenge, must learn their responsibilities, and take on leadership for change.

3. Cease dependence on inspection to achieve quality. Eliminate the need for inspection on a mass basis by building quality into the product in the first place.

4. End the practice of awarding business on the basis of price tag. Instead, minimize total cost. Move toward a single supplier for any one item, on a long-term relationship of loyalty and trust.

5. Improve constantly and forever the system of production and service, to improve quality and productivity, and thus constantly decrease costs.

6. Institute training on the job.

7. Institute leadership. The aim of supervision should be to help people, machines, and gadgets to do a better job. Supervision of management is in need of overhaul, as well as supervision of production workers.

8. Drive out fear, so that everyone may work effectively for the company.

9. Break down barriers between departments. People in research, design, sales, and production must work as a team, to foresee problems of production and in use that may be encountered with the product or service.

10. Eliminate slogans, exhortations, and targets (silos) for the work force asking for zero defects and new levels of productivity. Such exhortations only create adversarial relationships, as the bulk of the causes of low quality and low productivity belong to the system and thus lie beyond the power of the work force.

a. Eliminate work standards (quotas) on the factory floor. Substitute leadership.

b. Eliminate management by objective. Eliminate management by numbers, numerical goals. Substitute leadership.

11. Remove barriers that rob the hourly worker of his right to pride of workmanship. The responsibility of supervisors must be changed from sheer numbers to quality.

12. Remove barriers that rob people in management and in engineering of their right to pride of workmanship. This means, inter alia, abolishment of the annual or merit rating and of management by objective.

13. Institute a vigorous program of education and self-improvement.

14. Put everybody in the company to work to accomplish the transformation. The transformation is everybody’s job. (“Dr. Deming’s 14 Points for Management,” n.d., paras. 5-18)

Deming’s principles can be followed by nurse leaders to understand what is needed to transform health care delivery and to provide quality care by competent nurses. Quality improvement is the key to change and innovation. Health care is currently taking data and transforming the results into opportunities for improvement. Deming believed in education, and nurses are currently returning to school to obtain baccalaureate, master’s, and doctoral degrees. Nurse leaders must engage and empower nurses in quality care delivery. Improvement is a process over time. Deming believed if the workers were engaged in the process, they would then be able to effect change.

Quality Improvement

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Quality improvement

 is a way for health care organizations to “ensure the most current, clinically proven techniques and practices are being put into place to deliver the safest and highest quality care” (American Health Quality Association, 2017, para. 2). This is accomplished through the collaborative efforts of health care providers and health care organizations. Quality improvement occurs as a result of the collection and analysis of quality indicators, patient health records, and patient satisfaction surveys, so areas for improvement can be identified. One necessary practice for health care organizations is to ensure a culture of quality by developing multidisciplinary teams that meet regularly to discuss the results of data that have been collected and analyzed.

“Developing meaningful measures of overall health system quality, and how it is changing, requires a combination of indicators that can reliably show how the system—which includes providers, payers, and public health—is influencing the health of the population” (Claxton, Cox, Gonzales, Kamal, & Levitt, 2015, para. 7). It is important that health care organizations provide quality care because it is a vital service to people. Most people do not understand all of the complexities of health care, so people put their lives into the hands of health care professionals and health care organizations. Nurse leaders have the responsibility of leading and managing their teams to provide safe, quality, patient-centered health care and continuous quality improvement. The quality improvement process involves several basic concepts (see Figure 5.8).

Figure 5.8

Quality Improvement Process

Note. Adapted from “Basics of Quality Improvement,” by the American Academy of Family Physicians, located on the academy’s website.

Model for Improvement

Nurse leaders understand the importance of continuous quality improvement to increase efficiency and improve patient outcomes. Quality improvement begins with the establishment of a culture based in transparency and continuous evaluation of nurse-sensitive quality indicators and clinical outcomes. The model for improvement was developed by Associates in Process Improvement (API). It is a simple, yet powerful tool for accelerating improvement (IHI, n.d.b). The IHI combined the total quality management tool and the plan-do-study-act cycle (PDSA) into the model for improvement.

The first step is to select the right people to establish teams. “A process improvement team is critical to a successful improvement effort. Teams vary in size and composition” (IHI, n.d.b, para. 3). Health care organizations build teams based on the process that needs improvement. After the teams are formed, goals are set, and the team determines what it is trying to accomplish and what process needs to be improved. The goal should be measurable and time-specific. Teams use quantitative measures to determine whether a specific change led to improvement. A change must be made that will result in improvement. The change is implemented on a small scale for evaluation using the PDSA cycle.

The change will be planned, tried, and observed, and actions will be taken depending on what was learned. This is action-oriented learning (IHI, n.d.b). After testing the change to see if it was successful, it can be brought to the entire organization and improvements can be made. By analyzing the data and finding areas for improvement, teams can use the model for improvement to find processes that can be implemented for quality improvement.

Reflective Summary

The nurse leader has a major role in reengineering health care. They act as change agents by developing strategies for quality improvement. The nurse leader strives to contribute positive changes to the profession of nursing to improve patient outcomes. The nurse leader is an important part of the health care organization. This chapter has examined the different types of organization and the different strategies used to meet the goals of nursing leadership within a health care organization to be able to provide a safe environment for patients. Quality improvement is especially important to health care organizations because the communities they serve expect the very best that health care has to offer. In this age of information, people are aware of the quality of care provided by the health care organizations in their community. The expectation is one of safe, patient-centered care for themselves and their families. Nurses and their leaders must continue to impact health care delivery and work within health care organizations to be major contributors to quality improvement.

Key Terms

Accountability: Being morally responsible for actions and professional conduct and accepting ownership of those actions.

Bureaucratic Organization: A form of management that has a pyramidal command structure.

Classical Organizational Theory: Scientific approach to management developed by Frederick Taylor.

Clinical Decision Making: A contextual, continuous, and evolving process, in which data are gathered, interpreted, and evaluated in order to select an evidence-based choice of action.

Closed System Organization: An organization that has limited or no interaction with the outside environment. Everything that is produced stays within the organization, such as information or a production-line item.

Communication: Interpersonal sharing of information and/or feelings are exchanged in verbal and nonverbal methods.

Continuous Quality Improvement: The ongoing efforts of organizations, including groups and individuals, working in and with the organizations to improve services or products to meet the needs of customers.

Coordination: Ensuring the overall design of the team efficiently produces increased productivity and positive patient outcomes.

Culturally Competent Care: Care that respects diversity in the patient population and cultural factors that can affect health and health care, such as language, communication styles, beliefs, attitudes, and behaviors.

Delegation: The use of personnel to accomplish a desired task by allocation of responsibility and authority under the guidelines set forth by regulating health care boards at the state and national level.

Evaluation: The assessment or reassessment of a particular person or group, task, or performance that determines the efficiency or inefficiency of a particular process.

Mission Statement: Stated organizational purpose that is recognized and integrated into professional practice.

Open System Theory: Good internal and external environment exchange of information and feedback in order to promote positive change and meet the needs of stakeholders locally, regionally, nationally, or even globally.

Organization: A group of people working together to accomplish common goals.

Organizational Processes: Processes, including planning, decision making, delegation, coordination, communication, and evaluation, that have a direct effect on employee engagement and organizational culture.

Patient Safety: The prevention of harm to patients.

Quality Improvement: A systematic and formal approach to collecting, analyzing, and disseminating data in order to improve services or products that a business renders.

Quality Indicators: Standardized, evidence-based measures of health care quality that can be used with readily available hospital inpatient administrative data to measure and track clinical performance and outcomes.

Shared Governance: A partnership between bedside nurses and nursing managers and leaders that involves decision making and empowers nurses by giving them a voice.

Systems Theory: A management theory that views the organization as either an open system or a closed system.

Therapeutic Communication: Use of communication skills that convey a sense of trust and respect in order to understand the patient’s needs

Vision Statement: A clear declaration of the organization’s goals.

Workflow: The process an organization uses to complete tasks to accomplish a given goal.

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Class Resources:

Nursing Leadership and Management: Leading and Serving

Read Chapter 5 in Nursing Leadership and Management: Leading and Serving.

Running head:

Health Organization Evaluation

1

2

HEALTH ORGANIZATION EVALUATION

Health Organization Evaluation

Student Name

Grand Canyon University: NRS 451

Date

Health Organization Evaluation

Provide a brief introduction of what you will be writing about within the body of the paper. This paragraph should include a thesis statement.

Healthcare Organization

Describe the health care organization or network.

Organization Readiness

Describe the organization’s overall readiness based on your findings.

Strategic Plan

Prepare a strategic plan to address issues pertaining to network growth, nurse staffing, resource management, and patient satisfaction.

Theory/Model

Propose a theory or model that could be used to support implementation of the strategic plan for this organization. Explain why this theory or model is best.

Conclusion

Provide a brief conclusion paragraph that describes what was discussed in the body of the paragraph. The word count for this assignment is 1,000-1,250.

REFERENCES – should be on a separate page, and in APA format

Sources must be published within the last 5 years and appropriate for the assignment criteria and relevant to nursing practice.

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Healthcare organi7.ations are one of society’s most important institutions. The high

standards expected of such organizations and the effective delivery of health services necessitate

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the importance of proper management and strategic planning. Ha ltha rc systoru play I vrta l

role in ensuring prcvmtion. treatment , amJ the provis ion or mcJ,cal ICfVtea 10 111 mcmbcn of

the public, H well as cootmunity development. An 1n1ly•is of Banner healt h indicatc, 1h1t the

valuc.OOscd reimburscml-nl model nxlu ccs hc:ahhcuc cos1.1 while imrruving health oulcoma .

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Banner llcalth, headquartered in Phom ix , Arizona, is one of the lu 11ost non-profi1

organizations in the United States. This healthcare organization supcrvisa 29 hcalthain:

facilities in Colorado, Wyoming. California, Nevada. Nebraska, and Arizona, including hospitals

and specialized facilities like long-icrm healthcare faciliti~ . Home ca.re init ia tives and family

medical centres (Bann

Lutheran Health Systems and Samaritan Health Systems”. Banner Health currently employs over

47,000 people and scrvc, over 300,000 patients (Bcrlyl Institute, n.d.), covering basic medical

and emergency healthcare costs, Besides, this nonjKUfit organization has covered specialized

healthcare services like psychosocial and rehabilitative service.,. bone marrow transplants and

heart, and lifc-lhrcatcning hcalthcarc complications such as Alzheimer’s disease and spinal cord

injuries.

For an cxlcndcd period, Banner Health has centered its resources on giving qual ity and

safe care, which involves cs1ablishing stria measures 10 identify errors like mistaken patienl

identity. which can inhibit quality service delivery. Banner Health is primarily committed to the

organization’s mission of providing its service users with easy access to health care 10 improve

Banner Health is a non–profit organization that. rather than gcnL-rating profits.

provides essential healthcare services to populations. As a rcsull. every money Banner Health .
receives is invested in technologies, new medical services, hospital beds, employee salaries. and

facility and equipment maintenance.

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Banna Health has been quick lo adopt models ofvaluo-based repayment. This

implementation is pan of the readiness of the institution to meet the various health care need of

all the patients over the following ten year.;. Instead of such reimbursement models rewarding

volume. it rewards value. By shifting a significant amount of clinical and financial risk from

suppliers to payer.., they can help reduce high costs while increasing effectiveness, r,:sulting in

advancements in care qualiry. Such recognized programs focus on cost, efficiencies, p<>pulation

health management tactics, quality. and manber engagement.

Health systems arc shifting from volume to value reimbursements to prioritize the patient

(Oakes & Radomski, 2021 ). For health organizations and networks such as Banner Health, tbe

problem of worth is driven by the goal of lowering insurance premiums while boosting overall

Health and continuing to pursue continuous improvements in quality.

The health care cost, inside and outside the hospital setting, has been rising; it has grown

exponentially and now accounts for a sizable portion of Medicare expenses. In this regard.

various hcalthcan, systems have been tasked with devising new method< of providing effective,

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timely, safe, dependable, and reliable care. The basic idea of healthcare organizations~ on

population health. like Bunner Health, is to shift from a transaction-Oriented organization design

framework and way of thinking of paying people more for performing more to a comprehension

that the organization is accountable for the entire their pat ients’ core “Notional Academies of

Sciences, Engin~’Cring, and Medicine” (NASEM, 2018). Banner Health has taken a method

which involves the invention of many Imitation games that operate as sites for testing

innovatively fresh thoughts on numerous methods of delivering services that satisfy the

requirements of its service users to~ the shift of culture from value to volume.

Strategic Plan

Banner Health has implemented a process of strategic planning that considers the

atient’s satisfaction, owth, mana ement of the resource, and nurse staffin . Due to

the increasing population’s healthcare needs, Banner Health aims to build new buildings to meet

Americans’ future und current health needs (~. 2021 ). The organization’s strategic goal

is to establish full medical facilities that serve patients and their families effectively. The areas

across the country arc expanding rapidly, and Banner Health plans to make sure that its service

users under its care have easy access to health care whenever they need it.

Banner Health has taken a staffin
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healthcare services in tenns of nurse staffin

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how critical the nursin staff is in runnin the or nization, resultin in a better atient outcome.

Nurses have long been regarded as the foundation of excellent care for the patient. Banner Health

recognizes its unselfish role in providing the safest and best possible care for all service users at

every moment. The a enc is attem tin to k
atient-to-nurse ratio b doin this,

hence reventin nurse burnout and tent ial adverse effects on atients.

Furthermore, Banner Health is introducing innovative programs and strategies to increase

positive patient outcomes, allowing patients to start sharing their healthcare experiences.

used telemcdicine to enable interactions between h sicians and atients re rdless of distance.

to im rove efficienc , these tech no lo · es have been

shown to im rove rsonal communication strate ies. The

organization’s asset management is related to the allocation of cost-effective care. Banner Health

believes that effective papulation health management plans will result in a better healthcare

transformation system, such as enhanced services and better services at lower costs. As a result,

these chan es would vastl im ve resource mana ement and utilization in h itals and

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The organization’s asset management is related to the delivery of cost-<:fT«.1 i,-., care.

Banner Health believes that efTccii ve papulation heallh management plans wi ll result inn better

healthcare transfonnution system, like enhanced services und better scrvicn 11 lower co.ls. As a

result, these chungcs would vastly improve resource mun1gcmo:n1 and ut ili1..01ion in hospitals 011d

It is critical to n…:ognizc that 00111-baS<.-d stra tegic plunn inw bcKh'" wilh nn institution',

mission statcment or main objcc1ivc 011d then creates on action plan to achieve those objcciivc,

eta/., 2021). Bunner Hcnlth will be ublc todcfinc its ubjcx.1ivcs •• wcll llJI diffa-cn l

strategics to achieve the identi fied objectives by u1ing the goal-bnoeJ stmlcgic planning model,

which includes th OSCl held to a•..:ount for their execution as well as the resources requ ired.

Conclullon

Bunner Health, the leading non-profit healthcurc sy1tcrn in the United Slates, has made

critical strategic modifications to provide COllt-<:ffcctivc and quality care to its patient, over the

coming decades. Banner Health ha• moved its reimbursement model to valuo-baM:d from

pcrfonnance-bascd to reduce hcallhcarc costs while improving health outcomes. Banner Health

has strived to be a national leader in the healthcare industry by continuously improving its

network’s patential growth, nurse staffing, patienl satisfaction, and resource management.

References

Alshourah, S. (2021 ). Total quality management practices and their effects on the quality

pcrfonnance of Jordanian private hospitals. Management Science lellers, 1 /(I), 67-76.

http://growlngscience.com/msl/Volll/msl_2020_292

Banner Health. (n.d.). https://www.bannerhealtb.com/about/glan«thistory

Berlyl Institute (n.d.). Ba11ner Health: Best practices in leadership an exceptio11a/ patient

experience. https://www.tbeberyUnstltute.org/page/CASE1220IO

Deguest, R., Martellini, L, & Milhau , V. (2021 ). Goal-based Jnvesti11g: 7neorv and Practice.

https://www .worldsdentlflc.com/dol/pdf/1 0.l l 42/9789811240959 _ 0001

National Acadcmics of Sciences, Engineering, and Medicine. (2018). Models and Strategies To

Integrate Palliative Care Principles into Care fer People with Serious Illness:

Proceedings of a Workshop. Washington DC: National Academics Press Health

Organization Evaluation Essay.

6

Oakes, A. H., & Radomski, T. R. (2021 ). Reducing low-value care and improving health care

value. JAMA, 325(17), 1715-1716.

https:/lwww.europeanallianceforvalueinbealtb.eu/wp-

content/uploads/2021/04/JAMA-Reduclng-Low-Value-Care-and-lmproving-Heaith-

Care-Value

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I Web Corm,nt. ilt!p.,Jfu_.,,.:J,uulii=ll!rawt<.1/ll;,;,o.l.lll,: .

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