- Email: [email protected]
The Quality Burden
T h e Qu a l i t y B u rd e n Joanne Disch,
PhD, RN
a,
*, Marie Sinioris,
MPH
b,c
KEYWORDS Barriers to quality Quality improvement Factors affecting quality improvement Safe patient care Quality reporting Barriers to patient safety Patient safety KEY POINTS Achieving quality care is a national priority, and substantial efforts have been put in place to accomplish this. The quality burden is a phenomenon that compromises the quality and safety of health care. Attention must be paid to recognizing its extent and to identifying and implementing strategies for lessening its impact.
While the cost of care has become a major focus of attention in pursuing quality patient care, and significant investments have been made in quantifying these costs, little recognition has been given to the costs of the quality improvement (QI) efforts themselves: the time, energy, infrastructure, and emotional stress associated with documenting, monitoring, reporting, implementing, and evaluating quality indicators and initiatives. This article describes an emerging phenomenon, the quality burden, which is significant in size and impact although often hidden and unmeasured, and which accompanies ongoing efforts to improve the quality and safety of health care. Recommendations are given to mitigate the impact of the quality burden in delivering care and improving quality and safety. THE PURSUIT OF QUALITY
Since the publication of To Err is Human by the Institute of Medicine (IOM),1 dozens of organizations and hundreds of initiatives have emerged to improve the quality of health care. The Minnesota Hospital Association developed a diagram in 2004 to reflect the numerous players in QI at that time; since then, many others have emerged (Fig. 1). In addition to traditional regulatory agencies such as The Joint Commission, a
University of Minnesota School of Nursing, 308 Harvard Street Southeast, Minneapolis, MN 55455, USA; b Health Systems Management, Rush University, 1653 W Congress Expressway, Chicago, IL 60612, USA; c National Center for Healthcare Leadership, 1700 W Van Buren, Chicago, IL 60612, USA * Corresponding author. E-mail address: [email protected] Nurs Clin N Am 47 (2012) 395–405 http://dx.doi.org/10.1016/j.cnur.2012.05.010 nursing.theclinics.com 0029-6465/12/$ – see front matter Ó 2012 Elsevier Inc. All rights reserved.
396
Pursuing Perfection
Institute for Health System Improvement
Breakthrough Services
Standup for Patient Safety
Patient Safety Awareness Week
Foundation for Accountability ( FAACT)
National Quality Forum
National Patient Safety Efforts
National Patient Safety Foundation
Patient Safety Congress
The Leapfrog Group
Quality First for Long-Term Care
Research Program
Clearinghouse on Consumers Activation
Leapfrog: Rewarding Results
qualityhealthcare.org
Disch & Sinioris
Public Hospital Survey
National Center for Patient Safety
NQF 27 Events
30 Safe Practices
Health Plan Report Card
National Committee for Quality Assurance (NCQA)
Diabetes Physician Recognition Program
JCAHO
Institute of Medicine (IOM) AHRQ
Partnership 4 Patient Safety
Patient Safety Standards To Error Is Human
Patient Safety Goals Quality Chasm Report
HCUP
National Health Care Quality Report Patient Safety Improvement Corps
Fig. 1. National patient safety efforts. (Reprinted from Minnesota Hospital Association, 2004; with permission.)
The Quality Burden
various federal offices, state departments of health, and professional societies such as the American Heart Association and the American Academy of Pediatrics, several agencies targeted specifically at QI have stepped up their efforts to guide, direct, measure, and report on the provision of health care. Prominent organizations include: Quality Improvement Organizations (QIOs). Formerly known as peer-review organizations, these are private, usually not-for-profit organizations consisting of health care professionals who are trained to review health care. The Center for Medicare and Medicaid Services (CMS) contracts with one organization in each state, as well as the District of Columbia, Puerto Rico, and the US Virgin Islands to serve as that state/jurisdiction’s QIO.2 QIOs (1) help Medicare beneficiaries if they have complaints and (2) implement improvements in the quality of care available throughout the spectrum of care. The National Quality Forum (NQF). The NQF is a nonprofit organization comprising a variety of stakeholder groups and individuals, aimed at building consensus on national priorities and goals for performance improvement; developing and endorsing national consensus standards for measuring and publicly reporting on performance; and promoting the attainment of national goals through education and outreach programs.3 The National Committee for Quality Assurance (NCQA). The NCQA is a private, not-for-profit organization dedicated to improving health care quality by developing quality standards and performance measures, reporting of performance against these measures, and raising the visibility of quality performance through its accreditation, certification, and recognition programs.4 The Institute for Healthcare Improvement (IHI). The IHI is an independent, not-forprofit organization aimed at “motivating and building the will for change; identifying and testing new models of care in partnership with both patients and health care professionals; and ensuring the broadest possible adoption of best practices and effective innovations.”5 The Nursing Alliance for Quality Care (NAQC). The NAQC is a partnership among the nation’s leading nursing organizations, consumers, and other key stakeholders to “advance the highest quality, safety, and value of consumer-centered health care for all individuals-patients, their families, and their communities.”6 Other organizations have developed national recognition around models of QI that stimulate competition for these prestigious awards, such as the Malcolm Baldrige Performance Excellence Award given by the National Institute of Standards and Technology, a section of the US Department of Commerce7; and the John M. Eisenberg Patient Safety and Quality Award, given by The Joint Commission and the NQF.8 Most organizations and award programs aimed at improving quality are evidence based and require collecting, organizing, and reporting data against a set of criteria. One with particular relevance to nursing is the National Database of Nursing Quality Indicators (NDNQI), a proprietary database of the American Nurses Association (ANA) that collects, evaluates, and provides comparative data on unit-specific, nurse-sensitive data from hospitals in the United States for QI purposes.9 In addition, there are organizations collecting and reporting data to the public for more informed decision making and accountability, such as CMS (with its Hospital Compare program that provides consumers with information on hospital performance and recommended patient treatments)10; and the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, the first national, standardized, publicly reported survey of patients’ perspectives of hospital care, including nursingsensitive indicators available for national benchmarking for the first time.11 Finally,
397
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most states are also launching comprehensive reporting programs, such as in Minnesota (the Statewide Quality Reporting and Measurement System)12; the California Hospital Assessment and Reporting Taskforce (CHART) with its CalHospitalCompare.org Web site13; and Massachusetts (Massachusetts Health Quality Partners).14 While many of these initiatives are helpful, the sheer number of them has escalated, and health care leaders feel tremendous pressure to demonstrate acceptable performance against a growing number of benchmarks, whether they be legally mandated or competitively chosen. Richard Bankowitz, Premier’s medical director, estimates that the average hospital reports about 70 measures per quarter,15 but those are only reports to Premier. Estimates from health care leaders indicate that the number of indicators tracked range from 100 to several hundred.16,17 One chief quality officer acknowledged that their organization, an inner-city level 1 trauma center, tracks more than 1800 indicators (Hitt J, personal communication, 2012). In an effort to create some semblance of order, they have instituted a red/yellow/green system to indicate to providers and administrators how well they are meeting the targets for only a few hundred key indicators, but this, although helping with reporting on the indicators, will not necessarily reduce their monitoring. IMPLICATIONS OF QUALITY IMPROVEMENT EFFORTS
Despite these significant efforts, the consistent and predictable delivery of quality health care that is safe, timely, effective, efficient, equitable, and patient-centered remains elusive. Much good work has been done. However, a report from the Consumers Union,18 To Err is Human; To Delay is Deadly, noted: “Despite a decade of work, we have no reliable evidence that we are any better off today.” And Kathleen Sebelius, Secretary of the US Department of Health and Human Services, concluded: “If we only improve care as much in the next decade as we have in the past, we are failing the American public”.19 This level of performance is particularly disappointing, given the tremendous investment in time, energy, personnel engagement, and organizational focus necessary for documenting, monitoring, reporting, and analyzing performance on key indicators. In addition, tremendous effort is being expended on designing, implementing, and evaluating new interventions to maintain gains and to improve performance. A myriad of improvement methods such as LEAN, Six Sigma, Plan/Do/Check/Act (PDCA), and Total Quality Management (TQM) have become commonplace in health care, resulting in many ad hoc and competing improvement activities. Thus, in many organizations the functions of performance measurement and QI have resulted in the creation of a vast infrastructure comprising nurses, specialists, and administrators who do the work. Table 1 from the Government Accounting Office provides one example of the range of resources used for abstracting Medicare data at 8 hospitals. These data reflect only a fraction of a hospital’s investment, yet rarely are these costs explicitly factored into the organization’s assessment of the cost of quality care. Romley and Goldman20 ask “How costly is hospital quality?” but their analysis of hospital performance on revealed quality (risk-adjusted mortality rates for pneumonia) mirrors the typical research that is done on cost and quality, that is, the cost of clinical care for a particular patient population and not the costs of the quality infrastructure. Little quantification of or research on these costs is conducted. A second cost to the QI effort is the time required by direct care providers, often the nursing staff, for supporting QI efforts with scant or no increase in staffing commensurate with these added responsibilities. While improving quality is a fundamental
Table 1 Resources supporting QI in 8 hospitals Hospital A
B
C
D
E
F
G
H
Size/beds
300–349
>500
50–99
>500
100–149
>500
150–199
>500
Estimated FTEs for abstracting data
0.7
<2.0
<1.5
2.5
1.2
1.3
1.2
2
Estimated time to abstract 1 chart (min)
60
10–15
20
3–120
5–60
5–60
10–30
10–90
Average no. of charts abstracted per quarter (CHF, MI, and pneumonia)
222
399
86
686
118
252
190
202
Amount of projected reduction in fiscal year 2007 Medicare payments if quality data not submitted (US$)
801000
3.25 million
161000
2.30 million
283000
2.45 million
503000
608000
Abbreviations: CHF, congestive heart failure; FTE, full-time equivalent; MI, myocardial infarction. Data from Government Accountability Office (GAO). Hospital quality data. HHS should specify steps and timeline for using information technology to collect and submit data. 2007. p. 38. Available at: http://www.gao.gov/assets/260/259673.pdf. Accessed January 29, 2012.
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responsibility of nursing practice, the extent to which nurses have to interrupt the provision of care to support the QI process is becoming an increasing problem and one that may have negative, unintended consequences on quality outcomes. In a survey undertaken by the Center for Studying Health System Change (CSHSC),21 information was collected from 8 hospitals in the 4 initial communities selected to participate in the Robert Wood Johnson Foundation’s Aligning Forces for Quality Program (an initiative on performance reporting, QI, and consumer engagement in Detroit, Memphis, Minneapolis-St. Paul, and Seattle). Survey participants consistently reported greater demands for reporting by external groups, for example, QIOs, accreditation and regulatory bodies, professional organizations, state societies, and health plans; and an increase in internal QI activities. A concern expressed was that the significant administrative burden associated with QI may make it difficult for nurses to continue to actively engage in QI activities. The survey also noted that actual or potential nursing shortages, and having the right mix of nurses, also challenged their ability to have active nursing involvement in formal QI initiatives. In another study, however, nurses reported that QI activities were actually taking them away from patient care.22 In conducting site visits in 9 major health care systems across the country as to the role of the chief nurse office in QI, Disch and colleagues22 found instances whereby nurses were overwhelmed with their QI responsibilities, or cynical, citing the “scud missiles” (new quality initiatives) that came regularly, or “the flavor of the week.” Nurses in some organizations expressed frustration at having no sense of “conclusion” or “doing a good job.” One CEO acknowledged that “Right now, there are so many goals—we need to strategize where we want to leverage ourselves. It gets embraced on the senior side, foggy in the middle—when it gets to the staff level, it’s overwhelming.” A third cost is the emotional toll that engaging in QI can take. In addition to dealing with the sheer number of indicators being tracked and acted upon, for nurses the quality burden can take several other forms: Documentation. It is estimated that nurses spend 35% of their time on documentation, much of it to substantiate performance on required indicators.23 Preparing reports. Gellinas15 describes a situation she encountered: “.a nurse on her day off, coming in to extract data so she could go into a performance improvement committee the following day.” Monitoring the performance of others, most notably physicians, as to their compliance with activities such as hand hygiene, universal precautions, and other patient safety initiatives. Picking up the work of others, such as rewriting orders for physicians whose handwriting is illegible or who refuse to use the electronic health record. Developing implementation strategies for mandated initiatives with insufficient evidence as to their effectiveness. For example, medication reconciliation during care transitions was mandated by the Joint Commissions and CMS years before there were recommended strategies to guide clinicians in meeting the requirement. Meetings and participation in QI task forces. There is also a burden secondary to a poorly functioning quality system, such as when nurses and other clinicians are: Monitoring and reporting on performance while receiving (1) no feedback as to its impact, (2) inconsistent messages, or (3) feedback that was so delayed (eg, 6 months) that it was almost irrelevant.
The Quality Burden
Experiencing anxiety or fear from functioning in a culture of shame and blame. In a study on intimidation in health care settings by the Institute for Safe Medication Practices (ISMP)24 of 2095 health care providers (1565 of them nurses), 49% of all respondents reported that intimidation had altered the way they handle order clarifications or questions about medication orders; that 75% had asked colleagues to help them interpret an order or validate its safety so that they did not have to interact with an intimidating prescriber; and almost half (49%) felt pressured to accept the order, dispense a product, or administer a medication despite their concerns. Much of this fear can be mitigated if the culture of the organization is one that promotes a fair and just culture and addresses unhealthy work practices. THE QUALITY BURDEN
Taking into consideration the various ways by which the pursuit of quality can add to individual and organizational costs that are broadly defined, and often underestimated, the idea that this pursuit has unintended, or unreconciled, consequences has to be examined. The quality burden is the pressure exerted on an individual, department, or organization arising from QI activities that compromise the ability to deliver quality care. As already noted, the quality burden can take several forms, for example, financial costs, constraints of adequate time and resources, emotional stress, and inefficiency. Dreher and colleagues consider this a quality paradox; that is, in the pursuit of quality the achievement of it is compromised (Dreher, Disch, Davidson, Sinioris, and Wainio, unpublished data, 2012). There are several factors within the health care environment that increase the pressure on staff to perform their regular responsibilities, in addition to taking on the burden of QI activities. A related phenomenon to that of the quality burden is complexity compression, or the phenomenon that nurses experience when expected to assume additional, unplanned responsibilities while simultaneously conducting their multiple responsibilities in a condensed time frame.25 These researchers reported that up to 40% of the workday of nurses is taken up by meeting the ever-increasing demands of the systems of health care delivery in which nurses are employed. These demands include the need for increasing documentation, for learning new and seemingly everchanging procedures and technologies, and for adapting to turnover in management and administration. Through focus groups, the investigators identified factors influencing the experience of complexity compression, and clustered them into 6 major themes: personal, environmental, practice, systems and technology, autonomy/control, and administration/management. Kalisch and Aebersold26 identified 5 factors in the organization that can pose a burden and, if untreated, can result in errors: unclear values; fear of punishment and blame; lack of systematic analyses of mistakes; complexity of the work; and inadequate teamwork. Kalisch and Aebersold suggest that several practices can both promote a safety culture and improve safety: creating value-driven patient care units encompassing staff values and buy-in; encouraging, even rewarding, error and nearmiss reporting; consistently analyzing mistakes and near-misses; looking for the unexpected and using critical pathways and guidelines to identify what’s expected and why there are variances; simplifying the work; and minimizing interruptions. A study by Hudelson and colleagues27 focused on the ideas of quality held by practicing nurses and physicians, and what served as facilitators and barriers to quality. Both nurses and doctors emphasized that technical competency, personal motivation, and goodwill were considered essential to the ability to practice quality care.
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Nurses, but not the physicians, also included the concept of consensus within the team as critical, and felt “it was easier to provide good-quality care to patients when nurses and doctors agreed on what should be done and how.”27(p33) Whereas the quality of care was thought to depend largely on personal characteristics, the obstacles were seen to arise from the administrative level. Said one participant: “The big difficulty is the invasion of routine patient care by administrative and bureaucratic work. It’s an enormous problem that, in my opinion, leads to a reduction in the amount of time we spend with patients, in our availability. It lengthens the work day, leads to fatigue and demoralization.”27(p34) ADDRESSING THE QUALITY BURDEN
There are several realities today that must be acknowledged. First, there are increasing pressures on health care organizations, including from consumers, to deliver consistent, high-quality care. Second, the health care environment is increasingly complex, and very fragmented. Third, despite massive efforts to improve the safety of patient care, much work remains to be done. Fourth, to the extent that a quality burden exists, there are costs and negative impacts that are not being fully accounted for or addressed. Any effort to address the quality burden has to be multifactorial, that is, there are individual, organizational, and societal activities that must be undertaken to relieve the unintended burden of pursuing a quality agenda. First, the individual has a responsibility to be engaged; to participate in unit and department QI activities; to stay current on best practices so that care can be effective, patient-centered, and efficient; to carry out the assigned responsibilities for tracking and recording data; to report errors, near misses, and dangerous organizational practices. The organization, through its leadership structure, has the responsibility to provide needed resources for establishing the necessary systems and processes for QI, including an adequate number of trained staff; to create a fair and just culture that encourages active, blame-free reporting of errors and near misses; and to offer opportunities for staff to receive timely information about performance on QI indicators, as well as to make suggestions for improving the environment and providing feedback about the burden of nonpatient care activity requirements. Finally, society, in the form of national quality organizations, has a responsibility to coordinate efforts in identifying and prioritizing performance indicators that will improve quality, while reducing waste and inefficiency; to collaborate with relevant individuals and groups in creating reasonable, actionable national goals for quality and safety; and to consider the full impact of quality mandates on patient, personnel, and financial outcomes. None of this is possible without well-prepared, committed, team-oriented leadership. Disch and colleagues22 identified 4 factors that differentiated organizations in terms of their internal alignment and clarity of purpose about their quality journeys: (1) a strong leadership team wherein everyone’s abilities were used in pursuit of common, clearly stated goals; (2) strong partnerships between the chief nurse executive (CNE) and the chief medical officer, and CNE and chief financial officer; (3) a healthy work environment in which employees felt connected to the senior leadership team members and to the shared goals of the organization; and (4) strong employee engagement. It was noted that “nurses and physicians are often the first to identify threats to quality and safety, and are able to propose effective solutions. When employees are engaged, feel they have an important role to play, have input into key decisions, and see how their work impacts major goals, they are much more likely to help the organization achieve its objectives.”22(p183)
The Quality Burden
IMPLICATIONS FOR EDUCATION, RESEARCH, AND POLICY
Several implications can be drawn for education, research, and policy from the aforementioned recommendations. Education: 1. Nursing faculty must be prepared to educate students to today’s realities of practice related to quality, safety, human factors, just cultures, and high-reliability organizations. Participation in the Quality and Safety Education for Nurses (QSEN) initiative and the annual QSEN Forums are 2 ways to do this. Using content from the QSEN Web site (http://www.qsen.org) or the recently published Quality and Safety for Nurses28 and Teaching IOM29 offer additional resources. 2. Partnerships between academic and service leaders enrich the learning experiences for both students and staff nurses. Academic leaders can bring the latest in evidence, and practitioners can contribute the realities of the practice environment. Student learning experiences can be crafted to help students and staff gain experience in examining situations that threaten patient safety and identifying strategies that improve quality and safety. Research: 1. Several questions require exploration, such as: How pervasive is the quality burden? What contributes to the quality burden for nurses? What are the consequences of the quality burden to the nurse and the organization? What can leaders do to mitigate the impact of the quality burden? To what extent does the quality burden contribute to employee disengagement, staff turnover, and poor patient outcomes? 2. Dissemination strategies are needed to help nursing staff understand the latest in safety science, QI, performance measurement, and high-reliability organizations. Policy: 1. If not in place, organizations need to institute policies on the reporting of errors and near misses, handling of disruptive behavior, and promoting staff engagement and activation. 2. Organizations need to ensure that QI activities are coordinated, and that systems and structures are in place to ensure streamlined data collection and effective feedback loops. Electronic systems that minimize the need for clinician data entry need to be in place. 3. National leadership is required to help prioritize, simplify, and coordinate the external reporting requirements and the demands they place on health care organizations and health care practitioners. SUMMARY
Achieving quality care is a national priority, and substantial efforts have been put in place to accomplish this. However, these efforts have unintentionally become a burden on many health care providers who are most involved in this work. The quality burden is a phenomenon that compromises the quality and safety of health care. Attention must be paid to recognizing its extent and to identifying and implementing strategies for lessening its impact. REFERENCES
1. Institute of Medicine (IOM). To err is human. Washington, DC: National Academies of Science; 1999.
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2. Center for Medicare and Medicaid Services (CMS). What are QIOs? 2011. Available at: https://www.cms.gov/QualityImprovementOrgs/. Accessed January 29, 2012. 3. National Quality Forum (NQF). About NQF. 2012. Available at: http://www. qualityforum.org/About_NQF/About_NQF.aspx. Accessed January 21, 2012. 4. National Committee for Quality Assurance (NCQA). About NCQA. 2011. Available at: http://www.ncqa.org/tabid/675/Default.aspx. Accessed January 21, 2012. 5. Institute for Healthcare Improvement (IHI). About IHI. 2011. Available at: http:// www.ihi.org/about/pages/default.aspx. Accessed January 29, 2012. 6. National Alliance for Quality Care (NAQC). Available at: http://www.gwumc.edu/ healthsci/departments/nursing/naqc/. Accessed January 29, 2012. 7. National Institute of Standards and Technology (NIST). Why take the Baldrige journey? 2011. Available at: http://www.nist.gov/baldrige/enter/index.cfm. Accessed January 29, 2012. 8. The Joint Commission (TJC). The Eisenberg award. 2012. Available at: http:// www.jointcommission.org/topics/eisenberg_award.aspx. Accessed January 29, 2012. 9. American Nurses Association. National Database of Nursing Quality Indicators (NDNQI). 2012. Available at: https://www.nursingquality.org/Default.aspx. Accessed January 21, 2012. 10. Center for Medicare and Medicaid Services (CMS) (2011). Hospital compare. Available at: https://www.cms.gov/HospitalQualityInits/11_HospitalCompare.asp. Accessed January 29, 2012. 11. Center for Medicare and Medicaid Services (CMS). HCAHPS fact sheet. 2010. Available at: http://www.hcahpsonline.org/files/HCAHPS%20Fact%20Sheet% 202010.pdf. Accessed January 29, 2012. 12. Minnesota Department of Health (MDH). Health care quality measures. 2010. Available at: http://www.health.state.mn.us/healthreform/measurement/adoptedrule. html. Accessed January 29, 2012. 13. California Healthcare Foundation. California Hospital Assessment and Reporting Taskforce (CHART). 2012. Available at: http://www.chcf.org/projects/2009/ california-hospital-assessment-and-reporting-taskforce-chart. Accessed January 28, 2012. 14. Massachusetts Health Quality Partners (MHQP); 2012. Available at: http://www. mhqp.org/default.asp?nav5010000. Accessed January 29, 2012. 15. Healthcare Financial Management Association (HFMA). Quality reporting: reducing the nurse burden resource. Buyer’s Resource Guide. Westchester (IL): Healthcare Financial Management Association (HFMA); 2007. p. 40–2. 16. Agency for Healthcare Research and Quality. Refinement of the HCUP quality indicators. 2001. Available at: http://www.hcup-us.ahrq.gov/overview.jsp. Accessed July 14, 2012. 17. Government Accountability Office (GAO). Hospital quality data: HHS should specify steps and timeline for using information technology to collect and submit data. 2007. p. 38. Available at: http://www.gao.gov/assets/260/259673.pdf. Accessed January 29, 2012. 18. Consumers Union. Safe patient project. 2009. Available at: http://www. safepatientproject.org/pdf/safepatientproject.org-to_delay_is_deadly-2009_05.pdf. Accessed March 27, 2010. 19. Sebelius K. The Richard and Hinda Rosenthal Lecture 2011: new frontiers in patient safety. Washington, DC: Institute of Medicine, National Academies Press; 2011. 5.
The Quality Burden
20. Romley JA, Goldman DP. How costly is hospital quality? A revealed preference approach. 2010. Available at: http://www-bcf.usc.edu/wromley/How_Costly_Is_ Hospital_Quality_Oct_2010.pdf. Accessed January 29, 2012. 21. Draper DA, Felland LE, Liebhaber A, et al. The role of nurses in hospital quality improvement. HSC research brief no. 3. Center for health system change. 2008. Available at: http://hschange.org/CONTENT/972/. Accessed January 29, 2012. 22. Disch J, Dreher M, Davidson P, et al. The role of the chief nurse officer in ensuring patient safety and quality. J Nurs Adm 2011;41(4):179–85. 23. Hendrich A, Chow MP, Skierczynski BA, et al. A 36-hospital time and motion study: how do medical-surgical nurses spend their time? Perm J 2008;12(3): 25–34. 24. Institute for Safe Medication Practices (ISMP). Intimidation: practitioners speak up about this unresolved problem. Medication safety alert. 2004. Available at: http:// search.ismp.org/cgi-bin/hits.pl?in5517791&fh580&ph51&tk5g%3FEL%3FV %3FngL%3FqE%20%3FEL%3FV%3FngL%3FqEmu&su5h%3FppPcmmQQQ. %26wEP.kuImqTQwVTppTuwmSnbpTnSuTmSup%26nVTwm20040311g2. SwP&qy5dTWeT%26TgmeTKW&pd51. Accessed January 29, 2012. 25. Krichbaum K, Diemert C, Jacox L, et al. Complexity compression: nurses under fire. Nurs Forum 2007;42(2):86–94. 26. Kalisch B, Aebersold M. Overcoming barriers to patient safety. Nurs Econ 2006; 24(3):143–55. 27. Hudelson P, Cleopas A, Kolly V, et al. What is quality and how is it achieved? Practitioners’ views versus quality models. Qual Saf Health Care 2008;17:31–6. 28. Sherwood G, Barnsteiner J, editors. Quality and safety for nurses. Hoboken (NJ): John Wiley & Sons; 2012. 29. Finkelman A, Kenner C. Teaching IOM: implications of the Institute of Medicine Reports for Nursing Education. Washington, DC: American Nurses Publishing; 2009.
405
PhD, RN
a,
*, Marie Sinioris,
MPH
b,c
KEYWORDS Barriers to quality Quality improvement Factors affecting quality improvement Safe patient care Quality reporting Barriers to patient safety Patient safety KEY POINTS Achieving quality care is a national priority, and substantial efforts have been put in place to accomplish this. The quality burden is a phenomenon that compromises the quality and safety of health care. Attention must be paid to recognizing its extent and to identifying and implementing strategies for lessening its impact.
While the cost of care has become a major focus of attention in pursuing quality patient care, and significant investments have been made in quantifying these costs, little recognition has been given to the costs of the quality improvement (QI) efforts themselves: the time, energy, infrastructure, and emotional stress associated with documenting, monitoring, reporting, implementing, and evaluating quality indicators and initiatives. This article describes an emerging phenomenon, the quality burden, which is significant in size and impact although often hidden and unmeasured, and which accompanies ongoing efforts to improve the quality and safety of health care. Recommendations are given to mitigate the impact of the quality burden in delivering care and improving quality and safety. THE PURSUIT OF QUALITY
Since the publication of To Err is Human by the Institute of Medicine (IOM),1 dozens of organizations and hundreds of initiatives have emerged to improve the quality of health care. The Minnesota Hospital Association developed a diagram in 2004 to reflect the numerous players in QI at that time; since then, many others have emerged (Fig. 1). In addition to traditional regulatory agencies such as The Joint Commission, a
University of Minnesota School of Nursing, 308 Harvard Street Southeast, Minneapolis, MN 55455, USA; b Health Systems Management, Rush University, 1653 W Congress Expressway, Chicago, IL 60612, USA; c National Center for Healthcare Leadership, 1700 W Van Buren, Chicago, IL 60612, USA * Corresponding author. E-mail address: [email protected] Nurs Clin N Am 47 (2012) 395–405 http://dx.doi.org/10.1016/j.cnur.2012.05.010 nursing.theclinics.com 0029-6465/12/$ – see front matter Ó 2012 Elsevier Inc. All rights reserved.
396
Pursuing Perfection
Institute for Health System Improvement
Breakthrough Services
Standup for Patient Safety
Patient Safety Awareness Week
Foundation for Accountability ( FAACT)
National Quality Forum
National Patient Safety Efforts
National Patient Safety Foundation
Patient Safety Congress
The Leapfrog Group
Quality First for Long-Term Care
Research Program
Clearinghouse on Consumers Activation
Leapfrog: Rewarding Results
qualityhealthcare.org
Disch & Sinioris
Public Hospital Survey
National Center for Patient Safety
NQF 27 Events
30 Safe Practices
Health Plan Report Card
National Committee for Quality Assurance (NCQA)
Diabetes Physician Recognition Program
JCAHO
Institute of Medicine (IOM) AHRQ
Partnership 4 Patient Safety
Patient Safety Standards To Error Is Human
Patient Safety Goals Quality Chasm Report
HCUP
National Health Care Quality Report Patient Safety Improvement Corps
Fig. 1. National patient safety efforts. (Reprinted from Minnesota Hospital Association, 2004; with permission.)
The Quality Burden
various federal offices, state departments of health, and professional societies such as the American Heart Association and the American Academy of Pediatrics, several agencies targeted specifically at QI have stepped up their efforts to guide, direct, measure, and report on the provision of health care. Prominent organizations include: Quality Improvement Organizations (QIOs). Formerly known as peer-review organizations, these are private, usually not-for-profit organizations consisting of health care professionals who are trained to review health care. The Center for Medicare and Medicaid Services (CMS) contracts with one organization in each state, as well as the District of Columbia, Puerto Rico, and the US Virgin Islands to serve as that state/jurisdiction’s QIO.2 QIOs (1) help Medicare beneficiaries if they have complaints and (2) implement improvements in the quality of care available throughout the spectrum of care. The National Quality Forum (NQF). The NQF is a nonprofit organization comprising a variety of stakeholder groups and individuals, aimed at building consensus on national priorities and goals for performance improvement; developing and endorsing national consensus standards for measuring and publicly reporting on performance; and promoting the attainment of national goals through education and outreach programs.3 The National Committee for Quality Assurance (NCQA). The NCQA is a private, not-for-profit organization dedicated to improving health care quality by developing quality standards and performance measures, reporting of performance against these measures, and raising the visibility of quality performance through its accreditation, certification, and recognition programs.4 The Institute for Healthcare Improvement (IHI). The IHI is an independent, not-forprofit organization aimed at “motivating and building the will for change; identifying and testing new models of care in partnership with both patients and health care professionals; and ensuring the broadest possible adoption of best practices and effective innovations.”5 The Nursing Alliance for Quality Care (NAQC). The NAQC is a partnership among the nation’s leading nursing organizations, consumers, and other key stakeholders to “advance the highest quality, safety, and value of consumer-centered health care for all individuals-patients, their families, and their communities.”6 Other organizations have developed national recognition around models of QI that stimulate competition for these prestigious awards, such as the Malcolm Baldrige Performance Excellence Award given by the National Institute of Standards and Technology, a section of the US Department of Commerce7; and the John M. Eisenberg Patient Safety and Quality Award, given by The Joint Commission and the NQF.8 Most organizations and award programs aimed at improving quality are evidence based and require collecting, organizing, and reporting data against a set of criteria. One with particular relevance to nursing is the National Database of Nursing Quality Indicators (NDNQI), a proprietary database of the American Nurses Association (ANA) that collects, evaluates, and provides comparative data on unit-specific, nurse-sensitive data from hospitals in the United States for QI purposes.9 In addition, there are organizations collecting and reporting data to the public for more informed decision making and accountability, such as CMS (with its Hospital Compare program that provides consumers with information on hospital performance and recommended patient treatments)10; and the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, the first national, standardized, publicly reported survey of patients’ perspectives of hospital care, including nursingsensitive indicators available for national benchmarking for the first time.11 Finally,
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most states are also launching comprehensive reporting programs, such as in Minnesota (the Statewide Quality Reporting and Measurement System)12; the California Hospital Assessment and Reporting Taskforce (CHART) with its CalHospitalCompare.org Web site13; and Massachusetts (Massachusetts Health Quality Partners).14 While many of these initiatives are helpful, the sheer number of them has escalated, and health care leaders feel tremendous pressure to demonstrate acceptable performance against a growing number of benchmarks, whether they be legally mandated or competitively chosen. Richard Bankowitz, Premier’s medical director, estimates that the average hospital reports about 70 measures per quarter,15 but those are only reports to Premier. Estimates from health care leaders indicate that the number of indicators tracked range from 100 to several hundred.16,17 One chief quality officer acknowledged that their organization, an inner-city level 1 trauma center, tracks more than 1800 indicators (Hitt J, personal communication, 2012). In an effort to create some semblance of order, they have instituted a red/yellow/green system to indicate to providers and administrators how well they are meeting the targets for only a few hundred key indicators, but this, although helping with reporting on the indicators, will not necessarily reduce their monitoring. IMPLICATIONS OF QUALITY IMPROVEMENT EFFORTS
Despite these significant efforts, the consistent and predictable delivery of quality health care that is safe, timely, effective, efficient, equitable, and patient-centered remains elusive. Much good work has been done. However, a report from the Consumers Union,18 To Err is Human; To Delay is Deadly, noted: “Despite a decade of work, we have no reliable evidence that we are any better off today.” And Kathleen Sebelius, Secretary of the US Department of Health and Human Services, concluded: “If we only improve care as much in the next decade as we have in the past, we are failing the American public”.19 This level of performance is particularly disappointing, given the tremendous investment in time, energy, personnel engagement, and organizational focus necessary for documenting, monitoring, reporting, and analyzing performance on key indicators. In addition, tremendous effort is being expended on designing, implementing, and evaluating new interventions to maintain gains and to improve performance. A myriad of improvement methods such as LEAN, Six Sigma, Plan/Do/Check/Act (PDCA), and Total Quality Management (TQM) have become commonplace in health care, resulting in many ad hoc and competing improvement activities. Thus, in many organizations the functions of performance measurement and QI have resulted in the creation of a vast infrastructure comprising nurses, specialists, and administrators who do the work. Table 1 from the Government Accounting Office provides one example of the range of resources used for abstracting Medicare data at 8 hospitals. These data reflect only a fraction of a hospital’s investment, yet rarely are these costs explicitly factored into the organization’s assessment of the cost of quality care. Romley and Goldman20 ask “How costly is hospital quality?” but their analysis of hospital performance on revealed quality (risk-adjusted mortality rates for pneumonia) mirrors the typical research that is done on cost and quality, that is, the cost of clinical care for a particular patient population and not the costs of the quality infrastructure. Little quantification of or research on these costs is conducted. A second cost to the QI effort is the time required by direct care providers, often the nursing staff, for supporting QI efforts with scant or no increase in staffing commensurate with these added responsibilities. While improving quality is a fundamental
Table 1 Resources supporting QI in 8 hospitals Hospital A
B
C
D
E
F
G
H
Size/beds
300–349
>500
50–99
>500
100–149
>500
150–199
>500
Estimated FTEs for abstracting data
0.7
<2.0
<1.5
2.5
1.2
1.3
1.2
2
Estimated time to abstract 1 chart (min)
60
10–15
20
3–120
5–60
5–60
10–30
10–90
Average no. of charts abstracted per quarter (CHF, MI, and pneumonia)
222
399
86
686
118
252
190
202
Amount of projected reduction in fiscal year 2007 Medicare payments if quality data not submitted (US$)
801000
3.25 million
161000
2.30 million
283000
2.45 million
503000
608000
Abbreviations: CHF, congestive heart failure; FTE, full-time equivalent; MI, myocardial infarction. Data from Government Accountability Office (GAO). Hospital quality data. HHS should specify steps and timeline for using information technology to collect and submit data. 2007. p. 38. Available at: http://www.gao.gov/assets/260/259673.pdf. Accessed January 29, 2012.
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responsibility of nursing practice, the extent to which nurses have to interrupt the provision of care to support the QI process is becoming an increasing problem and one that may have negative, unintended consequences on quality outcomes. In a survey undertaken by the Center for Studying Health System Change (CSHSC),21 information was collected from 8 hospitals in the 4 initial communities selected to participate in the Robert Wood Johnson Foundation’s Aligning Forces for Quality Program (an initiative on performance reporting, QI, and consumer engagement in Detroit, Memphis, Minneapolis-St. Paul, and Seattle). Survey participants consistently reported greater demands for reporting by external groups, for example, QIOs, accreditation and regulatory bodies, professional organizations, state societies, and health plans; and an increase in internal QI activities. A concern expressed was that the significant administrative burden associated with QI may make it difficult for nurses to continue to actively engage in QI activities. The survey also noted that actual or potential nursing shortages, and having the right mix of nurses, also challenged their ability to have active nursing involvement in formal QI initiatives. In another study, however, nurses reported that QI activities were actually taking them away from patient care.22 In conducting site visits in 9 major health care systems across the country as to the role of the chief nurse office in QI, Disch and colleagues22 found instances whereby nurses were overwhelmed with their QI responsibilities, or cynical, citing the “scud missiles” (new quality initiatives) that came regularly, or “the flavor of the week.” Nurses in some organizations expressed frustration at having no sense of “conclusion” or “doing a good job.” One CEO acknowledged that “Right now, there are so many goals—we need to strategize where we want to leverage ourselves. It gets embraced on the senior side, foggy in the middle—when it gets to the staff level, it’s overwhelming.” A third cost is the emotional toll that engaging in QI can take. In addition to dealing with the sheer number of indicators being tracked and acted upon, for nurses the quality burden can take several other forms: Documentation. It is estimated that nurses spend 35% of their time on documentation, much of it to substantiate performance on required indicators.23 Preparing reports. Gellinas15 describes a situation she encountered: “.a nurse on her day off, coming in to extract data so she could go into a performance improvement committee the following day.” Monitoring the performance of others, most notably physicians, as to their compliance with activities such as hand hygiene, universal precautions, and other patient safety initiatives. Picking up the work of others, such as rewriting orders for physicians whose handwriting is illegible or who refuse to use the electronic health record. Developing implementation strategies for mandated initiatives with insufficient evidence as to their effectiveness. For example, medication reconciliation during care transitions was mandated by the Joint Commissions and CMS years before there were recommended strategies to guide clinicians in meeting the requirement. Meetings and participation in QI task forces. There is also a burden secondary to a poorly functioning quality system, such as when nurses and other clinicians are: Monitoring and reporting on performance while receiving (1) no feedback as to its impact, (2) inconsistent messages, or (3) feedback that was so delayed (eg, 6 months) that it was almost irrelevant.
The Quality Burden
Experiencing anxiety or fear from functioning in a culture of shame and blame. In a study on intimidation in health care settings by the Institute for Safe Medication Practices (ISMP)24 of 2095 health care providers (1565 of them nurses), 49% of all respondents reported that intimidation had altered the way they handle order clarifications or questions about medication orders; that 75% had asked colleagues to help them interpret an order or validate its safety so that they did not have to interact with an intimidating prescriber; and almost half (49%) felt pressured to accept the order, dispense a product, or administer a medication despite their concerns. Much of this fear can be mitigated if the culture of the organization is one that promotes a fair and just culture and addresses unhealthy work practices. THE QUALITY BURDEN
Taking into consideration the various ways by which the pursuit of quality can add to individual and organizational costs that are broadly defined, and often underestimated, the idea that this pursuit has unintended, or unreconciled, consequences has to be examined. The quality burden is the pressure exerted on an individual, department, or organization arising from QI activities that compromise the ability to deliver quality care. As already noted, the quality burden can take several forms, for example, financial costs, constraints of adequate time and resources, emotional stress, and inefficiency. Dreher and colleagues consider this a quality paradox; that is, in the pursuit of quality the achievement of it is compromised (Dreher, Disch, Davidson, Sinioris, and Wainio, unpublished data, 2012). There are several factors within the health care environment that increase the pressure on staff to perform their regular responsibilities, in addition to taking on the burden of QI activities. A related phenomenon to that of the quality burden is complexity compression, or the phenomenon that nurses experience when expected to assume additional, unplanned responsibilities while simultaneously conducting their multiple responsibilities in a condensed time frame.25 These researchers reported that up to 40% of the workday of nurses is taken up by meeting the ever-increasing demands of the systems of health care delivery in which nurses are employed. These demands include the need for increasing documentation, for learning new and seemingly everchanging procedures and technologies, and for adapting to turnover in management and administration. Through focus groups, the investigators identified factors influencing the experience of complexity compression, and clustered them into 6 major themes: personal, environmental, practice, systems and technology, autonomy/control, and administration/management. Kalisch and Aebersold26 identified 5 factors in the organization that can pose a burden and, if untreated, can result in errors: unclear values; fear of punishment and blame; lack of systematic analyses of mistakes; complexity of the work; and inadequate teamwork. Kalisch and Aebersold suggest that several practices can both promote a safety culture and improve safety: creating value-driven patient care units encompassing staff values and buy-in; encouraging, even rewarding, error and nearmiss reporting; consistently analyzing mistakes and near-misses; looking for the unexpected and using critical pathways and guidelines to identify what’s expected and why there are variances; simplifying the work; and minimizing interruptions. A study by Hudelson and colleagues27 focused on the ideas of quality held by practicing nurses and physicians, and what served as facilitators and barriers to quality. Both nurses and doctors emphasized that technical competency, personal motivation, and goodwill were considered essential to the ability to practice quality care.
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Nurses, but not the physicians, also included the concept of consensus within the team as critical, and felt “it was easier to provide good-quality care to patients when nurses and doctors agreed on what should be done and how.”27(p33) Whereas the quality of care was thought to depend largely on personal characteristics, the obstacles were seen to arise from the administrative level. Said one participant: “The big difficulty is the invasion of routine patient care by administrative and bureaucratic work. It’s an enormous problem that, in my opinion, leads to a reduction in the amount of time we spend with patients, in our availability. It lengthens the work day, leads to fatigue and demoralization.”27(p34) ADDRESSING THE QUALITY BURDEN
There are several realities today that must be acknowledged. First, there are increasing pressures on health care organizations, including from consumers, to deliver consistent, high-quality care. Second, the health care environment is increasingly complex, and very fragmented. Third, despite massive efforts to improve the safety of patient care, much work remains to be done. Fourth, to the extent that a quality burden exists, there are costs and negative impacts that are not being fully accounted for or addressed. Any effort to address the quality burden has to be multifactorial, that is, there are individual, organizational, and societal activities that must be undertaken to relieve the unintended burden of pursuing a quality agenda. First, the individual has a responsibility to be engaged; to participate in unit and department QI activities; to stay current on best practices so that care can be effective, patient-centered, and efficient; to carry out the assigned responsibilities for tracking and recording data; to report errors, near misses, and dangerous organizational practices. The organization, through its leadership structure, has the responsibility to provide needed resources for establishing the necessary systems and processes for QI, including an adequate number of trained staff; to create a fair and just culture that encourages active, blame-free reporting of errors and near misses; and to offer opportunities for staff to receive timely information about performance on QI indicators, as well as to make suggestions for improving the environment and providing feedback about the burden of nonpatient care activity requirements. Finally, society, in the form of national quality organizations, has a responsibility to coordinate efforts in identifying and prioritizing performance indicators that will improve quality, while reducing waste and inefficiency; to collaborate with relevant individuals and groups in creating reasonable, actionable national goals for quality and safety; and to consider the full impact of quality mandates on patient, personnel, and financial outcomes. None of this is possible without well-prepared, committed, team-oriented leadership. Disch and colleagues22 identified 4 factors that differentiated organizations in terms of their internal alignment and clarity of purpose about their quality journeys: (1) a strong leadership team wherein everyone’s abilities were used in pursuit of common, clearly stated goals; (2) strong partnerships between the chief nurse executive (CNE) and the chief medical officer, and CNE and chief financial officer; (3) a healthy work environment in which employees felt connected to the senior leadership team members and to the shared goals of the organization; and (4) strong employee engagement. It was noted that “nurses and physicians are often the first to identify threats to quality and safety, and are able to propose effective solutions. When employees are engaged, feel they have an important role to play, have input into key decisions, and see how their work impacts major goals, they are much more likely to help the organization achieve its objectives.”22(p183)
The Quality Burden
IMPLICATIONS FOR EDUCATION, RESEARCH, AND POLICY
Several implications can be drawn for education, research, and policy from the aforementioned recommendations. Education: 1. Nursing faculty must be prepared to educate students to today’s realities of practice related to quality, safety, human factors, just cultures, and high-reliability organizations. Participation in the Quality and Safety Education for Nurses (QSEN) initiative and the annual QSEN Forums are 2 ways to do this. Using content from the QSEN Web site (http://www.qsen.org) or the recently published Quality and Safety for Nurses28 and Teaching IOM29 offer additional resources. 2. Partnerships between academic and service leaders enrich the learning experiences for both students and staff nurses. Academic leaders can bring the latest in evidence, and practitioners can contribute the realities of the practice environment. Student learning experiences can be crafted to help students and staff gain experience in examining situations that threaten patient safety and identifying strategies that improve quality and safety. Research: 1. Several questions require exploration, such as: How pervasive is the quality burden? What contributes to the quality burden for nurses? What are the consequences of the quality burden to the nurse and the organization? What can leaders do to mitigate the impact of the quality burden? To what extent does the quality burden contribute to employee disengagement, staff turnover, and poor patient outcomes? 2. Dissemination strategies are needed to help nursing staff understand the latest in safety science, QI, performance measurement, and high-reliability organizations. Policy: 1. If not in place, organizations need to institute policies on the reporting of errors and near misses, handling of disruptive behavior, and promoting staff engagement and activation. 2. Organizations need to ensure that QI activities are coordinated, and that systems and structures are in place to ensure streamlined data collection and effective feedback loops. Electronic systems that minimize the need for clinician data entry need to be in place. 3. National leadership is required to help prioritize, simplify, and coordinate the external reporting requirements and the demands they place on health care organizations and health care practitioners. SUMMARY
Achieving quality care is a national priority, and substantial efforts have been put in place to accomplish this. However, these efforts have unintentionally become a burden on many health care providers who are most involved in this work. The quality burden is a phenomenon that compromises the quality and safety of health care. Attention must be paid to recognizing its extent and to identifying and implementing strategies for lessening its impact. REFERENCES
1. Institute of Medicine (IOM). To err is human. Washington, DC: National Academies of Science; 1999.
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2. Center for Medicare and Medicaid Services (CMS). What are QIOs? 2011. Available at: https://www.cms.gov/QualityImprovementOrgs/. Accessed January 29, 2012. 3. National Quality Forum (NQF). About NQF. 2012. Available at: http://www. qualityforum.org/About_NQF/About_NQF.aspx. Accessed January 21, 2012. 4. National Committee for Quality Assurance (NCQA). About NCQA. 2011. Available at: http://www.ncqa.org/tabid/675/Default.aspx. Accessed January 21, 2012. 5. Institute for Healthcare Improvement (IHI). About IHI. 2011. Available at: http:// www.ihi.org/about/pages/default.aspx. Accessed January 29, 2012. 6. National Alliance for Quality Care (NAQC). Available at: http://www.gwumc.edu/ healthsci/departments/nursing/naqc/. Accessed January 29, 2012. 7. National Institute of Standards and Technology (NIST). Why take the Baldrige journey? 2011. Available at: http://www.nist.gov/baldrige/enter/index.cfm. Accessed January 29, 2012. 8. The Joint Commission (TJC). The Eisenberg award. 2012. Available at: http:// www.jointcommission.org/topics/eisenberg_award.aspx. Accessed January 29, 2012. 9. American Nurses Association. National Database of Nursing Quality Indicators (NDNQI). 2012. Available at: https://www.nursingquality.org/Default.aspx. Accessed January 21, 2012. 10. Center for Medicare and Medicaid Services (CMS) (2011). Hospital compare. Available at: https://www.cms.gov/HospitalQualityInits/11_HospitalCompare.asp. Accessed January 29, 2012. 11. Center for Medicare and Medicaid Services (CMS). HCAHPS fact sheet. 2010. Available at: http://www.hcahpsonline.org/files/HCAHPS%20Fact%20Sheet% 202010.pdf. Accessed January 29, 2012. 12. Minnesota Department of Health (MDH). Health care quality measures. 2010. Available at: http://www.health.state.mn.us/healthreform/measurement/adoptedrule. html. Accessed January 29, 2012. 13. California Healthcare Foundation. California Hospital Assessment and Reporting Taskforce (CHART). 2012. Available at: http://www.chcf.org/projects/2009/ california-hospital-assessment-and-reporting-taskforce-chart. Accessed January 28, 2012. 14. Massachusetts Health Quality Partners (MHQP); 2012. Available at: http://www. mhqp.org/default.asp?nav5010000. Accessed January 29, 2012. 15. Healthcare Financial Management Association (HFMA). Quality reporting: reducing the nurse burden resource. Buyer’s Resource Guide. Westchester (IL): Healthcare Financial Management Association (HFMA); 2007. p. 40–2. 16. Agency for Healthcare Research and Quality. Refinement of the HCUP quality indicators. 2001. Available at: http://www.hcup-us.ahrq.gov/overview.jsp. Accessed July 14, 2012. 17. Government Accountability Office (GAO). Hospital quality data: HHS should specify steps and timeline for using information technology to collect and submit data. 2007. p. 38. Available at: http://www.gao.gov/assets/260/259673.pdf. Accessed January 29, 2012. 18. Consumers Union. Safe patient project. 2009. Available at: http://www. safepatientproject.org/pdf/safepatientproject.org-to_delay_is_deadly-2009_05.pdf. Accessed March 27, 2010. 19. Sebelius K. The Richard and Hinda Rosenthal Lecture 2011: new frontiers in patient safety. Washington, DC: Institute of Medicine, National Academies Press; 2011. 5.
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20. Romley JA, Goldman DP. How costly is hospital quality? A revealed preference approach. 2010. Available at: http://www-bcf.usc.edu/wromley/How_Costly_Is_ Hospital_Quality_Oct_2010.pdf. Accessed January 29, 2012. 21. Draper DA, Felland LE, Liebhaber A, et al. The role of nurses in hospital quality improvement. HSC research brief no. 3. Center for health system change. 2008. Available at: http://hschange.org/CONTENT/972/. Accessed January 29, 2012. 22. Disch J, Dreher M, Davidson P, et al. The role of the chief nurse officer in ensuring patient safety and quality. J Nurs Adm 2011;41(4):179–85. 23. Hendrich A, Chow MP, Skierczynski BA, et al. A 36-hospital time and motion study: how do medical-surgical nurses spend their time? Perm J 2008;12(3): 25–34. 24. Institute for Safe Medication Practices (ISMP). Intimidation: practitioners speak up about this unresolved problem. Medication safety alert. 2004. Available at: http:// search.ismp.org/cgi-bin/hits.pl?in5517791&fh580&ph51&tk5g%3FEL%3FV %3FngL%3FqE%20%3FEL%3FV%3FngL%3FqEmu&su5h%3FppPcmmQQQ. %26wEP.kuImqTQwVTppTuwmSnbpTnSuTmSup%26nVTwm20040311g2. SwP&qy5dTWeT%26TgmeTKW&pd51. Accessed January 29, 2012. 25. Krichbaum K, Diemert C, Jacox L, et al. Complexity compression: nurses under fire. Nurs Forum 2007;42(2):86–94. 26. Kalisch B, Aebersold M. Overcoming barriers to patient safety. Nurs Econ 2006; 24(3):143–55. 27. Hudelson P, Cleopas A, Kolly V, et al. What is quality and how is it achieved? Practitioners’ views versus quality models. Qual Saf Health Care 2008;17:31–6. 28. Sherwood G, Barnsteiner J, editors. Quality and safety for nurses. Hoboken (NJ): John Wiley & Sons; 2012. 29. Finkelman A, Kenner C. Teaching IOM: implications of the Institute of Medicine Reports for Nursing Education. Washington, DC: American Nurses Publishing; 2009.
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