Elsevier

Nursing Outlook

Volume 52, Issue 1, February 2004, Pages 17-22
Nursing Outlook

Article
Strategies to advance health care quality

https://doi.org/10.1016/j.outlook.2003.11.003Get rights and content

Abstract

Overcoming the quality crisis in American health care is an enormous challenge. Despite a large cadre of individuals committed to improving quality, progress is stifled by the multiple ways in which issues central to quality care are conceptualized. To realize bona fide improvements in care quality, it is essential to understand the dominant conceptualizations driving quality efforts. Steps must then be taken to revise those conceptualizations that are obstacles to advancing health care quality. In this paper, four strategies are proposed for refocusing quality initiatives: (1) Looking at quality from the clinicians' eyes, (2) moving beyond physician care as a synonym for quality, (3) expanding the triple typology used to classify quality, and (4) enriching the evidence base for quality. The paper concludes with a call to action for nurses to exert stronger leadership to advance quality.

Section snippets

Looking at quality through the clinicians' eyes

There are many stakeholders involved in the provision of quality care—patients, providers, purchasers, payers, policy makers, and researchers—each of whom may have a slightly different view about quality. The definition of quality care illustrates these variations. Researchers, policy makers and accrediting bodies typically define quality care as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with

Moving beyond physician care as a synonym for quality care

Quality care is more than care delivered by physicians. To date, however, there is a strong tendency to assess quality based on the profession of medicine. It is possible that the word “medicine” is used generically to encompass all health care disciplines. However, indicators suggest quality care is currently conceptualized using a physician focus which leads to impressions of problems that are only partially correct. Moreover, the powerful potential in calls for collaboration and

Expanding the triple typology used to classify quality problems

Health care quality problems are frequently classified using a triple typology related to overuse, underuse, and misuse.1, 2, 6, 20, 21 These terms generally refer to the “dose” of care as being too much (eg, prescribing antibiotics when they are not warranted), too little (eg, not prescribing beta-blockers when they are warranted), or incorrect (eg, errors in diagnosis and/or treatment) respectively. This typology focuses on treatments and the technical aspects of care.

If the purpose of the

Enriching the evidence base for quality care

Proponents of the quality movement correctly call for using knowledge as the foundation for practice as well as the basis for establishing sound environments of care. It is therefore disappointing to realize that scientific evidence has had only a modest impact on molding care delivery practices.2, 4 It is also disappointing to realize there are gaps in evidence that “…undermine efforts to improve the scientific basis of health care decisions…”.44 These gaps derive from a variety of sources

Nursing leadership for quality: a call to action

Nurses are recognized as the backbone of the health industry50 and the glue that holds hospitals together.51 Nevertheless, nurses and nursing remain conspicuously absent from influential quality initiatives. As a first step in changing this situation, nurses need to decide whether, as a profession, we want to seriously engage in the work of improving health care quality in America. If the answer is no, then we need to accept the status quo and cease voicing our concerns. If the answer is yes,

Conclusion

Bold strategies are needed to initiate the sweeping changes necessary to radically reform the quality of care in America. These strategies will meet with only modest success unless the conceptualizations underpinning current quality initiatives are identified and changed. Clinicians' views about quality need to become more dominant because their actions determine whether quality is really improving. The physician-oriented assessments of quality need to be replaced by genuine collaborative

Acknowledgements

The authors are grateful to several reviewers, both known and unknown, whose thoughtful critiques helped improve this paper. However, the opinions and ideas expressed in this paper are strictly the views of the authors.

Bonnie Mowinski Jennings is a Senior Nurse Scientist, Geneva Foundation and Health Care Consultant at Alexandria, VA.

References (53)

  • R.J Blendon et al.

    Views of practicing physicians and the public on medical errors

    N Engl J Med

    (2002)
  • M.R Lynn et al.

    Do nurses know what patients think is important in nursing care?

    J Nurs Care Qual

    (1999)
  • S.E Shannon et al.

    Patients, nurses, and physicians have differing views of quality of critical care

    J Nurs Sch

    (2002)
  • J.G Baggs et al.

    The association between interdisciplinary collaboration and patient outcomes in a medical intensive care unit

    Heart Lung

    (1992)
  • J.G Baggs et al.

    Association between nurse-physician collaboration and patient outcomes in three intensive care units

    Crit Care Med

    (1999)
  • W.A Knaus et al.

    An evaluation of outcome from intensive care in major medical centers

    Annals Int Med

    (1986)
  • P.H Mitchell et al.

    American Association of Critical-Care Nurses Demonstration ProjectProfile of excellence in critical care nursing

    Heart Lung

    (1989)
  • S.A Wheelan et al.

    The link between teamwork and patients' outcomes in intensive care units

    Am J Crit Care

    (2003)
  • E.A McGlynn et al.

    The quality of health care delivered to adults in the United States

    N Engl J Med

    (2003)
  • M.L Maas et al.

    Outcome data accountability

    Outcomes Manage Nurs Practice

    (1998)
  • Kelly KC, Huber DG, Johnson M, McCloskey JC, Maas M. The Medical Outcomes Study: A nursing perspective. J Prof Nurs...
  • M.A Schuster et al.

    How good is the quality of health care in the United States?

    Milbank Q

    (1998)
  • Schuster MA, McGlynn EA, Pham CB, Spar MD, Brook RH. The quality of health care in the United States: A review of...
  • A Donabedian

    The quality of care. How can it be assessed?

    JAMA

    (1988)
  • P.D Cleary et al.

    Health care qualtiy. Incorporating consumer perspectives

    JAMA

    (1997)
  • Cited by (0)

    Bonnie Mowinski Jennings is a Senior Nurse Scientist, Geneva Foundation and Health Care Consultant at Alexandria, VA.

    Margaret L. McClure is President of the American Academy of Nursing and a Professor at New York University, New York, NY, USA.

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