2 Quality care: International contexts
Globally, quality is defined in a variety of ways according to the location and context of care, features known to impact practice.
American Nurses Association (ANA) definition of quality
The American Nurses Association (ANA) defines quality as, “The degree to which nursing services for health care consumers, families, groups, communities, and populations increase the likelihood of desirable outcomes and are consistent with evolving nursing knowledge.” (American Nurses Association, 2021). The phrases in this definition focus on three aspects of quality: services (nursing interventions), desirable outcomes, and consistency with evolving nursing knowledge (evidence-based practices). Alignment of nursing interventions with current evidence-based practices is a key goal for quality care (Stevens, 2013).
Quality of Practice is embedded with the Standards for Professional Practice which are “authoritative statements of the actions and behaviors that all registered nurses, regardless of role, population, specialty, and setting are expected to perform competently.” (Institute of Medicine (US) Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, Institute of Medicine, 2011). See the competencies for the Registered Nurses and Registered Midwives.
Registered nurses (RNs)
- Employ a variety of thinking strategies and the best available evidence in making decisions and providing safe, quality nursing practice within person-centred and evidence-based frameworks.
- Practice is based on purposefully engaging in effective therapeutic and professional relationships. This includes collegial generosity in the context of mutual trust and respect in professional relationships.
- As regulated health professionals, RNs are responsible and accountable for ensuring they are safe, and have the capability for practice. This includes ongoing self-management and responding when there is concern about other health professionals’ capability for practice. RNs are responsible for their professional development and contribute to the development of others. They are also responsible for providing information and education to enable people to make decisions and take action in relation to their health.
- Accurately conduct comprehensive and systematic assessments. They analyse information and data and communicate outcomes as the basis for practice.
- Responsible for the planning and communication of nursing practice. Agreed plans are developed in partnership. They are based on the RN’s appraisal of comprehensive, relevant information, and evidence that is documented and communicated.
- Provide and may delegate, quality and ethical goal-directed actions. These are based on comprehensive and systematic assessment, and the best available evidence to achieve planned and agreed outcomes.
- Take responsibility for the evaluation of practice based on agreed priorities, goals, plans and outcomes and revises practice accordingly.
Registered midwives
- Support the woman’s wellbeing by providing safe, quality midwifery health care using the best available evidence and resources, with the principles of primary health care and cultural safety as foundations for practice.
- Establishes and maintains professional relationships with the woman by engaging purposefully in kind, compassionate and respectful partnerships. The midwife will also engage in professional relationships with other health practitioners, colleagues and/or members of the public. These relationships are conducted within a context of collaboration, mutual trust, respect and cultural safety.
- Accountable to the woman for safe and competent practice. The midwife is also accountable to themselves, the Nursing and Midwifery Board of Australia (NMBA), their employer, the public and the profession for practice that includes ongoing improvement, self-management, and responding to concerns about other health professionals’ capability for practice.
- The midwife, in all contexts of practice, continuously gathers, critically analyses and uses information and evidence to inform, validate and/ or improve midwifery practice.
- Critically analyses information and evidence to make professional judgements in planning for practice.
- Uses comprehensive knowledge and skills to safely and effectively achieve the best possible midwifery practice outcomes.
- Takes responsibility for the evaluation and continuous improvement of practice.
Reflective questions
- What Quality of Care competencies have you already demonstrated during your nursing education?
- What Quality of Care competencies are you most interested in performing next?
IOM Framework of Quality Health Care
A definition of quality that has historically guided the measurement of quality initiatives in health care systems is based on the framework for improvement created by the Institute of Medicine (IOM). The IOM framework includes six criteria for defining quality health care (Agency for Healthcare Research & Quality, 2018; Institute of Medicine (US) Committee on Quality of Health Care in America, 2001).
This framework continues to guide quality improvement initiatives across the health care system. The evidence-based practice (EBP) movement began with the public acknowledgement of unacceptable patient outcomes resulting from a gap between research findings and actual health care practices. For EBP to be successfully adopted and sustained, it must be adopted by nurses and other health care team members, system leaders, and policy makers. Regulations and recognitions are also necessary to promote the adoption of EBP. For example, the Magnet Recognition Program promotes nursing as a leader in catalysing adoption of EBP and using it as a marker of excellence (Stevens, 2013).
Magnet Recognition Program
The Magnet Recognition Program is an award from the American Nurses Credentialing Center (ANCC) that recognises organisational commitment to nursing excellence. The award recognises organisations worldwide where nursing leaders have successfully aligned their nursing strategic goals to improve the organisation’s patient outcomes. To nurses, Magnet Recognition means education and development are available through every stage of their career. To patients, it means quality care is delivered by nurses who are supported to be the best that they can be (American Nurses Credentialing Center, n.d.).
The reach of these programs extends and includes the following Australian Hospitals that have achieved magnet status:
- Princess Alexander (Brisbane)
- Sir Charles Gairdner Hospital (Perth)
- St Vincent’s Private Hospital (Sydney).
Reimbursement models
Quality health care is also defined by value-based reimbursement models used by Medicare, Medicaid, and private insurance companies paying for health services. As discussed in Health Care Reimbursement Models, value-based payment reimbursement models use financial incentives to reward quality health care and positive patient outcomes. For example, Medicare no longer reimburses hospitals to treat patients who acquire certain preventable conditions during their hospital stay, such as pressure injuries or urinary tract infections associated with use of catheters (James, 2012). These reimbursement models directly impact the evidence-based care nurses provide at the bedside and the associated documentation of assessments, interventions, and nursing care plans to ensure quality performance criteria are met.
CMS quality initiatives
The Centers for Medicare & Medicaid Services (CMS) establishes quality initiatives that focus on several key quality measures of health care. These quality measures provide a comprehensive understanding and evaluation of the care an organisation delivers, as well as patients’ responses to the care provided. These quality measures evaluate many areas of health care, including the following:
- health outcomes
- clinical processes
- patient safety
- efficient use of health care resources
- care coordination
- patient engagement in their own care
- patient perceptions of their care (Centers for Medicare & Medicaid Services, 2020).
These measures of quality focus on providing the care the patient needs when the patient needs it, in an affordable, safe, effective manner. It also means engaging and involving the patient so they take ownership in managing their care at home.
Visit CMS’s What is a quality measure.
Accreditation
Accreditation is a review process that determines if an agency is meeting the defined standards of quality determined by the accreditation body. The main accrediting organisations for health care in Australia are:
- The Australian Commission on Safety and Quality In Healthcare
- The Australian Council on Healthcare Standards
- Australian Health Service Safety and Quality Accreditation Scheme.
Accreditation standards aim to improve efficiency, equity, and delivery of high-quality care. Two terms commonly associated with accreditation that are directly related to quality nursing care are core measures and patient safety goals.
Core measures
Core measures are national standards of care and treatment processes for common conditions. These processes are proven to reduce complications and lead to better patient outcomes. Core measure compliance reports show how often a hospital successfully provides recommended treatment for certain medical conditions.
The accreditation process assesses and evaluates healthcare organisations adherence to the following safety and quality safety standards:
- National Safety and Quality Health Service (NSQHS) Standards including the:
- Multi-Purpose Services Aged Care (MPS) Module
- National Clinical Trials Governance Framework
- National Safety and Quality Digital Mental Health (NSQDMH) Standards
- National Safety and Quality Primary and Community Healthcare (NSQPCH) Standards
- Mental Health Standards for Community Managed Organisations
- and any other set of standards that may be developed by the Commission from time to time.
This chapter has identified some of the international quality and safety program utilised to enhance service delivery. The following chapter will further contextualise the concepts of quality and safety in healthcare in the Australian context from governance to the provision of care.
The NSQHS Standards, a collaborative effort between the Commission, the Australian Government, states and territories, private sector providers, clinical experts, patients, and carers, serve dual purposes: safeguarding the public from harm and enhancing the quality of healthcare delivery. These standards, comprising eight comprehensive domains, offer a uniform benchmark that delineates the standard of care consumers can anticipate across health services nationwide.
These include:
- Clinical Governance Standard
- Preventing and Controlling infections Standard
- Comprehensive care standard
- Blood management Standard
- Partnering with Consumers Standard ‘Medication Safety Standard
- Communicating for Safety Standard
- Recognising and responding to clinical deterioration standards.
Clinical care standard comprises of a set of quality statements outlining the care that patients should receive from healthcare professionals and services for a specific clinical condition or defined clinical pathway, aligning with the latest evidence-based practices.
Clinical care standards hold significance in ensuring the delivery of appropriate care and minimising unnecessary discrepancies by specifying and outlining the expected care individuals should receive, irrespective of their location within Australia.
Clinical care standards are used in:
- Acute anaphylaxis
- Acute coronary syndromes
- Acute stroke
- Antimicrobial stewardship
- Cataract
- Colonoscopy
- Delirium
- Heavy menstrual bleeding
- Hip fracture
- Lower back pain
- Management of peripheral intravenous catheters
- Opioid analgesic stewardship in acute pain
- Osteoarthritis of the knee
- Sepsis
- Stillbirth
- Third and fourth perineal tears
- Venous thromboembolism prevention.
References
Agency for Healthcare Research & Quality. (2018, November). Six domains of health care quality. https://www.ahrq.gov/talkingquality/measures/six-domains.html
American Nurses Credentialing Center. (n.d.). ANCC magnet recognition program. https://www.nursingworld.org/organizational-programs/magnet/
American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.
CMS.gov. (2020, February 11). Quality measures. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityMeasures
Institute of Medicine (US) Committee on Quality of Health Care in America. (2001). Crossing the quality chasm: A new health system for the 21st century. National Academies Press. https://pubmed.ncbi.nlm.nih.gov/25057539/
Institute of Medicine (US) Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine. (2011). The future of nursing: Leading change, advancing health. National Academies Press. https://www.ncbi.nlm.nih.gov/books/NBK209880/57413/
James, J. (2012, October 11). Pay-for-performance. Health Affairs. https://www.healthaffairs.org/do/10.1377/hpb20121011.90233/full/
John Hopkins Medicine. (n.d.). Core measures. https://www.hopkinsmedicine.org/patient_safety/core_measures.html
The Joint Commission. (n.d.). Measures. https://www.jointcommission.org/en/measurement/measures/
The Joint Commission. (2021). 2021 national patient safety goals. https://www.jointcommission.org/standards/national-patient-safety-goals/
Stevens, K. R. (2013). The impact of evidence-based practice in nursing and the next big ideas. OJIN: The Online Journal of Issues in Nursing, 18(2), manuscript 4. https://ojin.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol-18-2013/No2-May-2013/Impact-of-Evidence-Based-Practice.html
This chapter is adapted from “Quality care” in Leadership and Management of Nursing Care by Kim Belcik and Open Resources for Nursing, licensed under a Creative Commons Attribution 4.0 International License, except where otherwise noted.
