Policy and Politics in the Contemporary Work Environment

Pamela Thompson, Laura Caramanica, Elaine Cohen, Patricia Reid Ponte and Rose Sherman

“Far and away the best prize that life offers is the chance to work hard at work worth doing.”

—Theodore Roosevelt

The most important contemporary issues in the health care workplace are ultimately related to the ability of the health care system and practitioners to provide high-quality and safe care. There are several key elements that capture the essence of these issues. First, the drivers that demonstrate how we know we are providing safe and high-quality care are the measurable outcomes. Second, the delivery of consistent and sustainable quality outcomes is dependent on the performance of the health care team. Third, technology is quickly becoming a critical element that can support the health care team to achieve the desired outcomes. Finally, all of these issues come together when we consider the financial implications of providing quality care.

This chapter will explore some of the major policy issues in the workplace related to these key elements. Who decides what “quality” is and how it is done? How do we create and maintain environments that support high-reliability teams? How is nursing engaged in the deployment of technology? And how do we blend the control of cost by expenditure reduction with the ethics of delivering appropriate care?

Assuring Quality, Safety, and Reliability

Agencies Leading Quality and Safety Efforts

Quality and safety in health care have emerged as a key focus of consumer attention since the Institute of Medicine (IOM) reports about medical errors (2000, 2001, 2004) drew attention to medication error rates and prevention, patient safety, and quality. In the wake of these events, local and national regulatory agencies, insurers, health plans, and state and federal payers such as The Joint Commission (TJC), the Center for Medicare and Medicaid Services, and Blue Cross & Blue Shield have set new quality and safety standards. The goal of these standards is to assure positive patient outcomes by guiding providers, clinicians, and organizational performance. National quality and safety associations, funding agencies, and discipline-specific boards and agencies, such as the National Quality Forum (NQF), the National Patient Safety Foundation, the American Organization of Nurse Executives (AONE), the Agency for Healthcare Research and Quality (AHRQ), the American Medical Association (AMA), the American Nurses Association (ANA), and, most recently, the National Alliance for Nursing Quality and Safety (NQSF), have committed their constituencies to develop new knowledge and disseminate evidenced-based best practices in quality, safety, and patient outcomes (Kurtzman, 2009).

Quality and safety have also become a focus for organizations dedicated to educating clinicians. Academic institutions are beginning to integrate quality and safety topics into undergraduate curriculums using the content identified by the Quality and Safety Education for Nurses (QSEN) project (QSEN, 2010). Continuing education for current providers has also been addressed. Organizations such as the Institute for Health Improvement and Intermountain Health Care, whose missions include the development and teaching of best practices for effective, efficient, patient-centered, equitable, safe, and timely care delivery, have developed state-of-the-art provider- and clinician-directed training programs (IOM, 2001). These programs use the fundamental and foundational work of early industrial engineers such as Shewhart (1938), Deming (1982, 1986), and Juran (1951), and the groundbreaking health quality work of Donabedian (1980, 1982, 1985). These individuals developed theory and content on waste and variation reduction related to structure, process, and outcomes that were first applied to industry and later to health care services. General Electric’s Six Sigma program (General Electric, 2009) and Toyota’s Lean program (Liker, 2004) are examples of their application in industry.

Award Programs

Additionally, award programs for excellence in organizational performance have embraced measures and criteria related to quality and safety as core requirements for recognition. Examples of such award programs include the American Nurses Credentialing Center’s Magnet Recognition Program (American Nurses Credentialing Center, 2010), the American Association of Critical Care Nurses’ Beacon Award (American Association of Critical Care Nurses, 2009), and the Baldrige National Quality Program’s Malcolm Baldrige National Quality Award (National Institute of Standards and Technology, 2010). Finally, consumer organizations such as the AARP and the Institute for Family-Centered Care have begun to provide strong coalitions of patients, families, and citizens that demand a voice in assuring quality and safety in health care organizations.

All of these factors have set the stage for a highly interactive and inclusive culture that places quality and safety at the highest level of value during a decade fraught with commensurate increases in the cost of care. Consumers understand and want the safest and highest-quality care and related outcomes. Providers, clinicians, health organizations, insurers, and government want to deliver this high-quality care. However, the costs of care continue to soar due to inefficiencies, heavy administrative cost structures, and high numbers of uninsured Americans. This will require complex changes in policy and health care delivery processes.

On March 23, 2010, President Barack Obama signed into law the Affordable Care Act (ACA). This reform bill is the largest change to the health care system since the creation of Medicare and Medicaid. The bill addresses coverage, insurance reform, key delivery system reforms, workforce education, wellness and prevention, and payment reform. Cost and quality are key components in most aspects of the legislation. Implementation of all of the elements in the legislation will not take place until 2014, but it is clear that there will be significant and profound changes over the coming years.

Health Care Teams: Communication and Patient Safety

The second organizing concept to assure the attainment of meaningful and healthy patient outcomes involves coordination: among patient, family, and health care providers; between patient and caregiver; between nurse and physician, and among every member of the interdisciplinary team. The importance of forging these relationships is the basis of the IOM 2001 report, Crossing the Quality Chasm: A New Health System for the 21st Century, which focuses on the value that teamwork, collaboration, and effective communication have on positive patient outcomes. National efforts to put into operation the IOM aims of safe, timely, effective, efficient, and equitable care have resulted in a powerful partnership with the Robert Wood Johnson Foundation and the Institute for Healthcare Improvement (IHI) to improve hospital work environments. Their joint involvement led to the development of the Transforming Care at the Bedside (TCAB) model, which includes four elements: Safe and Reliable Care; Vitality and Teamwork; Patient-Centered Care; and Value-Added Care Processes (Rutherford et al., 2004, 2008) (see Chapter 54). The American Organization of Nurse Executives (AONE) has made TCAB a major initiative and added nurse manager leadership development, shared decision making, and nurse ownership of practice as additional key design themes.

Recognizing the importance of communicating accurate information to meet patient safety goals, TJC 2009 National Patient Safety Goals recommend developing a standardized approach to multiple types of “hand-off” communication (TJC, 2008a). Through their Nurse Manager Fellowship, AONE laid the foundation for the importance of collaboration and communication on a broader level (AONE 2008). Various academic partnerships use the principles of TCAB in their curriculum (AHRQ/TeamSTEPPS, 2007) to engage students to promote safe and reliable care. Various communication methodologies aimed at improving the safety of patients are being used in the clinical environments (Box 47-1). These are examples of promoting and ensuring connectedness and coordination of care, good communication, and positive patient outcomes.

BOX 47-1

Communication Methodologies

SBAR: The use of a standard communication formula of describing the Situation, Background of situation, Assessment of what is happening, and Recommendation for what is needed to address the situation. Following the SBAR streamlines clinician dialogue around patient care.

Intentional Rounding: Patient rounding to explore safety issues by asking staff if they see any issues that relate to safety.

Safety Huddles: Unit staff meeting for short sessions on a routine basis to discuss safety issues that have been observed.

Teamwork and Team Training

Hamman (2004) demonstrated that team training is an effective tool to improve operational performance of team members. Team training is a complex set of processes that requires an organizational commitment. Organizations must provide skill building and agreement by team leaders and members to be successful. Those that do are more likely to improve care delivery processes and outcomes.

The team training models in health care have arisen from the aviation experience with teamwork measurement aimed at preventing and mitigating error. The training approach draws on early educational theory and involves the systemic acquisition of knowledge (what we think), skills (what we do), and attitudes (what we feel)—known as “KSAs”—and leads to ideally improved performance. Cronenwett, Sherwood, and Gelmon (2009) used this approach in their framework for developing undergraduate nursing curriculum for quality and safety, in which interdisciplinary teamwork and collaboration are major components.

Team training approaches often include a method for task analysis of the team’s work within the given practice, the development of behavioral standards and expectations related to closed- loop communication and decision-making approaches and parameters, practice tools that help facilitate standardized processes of communication, mechanisms for ongoing team maintenance, and team building and team development (QSEN, 2010). Team training approaches consist of simulation exercises and the development or use of standardized measures of team effectiveness. These measures or markers may consist of team process attributes such as (1) information sharing; (2) inquiry; (3) assertion; (4) intentions shared; (5) teaching; (6) evaluation of plans; (7) workload management; (8) vigilance/environmental/situational awareness; (9) teamwork overall; and (10) leadership (Thomas, Sexton, and Helmrich, 2004; Burke, Salas, Wilson-Donnelly, & Priest, 2004; Hamman, 2004).