Quality and Safety in Health Care
Policy Issues
Ellen T. Kurtzman and Jean E. Johnson
“If a physician make a large incision with an operating knife and cure it…he shall receive ten shekels in money. …If a physician make a large incision with the operating knife, and kill him…his hands shall be cut off.”
—Code of Hammurabi, Code of Laws, No. 215, 218; ca 1760 BC
Beginning in the 1990s, the public was besieged with accounts of the United States health system’s failures. Landmark reports including the President’s Advisory Commission on Consumer Protection and Quality in the Health Care Industry, Quality First: Better Health Care for All Americans (1998), and the Institute of Medicine (IOM), Health in Transition: Protecting and Improving Quality (1994), along with media accounts of preventable mistakes (Millenson, 1997; Gibson & Singh, 2003) resulted in a greater awareness among consumers of the prevalence of medical errors and the significant gaps in quality. These accounts were closely followed by the media’s sensationalism of health care’s woes (Knox, 1995; Berens, 2002). Subsequent and ongoing reports of escalating cost (The High Cost of Health Care, 2007)—an increasing investment by the United States and by consumers for mediocre results—caused a public outcry.
In the decade after these events, problems continue to plague the best resourced and technologically advanced health care system in the world. While some of the sensation has dulled, reports continue to portray a system in chaos. IOM reports (Kohn, Corrigan, & Donaldson, 2000; IOM, 2001) have described the U.S. health care system as one that “…harms too frequently and routinely fails to deliver its potential benefits” (IOM, 2001, p. 1). Although some progress has been made, health care continues to be suboptimal, inconsistent, and error-prone in every setting and for all patients.
Annual reports issued by the Agency for Healthcare Research and Quality ([AHRQ] 2009a, 2009b), The Joint Commission (TJC) (2008), and the Commonwealth Fund (2008) reveal only modest improvements among certain populations and clinical conditions. In some cases, outcomes are actually worsening. McGlynn and colleagues (2003) discovered, for example, that among adults receiving care for the most common chronic conditions including asthma, breast cancer, diabetes, and lower back pain, nearly half fail to receive basic recommended care. Dismal performance exists among a handful of the ranking conditions, with adult patients receiving only 11%, 23%, and 25% of recommended care for alcohol dependence, hip fractures, and atrial fibrillation, respectively. For those who are most vulnerable—children and older adults—care is marginal. Fewer than 50% of children (Mangione-Smith, et al., 2007) and 52% of older adults (Asch, et al., 2006) receive recommended care. Alarmingly, quality lapses persist among patients in long-term care settings including nursing homes, home health care agencies, and hospices (AHRQ, 2009b).
This chapter will review a decade of federal policymaking intended to address health care value with a particular focus on the implications for nurses and the nursing profession. We will describe the critical factors above and beyond the inadequacies in quality that have contributed to the current political context, and we will discuss key organizations involved in the quality enterprise and their contributions. We will also provide examples that include Medicare’s hospital-acquired conditions rule and the emergence of public-private partnerships such as the Nursing Alliance for Quality Care (NAQC).
The Environmental Context
While ongoing underperformance has garnered the attention of consumers, providers, policymakers, and payers, there are other environmental influences that have motivated and enabled a 10-year stretch of policy setting. Most notably, shortfalls in quality have been accompanied by a growing, excessive investment in the health care system—more than $2.3 trillion and an estimated 16.2% of the gross domestic product (GDP) in 2008, up from 15.9% in 2007 (Hartman, Martin, Nunccio, Catlin, and the National Health Expenditures Account Team, 2010). By 2018, analysts estimate that health care spending in the U.S. is expected to nearly double from current levels, reaching $4.3 trillion and consuming 20.3% of the nation’s GDP (Sisko et al., 2009). Notable for 2008 was that the rate of growth of health care (4.4%) was the lowest in nearly 50 years due primarily to the recession. But, as the economy improves, the rate of cost increases is expected to accelerate again.
Undoubtedly, these investments have led to advancements in knowledge, technology, and innovation; however, while the U.S. surpasses other developed countries in spending and may outshine these nations in scientific advancements, outcomes lag for key indicators such as preterm births, infant mortality, and life expectancy (Hussey, et al., 2004; Reinhardt, Hussey, & Anderson, 2004). The nation simply cannot afford to keep paying exponentially more for health care without an equivalent improvement in quality.
Threats to health care access, quality, and costs have not been lost on patients, their families, or the public. Since the 1980s, the U.S. has experienced a rise in consumerism, generally, and a growth in consumer-driven health care, specifically (U.S. Congress, Office of Technology Assessment, 1988; Robinson & Ginsburg, 2009). Product information is more readily available than ever before. The growth of electronic media and performance ratings has led to a public that is a highly informed purchaser of supplies and products. The richness in performance data and the speed in which these data migrate through distribution channels have enabled activists to demand the same for health care.
The dissemination of performance results is a natural extension of this consumerism and an intentional response by policymakers to the growing problems. The 1998 President’s Advisory Commission on Consumer Protection and Quality in the Health Care Industry viewed consumers as central players in improving quality and driving value. In its report, the Commission recommended that, “mobilizing the full power of the marketplace to improve health care quality requires that the power of the individual consumer be maximized” (p. 115). The result has been a proliferation of provider-level performance reports that enable competitive comparisons (Marshall, Shekelle, Davies, & Smith, 2003). Health care, like other goods and services, is now seen as a commodity, and consumer choice is a vehicle to drive selection.
The Policy Context: Value-Driven Health Care
Value-driven health care or high-value health care are terms that typically refer to improving the quality of care while lowering or stabilizing its costs. In technical terms, value is “a specified stakeholder’s… preference-weighted assessment of a particular combination of quality and cost of care performance” (National Quality Forum [NQF], 2009, p. 61). In simple terms, value is obtaining more quality for the same investment. In recent years, intentions have shifted from merely improving the state of health care quality and safety to improving the value and efficiency of care. For the federal government, which operates Medicare—the nation’s largest health insurance program covering more than 45 million Americans (The Boards of Trustees, Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds, 2009)—achieving value is dependent on the government moving “from a passive payer of services into an active purchaser of higher-quality, affordable care” (U.S. Department of Health and Human Services [USDHHS], 2009).
In the years that have elapsed since the Commission’s report was published, the federal government has taken deliberate steps in this transformation. On August 22, 2006, then-President George W. Bush’s signed Executive Order 13410 (2006) to “…promote quality and efficient delivery of health care through the use of health information technology, transparency regarding health care quality and price, and better incentives for program beneficiaries, enrollees, and providers.” The Order effectively directed federal agencies to gather cost and quality outcomes and to publicly report performance results to their beneficiaries and enrollees. The government’s “value” agenda has relied on a three-pronged strategy embodied in this Executive Order and referred to as the quality enterprise: transparency in cost and quality, accountability for performance, and performance-based incentives to stimulate quality improvement.
Within the health care context, transparency and accountability are terms that typically refer to activities aimed at measuring and publicly disclosing provider performance along with a complementary set of tools that reward—typically through financial payments—high performance (USDHHS, 2009; JCAHO, 1994). Taken together, transparency and accountability are approaches to drive quality improvement and stimulate consumer choice. And while the Executive Order of 2006 placed a spotlight on efforts to drive higher value, the building blocks of transparency and accountability—performance measurement, public reporting, and value-based purchasing—were already in place. Table 48-1 provides a list of these building blocks and the key milestones in their development. A brief description follows.
TABLE 48-1
Decade of Emphasis on High-Value Health Care: Key Milestones
| 1997 | Clinton Advisory Commission on Consumer Protection and Quality in the Health Care Industry delivers Quality First |
| 1998 | The Joint Commission introduces ORYX initiative |
| 1999 | National Quality Forum (NQF) is established |
| 2000 | IOM releases the report, To Err Is Human |
| 2001 | IOM releases the report, Crossing the Quality Chasm HHS announces the Hospital Quality Initiative CMS launches Dialysis Facility Compare |
| 2002 | Joint Commission–accredited hospitals begin collecting data on standardized (i.e., “core”) performance measures Public-private partnerships emerge (HQA—2002, AQA—2004, PQA—2006) Nursing Home Compare is launched by CMS |
| 2003 | Medicare Prescription Drug, Improvement and Modernization Act (MMA) of 2003 and Reporting Hospital Quality Data or Annual Payment Update (RHQDAPU) are introduced CMS launches Home Health Care Compare |
| 2004 | NQF endorses 15 voluntary consensus standards for nursing-sensitive care |
| 2005 | Deficit Reduction Act of 2005 expands RHQDAPU CMS launches Hospital Compare IOM releases the report, Performance Measurement: Accelerating Improvement Massachusetts launches Patients First, a public website that portrays the quality of hospital care among Massachusetts hospitals including the portrayal of nursing-sensitive performance measures |
| 2006 | Executive Order 13410, Promoting Quality and Efficient Health Care, is issued Quality Alliance Steering Committee (QASC) is established IOM releases the report, Rewarding Provider Performance: Aligning Incentives in Medicare Maine statute through 22 M.R.S.A. §8708-A, Chapter 270 requires public reporting of nursing-sensitive performance measures |
| 2007 | Physician Quality Reporting Initiative (PQRI) is launched Report to Congress on hospital value-based purchasing is submitted |
| 2008 | HCAHPS data are included in Hospital Compare CMS’s hospital-acquired conditions policy is implemented National Priorities Partnership (NPP) announces national goals to transform health care |
| 2009 | Barack Obama is inaugurated as 44th president of the United States Stand for Quality is released Health care reform efforts begin |
| 2010 | LTQA is launched NAQC is launched Health reform legislation stalls and then is enacted |
Performance Measurement
Transparency is dependent on performance measures that accurately portray the features of the health care system. Because public reporting and performance-based incentives cannot exist in the absence of cost and quality outcomes on which they are based, performance measurement is a precursor to public reporting and accountability.
Health care performance measurement is not a new phenomenon. Florence Nightingale, the mother of contemporary nursing, had, in fact, recognized the virtues of measurement in her effort to explain inpatient mortality rates following the Crimean War (Nightingale, 1863). It was Nightingale who pioneered the systematic collection and analysis of hospital mortality rates that enabled comparative reporting and quality improvements in the UK’s public health system (McDonald, 2001). She was the first to use a pie chart to organize and display data collected on mortality to convince others of the need for change in care procedures. Her legacy was perpetuated by more contemporary proponents of performance measurement including Ernest Codman, Walter Shewhart, W. Edwards Deming, Joseph Juran, and Avedis Donabedian.
Performance measurement is foundational to high-value health care. The IOM’s report, Performance Measurement: Accelerating Improvement, noted: “Many proposals have been offered to improve and reform the functioning of the health care marketplace. … While each of these proposals is based on a different set of assumptions and values … all would require performance measures to achieve their goals.” (2006, p. 30). Since recognizing its virtues and acknowledging its necessity, hundreds of quality measures have been developed by government agencies (e.g., Centers for Medicare & Medicaid Services [CMS], Agency for Healthcare Research and Quality [AHRQ]), accreditation organizations (e.g., TJC, National Committee on Quality Assurance), professional societies and certification boards (e.g., American Medical Association-Physician Consortium for Performance Improvement, American Board of Medical Specialties), quality improvement organizations, and private organizations.
Nursing has made a significant investment in and contribution to performance measurement. Measures that portray nurses’ contributions to high-quality inpatient care, referred to as “nursing-sensitive measures,” have been developed, tested, and implemented by organizations such as the American Nurses Association, Veterans Health Administration, and Association of periOperative Registered Nurses (Kurtzman, Dawson, & Johnson, 2008). Consensus has been achieved among diverse stakeholders on the usefulness of measuring nursing’s contribution to quality as evidenced by the adoption of nursing-sensitive measures by the CMS and TJC.
Public Reporting
Measurement alone is not a remedy to the nation’s aforementioned problems. In fact, it is widely acknowledged that improvements in quality are motivated, if not driven, by public disclosure of performance results (Lansky, 2002). As a result, a sizable increase in the number of provider-level performance reports has been realized (Schneider & Lieberman, 2001; Marshall et al., 2003; Epstein, 1998). As of 2009, the AHRQ listed over 200 examples of performance reports in its online Health Care Report Card Compendium. A growing number of reports are available through websites created and sustained by the CMS including Hospital Compare, Nursing Home Compare, Home Health Compare, and Dialysis Compare. Some states, regional collaboratives, managed care organizations, commercial health insurers, and professional organizations and societies also provide performance reports with the intended purpose of enabling provider-level comparisons. So too has the demand for high-value health care led to public reporting of performance by such sponsors as HealthGrades and Consumer Reports, which have appealed to the consumer audience.
It is notable that a number of publicly disclosed performance reports are specific to the value of nursing. At least two states publicly report hospital-level nursing-sensitive performance on measures. In the case of Maine, state statute 22 M.R.S.A. §8708-A, Chapter 270, requires uniform statewide reporting of data related to health care quality including nursing-sensitive measures. A voluntary initiative undertaken by the Massachusetts Hospital Association and Massachusetts Organization of Nurse Executives, and referred to as Patient’s First, led to the public disclosure of hospital-level nursing-sensitive measures. While these are public reporting initiatives that are specific to nursing care, other reports—including the CMS’s Hospital Compare—include at least one or more measures that have been specified as nursing-sensitive.
While the CMS does not devote a dedicated public report to nursing care quality per se, several measures that address nursing care have been incorporated into Hospital Compare. In 2008, for example, performance results from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), which includes several measures related to nursing care, were posted to the website. In 2009, “failure to rescue” was added as a required measure under the Reporting Hospital Quality Data or Annual Payment Update (RHQDAPU) program. Since the CMS typically draws measures for public reporting on Hospital Compare from those that are required through the RHQDAPU, failure to rescue is likely to be publicly reported in the future.
The proliferation of performance measures and the growth in public reporting led, at least in part, to the need for and the establishment of the National Quality Forum (NQF). The NQF was established in 1999 as a voluntary consensus standards-setting organization as defined by the National Technology Transfer and Advancement Act of 1995 and the Office of Management and Budget’s (OMB) Circular A-119. In its early years, NQF work focused on the identification, examination, and consensual endorsement of uniform health care measurement and reporting standards (Kizer, 2001). It is in this spirit that the NQF endorsed a set of national voluntary consensus standards for nursing-sensitive care (2004) that reflect nursing’s contribution to high-quality inpatient care. Since its inception, the NQF’s role has expanded beyond the endorsement of measurement and reporting standards to one in which it also establishes national priorities for quality and safety and works with stakeholders to systematically implement the measures.
Despite these substantial efforts to standardize measurement and reporting, evidence is equivocal about the direct link between disclosure of health care performance and improvements in quality of care. A 2009 systematic review, for example, found a number of studies across settings in which reporting stimulated quality improvement activities but found no associations or mixed associations between public reporting and provider selection, greater effectiveness, safety, and patient-centeredness (Fung, Lim, Mattke, Damberg, & Shekelle, 2008). Studies of postacute care (Werner et al., 2009; Werner, Konetzka, & Kruse, 2009) found that public reporting has resulted in some improvements in selected quality measures, but there is evidence of widening gaps between high and low performers and declining quality scores on other measures. The 2006 IOM report on performance measurement acknowledged the absence of strong evidence linking performance measurement and reporting to value and recommended a greater federal investment for evaluation.
Performance-Based Incentives
A central component of high-value health care is the use of incentives—“arrangements that reward both those who offer and those who purchase high-quality, competitively-priced health care” (USDHHS, 2009)—that typically take the form of pay-for-performance or consumer-directed rewards programs.
In June 2003, the Medicare Advisory Payment Commission (MedPAC) examined the need to accelerate improvements in care and concluded that Medicare must lead efforts to improve quality through financial incentives (MedPAC, 2003). Since MedPAC issued its report, there has been a growth in performance-based incentive programs. While many of these programs have been initiated in the private sector (Baker & Carter, 2004-2005), the Medicare Program has taken the lead in pursuing performance-based payment with a goal of fostering clinical and financial accountability. Demonstrations have been conducted in hospitals, physician offices, and dialysis facilities, as well as in chronic care and long-term care (IOM, 2007). A 2007 report to Congress described a Medicare hospital pay-for-performance program that would incentivize hospitals for improvements in quality and sustained performance (CMS, 2007).
More contemporary applications of performance-based incentives include Medicare’s existing hospital-acquired conditions policy and innovations enacted under health reform including bundled payments, the patient-centered medical home, and accountable care organizations (ACOs). Bundled payments are also referred to as episode-based payment or case rates. Conceptually, a bundled payment provides a single payment that covers all services related to a condition or treatment. This could include physician visits, laboratory tests, hospitalization, and any other service needed. Under health reform legislation, demonstration projects were authorized to evaluate the use of bundled payments for Medicare beneficiaries that include a hospitalization and concurrent physician services. The bundled payment approach is a significant departure from the current system in which every service and provider is billed separately and is intended to provide incentives to providers to eliminate care that has limited to no benefit. The patient-centered medical home, a concept introduced by the American Academy of Pediatrics (AAP) and promoted by the AAP, the American Academy of Family Physicians, the American College of Physicians, and the American Osteopathic Association (2007) extends the concept of primary care to include an emphasis on improving outpatient care and engaging patients in health care decision making. Health reform legislation also enacts a shared savings program through ACOs. ACOs are groups of providers, including practitioners and suppliers who have an established shared governance arrangement operating in group practice arrangements, networks, or joint ventures, that are responsible for the quality, cost, and overall care of the assigned Medicare fee-for-service beneficiaries. ACOs are an effort to improve the efficiency through better care coordination, investment in infrastructure, and redesigned care processes. Those that deliver better care will receive financial bonuses (Devers & Berenson, 2009). While the details of each are unique, they effectively shift payment away from rewarding volume with the intention of stimulating more efficient use of resources, cost efficiencies, and more coordination within and across providers. The government’s swift adoption of performance-based payment policy is not yet matched with definitive results of its effectiveness. A number of studies and systematic reviews of the relationship between hospital pay-for-performance and quality (Rosenthal & Frank, 2006; Christianson, Leatherman, & Sutherland, 2008; Mehrotra, Damberg, Sorbero, & Teleki, 2009) have discovered significant, positive effects that have been somewhat mitigated by design limitations (e.g., small sample size, lack of comparison group, measure selection). Despite the equivocal nature of the evidence, the federal government is proceeding with its plan to reward high and penalize low performers.
The Affordable Care Act of 2010 includes provisions designed to stimulate high-value health care, including the development of performance measures and public reporting infrastructures. Demonstration and pilot projects will test approaches to bundled payments, ACOs, performance-based incentives, care coordination, transitional care, comparative effectiveness research, workforce capacity-building, nurse-managed health centers, and prevention and wellness. The aim is clearly to maintain and expand the existing value-driven health care agenda.
The Role of Public-Private Partnerships
Public-private partnerships have emerged to facilitate the role of the federal government in driving a high-value agenda by avoiding the protracted rule-making process. A number of these partnerships, referred to as quality “alliances,” exist and actively participate in the quality enterprise. Their role ranges from developing and testing performance measures (or contracting for those activities) to adopting implementation measures for public reporting and promoting quality improvement initiatives and the use of measures to support these improvement activities.
The Hospital Quality Alliance (HQA), established in 2002, was the first of these partnerships. Its membership includes hospitals, purchasers, government agencies, health plans, quality groups, and consumers for the purpose of making “meaningful, relevant, and easily understood information about hospital performance accessible to the public and to [inform] and [encourage] efforts to improve quality” (Hospital Quality Alliance, n.d.). Since its establishment, a number of other quality alliances have been established. These include the AQA (formerly known as the Ambulatory Care Quality Alliance), the Pharmacy Quality Alliance, the Alliance for Pediatric Quality, the Cancer Quality Alliance, the Surgical Quality Alliance, and the Kidney Care Quality Alliance.
In 2010, the NAQC was launched to provide a policy voice for nursing in the transparency and accountability agenda. The NAQC is a bold partnership among the nation’s leading nursing organizations to “advance the highest quality, safety, and value of consumer-centered health care for all individuals—patients, families, and communities.” To achieve this aim, the NAQC works to strengthen the visibility of nursing in performance measurement and public reporting activities, serves as a resource to federal partners in health care delivery and payment reform, and builds nursing’s capacity to serve in leadership roles that advance consumer-centered, high-quality health care. While the NAQC is a new public-private partnership, significant gains will be realized from having an informed and persuasive nursing presence.
Value-Driven Health Care and Nursing
As is evident, an enormous commitment in the quality enterprise has been made and has resulted in an infrastructure for transparency and accountability. While this infrastructure is not specifically designed to recognize nursing’s contributions nor align with it, nurses both impact and are impacted by this infrastructure and its by-products.
Most importantly, based on every indication, the policy directions of the last decade will be perpetuated and possibly accelerated. There will be more pressure on providers to provide higher value care. Nurses are exceedingly well positioned to deliver on that expectation. First, nurses are the single largest provider of health care in the U.S. (Bureau of Labor Statistics, n.d.) and frequent points of patient contact in many care settings. By sheer size, nurses represent a sizable workforce that could alter the value equation. Beyond size, however, associations between nursing and high-value health care have been demonstrated. A growing evidence base substantiates that nurse staffing effects outcomes in acute care settings (Kane, Shamliyan, Mueller, Duval, & Wilt, 2007). Researchers have begun to look at the effect of hospital nursing on economic indicators with signs of positive impact (Needleman, Buerhaus, Stewart, Zelevinsky, & Mattke, 2006; Dall, Chen, Seifert, Maddox, & Hogan, 2009); and a number of rigorous studies recognize the value of advanced practice nurses in primary care settings (Horrocks, Anderson, & Salisbury, 2002; Laurant et al., 2005; Eibner, Hussey, Ridgely, & McGlynn, 2009).
Restructuring the quality enterprise in such a way that it takes advantage of nursing’s contributions is an obvious solution; however, it will require continued development of nursing-sensitive measures, public reporting of these data, and advocacy by nurses for the inclusion of these performance measures in transparency and accountability initiatives. It is especially important to note that because the components of the existing infrastructure that reflect nursing have emphasized inpatient care, nursing should advocate or assume responsibility for the development and implementation of measures that reflect high value across settings, including care delivered by postacute, primary, long-term, and public health providers.
Second, while no federal performance-based payment program targets nurses per se, Medicare’s hospital-acquired conditions policy represents a value-based purchasing initiative that reflects the care delivered by hospital nurses and provides a “glimpse” into how future policies are likely to affect nursing. The policy eliminates certain Medicare payments for the occurrence of preventable and costly inpatient complications including several nursing-sensitive outcomes, and effectively creates a link between hospital revenue and nursing care. This link and the policy on which it is based present both an opportunity and threat for hospital nurses. A range of responses to the policy have been described in the literature (Wachter, Foster, & Dudley, 2008; Rosenthal, 2007). On the positive side, it can be argued that better nursing care results in higher Medicare reimbursement, and this is likely to be viewed favorably by hospital executives and give nurses more economic clout. On the other hand, hospitals experiencing reductions in Medicare revenue may take cost-saving measures that ultimately weaken the ability of nurses to maintain quality on the very outcomes for which reimbursement is being modified. Blaming behaviors directed at nurses who may be assumed to be responsible for these conditions could render the workforce incapable of teamwork, cooperation, or shared accountability (Kurtzman, 2007).
Recent evidence supports this possibility. Nurses who were surveyed about the effects of this hospital-acquired-conditions policy reported some positive effects—greater emphasis on prevention and surveillance activities and additional education and training. However, the nurses also identified negative effects including additional work and blame directed at them for the occurrence of these events (Buerhaus, Donelan, DesRoches, & Hess, 2009). These early warning signals suggest that this performance-based payment policy could weaken the nursing workforce and should be closely monitored and swiftly mitigated by (among other strategies) using data to substantiate nursing’s economic contributions, emphasizing a nonpunitive environment through “just culture” and structured teams, and systematic adoption of evidence-based nursing care to early identify and treat complications (Kurtzman & Buerhaus, 2008).
Finally, emphasis on value-driven health care by policymakers demonstrates the importance of nurses as active collaborators and contributors to policy development. Studies have found that nurses’ vivid anecdotes from first-hand involvement in health care are reported to be extremely powerful—making nurses very persuasive advocates (Gebbie, Wakefield, & Kerfoot, 2000). However, multiple barriers (e.g., socialization to the political process, time constraints) prevent nurses from contributing meaningfully (Winter & Lockhart, 1997). Findings from a national poll of opinion leaders conducted by the Gallup Organization in 2009 confirm these findings. Despite these leaders’ views of nurses as trusted sources of health information, they considered nursing’s influence on health policy to be eclipsed by that of government officials, insurance and pharmaceutical executives, health care executives, physicians, and patients (Gallup, Inc., 2010).
The administration’s ongoing commitment to the quality enterprise heightens the need for a stronger nursing presence. The NAQC and other advocacy groups should actively pursue a course that will awaken nursing’s interest in these policy directions and stimulate policymakers’ reliance on nurses.
For a list of related websites, please refer to your Evolve Resources at http://evolve.elsevier.com/Mason/policypolitics/
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