Objectives

After reading this chapter, the student should be able to do the following:

Although the concept of quality assurance has been a part of the health care arena for a number of years, it is only in the last few years that major movement to improve health care quality has begun in the United States. The Institute of Medicine (IOM, 2001), not confident of the current health care systems’ ability to deliver the quality of care expected, set forth a series of recommendations to transform current systems to meet American’s expectations. Very little is known about quality of care in this country for two reasons: (1) a variety of definitions of quality are used, and (2) it is difficult to obtain comparable data from all providers and health care agencies.

However, in the Healthcare Research and Quality Act of 1999 (PL 106-129), Congress mandated that the Agency for Healthcare Research and Quality (AHRQ) produce an annual report on health care quality in the United States beginning in fiscal year 2003. This National Healthcare Quality Report (NHQR) is a collaborative effort among the agencies of the U.S. Department of Health and Human Services (USDHHS) and includes a broad set of performance measures that will be used to monitor the nation’s progress toward improved health care quality. The NHQR represents the broadest examination of quality of health care, in terms of number of measures and number of dimensions of care, ever undertaken in the United States. The report represents progress toward improving quality as well as recommendations for how to improve quality outcomes (USDHHS, 2007).

The NHQR is intended to serve a number of purposes, such as demonstrating the validity (or lack) of concerns about quality, documenting whether health care quality is stable, improving, or declining over time and providing national benchmarks against which specific states, health plans, and providers can compare their performance (AHRQ, 2002; NCQA, 2009).

In a changing health care market, the demand for quality has become a rallying point for health care consumers. All consumers, including private citizens, insurance companies, industry, and the federal government, are concerned with the highest quality outcomes at the lowest cost (Wakefield and Wakefield, 2008). In addition to the demand for higher quality and lower cost, the public wants health care delivered with greater access, and health care that is accountable, efficient, and effective. Moreover, consumers want information about quality. Information is empowering to the consumer. With the expanded use of the Internet, access to information about quality in health care is readily available in topics ranging from talking to consumers about quality health care (http://www.talkingquality.gov) to clinical practice guidelines that promise to improve care for all (http://www.guideline.gov). Total quality management (TQM) is a management philosophy that includes a focus on client, continuous quality improvement (CQI), and teamwork (Kelly, 2007). Although relatively new in public health care, the concepts of TQM/CQI has been tried and proven in industry at large. The terms total quality management, continuous quality improvement, total quality, and organization-wide quality improvement are often used interchangeably. However, they have different meanings. As indicated, TQM refers to a management philosophy that focuses on the statistical processes by which to assess work done with the goal of organization-wide quality effectiveness. The term for TQM is often referred to as TQ, and both acronyms have the same meaning. CQI, while different from the other three terms, can be implemented not only to address system problems, but also to maintain and enhance good performance through the use of differing techniques. Everyone in the public health or community-based organization is involved in CQI, the leaders, the staff, and the client. By obtaining facts about work processes (e.g., all the steps in certifying a child for the women, infants, and children nutritional program [WIC]), it is possible to discover which steps are unnecessary (i.e., non–value adding) and to eliminate those steps to produce better health outcomes for individuals and communities (Carmichael, 2005). Box 26-1 presents several abbreviations that are commonly used in health care and quality management.

Both consumers and providers have a vested interest in the quality of the health care system.

Kovner and Jonas state that in health care there is a direct link between doing a good job and individual and professional survival. Health care providers pride themselves on individual achievement and responsibility for good client outcomes (Kovner and Knickman, 2008). Health care organizations are natural extensions of health care providers and thus can demonstrate their responsibility for optimal outcomes through a rigorous quality improvement process. The application of quality improvement strategies through six areas of performance could affect both process and outcomes of health care:

In the 1990s the United States entered a new era of population-centered, community-controlled delivery of care in which managed care organizations (MCOs) played an integral role. MCOs are agencies such as health maintenance organizations (HMOs) and preferred provider organizations (PPOs) designed to monitor and deliver health care services within a specific budget. Currently, providers, clients, payers, and policy makers all have input into the quality measurement process. The Health Plan Employer Data and Information Set (HEDIS), a data collection arm of the National Committee for Quality Assurance (NCQA), provides performance information, or report cards, for MCOs. In 2009, 702 HMOs and 277 PPOs reported audited HEDIS data to show the level of quality performance. These MCOs covered 116 million, or 2 in 5 Americans in that year (NCQA, 2009).

Although introduced in the 1990s, report cards for public health agencies are currently being developed and promoted to measure quality health care in communities. The term community health report card refers to different types of reports, community health profiles, needs assessments, scorecards, quality of life indicators, health status reports, and progress reports. All of these reports are critical components of community-based approaches to improving the health and quality of life of communities.

An example at the national level is the Community Health Status Indicator (CHSI) Project, which is a collaborative effort between the Health Resources and Services Administration (HRSA), the Association of State and Territorial Health Officials (ASTHO), the National Association of County and City Health Officials (NACCHO), and the Public Health Foundation. In 2000, the project published and disseminated community health status reports for all U.S. counties. These reports provided county-level data, including peer county and national comparisons, for every county in the country. The goal of CHSI is to provide an overview of key health indicators for local communities and to encourage dialogue about actions that can be taken to improve a community’s health. The CHSI report was designed not only for public health professionals, but also for members of the community who are interested in the health of their community. They are designed to support health planning by local health departments, local health planners, community residents, and others interested in community health improvement. The CHSI report contains over 200 measures for each of the 3141 United States counties. Although CHSI presents indicators like deaths resulting from heart disease and cancer, it is imperative to understand that behavioral factors such as tobacco use, diet, physical activity, alcohol and drug use, and sexual behavior substantially contribute to these deaths (Metzler et al, 2008).

These community health improvement initiatives have grown out of three major trends: (1) an increasing recognition of the importance of local community action to solve local problems, (2) an increasing emphasis on outcomes and accountability, and (3) the Healthy Cities/Healthy Communities movement (see Chapter 20). The Healthy Cities/Healthy Communities movement views community health and its determinants broadly, and they use a set of indicators (to track their progress) that reflects this broad definition. These indicators might include the following:

Community health report cards can be a useful tool in efforts to help identify areas where change is needed, to set priorities for action, and to track changes in population health over time. The report card may be used to track leading causes of morbidity and mortality in a community, looking at trends over time to see if public health interventions have improved health care outcomes. The card may also be used to assess a specific chronic disease, like diabetes, to determine the health status of the community for this particular disease (CDC, 2010). The report card may be used as an internal measure of public health program outcomes and CQI measures within the agency (Gunzenhauser et al, 2010).

In 2009, HEDIS measures of care included several that address public health issues, including breast and cervical cancer screening, childhood immunization status, comprehensive diabetes care, flu shots for adults, lead screening in children, physical activity in older adults, and prenatal and postpartum care, to name a few (NCQA, 2009).

As a part of a movement to provide quality health care in communities, health departments are increasingly examining their place in promoting quality (USDHHS, 2005b). McLaughlin and Kaluzny (2006) state that public health and CQI are connected because of the use of systems approaches that public health takes in identifying problems and developing interventions. Aspects of planning, implementing, and evaluating by TQM fall under each of the core public health functions of assessment, assurance, and policy development. However, it is with the assurance core function, related to ensuring available access to the health care services essential to sustain and improve the health of the population, that TQM programs must be undertaken. Public health cannot ensure services that improve health if those services lack quality. Public health will want to maintain quality in its workforce and continually evaluate the effectiveness of its services whether service is delivered to the individual, the community, or the population.

Nurses are in a perfect position to implement strategies to improve population-centered health care. Community assessments, identification of high-risk individuals, use of targeted interventions, case management, and management of illnesses across a continuum of care are strategies suggested as part of the focus in improving the health of communities (Quad Council of Public Health Nursing Organizations, 2009). These strategies have long been used by nurses.

The growth of the managed care industry has changed the face of health care in the United States, both in how health care is delivered and in how it is received by consumers. Consumers are forming partnerships in communities to counteract the power of MCOs by holding them accountable for health outcomes in relation to costs. Partnerships are using data-based community assessments to improve health and to ensure that communities receive quality services (Keyser et al, 2009).

Because of managed care agencies and consumer demands for quality nursing, objective and systematic evaluation of nursing care is a priority for the nursing profession. Since organized nursing is committed to direct individual accountability, is evolving as a scientific discipline, and is concerned about how costs of health services limit access, it demands delivery and evaluation of quality service aimed at superior client outcomes (ANA, 1999, 2010; Brownson, Fielding, and Maylahn, 2009). In the public health arena, the Quad Council of Public Health Nursing Organizations (2009) has identified competencies for public health nursing based on the Council on Linkages Between Academia and Public Health Practice document of 2008 with the most recent update on these competencies occurring in 2010 (Council on Linkages). Other states have developed models to document outcomes attributable to nursing interventions and are adding methods for evaluating total quality (Minnesota Department of Health, 2001; Keller et al, 2004a,b; Sakamoto and Avila, 2004; Smith and Bazini-Barakat, 2004; University of Wisconsin-Madison, 2010). Box 26-2 is a list of the areas of nursing interventions that nurses will want to be able to use. The chapters that discuss the interventions are noted. (See Chapter 9 for the most recent updates on the Keller et al. model of the Intervention Wheel.)

The competencies for public health leadership developed by the Council on Linkages (2001, updated 2010) are crucial to ensure the quality and performance of the public health workforce (Rowitz, 2009). (See Resource Tool 46.A on the Evolve website for a list of the competencies.)

Records are maintained on all health care system clients to provide complete information about the client and to show the quality of care being given to the client within the system. Records are a necessary part of a CQI process, as are the tools and methods for evaluating quality. Electronic medical records are becoming more common and are aiding in decreasing errors, increasing quality, and monitoring interventions.

THE CUTTING EDGE

Child care health consultation is a new population-based role for public health nurses. Child care health consultants (CCHCs) are trained through special programs to assist childcare providers in their quest to provide quality care to children. Through the use of research-based quality tools to measure center performance in infant and toddler care, CCHCs make a positive difference in the health and well-being of children in childcare.

From National Training Institute for Child Care Health Consultation: Caring for our children: National Health and Safety Performance Standards—guidelines for out-of-home child care. Available at http://www.sph.unc.edu/courses/childcare/. Accessed September 25, 2010.

Definitions and Goals

The IOM definition of quality is “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” (2001, p 1000). The AHRQ defines quality health care as doing the right thing, for the right client, and having the best possible results (2007). Quality in public health is defined as “the degree to which policies, programs, services, and research for the population increase desired health outcomes and conditions in which the population can be healthy” (USDHHS, 2008, p 2).

However, a definition of quality rests largely on the perception of the client, the provider, the care manager, the purchaser, the payer, or the public health official. Whereas the physician views quality in a more technical sense, the client may look at the personal outcome; the manager, purchaser, or payer may consider the cost-effectiveness; and the public health official will look at the appropriate use of health care resources to improve population health (Mead et al, 2008).

According to the AHRQ (2002), problems with quality of care were divided into five groups: variation of service, underuse of service, overuse of service, misuse of service, and disparities in quality. Variation in service refers to the lack of standards of practice continuity. This variation is often seen between regional, state, and local health care services and stems from lack of evolutionary health care practice and not keeping abreast of the constant changes taking place in health care (evidence-based practice) (NCQA, 2009). Underuse of service refers to conservative treatment practices. As an example, there is a lack of immunizations for pneumonia given to Asians 65 years or older as a preventive measure as compared with immunization levels of whites (AHRQ, 2008). Overuse of service refers to the over-ordering of unnecessary tests, surgeries, and treatments. This overuse drives up the cost of already expensive health care. Misuse of service refers to client safety issues and how disability and mortality can be reduced. With diligent care by health care providers, client injury and death can be avoided (NQF, 2009). Disparities in quality refer to racial, ethnic, and socioeconomic disparities in accessibility and affordability of health care (AHRQ, 2008).

The term health services applies to a wide range of health delivery institutions. Of particular interest to public health is the question of access to appropriate and needed services, a well-prepared workforce, and improvement in the status of the population’s health. Client satisfaction and well-being and the processes of client–provider interaction should be considered as well.

TQM is a process-driven, customer-oriented management philosophy that includes leadership, teamwork, employee empowerment, individual responsibility, and continuous improvement of system processes to yield improved outcomes (Carmichael, 2005). Under TQM, quality is defined as customer satisfaction. Quality assurance/quality improvement (QA/QI) is the promise or guarantee that certain standards of excellence are being met in the delivery of care. Godfrey et al (2007) discuss what is called the Juran trilogy. This consists of quality planning, quality control, and quality improvement. This trilogy combines components of QA as well as CQI to improve client outcomes in health care delivery.

QI is defined as a structured approach to improving performance (Lotstein et al, 2008). QI in public health is the use of a deliberate and defined improvement process, such as plan-do-check-act (PDCA), which is focused on activities that are responsive to community needs and improving population health. It refers to a continuous and ongoing effort to achieve measurable improvements in the efficiency, effectiveness, performance, accountability, outcomes, and other indicators of quality in services or processes that achieve equity and improve the health of the community (Bialek et al, 2010).

QA is concerned with the accountability of the provider and is only one tool in achieving the best client outcomes. Accountability means being responsible for care and answerable to the client (McLaughlin and Kaluzny, 2006). Under QA/QI, quality may have a variety of definitions. According to the National Health and Medical Research Council (NHMRC) (2003), QA should consist of peer review leading to QI to improve health care delivery. Client standards of care and safety issues are the core of QA.

The AHRQ has indicated that the assurance of quality is organized around four dimensions: effectiveness, client safety, timeliness and client centeredness and is assessed using four stages of care: staying healthy (primary prevention), getting better (secondary prevention), living with illness or disability, and coping with end of life (tertiary prevention) (AHRQ, 2008).

Quality traditionally has been an important issue in the delivery of health care. QA programs historically have ensured this accountability. The goals of QA and QI are on a continuum of quality, and in public health they are: (1) to continuously improve the timeliness, effectiveness, safety, and responsiveness of programs, and (2) to optimize internal resources to improve the health of the community (Riley et al, 2010).

Under a CQI philosophy, QA and QI are but two of the many approaches used to ensure that the health care agency fulfills what the client thinks are the requirements for the service. QA focuses on finding what providers have done wrong in the past (e.g., deviations from a standard of care found through a chart audit). CQI operates at a higher level on the quality continuum but requires the commitment of more organization resources to move in a positive direction. CQI focuses on the sources of differences in the ongoing process of health care delivery and seeks to improve the process (Kelly, 2007; Varkey et al, 2007).

The process of health care includes two major components: technical interventions (e.g., how well procedures are accomplished, accurate assessments, and effective interventions) and interpersonal relationships between public health practitioner and client. Both contribute to quality care, and both can be evaluated (Donabedian, 2003). Several approaches and techniques are used in quality programs. Approaches are methods used to ensure quality, and techniques are tools for measuring differences in quality (Kovner and Knickman, 2008).

Traditional approaches to quality focus on assessing or measuring performance, ensuring that performance conforms to standards, and providing remedial work to providers if those standards are not met. Such a definition of quality is too narrow in health care systems that try to meet the needs of many clients, both internal and external to the agency (Donabedian, 2003). CQI requires constant attention and should involve surveillance of all records while there is still the opportunity to intervene in both the client’s care and the practitioner’s actions. Comprehensive data analysis is necessary to detect process failure. Many agencies use some of the TQM/CQI concepts, such as client satisfaction questionnaires, but have not adopted the entire management philosophy. However, because QA/QI methods have traditionally been used and are still in use in many agencies, the QA/QI concepts will be covered.

HEALTHY PEOPLE 2020

Goal of Improving Access to Comprehensive, High-Quality Health Care, and Examples of Objectives to Eliminate Health Disparities

• AHS-1: Increase the proportion of persons with health insurance.

• AHS-5: Increase the proportion of persons who have a specific source of ongoing care.

• AHS-7: Increase the proportion of persons who receive evidence-based clinical preventive services.

From U.S. Department of Health and Human Services: Healthy People 2020, Washington, DC, 2010, U.S. Government Printing Office.

Historical Development

Improving the quality of care has been a part of nursing since the days of Florence Nightingale. In 1860 Nightingale called for the development of a uniform method to collect and present hospital statistics to improve hospital treatment. Nightingale was a pioneer in setting standards for nursing care. The movement to establish nursing schools in the United States came in the late 1800s from a desire to set standards that would upgrade nursing care. In the early 1900s efforts were begun to set similar standards for all nursing schools. From 1912 to 1930 interest in quality nursing education led to the development of nursing organizations involved in accrediting nursing programs. Licensure has been a major issue in nursing since 1892. By 1923 all states had permissive or mandatory laws directing nursing practice.

After World War II, the attention of the emerging nursing profession focused on establishing a scientific method of practice. The nursing process was the chosen method and included evaluation of how nursing activities helped clients (Maibusch, 1984). QA/QI was the evaluative steps in the nursing process.

The 1950s brought the development of QA measurement tools. One of the first tools was Phaneuf’s nursing audit method (1965), which has been used extensively in population-centered nursing practice.

In 1966, the American Nurses Association (ANA) created the Divisions on Practice. As a result, in 1972, the Congress for Nursing Practice was charged with developing standards to institute QA programs. The Standards for Community Health Nursing Practice were distributed to ANA Community Health Nursing Division members in 1973. In 1986, 1999, and in 2005, with updates in 2007, the scope and standards were again revised with a change in focus from community health nursing to public health nursing.

In 1972, the Joint Commission on Accreditation of Hospitals (JCAH) clearly stated the responsibilities of nursing in its description of standards for nursing services. The JCAH called on the nursing industry to clearly plan, document, and evaluate nursing care provided. In the mid-1980s, the JCAH became the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and began developing quality control standards for hospital and home health nursing. JCAHO is now known as The Joint Commission (TJC) and presently incorporates CQI principles in its standards.

Also in 1972, the Social Security Act (PL 92-603) was amended to establish the Professional Standards Review Organization (PSRO) and to mandate the process review of the delivery of health care to clients of Medicare, Medicaid, and maternal and child health programs. The PSRO program later became the Professional Review Organization (PRO) under the 1983 Social Security amendments. The purpose of the PROs was to monitor the implementation of the prospective reimbursement system for Medicare clients (the diagnosis-related groups [DRGs]). Although PSROs were intended for physicians, PROs have made QI a primary issue for all health care professionals.

In response to increasing charges of malpractice, the government passed the National Health Quality Improvement Act of 1986. Although it was not funded until 1989, its two major goals were to encourage consumers to become informed about their practitioner’s practice record and to create a national clearinghouse of information on the malpractice records of providers. The emphasis of this act continued to be on the structure of care rather than the process or outcomes of care (Dlugacz, Restifo, and Greenwood, 2004; NAHQ, 1993). (See Chapter 25 for discussion of structure, process, and outcome.)

Efforts to strengthen nursing practice in the community have been carried out by several nursing organizations, including the ANA, the Public Health Nursing Section of the American Public Health Association (APHA), the Association of State and Territorial Directors of Nursing (ASTDN), and the Association of Community Health Nursing Educators (ACHNE). As mentioned previously, these organizations are called the Quad Council for Public Health Nursing. The quality of nursing education is a major concern of the ACHNE, which was established in 1978. In 1993, 2000, and 2003, four reports published by this organization identified the curriculum content required to prepare nursing students for practice in the community (ACHNE, 1993, 2000a,b, 2003). In 2005, and again in 2007, the Quad Council reviewed scopes and standards of population-focused (public health) and community-based nursing practice and developed new standards to guide the profession in obtaining the best health outcomes for the populations they serve. QA/QI programs remain the enforcers of standards of care for many agencies that have not elected to engage in a program of CQI. These activities are called assurance activities because they make certain that those policies and procedures are followed so that appropriate quality services are delivered.

The Council on Linkages Between Academia and Public Health Practice (the Council) is a coalition of representatives from 17 national public health organizations. Since 1992, the Council has worked to further academic/practice collaboration to ensure a well-trained, competent workforce and a strong, evidence-based public health infrastructure. The Council is funded by the CDC and staffed by the Public Health Foundation. The most recent core competencies were updated in 2010. These competencies are used in QA/QI as performance measurements of providers to ensure quality of services (Council on Linkages, 2010). In 2003 and using the work of the Council on Linkages, the Quad Council of Public Health Nursing developed a set of core competencies for public health nurses. This was updated in 2009 and can be used as a performance measure for public health nursing practice.

Approaches to Quality Improvement

Two basic approaches exist in QI: general and specific. The general approach involves a large governing or official body’s evaluation of a person’s or an agency’s ability to meet criteria or standards. Specific approaches to QI are methods used to manage a specific health care delivery system in an attempt to deliver care with outcomes that are acceptable to the consumer. QA/QI programs that evaluate provider and client interaction through compliance with standards historically have been used alone to monitor quality care. In a TQM approach, CQI with QA/QI methods are an integral, but not the only, tool for ensuring quality or customer satisfaction.

General Approaches

General approaches to protect the public by ensuring a level of competency among health care professionals are credentialing, licensure, accreditation, certification, charter, recognition, and academic degrees. Although there has been a long history of public oversight of quality in the United States, this public oversight increasingly involves the private sector. Public oversight for quality emerged when the private market failed to focus on health care quality. Previously mentioned reports about quality on p 576 are indicators of public sector involvement in public oversight of quality.

Credentialing is generally defined as the formal recognition of a person as a professional with technical competence, or of an agency that has met minimum standards of performance. These mechanisms are used to evaluate the agency structure through which care is provided and the outcomes of care given by the provider. Credentialing can be mandatory or voluntary. Mandatory credentialing requires laws. State nurse practice acts are examples of mandatory credentialing. Voluntary credentialing is performed by an agency or an institution. The certification examinations offered by the ANA through the American Nurses Credentialing Center are examples of voluntary credentialing. Licensing, certification, and accreditation are all examples of credentialing.

Licensure is one of the oldest general QA approaches in the United States and Canada. Individual licensure is a contract between the profession and the state. Under this contract, the profession is granted control over entry into, and exit from, the profession and over quality of professional practice.

The licensing process requires that written regulations define the scope and limits of the professional’s practice. Job descriptions based on these regulations set minimum and maximum limits on the functions and responsibilities of the practitioner. Licensure of nurses has been mandated by law since 1903. Today all 50 states have mandatory nurse licensure, which requires all individuals who practice nursing, whether it be for money or as a volunteer, be licensed. A new approach to interstate practice requires a pact between states so that nurses can practice across state borders. Although reciprocity (which means nurses can have their license accepted through an application process if there is agreement between the states requiring application) exists among states for nursing licensure, interstate practice without approval is an issue for state boards of nursing. The states’ compact agreements were to reduce the barriers for interstate practice. The mutual recognition model of nurse licensure allows a nurse to have one license (in his or her state of residency) and to practice in other states (both physical and electronically when giving advise through programs like ‘ask a nurse’), subject to each state’s practice law and regulation. Under mutual recognition, a nurse may practice across state lines unless otherwise restricted. This is referred to as a multi-state nurse licensure model, specifically referred to as the Nurse Licensure Compact (NLC). All states that currently belong to the NLC also operate the single state licensure model for those nurses who do not reside legally in an NLC state or do not qualify for multi-state licensure. In order to achieve mutual recognition, each state must enact legislation or regulation authorizing the NLC. States entering the compact also adopt administrative rules and regulations for implementation of the compact.

Once the compact is enacted, each compact state designates a Nurse Licensure Compact Administrator to facilitate the exchange of information between the states relating to compact nurse licensure and regulation. On January 10, 2000, the Nurse Licensure Compact Administrators (NLCA) were organized to protect the public’s health and safety by promoting compliance with the laws governing the practice of nursing in each party state through the mutual recognition of party state licenses (NCSBN, 2010).

WHAT DO YOU THINK?

Historically, licensure has protected the public by ensuring at least a beginning level of competence. Nurses are licensed by state government, even though all nurses take the same licensing examination. What do you think about allowing nurses to practice across state lines without registering in each state?

Accreditation, a voluntary approach to QC, is used for institutions. Since 1954 the National League for Nursing (NLN), a voluntary organization, has had established standards for inspecting nursing education programs. In 1997 the NLN board established an accrediting body as an independent organization: the NLN Accrediting Commission (NLNAC). In 1997 the American Association of Colleges of Nursing (AACN), also a voluntary organization supporting baccalaureate and higher degree programs, established an affiliate—the Collegiate Commission on Nursing Education (CCNE)—to accredit baccalaureate and higher degree nursing programs. In 1966 community health/home health program standards were established by the NLN for the purpose of accrediting these programs through their Community Health Accreditation Program (CHAP). In addition, state boards of nursing accredit basic nursing programs so that their graduates are eligible for the licensing examination. In some states, state boards of nursing accredit graduate programs.

The accreditation function is quasi-voluntary. Although accreditation appears to be a voluntary program, it is often linked to government regulation that encourages programs to participate in the accrediting process. Examples include the federal Medicare regulations restricting payments only to accredited public health and home health care agencies.

Accreditation, whether voluntary or required, provides a means for effective peer review and an opportunity for an in-depth review of program strengths and limitations. Accreditation applies external pressure and places demands on institutions to improve quality of care. In the past, the accreditation process primarily evaluated an agency’s physical structure, organizational structure, and personnel qualifications. However, beginning in 1990, more emphasis was placed on evaluation of the outcomes of care and on the educational qualifications of the person providing the care.

In the past there has not been a mechanism for accrediting public health agencies. In 2007 the Public Health Accreditation Board (PHAB) was incorporated, after public health leaders explored the feasibility of a national accreditation program. The field saw the need for, and value of, public health accreditation, and advocated for the implementation of a national voluntary program. The PHAB was developed in accordance with the recommendations generated by the Exploring Accreditation Steering Committee. The Steering Committee was comprised primarily of state and local public health officials, including boards of health. The committee called on the expertise from other specialty areas engaged in accreditation. The PHAB is a non-profit organization and is developing and testing national standards and processes that will be used to assess the strengths and areas for improvement in public health.

The PHAB mission is to promote and protect the health of the public by advancing the quality and performance of all public health departments in the United States. The PHAB works in pursuit of creating a high-performing public health system that will make the United States the healthiest nation.

The CDC and the Robert Wood Johnson Foundation are funders, and partners, of PHAB. The goal is for the accreditation program to be self-sustaining, and the accrediting process which began in 2011 (PHAB, 2010).

Certification, another general approach to quality, combines features of licensure and accreditation. Certification is usually a voluntary process within professions. Educational achievements, experience, and performance on an examination determine a person’s qualifications for functioning in an identified specialty area. The American Nurses Credentialing Center provides certification in several areas of nursing. Many other professional nursing specialty credentialing organizations also provide for individual certification.

Although usually a voluntary process, certification can also be a quasi-voluntary process. For example, to function as a nurse practitioner in some states, one must show proof of educational credentials and take an examination to be certified to practice within the boundaries of the state.

Major concerns exist about certification as a QA mechanism. Data are lacking about the clinical competence of the practitioner at the time of certification because clinical competency is usually not measured by a written test. Although better data exist about the quality of the practitioner’s work after the certification process, the American Nurses Credentialing Center conducted a research program to look at how certification is related to the work of the certified nurse (Cary, 2000; Damberg et al, 2008). Except for occupational health nurses and nurse anesthetists, certification has not been recognized by employers as an achievement beyond basic preparation, so financial rewards are few (Keefe, 2010).

Although the nursing profession has accepted the certification process as a mechanism for recognizing competence and excellence, certifying bodies must help nurses communicate the importance of certified nurses to the public.

Charter, recognition, and academic degrees are other general approaches to QA. Charter is the mechanism by which a state government agency, under state laws, grants corporate status to institutions with or without rights to award degrees (e.g., university-based nursing programs).

Recognition is a process whereby one agency accepts the credentialing status of and the credentials conferred by another. For example, some state boards of nursing accept nurse practitioner credentials that are awarded by the American Nurses Credentialing Center or by one of the specialty credentialing agencies. Academic degrees are titles awarded to individuals recognized by degree-granting institutions as having completed a predetermined plan of study in a branch of learning. There are four academic degrees awarded in nursing, with some variety at each degree level: Associate of Arts/Sciences; Bachelor of Science in Nursing; master’s degrees, such as Master of Science in Nursing and Master of Nursing; and doctoral degrees, such as Doctor of Philosophy and Doctor of Nursing Practice.

Although these general quality management methods are important and should continue, newer and better approaches must be devised. If performance in the area of quality health care is to advance, better diagnosis of performance problems and corrective strategies that are effective will be necessary (Mead et al, 2008).

A recent approach to recognition is the Magnet nursing services recognition status given by the American Nurses Credentialing Center to agency nursing services that, after an extensive review, are considered excellent. This program began with recognition of excellent hospital nursing services. Although the Magnet program has expanded to include nursing home and home health agencies, approximately 6% (372 of 5815) of the nation’s hospitals had qualified for Magnet designation as of 2010. Reapplication for Magnet status must occur every 4 years to ensure that Magnet organizations stay at the top of their games (ANCC, 2010).

Specific Approaches

Historically, QA programs conducted by health care agencies have measured or assessed the performance of individuals and how they conformed to standards set forth by accrediting agencies. TQM as a management philosophy uses CQI methods that incorporate many tools, including QA, to increase customer satisfaction with quality care. According to the AHRQ, quality health care means doing the right thing, at the right time, in the right way, for the right people—and having the best possible results (AHRQ, 2001, 2008). To the Institute of Medicine (IOM, 2001, p 3), quality health care is care that is:

• Effective—Providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit

• Safe—Avoiding injuries to clients from the care that is intended to help them

• Timely—Reducing waits and sometimes harmful delays for both those who receive and those who give care

• Client-centered—Providing care that is respectful of and responsive to individual client preferences, needs, and values and ensuring that client values guide all clinical decisions

• Equitable—Providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status

• Efficient—Avoiding waste, including waste of equipment, supplies, ideas, and energy

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