Quality Assessment, Assurance, and Improvement

Quality assurance in the consumer world refers to the accountability of a product-a warranty or guarantee. The Good Housekeeping stamp of approval. In most instances where we have such an assurance of quality, we can take a product back to the retail merchant where we bought it and expect repair, replacement, or refund. This is not possible for consumers of health care. So our quality assurance in nursing refers to the accountability of nursing and other health care providers for the quality of care given to patients. Florence Nightingale actually began quality of care indicators in the use of data to measure improvements in care. Nationwide quality assurance in health care began in the 1970s with legislative action linked to Medicare reimbursement. Norma Lange, whom we honor with this issue of Nursing Administration Quarterly, is one of the nursing world's leaders in quality assessment, assurance, and improvement and certainly is our profession's pioneer leader in quality measurements of nursing care.

Serving the profession in the most challenging quality improvement position is our issue editor Rhonda Anderson, RN, CNAA, FAAN, CHE, Chief Operating Officer at Banner Desert Medical Center in Mesa, Arizona. Rhonda serves as a JCAHO Commissioner and is on the JCAHO Board, Accreditation Committee, and chairs the Performance Measurement Committee. She is also a member of the American Hospital Association Quality Task Force and its Patient Safety Quality Awards Committee. She also serves on the National Advisory Board of Simulis LLC, Healthcare Division, giving oversight and strategic direction to development of device training and simulation/scenario education around critical incidents in health care that affect life and safety of people at the human/technology interface. Simulus is focused on fostering the safety/quality of health care and helping craft data and information tracking processes, which demonstrate competency and performance across the career span.

Each nurse administrator continues to find greater predicaments and quandaries in attempting to provide a solid professional practice environment for quality patient care. The quality dilemma relates to financial resources and cutbacks that place the nurse executive in a conundrum between limiting expenditures and containing costs and the need to provide adequate nursing services to deliver so-called "quality care." The most apropos description of this quality dilemma lies in the definition of a Gordian knot: "A knot, held to be capable of being untied only by the future ruler of Asia, and cut by Alexander the Great with his sword." This represents an intricate problem, a problem unsolvable on its own terms. Do we change the structure of nursing staff or hire staff at lower wages who are deficient in technical and clinical skills to accomplish more work in a less costly way? This forces nurses to be "checkers-up of cheaper doers." And "caregivers by proxy." I did not become a nurse to give my primary role as a caregiver to those less qualified while I do nonclinical decision making tasks. We need to look at the quality attributes that are essential to be done by registered nurses and design support systems to enable quality nursing practice.

In the 1970s, we designed primary nursing systems that began to place stronger accountability for patient care on the shoulders of the staff nurse, and we attempted to place different levels of health care workers away from patients but in supportive roles, doing non-nursing functions so that nurses could truly practice professional nursing. And nurses and patients were more than satisfied, as were the doctors who experienced primary nursing in the fullest sense.

In the 1980s, we moved forward to case management systems, proposals from the American Medical Association for registered care technicians, and other adaptations. All of these efforts to accommodate cost increases attempted to introduce lower salaried workers while still maintaining some sense of integrity for nursing's mission of excellence and quality care. Then with corporate mergers and downsizing, nurses were laid off-all in the interest of cost saving-and quality improvement was what we could constantly strive for. Improve what? A dysfunctional health care system where it is commonly known that if you expect to survive a hospitalization, you had better bring a family member to be your advocate and safety net. Health costs are continuing to soar and insurance is shrinking or unaffordable by many. Medicaid and children's coverage is being cut in many if not all states. Once again presidential candidates are making health care reform a priority. There are several major issues to be readdressed: Does universal coverage cost too much? Well, if you are uninsured or underinsured, you will probably get less care and have more serious health problems costing more in the long run than universal coverage. All the other developed countries have decided the cost/benefit of covering all citizens is worth it. The cost of uninsured is not free. In 2001, it cost $35 billion, and health care is only 14% of our $10.1 trillion economy. Forget the tax breaks and provide quality care to all.

Are only the poor and young uninsured? A third of people who were uninsured in 2001 lived in households with income above $50,000. Most uninsured are low income and 60% are under age 35. And they are not healthy just because they are young. Do these people get care when they really need it? Well, I guess if you are on death's door, someone will take you in, and then the care will be more costly than if you were maintained to prevent catastrophic illness. Should our government control all health care, as is done in some socialized medicine countries? Even if that happened there would still be multitiered health care and the wealthy would pay for what they wanted and needed as they do now. Is health care a right, like public education? Provision of health care to all could be universal, and market forces would trim for more efficient delivery systems. We will continue in this never-ending search for a way to maintain a quality care system, have it accessible to all, and keep costs under control. Then maybe we can focus our energies and resources to address the overall public health concerns such as SARS and whatever comes next. We cannot legislate wellness by fining for smoking, drinking too many alcoholic beverages, or using fast food to sustain our national obesity. This is America and I for one am proud and privileged to be here. Whether people choose to believe it or not, we still have the best health care and nursing practices in the world, and nursing plays the most significant role in quality of care provided to all people of all ages in all settings.