The Never-ending Road to Excellence

Excellence is certainly a key word in today's global marketplace. With a myriad of choices available to consumers and users, the edge that differentiates one choice from another is the measure of quality and user satisfaction. However, the Achilles' heel of all of this focus on quality is the lack of sound and definitive measures for quality. This is no less true for nursing.

For the past 3 decades over which I have been in nursing leadership, nurses have talked and written about quality as broadly and extensively as can be done by any one discipline. Still, evidence of both sustainable measures and delivery of quality remains scant. The intense challenge today, however, is both a qualitative and quantitative move away from measuring process alone to determining the intensity of the relationship between process and outcome. Value demands that focus be on what is delivered and whether the delivery meets the expectations of standards defined for it by both a provider and a user. This growing emphasis on "value" creates the requisite to reconceptualize nursing emphasis for clinical care as well as for value-driven measures.

Patients come to the health service system for what they need to get from it not necessarily for what it gives. This historic focus on "give" has increasingly become an impediment to the nursing provider's focus on the patient's right and expectation to "get." Yet, the language of "get," the language of value, is becoming the cornerstone of the future of both measurement and payment of, and for, the value of practice. This growing focus on value is driven by the increasing potential of technology and its various applications to gather data, generate information and analysis, and inform immediate thinking and action in both a predictive and anticipatory manner. The growing demand for exceptional practice and patient experience creates for the clinical leader a unique opportunity to refocus the perspective of clinical providers on questions of delivery (outcome) and away from the litany of task and process. This demand for value calls practice leadership into more firmly enumerated expectation and, ultimately, "backing into" whatever processes or performance is necessary to obtain it.

It is anticipated that evidence-based practices will help solidify this critical relationship between process and outcome. It is further hoped that evidentiary foundations for practice will create more legitimate and substantive definers of value that are both practical and real-time. The old industrial age dependence on policy and procedural frames for practice will increasingly become irrelevant to effective practice and will ultimately give way to the more relevant and value-based technologies and methodologies directing evidence-grounded clinical practices. The overwhelming work of the leader, in this circumstance, will be to unhitch nurses from a historic dependency on ritual and routine, precedent, and functional "procedurism." In so doing, the nurse leader will be creating positive context and availability for the clinical practitioner to engage evidentiary methodologies that can best lead to a definitive and precise foundation for excellence.

In this issue, we have attempted to gather a wide variety of authors who demonstrate this link between process and outcome in a way that demonstrates true sustainable value. Each author demonstrates a facet of excellence that, taken individually, offers a partial yet important perspective of the application of excellence. However, when taken as an aggregate, each of these articles contributes to a mosaic of insights that can both help better define the characteristics of excellence and also demonstrate it. We hope that the reader will find this issue both informative and helpful and that it will be useful in raising some challenges to notions of excellence that can be translated into dramatically configuring nursing practice for a clinical future reflecting sustainable excellence.

-Tim Porter-O'Grady, DM, EdD, APRN, FAAN

Senior Partner, Tim Porter-O'Grady Associates, Inc, Atlanta, Georgia Associate Professor, College of Nursing and Healthcare Innovation Phoenix, Arizona Visiting Professor School of Nursing, University of Maryland, Baltimore