Governing for improved quality and patient safety

Board members have a critical oversight role to play in monitoring and providing direction to improve health care quality and safety. In the emerging environment of health care reform, the board's role in overseeing quality and safety on behalf of stakeholders will become as or even more important than its financial oversight role. Nurses can expand their impact by joining the ranks of health care organization governing boards to lead and guide the entire health care enterprise to realize the goal of improved care and outcomes for all patients.     

Patient safety: the four domains of nursing leadership

The role of the nurse leader in patient safety can be characterized as follows: to establish the right culture; to infuse that culture with shared leadership so that the expert voice at the bedside is really defining the work; to possess the competencies necessary to coordinate and advance this complex initiative; and to forge both internal and external partnerships, because we will not be able to do this work alone. To further the work on this topic, nurse leaders who participated in the Nursing Leadership Congress are committed to identifying additional resources to help nurse leader colleagues drive patient safety efforts throughout their organizations.     

Separating complements: the effects of competition and quality leadership

The literature on the tragedy of the anticommons typically suggests that producers of complementary goods should integrate themselves. Recent decisions by the antitrust authorities seem however to indicate that there exists a tradeoff between the “tragedy” and the lack of competition characterizing an integrated market structure. In this paper we analyze such tradeoff in oligopolistic complementary markets when products are vertically differentiated. We show that quality leadership plays a crucial role. When there is a quality leader, forcing divestitures or prohibiting mergers, thus increasing competition, lowers prices and enhances consumer surplus. However, when quality leadership is shared, “disintegrating” firms may lead to higher prices. In this case, concerns about the tragedy of the anticommons are well posed in antitrust decisions.     

Expertise isn't the only answer to leadership in safety

In the words of Covey (2004), we all have the power to decide to live a great life rather than a life of mediocrity. Unfortunately, in patient safety, we in health care have chosen to live a life of mediocrity because we have not made a commitment to error-free versus an error-tolerant industry. Compared to what other industries have accomplished in safety, we must make a commitment to do better. We must stop benchmarking ourselves against the median or average, which is mediocrity at its finest, and accept the challenge that an error-free environment is possible. In the words of Collins (2001), "Good is the enemy of Great" (p. 1). With new eyes that represent diverse cognitive skills, we will overcome our blindness to defects and move from good to great.     

Trade policy and quality leadership in transition economies

Trade policy and quality leadership in transition economies are analyzed in a duopoly model of trade and vertical product differentiation. We first show that the incidence of trade liberalization is sensitive to whether firms in transition economies are producers of low or high quality. Second, we find that neither free trade nor the absence of a domestic subsidy are optimal: Both a tariff and a subsidy increase price competition and while the former extracts foreign rents the latter results in quality upgrading. Third, there exists a rationale for a government to commit to a socially optimal policy to induce quality leadership by the domestic firm when cost asymmetries are low. Finally, we establish an equivalence result between the effects of long-run exchange rate changes and those of trade policy on price competition (but not on social welfare).     

A fragmented patient safety concept: the structure and culture of safety management in health care

The uniform and visible commitment to safety management is a cultural and structural change that health care organizations have not typically attempted. Committee structures are just one example of how culture drives structure in managing health care safety. The question is: "Are we interested in making nonpatient safety programs as well understood and as culturally significant as patient safety programs?" Models exist to institutionalize safety management in health care. We need only look to the JCAHO or OSHA and other high-hazard industry models for examples of safety management. Change requires a focus on safety, not occupational safety or patient safety, but just safety. In health care, safety would be a key characteristic of organizational culture. The organizational expectation is then that all employees will work safely and practice safety. Employees will apply safe practices when handling chemicals, in lifting, and when giving medications. Only when safety imbues the work and decisions of each employee in this way will the highest level of safety be attained.     

Quality, patient safety, and the board

It is now broadly recognized that good outcomes for patients depend on more than a clinician's knowledge and skills and use of proven, effective practices or evidence-based medicine. Good outcomes also depend on the organization's culture, which affects how well providers and patients work together. Boards play a key role in helping their hospitals improve the quality and safety of the care they deliver--a governance imperative to ensure hospitals meet the needs of key stakeholders and perform effectively in an environment of reform. Nurse leaders who understand this key board responsibility will be better prepared to serve on boards and contribute to effective governance.     

Nursing unit characteristics and patient outcomes

In this exploratory cross-sectional study, nursing unit organizational characteristics and how they influenced patient outcomes in the form of nurse-sensitive adverse events and failure to rescue were examined. Results showed significant associations between characteristics and adverse events at the unit level. Autonomy/collaboration was associated with pressure ulcer and failure to rescue, practice control with urinary tract infection, and continuity/specialization with death. Unit-level study provided a better understanding of the effect of unit work environment upon nursing practice and outcomes.     

Crossing the quality chasm: creating the ideal patient care experience

To create a health system that better meets patients' needs requires a fundamental redesign of our care delivery system and a new framework. Without a payment mechanism to reflect the value of care provided other than the face-to-face visit, adoption of advanced medical home principles will be challenging. The hand-off of the patient between providers and settings of care is a critical time for the patient and its effectiveness impacts patient care outcomes. The appropriate utilization of hospital and other health system resources is crucial, especially as hospitals, emergency departments, and other health care venues increasingly face capacity constraints and throughput challenges. It becomes the responsibility of the multidisciplinary team of providers to ensure that patients being discharged have an identified personal physician or team who will provide a medical home, and that the handoff to this medical home is thorough and well coordinated. An ideal patient care experience is one in which all systems and processes are geared to meet the needs of the patient: a safety-oriented system that provides standardized, evidence-based care supported by technology, but that recognizes and responds to individual needs.     

Computerized physician order entry: a prescription for patient safety

Clinician adoption of CPOE/CDS solutions is crucial to helping caregivers reduce medical errors and enhance patient safety. The LeapFrog Group CPOE/CDS report can be a helpful guide, but as clinicians concerned about the quality of health care and the well-being of our patients, we must play an active role in the successful adoption of these solutions by: 1. Making sure that your institution is committed to having the appropriate people involved in the entire process, including nurse leaders. 2. Selecting a vendor that has the knowledge and clearly understands the importance of implementing this type of system. 3. Ensuring that your organization is selecting a system that actually meets the criteria defined by the LeapFrog Group.     

Public goods and the value of product quality regulations: the case of food safety

The paper examines preferences for product quality regulations. Our premise is that preferences for product quality regulations derive from preferences for both private and public goods. The model is used to explain public attitudes toward a referendum measure to eliminate pesticide residues on food. Results from a survey of consumers are consistent with the conceptual model and show that preferences for public goods influence support for the product quality regulation. The results help explain why consumption behavior is a poor predictor of political behavior, and have implications for methods that use voting and market behavior to value public goods.     

Nursing home costs and quality of care outcomes

The relationship between cost and quality of care in nursing homes was examined using quality indicator measures of resident outcomes. While each individual quality measure makes only small contributions to costs, when considered across the facility, quality could have a substantial financial impact on the operations of the home.