health care organizations and clinicians across care settings to implement and strengthen shared decision‐making—making it a reality for all patients.
NQP’s Advanced Illness Care Issue Brief provides physicians with tools to discuss complex issues with patients about their preferences and goals for advanced illness care.
Early Elective Delivery Playbook contributed to a 50% decline in early elective deliveries nationwide over a three‐year period.
See https://www.qualityforum.org/nqf_store.aspx for all these publications.
National Quality Forum Measure Incubator
The NQF Measure Incubator is an innovative effort that facilitates efficient measure development and testing through collaboration and partnership. It addresses important aspects of care for which quality measures are underdeveloped or nonexistent. Even though there are hundreds of measures to define various aspects of health and health care quality, there are still gaps where measures are important in driving improvement. Several of these gaps represent work where nurses figure prominently. Some examples of gap areas include palliative and end‐of‐life care, diagnostic accuracy, behavioral health, and care of people with multiple chronic conditions and individuals with Alzheimer’s disease. And while measures of patient satisfaction exist, these and measures of patient‐reported outcomes are still needed. The Measure Incubator connects groups interested in particular measure concepts with measure development experts, financial and technical resources, and continuous sources of data. It is unclear whether nurses are currently engaged in any of the Measure Incubator projects.
National Database of Nursing Quality Indicators: Capturing the Data
Even before the release of To Err Is Human (Institute of Medicine, 2000) and Crossing the Quality Chasm (Institute of Medicine, 2001), the nursing profession had begun to speak up about eroding of the quality of care patients received. Not surprisingly, this concern surfaced early at the national nursing policy level. In 1994, the ANA House of Delegates at its annual meeting approved a house resolution that urged ANA leadership to address the problem of declining patient care quality experienced in many institutions, perceived by nurses to be due in part to reductions in staffing levels implemented following declining revenue. ANA, when addressing this problem with its interdisciplinary colleagues, was repeatedly asked to show the evidence that reduced nursing staffing led to such declines in quality care. Nurse leaders determined that not only was there a need for education about principles of quality, but that in fact data were required that would put to rest the criticisms of those claiming that the value of nursing could not be substantiated.
In the mid‐1990s, ANA began a national effort to educate nurses about the value of data and quality through regional conferences. It simultaneously convened nurse experts Dr. Norma Lang, Dr. Marilyn Chow, and others to identify structural, process, and outcome measures that would support the relationship between staffing levels, skill mix, and the quality of nursing care. Those initial measure definitions became the basis for the NQF‐endorsed nursing‐sensitive measures. As a result of recommendations from this group of experts, ANA funded a contract to develop a national database, with Dr. Nancy Dunton as principal investigator, that could receive and aggregate data collected via these measures. In 1998, ANA awarded grants to seven state nurses associations to encourage hospitals in those states to collect and submit data to this new database, the National Database of Nursing Quality Indicators (NDNQI), a proprietary database of the ANA (Montalvo and Dunton, 2007). Since 1998, the number of acute and specialty hospitals that submit quarterly nursing‐related quality data has grown to 2,000, more than one‐third of all US acute care facilities.
The impact of NDNQI on policy conversations at the institutional, state, or national level has been far‐reaching. Studies published at the national level utilizing the aggregated data support the impact of the quantity and skill mix on the quality of nursing care, the link between nursing satisfaction and improved satisfaction of patients with their care, and the impact of levels of nursing education with the outcomes of care. It has provided comparisons of similar institutions and unit types, both within the state and across the country, to assist chief nursing officers and nurse managers to defend the appropriate levels and skill mix of nurse staffing in their institutions, describe the impact of decreased levels on patient outcomes, and drive performance improvements at unit and institutional levels. NDNQI data reports provided back to the institutions point to opportunities for deeper examination of the processes of care and the need for evidence that supports care decisions.
Data from NDNQI have been used at the state level for public reporting, driving state initiatives, and supporting staffing legislation that defends the hospital and the nursing unit‐level leaderships’ rights to make decisions about safe staffing levels based on the evidence, rather than on state‐mandated ratios. Major insurers provide higher ratings to those institutions that participate in NDNQI, based on their conviction that institutions that care about nursing care quality are more likely to have positive outcomes.
In 2014 ANA made a decision to divest itself of NDNQI and arranged for its purchase by Press Ganey, an established for‐profit business that supports data collection and reporting on the patient experience of care. ANA retains stewardship of certain NDNQI measures and an advisory role in the further development of NDNQI. Press Ganey still owns NDNQI and manages the approximately 2,000 hospitals that collect, report, and compare 17 quality outcome indicators of nursing quality, identifying annually those hospitals receiving awards for Outstanding Nursing Quality. NDNQI has long worked to expand its footprint in other countries around the globe as well, from the Middle East and India to Europe and Asia.
Institute for Healthcare Improvement Focused on System Improvement
Founded in 1991, the Institute for Healthcare Improvement (IHI) has been a major driver of quality care and health care change, based on the philosophy that almost any product or service, including health care, can be improved. The IHI encouraged systems thinking with implementation of a systems idea: if one can change the way things are done, one can get better results. IHI aims to improve the lives of patients, the health of communities, and the joy of the health care workforce by focusing on the IOM’s six improvement aims for the health care system: safety, effectiveness, patient‐centeredness, timeliness, efficiency, and equity (Institute of Medicine, 2001). IHI may be best known for its campaigns to Save 100,000 Lives, later to Save Five Million Lives, and currently the Triple Aim initiatives of better care, better health, at lower cost. IHI provides a variety of services and educational programs and tools to assist hospitals and other stakeholders to achieve these aims. Its structure and campaigns have enabled institutions and individual providers of care, including nurses, to share their “near misses” and successes in instructive ways. Nursing organizations have participated in IHI to contribute to discussions and to influence actions that have global and national consequences. Today, not only is IHI an influential force in health and health care improvement in the United States, it has expanded its footprint to many countries around the world, including Canada, England, Scotland, Denmark, Sweden, Singapore, Latin America, New Zealand, Ghana, Malawi, South Africa, the Middle East, and elsewhere.
In 2018 IHI convened the National Steering Committee (NSC) for Patient Safety (within which several nurse leaders participate), resulting in 2020 in the release of Safer Together: A National Action Plan to Advance Patient Safety (IHI, 2020), described in Textbox 2.2. The Steering Committee, in developing this plan and its companion components, dedicated itself to reducing preventable harm in every setting, whether acute, long‐term, or home‐based care, and for patients, caregivers, and health care workers alike.
NSC members also identified three cross‐cutting themes that are integral to the four
