range of service functions, including the accreditation under its deemed status of integrated health plans. URAC is governed by a board with representatives from multiple constituencies, including consumers, providers, employers, regulators, and industry experts. Nursing has a long well‐established presence on its board.
Common Strategies Run through Formalized Initiatives
There are common strategies that each collective effort employs to gain political will for quality improvement. The various alliances and other collaborative initiatives have several strategies in common, which in and of themselves contribute to a set of tactics around quality that may be applied to other policy discussions. Strategic themes among these initiatives include the following, which are critical when considering quality and safety:
Most formal entities include consumers on their governing bodies or among the stakeholder groups they convene to ensure that the needs of the recipients of the care are heard and addressed.
Many health systems, and those entities seeking to improve quality, are actively seeking patients and families as advocates and representatives, as health systems seek to close the gap between providers and patient satisfaction, in part driven by measures of the patient’s experience of care.
Increasing emphasis, often less than successful, is focused on seeking broader diversity of patient, family, and consumer representation in order to reduce health care disparities.
The inclusion of a broad base of stakeholders is almost universally applied, acknowledging the complexity of the challenges facing health care.
The inclusion of multiple disciplines in most formal collaboratives reinforces that developing policy solutions is a team sport, with no discipline having the political clout to dictate or finalize solutions independently.
Most collective efforts include one or more federal agencies among their board members in some capacity to ensure federal efforts and other entities are moving in concert.
Professional organizations and other stakeholder groups participate in multiple efforts, maximizing their opportunities to influence policy.
Participants on the various alliances, agencies, and accrediting bodies often participate with multiple groups. Questions remain over whether this is more expeditious or not.
Consensus building is the preferred approach to derive proposed solutions.
Convergence on proposed solutions occurs among stakeholders and alliances, with the result that while the details might look a little different, the same conceptual underpinnings run similarly across many collaborative efforts.
The cost of health care is a worry that overrides all other efforts to improve quality, increase access to care, and ensure patient safety.
Social determinants of health are increasingly shown to challenge all efforts to improve health and reduce negative outcomes of care.
Challenges All Collective Efforts Face in Improving the Quality of Care
With approximately 200 national entities, including professional organizations and consumer groups, along with thousands of hospitals and other institutions and agencies engaged in the effort to improve quality, there have been substantial investments of financial and other resources, including human resources, over the last 30 years. The timing of many of these efforts in the early 1990s suggests that long before the publication of To Err Is Human and Crossing the Quality Chasm, leaders in the health care industry understood that lack of quality was a significant problem. Nurses were early adopters in hospital efforts to identify opportunities for continuous quality improvement. Many engaged in dialogue with individual physicians who were being challenged by state performance review boards and utilization review committees. Then the focus was primarily on local quality improvement and policy initiatives rather than state or national efforts. Global quality leaders (Deming, 1986; Juran, 1998) stated that 85% of errors in complex organizations were due to system design rather than to inadequate individual job performance. But even their discussions were addressed in departmental, corporate, or institutional policy terms.
Yet, in 2022, the magnitude of the current efforts to transform the health care system into a high‐quality system dwarfs all previous efforts. Health systems were focused on being high‐reliability organizations while at the same time striving to be recognized as safety cultures and just cultures. Why has this exploded to such mammoth proportions?
Prior to the implementation of the ACA, looking at any acute care facility, large or small, the number of outpatient procedures and the revenue generated from them had kept pace or overtaken the revenue from acute care services. Now the numbers of providers in even the smallest facility have increased, including increases in specialists, whether providing virtual or face‐to‐face medicine. The enormity and complexity of the systems now needing improvement do not differ all that much, whether one considers the problems of the critical access hospital or the largest multihospital system. The systems are complicated and the communications and organizational structures required to ensure efficiency and safety are interrelated, transdisciplinary, and require transparency.
The technology needs of the solo and small group practitioner reflect a similar need for technological capabilities as those required by larger health service plans to which many providers belong. At the same time, fewer and fewer patients see their own primary provider once they entered an acute care facility, regardless of the size of the institution. The hospitalist providing their care may have never seen them previously and will have no connection to their care once they are discharged. Home care and hospice programs are using technology to replace the face‐to‐face time that nurses and others have traditionally relied upon with homebound patients to determine their unspoken needs and vulnerabilities, including electronic profiles on patient caseloads and communication about patients only via electronic records. The latest explosion of telehealth onto the health care scene, whether in transport, in primary care thanks to COVID‐19, or in treating mental and behavioral health disorders, requires greater privacy protections and interoperability than ever before. Yet, due to emergency declarations and easing of certain restrictions to support telehealth visits, many of these same privacy protections, even those under the Health Insurance Portability and Accountability Act (HIPAA), have been eroded.
What has COVID‐19 shown us? The complexities of providing high‐quality health care that keeps patients, families, and health care workers from harm simply became almost impossible. Our health risks as we know them have gone global in a way that nothing has before. The United States can now see clearly where it has failed its citizens. Health inequities and the challenges of multiple chronic conditions are tough enough when the financial resources are available to make access to care possible. But during this time millions of individuals do not have the luxury of performing jobs from home, or have been unable to work because the business or company they work for has been closed due to quarantine, or the job has been lost because the company has gone out of business, or other restrictions have made it difficult or impossible to keep oneself safe. For many of these people, along with such considerations, the loss of a job means not only loss of income but loss of health care insurance coverage as well. For essential workers, whether first responders, nurses, physicians, maintenance workers, or grocery store clerks, personal protective equipment, something most of us took for granted, disappeared. Even cleaning supplies, hand sanitizer, and hand soap disappeared from store shelves for a time. Each of these shortfalls created additional fears about reaching out to a health care provider for anything short of COVID‐like symptoms.
The challenges of ensuring effective care transitions, care coordination, and engagement of patients are difficult without effective
