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Chapter: Medical Surgical Nursing: Health Care Delivery and Nursing Practice

Demand for Quality Care - Influences on Health Care Delivery

The general public has become increasingly interested in and knowledgeable about health care and health promotion.



The general public has become increasingly interested in and knowledgeable about health care and health promotion. This awareness has been stimulated by television, newspapers, maga-zines, and other communications media and by political debate. The public has become more health conscious and has in general begun to subscribe strongly to the belief that health and quality health care constitute a basic right, rather than a privilege for a chosen few.


In 1977, the National League for Nursing (NLN) issued a statement on nurses’ responsibility to uphold patients’ rights. The statement addressed patients’ rights to privacy, confidentiality, informed participation, self-determination, and access to health records. This statement also indicated ways in which respect for patients’ rights and a commitment to safeguarding them could be incorporated into nursing education programs and upheld and reinforced by those in nursing service. Nurses can directly involve themselves in ensuring specific rights, or they can make their in-fluence felt indirectly (NLN, 1977).


The ANA has worked diligently to promote the delivery of quality health and nursing care. Efforts by the ANA range from assessing the quality of health care provided to the public in these changing times to lobbying legislators to pass bills related to is-sues such as health insurance or length of hospital stay for new mothers.


Legislative changes have promoted both delivery of quality health care and increased access by the public to this care. The National Health Planning and Resources Act of 1974 empha-sized the need for planning and providing quality health care for all Americans through coordinated health services, staffing, and facilities at the national, state, and local levels. Medically under-served populations were the target for the primary care services provided for by this act. By the passage of bills supporting health insurance reform, barring discrimination against individuals with preexisting conditions, and expanding the portability of health care coverage, Congress has acknowledged the needs of con-sumers for adequate health insurance in this time of longer life spans and chronic illnesses. Efforts in some states to provide full health care coverage for citizens, particularly children, represent measures by state governments to promote access to health care. Legislative support of advanced practice nurses in individual practice is a recognition of the contribution of nursing to the health of consumers, particularly underserved populations.


Quality Improvement and Evidence-Based Practice


In the 1980s, hospitals and other health care agencies implemented ongoing quality assurance (QA) programs. These programs were required for reimbursement for services and for accreditation by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). QA programs sought to establish accountability on the part of the health professions to society for the quality, appropri-ateness, and cost of health services provided.


The JCAHO developed a generic model that required moni-toring and evaluation of quality and appropriateness of care. The model was implemented in health care institutions and agencies through organization-wide QA programs and reporting systems.Many aspects of the programs were centralized in a QA depart-ment. In addition, each patient care and patient services depart-ment was responsible for developing its own plan for monitoring and evaluation. Objective and measurable indicators were used to monitor, evaluate, and communicate the quality and appro-priateness of care delivered.

In the early 1990s, it was recognized that quality of care as de-fined by regulatory agencies continued to be difficult to measure. QA criteria were identified as measures to ensure minimal expec-tations only; they did not provide mechanisms for identifying causes of problems or for determining systems or processes that need improvement. Continuous quality improvement (CQI) was identified as a more effective mechanism for improving the qual-ity of health care. In 1992, the revised standards of the JCAHO mandated that health care organizations implement a CQI pro-gram. Recent amendments to JCAHO standards have specified that patients have the right to care that is considerate and pre-serves dignity; that respects cultural, psychosocial, and spiritual values; and that is age specific (Krozok & Scoggins, 2001). Qual-ity improvement efforts have focused on ensuring that the care provided meets or exceeds JCAHO standards.


Unlike QA, which focuses on individual incidents or errors and minimal expectations, CQI focuses on the processes used to provide care, with the aim of improving quality by assessing and improving those interrelated processes that most affect patient care outcomes and patient satisfaction. CQI involves analyzing, understanding, and improving clinical, financial, or operational processes. Problems identified as more than isolated events are an-alyzed, and all issues that may affect the outcome are studied. The main focus is on the processes that affect quality.


As health care agencies continue to implement CQI, nurses have many opportunities to be involved in quality improvement. One such opportunity is through facilitation of evidence-based practice. Evidence-based practice—identifying and evaluating current literature and research and incorporating the findings into care guidelines—has been designated as a means of ensuring quality care. Evidence-based practice includes the use of outcome assessment and standardized plans of care such as clinical guide-lines, clinical pathways, or algorithms. Many of these measures are being implemented by nurses, particularly by nurse managers and advanced practice nurses. Nurses directly involved in the de-livery of care are engaged in analyzing current data and refining the processes used in CQI. Their knowledge of the processes and conditions that affect patient care is critical in designing changes to improve the quality of the care provided.

Clinical Pathways and Care Mapping


Many hospitals, managed care facilities, and home health services nationwide use clinical pathways or care mapping to coordinate care for a caseload of patients (Klenner, 2000). Clinical pathways serve as an interdisciplinary care plan and as the tool for tracking a patient’s progress toward achieving positive outcomes within specified time frames. Clinical pathways have been developed for certain DRGs (eg, open heart surgery, pneumonia with comor-bidity, fractured hip), for high-risk patients (eg, those receiving chemotherapy), and for patients with certain common health problems (eg, diabetes, chronic pain). Using current literature and expertise, pathways identify best care. The pathway indicates key events, such as diagnostic tests, treatments, activities, med-ications, consultation, and education, that must occur within specified times for the patient to achieve the desired and timely outcomes.

A case manager often facilitates and coordinates interventions to ensure that the patient progresses through the key events and achieves the desired outcomes. Nurses providing direct care have an important role in the development and use of clinical path-ways through their participation in researching the literature and then developing, piloting, implementing, and revising clinical pathways. In addition, nurses monitor outcome achievement and document and analyze variances. Figure 1-2 presents an example of a clinical pathway. Other examples of clinical pathways can be found in Appendix A.


Care mapping, multidisciplinary action plans (MAPs), clini-cal guidelines, and algorithms are other evidence-based practice tools that are used for interdisciplinary care planning. These tools are used to move patients toward predetermined outcome mark-ers using phases and stages of the disease or condition. Algorithms are used more often in an acute situation to determine a particu-lar treatment based on patient information or response. Care maps, clinical guidelines, and MAPs (the most detailed of all tools) provide coordination of care and education through hos-pitalization and after discharge (Cesta & Falter, 1999).


Because care mapping and guidelines are used for conditions in which the patient’s progression often defies prediction, specific time frames for achieving outcomes are excluded. Patients with highly complex conditions or multiple underlying illnesses may benefit more from care mapping or guidelines than from clinical pathways, because the use of outcome markers (rather than spe-cific time frames) is more realistic in such cases.


Through case management and the use of clinical pathways or care mapping, patients and the care they receive are continually assessed from preadmission to discharge—and in many cases after discharge in the home care and community settings. These tools are used in hospitals and alternative health care delivery systems to facilitate the effective and efficient care of large groups of patients. The resultant continuity of care, effective utilization of services, and cost containment are expected to be major benefits for society and for the health care system.


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