Page 459 - Encyclopedia of Nursing Research

426 n QuAlITy OF cARE

no longer a goal but a mandate. Part of the practice nurses to evaluate how the unit’s
issue in health care today, according to the structure and that of the larger organization
Q assumptions presented by these authors, is affect quality of care for the patients under
that the costs, processes, and outcomes of their care. Measures of structure have pri-
care are so interrelated and reciprocal that marily included cost and financial resources
changes in one of these areas may have sig- required to provide care, as well as human
nificant effects on the other components. On resources such as skill mix, staff character-
October 1, 2008, the centers for Medicare istics, patient severity of illness factors, and
and Medicaid Services (2007) implemented environmental factors of the hospital or care
a policy that began a paradigm shift in the agency. During the 1970s and 1980s, patient
established model for quality measurement classification systems were developed but
and reimbursement, that is, hospitals will were never extensively implemented. More
no longer be paid for preventable medical recently, diagnosis related groups and
errors defined as hospital-acquired condi- nursing diagnoses are frequently used sep-
tions (HAcs). arately or together to describe patient char-
Recommendations included in the IOM acteristics in research and care effectiveness
(1999) report on the quality of health care evaluations.
in hospitals remain a focal point of national A second component of quality is process
efforts to improve the quality of health care quality, which focuses on the interactions of
in the united States. The IOM stated that nurses with their clients. In nursing, a very
“Health care today harms too frequently and process-focused discipline, we see the histor-
routinely fails to deliver its potential ben- ical contribution of care plans as an impor-
efits” (IOM, 1999). This report further states tant process tool, and more recently, critical
that all health care should be “safe, effective, paths and care maps have added to this pro-
patient-centered, timely, efficient, and equi- cess focus. The best process measures are
table” (IOM, 1999, p. 6). The IOM adopted based on research evidence that the pro-
a definition that states that “quality is the cess leads to better outcomes for patients.
degree to which health services for individu- In today’s health care system, most attempts
als and populations increase the likelihood to measure quality focus on process eval-
of desired outcomes and are consistent with uation by assessing the appropriateness of
current professional knowledge” (IOM, 1999, care and the adherence to professional stan-
p. 244). Patients receive quality care when the dards. Discharge planning and case manage-
services provided are technically competent, ment are nursing interventions included in
provide good communication, share decision the Nursing Interventions classification that
making with the patient and family, and are focus on achieving quality care through a pro-
culturally sensitive. cess format (Dochterman & Bulechek, 2004).
Donabedian’s (1980) model of quality A third component of quality is out-
measurement based on structure, process, and comes, which provides evidence of the effec-
outcome has become the foundation of most tiveness of the interventions nurses provide
current strategies to measure quality of care for the health problems and concerns of
in health care systems. using Donabedian’s patients. The IOM (1999) report states that
model, quality can be evaluated based on the best measures of outcomes are those tied
the three components of structure, process, to the process of care. Attempts by nurses
and outcomes (IOM, 1999). using this frame- to enhance quality strategies, such as criti-
work, structural quality evaluates the capacity cal paths and care maps, have challenged the
of the health care structure to provide high- sacred care plan in nursing and have shifted
quality care. In nursing, this requires lPNs, nurses’ thinking from goals to outcomes.
RNs, nurse practitioners, and other advanced Some of these paths and maps have included