Rosemary Kennedy, PhD, RN, MBA, FAAN
Judy Murphy, RN, FACMI, FAAN
Darryl W. Roberts, PhD, MS, RN
The definition of quality healthcare, its accurate measurement, and its effective management is nebulous and constantly evolving. Even the most respected and knowledgeable experts cannot come to consensus on exactly what quality means. Levels of measurement, as well as questions of whom, how, and when to measure are topics of continual deliberation. These discussions occur at multiple levels through councils, committees, workgroups, task forces, and expert panels. Many policy-related decisions these groups make affect nurses and nursing care. All of them affect how patients receive or engage in healthcare. This article discusses the National Quality Strategy by offering a description and history of the quality conversation, including federal advisory committees and quality measurement data standards. There are several gaps in the quality conversation to which nurses could contribute valuable insights. The authors describe ways that nurses can engage in the national quality agenda. The article concludes with a call to action to encourage nurses to take a larger role in driving the National Quality Strategy.
Citation: Kennedy, R., Murphy, J. Roberts, D., (September 30, 2013) "An Overview of the National Quality Strategy: Where Do Nurses Fit?" OJIN: The Online Journal of Issues in Nursing Vol. 18, No. 3, Manuscript 5.
Key words: quality, National Quality Strategy, meaningful use, quality legislation, Quality Measurement Data Standards
Even the most respected and knowledgeable experts cannot come to consensus on exactly what quality means. The definition of healthcare quality, its accurate measurement, and its effective management is nebulous and constantly evolving. Even the most respected and knowledgeable experts cannot come to consensus on exactly what quality means (Beattie, Shepherd, & Howieson, 2013; Wharam & Sulmasy, 2009). Levels of measurement, as well questions of whom, how, and when to measure are topics of continual discussion at multiple levels through councils, committees, workgroups, task forces, and expert panels.
Participation by nurse experts ensures that decisions and recommendations coming from these committees include nursing perspectives and nurses’ needs. At the federal level, the U.S. Department of Health and Human Services (HHS) convenes federal advisory committees (FACAs) to inform, advise, and guide decisions about regulation, implementation, and enforcement of legislation (U.S. Government Services Administration [GSA], 2012). As committees form, or as vacancies on existing committees occur, HHS publishes requests for participation in FACAs in the Federal Register. Typically, FACA participation is open to the general public. The agency or contractor seeking participation will detail recommended backgrounds and time commitments in the request (GSA, 2012). An individual wanting to participate may submit his/her information independently; however, professional organizations like the American Nurses Association (ANA) often submit letters of support for nominees with particularly appropriate backgrounds or experiences. For instance, ANA supported the nominations of Norma M. Lang, PhD, RN, FAAN, FRCN, LL to the Health Information Technology Policy Committee Quality Measures Workgroup and Patricia Flatley Brennan, RN, PhD, FAAN, FACMI to the Food and Drug Administration Safety Innovation Act Workgroup. Participation by nurse experts ensures that decisions and recommendations coming from these committees include nursing perspectives and nurses’ needs.
Presently, FACAs convened by the Centers for Medicare and Medicaid Services (CMS), the Office of the National Coordinator for Health IT (ONC), and the National Quality Forum (NQF—a HHS contractor) are engrossed in decision making about the implementation of the Patient Protection and Affordable Care Act (PPACA or Health Reform; PL 111-148) (U.S. Government Printing Office, 2010) and meaningful use (MU) under the Health Information Technology for Economic and Clinical Health (HITECH) Act (Blumenthal & Tavenner, 2010; ONC, 2012). Health reform affects nearly every part of the U.S. healthcare system (PL 111-148). Of most significance to this article, the PPACA outlines many of the criteria and subsequent incentives paid to eligible professionals (e.g., physicians, nurse practitioners) and hospitals for improving the quality of healthcare delivered in the United States. The purpose of incentives is to focus clinicians’ attention on improving care (Stone et al., 2010; Werner, Kolstad, Stuart, & Polsky, 2011).
The HITECH Act establishes criteria for MU, or the set of standards used to incentivize eligible professionals, facilities, and critical access hospitals to use electronic health records (EHRs) in a meaningful way (P.L. 111-5; Blumenthal, 2010). The purpose of MU incentives is to increase the speed of EHR adoption and healthcare improvement. MU of EHRs provides three main benefits: 1) to improve completeness and accuracy of health information; 2) to improve accessibility and sharing of information; and 3) to facilitate patient engagement by encouraging clients to access their own health information electronically and securely over the Internet; share that information with their families; and more actively participate in their own care (ONC, 2012).
... very few nurses engage in discussions that may greatly impact their profession; however, policymakers depend on stakeholder input to make decisions... Members of ANA's Nursing Practice and Policy Department note that very few nurses engage in discussions that may greatly impact their profession; however, policymakers depend on stakeholder input to make decisions about how to plan, implement, and enforce laws and regulations (Dr. Maureen Dailey, personal communication, July 18, 2013). This introductory information about quality and MU is intended to provide context for readers to be conversant on this important and fast-moving topic. This article will outline the quality conversation and some of its participants; reveal some of the perceived gaps in the conversation into which nursing could contribute valuable insights; and hopefully prompt nurses to volunteer to participate in committees, comment on regulations, or otherwise engage in the discussion. Nurses are clinicians and caregivers for children, families, and a diverse array of patients. Decision makers value their input.
The National Quality Strategy and Nursing
Description and History
The National Quality Strategy was established with the intent of improving American healthcare quality The National Quality Strategy (NQS) was established under the PPACA as a national effort to align the interests of public and private partners with the intent of improving American healthcare quality (Conway, Mostashari, & Clancy, 2013; U.S. Government Printing Office, 2010). The NQS aims of better care, affordable care, and healthy people and communities set forth a unified vision of the healthcare system that was understandable and applicable to all stakeholders at every level—local, state, and national (Berwick, Nolan, & Whittington, 2008). To make quantifiable progress toward achieving the NQS vision, the use of health information technology (health IT) for performance improvement is essential. When data necessary for quality measurement are captured as a byproduct of care delivery, and when those data are easily shared between health IT systems, care can be better coordinated, and is safer, more efficient, and of higher quality. Members of the Department of HHS are working specifically to move the quality enterprise forward by supporting measurement, reporting, and improvement of healthcare with health IT (Conway et al., 2013).
The use of health IT for quality measurement and improvement aligns closely with a position statement published by the ANA (2009). This statement supports use of standards-based health IT, specifically electronic health records (EHRs), whereby data are accurately and efficiently collected, analyzed, and reported to generate knowledge that leads to improved outcomes through all segments of the healthcare system (Androwich, 2013). Furthermore, the ANA document supports capturing data once and reusing it many times by taking advantage of interoperability standards that promote unencumbered transmission of data, information, and knowledge. The ANA statement on nursing’s social policy clearly articulates that nurse input is not only essential, but is a responsibility of practice for both nurses and professional nursing organizations (ANA, 2010b).
Nurses are involved in providing initial input on the overarching aims and priorities of the NQS through programs such as the National Priorities Partnership (NPP) and the Measures Application Partnership (MAP). The NPP provides input to HHS on the development of a national strategy as well as priorities for healthcare performance measurement and improvement. The MAP focuses on alignment around the best measures of quality for use in public reporting and performance-based payment programs, such as Pay-for-Performance (NQF, 2011).
Quality reports supported by these programs vary from those used for internal quality improvement and those used for public reporting. For instance, participants in the ANA National Database of Nursing Quality Indicators® (NDNQI®, 2013) could use reports on such measures as hospital acquired pressure ulcers and unassisted falls to improve quality outcomes at the unit level. Additionally, CMS publishes Hospital Compare, which reports metrics (e.g. readmissions, complications, and deaths) for public reporting and comparison. For an example, see the link to the VA Maryland Healthcare System, Baltimore (Medicare.gov, n.d.) to the Centers for Medicare and Medcaid Services for the Veterans Affairs Maryland Healthcare System, Baltimore, which reports available data and comparisons.
Federal Advisory Committees
Through development and adoption of data standards, the EHR can be used for electronic quality reporting. Building an electronic data infrastructure is a fundamental backbone for successful quality measurement and improvement. It is also an essential component for meeting the criteria for MU (Blumenthal & Tavenner, 2010; Buntin, Jain, & Blumenthal, 2010). The nation has invested in building a data infrastructure so EHRs and other clinical information systems can capture data needed for performance measurement as a byproduct of care delivery. When nursing data are included, nursing impact on outcomes and contributions to health can be measured. Historically, EHRs often contained rich and critical clinical data but access to the data has been a difficult and manual process. Through development and adoption of data standards, the EHR can be used for electronic quality reporting. This requires an electronic data infrastructure (Ricciardi et al, 2013).
There are two important FACAs setting the direction for the adoption of data standards for ONC. One is the Health IT Policy Committee, charged to make recommendations on development and adoption of a nationwide health information infrastructure, including standards for healthcare data exchange. The other is the Health IT Standards Committee, chartered to make recommendations on standards, implementation specifications, and certification criteria for the electronic exchange and use of health information (ONC, 2012). The Health IT Standards Committee’s goal is to ensure these standards contain important data and information derived from quality measures in order to use the data captured as a byproduct of care delivery for quality measurement.
Nurses hold seats on both ONC FACAs, as well in the FACAs’ working groups. Committee membership by nurses helps to ensure that the proposed standards represent nursing practice. The nursing profession has played a key role in the quality measurement enterprise by helping to set priorities and goals for using EHRs to measure and publicly report quality performance. Input from nurses has helped HHS to promote and support the transition from traditional paper-based quality measure formats to the electronic quality measures (eMeasures) format that can be processed by EHRs to generate quality measure reports (ONC, 2012).
Quality Measurement Data Standards
Historically, quality measures have been paper-based and lacked consistency, which hindered the ability to compare performance results across healthcare settings. The Department of HHS spearheaded the development of eMeasures, which are quality measures represented in a standardized electronic format, allowing a consistent, replicable comparison of quality (Knecht, Boberg, Kiley, & Giles, 2012; White, McColm, Kmetik, & Fischer, 2010). Historically, quality measures have been paper-based and lacked consistency, which hindered the ability to compare performance results across healthcare settings. For example, the term “medications” was not explicitly represented across measures, to indicate whether the measure required medications ordered, dispensed, or administered (NQF, 2013). eMeasures allow for the explicit representation of quality measures through use of data standards. The eMeasure is the electronic format for quality measures using the Quality Data Model (QDM) and the Healthcare Quality Measure Format (HQMF), which is formatted under an international data standard known as Health Level 7 (HL7; Fu, Rosenthal, Pevnick, & Eisenberg, 2012).
The QDM is an information model that clearly defines concepts used in quality measures. The QDM is the backbone for representation of eMeasures and is used by stakeholders involved in electronic quality measurement and reporting, such as measure developers, federal agencies, health IT vendors, standards organizations, informatics experts, providers, and researchers. The QDM also describes information so EHRs and other health IT systems consistently interpret and locate data required for measurement. HQMF is an HL7 draft standard electronic format used to represent quality measures consistently. Quality measure data is extracted from EHRs and generates a report that must also follow a standard format so clinicians can compare outcome data across the nation (Fu et al, 2012).
Nurses have provided input into the QDM since its inception. Nurses, such as Laura Heermann Langford, RN, PhD of Intermountain Health, are involved in the working committees at HL7 to provide input to ensure that standards support person-centered care and nursing practice. Use of the QDM for documenting quality measures and care will provide a mechanism for reporting of clinicians’ influences on outcomes and subsequent improvement in care at a national level (NQF, 2011; NQF Testimony, 2012). Changes in documentation and care brought on by eMeasures will affect nurses as well as other clinicians. ANA is currently developing eMeasures of nursing quality for NDNQI using the QDM and HQMF.
eMeasures allow for the explicit representation of quality measures through use of data standards. To illustrate how an eMeasure differs from a traditional, paper-based quality measure, consider how NDNQI currently captures the number of unit-acquired pressure ulcers (UAPU) per 1,000 patient days, as a measure of unit quality today, versus how it might collect UAPU using an eMeasure in the future. Current UAPU data collection requires that nurses on a given unit report the midnight census (number of patients admitted to that unit as of midnight). Then, certified wound and ostomy nurses complete a pressure ulcer assessment for each patient on that unit, documenting pressure ulcers present on admission, developed elsewhere in the hospital since admission, and developed on the unit since admission. Nurses then manually document their findings for submission to NDNQI (NOTE: The authors simplified this overview of data collection to include only the essential steps). Using an eMeasure, UAPU data capture would occur as a byproduct of care using documentation already entered into individual patient EHRs from the nurses’ assessments at admission and throughout the patients’ stays. The eMeasure program would combine those data with the midnight census for that unit and report those data to NDNQI.
Programmers writing this eMeasure are using the QDM as a framework and the HQMF as the standardized mechanism for capturing the UAPU data from EHR database fields. This change in measurement modality would simplify data collection, reduce nursing workload, and decrease ambiguity in pressure ulcer definitions by setting a standard for specific EHR data to represent a pressure ulcer.
Engaging in the National Quality Agenda
The overview provided above discussed several examples of nurses working to make a difference in the national quality agenda. Many more are needed. This section discusses how a nurse interested in quality and healthcare might become involved in health IT, engage in discussions about meaningful use, take a leadership role, and participate both nationally and locally.
Becoming Involved in Health IT
Health IT impacts quality by providing users the unique ability and opportunity to truly capture and derive the benefits from data. Health IT is a foundational tool to change the healthcare industry; however, it is not an instant fix. Rather, it is one tool in the arsenal of health reform. Health IT impacts quality by providing users the unique ability and opportunity to truly capture and derive the benefits from data. This allows users to translate seemingly independent pieces of data into meaningful conclusions that, if applied and implemented correctly, can improve the health of individuals and populations; lower costs; and help tailor healthcare to individual patient needs. Health IT can be implemented and employed in such a way as to support the National Quality Strategy and help achieve the 3-part aim of better care, better health, and lower cost (Berwick et al., 2008).
Nurses knowledgeable about the usefulness of health IT and active in professional organizations can be instrumental in facilitating improvements in the quality and safety of patient care. They can engage in committee work and with groups that develop and implement health IT and policies and procedures that support it (Bowles, Gélinas, & Clancy, 2013). Implementation depends especially on nurses, as they understand the work of patient care and can assist in integrating health IT with existing or new work processes. They are also keenly interested in safeguarding patients across transitions in care from the hospital to their own homes, to home health, or to skilled nursing facilities. As agents in transitions of care, nurses are encouraged to own this transition and utilize health IT to assure accurate and complete information exchange across care boundaries. One way for this process to occur is with quality through development of effective transition of care documents (ANA, 2010a).
Health IT strategist Leonard Kish stated, “Patient engagement is the blockbuster drug of the century” (Chase, 2012, para. 1). Engaged patients are more effective managers of their own care. Nurses have an essential role to engage patients in their own care; patients and their families trust nurses (ANA, 2010b; Schumann, 2013). Nurses teach patients and families and can influence their perceptions of how to engage in their own care. Providing patients an electronic copy of their record or making them aware of a patient portal gives them the ability to view and download healthcare encounter data available from Medicare, the Department of Veterans Affairs, or other payers. Enrolling patients in portal accounts, such as Medicare’s Blue Button (Ricciardi, Mostashari, Murphy, Daniel, & Siminerio, 2013), and teaching patients how to use them are important steps toward strengthening patient access to their health information and engagement in their own healthcare. These examples illustrate just some of the ways that nurses can impact healthcare quality by involvement in health IT initiatives.
Engaging in Discussions about Meaningful Use as a Quality Platform
The American Recovery and Reinvestment Act (ARRA) of 2009 (PL 111-5) mandated the EHR Incentive Program (U.S. Government Printing Office, 2009). Because continuous quality and process improvement are essential elements of MU of EHRs, eligible professionals, healthcare facilities, and critical access hospitals must attest to meeting MU criteria to earn federal incentives. Nurses are the most plentiful clinicians and the most proximal to the patient, thus their input toward effective use of incentives to improve care is important to successful implementation (Kaplan, 2013) For more information about EHR incentives, see the Medicare & Medicaid EHR Incentive Program website (CMS, 2013).
Meaningful use of health IT is best considered as a platform for continuous quality and process improvement, as opposed to simply implementing technologies as an end unto themselves. There is much work to do once an EHR is installed before an organization has attested to and achieved MU. This work includes creating an environment in which use of the EHR becomes essential to support an ongoing, programmatic approach to improve patient care safety and quality and drive the changes to decrease cost. Organizations and individuals need to identify and articulate how achieving meaningful use fits with their unique strategic plan related to those specific outcomes.
...nurse leaders sitting on FACAs and measurement development teams are working to think about how to leverage MU to drive a patient-centered, quality and safety agenda that includes nursing input. While meaningful use criteria are not nursing specific, nurse leaders sitting on FACAs and measurement development teams are working to think about how to leverage MU to drive a patient-centered, quality and safety agenda that includes nursing input. There are many potential patient benefits for nurse leaders to consider as they help implement EHRs and encourage health IT adoption and use (ONC, 2012).
Taking a Leadership Role
Nurses can lead from any chair. In the case of health IT, nurses can lead as role models who use their own electronic personal health records. They can then talk to every patient they care for and to their colleagues about the importance and value of having and maintaining an up-to-date health record. In nursing informatics positions, nurses may move from individual contributions to becoming team leaders on EHR or other health IT implementation projects.
Nurses can raise a hand to say “yes, I’ll participate”... In addition, hospitals and other healthcare employers often have committees to address quality improvement, automated documentation, and patient engagement. Nurses can raise a hand to say “yes, I’ll participate” and get involved in these activities. Some employers will temporarily reassign employees who are interested in helping select and implement new initiatives onto a dedicated team. Nurses with higher levels of education and skillsets can take even greater roles in nurse informatics or leadership. As more nurses participate in leadership roles such as these to impact quality, more of the nursing perspective will become a part of quality initiatives.
Participating in the National Quality Agenda Locally and Nationally
There are other ways that nurses can participate in quality work within their own organizations, such as getting involved in shared governance or professional practice activities (e.g., standards of practice, quality assurance, or performance improvement committees). These activities can make a real difference to the quality of care provided at an organization. Nurses are an essential part of healthcare delivery, but often their voices are lacking in the development and implementation of the learning health system.
Evolution of quality standards and measurement tools often occurs through standing committees at professional organizations. Nurses could consider involvement in the work of their specialty organizations or state nurses associations on quality initiatives, quality committees, task forces, or on the American Nurses Association Professional Issues Panels (ANA, 2013). Evolution of quality standards and measurement tools often occurs through standing committees at professional organizations. Even nurses who choose not to participate can remain aware of activities at the organizational, state, and national levels. This awareness can help nurses to serve as useful resources for colleagues who may wish to learn about or participate in various initiatives.
Opportunities for periodic involvement will also arise, such as responding to Requests for Comments (RFC) or Requests for Information (RFI) on pending standards, regulations, or other federal guidance documents. For example, earlier this year the Agency for Healthcare Research and Quality (AHRQ) solicited public comments on the National Quality Strategy originally published as a result of the PPACA. Nurses can also engage in the quality agenda by helping their organizations develop position statements on important healthcare issues, volunteering to provide expert testimony at hearings on quality topics, or writing a letters to federal and state representatives or senators. Many of these activities are open and transparent processes, so participation as an observer seeking knowledge and awareness of current initiatives is also easy to accomplish.
Finding out where and when a FACA or other committee will form and what purpose it will serve can be a challenge. Federal law requires the federal government to announce FACAs in the Federal Register (n.d.). While the Federal Register is publicly available, few people review it with enough regularity to track FACA calls. Additionally, because of its scope, size, and frequency, finding important notices in the Federal Register is not always easy. Non-government entities, such as NQF and The Joint Commission, convene committees and panels to improve processes and gain stakeholder input. Even announcements for these committees are not always easy to find. To help stakeholders track opportunities, many professional associations, such as ANA and the Association of periOperative Registered Nurses (AORN) monitor these announcements and post information about them on their websites. Watching for this information can help members become aware of the chance to pursue committee membership and the process for endorsing their attendance with organizational letters of support.
Conclusion: Call to Action
Nurses cannot provide quality care without the right information to make the right decisions when caring for patients. Nursing has become an information-based profession that provides healthcare. Technology gives nurses access to information at the point of care for decision-making. It can also remind or inform them of best practices. Nurses who are aware of the multiple changes in access and portability of information can help to inform development and adoption of new technologies facilitate quality healthcare.
Through strong leadership and active participation, nurses will be able to complete the hard work necessary to create changes to drive the quality agenda and transform healthcare. Leadership makes a difference. If nurses do not engage in discussions about quality in healthcare, their ideas and opinions will not be heard. Nurses can take on leadership roles to influence healthcare delivery, improving quality, safety, and efficiency, and bring evidence for decision-making to the point of care to empower patients as partners. Collectively, nurses must respond to the challenges and opportunities outlined in this article, such as increasing awareness of initiatives and/or committee participation, to advance the nursing role in leading change and advancing positive health outcomes through quality care. Whatever chair they occupy, nurses must be confident that they can influence health policies and practices at the local, regional, state, and national level. Through strong leadership and active participation, nurses will be able to complete the hard work necessary to create changes to drive the quality agenda and transform healthcare.
Rosemary Kennedy, PhD, RN, MBA, FAAN
Dr. Kennedy, RN, MBA, FAAN, is President and CEO of eCare Informatics, and also Associate Professor and Associate Dean of Strategic Initiatives at Thomas Jefferson University School of Nursing in Philadelphia, PA. Most recently, Dr. Kennedy was Vice President of Health Information of Technology at the National Quality Forum in Washington, DC. In addition to being an informatics domain expert, she holds many leadership roles through her work with the American Medical Informatics Association (AMIA) and Technology Informatics Guiding Educational Reform Board (TIGER). Dr. Kennedy is widely presented and published in the field of nursing informatics, clinical documentation and terminology standards. She is a fellow in the American Academy of Nursing and received the HIMSS 2009 Nursing Informatics Award as well as the top 25 women in healthcare award for 2009. She is currently on the TIGER board and sits on the safety council for the American Association of Medical Instrumentation. For many years, she was the Chief Nursing Informatics Officer for Siemens Healthcare Solutions.
Judy Murphy, RN, FACMI, FAAN
Judy Murphy is Deputy National Coordinator for Programs & Policy at the Office of the National Coordinator for Health IT, Department of Health and Human Services in Washington D.C. In this role, she coordinates federal efforts to assist healthcare providers and organizations to adopt health information technology to improve care and promote consumers’ greater understanding and use of health information technology. Prior to this, she was Vice President-Electronic Health Record Applications at Aurora Health Care in Wisconsin, where she led the EHR program and was involved with health informatics for over 25 years. Judy served on the American Medical Informatics Association (AMIA) Board of Directors and the Health Information and Management Systems Society (HIMSS) Board of Directors. She is a Fellow in the American Academy of Nursing, the American College of Medical Informatics and HIMSS. She received the 2006 HIMSS Nursing Informatics Leadership Award, was named one of the “20 People Who Make Healthcare Better” in 2007 by HealthLeaders magazine, and was selected as one of 33 Nursing Informatics’ Pioneers to participate in the Nursing Informatics History Project sponsored by AMIA, NLM, AAN, and RWJF.
Darryl W. Roberts, PhD, MS, RN
Darryl W. Roberts, PhD, MS, RN is a Senior Policy Fellow at the American Nurses Association (ANA). In addition, he is an adjunct professor at Stevenson University School of Graduate and Professional Studies and at the University of Baltimore College of Public Affairs. He has been a nurse with 25 years of experience in such diverse areas as chronic pulmonary care, hospice, mental health, informatics, health care quality, and the learning healthcare system. He earned graduate degrees in Nursing Informatics and Policy Sciences from the University of Maryland School of Nursing and the University of Maryland Baltimore County (UMBC), respectively. He later earned a PhD in Public Policy Evaluation from UMBC. As evaluation scientist, nurse informatician, clinical researcher, policy advisor, and university educator, Dr. Roberts gives a unique perspective to health care and nursing. In his several roles, he has the privilege of investigating, acting on, advocating for, and teaching about the confluences of healthcare, health information technology, health policy, and health care quality. The body of his work has been captured in numerous publications, as well as presentations at research and professional conferences nationally and internationally.
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© 2013 OJIN: The Online Journal of Issues in Nursing
Article published September 30, 2013
- Building Linkages between Nursing Care and Improved Patient Outcomes: The Role of Health Information Technology
Patricia C. Dykes, PhD, RN, FAAN, FACMI; Sarah A. Collins, PhD, RN (September 30, 2013)
- Quality and Safety Education for Nurses (QSEN): The Key is Systems Thinking
Mary A. Dolansky, PhD, RN; Shirley M. Moore, PhD, RN, FAAN (September 30, 2013)
- An Academic Practice Partnership: Helping New Registered Nurses to Advance Quality and Patient Safety
Deborah Flores, EdD, RN; Gale Hickenlooper, RN, MPH; Rebecca Saxton, PhD, RN (September 30, 2013)
- The Influence of Quality Improvement Efforts on Patient Outcomes And Nursing Work: A Perspective from Chief Nursing Officers at Three Large Health Systems
Marla Weston, PhD, RN, FAAN; Darryl W. Roberts, PhD, MS, RN (September 30, 2013)