“Why can’t we give quality care to all of the people all of the time?” asked Lucian Leape, MD, a leader of the patient safety movement, during his keynote address at the 2014 American Nurses Association (ANA) Quality Conference, “Advancing Quality Outcomes: Practice, Innovation, and Impact,” Feb. 5-7 in Phoenix, AZ. His answer was, “We have a culture of disrespect,” which he called “the elephant in the room.” Leape said health care organizations need to address disrespect and create a “learning culture” where health care worker physical and emotional safety is the norm. The culture should include effective leadership, transparency, commitment to improvement, accountability and collaboration to advance quality.
During the conference, more than 1,000 attendees, many of whom battled their way through winter weather to reach Phoenix, listened to engaging presentations from Leape and nurse experts, and tapped into opportunities to exchange ideas through networking. A wide variety of nurses, from seasoned leaders to novice nurses, attended more than 30 educational programs and more than 100 poster sessions, all providing food for thought about the nature of quality and how to achieve it.
Karen A. Daley, PhD, RN, FAAN, president of ANA, welcomed participants by saying, “I can’t recall a time in my career when the topic of health care quality has been more front and center.” Daley noted, “Patients and institutions are reaping the benefits of nursing’s contributions to better outcomes,” citing benefits such as fewer readmissions, fewer hospital acquired conditions and better care, all leading to better reimbursements. She also highlighted three ANA quality initiatives — measuring the quality of ambulatory care, promoting care coordination and developing electronic quality measures, or eMeasures. Daley ended by saying, “Thank you for contributing to our profession’s quality journey by being here. ANA is committed to being with you every step of the way.”
Leape, an adjunct professor of health policy at the Harvard School of Public Health, reviewed past initiatives to improve quality, saying that although progress has been made, “We keep falling short.” He reminded participants, “It’s not bad people; it’s bad systems.” One problem is disruptive behavior and disrespect.
Disrespect occurs because “We teach it, we tolerate it and we cause it,” Leape said, adding, “We need to change our policies, we need to change our practice and we need to change our behavior.” Policies should have zero tolerance for disruptive behavior, and Leape noted, “If it’s going to be meaningful, it has to start at the top.” Practice includes having a protocol for how to respond to disruptive behavior. “There has to be consequences for rules violations,” Leape said. Prevention, including training staff in respect skills and identifying problem behaviors early, is also important.
Leape acknowledged that physicians and nurses face many external pressures that affect behavior and satisfaction. He noted that in his book Drive, Daniel Pink says intrinsic—rather than extrinsic—motivation is more powerful. Creating an environment of autonomy, mastery and purpose will facilitate intrinsic motivation.
Leape ended by quoting Francis Weld Peabody, who said, “The secret of the care of the patient is caring for the patient.” Leape then said, “The secret of the care of the patient is also caring for the caregiver.”
Day one of the conference concluded with Patricia Brennan, PhD, RN, discussing “what’s next” in quality improvement, saying, “Action is where we need to be. Action with patients, and action with ourselves.” Brennan, who is the Lillian L. Moehlman Bascom Professor at the School of Nursing and College of Engineering at the University of Wisconsin-Madison, said that in 10 years, the health experience “will look nothing like it is now—and that’s a good thing.” One positive change is that the point of care will move from the health care setting to the patient’s daily life. Brennan, a Wisconsin Nurses Association member, said nurses should “listen to what health means to the person,” and noted, “Smart patients are partners in quality.” She co-chaired the National Quality Forum Patient-reported Outcomes Steering Committee in 2013, identifying strategies to incorporate the patient’s voice in evaluating health care quality outcomes.
Brennan said technology “allows us a window into the life of a person. The quality agenda will only be accomplished when nurses harness technology so they can work with patients across the (care) continuum.” Brennan, who is national program director of Project HealthDesign, a Robert Wood Johnson Foundation program, showed videos illustrating how patients are using technology such as apps on tablets to manage their health. These types of innovations will affect workflow, technology infrastructure and outcomes measures. “We need to measure quality where the patient is, not where the care was delivered,” Brennan said.
The second day of the conference opened with Nancy Dunton, PhD, FAAN, and Emily Cramer, PhD, who showcased the newest research from the NDNQI®, a quality improvement solution of ANA.
Dunton, a research professor at the University of Kansas Medical Center and director of NDNQI, focused on the value of nursing. She summarized peer-reviewed research in this area, saying it’s “well documented” that having a higher number of nurses-to-patient ratio and a higher percentage of RNs in the skill mix reduces patient harm. Although important to society, the cost savings doesn’t always directly affect the hospital’s bottom line, which contributes to perceptions that “increased nurse staffing is an added cost.”
Analyzing NDNQI data demonstrates the value of nursing, and Dunton shared the latest results, expected to be published soon. Based on existing literature, she then outlined how improving the work environment in four areas—leadership, work processes, RN workforce and organizational culture—can reduce nurse turnover.
Cramer, a research assistant professor in the School of Nursing at the University of Kansas Medical Center, said the focus of the safe patient handling and mobility (SPHM) NDNQI study was to describe current SPHM practices in hospitals. Publication of the data is planned, and Cramer shared general findings, saying, “There were statistically but not clinically significant differences in SPHM practices between states with and without SPHM legislation, and there were significant differences across practice settings.”
The conference ended with Bernadette Mazurek Melnyk, PhD, CPNP/PMHNP, FNAP, FAAN, associate vice president for health promotion, university chief wellness officer, and dean of the College of Nursing at The Ohio State University, who provided a how-to guide on empowering frontline nurses with evidence-based practice (EBP). Melnyk, an ANA member, noted that “Evidence-based practice within a context of caring and evidence-based culture and environment results in the highest quality of patient care.”
The strength of the evidence plus the quality of evidence equals the confidence to act, Melnyk said. She acknowledged barriers to EBP such as lack of knowledge and skills and perceived lack of time, and noted that EBP facilitators can help reduce these barriers.
Melnyk ended by discussing the “critical components” of EBP, including organization commitment, a spirit of inquiry, a cadre of EBP mentors, administrative role modeling and support, infrastructure and recognition. “We must make it easy and fun for clinicians to implement best practices,” she said.
In addition to education programs, participants spent time talking with 50 exhibitors to learn about valuable resources. Many attendees are likely already marking their calendars for the 2015 Quality Conference, Feb. 4-6 at Disney’s Coronado Springs Resort in Lake Buena Vista, FL.
— Cynthia Saver is president of CLS Development, Inc.