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Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr.

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Patient Safety and Quality: An Evidence-Based Handbook for Nurses.

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Chapter 20b[Vignette] Who Should Lead the Patient Quality/Safety Journey?


Joanne Disch, Ph.D., R.N., F.A.A.N., Clinical Professor and Director, Katharine J. Densford International Center for Nursing Leadership and Katherine R. and C. Walton Lillehei Chair in Nursing Leadership, University of Minnesota School of Nursing; e-mail: ude.nmu@300hcsid

Batalden and colleagues1 remind us that improving quality and safety for patients and families requires leaders to lead—and that the words leader, leading, and leadership stem from laitho or laithan, meaning “way,” “journey,” or “to travel.”2, 3 Much has been written about the need for and characteristics of leadership for this journey.4–8 This section challenges Chief Nurse Executives (CNEs) to lead the journey and highlights how patients, their families, and health care organizations would benefit immeasurably if CNEs stepped forward and accepted this leadership role. There are many examples across the country where this has been exquisitely demonstrated.

The CNE should lead the journey because the nursing profession has been at the forefront of assuring quality and safety. Before the first Institute of Medicine study,9 or the Chicago Tribune article with the headline “Nursing Mistakes Kill Thousands,”10 or the National Patient Safety Foundation, or the Institute for Healthcare Improvement, there were nurses at all levels in hospitals and health care organizations concerned about patient safety and quality of care. For decades, nursing leaders like Marie Zimmer and Norma Lang have developed and tested quality indicators. For generations, nurses have taken seriously their Code of Ethics and their role as one who “promotes, advocates for, and strives to protect the health, safety and rights of the patient.”11 Florence Nightingale reminded us that “the very first requirement in a hospital [is] that it should do the sick no harm”12—and proceeded to set up systems and practices that are still being used today to enhance the quality and safety of patient care.

The CNE should lead the journey because nurses understand what the issues are. While many physicians, administrators, policymakers, and others have come to realize only recently that health care is frighteningly unsafe, nurses have been raising concerns for many years. Nurses do not need to be alerted to the dangers of malfunctioning equipment, or the likelihood of medication error when getting medications ready and being interrupted 16 times, or the safety threat when orientation to the new computer system is inadequate, or the potential for serious injury to the patient and self when struggling to lift a 287 pound patient. Nurses are there 24/7 and, through the nursing lens, recognize the system issues, dangerous shortcuts, work-arounds, and waste.

The CNE should lead the journey because nurses have workable solutions. We recognize the problems, and we also have solutions. We blend practical wisdom with scientific knowledge and finely-honed interpersonal skills or, as a Boston cab driver once noted, we’re “caring, shrewd, and a little bit crazy.” We see the big picture and the details—the interconnectedness among departments and professions. We understand everything that needs to be done to complete the job, whatever it is. We are holistic—whether it be caring for a patient in the context of family, or coming up with a solution to a problem that incorporates the concerns of everyone involved. And nurses are resourceful. Who else can coordinate the administration of three antibiotics, two units of packed cells, and four units of platelets; cajole the pharmacist to bring up a missing drug; hunt down the needed blood filter, extra IVAC, flexicare mattress, cardiac chair for a wife; and find a nurse to work an extra 12-hour shift for nights—all within an 8-hour period?

As leaders within their organizations, CNEs have the background, perspective, and platform to help their organizations seriously tackle safety issues that jeopardize patient care and that face nurses and their colleagues daily. They can

  • Create a healthy culture that promotes safety, inquiry, continuous learning, and collaboration.
  • Design systems and processes that help people do their best work and deliver quality care (safe, timely, effective, efficient, equitable, patient-centered).
  • Acquire and align resources to get the work done and achieve organizational goals.
  • Assure the existence of a professional practice environment that values evidence as a basis for decisionmaking and the ongoing development of everyone.
  • Implement quality and safety programs that are effective, supported, embedded in the culture, and get the job done.

What Are the Barriers to CNEs Taking on This Particular Leadership Journey?

Barriers can exist at the organizational or individual level. These include

  • Organizations that rely on hierarchical structures with a traditional complement of leaders, and that sustain a culture that resists change and blames individuals for system failures.
  • Organizational leaders who impose arbitrary solutions and/or weigh financial imperatives more heavily than quality/safety concerns.
  • CNEs themselves who retreat behind balance sheets and abdicate their role as senior patient care officers and architects for a truly professional practice environment for nurses.

In addition, a number of other factors make this journey difficult, such as a lack of resources, insufficient time, pressures from competing priorities, and the complexity of the health care system.

Evidence and Collaboration Will Enable This Journey To Be Taken Successfully

  • Evidence that clearly outlines strategies that improve safety and quality while using reasonable levels of resources. The idea that quality is more expensive is wrong, and more is not always better, e.g., when patients get extra doses of medications, or two x-rays when one is ordered, or extra days in the intensive care unit when transfer orders are held up. CNEs can extract excellent, evidence-based strategies from this book and build the business, legal, and ethical case for safety and quality.
  • Collaboration among nurses, physicians, other care providers, staff, boards of trustees, and organizational leaders who share a passion and commitment for a safer health care experience. The vast majority of individuals in health care want to collaborate, but don’t always know how to do it. Most often, the CNE has the knowledge, perspective, and aptitude to skillfully bring people together to achieve common goals— in this case, quality and safety for patients, their families, and caregivers.


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