9.2 Quality Care
Quality is defined in a variety of ways that impact nursing practice.
ANA Definition of Quality
The American Nurses Association (ANA) defines quality as, “The degree to which nursing services for health care consumers, families, groups, communities, and populations increase the likelihood of desirable outcomes and are consistent with evolving nursing knowledge.”[1] The phrases in this definition focus on three aspects of quality: services (nursing interventions), desirable outcomes, and consistency with evolving nursing knowledge (evidence-based practice). Alignment of nursing interventions with current evidence-based practice is a key component for quality care.[2] Evidence-based practice (EBP) will be further discussed later in this chapter.
Quality of Practice is one of the ANA’s Standards of Professional Performance. ANA Standards of Professional Performance are “authoritative statements of the actions and behaviors that all registered nurses, regardless of role, population, specialty, and setting are expected to perform competently.” See the competencies for the ANA’s Quality of Practice Standard of Professional Performance in the following box.[3]
Competencies of ANA’s Quality of Practice Standard of Professional Performance[4]
- Ensures that nursing practice is safe, effective, efficient, equitable, timely, and person-centered.
- Incorporates evidence into nursing practice to improve outcomes.
- Uses creativity and innovation to enhance nursing care.
- Recommends strategies to improve nursing care quality.
- Collects data to monitor the quality of nursing practice.
- Contributes to efforts to improve health care efficiency.
- Provides critical review and evaluation of policies, procedures, and guidelines to improve the quality of health care.
- Engages in formal and informal peer review processes of the interprofessional team.
- Participates in quality improvement initiatives.
- Collaborates with the interprofessional team to implement quality improvement plans and interventions.
- Documents nursing practice in a manner that supports quality and performance improvement initiatives.
- Recognizes the value of professional and specialty certification.
Reflective Questions
- What Quality of Practice competencies have you already demonstrated during your nursing education?
- What Quality of Practice competencies are you most interested in mastering?
- What questions do you have about the ANA’s Quality of Practice competencies? Where could you find answers to those questions (e.g., instructors, preceptors, health care team members, guidelines, or core measures)?
This chapter will review content related to the competencies of the ANA’s Quality of Practice Standard of Professional Performance. Additional information about peer review is discussed in the “Leadership and Management” chapter, and specialty certification is discussed in the “Preparation for the RN Role” chapter.
Quality and Safety Education for Nurses
The Quality and Safety Education for Nurses (QSEN) project advocates for safe, quality client care by defining six competencies for prelicensure nursing students: Patient-Centered Care, Teamwork and Collaboration, Evidence-Based Practice, Quality Improvement, Safety, and Informatics. These competencies are further discussed in the “Advocacy” chapter.
Framework of Quality Health Care
A definition of quality that has historically guided the measurement of quality initiatives in health care systems is based on the framework for improvement originally created by the Institute of Medicine (IOM). The IOM name changed to the National Academy of Medicine in 2015. The IOM framework includes the following six criteria for defining quality health care[5],[6]:
- Safe: Avoiding harm to clients from the care that is intended to help them.
- Effective: Providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit (i.e., avoiding underuse and misuse).
- Client-centered: Providing care that is respectful of and responsive to individual client preferences, needs, and values and ensuring that client values guide all clinical decisions.
- Timely: Reducing waits and sometimes harmful delays for both those who receive and those who provide care.
- Efficient: Avoiding waste, including waste of equipment, supplies, ideas, and energy.
- Equitable: Providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status.
This framework continues to guide quality improvement initiatives across America’s health care system. The evidence-based practice (EBP) movement began with the public acknowledgement of unacceptable client outcomes resulting from a gap between research findings and actual health care practices. For EBP to be successfully adopted and sustained, it must be adopted by nurses and other health care team members, system leaders, and policy makers. Regulations and recognitions are also necessary to promote the adoption of EBP. For example, the Magnet Recognition Program promotes nursing as a leader in catalyzing adoption of EBP and using it as a marker of excellence.[7]
Magnet Recognition Program
The Magnet Recognition Program is an award from the American Nurses Credentialing Center (ANCC) that recognizes organizational commitment to nursing excellence. The award recognizes organizations worldwide where nursing leaders have successfully aligned their nursing strategic goals to improve the organization’s client outcomes. To nurses, Magnet Recognition means education and development are available through every stage of their career. To clients, it means quality care is delivered by nurses who are supported to be the best that they can be.[8] See Figure 9.2[9] for an image related to the Magnet Recognition Program.
Reimbursement Models
Quality health care is also defined by value-based reimbursement models used by Medicare, Medicaid, and private insurance companies paying for health services. As discussed in the “Health Care Reimbursement Models” section of the “Health Care Economics” chapter, value-based payment reimbursement models use financial incentives to reward quality health care and positive client outcomes. For example, Medicare no longer reimburses hospitals to treat clients who acquire certain preventable conditions during their hospital stay, such as pressure injuries or urinary tract infections associated with use of catheters.[10] These reimbursement models directly impact the evidence-based care nurses provide at the bedside and the associated documentation of assessments, interventions, and nursing care plans to ensure quality performance criteria are met.
CMS Quality Initiatives
The Centers for Medicare & Medicaid Services (CMS) establishes quality initiatives that focus on several key quality measures of health care. These quality measures provide a comprehensive understanding and evaluation of the care an organization delivers, as well as clients’ responses to the care provided. These quality measures evaluate many areas of health care, including the following:[11]
- Health outcomes
- Clinical processes
- Client safety
- Efficient use of health care resources
- Care coordination
- Client engagement in their own care
- Client perceptions of their care
These measures of quality focus on providing the care the client needs when the client needs it, in an affordable, safe, effective manner. It also means engaging and involving the client, so they take ownership in managing their care at home.
Visit the CMS What is a Quality Measure web page.
Accreditation
Accreditation is a review process that determines if an agency is meeting the defined standards of quality determined by the accrediting body. The main accrediting organizations for health care are as follows:
- The Joint Commission
- National Committee for Quality Assurance
- American Medical Accreditation Program
- American Accreditation Healthcare Commission
The standards of quality vary depending on the accrediting organization, but they all share common goals to improve efficiency, equity, and delivery of high-quality care. Two terms commonly associated with accreditation that are directly related to quality nursing care are core measures and client safety goals. Please see Table 9.2 for more information on accrediting organizations.
Table 9.2. Accrediting Organizations [12], [13], [14] [15]
| Organization | Overview | History | Accreditation Process | Standards | Impact |
| The Joint Commission | Non-profit organization accrediting and certifying health care organizations and programs in the U.S. | Founded in 1951, aims to improve public health care quality and safety | Conducts rigorous on-site surveys to assess compliance with standards covering client care, medication safety, infection control, and overall performance | Developed with input from health care professionals, providers, and consumers and designed to help measure, assess, and improve performance | Recognized as a symbol of quality, reflecting commitment to high performance standards |
| National Committee for Quality Assurance (NCQA) | Private, non-profit organization improving health care quality through evidence-based standards, measures, programs, and accreditation | Established in 1990, provides quality information for health care decision-making | Comprehensive review of policies and procedures, including quality management, utilization management, credentialing, and member rights | Widely regarded standards used by CMS and state governments for quality oversight | Demonstrates commitment to improving health care quality and adhering to high performance standards |
| American Medical Accreditation Program (AMAP) | Program by AMA aimed at improving medical care quality by setting high standards for physicians | Launched in the late 1990s, assesses physicians’ qualifications and ethical standards | Detailed review process, including verification of credentials, practice history assessment, and compliance with CME requirements | Ensures physicians provide high-quality care, maintain competency, and adhere to ethical practices | Recognizes physicians’ commitment to high-quality care and medical practice standards |
| American Accreditation Healthcare Commission (AAHC) / URAC | Independent, non-profit organization promoting health care quality through accreditation, certification, and measurement | Founded in 1990, expanded from utilization review to a wide range of health care services | Thorough review of policies, procedures, and performance, including on-site visits and compliance assessment | Developed by a broad array of stakeholders to promote evidence-based practices, client safety, and continuous improvement | Recognized as a mark of excellence, demonstrating commitment to quality and accountability |
Core Measures
Core measures are national standards of care and treatment processes for common conditions. These processes are proven to reduce complications and lead to better client outcomes. Core measure compliance reports show how often a hospital successfully provides recommended treatment for certain medical conditions. In the United States, hospitals must report their compliance with core measures to The Joint Commission, CMS, and other agencies.[16]
In November 2003, The Joint Commission and CMS began work to align common core measures, so they are identical. This work resulted in the creation of one common set of measures known as the Specifications Manual for National Hospital Inpatient Quality Measures. These core measures are used by both organizations to improve the health care delivery process. Examples of core measures include guidelines regarding immunizations, tobacco treatment, substance use, hip and knee replacements, cardiac care, strokes, treatment of high blood pressure, and the use of high-risk medications in the elderly. Nurses must be aware of core measures and ensure the care they provide aligns with these recommendations.[17]
Read more about the National Hospital Inpatient Quality Measures.
National Patient Safety Goals
Patient safety goals are guidelines specific to organizations accredited by The Joint Commission that focus on health care safety problems and ways to solve them. The National Patient Safety Goals (NPSG) were first established in 2003 and are updated annually to address areas of national concern related to client safety, as well as to promote high-quality care. The NPSG provide guidance for specific health care settings, including hospitals, ambulatory clinics, behavioral health, critical access hospitals, home care, laboratory, skilled nursing care, and surgery.
The following goals are some examples of NPSG for hospitals[18]:
- Identify patients correctly
- Improve staff communication
- Use medicines safely
- Use alarms safely
- Prevent infection
- Identify patient safety risks
- Prevent mistakes in surgery
Nurses must be aware of the current NPSG for their health care setting, implement appropriate interventions, and document their assessments and interventions. Documentation in the electronic medical record is primarily used as evidence that an organization is meeting these goals.
Read the current agency-specific National Patient Safety Goals.
- American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵
- Stevens, K. R. (2013). The impact of evidence-based practice in nursing and the next big ideas. OJIN: The Online Journal of Issues in Nursing, 18(2), manuscript 4. https://ojin.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol-18-2013/No2-May-2013/Impact-of-Evidence-Based-Practice.html ↵
- American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵
- American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵
- Agency for Healthcare Research & Quality. (2022). Six domains of health care quality. https://www.ahrq.gov/talkingquality/measures/six-domains.html ↵
- Institute of Medicine (US) Committee on Quality of Health Care in America. (2001). Crossing the quality chasm: A new health system for the 21st century. National Academies Press. https://pubmed.ncbi.nlm.nih.gov/25057539/ ↵
- Stevens, K. R. (2013). The impact of evidence-based practice in nursing and the next big ideas. OJIN: The Online Journal of Issues in Nursing, 18(2), manuscript 4. https://ojin.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol-18-2013/No2-May-2013/Impact-of-Evidence-Based-Practice.html ↵
- American Nurses Credentialing Center. (2024). ANCC magnet recognition program. https://www.nursingworld.org/organizational-programs/magnet/ ↵
- “Magnet_Recognition_Logo_CMYK_-png-.png” by Mattmitchell37 is licensed under CC BY-SA 4.0 ↵
- James, J. (2012). Pay-for-performance. Health Affairs. https://www.healthaffairs.org/do/10.1377/hpb20121011.90233/full/ ↵
- CMS.gov. (2024). Quality measures. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityMeasures ↵
- Joint Commission International. (2024). Who we are. https://www.jointcommission.org/?utm_campaign=tjc_brand__1_core&utm_source=google&utm_medium=cpc&gad_source=1&gclid=CjwKCAjwnK60BhA9EiwAmpHZw55yd91qdT0f3Q6nauq82Oo3uHe5nPJKBwT81CxvmdtkGrjdc26GchoCvz8QAvD_BwE ↵
- NCQA. (2024). About NCQA. https://www.ncqa.org/about-ncqa/ ↵
- AMA Ed Hub. (2024). About the AMA's CME accreditation. https://edhub.ama-assn.org/pages/ama-cme ↵
- ACHC. (2024). About accreditation. https://www.achc.org/ ↵
- John Hopkins Medicine. (n.d.). Core measures. https://www.hopkinsmedicine.org/patient_safety/core_measures.html ↵
- The Joint Commission. (n.d.). Measures. https://www.jointcommission.org/en/measurement/measures/ ↵
- The Joint Commission. (2025). 2025 national patient safety goals. https://www.jointcommission.org/standards/national-patient-safety-goals/ ↵
The degree to which nursing services for health care consumers, families, groups, communities, and populations increase the likelihood of desirable outcomes and are consistent with evolving nursing knowledge.
authoritative statements of the actions and behaviors that all registered nurses, regardless of role, population, specialty, and setting are expected to perform competently.
A review process to determine if an agency meets the defined standards of quality determined by the accrediting body.
National standards of care and treatment processes for common conditions. These processes are proven to reduce complications and lead to better patient outcomes.
Guidelines specific to organizations accredited by The Joint Commission that focus on problems in health care safety and ways to solve them.