Читать книгу Quality and Safety in Nursing - Группа авторов - Страница 90

With approximately 200 national entities, including professional organizations and consumer groups, along with thousands of hospitals and other institutions and agencies engaged in the effort to improve quality, there have been substantial investments of financial and other resources, including human resources, over the last 30 years. The timing of many of these efforts in the early 1990s suggests that long before the publication of To Err Is Human and Crossing the Quality Chasm, leaders in the health care industry understood that lack of quality was a significant problem. Nurses were early adopters in hospital efforts to identify opportunities for continuous quality improvement. Many engaged in dialogue with individual physicians who were being challenged by state performance review boards and utilization review committees. Then the focus was primarily on local quality improvement and policy initiatives rather than state or national efforts. Global quality leaders (Deming, 1986; Juran, 1998) stated that 85% of errors in complex organizations were due to system design rather than to inadequate individual job performance. But even their discussions were addressed in departmental, corporate, or institutional policy terms.

Yet, in 2022, the magnitude of the current efforts to transform the health care system into a high‐quality system dwarfs all previous efforts. Health systems were focused on being high‐reliability organizations while at the same time striving to be recognized as safety cultures and just cultures. Why has this exploded to such mammoth proportions?

Prior to the implementation of the ACA, looking at any acute care facility, large or small, the number of outpatient procedures and the revenue generated from them had kept pace or overtaken the revenue from acute care services. Now the numbers of providers in even the smallest facility have increased, including increases in specialists, whether providing virtual or face‐to‐face medicine. The enormity and complexity of the systems now needing improvement do not differ all that much, whether one considers the problems of the critical access hospital or the largest multihospital system. The systems are complicated and the communications and organizational structures required to ensure efficiency and safety are interrelated, transdisciplinary, and require transparency.

The technology needs of the solo and small group practitioner reflect a similar need for technological capabilities as those required by larger health service plans to which many providers belong. At the same time, fewer and fewer patients see their own primary provider once they entered an acute care facility, regardless of the size of the institution. The hospitalist providing their care may have never seen them previously and will have no connection to their care once they are discharged. Home care and hospice programs are using technology to replace the face‐to‐face time that nurses and others have traditionally relied upon with homebound patients to determine their unspoken needs and vulnerabilities, including electronic profiles on patient caseloads and communication about patients only via electronic records. The latest explosion of telehealth onto the health care scene, whether in transport, in primary care thanks to COVID‐19, or in treating mental and behavioral health disorders, requires greater privacy protections and interoperability than ever before. Yet, due to emergency declarations and easing of certain restrictions to support telehealth visits, many of these same privacy protections, even those under the Health Insurance Portability and Accountability Act (HIPAA), have been eroded.

What has COVID‐19 shown us? The complexities of providing high‐quality health care that keeps patients, families, and health care workers from harm simply became almost impossible. Our health risks as we know them have gone global in a way that nothing has before. The United States can now see clearly where it has failed its citizens. Health inequities and the challenges of multiple chronic conditions are tough enough when the financial resources are available to make access to care possible. But during this time millions of individuals do not have the luxury of performing jobs from home, or have been unable to work because the business or company they work for has been closed due to quarantine, or the job has been lost because the company has gone out of business, or other restrictions have made it difficult or impossible to keep oneself safe. For many of these people, along with such considerations, the loss of a job means not only loss of income but loss of health care insurance coverage as well. For essential workers, whether first responders, nurses, physicians, maintenance workers, or grocery store clerks, personal protective equipment, something most of us took for granted, disappeared. Even cleaning supplies, hand sanitizer, and hand soap disappeared from store shelves for a time. Each of these shortfalls created additional fears about reaching out to a health care provider for anything short of COVID‐like symptoms.

The challenges of ensuring effective care transitions, care coordination, and engagement of patients are difficult without effective digital communication systems. But alas, electronic systems in a hospital or system department are still struggling to share information with another department in a timely manner, or more frequently with someone outside the institution. Electronic records and communications are expected to have filled the gap, but they may often collect information that is not meaningful or used. Patients suffer from the lack of effective communication with and among professional staff. COVID‐19 has meant that any support to communicate with professional staff is further hindered by lack of supportive family, who cannot be present when life and death decisions are being made. While theoretically technology exists via iPads and Facetime, those resources are few and far between on the clinical units where they are needed, and due to staffing shortages opportunities to provide these technology‐assisted communications are further limited. The situation is magnified when ineffective communication couples with the payment system and reimbursement that reward undesired outcomes of care, such as continued disease rather than wellness or health, or complications of hospitalization rather than speedy recovery and discharge to another level of care. One begins to see how local policies and regulations have little effect. As the interconnectedness has grown, so have the problems and the solutions required to correct them.

Part of the anticipated effectiveness of ACA was the inclusion of millions of previously uninsured US citizens under Medicaid expansion. The unevenness of implementation across states has impacted services, costs, and meeting chronic health needs, particularly for underserved and minority populations (Long et al., 2014). In addition, despite many efforts to harness the costs of caring for high needs patients and dual eligibles (those whose services are covered by both Medicare and Medicaid), this is a challenge that still needs to be better managed. These are challenges faced by the various collaborations striving to improve upon the policies, regulations, and incentives incorporated in every community hoping to improve the quality of care. Nowhere has this been more evident than in the attempts to manage the resources and knowledge required to effectively control a pandemic.