• Patient centeredness: Many systems and processes are still designed to meet the needs of providers rather than patients. True patient- and family-centered care will focus on the whole patient, putting the patient, family, and care team together as a system.

  • Timeliness: Delays impose costs not only on hospitals, but on patients in terms of questions unanswered, delayed diagnoses, suffering incurred while waiting for treatments, and lack of coordination. Yet some hospitals have demonstrated that delays in surgeries, for example, can be virtually eliminated. “Our mantra should be: the right care, in the right place, at the right time, in every place in the country,” Bisognano said.

  • Inequity: Continued variations in care delivered and outcomes among socioeconomic and ethnic groups remain unacceptable.

Improvements in the quality of hospital care often occur as a result of national campaigns or programs. By identifying a small number of goals, Bisognano said, such initiatives can work to close gaps among settings. For example, the Commonwealth Fund Commission on a High-Performance Health System has supported the development of a state scorecard on health system performance that has made it possible to translate best practices and knowledge across the system. On a set of hospital clinical quality indicators, the rates in the five lowest performing states approached the previous levels of the highest performing states (McCarthy et al., 2009). “We are starting to see a national awareness of quality and safety and the beginnings of a system to share” best practices and knowledge.

Nurses play a unique role in ensuring quality and safety in hospitals, Bisognano said. “We are the pivot point, we are the people who spend the time, we are the people who see patients across transitions in care.” Yet nursing faces many challenges. Care is becoming more complex even as hospital stays become shorter. The nursing population is growing older. The average age of nurses is 44, with many older nurses returning to the workforce in the current economy. Despite the increasing average age of nurses, hospitals are imposing uniform standards and workloads on all nurses. Turnover of nurses is high, shortages of nurses are looming, and nursing staff levels are inadequate in many locations. Finally, nurses still experience an unacceptably high number of work-system failures (an average of 8.4 times per 8-hour shift) and interruptions (an average of 8.1 times per 8-hour shift) (Tucker and Spear, 2006). “Poor



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