leadership, care management, quality improvement processes, and systems thinking—a subject discussed in Chapter 4.

Nurses as Health Coaches

The committee envisions a health care system in which all individuals have a health coach who helps stay them healthy. The coach ensures that they understand why their primary care provider—whether a physician, physician assistant, or NP—has recommended a particular course of treatment. He/she coordinates patients’ care with multiple providers so that, for example, an elderly grandfather with diabetes, arthritis, and heart disease can continue to live at home and avoid costly hospitalizations. The role of health coach has much in common with case management services, but it goes even further. The coach educates family, friends, and other informal caregivers about how they can help, addressing not just physical needs but also social, environmental, mental, and emotional factors that may promote or interfere with the maintenance of health. The coach helps overcome features in the health care system that may lead to inequities in care delivery. He/she also stays involved with patients if they enter the hospital and coordinates transitional services with APRNs and other care providers after discharge. Given all these job requirements, the health coach most often will be an RN. Box 2-7 presents a case study in which baccalaureate-trained RNs serve as health coaches for women who are first-time mothers and may be at risk of abusing or neglecting their children.

Nurses as System Innovators3

One of the fundamental insights of the quality improvement movement is that all health professionals should both perform their current work well and continuously look for ways to make their performance and that of the larger system better. Or as one nurse told a physician 20 years ago in a course on health care improvement, “I see. You’re saying that I have two jobs: doing my job and making my job better” (Berwick, 2010).

The nursing profession is well positioned to produce system innovators. A few years ago, the Institute for Healthcare Improvement (IHI) launched a national project to reduce patient injuries, called the 100,000 Lives Campaign. The project translated the aims of safety and effectiveness into operational form as “bundles” of care procedures (Berwick et al., 2006; McCannon et al., 2006), such as the Central Line Bundle to prevent catheter-associated bloodstream infections. Hundreds of hospitals reported success in terms of improved patient outcomes.


This section draws on a paper commissioned by the committee on “Preparing Nurses for Participation in and Leadership of Continual Improvement,” by Donald M. Berwick, Institute for Healthcare Improvement (see Appendix I on CD-ROM).

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