Kelly Vana's Nursing Leadership and Management

FIGURE 2.1 Florence Nightingale's coxcomb diagram of the causes of mortality in the army in the East.

Source: Florence Nightingale (1820–1910). [Public domain].

Today, data is collected through patient records, surveys, and administrative systems. From these, reports are developed, such as To Err is Human (IOM, 1999); the CDC National Vital Statistics Reports (Martin, Hamilton, Sutton, & Ventura, 2006); and The National Healthcare Disparities Report(NHDR) ( Agency for Healthcare Research and Quality(AHRQ), 2005). These reports provide invaluable information, and data is displayed with charts and pictures to emphasize the successes and failures of health care throughout our nation. Evidence of significant disparities and low quality continue to demonstrate the need for significant health care improvement.

Recognizing the influence of external forces on care delivery and scope of practice, Nightingale also kept informed of the activities of practitioners and government policy makers (Dossey, Selanders, & Beck, 2005). With health care being the largest sector of our economy, employers, clinicians, managers, and patients all have vested interests in proposed changes to health care financing, organization, and the responsibilities and scope of practice for clinicians. Today, nursing leaders, managers, and staff need to be aware of and involved in the ongoing processes of making health policy.

Health care systems have three main components: structure, process, and outcome. The structure component of healthcare includes resources or structures needed to deliver quality health care, for example, human and physical resources, such as nurses and nursing and medical practitioners, hospital buildings, medical records, and pharmaceuticals. The process component of healthcare includes the quality activities, procedures, tasks, and processes performed within the health care structures, such as hospital admissions, surgical operations, and nursing and medical care delivery following standards and guidelines to achieve quality outcomes. The outcome component of healthcare refers to the results of good care delivery achieved by using quality structures and quality processes and includes the achievement of outcomes such as patient satisfaction, good health and functional ability, and the absence of health care acquired infections and morbidity. See Table 2.1for examples of structure, process, and outcome performance measures in clinical care, financial management, and human resources management. The American Nurses Association's (ANA) Nursing Care Report Card for Acute Care (1995) also uses the structure, process, outcome framework for its indicators of quality.

Table 2.1 Examples of Performance Measures by Category

Source: Compiled with information from Shortell, S. M., & Kaluzny, A. D. (2006). Health care management (5th ed.). Clifton Park, NY: Delmar Cengage Learning.

It would be naïve to consider health care in the United States, as it is currently being delivered, as being an effective system of care. If that were true, it would imply that health care is based on shared values and goals; is organized around the patient; utilizes all pertinent information; ensures value‐based and quality‐based care; rewards quality care; is universally standardized and simplified; is available to everyone regardless of income, race, ethnicity, or education; is affordable; and reflects effective collaboration among clinicians and with patients. The World Health Organization(WHO) has put forth primary goals for what good health care should do: improve equity in health, reduce health risks, promote healthy lifestyles and settings, and respond to the underlying determinants of health (World Health Organization (WHO), 2019).

Consistent with these goals, Healthy People 2020 has also developed overarching goals to increase quality and years of healthy life and eliminate health disparities. These goals are:

Attain high‐quality, longer lives, free of preventable disease, disability, injury, and premature death.

Achieve health equity, eliminate disparities, and improve the health of all groups.

Create social and physical environments that promote good health for all.

Promote quality of life, healthy development, and healthy behaviors across all life stages (Healthy People 2020, 2010).

What can be said about the United States health care system is that it is not really a system, but rather a hodge‐podge of systems, some great, some not so great, with a “sometimes” desire for universal service, but with also the fierce energy of independent individuals seeking autonomy.

Ellyn Stecker, MD

Shipshewana, Indiana

Despite having the most expensive health care, the United States ranks last overall among the 11 countries on measures of health system equity, access, administrative efficiency, care delivery, and health care outcomes. While there is room for improvement in every country, the U.S. has the highest costs and lowest overall performance of the nations in the study, which included Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, and the United Kingdom. The U.S. spent $9,364 per person on health care in 2016, compared to $4,094 in the U.K., which ranked first on performance overall (Commonwealth Fund, 2017). An overall score of 64% was recently given to the United States for its achievement across 42 core health indicators related to long, healthy, and productive lives; quality; access; efficiency; and equity of health care (Commonwealth Fund, 2012) (see Figure 2.2).