In my early career as a staff development professional and chief nursing officer, having mastery of quality and safety content and competencies was expected. Nurse leaders assume a disproportionate responsibility for the quality and safety of patients that is indigenous to the role that nurses and nurse leaders play in advocating for patients (keeping them from being harmed by others) and carrying out multiple interventions (protecting them from nurse-derived harm). Over time, quality science has evolved, commensurate with the preponderance of specialized roles involved in patient care, the complexity and risk associated with clinical interventions, and expanded consumer awareness and expectations. For these reasons, quality and safety competencies are essential to leadership roles.
From last July until now, I have had the privilege of a relationship with the Langston Center for Quality, Safety, and Innovation at Virginia Commonwealth University School of Nursing, directed by Dr. Marianne Baernholdt, supported by Jamie Smalley, and named after retired Dean Nancy Langston in tribute to her leadership. The Langston Center is a clearinghouse for curated quality and safety information, a provider of continuing education, and a partner with Virginia Commonwealth University Hospital and Health System in advancing clinical quality through a designed quality and safety fellowship. As a partner with Dr. Deb Zimmerman, Chief Nursing Officer for the Virginia Commonwealth University Hospital and Health System, and in collaboration with the Langston Center and Dean Jean Giddens and faculty, I have benefited from perspectives that mark essential core content for leadership development. This article presents those observations to assess, implement, and evaluate professional education programming in quality and safety.
Competency Set One: A Symphony of Systems—Science
Leaders must first understand that the systems and the processes that comprise our systems drive human behavior. For instance, the questions asked on the baseline admission assessment—part of a process of patient onboarding—will determine the amount of time, effort, and energy that each nurse will minimally spend with each patient. How the information is recorded, critically analyzed, and used to shape care delivery that affects the outcomes varies more, but inherent in the design of the assessment is the standard of care. This is but one example of a legion of tasks that emanate from systems and processes that are designed for patient care.
Leaders think beyond tasks and processes to be true systems-oriented role models. Although the task of filling out the admissions assessment may seem logical and linear, a systems-oriented leader realizes there is a multilayered dynamic in play. Patients may have cultural sensory impairment or other reasons for not answering questions. They may see computer entry of their information as intrusive. They may be longing for eye contact and human touch from the provider or data collector. The optics of what are transpiring during the admission assessment is complex, whereas collecting the data without the patient context is simple. The zone of complexity occurs at the pinnacle from where the task began and where the data input is complete. The arc is where human bonding, trust, and feeling safe begins for the patient and the practitioner (Kluger, 2008).
The competency required here is this: the consumer–patient seeks human and technological expertise tied to complex judgments and interventions to provide cure or resolution. The leader connects this human experience with other system factors—safety, cost, efficiency, and effectiveness that the leader, through process design, influences and inspires others to use.
Competency Set Two: Leading Knowledge Workers
Noted above, leaders must possess knowledge of systems and processes designed for the consumer–patient seeking health care. It is noted that tasks that appear simple may be complex when layered with socioeconomic, cultural, family, and financial concerns. To accommodate this complexity, health care leaders have increasingly depended on knowledge workers—nurses, physicians, technicians, and other specialists—to deal with and adapt processes to achieve outcomes.
There are characteristics of knowledge workers that leaders must embrace. Knowledge workers understand the tasks at hand but are not inherently motivated by the task itself. The knowledge worker is motivated by autonomy—being able to do the right thing at the right time. If the processes are flawed, they want input into improving it or innovating a new process. Being able to achieve quality—that is, aligning their abilities to affect patient care and doing so according to effective processes that enhance their freedom to adapt to standards of care and practice—is empowering. Knowledge workers want to experience a work culture that values them as an asset, not as a cost (Drucker, 2006).
The second set of leadership competencies is to acknowledge, respect, and shape a culture that is less regimented and prescriptive, while concurrently providing effective processes to capitalize on the vast human resource capacity that comprises the health care team.
Competency Set Three: Implementation Science and Big Data Competencies
With strong ties to systemic change management, implementation science has emerged to study the dissemination of innovations that originate from research and, I contend, from learning organizations that engage in formal quality improvement activities. Many quality improvement initiatives occur that improve care for a single unit, department, or clinical population. Missing from this is the opportunity for system-wide effect. Implementation science provides frameworks drawn from change theorists, communication studies, medical sociology, and marketing (Demiris, Oliver, Capurro, & Wittenberg-Lyles, 2014), all that reduce the gap from knowledge discovery to scalable, rapid uptake.
When scalable change is implemented, it stands to reason that measurement will be needed to capture the scope, effects, and magnitude of change. Electronic health records that span health system boundaries are now commonplace and deploy clinical pathways that reflect standards of care and practice and evidence-based guidelines to reference procedures and practice bundles—the sequential steps to care management that influences clinical outcomes. Nurse leaders have the opportunity to capture clinical information to substantiate and validate the root cause of a problem, to collect data during a change initiative aimed at improvement, and to evaluate short- and long-term impact of interventions (Landstrom, 2017).
The competencies needed by leaders in implementation science include basic knowledge of change theory, motivation and reward techniques for individuals and groups, thinking in scalable terms from the onset of innovation, and innovation capture. An additional competency is the ability to capture, analyze, and evaluate data from large databases.
Competency Set Four: Tools and Techniques
Ironically, tools, techniques, and meeting facilitation are among the first competencies that leaders acquire yet, without the possessing the preceding competencies, there is little to apply the tools and techniques used to advance a quality and safety agenda. There is an array of tools that facilitate group functioning and process analysis, ranging from brainstorming, statistical process control (still underused in my observations), storyboards, cause-and-effect diagrams, and more. A classic reference that offers leaders insights into microsystems and tools and techniques is Quality by Design (Nelson, Batalden, & Godfrey, 2007), although other references are found in nearly any text that addresses quality and safety. The leader should possess competency in using these elemental tools, helpful in the broadest sense beyond that required for quality and safety initiatives.
More obscure are tools the align the organization's goals, design, and management with process goals, design, and management. In well-orchestrated quality improvement programs, there is a clear cascading of what the organization needs to achieve strategically (i.e., growth orientation) and operationally (i.e., the day-to-day foundation required for effective throughput, worker satisfaction, and an empowering culture). The alignment of organizational and process priorities and goals is critical, but only when work is designed to consider human factors and alignment. Position descriptions developed in human resources may lack the operational specifics that links to quality and safety; each should include performance specifications (to include responsibilities for processes), task support, consequences, feedback, skills and knowledge, and individual capacity (Rummler & Brache, 1995). Leader competencies must include a holistic view of organizational priorities, the goals tied to critical organizational processes, and the alignment of job titles and work outcomes to achieve the synergy needed to create and sustain a quality and safety agenda.
The extent and context that quality and safety education and training is robust and specific is a surprise to many who work around its edges. Quality and safety education is only appreciated when applied as organizational science in applied field-based settings, making it complex and messy at times. Conducting any query within a nonlaboratory setting is a challenge, but in the case of health care, there are no other options.
- Demiris, G., Oliver, D.P., Capurro, D. & Wittenberg-Lyles, E. (2014). Implementation science: Implications for intervention research in hospice and palliative care. The Gerontologist, 54, 163–171. doi:10.1093/geront/gnt022 [CrossRef]
- Drucker, P.F. (2006). Knowledge-worker productivity: The biggest challenge. In Gallos, J.V.(Ed.), Organization development (pp. 914–933). San Francisco, CA: Jossey-Bass.
- Kluger, J. (2008). Simplexity: Why simple things become complex (and how complex things can be made simple). New York, NY: Hyperion.
- Landstrom, G.L. (2017). Big data impact on transformation and healthcare systems. In Delaney, C.W., Weaver, C.A., Warren, J.J., Clancy, T.R. & Simpson, R.L. (Eds.), Big data-enabled nursing: Education, research and practice (pp. 253–263). New York, NY: Springer. doi:10.1007/978-3-319-53300-1_13 [CrossRef]
- Nelson, E.C., Batalden, P.B. & Godfrey, M. M. (2007). Quality by design: A clinical microsystems approach. San Francisco, CA: Jossey-Bass.
- Rummler, G.A. & Brache, A.P. (1995). Improving performance: How to manage the white space on the organization chart. San Francisco, CA: Jossey-Bass.