With a predicted nursing shortage in the coming years and a decrease in enrollment in nursing programs, it is necessary for nursing education programs to demonstrate the quality of education they provide to students (General Accounting Office, 2001). During the past several decades, regulatory agencies such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) have required health care agencies to comply with guidelines to assure quality. The JCAHO performance improvement framework has been used successfully in diverse health care settings to measure, assess, and improve patient outcomes. Designing and redesigning functions and processes are hallmarks of the JCAHO framework.
After an extensive literature review, no articles were found that applied the JCAHO framework in health care education, including nursing schools. Increased accountability for improving student satisfaction and justification for educational spending are causing rapid changes in academia. The same framework that applies to health care agencies also can apply to the goal of nursing education (i.e., to establish quality standards that will ultimately improve community health care). This article discusses the history of the performance improvement framework, explains the framework, and describes how it could be applied in an academic setting to improve student and organizational outcomes.
History of the Framework
Performance improvement, which has revolutionized the accreditation process of health care agencies, makes systems, functions, and processes the focus for improvement, while concentrating less on "problems" and more on "improvement." Organizations that have fully implemented the principles of performance improvement can attest to the effects this "new way of thinking" can have on organizational management and planning. The basic principles of perfonnance improvement are not new. They were built on the principles used by the American "father" of total quality management (TQM), W. Edwards Deming. Total quality management was adopted in Japan after World War II to help the Japanese rebuild their industry (Sullivan & Decker, 1997). Total quality management principles were not readily adopted in the United States until the 1980s, when major corporations realized the quality achieved by Japanese industries and began competing with them to improve the quality of American-made products.
As the business industry incorporated TQM, health care was reluctant to incorporate the "paradigm shift" into its evaluation process. Since the mid 1950s, the JCAHO had achieved its mission of improving the quality of health care through onsite, standards-based accreditation of organizations. However, in the 1980s, the industry began to realize that although the accreditation process was useful, it lacked information regarding actual performance and outcomes of care provided. In 1986, the JCAHO presented its agenda for change, which introduced a systematic conversion from quality assurance, to continuous quality improvement (CQI), then later to performance improvement (JCAHO, 1999a).
Figure. Performance improvement framework. Reprinted with permission from Joint Commission on Accreditation of Healthcare Organizations. (1 995). Framework lor improving performance: A guide for home care and hospice organizations (p. 1 8). Oakbrook Terrace, IL: Author. Copyright 1995 by the Joint Commission on Accreditation of Healthcare Organization.
While quality assurance focuses on fault finding directed at people, CQI focuses on seeking problems with processes. As CQI developed, a customer-driven emphasis for improving quality emerged. Beginning in the 1990s, performance improvement expanded CQI to emphasize organization- wide team efforts for making improvements and to become more data driven. Agencies began benchmarking and comparing data to maximize improvement, and the key question became "What did the organization actually achieve?," rather than "What is the organization capable of achieving?" (JCAHO , 1999a).
Performance Improvement Framework
The JCAHO framework for performance improvement offers a systematic approach to improving performance in the way functions and processes are implemented within a health care organization. Both patient-focused and organizationfocused functions are addressed. Organizations no longer concentrate solely on the direct patient-care components of its operations but also realize the effects of organizational functions (e.g., leadership, management of human resources, management of information) on the ultimate outcomes of patient care. According to the JCAHO (1994), there are three components of the framework:
* External environment.
* Internal environment.
* Cycle for improving performance (Figure).
The external environment refers to the factors outside of organizations that affect the way their services are designed and implemented and includes the demands of purchasers, payers, employers, regulators, consumers, and accrediting bodies. In health care organizations, the external environment includes customers; federal, state, and private regulatory bodies; and the community (JCAHO1 1994). Because health care reform, laws, and standards also create unpredictable changes that may cause organizational restructuring, organizations must constantly monitor the external environment for changes in trends, regulations, and standards of practice, and feedback from customers and the community.
Organizations must be flexible enough to quickly develop new services based on the external environment. The agencies and community also must consider the external environment when designing new programs and implementing new services to meet the health care needs of the public.
The internal environment includes the functions within organizations that affect the quality of care delivered to customers and customers' perceptions of their satisfaction with the services received (e.g., knowledge, clinical expertise, critical thinking skills, coordination of services). According to the JCAHO (1994), in health care organizations, the internal environment includes:
Dimensions of Performance for Nurse Educators
* The organizational system of the agency, including the performance of its leaders (e.g., team building, promoting lifelong learning, risk taking, mentoring).
* Management of human resources (e.g., staffing, licensing, continuing education, rewards).
* Management of information (e.g., data-based decision making to coordinate, integrate, and improve work performance).
* Continuous improvement of performance and outcomes (e.g., communication between employees, patients, community).
Cycle for Improving Performance
This flexible, continuous cycle is the main blueprint for performance improvement of functions and processes within organizations. Work on improvement can begin at any point along the cycle. Improving performance and outcomes involves a systematic and scientific approach, including the components of design, data collection, aggregation and analysis, performance improvement, and redesign in a variety of ways.
Being process minded and outcomes oriented is the anchor point for teams and organizations implementing a successful performance improvement program. Processes provide the means and maps to take organizations in the desired direction, and outcomes are the desired result. The inherent relationship between processes and outcomes must always be the center of performance improvement activities if they are to be significant and meaningful (JCAHO, 1999a).
Using the Framework in Nursing Education
In education, performance involves what is done, and how well, to provide nursing education, prepare competent clinicians, and promote scholarship in a university setting. A performance improvement framework for nurse educators has been developed using current accreditation standards of nursing education, Buyer's model of scholarship (i.e., teaching, research, service), and the JCAHO's performance improvement standards. Dimensions of performance have been adapted from the JCAHO (Table 1).
Nurse educators have not consistently used a systematic approach to improve performance in the way functions and processes are implemented in nursing education. Outcomes and satisfaction measures related to students, nursing programs, universities, and employers of graduates should be analyzed (Table 2). Practicing nurses face many challenges, including differentiating practice, cost containment, technology, informatics, taxonomy for nursing language, practice in community settings, and cultural competence. Nursing education reflects this in such challenges as outcome-based education, collaboration with community agencies, and reform in higher education. Because of these challenges, nursing programs can no longer concentrate on singular measurements of success, such as the NCLEX pass rate. Instead, they must examine both the effects the program can have on its students and faculty and how well it performs key functions including leadership, management of human resources, and management of information. Tb determine its level of success, nursing programs can use the three components of performance improvement.
External Environment in Nursing Education
A variety of external factors can affect the way a college of nursing is maintained. Depending on the economics of the state or region, state regulatory agencies may influence the budget a university will receive, and adjusted budgets may result in tuition increases, operational expenses, or insurance coverage for students. In colleges of nursing in particular, budget cuts can affect the number of students considered for admission to undergraduate and graduate programs; the number and type of courses taught; faculty appointment, promotion, and tenure; and faculty compensation for scholarly work, such as presentations and travel.
Currently, accrediting agencies hold nursing schools accountable for the quality of their institution and educational programs. According to the Commission on Collegiate Nursing Education (American Association of Colleges of Nursing [AACNl, 1998), two forms of accreditation are recognized in nursing:
* Institutional, which considers how the organization meets its mission, goals, and objectives.
* Professional, which examines programs of study in professional or occupational fields.
The core values of accreditation emphasize learning, community, responsibility, integrity, and quality programs based on high standards and achievement (National League for Nursing Accrediting Commission, 1999).
In response to the need for standardized information about financial and educational performance in nursing schools, the AACN (2001) developed a benchmarking project to answer questions about performance measures in baccalaureate nursing programs. This project has evolved to include assessment tools, such as a survey of faculty, alumni, and employers for undergraduate nursing programs across the United States, which will benchmark teaching effectiveness, clinical coursework, core knowledge and competencies, satisfaction with school and university services, classmates, facilities, curriculum structures, skills development, professional values, and information related to AACN (Educational Benchmarking, Inc., 2000). According to the AACN (2001), other plans for benchmarking may include:
* Unrestricted revenue (e.g., appropriations, tuition, student fees, endowments).
* Restricted revenues (e.g., grants and contracts involving private, local, state, federal, and endowment incomes).
* Expenditures (e.g., salaries, fringes, building costs, space, equipment, furnishings, scholarships, financial aid, travel, overhead costs).
* Financial status (e.g., market value of school, operating funds).
* Student data (e.g., enrollment, graduations).
* Faculty data (e.g., doctoral degrees, number of tenured and parttime faculty).
* Faculty productivity (e.g., grants, paper presentations, books authored, editorial board membership, offices held at a national level in professional organizations).
* Revenues (e.g., grants, tuition, appropriations, endowments, gifts, donations).
* Ratios (e.g., faculty to student, graduate student to faculty, salaries to expenditures, scholarships to tuition fees, full-time equivalent [FTE] students to faculty salaries).
Internal Environment in Nursing Education
Most educational programs have the same internal environmental factors as health care settings, and these factors can affect faculty, student, and community perceptions regarding the quality of education provided. Internal leadership issues involve how the program is organized based on its philosophy. The functioning of the leadership influences faculty commitment to the program, which in turn affects faculty and student recruitment and retention. The success of implementing and managing information can affect whether decisions are based on measurable data and whether students receive consistent, well organized advice on their course of study.
Cycle for Improving Performance in Nursing Education
Nursing programs usually have blueprints on organizational structure, committee involvement requirements, and curriculum design, but how are these blueprints evaluated for successful outcomes, and by whom? Is the cycle for improving performance flexible and continuous, and does it involve a systematic and scientific approach using design, data collection, aggregation and analysis, performance improvement, and redesign?
Tb be process minded and outcomes oriented in using the cycle, programs must have a specific blueprint of the outcomes faculty want to achieve. This should be generated through the philosophy, goals, and mission of the university, college, and program. Each program should be designed according to the unique needs of its faculty and students.
Outcome categories for performance improvement for nursing programs have been identified using outcome measures for quality (Jennings, Staggers, & Brosch, 1999). These outcomes have been identified as student-focused outcomes, curriculumfocused outcomes, college of nursing outcomes, and university outcomes (Table 2).
Performance improvement in nursing education is a new concept. Most educators do not have an answer when asked:
* How does your nursing school look at the effectiveness of the process of education?
* How does your school benchmark with others in your area, state, region?
* How does your college of nursing compare with other colleges in your university as a business in terms of generating revenue, productivity, or income?
Measurement of these outcomes is relevant now because universities can no longer depend on state funding and must increasingly rely on private funds for survival.
The health care organizations that employ nursing students use various quality frameworks and models successfully, and with increasing pressures on nursing programs, nurse educators must do the same. We must identify outcome measures that adequately examine the full scope of practices and services provided to health care organizations and the community. To be more data driven, organization- wide efforts must emphasize valid methods of measuring functions and processes within nursing programs while focusing on being less problem focused and more improvement oriented. Nursing programs must begin benchmarking and comparing data to maximize improvements within the educational community. If we are to continue to meet the needs of our students and the public as we move into the new millennium, we must begin to measure our outcomes through the use of a performance improvement framework.
- American Association of Colleges of Nursing. ( 1998). Commission on Collegiate Nursing Education proposed standards for accreditation of baccalaureate and graduate nursing programs. Retrieved May 7, 2001, from http://www.aacn.nche.edu/ accreditation/standards.htm
- American Association of Colleges of Nursing. (2001). Benchmarking project: Questions and answers about performance measures and benchmarking reports. Retrieved May 7, 2001, from http ://www.aacn. nche .edu/data/bench. htm
- Educational Benchmarking Inc. (2000). Nursing education study. Retrieved May 7, 2001, from http^/www. webebi.com/nursing/
- General Accounting Office. (2001, July 10). Nursing workforce: Emerging nurse shortage due to multiple factors (GAO-01-944). Retrieved July 29, 2003, from http://frwebgate.access.gpo. gov/cgi-bin/useftp. cgi?IPaddress= 162. 140.64.21&filename=d01944.pdf& directory =/disfcb/wais/data/gao
- Jennings, B.W., Staggers, N., & Broach, L. R. (1999). A classification scheme for outcome indicators. Image, 31, 381388.
- Joint Commission on Accreditation of Healthcare Organizations. (1994). Framework for improving performance: From principles to practice. Oakbrook Terrace, IL: Author.
- Joint Commission on Accreditation of Healthcare Organizations. (1995). Framework for improving performance: A guide for home care and hospice organizations. Oakbrook Terrace, IL: Author.
- Joint Commission on Accreditation of Healthcare Organizations. (1999a). Using performance measurement to improve outcomes in home care and hospice settings. Oakbrook Terrace, IL: Author.
- Joint Commission on Accreditation of Healthcare Organizations. (1999b). 1999-2000 comprehensive accreditation manual for home care. Oakbrook Terrace, IL: Author.
- National League for Nursing Accrediting Commission. (1999). Accreditation manual and interpretive guidelines by program type for post secondary, baccalaureate and higher degree programs in nursing. Retrieved May, 7, 2001, from http://www.nlnac.org/Manual% 20&%20IG^nterpretive_guideUnes.htm
- Suilivan, E., & Decker, P. (1997). Effective, leadership and management in nursing (4th ed.). Menlo Park, CA: AddisonWesley.
Dimensions of Performance for Nurse Educators