Question

Which leadership strategies promote safety and improve quality in nursing practice and increase collaboration with other disciplines when planning patient-centered care within systems-based practice?

Answer 1

Strong leadership is critical if the vision of a transformed health care system is to be realized. Yet not all nurses begin their career with thoughts of becoming a leader. The nursing profession must produce leaders throughout the health care system, from the bedside to the boardroom, who can serve as full partners with other health professionals and be accountable for their own contributions to delivering high-quality care while working collaboratively with leaders from other health professions.

As the complexity of health care delivery has increased, it has become essential for physicians to understand how individual practices relate to the larger system of care. It is within this context that the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Medical Specialties (ABMS) identified systems-based practice (SBP) as one of the six core competencies in which physicians must be proficient to deliver patient care that is safe and high in quality. SBP is challenging to define, incorporate into training and practice, and evaluate. Competency in SBP requires that physicians understand how patient care relates to the health care system as a whole and how to use the system to improve the quality and safety of patient care. Systems thinking is the cornerstone of SBP. Fostering the ability to recognize the contribution of the system is important for medical students, residents, and practicing physicians. However, current efforts in medical education focus on mastering knowledge of disease, diagnostic skills, and treatment at the level of the physician-patient interaction. As a result, there is a preoccupation with system components, while the system as a whole and its effect on the quality and safety of care remain invisible. To clarify the definition of SBP and to develop effective strategies for teaching and assessing SBP, it is necessary to provide a broad awareness of systems within a context of systems thinking. Patient safety is a good entry point into SBP because the concepts of safety, errors, and harm all place the individual, whether patient or provider, within the framework of a system.

The Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Medical Specialties (ABMS) identified six core competencies required of residents and physicians to deliver high quality medical care—patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice. Of these six, systems-based practice is one of the most challenging to define, incorporate into training and practice, and evaluate.

Strong leadership will be required to realize the vision of a transformed health care system. Although the public is not used to viewing nurses as leaders, and not all nurses begin their career with thoughts of becoming a leader, all nurses must be leaders in the design, implementation, and evaluation of, as well as advocacy for, the ongoing reforms to the system that will be needed. Additionally, nurses will need leadership skills and competencies to act as full partners with physicians and other health professionals in redesign and reform efforts across the health care system. Nursing research and practice must continue to identify and develop evidence-based improvements to care, and these improvements must be tested and adopted through policy changes across the health care system. Nursing leaders must translate new research findings to the practice environment and into nursing education and from nursing education into practice and policy.

Systems-based practice can be thought of as an analytic tool, as well as a way of viewing the world, both of which can make caregiving and change efforts more successful. Those involved in the health care system—nurses, physicians, patients, and others—play increasingly interdependent roles. Problems arise every day that do not have easy or singular solutions. Leaders who merely give directions and expect them to be followed will not succeed in this environment.

The common program requirements for SBP, as approved by the ACGME are outlined as follows: Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care. Residents are expected to:

• Work effectively in various health care delivery settings and systems relevant to their clinical specialty.
• Coordinate patient care within the health care system relevant to their clinical specialty.
• Incorporate considerations of cost awareness and risk-benefit analysis in patient and/or population-based care as appropriate.
• Advocate for quality patient care and optimal patient care systems.
• Work in interprofessional teams to enhance patient safety and improve patient care quality.
• Participate in identifying system errors and implementing potential systems solutions.

The new style of leadership that is needed flows in all directions at all levels. Everyone from the bedside to the boardroom must engage colleagues, subordinates, and executives so that together they can identify and achieve common goals. All members of the health care team must share in the collaborative management of their practice. Physicians, nurses, and other health professionals must work together to break down the walls of hierarchal silos and hold each other accountable for improving quality and decreasing preventable adverse events and medication errors. All must display the capacity to adapt to the continually evolving dynamics of the health care system.

Implementing and evaluating SBP in a medical context requires a broader understanding of what constitutes a “system,” coupled with an understanding of systems thinking. Bertalanffy, the founder of the scientific, mathematical “Theory of Systems,” defined a system as a set of interacting, interrelated, or interdependent elements that work together in a particular environment to perform the functions that are required to achieve the system’s aim. The importance of understanding systems as interrelated parts of a whole cannot be overstated. Systems can be continually improved, but one must consider how its products are created, why they are created, and how they can be improved. Comprehending the assembly of the system as a whole can inform the work of those who are trying to create successful, interdependent systems.

Systems have certain rules (or principles) that help us predict how they will behave:

• The whole has one or more defining functions.
• Each part can affect the behavior or properties of the whole.
• Each part is necessary but alone is insufficient to carry out the defining function of the whole.
• Behavior and properties of one part of the system depend on the behavior and properties of at least one other part of the system.

Systems thinking is the cornerstone of how “learning organizations” think about their world. Learning organizations are those that measure outcomes and strive for improvement. Many fields outside health care—including education, telecommunications, and aviation—use systems theory to better serve their clients, understand applicable research, improve outcomes, and ensure quality and safety. Recognizing feedback from the system and using that feedback for design and redesign of services is an inherent element of systems thinking.

Competence in SBP necessitates that physicians understand how patient care and other practices relate to the health care system as a whole and how to use the system to improve patient outcomes, safety, and quality. SBP is care that is sensitive to the context in which it is delivered. Fostering the ability to recognize the contribution of the system is important for medical students, residents, and practicing physicians because care is never delivered in a vacuum—there is always a powerful context.

However, current efforts in medical education focus on mastering knowledge of disease, diagnostic skills, and treatment at the level of the physician-patient interaction, resulting in preoccupation with system elements, while the system as a whole and its effect on patients remains invisible. The context is what has been minimized as educators try to standardize the experience for trainees. Systems thinking and the application of systems thinking through SBP provide an opportunity to look at the context.

“The systems we work in often can be difficult to identify and define. Although we work in numerous systems all day, every day, it’s difficult to ‘see’ a system. It’s like asking fish to describe water—it’s easier to be aware of the system when the system fails”.

Health care is composed of a large set of systems—e.g., ambulatory care centers, physician office practices, inpatient hospital units, home health care, laboratories, and pharmacies—all interacting with one another. Each of these systems is connected via individuals and teams, regulations and rules, and technology. Understanding how one functions within the system as a whole, and how one’s actions affect all other aspects of the system, is the key to unlocking an effective SBP strategy.

Nurses at all levels need strong leadership skills to contribute to patient safety and quality of care. Yet their history as a profession dominated by females can make it easier for policy makers, other health professionals, and the public to view nurses as “functional doers”—those who carry out the instructions of others—rather than “thoughtful strategists”—those who are informed decision makers and whose independent actions are based on education, evidence, and experience.

“Nursing Leadership from Bedside to Boardroom: Opinion Leaders’ Perceptions,” identified nurses as “one of the most trusted sources of health information”. Nurses as the health professionals should have greater influence than they currently do in the critical areas of quality of patient care and safety. The leaders surveyed believed that major obstacles prevent nurses from being more influential in health policy decision making.