Are We Creating a Culture to Support Quality Improvement?

In 2000, the Institute of Medicine (IOM) published its landmark report, To Er is Human: Building a Safer Health System, upon which the current trend toward quality care and measurable outcomes is largely grounded.1 Since then, additional IOM reports have delved further into healthcare quality and safety, providing objective, evidence-based data on the current state of patient care in the United States.2-4

In these reports, the IOM presented and defined the following six key elements to quality care—safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity. Furthermore, the IOM proposed the concept of aligning financial reimbursement with quality improvement, setting into motion various multidisciplinary consensus groups to determine and define the specific metrics that should be tracked and measured.

IOM reports have also identified areas where our healthcare system both underperforms and is wasteful, which is particularly applicable to chronic disease care such as rheumatology. In fact, a 2001 IOM report identified rheumatology as one of the chronic disease areas having the greatest potential to improve access to care, service, and disease outcomes.

One more recent IOM report also bears revisiting—the 2010 Future of Nursing: Leading Change, Advancing Health. This landmark report declared that nurses are to be full partners with physicians and other healthcare professionals in the design and structure of innovative healthcare strategies.4 It is unclear, however, where NP’s, DNP’s, and CNS’s fit into the process.

As one of the initial dominoes from the IOM’s work, in 2005, the Robert Wood Johnson Foundation gathered a group of experts in quality and safety to begin a national study of nursing faculty and nursing students focused on patient safety and healthcare. In 2007, this group— called the Quality & Safety Education for Nurses (QSEN) committee—defined six competencies and the associated Knowledge, Skills, and Attitudes (KSAs) nurses must possess to master these competencies. They are similar in nature to those previously identified by the IOM, though with some clear differences —safety, quality improvement, patient-centered care, teamwork and collaboration, evidence-based practice, and informatics.

The ongoing phase III of the QSEN’s work aims to instill these competencies in textbooks, licensing, accreditation, and certification standards, as well as supporting innovative teaching techniques of the competencies and KSAs. Additional work is being done to develop a new group of nursing leaders focused on the emerging science of quality and safety in the interprofessional arena.5

The concept of quality care is certainly not new to rheumatology nurses. The concept of safety and quality care has always been threaded throughout formal nursing curricula. As nurses, we have learned to evaluate clinical issues through a comprehensive and holistic assessment of our patients, leading to a diagnosis and treatment plan. We are then often responsible for helping to implement that plan and evaluate short- and long-term patient outcomes.

So if and when you hear others in your practice discussing quality improvement and how these efforts may be incorporated into your systems, it is important to not be shy and to ask for a seat at the table during the consensus-building process for quality care, safety, patient satisfaction, optimal outcomes, and payment systems. The QSEN and its KSAs have laid a blueprint that can be buffeted with rheumatology-specific evidence-based practices and research. All it takes for our voice to be heard is to speak up.

Sheree C. Carter, PhD, RN, is an Assistant Professor at The University of Alabama Capstone College of Nursing, Tuscaloosa, Alabama, and President of the Rheumatology Nurses Society.




  1. Institute of Medicine. To err is human: Building a safer health system. 2000; Washington, DC: National Academy Press.
  2. Institute of Medicine. Health professions education: A bridge to quality. 2003; Washington, DC: The National Academies Press.
  3. Institute of Medicine. Crossing the quality chasm: A new health system for the 21st century. 2001; Washington, DC: The National Academies Press.
  4. Institute of Medicine. The future of nursing: Leading change, advancing health. 2011; Washington, DC: The National Academies Press.
  5. Disch J. QSEN? What’s QSEN? Nursing Outlook. 2012;60(2):58-59.