Governmental agencies, organizations, and citizens have a role in health policy development and analysis. Nurses have served as client advocates to safeguard the quality of health care since the beginning of modern nursing. Florence Nightingale held nurses accountable for using their assessment skills and for providing a healthy environment. She also provided the foundation for the use of statistical measures in health care.

In 1910, Ernest Codman, MD, expanded on Florence Nightengale’s ideas and developed a tracking system to follow acute care clients. This tracking system was incorporated into the American College of Surgeons (ACS) inspections of hospitals, beginning in 1918. Beginning in 1951, the ACS, the American Hospital Association (AHA), the American Medical Association (AMA), and the Canadian Medical Association (CMA) formed the Joint Commission on Accreditation of Hospitals (JCAH), a not-for-profit organization.

JCAH began accrediting hospitals in 1953. In 1965, Congress recognized JCAH accreditation as a benchmark, or standard of excellence, for hospital reimbursement for Medicare and Medicaid programs. Currently, JCAH is now known as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). JCAHO provides accreditation for the entire organization, not just the hospital. Accreditation is recognition or approval bestowed by an authorized organization or agency.

JCAHO began charging for hospital accreditation visits in the mid-1960s. Avedis Donabedian published a framework for the assessment of quality in health care around the same time. JCAHO revised accreditation standards in 1970 by changing its focus from minimum to optimal standards of quality. Registered nurses and administrators joined physicians on the JCAHO survey team in the same year.

Donabedian’s quality assurance (QA) framework outlines three domains for QA: structure, process, and outcome. Criteria for these domains are developed first and are then used to measure performance. Structure refers to the infrastructure of the organization, such as human, informational, facility, and technological resources. The process domain of the model examines the activities used to deliver health care. Client outcomes are the ultimate measure of quality of care. Client-focused outcomes relate to the diagnosis, any changes in health status, and related holistic client responses. Provider-focused outcomes relate to provider proficiency, such as complication rates or appropriateness of interventions. Provider-focused outcomes are measured through peer review in which the health provider’s charts are reviewed by a peer.

Quality assurance provides tools to measure quality of care. Quality improvement (QI) is a multidisciplinary approach to changing processes and measuring improvements. The FOCUS PDCA model is a common QI model. Using this model, the organization “F”inds the problem, “O”rganizes a multidisciplinary team that “C”larifies the process, “U”ncovers the problem, and “S”elects a solution. The team then “P”lans the improvement, “D”oes or implements the improvement, “C”hecks or monitors the problem, and “A”cts, to either return to the planning phase or to hold the gain.

QI is customer focused, with a broad definition of customer. An internal customer is a person employed by the organization, such as a nurse who has requested an X-ray or laboratory test. An external customer is a person who is not employed by the organization and uses the services it provides, such as clients or physicians.

The JCAHO accreditation survey requires teamwork from the organization. Many organizations conduct mock surveys to prepare themselves for periodic surveys. JCAHO assesses the clinical competencies of staff members; organizational competencies, such as hazard recognition and emergencies; and the content of clinical policies. The Environment of Care (EOC) standards are important because they provide a framework for the organizational safety program. JCAHO has recently teamed with the Occupational Safety and Health Administration (OSHA) to emphasize employee safety and the EOC. Eligibility for Medicare, Medicaid, and other third-party reimbursements, depend upon JCAHO accreditation.

The levels of JCAHO accreditation are (1) Accreditation with Full Standards Compliance, (2) Accreditation with Requirements for Improvement, and (3) denial. The most serious deficiencies discovered during a survey are either Type I recommendations or supplemental recommendations. Type I recommendations require the organization to act within a time frame to resolve a substandard finding. Supplemental recommendations indicate a less serious noncompliance with standards in an area. A sentinel event is an unexpected event involving death or serious injury to a client. Near misses are deviations from processes that do not harm a client but could place a client at risk if they were to recur.

Two studies by the Institute of Medicine (2000) have highlighted the need for quality improvement in health care: “To Err is Human: Building a Safer Health System” and “Crossing the Quality Chasm: A New Health System for the 21stt Century.” The former described the need to decrease hospital errors and the latter outlined six goals, which have been implemented by the JCAHO: safe, effective, client-centered, timely, efficient, and equitable care.

Quality care is influenced by health policies, which are written decisions directing or influencing the actions or decisions of others. Health policies can be in the form of laws, rules and regulations, operational decisions, or judicial rulings.

Nurses influence policy making through joining and participating in professional organizations, lobbying as part of political action teams, and as individual professionals. In other words, they participate in politics—the use of power to effect change.

Organizational policy making effects nursing process through the use of standards of care, procedures, guidelines, and algorithms. Clinical practice guidelines standardize care by outlining the best practice for a particular clinical problem. Clinical practice guidelines, such as those published by the Agency for Healthcare Research and Quality (AHRQ), are evidence-based. Evidence-based guidelines are based on research. Clinical practice guidelines are also published by professional organizations and private healthcare organizations (through clinical practice committees, for example).

Procedures are step-by-step directions, based on research, on how to perform a clinical activity or skill. Algorithms are graphical representations, such as flow charts, depicting the steps of a particular clinical decision-making processes.