Organizational Climate and Culture
All health care organizations have a climate and culture. Climate is described as the emotional states, feelings, and perceptions shared by the members of the organization. Climate can be described by such terms as positive or negative, hopeful or negative, trusting or suspicious, and competitive or nurturing. The APRN can influence the climate or be influenced by it. Climate can influence interactions and responses by patients and coworkers alike. It is a component of job satisfaction and enjoyment in one's work life. An organizational climate that is inconsistent with an APRN's preferred orientation can cause dissatisfaction and limit the ability to excel. However, the seasoned APRN can be pivotal in establishing the day-to-day climate in the practice setting.
An organization's social system, including its beliefs, norms, mission, philosophies, traditions, and values, make up its culture. It represents the perspectives, values, assumptions, language, and behaviors that have been effectively used by the members of the organization. Culture influences the formal and informal methods and styles of communication. When considering employment in an organization, an APRN should assess the culture and climate of an organization to assess whether it is an appropriate fit. The APRN may wish to practice with a specific population or within a specialty area. However, without an appreciation of the organization's climate and culture, the APRN may be unable to implement the changes and level of care he or she hopes to provide. Finding an organization that is consistent with the APRN's preferred culture and climate can provide a solid and more comfortable practice arena for an individual practitioner.
The Culture of Safety and Quality
Beginning in the 1980s and continuing with increased emphasis during the past decade, there has been a nationwide agenda to address the culture of safety and quality in health care organizations. National health care quality accreditation and regulatory agencies have taken major steps to enhance quality and safety by identifying evidence-based best practices and encouraging measurement and monitoring of these practices and care outcomes. The Joint Commission (formerly known as the Joint Commission on the Accreditation of Health Care Organizations [JCAHO]), the Institute of Medicine (IOM), the Agency of Healthcare Research and Quality (AHRQ), and the Centers of Medicare & Medicaid Services (CMS) of the U.S. Department of Health and Human Services (HHS) are just a few of the many organizations and agencies focused on enhancing health care quality and safety.
The IOM has identified safety concerns and problems with quality of care. It defines quality as "the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge" (Lohr, 1990, p.21).
A series of IOM reports help illustrate how wide the quality chasm is and how important it is to close the gulf between our standards of high-quality care and the prevailing norm in practice. Two landmark reports released by the IOM, To Err Is Human: Building a Safer Health System (1999) and Crossing the Quality Chasm: A New Health System for the 21st Century (2001), moved the national dialogue, asserting that reform is not accomplished by simply addressing the issues around its margins. The third phase of the IOM's Quality Initiative focuses on setting the vision outlined in Quality Chasm into operation. This implementation is on three levels: environmental, health care organization, and interaction between clinicians and patients. Thus far, focus has been on the redesign of care delivery, reform of health professions' education, technology implementation, safety, and quality care that is accessible and cost-effective (IOM, 2001, 2003c, 2005,2006).
The overall goal for the Quality and Safety Education for Nurses (QSEN) project (2012) is to meet the challenge of preparing future nurses who will have the knowledge, skills, and attitudes (KSAs) necessary to continuously improve the quality and safety of the health care systems in which they work. Using the IOM Health Professions Education: A Bridge to Quality (2003a) competencies, QSEN faculty and a national advisory board have defined quality and safety competencies for graduate-level nursing and proposed targets for the knowledge, skills, and attitudes to be developed in APRN programs for each competency (AACN, 2012). These competencies serve as a guide to curricular development for formal academic programs, transition to practice, and continuing education programs (Bargagliotti & Lancaster, 2007; Cronenwett et al, 2007).
CMS finalized its initiatives to develop quality measures of health care providers following the institution of the ACA in 2011. One of these initiatives is the "Pay for Reporting and Pay for Performance" standard. This standard outlines four quality measures that will be tracked, and provider reimbursement will be affected by the outcomes. These measures are tracked with a variety of methods, including patient surveys, claims calculation, electronic health record (EHR) review, and group practice reporting option (CMS, 2012).
The APRN should be aware of these outcome measures when considering a place of employment and use them as a mechanism to monitor the quality of services provided by their organization. There are now innumerable quality and safety initiatives nationwide, and astute APRNs will understand what is occurring in their place of employment and will help shape its practices to enhance quality. Several studies show APRNs' practices are already demonstrating high-level outcomes for patient satisfaction and chronic disease management (Boville et al., 2007; Dinh, Walker, Parameswaran, & Enright, 2012; Green & Davis, 2005). Continued positive outcomes will propel APRNs to be the exemplary model of quality health care.
The APRN of today and tomorrow will need to address organizational and system issues. Although it may seem daunting in our changing health care landscape, APRNs must develop the knowledge to analyze organizational variables and the skills and abilities to enhance quality and safety. The APRN must be a leader and change agent instrumental in creating the care delivery systems that will be needed in the future.
The author acknowledges the contributions of Mary Zwygart-Stauffacher to this chapter in a previous edition.