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Principles And Quality Health Care

Principles And Quality Health Care

The poor performance of our country’s healthcare system should come as no surprise. According to a recent poll, most Americans are concerned about the state of our healthcare system, with three-quarters believing it is “in a state of crisis” or “has major problems” (Reinhart, 2018). Our healthcare system consistently needs to meet our expectations.

Despite having the world’s most expensive healthcare system, the United States ranks lower than comparable high-income countries in many quality measures, including infant mortality, maternal mortality, life expectancy, and the number of medical errors (Bradley & Taylor, 2013; OECD, 2017; Sawyer & McDermott, 2019). According to the Commonwealth Fund’s set of metrics for comparing healthcare system performance, the United States ranks last in administrative efficiency, last in access to healthcare, last in health equity, and next to last in overall health outcomes (Table 1.1; Schneider, Sarnak, Squires, Shah, & Doty, 2017).
principles and quality health care
We are not receiving value for our money. We spend more on healthcare—one-and-a-half times more than the following most expensive country in the world (Bradley & Taylor, 2013; OECD, 2017)—but we do not get good results (Schneider et al., 2017). Hiring more people or spending more money are not the best solutions to our healthcare performance problems (McGinnis et al., 2016). The healthcare system employs more people than any other industry in the United States (Thompson, 2018), but the healthcare workforce is underproductive (Carnevale, Smith, Gulish, & Beach, 2012).

Why does the United States perform so poorly despite having the most people and resources? Because the issue is not with the people or the resources but the system. We perform to the best of our ability within our current system design constraints. According to Don Berwick, founder of the Institute for Healthcare Improvement (IHI), the central law of quality improvement is as follows: “Every system is perfectly designed to achieve the results it achieves” (Berwick, 1996, p. 619). He joked that this adage should be “tattooed on the body” of people who work in healthcare quality management to remind us that quality problems are caused by our processes, not our people (Donahue, 2015).

Table 1.1 Commonwealth Fund Performance Rankings of Healthcare Systems




Overall standings
2 9 10 8 3 4 4 6 6 1 11 Care procedure
2 6 9 8 4 3 10 11 7 1 5
4 10 9 2 1 7 5 6 8 3 11 Administrative Effectiveness
1 6 11 6 9 2 4 5 8 3 10
7 9 10 6 2 8 5 3 4 1 11
Medical outcomes
1 9 5 8 6 7 3 2 4 10 11
Source: Schneider, E. C., Sarnak, D. O., Squires, D., Shah, A., and Doty, M. M., with permission (2017). Mirror, Mirror 2017: International comparison reveals flaws and opportunities for better health care in the United States. Retrieved from

Why is it essential to improve healthcare quality? First and foremost, patients are entitled to high-quality healthcare. Our efforts to improve healthcare quality should center on patient perspectives and experiences (Balik, Conway, Zipperer, & Watson, 2011). Following that, healthcare professionals, including nonclinical managers, have an ethical obligation to provide high-quality medical care (Baily, Bottrell, Lynn, & Jennings, 2006). From an ethical standpoint, healthcare quality management should be considered a necessary component of normal healthcare operations. Finally, organizational survival is at stake. Healthcare quality management implementation is highest, where competition is fiercest (Weiner, Alexander, Baker, Shortell, & Becker, 2006). In other words, quality management gives healthcare organizations that improve quality a competitive advantage; organizations that fail to perform will cease to exist.

Assume you can improve the United States healthcare system. Where would you begin if you adopted the right mindset, learned the fundamental skills, and obtained organizational support? Would you like to improve health outcomes, make healthcare safer, make work processes more efficient, or increase patient satisfaction? Would you raise the cost of healthcare in your community?

With so many opportunities for improvement, solving these complex healthcare problems necessitates a complicated approach. The inverse is true. To improve healthcare quality, you must adopt a mindset that clarifies, simplifies, and streamlines. This is not a revolutionary mindset. Indeed, the approach is founded on hundreds of years of scientific research. The scientific method and quality management rely on asking questions, making predictions, measuring, observing, analyzing, and controlling.

You can solve some of our most difficult healthcare quality challenges by combining the quality improvement mindset with fundamental management skills (Field, Heineke, Langabeer, & DelliFraine, 2014). Broken processes, medical errors, dissatisfied patients, and poor performance can all be improved. The skills of quality management are both problematic and radical. When used correctly, these skills will enable you to identify the root causes of problems, analyze dirty data, define new ways of working, recommend solutions, measure outcomes, and sustain changes.

The casebook contains realistic (but entertaining) case studies on various healthcare quality issues in various management settings. The case study method, on the other hand, is not for the inactive learner. This casebook will require you to investigate messy healthcare issues actively. There is no “correct” answer; each case will have multiple interpretations. Of course, this raises the difficulty level, but it will better prepare you to face real-world healthcare quality challenges.

What exactly do we mean by healthcare quality management? Let us begin with a definition of quality. W. Edwards Deming, a renowned quality management expert, defines quality as “a predictable degree of uniformity and dependability with a quality standard suited to the customer” (Deming, 1982, p. 229). This definition assumes that a standard has been established and that the system can produce that standard consistently and without variation. Furthermore, according to this definition, the customer is the quality standard-bearer.

The definition of healthcare quality, like Deming’s general definition, includes both a standard and a standard-bearer. Following Deming’s logic, the Institute of Medicine (IOM) defines healthcare quality as “the extent to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” (IOM, 1990, as cited in IOM, 2001, p. 44). The “consistent with current professional knowledge” component reflects the community of healthcare practitioners’ standard of care based on the best available medical evidence. The “desired health outcomes” element represents the quality standard established by patients or their families.

The IOM definition, however, does not address what Deming refers to as “a predictable degree of uniformity and dependability.” The old healthcare quality adage “the right care for the right patient at the right time” also reveals this oversight. According to quality expert Carolyn M. Clancy, MD, “every time” should be added to this axiom (Clancy, 2009). Healthcare does not provide a consistent, uniform standard of care. In other words, variability in healthcare delivery is a significant issue in our healthcare system. As a result, healthcare quality management should strive to provide the appropriate care to the appropriate patient at the appropriate time, every time.

Systematic management practices are required to achieve highly reliable healthcare quality. According to one definition, management practices are “processes composed of interrelated social and technical functions and activities that occur within a formal organizational setting for the purpose of achieving predetermined objectives through the utilization of human and other resources” (Longest & Darr, 2014, p. 255). In other words, managers must organize human and nonhuman resources to accomplish activities following a predetermined goal.

By combining these concepts, we offer our working definition of healthcare quality management for this casebook. Healthcare quality management is the systematic application of practices that guide the formation of reliable processes in healthcare organizations to increase the likelihood of delivering evidence-based care and achieving the health outcomes expected by patients, their families, and caregivers.

According to the Commonwealth Fund’s standard of healthcare quality, the United States ranks dead last in the world regarding health system performance (Schneider et al., 2017). They developed their assessment by combining dozens of quality metrics to calculate an objective composite performance scoring system. Their ranking system includes many metrics for which the American healthcare system falls short, such as the preventive care metric “avoidable hospital admissions for asthma” and the affordability metric “cost-related access problem to medical care in the previous year.” The Commonwealth Fund also examines the quality of medical care delivery through a metric known as “mortality amenable to healthcare.” This metric is defined as “deaths under the age of 75 from specific causes thought to be preventable in the presence of timely and effective health care.” In 2014, medical care in the United States lagged far behind its global counterparts (Figure 1.1).

Of course, as the Commonwealth Fund acknowledges, these negative findings do not tell the entire story of the healthcare system in the United States. Other quality measures place the United States ahead of the competition. The United States, for example, excels at provider-patient relationship measures such as “talked with provider about healthy diet, exercise, and physical activity in the past 2 years” and “women aged 50-69 with mammography screening in the past year.” This makes sense because the educational system in the United States is highly regarded around the world. Many medical schools in the United States are excellent, with 28 of the top 50 in the world located in the country in 2018. (U.S. News and World Report, 2019). Furthermore, our doctors excel at treating breast and cervical cancers, heart attacks, and ischemic strokes, all of which require highly skilled interventions, and where mortality rates from these diseases are lower in the United States than in comparable countries (Sawyer & McDermott 2019). Our well-trained providers’ success with sophisticated, technology-supported interventions supports the notion that our processes, not our people cause our healthcare quality challenges.

Consider our definition of healthcare quality management once more. Depending on the standard-point bearer’s view, the United States healthcare system performs well in some areas and poorly in others. When attempting to improve healthcare quality through management practices, defining the quality standard is necessary. Quality definitions must be precise and scientific. The process of scientifically defining quality is known as operationalization. This is not as simple as it appears. For example, “consistent with current professional knowledge” is constantly changing in response to new medical evidence. Furthermore, the quality standard bearer can shift. The patient’s perception of “desired health outcomes” may differ significantly from that of his or her doctor. To ensure effective healthcare quality management, you must clearly identify the standard-bearer and objectively define the quality standard. This means that many of the metrics used to assess the performance of the U.S. healthcare system are debatable and should be.

Source: Schneider, E. C., Sarnak, D. O., Squires, D., Shah, A., and Doty, M. M., with permission (2017). Mirror, Mirror 2017: International comparison reveals flaws and opportunities for better health care in the United States. Retrieved from

Nonetheless, by most accepted measures, the quality of healthcare in the United States—uneven and unreliable—can be dramatically improved (Jha, 2017; McGlynn et al., 2003). We provide you with realistic scenarios and detailed data on healthcare quality issues that regularly vex healthcare quality management practitioners in this casebook. We classified healthcare quality management issues into four categories: process improvement, patient experience, patient safety, and performance enhancement.

Process Enhancement
The underperformance of the U.S. healthcare system is caused by chaotic, redundant, and unexamined work processes. Healthcare inefficiencies are easy to identify—from confusing hospital layouts to long patient wait times—but the solutions are not so simple (Glied & Sacarny, 2018). Although delivery of care, coordination of care, and overtreatment are the primary causes of inefficiencies (Berwick & Hackbarth, 2012), opportunities to improve processes exist throughout the healthcare system.

A process is a series of steps that, when completed in a specific order, yield results. A system is made up of a collection of processes. Process improvement projects typically include step mapping and process measurement using carefully defined performance metrics (de Mast, Kemper, Does, Mandjes, & van der Bijl, 2011).

Process improvement can occur in clinical settings, such as patient care flow or facility design, or in business settings, such as human resource management or payment policies. Process enhancements include increasing capacity and utilization of staff and equipment, decreasing throughput and waiting times, implementing standardized work processes, and mitigating failure opportunities (de Mast et al., 2011). These processes are typically modified or supplemented with subprocesses, and are occasionally eliminated entirely.

Table 1.2 shows some of the process improvement opportunities described in this casebook.

Patient Knowledge
The healthcare system in the United States struggles to provide patients with the high-quality customer experiences seen in other economic sectors (Needham, 2012). The judgment, attitude, or perception of all interactions in a healthcare setting is referred to as patient experience. Patient experience refers not only to patient satisfaction but also to whether patients’ expectations about their experiences were met (Agency for Healthcare Research and Quality, 2017). IHI founder Don Berwick defined patient centeredness as “the experience (to the extent the informed, individual patient desires it) of transparency, individualization, recognition, respect, dignity, and choice in all matters, without exception, related to one’s person, circumstances, and relationships in health care” (2009, p. w560). These concepts, whether referred to as “patient experience,” “patient satisfaction,” or “patient centeredness,” seek to understand the quality of healthcare from the patient’s point of view.

Case Studies on Process Improvement
Case 1: A Journal of a Summer Internship
Inadequate patient flow can cause issues throughout the hospital, including potentially dangerous delays in admissions from the emergency department, PACU, and cardiac catheterization lab (Destino et al., 2019).
Case 2: Payment Processing for Claims
Uncertain communication processes can cause delays in payments from managed care organizations to healthcare providers. Effective revenue cycle management can boost patient revenues and profitability (Hodges, 2002).
Case 3: Resumption of Employment at a Home Health Agency
Clinicians are frequently injured while performing patient care activities, which may necessitate time away from work, a benefit covered by the FMLA. 91% of healthcare risk managers rank return-to-work process administration as one of their top three priorities (Mercer, 2010).
Case 4: The Sightless Ophthalmologist (The Waste)
Reduced payments from Medicare and other payers force healthcare organizations to cut costs. Healthcare service delivery is fraught with unnecessary operational inefficiencies that medical providers are unaware of (de Koning, Verver, van den Heuvel, Bisgaard, & Does, 2006).
Case 5: Constructing a New I.R. Suite
Inefficiencies in healthcare facility physical layout increase the effort and cost of providing health services. Optimized hospital design can result in improved workflow (Reijula, Nevala, Lahtinen, Ruohomaki, & Reijula, 2014).
Case 6: Emergency Department Heroes (Schwarz, Hasson, & Athlin, 2016) E.D. crowding and patient throughput challenges are caused by inefficiencies in triage processes and other issues (Arbune, Wackerbarth, Allison, & Conigliaro, 2017).
E.D. stands for emergency department; FMLA stands for Family and Medical Leave Act; I.R. stands for interventional radiology; and PACU stands for post-acute anesthesia care unit.

Improving patient experience necessitates a paradigm shift in healthcare delivery. The measurement of patient experience is not universally accepted by clinicians (Manary, Boulding, Staelin, & Glickman, 2013), who may object to “patient satisfaction” scores, believing that patients only evaluate trivial items such as wait times, or, worse, that they encourage bad medicine such as prescribing unnecessary pain medications (Nash, 2015). Furthermore, some clinicians are concerned that by refusing specific requests for care from patients, regardless of the benefit, their performance rating will suffer (Manary et al., 2013). Despite this ongoing debate, research consistently shows a positive relationship between patient experience measures and clinical effectiveness, particularly patient adherence to medical treatment recommendations (Doyle, Lennox, & Bell, 2013).

Consumers and buyers are increasingly interested in learning more about their healthcare experience (Lake, Kvam, & Gold, 2005). The United States government—the Agency for Healthcare Research and Quality (AHRQ) and the Centers for Medicare and Medicaid Services (CMS)—responded in 2006 with the final version of the Consumer Assessment of Healthcare Providers and Systems survey series (CAHPS; Giordano, Elliott, Goldstein, Lehrman, & Spencer, 2010). The CAHPS (pronounced “caps”) surveys inquire about patients’ willingness to recommend, interactions with doctors and nurses, timeliness of their care, facility cleanliness, and other factors (Giordano et al., 2010). The government posts survey results, adjusted for patient-level factors, to the Hospital Compare website and the CAHPS Online Reporting System for consumer shopping comparisons and various pay-for-performance programs (Anhang Price et al., 2014). In response to the consumer and government purchasers’ desire for a better patient experience, healthcare organizations have made significant investments in work processes and workforce training (Burrill & Kane, 2018).

The case studies in Table 1.3 depict a variety of patient experience issues.

Case Studies of Patient Experience
Hurricane Mia hits the Patient Access Call Center in Case 7
Inefficient call center scheduling processes can result in unnecessary delays in patient care, lowering patient satisfaction ratings (Brandenburg, Gabow, Steele, Toussaint, & Tyson, 2015; Rohleder et al., 2013).
Case 8: The Patient Experience of the Cowboy Doctor
Although some physicians object to evaluating patient experience (Nash, 2015), communication training can change physician behaviors and increase patient satisfaction (Boissy et al., 2016).
Case 9: Ortho Clinic Patient Navigation
The surgeon’s patient consent may not be sufficient to ensure patient satisfaction (McGaughey, 2004). Navigators can significantly improve communication and outpatient patient experience scores for orthopedic surgery (Goldsmith et al., 2017; van Eck, Toor, Banffy, & Gambardella, 2018).
Case 10: HCAHPS and the Nighttime Quietness Measure
Some critics argue that patient experience scores measure insignificant aspects of healthcare, such as whether the hospital is quiet at night (Jha, 2017), but patient satisfaction may be strongly related to health outcomes (Isaac, Zaslavsky, Cleary, & Landon, 2010).
Case 11: Terminate Phone Calls (In Spanish)
Although automated inpatient discharge communications have been shown to improve health outcomes (Olsen, Courtemanche, & Hodach, 2016), a lack of cultural competence in healthcare operations may result in lower overall patient experience scores (Weech-Maldonado et al., 2012).
Case 12: Home Care Patient Experience
To increase revenue growth in the competitive home healthcare market, patient referrals from satisfied clients are required (Abusalem, Myers, & Aljeesh, 2013; Kunz, 2018). “How likely is it that you would recommend our company to a friend or colleague?” asks the HH-CAHPS Net Promoter Score.
HCAHPS is an abbreviation for Hospital Consumer Assessment of Healthcare Providers and Systems; HH-CAHPS is an abbreviation for Home Healthcare Consumer Assessment of Healthcare Providers and Systems.

Patient Security
Unreliable healthcare work processes endanger patients. According to the IOM (Kohn, Corrigan, & Donaldson, 2000), preventable medical errors kill between 44,000 and 98,000 people in the United States each year. These errors are most likely to occur in hospitals, specifically in intensive care units, operating rooms, and emergency departments, but adverse drug events, falls, burns, pressure ulcers, and misidentified patients can occur anywhere along the healthcare continuum (Kohn et al., 2000). The IOM advocated for a comprehensive medical error prevention strategy to identify errors, improve performance, and put safety systems in place (Kohn et al., 2000).

More than 20 years have passed since the first estimates of the extent of medical harm in U.S. hospitals were published. Despite significant time, money, and effort invested in patient safety initiatives, the risk of death from medical error remains too high—roughly the same as dying from diabetes, the seventh leading cause of death in the United States (CDC National Center for Health Statistics, 2017; Sunshine et al., 2019).

The medical errors addressed in this casebook are listed in Table 1.4.

Table 1.4 Case Studies on Patient Safety
Case 13: Patient Falls Reduction: The Sleuth Resident
Every year, between 700,000 and 1 million patients are admitted to hospitals in the United States (Ganz et al., 2013). Patient falls are one of the leading causes of both fatal and nonfatal injuries in the elderly (Bergen, 2016).
Case 14: Keeping Hand Hygiene
Sustaining even the most basic quality improvement intervention can be difficult. Ignaz Semmelweis, a Hungarian physician, demonstrated in 1847 that hospital-acquired infections were transmitted through the hands of clinicians (Kadar, 2019). Even today, it is difficult to maintain strict handwashing routines (World Health Organization, 2009).
Case 15: A State Regulator’s Warning Letter
Patient misidentification errors can cause serious harm or even death (Hall, 2008). A variety of circumstances can contribute to patient identification errors in complex healthcare settings.
Case 16: Rescue Failure
Failure to follow established clinical protocols can result in patient death, a phenomenon known as failure-to-rescue (Garvey, 2015). Medical errors can result in a “second victim,” in which clinicians experience stress, anxiety, depression, denial, and withdrawal (Seys et al., 2013).
Case 17: Medication Errors at CLIF
Medication errors are one of the most common types of inpatient safety issues in the United States, affecting nearly 5% of all hospitalized patients (AHRQ Patient Safety Network, 2019; Hauck, & Zhao, 2011). Technology can not only help reduce medical errors, but it can also have unintended consequences for patient safety (Campbell, Sittig, Ash, Guappone, & Dykstra, 2006).
Case 18: A Mom’s Sepsis Story
Infections caused by sepsis are a leading cause of death in the United States (Cohen et al., 2015). Early detection is critical to avoiding potentially fatal delays in sepsis treatment (Kumar et al., 2006; Lynn, Gupta, Vaaler, Held, & Leon, 2018).
Performance Enhancement
The terms “performance improvement” and “quality improvement” are frequently used interchangeably. For the purposes of this casebook, we define performance improvement as quality issues related to external demands. Healthcare organizations must respond to a variety of externally generated quality management imperatives because they are disconnected from community needs, government policies, and competitive pressures. For example, the opioid addiction epidemic has a significant impact on communities across the United States, where overdoses put a strain on hospital emergency department capacity (Vivolo-Kantor et al., 2018). Furthermore, ongoing reductions in payments from health insurance companies encourage health-care organizations to reexamine care processes for inefficiencies (Balzer, Raackow, Hahnenkamp, Flessa, & Meissner, 2017).

Nothing else has pushed healthcare organizations to improve their performance more than value-based purchasing, also known as “pay-for-performance” (VanLare & Conway, 2012). The concept of value-based purchasing is that healthcare payers, such as Medicare and insurance companies, replace payments for the number of services provided with incentives to keep patients healthy (Blumenthal & Jena, 2013). The term “value” refers to the level of health achieved per dollar spent (Porter & Teisberg, 2006). In other words, healthcare organizations are financially rewarded for improving quality and lowering costs. This is a game-changing shift in the healthcare system’s incentive structure (Porter & Kaplan, 2017). Healthcare organizations must now control costs while also investing in healthcare quality management initiatives, tasks for which the U.S. healthcare system is woefully unprepared.

To encourage the shift to value-based incentives, the U.S. government has implemented a number of policies that reward providers for the quality of care they provide (Blumenthal, Davis, & Guterman, 2015). Accountable Care Organizations (ACOs), for example, are a Medicare program called the “Medicare Shared Savings Program” that encourages a variety of specialists, hospitals, and other providers to collaborate and reduce overall healthcare costs. If the ACO reduces overall costs below predetermined expenditure benchmarks, the savings are shared by Medicare and the ACO. But there’s a catch. Only if the ACO meets the quality measure targets does it receive a bonus. The program monitors dozens of indicators, such as breast cancer screening and depression remission after a year (CMS, 2019). As a result, the ACO’s goal is to increase the value of the Medicare program by providing better care at a lower cost.

Medicare does not just give carrots; it also gives sticks. The Hospital Readmissions Reduction Program is a value-based purchasing program that penalizes hospitals that have “worse-than-expected” readmission rates within 30 days of discharge (CMS, 2014). If hospitals have high 30-day readmission rates for six specific conditions, CMS will withhold up to 3% of Medicare payments. A revenue reduction of that magnitude on all Medicare patients would be a big stick for a hospital industry whose profit margins are typically less than 3%. (Ellison & Cohen, 2018; Mulvany, 2016).

In our casebook’s conceptualization, performance improvement entails effective quality management responses to unavoidable changes in the external environment. Consider the case studies of performance improvement in Table 1.5.

Case Studies on Performance Improvement
Case 19: Recovery in the Operating Room
Tightening hospital budgets necessitates better planning of operating room use. Improved operating room efficiency necessitates an examination of complex surgical procedures (Balzer et al., 2017).
Case 20: Emergency Department Opioid Overdoses
Failure to adhere to established clinical protocols can have a negative impact on community health performance, as seen in the opioid overdose epidemic (Califf, Woodcock, & Ostroff, 2016).
Case 21: Physician Engagement in a PCMH Lunchroom
The PCMH, a new model of healthcare delivery, incentivizes performance measures (NCQA, 2014). Such organizational changes can put providers under psychological strain and lead to burnout (Swensen, Kabcenell, & Shanafelt, 2016), so efforts to engage physicians in performance improvement should be implemented with caution (Lee & Cosgrove, 2014).
Case 22: The Affair of Fulfillment
Because behavioral and social factors, rather than quality-measurement scores, may predict high-cost patients (Sterling et al., 2018), performance improvement necessitates a close examination of patients’ environments.
Case 23: Quality Composite Measures
Composite quality measures provide a useful summary of quality across several dimensions and are increasingly used to evaluate healthcare organization performance in value-based purchasing programs (Friebel & Steventon, 2019; Shwartz, Restuccia, & Rosen, 2015).
Case 24: Considering Both/And Readmission Prevention
To avoid financial penalties imposed by Medicare, the multifaceted causes of inpatient readmissions necessitate interprofessional collaboration (Auerbach et al., 2016).
Case 25: Suicide Prevention Through Community Collaboration
Nonprofit hospitals are required by federal law to assess community health needs and develop strategies for improved population health, including suicide mortality. Inadequate performance may result in the loss of tax-exempt status (Rosenbaum, 2015).
NCQA stands for National Committee for Quality Assurance; PCMH stands for patient-centered medical home.

The United States’ healthcare system is the most expensive in the world, and it lags behind comparable high-income countries in many quality measures. Because of the low value of the American healthcare system, adopting the quality management mindset and mastering the fundamental skills is essential. Healthcare quality management is the systematic application of practices that guide the formation of reliable processes in healthcare organizations in order to increase the likelihood of delivering evidence-based care and achieving the health outcomes expected by patients, their families, and caregivers. However, the healthcare system in the United States does not provide a consistent, uniform standard of care. Healthcare quality management practices address our healthcare system’s central problem: the variability of healthcare delivery. The challenges of healthcare quality management are divided into four categories in this casebook: process improvement, patient experience, patient safety, and performance improvement. This casebook will prepare you to face a variety of quality management challenges, ranging from inefficient patient flow to patient harm.
Which learning theories and principles do you think are most useful to the advanced practice nurse (APN) in providing high quality health care to clients, and why?

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