Chapter 9. Synergistic Opportunity to Connect 

Quality Improvement and Emergency Preparedness 

Sally Phillips, Ronda G. Hughes, and Lucy A. Savitz 

Background 

A critical element in the mission of health care organizations is high quality health care. 

Organizationally, the hospital enterprise is a hierarchical structure that has separate functional 

charges, lines of authority, and personnel resources for quality improvement and emergency 

management. The overall umbrella of safety and health care delivery can be viewed to 

encompass quality improvement and emergency preparedness, and nursing plays an integral role 

in ensuring continuous quality improvement. The interaction of quality improvement and 

emergency preparedness resources in hospital settings promises to yield a combined effect that is 

greater than the sum of their individual efforts to ensure patient safety and enhanced health care 

quality. By strengthening communication channels and fostering opportunities for collaborative 

project implementation across quality improvement, emergency preparedness and organizational 

functions can be highly synergistic. 

Engaging People in Place 

According to the current working knowledge of quality improvement and emergency 

management in hospitals, it is suggested that the bioterrorism/emergency response function 

resides in the facilities management area, while quality improvement is incorporated into clinical 

operations. Job enlargement of selected nursing staff can serve to bridge the quality 

improvement–emergency preparedness gap. Quality improvement and patient safety initiatives 

are led by executives who report directly to the chief medical officer and/or vice president for 

quality/safety. Emergency management typically has a less direct reporting route through the 

chain of command; however, there are exceptions. Exceptions are likely to appear in hospitals 

and health systems that have experience with natural disasters (e.g., University of North Carolina 

Hospitals’ experience with hurricanes), known manmade threats (e.g., Intermountain 

Healthcare’s experience with chemical stockpiles and manufacturing research facilities), and/or 

specialized facets of bioterrorism threats (e.g., University of Pittsburgh Medical Center Health 

System). The boards of directors of such health systems are beginning to request 

methodologically rigorous research and comparative preparedness data for benchmarking and 

quality improvement of emergency management—the customary practice over the past decade 

for health care quality and, more recently, patient safety. 

The Agency for Healthcare Research and Quality (AHRQ) sponsored the Integrated Delivery 

System Research Network (IDSRN),*

 a network of five health systems with nearly 70 hospitals 

in seven States across the United States committed to applied research representing a crosssection of the hospital industry. In-depth knowledge of these health care systems—and more 

 

*

 RTI Master Task Order Contract No. 290-00-0018, L.A. Savitz, Director; 2004. 

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general knowledge of the hospital industry—was obtained, affording the opportunity to identify 

several common practices. The leadership of the administrative emergency management function 

in health care organizations was often former military personnel with security experience or 

individuals who had worked their way up through increasing responsibility in 

facility/environmental services. Only those organizations with the most visible commitment to 

emergency preparedness also had clinical champions who partnered with the administrative 

emergency management function. Conversely, quality management typically had clinical leaders 

(i.e., physicians and/or nurses) with some training or on-the-job experience in health care 

administration. These individuals were repeatedly trained through continuing education and 

professional society meetings, used a journal specifically dedicated to implementation science 

(visit http://www.implementationscience.com), and reinforced change management principles 

using the Institute for Healthcare Improvement collaborative model (visit http://www.ihi.org). A 

corollary for support of similar change management efforts does not exist for emergency 

management. However, fostering transfunctional collaboration of emergency preparedness and 

quality improvement is promising; both the Joint Commission (see the Joint Commission–issued, 

revised emergency management standards that were effective January 1, 2008 – visit 

http://www.jcrinc.com/28380) and the American Hospital Association are working toward 

increasing opportunities for such dialogues. 

Recent experience with Hurricane Katrina has highlighted the “soft underbelly” of hospital 

preparedness and emphasized the inseparable role that emergency management plays in the 

overall quality and safety of health care delivery. The emergency preparedness of this country is 

based on a robust health care delivery system. The public expects and is entitled to receive the 

highest quality evidence-based care within the most efficient delivery system possible. At times 

of crisis be it a disaster, natural or man made, or a major infectious disease, SARS or Pandemic, 

the already stressed health care system operating at the margins will be challenged to deliver this 

level of care without concerted planning and cooperation. Nurse executives must lead a cultural 

shift towards using evidence-based management and clinical practices (Williams 2006) in both 

quality improvement and emergency preparedness. Principal team players must include nurses, 

who are the essential back-bone of successful change efforts in hospitals (Savitz & Kaluzny, 

2000). The extent to which nursing leaders, including middle managers, can be engaged in 

change management activities (Dopson & Fitzgerald, 2006) for emergency preparedness will be 

an important investment in successful design and implementation of targeted interventions. 

There is not good visibility for emergency preparedness commitment on the part of clinical staff 

in operational areas demonstrated, for example by most staff avoiding required drills failing to 

see the priority from their leaders. Health system leadership can change this by appropriately 

acknowledging and rewarding such efforts and modeling the commitment. 

Opportunity for Learning Exchange 

Development of meaningful working relationships and opportunities for learning exchanges 

between quality improvement and emergency preparedness initiatives could fundamentally 

enhance change management efforts within these separate functional areas in hospitals. There are 

differences in the degree to which initiatives in emergency preparedness are germane to quality 

improvement with respect to knowledge utilization (e.g., community collaboratives, data sharing, 

information technology solutions, measurement and feedback reporting to involved staff). This is 

because nurses can be involved in both quality improvement and emergency response in their 

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role as caregivers and clinical managers. Consequently, it would be possible to link knowledgebased learning about how interventions are implemented (a.k.a., implementation science) so that 

advancements in our understanding are not confined to any single aspect of quality health care 

delivery, but are opportunities for cross-fertilization and synergy. 

As stated by Mittman,4 implementation science focuses on a second level of research 

translation where one takes evidence-established benchmarks from limited settings (i.e., level 1 

translation) to practice innovations, and more broadly to disseminate that knowledge. 

Implementation science (or second-level research translation) is an evolving, multidisciplinary 

area, and the terminology has not yet been consistently established. For example, Chapter 7 

(“The Evidence for Evidence-Based Practice Implementation”) in this Handbook discusses 

“translation science” to describe the same concept. Despite the inconsistent terminology, 

researchers and practitioners are committed to implementing and disseminating promising 

practices. 

Disseminating and Implementing Promising Practices 

The difficulty of disseminating innovations is a persistent conundrum across settings and 

situations. There is limited ability to spread successful interventions across a single health care 

organization, let alone to unaffiliated organizations. The real challenge for health care 

implementation science is figuring out how to “flatten our world.”5 Opportunities for shared 

learning (Figure 1) could serve to accelerate the diffusion of innovation processes.6 By directly 

engaging nursing leadership, current organizational barriers that inhibit application and shared 

approaches that promote quality improvement3 and readiness for emergency response could be 

ameliorated, but integrating both tacit (i.e., personal experience) and explicit knowledge (e.g., 

evidence) can be difficult to achieve.7 The challenge to nursing will be translating quality 

improvement research into practice to address both functional roles—quality and preparedness. 

Figure 1. Shared Learning 

Quality Improvement

Fusion Process

Bioterrorism Preparedness

Fusion Process

The notion of an implementation deficit between what is planned versus achieved and the 

challenge of effectively translating research into practice has a long-standing literature base, 

primarily in organizational studies and public policy analysis.6, 8, 9 In terms of nursing, the 

research has been inconclusive even about the evidence for specific interventions.10 A 

generalized conceptual model of translational implementation, based on Rogers’s seminal work,6

has been incorporated into numerous change management efforts such as the RE-AIM11, 12

(Figure 2). 

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Figure 2. Conceptual Model 

Practice Setting 

Characteristics 

Intervention 

Characteristics 

Research-to-Practice “Translation” Process 

 

 

 

Adoption 

 Problem Recognition

 Search for Solutions

 Locus of Decision 

Making

 Drivers/Barriers

Implementation 

 Essential vs. Adapted 

Elements of Intervention

 Drivers/Barriers

 Process Redesign

 End-User Participation

Routinization or 

Institutionalization 

 Essential vs. Adapted 

Elements of Intervention

 Organizational Changes

 Benefits/Costs

 Level of Use/Outcomes

What we know from reported studies and have been learning in subsequent research is that 

change will be a nonlinear process stymied by individual and organizational barriers.2, 13–16

Attempts to advance implementation science in health care have focused on the factors that 

affect adoption and sorting out different strategies to accelerate that second level of translating of 

research into practice.2, 17, 18 A recent report by Hamel19 described the conditions necessary for 

management innovation that produced bold breakthroughs in how business was done, including 

commitment to a big problem (e.g., bioterrorism preparedness), new approaches (e.g., 

application of information technology such as electronic medical records), deconstruction of 

management orthodoxies (via exchanged resources and knowledge between the quality 

improvement and emergency management silos), and shared stories from diverse organizations 

that redefined what is possible. Early adopters lead the way. 

Over the past decade, targeted research related to understanding how clinical process 

innovations are adopted has been funded by the AHRQ. Building on that base effort, the AHRQ 

funded the Partnership for Advancing Quality Together (PAQT) grant* (part of the AHRQ’s 

Partnerships for Quality initiative) to achieve the following specific aims: strengthen an existing 

research network that promotes sharing of local innovations, explore factors that impede and 

facilitate inter- and intra-organizational sharing of knowledge, provide a mechanism to test the 

transportability of clinical process innovations, influence the breadth and depth of the evidence 

base for quality improvement, and accelerate the rate at which knowledge utilization occurs. 

Underlying these aims was a directive to explore the potential synergies between quality 

improvement and emergency preparedness. 

Collaborative efforts to address these issues was done in a focused manner through 17 

applied research projects, which led to several important findings and strategies for supporting 

knowledge transfer and implementation science that are relevant to both quality improvement 

and emergency preparedness. The three main findings are: 

*

 AHRQ 5 U18 HS13706. 

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Connecting Quality Improvement & Emergency Preparedness

• Organizational modeling by credible organizations can accelerate knowledge transfer. 

• The primary evidence base (the peer-reviewed literature) is limited to the extent that 

many innovations are not reported and there is a bias toward reporting only successful 

efforts, when we can often learn as much from failed attempts. 

• Innovations in health care delivery are often complex interventions with multiple 

elements that are not fully reported, and essential versus adaptable elements of these 

complex interventions are not clearly delineated. 

The bedrock propositions, common to all innovation packages, are that (1) how we deliver 

preventive or therapeutic services and how we organize those efforts within health care systems 

and facilities should, whenever possible, be based on knowledge of what works; and (2) 

effectively sharing such knowledge is a common feature of successful efforts generalized beyond 

a single program or facility.20, 21 Understanding how knowledge (i.e., research information and 

data together with developed tools) can be used to drive high-quality and safe care delivery is 

critical. This understanding will allow for necessary and innovative changes in practice and 

processes at both the organizational level and at the point of service.16

Health care organizations typically view information and analysis in the context of local data 

derived from the experiences of patients served in their own organizational settings. Efforts to 

drive change innovations have expanded this notion of information to include both health 

services research conducted locally and studies reported in the peer-reviewed literature. Such 

research reports offer tested models for improvement; however, various barriers such as 

publication bias,22 reporting time lags,23 journal prestige,24 and the overwhelming volume of a 

dispersed body of literature diminish the accessibility of such needed evidence. The problem of 

nontransportability of potential advances in health care information technology efforts is just the 

newest illustration of a much larger dilemma of generalizability beyond single institutions or 

systems. The challenge is to build an evidence base and place such evidence in the hands of 

those who are charged to operationalize knowledge transfer. 

Evidence-Based Quality and Safety 

Health services researchers and organizational leaders have more recently advocated 

evidence-based health care or EBHC.8, 15, 20, 25–27 Sackett28 defined EBHC as a “bottom-up 

approach based on good clinical management and supported by the best available evidence and 

taking into account patient priorities.” The “enthusiasts of EBHC naively assumed that the case 

for implementation would be self-evident and that it would spread automatically and 

quickly”8 (p. 29). Further, the authors contend, “There should be a strategy of creating evidence 

in priority areas, with concomitant systematic efforts to accumulate evidence in the form of 

robust bodies of knowledge” (p. 30). AHRQ has led the way for the synthesis of evidence 

through its Evidence-Based Practice Centers or EPCs (visit http://www.ahrq.gov/clinic/epc). Such 

evidence should be actively disseminated to where it is most needed and made available for the 

widest possible use.8

Health care organizations characterized by different levels of experience with clinical process 

innovation and staff tolerance for change set the “evidence bar” quite differently.2 Mature 

organizations with extensive experience and local pilot projects require independent research by 

affiliated researchers whose results were published in the peer-reviewed literature. Less 

experienced organizations are comfortable simply modeling clinical process innovations based 

on evidence in the peer-reviewed literature, but without local development and testing. Further, 

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we have learned29 that there is a life cycle associated with organizational learning, and where an 

organization or unit sits on that life cycle is influenced by staff tolerance for change and 

experience with innovation implementation over time. Whether the evidence is self-generated or 

modeled from reports in the literature, a primary issue is how to appropriately target intended 

end users. Novel approaches and use of preexisting dissemination channels will be needed to 

accelerate the rate at which such knowledge is put into practice. 

Implementation Science in Practice 

A great deal of attention has been paid to understanding the process of implementing science 

into practice.30–33 Recent work conducted by Helfrich and colleagues34 in studies funded by the 

Centers for Disease Control and Prevention and AHRQ suggest that it is more meaningful to 

examine how knowledge is used to influence changes in organizations and the microsystems of 

care by viewing this as a “fusion versus 

diffusion” process. Level 2 translation of 

research into practice (Figure 3) 

traditionally presumes a unidirectional 

flow or diffusion of information from 

research to practice; this presumption may 

act as a barrier to uptake quite apart from 

the limitations of the evidence base noted 

above. In contrast, a fusion perspective acknowledges shared learning between research and 

practice (i.e., knowledge utilization) whereby each informs the other to advance 

understanding.35, 36 Concomitantly, the source of evidence and how that evidence is packaged 

and communicated greatly influences its use. Active engagement of organizational leaders and 

clinical investigators in the research process, as we propose herein, has proven critical to 

effective fusion/knowledge transfer.13, 15, 37–39 Chapter 7 in this Handbook discusses steps for 

evidence-based practice in greater detail, drawing on Rogers’s6 work and the AHRQ model 

(Figure 3). 

Figure 3. Understanding Roles of Research and 

Practice 

Our review of literature reporting on health care innovations suggests that there are three 

overarching problems to the dissemination of evidence-based innovations: (1) incomplete 

reporting of interventions being implemented, (2) biased literature, and (3) the fact that 

interventions evolve over time as an effort moves through various stages from adoption to 

implementation through institutionalization/routinization. 

Implementation efforts are not fully reported, limiting dissemination and uptake in other 

places. With this limitation in mind, we demonstrated our ability to fully capture all elements of 

complex interventions in a recent study of diabetes management in 15 community-based sites: 

Evaluation of the Robert Wood Johnson Foundation Diabetes Initiative (2003–2005), L.A. 

Savitz, Qualitative Research Director. A key finding from the formative evaluation was the 

breadth and complexity of interventions that evolved as the programs were implemented. Indeed, 

without probing, none of the sites visited had fully reported the breadth of intervention elements 

(ranging from 9 to 37) they developed and were using. 

We have observed that interventions are adapted as they are implemented in varying clinical 

settings and/or for different patient populations. In addition to our understanding of the extent to 

which innovations are underreported and bias in the literature (limiting knowledge transfer), our 

observation that interventions evolve during implementation through institutionalization/ 

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Connecting Quality Improvement & Emergency Preparedness

routinization is important; and we have the tools to monitor such evolution in comparing and 

contrasting a single intervention across multiple clinical sites. 

Generalized Approach for Implementing Quality and Safety 

Interventions 

Basic tenets of quality improvement in health care organizations include the necessity to 

embed and routinize an intervention into the normal work process. From an emergency 

preparedness perspective, this same issue is addressed through the design of dual-use tools and 

technologies. The shared intent is to ensure that an intervention is practiced and available when 

needed (e.g., resuscitation procedures on medical units, personal protective equipment and 

isolation precautions hospital-wide). The construction of such interventions follows a knowledge 

management and decision support model whereby 

• A problem is identified and has visibility with executive management. 

• A clinical champion is identified and a team is formed. 

• The process is flow charted before and after implementation of the intervention so that 

changes in responsibility and resource needs are transparent. 

• Necessary tools to support the change are developed and used (outcomes tracking, built 

into decision support information systems, and education/training materials). 

• Monitoring with feedback is provided to involved staff on a periodic basis for review. 

• Continual detailing of the intervention is recorded for ongoing improvement and 

maintenance. 

While quality improvement in health care has built on the existing evidence base around how 

to manage and guide change, similar evidence is virtually nonexistent in the 

emergency/bioterrorism preparedness literature. Nevertheless, similar strategies for improved 

functioning are observed (e.g., systematically conducting drill exercises with evaluation 

measures for monitoring, feedback, and improvement), and these initiatives would likely benefit 

from the growing implementation science evidence base. 

Specific examples of similar, yet separate, strategic interventions for enhanced functioning 

used in hospital settings include the following: 

• Drilling: Scenario-based event drills are used in both functional areas; for example, 

emergency preparedness drills40–42 and maternity ward eclampsia drills43 have been used 

to train and refresh staff knowledge of key processes and protocols in the event of an 

infrequent yet crisis situation. 

• Training and simulation technology: Skill-based training is deeply rooted in both areas 

with tools developed to support such efforts.44–46 For example, simulation as a training 

and assessment tool has been used at Cornell-Weill, UPMC Wiser Center, and in the 

United Kingdom for intubation training. 

• Triage: This is a common concept used in providing quality health care and in 

emergency response.47, 48 However, a major departure from clinical training for triage 

activities occurs when a health care facility has scarce resources and is overwhelmed by 

the victim load, requiring battlefield triage in which the most likely survivors are treated 

first (i.e., frail elderly and small children may not be the highest priority given their 

vulnerability to succumb).49

• Surveillance: Quality improvement and infection control have long-standing experience 

in conducting surveillance for nosocomial infections, and a growing area in patient safety 

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is targeted injury detection systems. Surveillance systems for bioterrorism have been 

deployed at the health system (e.g., Intermountain Healthcare during the Winter 

Olympics) and regional levels for monitoring select illness and disease patterns to 

mitigate potential events. 

• Performance measurement: Performance measurement in quality improvement is 

currently getting a great deal of attention50 due to the early mantra of leading thinkers like 

Juran—you can’t manage what you can’t measure. Boards are now asking for emergency 

preparedness measures to ascertain comparative readiness.*

As illustrated by these examples, both areas—quality improvement and emergency 

preparedness—are focused on preparedness, and both face the challenge of how to implement 

targeted interventions. As one seeks to implement new programs and interventions in complex 

health care settings, one faces the same challenges associated with adoption, implementation, 

and maintenance of the intervention. Teams in both domains should consistently report both 

successes and failures within their settings and in publications that reach those most likely to use 

such information and be open to understanding how such reports can advance their respective 

work. Further, taking successful quality improvement or emergency preparedness interventions 

and disseminating such promising practices across a health system, a community, and/or to the 

industry is a hurdle at best. 

Generalized Approach to Dissemination and Implementation 

As part of the PAQT work, a committed group of organizational liaison staff was established 

that has worked successfully together on 17 projects in both bioterrorism preparedness and 

quality improvement. This PAQT grant has allowed the investigators to bring staff from partner 

health systems together for in-person meetings to discuss key organizational and care process 

issues, create a community for shared issue identification and learning, and explore the diffusion 

of knowledge within and across integrated delivery systems. In particular, the focus has been to 

study successful bioterrorism preparedness and quality improvement interventions, their 

adoption, and diffusion across the research network, together with identifying synergies across 

quality/safety and emergency preparedness. From the assessment of required implementation in 

the PAQT grant, a six-step strategy to promote cross-system diffusion of learning has been 

identified (Table 1). 

Table 1. Generalized Strategy for Dissemination and Implementation 

“Implementation Science” Learning from Partnership in Advancing Quality Together 

Step 1 Pilot innovation in credible place by a credible clinical champion with an engaged team 

that is empowered with resources. 

Step 2 Create a toolkit or manual that serves as a conduit with audit tool for performance 

monitoring and feedback to involved staff. 

Step 3 Review by adopting organization/unit facilitated by linking agent/clinical champion and 

his/her team. 

Step 4 Adaptation by adopting organization/unit. 

Step 5 Phased implementation: seeding the innovation on a small scale to support minimal 

adaptation and demonstrate value. 

Step 6 Spread; organization-wide diffusion as appropriate. 

 

*

 The American Hospital Association is currently fielding a survey that is intended to generate data that will yield 

comparative results on hospital preparedness. 

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Visibility with facility leadership and a six-step approach have been developed from 

observed implementation efforts over the past 2 years. This generalized approach to 

dissemination and implementation is both evidence- and experience-based, having been used 

successfully in leading partner health systems for both bioterrorism preparedness and quality 

improvement interventions. 

Key among these six steps is the preparation of the training manual (the conduit) and the sitespecific clinical champions (linking agents), which are believed to be essential in accelerating 

innovation diffusion and institutionalization.* The constructs of conduits and linking agents were 

recently conceptualized by Rogers6 within his diffusion of innovation framework and related 

literature. Conduits are those tools or dissemination vehicles developed to facilitate uptake of 

research into practice (i.e., a DVD and companion training manual). Using conduits has been a 

major focus of our applied research and dissemination efforts to date. Linking agents have been 

described both in terms of agencies within a system (e.g., community hospital policies) and 

individuals (e.g., staff nurses implementing guideline recommendations); linking agents are the 

same as opinion leaders/champions or change agents. While the importance of conduits and 

linking agents are separately acknowledged in the change management and quality improvement 

literature, integration of the conduit and linking agent constructs into formal implementation 

planning processes has not been done. 

Practice Implications 

As a hospital addresses quality improvement throughout its operating structure, it should be 

examining all aspects of performance relating to delivering safe and high-quality services to its 

patients in all situations. These quality improvement efforts not only address the day-to-day 

services and functions, but also address the ability to meet those challenges presented during an 

emergency. Institutions should be incorporating evidence-based quality improvement measures 

that build on efforts already in place and begin to build the evidence and experience for 

emergency preparedness that complement these efforts. Maintaining separate structures for these 

activities is not only inefficient, but counterproductive. 

As health care systems institute change management efforts, they should be incorporating 

emergency preparedness initiatives. Health care organizations should address a series of 

emergency preparedness activities and should initiate them within their quality improvement 

framework. For example, if an exercise is conducted to test the emergency preparedness plan, 

meeting one of the performance standards of the Joint Commission accreditation, it should be set 

up within a quality improvement framework. The institutional or unit performance should be 

measured for emergency preparedness using evidence-based tools like the one developed by 

AHRQ.51 This quality improvement strategy—deployed throughout the system to address 

efficiency, effectiveness, and safety/quality—is no different or separate from this one dimension 

of emergency preparedness. As the metric of preparedness performance is measured, focused 

quality improvements can be initiated. 

There is an impressive body of quality improvement literature that can be brought to bear on 

emergency preparedness. However, the literature on the metrics for preparedness and quality 

 

*

 The research evidence for this approach is reviewed in depth in Chapter 7 of this Handbook. 

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improvement is scant and inconclusive.52 Health care organizations on the cutting edge of this 

field are encouraged to report the use of evidence-based tools and piloted quality improvement 

measures in the literature and share their experience with colleagues. It was mentioned earlier in 

this paper that there are few forums that address institutional emergency preparedness measures 

that are initiated within a quality improvement framework. Hospitals and health systems should 

create opportunities for dialogue and shared learning; they should support the development of 

leaders within their organizations who bridge the chasm between the two activities. Nurses are 

well positioned to provide such leadership. The astute manager of these organizations should 

address vital strategies for reorganization that merge these activities and consider the career path 

for clinical leaders within the organization who can participate and provide leadership in the 

planning and evaluation strategies for these innovations. To achieve organizational awareness 

and commitment, the merged mission activities need to be supported though open dialogues and 

structured committee discussions at all levels of the organization affected by emergency 

preparedness. 

The emergency preparedness activities thrust on an organization can either be presented as an 

annoying add-on function that distracts the organization from its primary mission, or they can be 

incorporated into the fabric of the mission and staff roles. The unique exercises and training 

activities required for emergency preparedness could be expanded to incorporate testing and 

evaluating new quality improvement measures. For example, resuscitation competency training 

in the emergency department could easily be incorporated into a drill testing the emergency 

department’s response to an explosive or mass-casualty attack—thereby testing a day-to-day 

activity that can be measured for improvement and instituting remedial training alongside other 

skills and competencies for an effective emergency response. Also, essential in emergency 

preparedness planning are critical functions and strategies that require activities to protect the 

staff and the facility (e.g., avoiding contact with an infectious agent or a contaminant). Strategies 

such as fit testing masks, decontamination procedure, mass prophylaxis of staff and their 

families, and enhanced infection control measures are not unique to emergency preparedness 

and, therefore, are easily accommodated in day-to day-quality improvement, education, and 

training requirements of any health care institution. A good clinical champion from the infectious 

disease department (usually a nurse) can easily translate the interrelatedness of the two functions 

and readily get on board with an integrated approach. 

Research Implications 

This is an exciting and dynamic area in which little is currently known. Nurse leaders, nurse 

researchers and other nurses should and can have a critical role in taking these aforementioned 

concepts and design strategies, building on quality improvement and emergency preparedness 

methods, and demonstrating their effectiveness and impact. High priority should be given to 

developing and testing models that can be generalizable and actionable for clinicians that clearly 

define the roles and impact of nursing leadership. In so doing, the actual process of integrating 

quality improvement and emergency preparedness needs to be clearly delineated so that the 

successes of demonstration projects can be understood and replicated, particularly in preparation 

for unanticipated catastrophic events. 

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Conclusions 

Nursing leadership has the opportunity to use new emergency preparedness evidence- and 

experienced-based measures that are or can be developed and disseminated. To realize this 

integrated approach locally, it is essential to embed interventions into the fabric of work and 

make these efforts visibly present so that staff are perpetually readied for the day-to-day issues of 

improving quality and safety, and the extraordinary issues of an unanticipated catastrophic event. 

With strong mission leadership to merge the two areas structurally and functionally, acceptance 

of valid measures and cross-integration can be achieved. In conclusion, hospital leadership 

should 

1. Recognize the synergies between quality improvement and emergency preparedness, 

providing support, visibility, and performance feedback for these shared functions; 

2. Empower clinical leaders to formally bridge the gap and share knowledge across these 

functional areas; and 

3. Support the evidence base by providing resources to contribute to the literature on 

implementation science that can foster modeling in other facilities and communities. 

Building the evidence base and recognizing the synergies between quality improvement and 

emergency preparedness is vital for the safety of patients in the resource-constrained 

environment in which we provide hospital care. Executive management is challenged to think 

prospectively to connect the dots and take advantage of these synergies to efficiently provide the 

highest quality health care possible to their patients. 

Author Affiliations 

Sally Phillips, Ph.D., R.N., director for Public Health Emergency Preparedness Research, 

Center for Primary Care, Prevention and Clinical Partnerships, Agency for Healthcare Research 

and Quality. E-Mail: Sally.Phillips@ahrq.hhs.gov. 

Ronda G. Hughes, Ph.D., M.H.S., R.N., senior health scientist administrator, Center for 

Primary Care, Prevention and Clinical Partnerships, Agency for Healthcare Research and 

Quality. E-mail: Ronda.Hughes.@ahrq.hhs.gov. 

Lucy A. Savitz, Ph.D., M.B.A., senior associate, Domestic Health, Abt Associates. E-mail: 

Lucy.Savitz@gmail.com. 

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