Chapter 20b. [Vignette] Who Should Lead the Patient 

Quality/Safety Journey? 

Joanne Disch

Batalden and colleagues1 remind us that improving quality and safety for patients and 

families requires leaders to lead—and that the words leader, leading, and leadership stem from 

laitho or laithan, meaning “way,” “journey,” or “to travel.”2, 3 Much has been written about the 

need for and characteristics of leadership for this journey.4–8 This section challenges Chief Nurse 

Executives (CNEs) to lead the journey and highlights how patients, their families, and health 

care organizations would benefit immeasurably if CNEs stepped forward and accepted this 

leadership role. There are many examples across the country where this has been exquisitely 

demonstrated. 

The CNE should lead the journey because the nursing profession has been at the forefront of 

assuring quality and safety. Before the first Institute of Medicine study,9

 or the Chicago Tribune

article with the headline “Nursing Mistakes Kill Thousands,”10 or the National Patient Safety 

Foundation, or the Institute for Healthcare Improvement, there were nurses at all levels in 

hospitals and health care organizations concerned about patient safety and quality of care. For 

decades, nursing leaders like Marie Zimmer and Norma Lang have developed and tested quality 

indicators. For generations, nurses have taken seriously their Code of Ethics and their role as one 

who “promotes, advocates for, and strives to protect the health, safety and rights of the 

patient.”11 Florence Nightingale reminded us that “the very first requirement in a hospital [is] 

that it should do the sick no harm”12—and proceeded to set up systems and practices that are still 

being used today to enhance the quality and safety of patient care. 

The CNE should lead the journey because nurses understand what the issues are. While many 

physicians, administrators, policymakers, and others have come to realize only recently that 

health care is frighteningly unsafe, nurses have been raising concerns for many years. Nurses do 

not need to be alerted to the dangers of malfunctioning equipment, or the likelihood of 

medication error when getting medications ready and being interrupted 16 times, or the safety 

threat when orientation to the new computer system is inadequate, or the potential for serious 

injury to the patient and self when struggling to lift a 287 pound patient. Nurses are there 24/7 

and, through the nursing lens, recognize the system issues, dangerous shortcuts, work-arounds, 

and waste. 

The CNE should lead the journey because nurses have workable solutions. We recognize the 

problems, and we also have solutions. We blend practical wisdom with scientific knowledge and 

finely-honed interpersonal skills or, as a Boston cab driver once noted, we’re “caring, shrewd, 

and a little bit crazy.” We see the big picture and the details—the interconnectedness among 

departments and professions. We understand everything that needs to be done to complete the 

job, whatever it is. We are holistic—whether it be caring for a patient in the context of family, or 

coming up with a solution to a problem that incorporates the concerns of everyone involved. And 

nurses are resourceful. Who else can coordinate the administration of three antibiotics, two units 

of packed cells, and four units of platelets; cajole the pharmacist to bring up a missing drug; hunt 

down the needed blood filter, extra IVAC, flexicare mattress, cardiac chair for a wife; and find a 

nurse to work an extra 12-hour shift for nights—all within an 8-hour period? 

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Patient Safety and Quality: An Evidence-Based Handbook for Nurses

As leaders within their organizations, CNEs have the background, perspective, and platform 

to help their organizations seriously tackle safety issues that jeopardize patient care and that face 

nurses and their colleagues daily. They can 

• Create a healthy culture that promotes safety, inquiry, continuous learning, and 

collaboration. 

• Design systems and processes that help people do their best work and deliver quality care 

(safe, timely, effective, efficient, equitable, patient-centered). 

• Acquire and align resources to get the work done and achieve organizational goals. 

• Assure the existence of a professional practice environment that values evidence as a 

basis for decisionmaking and the ongoing development of everyone. 

• Implement quality and safety programs that are effective, supported, embedded in the 

culture, and get the job done. 

What Are the Barriers to CNEs Taking on This 

Particular Leadership Journey? 

Barriers can exist at the organizational or individual level. These include 

• Organizations that rely on hierarchical structures with a traditional complement of 

leaders, and that sustain a culture that resists change and blames individuals for system 

failures. 

• Organizational leaders who impose arbitrary solutions and/or weigh financial 

imperatives more heavily than quality/safety concerns.

• CNEs themselves who retreat behind balance sheets and abdicate their role as senior 

patient care officers and architects for a truly professional practice environment for 

nurses. 

In addition, a number of other factors make this journey difficult, such as a lack of resources, 

insufficient time, pressures from competing priorities, and the complexity of the health care 

system.

Evidence and Collaboration Will Enable This 

Journey To Be Taken Successfully 

• Evidence that clearly outlines strategies that improve safety and quality while using 

reasonable levels of resources. The idea that quality is more expensive is wrong, and 

more is not always better, e.g., when patients get extra doses of medications, or two xrays when one is ordered, or extra days in the intensive care unit when transfer orders are 

held up. CNEs can extract excellent, evidence-based strategies from this book and build 

the business, legal, and ethical case for safety and quality. 

• Collaboration among nurses, physicians, other care providers, staff, boards of trustees, 

and organizational leaders who share a passion and commitment for a safer health care 

experience. The vast majority of individuals in health care want to collaborate, but don’t 

always know how to do it. Most often, the CNE has the knowledge, perspective, and 

aptitude to skillfully bring people together to achieve common goals— in this case, 

quality and safety for patients, their families, and caregivers. 

2 
[Vignette] Who Should Lead for Quality/Safety?

Author Affiliations 

Joanne Disch, Ph.D., R.N., F.A.A.N., Clinical Professor and Director, Katharine J. Densford 

International Center for Nursing Leadership and Katherine R. and C. Walton Lillehei Chair in 

Nursing Leadership, University of Minnesota School of Nursing; e-mail: disch003@umn.edu. 

References

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Microsystems in health care: Part 5. How leaders 

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