Date of Award


Degree Name

PhD Nursing

Dissertation Committee

Linda D. Urden, DNSc, RN, CNS, NE-BC, FAAN, chairperson; Ann M. Mayo, RN, DNSc, FAAN; Laurie Ecoff, PhD, RN, NEA-BC


Hospital-Acquired Conditions, Hospital Quality, Hospital Safety, Never Events, Performance Improvement


Preventable medical errors in hospitals cost our nation an estimated 180,000 annual deaths and tens of billions of dollars. The Patient Protection and Affordable Care Act mandated improvements in quality and patient safety. The Centers for Medicare and Medicaid Services, acting on these imperatives initiated legislation-mandated programs halting reimbursement to hospitals for specific hospital-acquired conditions (HAC) coined as Never Events. To date, studies have focused on quantifying incidence of specific HAC and assessing policy impact without correlating findings to actual outcome performance. The purpose of this study was to develop an understanding of organizational, contextual, process, and other factors occurring in hospitals performing in the top decile on HAC measures.

Top decile performing hospitals in California were strategically targeted after analysis and sorting of HAC data publicly reported on the Medicare’s Hospital Compare website. From this group, three hospitals were targeted based on characteristics accounting for potential differences in systems factors. Key informants identified by the Chief Nursing Officer were interviewed and data constantly compared and analyzed using and open, focused, and theoretical coding. Grounded Theory tenets further provided the basis for development an emergent theoretical model enlightening factors related to best outcomes.

The model revealed three major interacting themes of Getting on Board with Why, Coming Together for How, and Getting Consistent with What to assist in understanding what happened in hospitals keeping patients most safe from HACs. Circumstances of defining the why, championing the why, and selling the why produced a dynamic state of Getting on Board with Why to focus on patient safety and quality. What happened in Coming Together for How to get there from here was identified as uniting, identifying and unlocking key drivers, and mobilizing resources. Participants also described standardizing, ensuring compliance, managing data and messages, and continuing as leading to Getting Consistent with What needed to happen. Implications for nursing practice and education included improving quality of patient outcomes, care coordination, and innovative partnerships. The findings potentially present a new road map for strategically covering performance improvement in HAC avoidance including what should be happening and what processes can assist.

Document Type

Dissertation: Open Access



Included in

Nursing Commons