Domain 7: Systems-Based Practice

Descriptor: Responding to and leading within complex systems of health care. Nurses effectively and proactively coordinate resources to provide safe, quality, and equitable care to diverse populations.

Contextual Statement: Using evidence-based methodologies, nurses lead innovative solutions to address complex health problems and ensure optimal care. Understanding of systemsbased practice is foundational to the delivery of quality care and incorporates key concepts of organizational structure, including relationships among macro-, meso-, and microsystems across healthcare settings. Knowledge of financial and payment models relative to reimbursement and healthcare costs is essential. In addition, the impact of local, regional, national, and global structures, systems, and regulations on individuals and diverse populations must be considered when evaluating patient outcomes. As change agents and leaders, nurses possess the intellectual capacity to be agile in response to continually evolving healthcare systems, to address structural racism and other forms of discrimination, and to advocate for the needs of diverse populations. Systems-based practice is predicated on an ethical practice environment where professional and organizational values are aligned, and structures and processes enable ethical practice by all members of the institution.

Integrated healthcare systems are highly complex, and gaps or failures in service and delivery can cause ineffective, harmful outcomes. These outcomes also span individual through global networks. Cognitive shifting from focused to big picture is a crucial skill set. Similarly, the ability for nurses to predict change, employ improvement strategies, and exercise fiscal prudence are critical skills. System awareness, innovation, and design also are needed to address such issues as structural racism and systemic inequity.

Entry-Level Domain 7 Competencies

7.1 Apply knowledge of systems to work effectively across the continuum of care.

  • 7.1a Describe organizational structure, mission, vision, philosophy, and values.
     
  • 7.1b Explain the relationships of macrosystems, mesosystems, and microsystems.
     
  • 7.1c Differentiate between various healthcare delivery environments across the continuum of care.
     
  • 7.1d Recognize internal and external system processes that impact care coordination and transition of care.

7.2 Incorporate consideration of cost-effectiveness of care.

  • 7.2a Describe the financial and payment models of health care.
     
  • 7.2b Recognize the impact of health disparities and social determinants of health on care outcomes.
     
  • 7.2c Describe the impact of healthcare cost and payment models on the delivery, access, and quality of care.
     
  • 7.2d Explain the relationship of policy, regulatory requirements, and economics on care outcomes.
     
  • 7.2e Incorporate considerations of efficiency, value, and cost in providing care.
     
  • 7.2f Identify the impact of differing system structures, leadership, and workforce needs on care outcomes.

7.3 Optimize system effectiveness through application of innovation and evidence-based practice.

  • 7.3a Demonstrate a systematic approach for decision-making.
     
  • 7.3b Use reported performance metrics to compare/monitor outcomes.
     
  • 7.3c Participate in evaluating system effectiveness.
     
  • 7.3d Recognize internal and external system processes and structures that perpetuate racism and other forms of discrimination within health care.

Advanced-Level Domain 7 Competencies

7.1 Apply knowledge of systems to work effectively across the continuum of care.

  • 7.1e Participate in organizational strategic planning.
     
  • 7.1f Participate in system-wide initiatives that improve care delivery and/or outcomes.
     
  • 7.1g Analyze system-wide processes to optimize outcomes.
     
  • 7.1h Design policies to impact health equity and structural racism within systems, communities, and populations.

7.2 Incorporate consideration of cost-effectiveness of care.

  • 7.2g Analyze relevant internal and external factors that drive healthcare costs and reimbursement.
     
  • 7.2h Design practices that enhance value, access, quality, and cost-effectiveness.
     
  • 7.2i Advocate for healthcare economic policies and regulations to enhance value, quality, and costeffectiveness.
     
  • 7.2j Formulate, document, and disseminate the return on investment for improvement initiatives collaboratively with an interdisciplinary team.
     
  • 7.2k Recommend system-wide strategies that improve cost- effectiveness considering structure, leadership, and workforce needs.
     
  • 7.2l Evaluate health policies based on an ethical framework considering cost-effectiveness, health equity, and care outcomes.

7.3 Optimize system effectiveness through application of innovation and evidence-based practice.

  • 7.3e Apply innovative and evidence-based strategies focusing on system preparedness and capabilities.
     
  • 7.3f Design system improvement strategies based on performance data and metrics.
     
  • 7.3g Manage change to sustain system effectiveness.
     
  • 7.3h Design system improvement strategies that address internal and external system processes and structures that perpetuate structural racism and other forms of discrimination in healthcare systems.