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.

Implementing the Progression Indicators
One-Pager Guides & Videos

 

Progression Indicators:
An Overview

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In this video, Drs. Bimbola Akintade and Cynthia O'Neal from AACN's Assessment Expert Working Group introduce the progression indicators and how incorporating them into nursing curricula can improve competency assessment strategies.

Clarifying Expectations & Advancing Competency With PIs

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Dr. Mary Fey discusses the importance of aligning descriptive, observable behaviors with the Essentials sub-competencies for student assessment.

Clustering Competencies During Assessment

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Dr. Dana Tschannen provides an overview of how faculty can cluster Essentials competencies to ensure alignment throughout program curricula.

 

Competencies, Sub-competencies, and Progression Indicators Table by Level

Below presents sub-competencies by entry-level and advanced-level, with associated progression indicators. Select a competency from the dropdown to view its corresponding table of developing and developed competence. 

Table Legend:

Level 1: Entry-Level
Level 2: Advanced-Level

  Sub-competency Progression Indicators (Observable Behaviors)
    Developing (Developing Competence) Developed (Competent)
Level 1: Entry-Level 7.1a Describe organizational structure, mission, vision, philosophy, and values.

Explain the organizational structure and key leadership roles within a healthcare setting.

Identify a healthcare organization's mission, vision, philosophy, and values.

Articulate the relationship between an organization’s structure, mission, vision, philosophy, and values, emphasizing their influence on patient care and nursing practice.

Explain how the organizational structure shapes clinical decision-making and interdisciplinary collaboration.

7.1b Explain the relationships of macrosystems, mesosystems, and microsystems. Differentiate among macrosystems, mesosystems, and microsystems within healthcare organizations. Analyze the interactions between these systems to explain their influence on patient care delivery and outcomes.
7.1c Differentiate between various healthcare delivery environments across the continuum of care.

Identify key characteristics of different healthcare environments across the continuum of care.

Define the nurse’s role in ensuring continuity of care during patient transitions.

Analyze how transitions between healthcare settings impact patient outcomes and nursing responsibilities.
7.1d Recognize internal and external system processes that impact care coordination and transition of care.

Identify internal processes and external factors influencing care coordination and patient transitions.

Identify barriers to effective care transitions. 

Evaluate the effectiveness of internal processes in facilitating care coordination and patient transitions.

Propose strategies to address barriers to effective care transitions.

       
Level 2: Advanced-Level 7.1e Participate in organizational strategic planning.

Describe the elements of organizational SWOT (strengths, weaknesses, opportunities, and threats) analysis.

Analyze data and trends relevant to strategic goals within a healthcare organization and summarize findings, linking them to potential strategic initiatives.

Develop and present a strategic plan proposal based on a SWOT analysis, addressing a specific organizational priority using evidence-based practices.

Evaluate the alignment between a healthcare organization’s strategic goals and its mission, vision, and values while identifying opportunities for improvement.

Collaborate with interdisciplinary team members to develop evidence-based strategies to achieve organizational goals.

7.1f Participate in system-wide initiatives that improve care delivery and/or outcomes.

Collaborate with an interdisciplinary team to identify barriers and propose evidence-based solutions for system improvements.

Contribute to designing or evaluating system-wide initiatives to improve care delivery or patient outcomes.

Assess the impact of system-wide initiatives on patient outcomes and organizational performance.

Communicate the outcomes of system-wide initiatives to stakeholders, emphasizing their impact on care quality.

Integrate evidence-based practices into system-wide initiatives to ensure alignment with organizational goals and standards of care.

7.1g Analyze system-wide processes to optimize outcomes.

Utilize data analytics to assess the effectiveness of system-wide processes in patient care and organizational performance.

Propose evidence-based strategies to enhance the efficiency and effectiveness of system-wide processes.

Conduct a comprehensive analysis of a system-wide process to identify gaps and recommend optimization strategies.

Evaluate the impact of implemented changes on system-wide processes, patient outcomes, and organizational performance.

Collaborate with interdisciplinary team members to implement improved system-wide processes, ensuring alignment with evidence-based practices and optimizing outcomes.

7.1h Design policies to impact health equity and structural racism within systems, communities, and populations. Analyze institutional, state, and federal policies for their impact on health equity.

Develop policy proposals aimed at eliminating structural barriers and improving equitable healthcare delivery.

Present policy proposals to stakeholders to advocate for systemic change.

Engage in policymaking at the organizational or governmental level to promote health equity and social justice in healthcare.

Table Legend:

Level 1: Entry-Level
Level 2: Advanced-Level

  Sub-competency Progression Indicators (Observable Behaviors)
    Developing (Developing Competence) Developed (Competent)
Level 1: Entry-Level 7.2a Describe the financial and payment models of health care.

Identify key financial concepts in healthcare.

Describe basic insurance coverage principles and their role in patient access to care.

Explain how different payment models shape care delivery.
7.2b Recognize the impact of health disparities and social determinants of health on care outcomes.

Identify how social determinants of health contribute to disparities in patient outcomes.

Describe the relationships between social and environmental factors and their influence on health status among populations.

Articulate patients’ unique circumstances, demonstrating sensitivity to how social determinants affect health and access to care.


Integrate knowledge of health disparities into patient assessments and care planning.
7.2c Describe the impact of healthcare cost and payment models on the delivery, access, and quality of care.

Describe basic payment models and their influence on healthcare access and quality.

Identify how cost considerations affect care delivery and patient outcomes.


Analyze how payment models influence nursing practice, patient outcomes, and healthcare access.
7.2d Explain the relationship of policy, regulatory requirements, and economics on care outcomes.

Identify fundamental healthcare policies and regulations that influence nursing practice and patient care.

Articulate how economic factors interact with policies to shape patient access and health outcomes.

Describe examples of how regulatory requirements affect care delivery processes within clinical settings.


Describe the intersection of policy, regulation, and economics, evaluating their impact on resource allocation, patient care quality, safety, and outcomes.
7.2e Incorporate considerations of efficiency, value, and cost in providing care.

Describe the importance of efficiency, resource utilization, and value in patient care while identifying cost-saving strategies that maintain quality outcomes.

Explore how evidence-based practices contribute to high-value care by optimizing resource use and improving efficiency.    

Assess the impact of cost and efficiency in nursing care delivery and provide alternatives during care planning.
7.2f Identify the impact of differing system structures, leadership, and workforce needs on care outcomes. Identify workforce needs within clinical settings and their impact on care coordination and patient outcomes.

Analyze how leadership styles and team dynamics influence safe, effective care delivery.

Explain how system-level structures affect the quality and consistency of patient care.

       
Level 2: Advanced-Level 7.2g Analyze relevant internal and external factors that drive healthcare costs and reimbursement.

Examine key internal factors that impact healthcare costs.

Identify external cost drivers and explain how they influence healthcare costs and reimbursement.

Examine the interplay between cost drivers and reimbursement models.

Synthesize data from organizational reports or policy analyses to assess the influence of internal and external factors on financial outcomes and healthcare quality.

Apply knowledge of cost drivers to advocate for strategies that improve efficiency and reimbursement rates while maintaining quality healthcare.

7.2h Design practices that enhance value, access, quality, and cost-effectiveness.

Explore evidence-based practices that improve healthcare quality and patient outcomes while addressing cost considerations.

Identify barriers to access and equity within healthcare systems and consider potential solutions.

Propose strategies to enhance value and cost-effectiveness.

Adopt care models, workflows, or processes that prioritize value, quality, and efficiency through evidence-based approaches.

Prioritize interventions supported by research and best practices.

Evaluate, redesign, and refine practices to improve cost-effectiveness and care quality.

7.2i Advocate for healthcare economic policies and regulations to enhance value, quality, and cost effectiveness.

Identify key healthcare policies and regulations that impact cost, quality, and value in healthcare delivery.

Explore advocacy strategies and participate in discussions regarding economic policy changes.

Advocate for policy changes that align with evidence-based practices and improve cost-effectiveness and value in care delivery.

Engage with organizations and healthcare professionals to support policies that enhance quality and equity.

Evaluate proposals addressing economic challenges within healthcare delivery systems.

7.2j Formulate, document, and disseminate the return on investment for improvement initiatives collaboratively with an interdisciplinary team.

Explore methods for calculating return on investment (ROI) using fundamental tools and metrics in quality improvement projects.

Contribute to discussions regarding ROI and value-based care initiatives.
Draft initial reports documenting outcomes and cost savings from small-scale improvement projects.

Collaborate with interdisciplinary team members to formulate comprehensive ROI analyses for improvement initiatives by integrating financial and clinical outcomes. 

Prepare reports and present findings on ROI, utilizing evidence to advocate for continued investment in high-value initiatives.

7.2k Recommend system-wide strategies that improve cost- effectiveness considering structure, leadership, and workforce needs.

Analyze organizational structures and workforce challenges to identify opportunities for enhancing cost-effectiveness.

Explore leadership strategies that support financial efficiency while maintaining quality standards.

Participate in team discussions on system-level changes to optimize resource utilization and reduce costs.

Recommend strategies that address workforce needs and improve cost-effectiveness across healthcare systems.

Develop proposals for system-wide changes that incorporate evidence-based practices and workforce data.

Collaborate with interdisciplinary teams to implement initiatives that align with financial and quality improvement goals.

7.2l Evaluate health policies based on an ethical framework considering cost-effectiveness, health equity, and care outcomes.


Review health policies through an ethical lens, focusing on their impact on cost-effectiveness and patient care.

Participate in discussions on health equity, analyzing how policies address disparities in access and outcomes.

Evaluate health policies for alignment with ethical principles, cost-effectiveness, and equity in care delivery.

Develop policy recommendations that address gaps in health equity and improve patient outcomes.

Collaborate with stakeholders to advocate for ethically sound policies that optimize care delivery.

Table Legend:

Level 1: Entry-Level
Level 2: Advanced-Level

  Sub-competency Progression Indicators (Observable Behaviors)
    Developing (Developing Competence) Developed (Competent)
Level 1: Entry-Level 7.3a Demonstrate a systematic approach for decision-making.

Collect appropriate patient-specific information from health information systems to inform clinical decision-making.

Articulate pertinent patient information and align it with evidence-based practices to justify clinical decisions.

Apply patient-specific information from health information systems to guide clinical decision-making in practice.

Utilize structured tools or frameworks to support clinical reasoning and ensure evidence-based practice.

7.3b Use reported performance metrics to compare/monitor outcomes.

Identify standard healthcare quality metrics.

Demonstrate the ability to locate and interpret outcome data.

Evaluate the effectiveness of nursing care interventions using specific quality metrics.

Incorporate quality metrics into plans of care to monitor trends and compare outcomes over time.

7.3c Participate in evaluating system effectiveness

Identify areas of system performance that impact patient care outcomes based on evidence-based practice guidelines.

Propose preliminary ideas for addressing identified gaps using evidence-based practices.

Use evidence-informed practice guidelines to assess system-level impact on patient outcomes and care processes.

Analyze and interpret system-level performance metrics at the unit level to assess effectiveness of evidence-based interventions.

7.3d Recognize internal and external system processes and structures that perpetuate racism and other forms of discrimination within health care.

Identify examples of structural or systemic racism and discrimination in healthcare settings.

Reflect on and discuss personal experiences or observed practices in clinical settings that contribute to inequities in healthcare delivery.


Identify actionable, evidence-informed recommendations to address systemic inequities in healthcare.
       
Level 2: Advanced-Level 7.3e Apply innovative and evidence-based strategies focusing on system preparedness and capabilities.

Conduct a needs assessment to identify gaps in system preparedness and capabilities.

Review and critique current organizational policies or protocols on emergency preparedness and system resilience using evidence-based frameworks.

Propose initial strategies for improving system capabilities based on evidence from recent literature or guidelines.

Design innovative, evidence-based strategies to enhance system preparedness and capabilities in response to complex healthcare challenges.

Integrate interdisciplinary perspectives to develop robust preparedness plans.

Evaluate the effectiveness of preparedness interventions by analyzing outcome metrics and providing actionable feedback for improvement.

7.3f Design system improvement strategies based on performance data and metrics.

Access and interpret organizational performance metrics.

Analyze trends in performance data to identify opportunities for improvement.

Develop and present a plan for system improvements using organizational performance data and evidence-based methodologies.

Utilize performance metrics to monitor the effectiveness of implemented strategies and modify interventions as needed.

7.3g Manage change to sustain system effectiveness.

Identify internal and external factors that influence the success of change initiatives.

Collaborate with stakeholders to foster support for change initiatives and enhance system effectiveness using evidence-based strategies.

Utilize change management frameworks to design interventions that enhance clinical practice.

Develop a comprehensive change management strategy to address system issues, ensuring alignment with organizational goals and evidence-based practices.

Implement evaluation processes to monitor the impact of change initiatives on system effectiveness using performance data and metrics.

Develop strategies to sustain successful changes and ensure long-term 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.

Analyze performance metrics, health outcomes data, and organizational policies to identify areas where systemic inequities, structural racism, or discrimination exist.

Appraise literature on interventions designed to reduce disparities and discrimination within healthcare systems.

Address identified inequities by incorporating evidence, stakeholder perspectives, and feedback to refine improvement strategies.

Develop a system improvement plan targeting processes and structures that perpetuate inequities in healthcare.

Evaluate the outcomes of implemented strategies using performance metrics and patient outcome data.

Promote a culture of continuous improvement by identifying areas for further intervention and sustaining successful initiatives through system-wide policies.