Brilliant, Simple & Effective Concept in Nursing Teams for Improving Patient Safety! Community of CompetenceTM:

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by Matthew C. Mireles, Ph.D., MPH and Elizabeth A. Smith, Ph.D.                    Community Medical Foundation for Patient Safety

Concept and Meaning of Community

Man has always lived and worked in some form of group or social network.  The forces driving group formation range from safety and survival in primitive, hostile environments to socialization at work.  We all belong to many communities, whether at home, work, school, or elsewhere.  We all want to belong to a community that recognizes, accepts, and appropriately rewards our skills, abilities, knowledge, and unique talents or competencies.  Being valued by peers is the greatest reward of all.

Smith linked “community” and competence” and created a new organizational model she trademarked Community of Competence (Smith 2005).  Major theories and concepts in socialization, self-organizing systems, systems thinking, creativity, group dynamics, and learning are embedded in our problem-solving model. A Community of CompetenceTM (CC) is defined as ” … a new framework and method to describe, assess, and combine separate strengths and core competences of individuals, groups, and organizations into a meaningful, goal-oriented whole” (Smith 2005 & 2006).  The word “community” is rapidly becoming a metaphor for the word “organization”.

Improving Patient-Caregiver Communication and Relationships

Our purpose is to describe and illustrate how a unique Community of Nurses identified a prime  health care concern and worked cohesively to achieve a simple solution by creating our two-page Patient Safety Checklist©.

Five years ago, the framework and methods of CC were used to: 1) address the problem of how to help patients better prepare for their medical appointments, 2) facilitate more effective, two-way communication between patients and caregivers, and 3) improve relationships between patients and caregivers.  Nurses, as the primary caregivers to patients, have the most contact with patients and possess the most useful clinical information for patient care.  Due to steadily growing demands on nurses and patient-caregiver time, true patient-relationships are often minimized.  Inadequate patient assessment at the beginning of an appointment is an increasing concern, particularly when important family and medical history is needed for accurate diagnosis and prognosis.

The Community of Nurses representing several schools of nursing convened to discuss this concern and develop a strategy based on CC to better prepare patients and families for a medical appointment.  Our coordinator or convener communicated with all group members using email, telephone, and face-to-face meetings. Each member was asked to: 1) use clear, concise communication and adequately define and prioritize concerns in nursing in ways that specify how this community may derive an effective solution to a problem based on consensus (Smith 2010), and 2) determine how to evaluate or measure the impact and outcome of their proposed solution.

During a two-week period, nurses: 1) defined the scope and nature of the problem, 2) created a realistic action plan, 3) communicated with their own group members and with other knowledgeable people and experts, not necessarily nurses, 4) produced and circulated several drafts electronically, 5) modified, and returned the draft to all members, and 6) finalized the two-page checklist by telephone.  The resulting Patient Safety Checklist for a Medical Appointment is attached.   This checklist has been widely distributed in the U.S. and Canada among various health practitioners.

Safety checklists are important reminders and tools to accomplish specific procedures or a sequence of tasks.  With greater focus on safety and quality as outcomes of health care, checklists have become more routine.  Our Community of Nurses explored the need of a Patient Safety Checklist© for patients and families and demonstrated that a simple Checklist can be used by non-healthcare professionals to enhance communication and patient engagement.  This Checklist serves as an effective reminder for patients to recall and record their medical history, family history, list of medications, purpose of the appointment, and other important information.  Many clinics use this Checklist as the face sheet in the medical chart.  The Checklist provides a focal point of discussion during the appointment and increases the comfort and trust between the patient and the caregiver.

Patients, as the only true customers of healthcare, are always the prime focus of the CC.  For example, the superordinate or common goal defined by a consensus of all communities within our CC, is to achieve a true patient-centered healthcare system and practice. The efforts and enthusiasm of the Community of Nurses helped create our first Patient Safety Checklist© (Mireles, 2005).  In the above diagram of the CC (Smith & Mireles, 2010a), the outer boundary represents the cyclic, market-driven environment. The inner boundary should, but not always, represents a positive, supportive organizational culture.  Each of the 11 communities surrounding the patient has five to ten members, totaling more than 80 members. In the past five years, various communities shown above have worked on many diverse patient safety projects and created more than 55 Patient Safety Checklists.

Conclusions and Recommendations

CC is proposed as a new organizational model to address and develop realistic, cost-effective solutions to simple … complex problems. Content experts can work together productively by sharing scarce financial resources and streamlining their efforts.

Working in a finely tuned, intact, motivated community of competent members who clearly defined and understand their goal is far superior to many forms of traditional work groups.  To illustrate, the quality of the products or services created is greatly enhanced when individuals of proven competence collaborate to achieve a valued goal that no individual could achieve alone.

CC is also presented as a new form of work group having more flexibility and focus than traditional work groups. Our Community of Nurses who created the Patient Safety Checklist© clearly demonstrated the utility and practicality of CC.


Mireles M.C. (2005).  The patients in patient safety.  Patient Safety and Quality Healthcare, March/April, 2(2): 21-26.

Smith, E.A. (2005).  Communities of Competence: New Resources in the Workplace, Journal of Workplace Learning, Special Edition, Vol. 17, No. 1/2, 7-23.

Smith, E.A. (2006).  Communities of Competence as Catalysts for Change.  The 2006 Annual: Consulting, San Francisco:  Jossey-Bass/Pfeiffer, 111-129.

Smith, E.A. (2010, 1st Ed.).  The Dictionary of Patient Safety. Community Medical Foundation for Patient Safety, Houston, TX, 130 pages.

Smith, E.A. & Mireles, M.C. (2010a).  Community of CompetenceTM: background theory and concepts – part I.  Clinical Governance: An International Journal, Vol. 15, No. 3, 220-229.

Smith, E.A. & Mireles, M.C. (2010b).  Community of CompetenceTM: application of a neworganizational concept to health care – part II. Clinical Governance: An International Journal. (In press, to be published in November 2010.)
Elizabeth A. Smith, Ph.D.

Dr. Smith, Founder of Community Medical Foundation for Patient Safety, has a B.A. in psychology, University of Alberta, Canada and M.A. and Ph.D. degrees in human factors, University of Wyoming.  She has more than 35 years experience in business, academic teaching, and research, including 15 years in health care.  Dr. Smith has authored six books and more than 45 peer-reviewed articles in healthcare, psychology, and business.  Graduate level course taught are in organizational theory and behavior, organizational development, and productivity at Rice University, University of Houston Clear Lake, Houston Baptist University, and the Air Force Institute of Technology, F.E. Warren Air Force Base.  She is a longstanding member of Sigma Xi, the Scientific Research Society.


Matthew C. Mireles, Ph.D., M.P.H.

Dr. Mireles, President and CEO of Community Medical Foundation for Patient Safety, has a B.S. in biomedical engineering, Texas A & M University, College Station, Texas and M.P.H. and Ph.D. degrees in Public Health, University of Texas Health Science Center, School of Public Health, Houston, Texas.  Work experience includes clinical engineering at a large teaching hospital and flight training with the U.S. Navy.  His research interests are in injury and occupational epidemiology, emergency medicine, human factors and performance, and patient safety.  Dr. Mireles is widely published in injury epidemiology, clinical engineering, and public health. He holds a faculty appointment at the Center for International Studies, University of St. Thomas, Houston, Texas.  He also is the President of the Rice University-Texas Medical Center Chapter of Sigma Xi, the Scientific Research Society.

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