{"id":202,"date":"2021-08-30T15:39:11","date_gmt":"2021-08-30T15:39:11","guid":{"rendered":"https:\/\/pressbooks.ccconline.org\/accnursing2030\/chapter\/9-3-measuring-and-improving-quality\/"},"modified":"2025-02-18T18:43:03","modified_gmt":"2025-02-18T18:43:03","slug":"9-3-measuring-and-improving-quality","status":"publish","type":"chapter","link":"https:\/\/pressbooks.ccconline.org\/accnursing2030\/chapter\/9-3-measuring-and-improving-quality\/","title":{"raw":"9.3 Measuring and Improving Quality","rendered":"9.3 Measuring and Improving Quality"},"content":{"raw":"Now that we have discussed the various ways that quality health care is defined, let\u2019s discuss how quality care is measured, evaluated, and improved.\n<h2>Utilization Review<\/h2>\nThinking back to value-based reimbursement models discussed in the \u201c<a href=\"https:\/\/pressbooks.ccconline.org\/accnursing2030\/chapter\/8-1-economics-introduction\/\" target=\"_blank\" rel=\"noopener\">Health Care Economics<\/a>\u201d chapter, recall how health care agencies are reimbursed from Medicare, Medicaid, and private insurance based on their quality performance measures. A <strong>[pb_glossary id=\"448\"]utilization review[\/pb_glossary]<\/strong> is an investigation of health care services performed by doctors, nurses, and other health care team members to ensure money is not wasted covering unnecessary or inefficient expenditures for proper treatment. Utilization review also allows organizations to objectively measure how their health care services and resources are being used to best meet their clients\u2019 needs. Information from clients\u2019 medical records is analyzed, along with client demographics, to evaluate resource allocation, efficiency, and quality of health promotion initiatives.<sup>[footnote]Institute of Medicine (US) Committee on Utilization Management by Third Parties, Gray, B. H., &amp; Field, M. J., (Eds.). (1989). <em>Controlling costs and changing patient care? The role of utilization management.<\/em> National Academies Press. <a href=\"https:\/\/www.ncbi.nlm.nih.gov\/books\/NBK235000\" target=\"_blank\" rel=\"noopener\">https:\/\/www.ncbi.nlm.nih.gov\/books\/NBK235000<\/a>[\/footnote]<\/sup> See Figure 9.3<sup>[footnote]\u201c<a href=\"https:\/\/commons.wikimedia.org\/wiki\/File:Analyzing_Financial_Data_(5099605109).jpg\" target=\"_blank\" rel=\"noopener\">Analyzing_Financial_Data_(5099605109).jpg<\/a>\u201d by <a href=\"https:\/\/www.flickr.com\/people\/37387065@N05\" target=\"_blank\" rel=\"noopener\">Dave Dugdale<\/a> is licensed under <a href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/2.0\/deed.en\" target=\"_blank\" rel=\"noopener\">CC BY-SA 2.0<\/a>[\/footnote]<\/sup> for an illustration of utilization review related to costs.\n\n[caption id=\"attachment_201\" align=\"aligncenter\" width=\"459\"]<img class=\"wp-image-913 \" title=\"\u201cAnalyzing_Financial_Data_(5099605109).jpg\u201d by Dave Dugdale is licensed under CC BY-SA 2.0\" src=\"https:\/\/pressbooks.ccconline.org\/accphysicalgeology\/wp-content\/uploads\/sites\/225\/2021\/08\/Analyzing_Financial_Data_5099605109-1-scaled-1.jpg\" alt=\"Photo showing closeup of hand holding pen over expense sheet, with calculator to side\" width=\"459\" height=\"306\"> Figure 9.3 Utilization Review[\/caption]\n<h2>Using Informatics to Promote Quality<\/h2>\nUtilization review relies on the collection of meaningful data from health records to determine if quality metrics are being met. <strong>[pb_glossary id=\"449\"]Informatics[\/pb_glossary]<\/strong> refers to using information and technology to communicate, manage knowledge, mitigate error, and support decision-making.<sup>[footnote]QSEN Institute. (n.d.). <em>QSEN competencies: Quality improvement (QI).<\/em> <a href=\"https:\/\/qsen.org\/competencies\/pre-licensure-ksas\/#quality_improvement\" target=\"_blank\" rel=\"noopener\">https:\/\/qsen.org\/competencies\/pre-licensure-ksas\/#quality_improvement<\/a>[\/footnote]<\/sup>\u00a0Informatics allows members of the health care team to share, store, and analyze health-related information. Nurses have an important role in informatics. <strong>[pb_glossary id=\"450\"]Nursing informatics[\/pb_glossary]<\/strong> is the science and practice of integrating nursing knowledge with information and communication technologies to promote the health of people, families, and communities worldwide.<sup>[footnote]AMIA. (n.d.). <em>Informatics: Research and practice.<\/em> <a href=\"https:\/\/amia.org\/about-amia\/why-informatics\/informatics-research-and-practice\" target=\"_blank\" rel=\"noopener\">https:\/\/amia.org\/about-amia\/why-informatics\/informatics-research-and-practice<\/a>[\/footnote]<\/sup> It is a nursing specialty with certification available from the ANCC. See Figure 9.4<sup>[footnote]\u201c<a href=\"https:\/\/pixabay.com\/ko\/illustrations\/%ec%a0%95%eb%b3%b4%ed%95%99-%ea%b8%b0%ec%88%a0-%ec%a0%95%eb%b3%b4-%ec%84%9c%eb%b9%84%ec%8a%a4-1322241\/\" target=\"_blank\" rel=\"noopener\">informatics-1322241_1920.jpg<\/a>\u201d by <a href=\"https:\/\/pixabay.com\/ko\/users\/mariojsantos-2351841\/\" target=\"_blank\" rel=\"noopener\">mariojsantos<\/a> at <a href=\"http:\/\/Pixabay.com\" target=\"_blank\" rel=\"noopener\">Pixabay.com<\/a> is licensed under <a href=\"https:\/\/creativecommons.org\/share-your-work\/public-domain\/cc0\/\" target=\"_blank\" rel=\"noopener\">CC0<\/a>[\/footnote]<\/sup> for an artistic rendition of informatics.\n\n[caption id=\"attachment_201\" align=\"aligncenter\" width=\"271\"]<img class=\"wp-image-199 \" title=\"\u201cinformatics-1322241_1920.jpg\u201d by mariojsantos at Pixabay.com is licensed under CC0\" src=\"https:\/\/pressbooks.ccconline.org\/accphysicalgeology\/wp-content\/uploads\/sites\/225\/2025\/02\/informatics-1322241_1920-212x300.png\" alt=\"Illustration showing human figure sitting at desk with laptop, a large globe of earth floating above\" width=\"271\" height=\"383\"> Figure 9.4 Informatics[\/caption]\n\nThese are several benefits of using informatics in health care<sup>[footnote]Otokiti, A. (2019). Using informatics to improve healthcare quality. <em>International Journal of Health Care Qual Assurance, 32<\/em>(2), 425-430. <a href=\"https:\/\/doi.org\/10.1108\/ijhcqa-03-2018-0062\" target=\"_blank\" rel=\"noopener\">https:\/\/doi.org\/10.1108\/ijhcqa-03-2018-0062<\/a>[\/footnote]<\/sup>:\n<ul>\n \t<li style=\"font-weight: 400;\"><strong>Improvement of Client Safety:<\/strong> Informatics allows for up-to-date information sharing by both the client and members of the health care team. Using informatics can help to reduce the occurrence of medication errors, as well as monitor client side effects and overall health status. For example, barcode scanning has reduced medication errors by ensuring the correct dose is administered to the correct client at the correct time.<\/li>\n \t<li style=\"font-weight: 400;\"><strong>Reduction of Delays in Care:<\/strong> Some health care informatics systems allow for direct communication between health care team members and clients. The ability to ask and answer questions without needing to schedule an office appointment promotes the ability for care to be delivered efficiently in a cost-effective manner.<\/li>\n \t<li style=\"font-weight: 400;\"><strong>Reduction of Waste:<\/strong> The use of informatics to share information between care team members reduces waste associated with duplication of tests or exams when more than one provider is on the care team. Additionally, clients can request their records be shared with health providers from other health organizations, which reduces duplication and unnecessary spending across the nation.<\/li>\n \t<li style=\"font-weight: 400;\"><strong>Promotion of Client-Centered Care:<\/strong> Many informatics systems have \u201cportal\u201d options where the client and\/or designated personnel are able to be active participants in the care planning and health promotion processes. Informatics offers an inclusive environment for clients to communicate and share directly with their care team regardless of physical location and timing.<\/li>\n \t<li style=\"font-weight: 400;\"><strong>Support of Quality Improvement:<\/strong> The continuous process of quality improvement requires the ability to collect and analyze data in a systematic and reliable manner. Using informatics provides members of the health care team a secure place to store data, as well as the ability to review in a timely manner.<\/li>\n<\/ul>\n<h2>Quality Indicators<\/h2>\nThe National Database of Nursing Quality Indicators (NDNQI) was developed as a national nursing database used to evaluate quality in nursing care. This database was purchased by Press Ganey in 2014. In collaboration with the American Nursing Association (ANA), the original NDNQI database established nurse-sensitive quality indicators such as these<sup>[footnote]Montalvo, I. (2007). The National Database of Nursing Quality Indicators (NDNQI). <em>The Online Journal of Issues in Nursing, 12<\/em>(3). <a href=\"https:\/\/ojin.nursingworld.org\/MainMenuCategories\/ANAMarketplace\/ANAPeriodicals\/OJIN\/TableofContents\/Volume122007\/No3Sept07\/NursingQualityIndicators.aspx\" target=\"_blank\" rel=\"noopener\">https:\/\/ojin.nursingworld.org\/MainMenuCategories\/ANAMarketplace\/ANAPeriodicals\/OJIN\/TableofContents\/Volume122007\/No3Sept07\/NursingQualityIndicators.aspx<\/a>[\/footnote]<\/sup>:\n<ul>\n \t<li style=\"font-weight: 400;\">Nursing Care Hours Per Patient Day<\/li>\n \t<li style=\"font-weight: 400;\">Hospital-Acquired Pressure Injuries<\/li>\n \t<li style=\"font-weight: 400;\">RN Job Satisfaction<\/li>\n<\/ul>\nNurses use quality indicators to support practice changes with evidence directly related to improved client outcomes.\n<div class=\"textbox shaded\"><span class=\"arrow\"> Read about current quality measures promoting clinical excellence at the <a href=\"https:\/\/www.pressganey.com\/industry-initiatives\" target=\"_blank\" rel=\"noopener\">Press Ganey website<\/a>.<\/span><\/div>\n<h2>Quality Improvement<\/h2>\n<strong>[pb_glossary id=\"451\"]Quality Improvement (QI)[\/pb_glossary] <\/strong>is a systematic process using measurable data to improve health care services and the overall health status of clients.<sup>[footnote]Study.com. (n.d.).<em> What is economics? - Definition, history, timeline &amp; importance<\/em> [Video]. <a href=\"https:\/\/study.com\/academy\/lesson\/what-is-economics-definition-history-timeline-importance.html\" target=\"_blank\" rel=\"noopener\">https:\/\/study.com\/academy\/lesson\/what-is-economics-definition-history-timeline-importance.html<\/a>[\/footnote]<\/sup> QI is one of the competencies of the Quality and Safety Education (QSEN) project and defined as, \u201cusing data to monitor the outcomes of care processes and using improvement methods to design and test changes to continuously improve the quality and safety of health care systems.\u201d<sup>[footnote]QSEN Institute. (n.d.). <em>QSEN competencies: Quality improvement (QI)<\/em>. <a href=\"https:\/\/qsen.org\/competencies\/pre-licensure-ksas\/#quality_improvement\" target=\"_blank\" rel=\"noopener\">https:\/\/qsen.org\/competencies\/pre-licensure-ksas\/#quality_improvement<\/a>[\/footnote]\u00a0<\/sup>\n\nThe overall goal of the QI process is to improve the quality and safety of health care. The process of quality improvement is very similar to the nursing process, but its purpose is to answer these three main questions:\n<ul>\n \t<li style=\"font-weight: 400;\">What are we trying to accomplish?<\/li>\n \t<li style=\"font-weight: 400;\">How will we know if a change is an improvement?<\/li>\n \t<li style=\"font-weight: 400;\">What changes can we make that will result in an improvement?<\/li>\n<\/ul>\nSee Figure 9.5<sup>[footnote]\u201c<a href=\"https:\/\/commons.wikimedia.org\/wiki\/File:Model_for_Improvement.jpg\" target=\"_blank\" rel=\"noopener\">Model_for_Improvement.jpg<\/a>\u201d by <a href=\"https:\/\/commons.wikimedia.org\/w\/index.php?title=User:Cliffnorman&amp;action=edit&amp;redlink=1\" target=\"_blank\" rel=\"noopener\">Cliffnorman<\/a> is licensed under <a href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/4.0\/deed.en\" target=\"_blank\" rel=\"noopener\">CC BY-SA 4.0<\/a>[\/footnote]<\/sup> for an illustration of the quality improvement process.\n\n[caption id=\"attachment_201\" align=\"aligncenter\" width=\"301\"]<img class=\"wp-image-200 \" title=\"\u201cinformatics-1322241_1920.jpg\u201d by mariojsantos at Pixabay.com is licensed under CC0\" src=\"https:\/\/pressbooks.ccconline.org\/accphysicalgeology\/wp-content\/uploads\/sites\/225\/2025\/02\/Model_for_Improvement.jpg\" alt=\"Image depicting a model for improvement, with a circle split into four parts and textual labels\" width=\"301\" height=\"414\"> Figure 9.5 Quality Improvement Process[\/caption]\n\nTo answer these questions, QI is a continuous process in which a project is planned, interventions are implemented, data is collected, results are studied, and outcomes are evaluated. The process is repeated after additional planning. During the QI process, four key steps are used to evaluate current client care and determine if changes are needed. These components are referred to as Plan, Do, Study, and Act:\n<ul>\n \t<li style=\"font-weight: 400;\"><strong>Plan:<\/strong> The first step in the QI process is to identify what you will be testing or focusing on and what will be measured. Similar to the nursing process where subjective and objective data are collected, the nurse determines what data will be needed during the QI process. The nurse also determines a timeline for the QI project, such as one year, including a specific framework for when data is collected and when it will be reviewed. For example, fall rates will decrease 10% in one year.<\/li>\n \t<li style=\"font-weight: 400;\"><strong>Do:<\/strong> After the plan is determined, the nurse works with a health care team to implement the project and ensure data collection occurs.<\/li>\n \t<li style=\"font-weight: 400;\"><strong>Study:<\/strong> During this phase, the nurse works with the health care team to review and analyze the data that was collected and determine if the outcomes were achieved or not.<\/li>\n \t<li style=\"font-weight: 400;\"><strong>Act:<\/strong> In the fourth step of the QI process, the team discusses the outcomes. In this step the team identifies barriers, strengths, and weaknesses and then decides if additional changes are needed in nursing practice. The QI process is continuous, so the QI team uses outcome findings to continue the process of Plan, Do, Study, and Act to ensure safe, quality client care.<\/li>\n<\/ul>\n<div class=\"textbox shaded \">\n\n<strong>PDSA Fall Rates Example<\/strong>\n\n<strong>Reducing Client Fall Rates<\/strong>\n\n<strong>Objective:<\/strong> Decrease the client fall rate in the hospital by 10% within one year.\n\n<span style=\"text-decoration: underline;\"><strong>Plan<\/strong><\/span>\n<ol>\n \t<li><strong>Identify the Focus:<\/strong> The QI project will focus on reducing client falls in the hospital.<\/li>\n \t<li><strong>Determine What to Measure:<\/strong> The primary metric will be the fall rate, calculated as the number of falls per 1,000 client days.<\/li>\n \t<li><strong>Collect Data:<\/strong> Baseline fall rates will be collected for the past year to understand current performance.<\/li>\n \t<li><strong>Set Goals:<\/strong> Aim to reduce the fall rate by 10% within one year.<\/li>\n \t<li><strong>Develop a Timeline:<\/strong>\n<ul>\n \t<li><strong>Initial Planning and Baseline Data Collection:<\/strong> Month 1<\/li>\n \t<li><strong>Intervention Implementation:<\/strong> Months 2-4<\/li>\n \t<li><strong>Data Collection and Monitoring:<\/strong> Months 2-12<\/li>\n \t<li><strong>Initial Data Analysis:<\/strong> Month 6<\/li>\n \t<li><strong>Final Data Analysis and Review:<\/strong> Month 12<\/li>\n<\/ul>\n<\/li>\n<\/ol>\n<span style=\"text-decoration: underline;\"><strong>Do<\/strong><\/span>\n<ol>\n \t<li><strong>Implement Interventions: <\/strong>Conduct fall prevention training sessions for all nursing staff. Ensure that client rooms are free from clutter and that non-slip mats are in place. Install bed alarms and provide non-slip socks for clients. Implement a protocol for frequent rounding, especially for high-risk clients.<\/li>\n \t<li><strong>Data Collection:<\/strong> Continuously collect data on fall incidents, including the circumstances of each fall.<\/li>\n<\/ol>\n<span style=\"text-decoration: underline;\"><strong>Study<\/strong><\/span>\n<ol>\n \t<li><strong>Data Analysis: <\/strong>Review the fall rates monthly and compare them to the baseline data. Analyze trends and identify any patterns in the fall incidents. Determine if the interventions are associated with a reduction in fall rates.<\/li>\n \t<li><strong>Outcome Evaluation: <\/strong>Assess whether the goal of a 10% reduction in fall rates is being met. Identify any unexpected outcomes.<\/li>\n<\/ol>\n<span style=\"text-decoration: underline;\"><strong>Act<\/strong><\/span>\n<ol>\n \t<li><strong>Discuss Outcomes: <\/strong>Hold meetings with the health care team to discuss the results. Identify barriers to successful implementation (e.g., lack of compliance with protocols, insufficient training). Recognize strengths (e.g., effective use of bed alarms, positive feedback from staff).<\/li>\n \t<li><strong>Make Adjustments: I<\/strong>f the fall rate has not decreased as expected, identify additional changes that might be needed (e.g., more frequent training, adjusting the rounding protocol). If successful, consider ways to further enhance the fall prevention program.<\/li>\n \t<li><strong>Continuous Improvement: <\/strong>Use the findings to plan the next cycle of improvements. Set new goals based on the outcomes and continue the PDSA cycle to maintain and further improve client safety<\/li>\n<\/ol>\n<\/div>\nSee Figure 9.6<sup>[footnote]\u201cComparison_QI Process_Nursing Process.jpg\u201d by Amy Tyznik, MPTC for <a href=\"https:\/\/www.cvtc.edu\/landing-pages\/grants\/open-rn\" target=\"_blank\" rel=\"noopener\">Open RN<\/a> is licensed under <a href=\"https:\/\/creativecommons.org\/licenses\/by\/4.0\/\" target=\"_blank\" rel=\"noopener\">CC BY 4.0<\/a>[\/footnote]<\/sup> for an illustration comparing the QI process to the nursing process.\n\n[caption id=\"attachment_201\" align=\"aligncenter\" width=\"549\"]<img class=\"wp-image-201 \" title=\"\u201cComparison_QI Process_Nursing Process.jpg\u201d by Amy Tyznik, MPTC forOpen RN is licensed under CC BY 4.0\" src=\"https:\/\/pressbooks.ccconline.org\/accphysicalgeology\/wp-content\/uploads\/sites\/225\/2025\/02\/unnamed-1.png\" alt=\"Image showing comparison of the Q I Process and the Nursing Process, with textual labels\" width=\"549\" height=\"307\"> Figure 9.6 Comparison of the QI Process and the Nursing Process (Source: Amy Tyznik, MPTC)[\/caption]\n\nIt is important to note that quality improvement is different from nursing research. QI evaluates processes in place and determines if changes are needed, whereas the goal of research is to identify new innovations in nursing practice.<sup>[footnote]Agency for Healthcare Research and Quality. (2013, May). Module 4. Approaches to quality improvement. <em>Practice facilitation handbook.<\/em> <a href=\"https:\/\/www.ahrq.gov\/ncepcr\/tools\/pf-handbook\/mod4.html\" target=\"_blank\" rel=\"noopener\">https:\/\/www.ahrq.gov\/ncepcr\/tools\/pf-handbook\/mod4.html<\/a>[\/footnote]<\/sup>\n<h2>Barriers to Quality Improvement<\/h2>\nBarriers to quality improvement (QI) in health care organizations can be multifaceted, arising from a range of systemic, cultural, and practical challenges. One of the primary barriers is resistance to change among health care professionals. This resistance can stem from a lack of understanding of QI principles, fear of additional workload, or skepticism about the effectiveness of new practices. Overcoming this barrier requires robust education and training programs that highlight the benefits of QI initiatives and provide staff with the skills and knowledge needed to implement changes effectively. Also, having transparent conversations, discussing the process steps, and engaging staff questions are paramount.<sup>[footnote]Giannitrapani, K., Satija. A., Ganesh, A., Gamboa, R., Fereydooni, S., Hennings, T., Chandrashekaran, S., Mickelsen, J., DeNatale, M., Spruijt, O., Bhatnagar, S., &amp; Lorenz, K. A. (2021). Barriers and facilitators of using quality improvement to foster locally initiated innovation in palliative care services in India. <em>Journal of General Internal Medicine, 36<\/em>(2), 366-373. <a href=\"https:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC7878595\/\" target=\"_blank\" rel=\"noopener\">https:\/\/doi.org\/10.1007\/s11606-020-06152-y<\/a>.[\/footnote]<\/sup>\n\nAnother significant barrier is inadequate data management systems. Quality improvement relies heavily on accurate and timely data to identify areas for improvement, track progress, and measure outcomes. However, many health care organizations struggle with fragmented or outdated information systems that hinder data collection and analysis. Investing in modern, integrated health information technologies can facilitate better data management and support QI efforts. It also saves significant manpower and staff resources, allowing for more rapid identification of issues and trends.<sup>[footnote]Giannitrapani, K., Satija. A., Ganesh, A., Gamboa, R., Fereydooni, S., Hennings, T., Chandrashekaran, S., Mickelsen, J., DeNatale, M., Spruijt, O., Bhatnagar, S., Lorenz, K. A. (2021). Barriers and facilitators of using quality improvement to foster locally initiated innovation in palliative care services in India. <em>Journal of General Internal Medicine, 36<\/em>(2), 366-373. <a href=\"https:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC7878595\/\" target=\"_blank\" rel=\"noopener\">https:\/\/doi.org\/ 10.1007\/s11606-020-06152-y<\/a>.[\/footnote]<\/sup>\n\nResource constraints also pose a substantial challenge to quality improvement in health care. Financial limitations, staffing shortages, and limited time can impede the ability to implement and sustain QI initiatives. Organizations may find it difficult to allocate the necessary resources for training, process redesign, and continuous monitoring. Addressing this barrier often requires strategic planning, prioritization of QI projects, and seeking external funding or partnerships to support initiatives. Many organizations may have quality departments while others may utilize nursing staff to complete QI initiatives.<sup>[footnote]Alexander, C., Tschannen, D., Argetsinger, D., Hakim, H., &amp; Milner, K. A. (2022). A qualitative study on barriers and facilitators of quality improvement engagement by frontline nurses and leaders. <em>Journal of Nursing Management, 30<\/em>(3), 694-701. <a href=\"https:\/\/pubmed.ncbi.nlm.nih.gov\/34969172\/\" target=\"_blank\" rel=\"noopener\">https:\/\/doi.org\/10.1111\/jonm.13537<\/a>.[\/footnote]<\/sup>\n\nCultural factors in health care organizations can also impede quality improvement. Organizational culture that does not prioritize client safety and continuous improvement can undermine QI efforts. This barrier can be addressed by fostering a culture of transparency, accountability, and collaboration. Leadership plays a crucial role in setting the tone and demonstrating a commitment to quality improvement. Engaging all levels of staff in QI processes and celebrating successes can help build a positive culture that supports ongoing improvement.<sup>[footnote]Alexander, C., Tschannen, D., Argetsinger, D., Hakim, H., &amp; Milner, K. A. (2022). A qualitative study on barriers and facilitators of quality improvement engagement by frontline nurses and leaders. <em>Journal of Nursing Management, 30<\/em>(3), 694-701. <a href=\"https:\/\/pubmed.ncbi.nlm.nih.gov\/34969172\/\" target=\"_blank\" rel=\"noopener\">https:\/\/doi.org\/10.1111\/jonm.13537<\/a>.[\/footnote]<\/sup>\n\nLastly, regulatory and policy constraints can limit the scope and flexibility of QI initiatives. Health care organizations operate within a complex regulatory environment that can sometimes create barriers to innovative practices. Navigating these regulations while attempting to implement QI can be challenging. Advocacy for policy changes that support QI, along with a thorough understanding of existing regulations, can help organizations find ways to work within or adapt to these constraints.<sup>[footnote]Alexander, C., Tschannen, D., Argetsinger, D., Hakim, H., &amp; Milner, K. A. (2022). A qualitative study on barriers and facilitators of quality improvement engagement by frontline nurses and leaders. <em>Journal of Nursing Management, 30<\/em>(3), 694-701. <a href=\"https:\/\/pubmed.ncbi.nlm.nih.gov\/34969172\/\" target=\"_blank\" rel=\"noopener\">htttps:\/\/doi.org\/10.1111\/jonm.13537<\/a>.[\/footnote]<\/sup>","rendered":"<p>Now that we have discussed the various ways that quality health care is defined, let\u2019s discuss how quality care is measured, evaluated, and improved.<\/p>\n<h2>Utilization Review<\/h2>\n<p>Thinking back to value-based reimbursement models discussed in the \u201c<a href=\"https:\/\/pressbooks.ccconline.org\/accnursing2030\/chapter\/8-1-economics-introduction\/\" target=\"_blank\" rel=\"noopener\">Health Care Economics<\/a>\u201d chapter, recall how health care agencies are reimbursed from Medicare, Medicaid, and private insurance based on their quality performance measures. A <strong><a class=\"glossary-term\" aria-haspopup=\"dialog\" aria-describedby=\"definition\" href=\"#term_202_448\">utilization review<\/a><\/strong> is an investigation of health care services performed by doctors, nurses, and other health care team members to ensure money is not wasted covering unnecessary or inefficient expenditures for proper treatment. Utilization review also allows organizations to objectively measure how their health care services and resources are being used to best meet their clients\u2019 needs. Information from clients\u2019 medical records is analyzed, along with client demographics, to evaluate resource allocation, efficiency, and quality of health promotion initiatives.<sup><a class=\"footnote\" title=\"Institute of Medicine (US) Committee on Utilization Management by Third Parties, Gray, B. H., &amp; Field, M. J., (Eds.). (1989). Controlling costs and changing patient care? The role of utilization management. National Academies Press. https:\/\/www.ncbi.nlm.nih.gov\/books\/NBK235000\" id=\"return-footnote-202-1\" href=\"#footnote-202-1\" aria-label=\"Footnote 1\"><sup class=\"footnote\">[1]<\/sup><\/a><\/sup> See Figure 9.3<sup><a class=\"footnote\" title=\"\u201cAnalyzing_Financial_Data_(5099605109).jpg\u201d by Dave Dugdale is licensed under CC BY-SA 2.0\" id=\"return-footnote-202-2\" href=\"#footnote-202-2\" aria-label=\"Footnote 2\"><sup class=\"footnote\">[2]<\/sup><\/a><\/sup> for an illustration of utilization review related to costs.<\/p>\n<figure id=\"attachment_201\" aria-describedby=\"caption-attachment-201\" style=\"width: 459px\" class=\"wp-caption aligncenter\"><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-913\" title=\"\u201cAnalyzing_Financial_Data_(5099605109).jpg\u201d by Dave Dugdale is licensed under CC BY-SA 2.0\" src=\"https:\/\/pressbooks.ccconline.org\/accphysicalgeology\/wp-content\/uploads\/sites\/225\/2021\/08\/Analyzing_Financial_Data_5099605109-1-scaled-1.jpg\" alt=\"Photo showing closeup of hand holding pen over expense sheet, with calculator to side\" width=\"459\" height=\"306\" \/><figcaption id=\"caption-attachment-201\" class=\"wp-caption-text\">Figure 9.3 Utilization Review<\/figcaption><\/figure>\n<h2>Using Informatics to Promote Quality<\/h2>\n<p>Utilization review relies on the collection of meaningful data from health records to determine if quality metrics are being met. <strong><a class=\"glossary-term\" aria-haspopup=\"dialog\" aria-describedby=\"definition\" href=\"#term_202_449\">Informatics<\/a><\/strong> refers to using information and technology to communicate, manage knowledge, mitigate error, and support decision-making.<sup><a class=\"footnote\" title=\"QSEN Institute. (n.d.). QSEN competencies: Quality improvement (QI). https:\/\/qsen.org\/competencies\/pre-licensure-ksas\/#quality_improvement\" id=\"return-footnote-202-3\" href=\"#footnote-202-3\" aria-label=\"Footnote 3\"><sup class=\"footnote\">[3]<\/sup><\/a><\/sup>\u00a0Informatics allows members of the health care team to share, store, and analyze health-related information. Nurses have an important role in informatics. <strong><a class=\"glossary-term\" aria-haspopup=\"dialog\" aria-describedby=\"definition\" href=\"#term_202_450\">Nursing informatics<\/a><\/strong> is the science and practice of integrating nursing knowledge with information and communication technologies to promote the health of people, families, and communities worldwide.<sup><a class=\"footnote\" title=\"AMIA. (n.d.). Informatics: Research and practice. https:\/\/amia.org\/about-amia\/why-informatics\/informatics-research-and-practice\" id=\"return-footnote-202-4\" href=\"#footnote-202-4\" aria-label=\"Footnote 4\"><sup class=\"footnote\">[4]<\/sup><\/a><\/sup> It is a nursing specialty with certification available from the ANCC. See Figure 9.4<sup><a class=\"footnote\" title=\"\u201cinformatics-1322241_1920.jpg\u201d by mariojsantos at Pixabay.com is licensed under CC0\" id=\"return-footnote-202-5\" href=\"#footnote-202-5\" aria-label=\"Footnote 5\"><sup class=\"footnote\">[5]<\/sup><\/a><\/sup> for an artistic rendition of informatics.<\/p>\n<figure id=\"attachment_201\" aria-describedby=\"caption-attachment-201\" style=\"width: 271px\" class=\"wp-caption aligncenter\"><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-199\" title=\"\u201cinformatics-1322241_1920.jpg\u201d by mariojsantos at Pixabay.com is licensed under CC0\" src=\"https:\/\/pressbooks.ccconline.org\/accphysicalgeology\/wp-content\/uploads\/sites\/225\/2025\/02\/informatics-1322241_1920-212x300.png\" alt=\"Illustration showing human figure sitting at desk with laptop, a large globe of earth floating above\" width=\"271\" height=\"383\" srcset=\"https:\/\/pressbooks.ccconline.org\/accnursing2030\/wp-content\/uploads\/sites\/225\/2025\/02\/informatics-1322241_1920-212x300.png 212w, https:\/\/pressbooks.ccconline.org\/accnursing2030\/wp-content\/uploads\/sites\/225\/2025\/02\/informatics-1322241_1920-724x1024.png 724w, https:\/\/pressbooks.ccconline.org\/accnursing2030\/wp-content\/uploads\/sites\/225\/2025\/02\/informatics-1322241_1920-768x1087.png 768w, https:\/\/pressbooks.ccconline.org\/accnursing2030\/wp-content\/uploads\/sites\/225\/2025\/02\/informatics-1322241_1920-1086x1536.png 1086w, https:\/\/pressbooks.ccconline.org\/accnursing2030\/wp-content\/uploads\/sites\/225\/2025\/02\/informatics-1322241_1920-65x92.png 65w, https:\/\/pressbooks.ccconline.org\/accnursing2030\/wp-content\/uploads\/sites\/225\/2025\/02\/informatics-1322241_1920-225x318.png 225w, https:\/\/pressbooks.ccconline.org\/accnursing2030\/wp-content\/uploads\/sites\/225\/2025\/02\/informatics-1322241_1920-350x495.png 350w, https:\/\/pressbooks.ccconline.org\/accnursing2030\/wp-content\/uploads\/sites\/225\/2025\/02\/informatics-1322241_1920.png 1357w\" sizes=\"auto, (max-width: 271px) 100vw, 271px\" \/><figcaption id=\"caption-attachment-201\" class=\"wp-caption-text\">Figure 9.4 Informatics<\/figcaption><\/figure>\n<p>These are several benefits of using informatics in health care<sup><a class=\"footnote\" title=\"Otokiti, A. (2019). Using informatics to improve healthcare quality. International Journal of Health Care Qual Assurance, 32(2), 425-430. https:\/\/doi.org\/10.1108\/ijhcqa-03-2018-0062\" id=\"return-footnote-202-6\" href=\"#footnote-202-6\" aria-label=\"Footnote 6\"><sup class=\"footnote\">[6]<\/sup><\/a><\/sup>:<\/p>\n<ul>\n<li style=\"font-weight: 400;\"><strong>Improvement of Client Safety:<\/strong> Informatics allows for up-to-date information sharing by both the client and members of the health care team. Using informatics can help to reduce the occurrence of medication errors, as well as monitor client side effects and overall health status. For example, barcode scanning has reduced medication errors by ensuring the correct dose is administered to the correct client at the correct time.<\/li>\n<li style=\"font-weight: 400;\"><strong>Reduction of Delays in Care:<\/strong> Some health care informatics systems allow for direct communication between health care team members and clients. The ability to ask and answer questions without needing to schedule an office appointment promotes the ability for care to be delivered efficiently in a cost-effective manner.<\/li>\n<li style=\"font-weight: 400;\"><strong>Reduction of Waste:<\/strong> The use of informatics to share information between care team members reduces waste associated with duplication of tests or exams when more than one provider is on the care team. Additionally, clients can request their records be shared with health providers from other health organizations, which reduces duplication and unnecessary spending across the nation.<\/li>\n<li style=\"font-weight: 400;\"><strong>Promotion of Client-Centered Care:<\/strong> Many informatics systems have \u201cportal\u201d options where the client and\/or designated personnel are able to be active participants in the care planning and health promotion processes. Informatics offers an inclusive environment for clients to communicate and share directly with their care team regardless of physical location and timing.<\/li>\n<li style=\"font-weight: 400;\"><strong>Support of Quality Improvement:<\/strong> The continuous process of quality improvement requires the ability to collect and analyze data in a systematic and reliable manner. Using informatics provides members of the health care team a secure place to store data, as well as the ability to review in a timely manner.<\/li>\n<\/ul>\n<h2>Quality Indicators<\/h2>\n<p>The National Database of Nursing Quality Indicators (NDNQI) was developed as a national nursing database used to evaluate quality in nursing care. This database was purchased by Press Ganey in 2014. In collaboration with the American Nursing Association (ANA), the original NDNQI database established nurse-sensitive quality indicators such as these<sup><a class=\"footnote\" title=\"Montalvo, I. (2007). The National Database of Nursing Quality Indicators (NDNQI). The Online Journal of Issues in Nursing, 12(3). https:\/\/ojin.nursingworld.org\/MainMenuCategories\/ANAMarketplace\/ANAPeriodicals\/OJIN\/TableofContents\/Volume122007\/No3Sept07\/NursingQualityIndicators.aspx\" id=\"return-footnote-202-7\" href=\"#footnote-202-7\" aria-label=\"Footnote 7\"><sup class=\"footnote\">[7]<\/sup><\/a><\/sup>:<\/p>\n<ul>\n<li style=\"font-weight: 400;\">Nursing Care Hours Per Patient Day<\/li>\n<li style=\"font-weight: 400;\">Hospital-Acquired Pressure Injuries<\/li>\n<li style=\"font-weight: 400;\">RN Job Satisfaction<\/li>\n<\/ul>\n<p>Nurses use quality indicators to support practice changes with evidence directly related to improved client outcomes.<\/p>\n<div class=\"textbox shaded\"><span class=\"arrow\"> Read about current quality measures promoting clinical excellence at the <a href=\"https:\/\/www.pressganey.com\/industry-initiatives\" target=\"_blank\" rel=\"noopener\">Press Ganey website<\/a>.<\/span><\/div>\n<h2>Quality Improvement<\/h2>\n<p><strong><a class=\"glossary-term\" aria-haspopup=\"dialog\" aria-describedby=\"definition\" href=\"#term_202_451\">Quality Improvement (QI)<\/a> <\/strong>is a systematic process using measurable data to improve health care services and the overall health status of clients.<sup><a class=\"footnote\" title=\"Study.com. (n.d.). What is economics? - Definition, history, timeline &amp; importance [Video]. https:\/\/study.com\/academy\/lesson\/what-is-economics-definition-history-timeline-importance.html\" id=\"return-footnote-202-8\" href=\"#footnote-202-8\" aria-label=\"Footnote 8\"><sup class=\"footnote\">[8]<\/sup><\/a><\/sup> QI is one of the competencies of the Quality and Safety Education (QSEN) project and defined as, \u201cusing data to monitor the outcomes of care processes and using improvement methods to design and test changes to continuously improve the quality and safety of health care systems.\u201d<sup><a class=\"footnote\" title=\"QSEN Institute. (n.d.). QSEN competencies: Quality improvement (QI). https:\/\/qsen.org\/competencies\/pre-licensure-ksas\/#quality_improvement\" id=\"return-footnote-202-9\" href=\"#footnote-202-9\" aria-label=\"Footnote 9\"><sup class=\"footnote\">[9]<\/sup><\/a>\u00a0<\/sup><\/p>\n<p>The overall goal of the QI process is to improve the quality and safety of health care. The process of quality improvement is very similar to the nursing process, but its purpose is to answer these three main questions:<\/p>\n<ul>\n<li style=\"font-weight: 400;\">What are we trying to accomplish?<\/li>\n<li style=\"font-weight: 400;\">How will we know if a change is an improvement?<\/li>\n<li style=\"font-weight: 400;\">What changes can we make that will result in an improvement?<\/li>\n<\/ul>\n<p>See Figure 9.5<sup><a class=\"footnote\" title=\"\u201cModel_for_Improvement.jpg\u201d by Cliffnorman is licensed under CC BY-SA 4.0\" id=\"return-footnote-202-10\" href=\"#footnote-202-10\" aria-label=\"Footnote 10\"><sup class=\"footnote\">[10]<\/sup><\/a><\/sup> for an illustration of the quality improvement process.<\/p>\n<figure id=\"attachment_201\" aria-describedby=\"caption-attachment-201\" style=\"width: 301px\" class=\"wp-caption aligncenter\"><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-200\" title=\"\u201cinformatics-1322241_1920.jpg\u201d by mariojsantos at Pixabay.com is licensed under CC0\" src=\"https:\/\/pressbooks.ccconline.org\/accphysicalgeology\/wp-content\/uploads\/sites\/225\/2025\/02\/Model_for_Improvement.jpg\" alt=\"Image depicting a model for improvement, with a circle split into four parts and textual labels\" width=\"301\" height=\"414\" srcset=\"https:\/\/pressbooks.ccconline.org\/accnursing2030\/wp-content\/uploads\/sites\/225\/2025\/02\/Model_for_Improvement.jpg 369w, https:\/\/pressbooks.ccconline.org\/accnursing2030\/wp-content\/uploads\/sites\/225\/2025\/02\/Model_for_Improvement-218x300.jpg 218w, https:\/\/pressbooks.ccconline.org\/accnursing2030\/wp-content\/uploads\/sites\/225\/2025\/02\/Model_for_Improvement-65x89.jpg 65w, https:\/\/pressbooks.ccconline.org\/accnursing2030\/wp-content\/uploads\/sites\/225\/2025\/02\/Model_for_Improvement-225x309.jpg 225w, https:\/\/pressbooks.ccconline.org\/accnursing2030\/wp-content\/uploads\/sites\/225\/2025\/02\/Model_for_Improvement-350x481.jpg 350w\" sizes=\"auto, (max-width: 301px) 100vw, 301px\" \/><figcaption id=\"caption-attachment-201\" class=\"wp-caption-text\">Figure 9.5 Quality Improvement Process<\/figcaption><\/figure>\n<p>To answer these questions, QI is a continuous process in which a project is planned, interventions are implemented, data is collected, results are studied, and outcomes are evaluated. The process is repeated after additional planning. During the QI process, four key steps are used to evaluate current client care and determine if changes are needed. These components are referred to as Plan, Do, Study, and Act:<\/p>\n<ul>\n<li style=\"font-weight: 400;\"><strong>Plan:<\/strong> The first step in the QI process is to identify what you will be testing or focusing on and what will be measured. Similar to the nursing process where subjective and objective data are collected, the nurse determines what data will be needed during the QI process. The nurse also determines a timeline for the QI project, such as one year, including a specific framework for when data is collected and when it will be reviewed. For example, fall rates will decrease 10% in one year.<\/li>\n<li style=\"font-weight: 400;\"><strong>Do:<\/strong> After the plan is determined, the nurse works with a health care team to implement the project and ensure data collection occurs.<\/li>\n<li style=\"font-weight: 400;\"><strong>Study:<\/strong> During this phase, the nurse works with the health care team to review and analyze the data that was collected and determine if the outcomes were achieved or not.<\/li>\n<li style=\"font-weight: 400;\"><strong>Act:<\/strong> In the fourth step of the QI process, the team discusses the outcomes. In this step the team identifies barriers, strengths, and weaknesses and then decides if additional changes are needed in nursing practice. The QI process is continuous, so the QI team uses outcome findings to continue the process of Plan, Do, Study, and Act to ensure safe, quality client care.<\/li>\n<\/ul>\n<div class=\"textbox shaded\">\n<p><strong>PDSA Fall Rates Example<\/strong><\/p>\n<p><strong>Reducing Client Fall Rates<\/strong><\/p>\n<p><strong>Objective:<\/strong> Decrease the client fall rate in the hospital by 10% within one year.<\/p>\n<p><span style=\"text-decoration: underline;\"><strong>Plan<\/strong><\/span><\/p>\n<ol>\n<li><strong>Identify the Focus:<\/strong> The QI project will focus on reducing client falls in the hospital.<\/li>\n<li><strong>Determine What to Measure:<\/strong> The primary metric will be the fall rate, calculated as the number of falls per 1,000 client days.<\/li>\n<li><strong>Collect Data:<\/strong> Baseline fall rates will be collected for the past year to understand current performance.<\/li>\n<li><strong>Set Goals:<\/strong> Aim to reduce the fall rate by 10% within one year.<\/li>\n<li><strong>Develop a Timeline:<\/strong>\n<ul>\n<li><strong>Initial Planning and Baseline Data Collection:<\/strong> Month 1<\/li>\n<li><strong>Intervention Implementation:<\/strong> Months 2-4<\/li>\n<li><strong>Data Collection and Monitoring:<\/strong> Months 2-12<\/li>\n<li><strong>Initial Data Analysis:<\/strong> Month 6<\/li>\n<li><strong>Final Data Analysis and Review:<\/strong> Month 12<\/li>\n<\/ul>\n<\/li>\n<\/ol>\n<p><span style=\"text-decoration: underline;\"><strong>Do<\/strong><\/span><\/p>\n<ol>\n<li><strong>Implement Interventions: <\/strong>Conduct fall prevention training sessions for all nursing staff. Ensure that client rooms are free from clutter and that non-slip mats are in place. Install bed alarms and provide non-slip socks for clients. Implement a protocol for frequent rounding, especially for high-risk clients.<\/li>\n<li><strong>Data Collection:<\/strong> Continuously collect data on fall incidents, including the circumstances of each fall.<\/li>\n<\/ol>\n<p><span style=\"text-decoration: underline;\"><strong>Study<\/strong><\/span><\/p>\n<ol>\n<li><strong>Data Analysis: <\/strong>Review the fall rates monthly and compare them to the baseline data. Analyze trends and identify any patterns in the fall incidents. Determine if the interventions are associated with a reduction in fall rates.<\/li>\n<li><strong>Outcome Evaluation: <\/strong>Assess whether the goal of a 10% reduction in fall rates is being met. Identify any unexpected outcomes.<\/li>\n<\/ol>\n<p><span style=\"text-decoration: underline;\"><strong>Act<\/strong><\/span><\/p>\n<ol>\n<li><strong>Discuss Outcomes: <\/strong>Hold meetings with the health care team to discuss the results. Identify barriers to successful implementation (e.g., lack of compliance with protocols, insufficient training). Recognize strengths (e.g., effective use of bed alarms, positive feedback from staff).<\/li>\n<li><strong>Make Adjustments: I<\/strong>f the fall rate has not decreased as expected, identify additional changes that might be needed (e.g., more frequent training, adjusting the rounding protocol). If successful, consider ways to further enhance the fall prevention program.<\/li>\n<li><strong>Continuous Improvement: <\/strong>Use the findings to plan the next cycle of improvements. Set new goals based on the outcomes and continue the PDSA cycle to maintain and further improve client safety<\/li>\n<\/ol>\n<\/div>\n<p>See Figure 9.6<sup><a class=\"footnote\" title=\"\u201cComparison_QI Process_Nursing Process.jpg\u201d by Amy Tyznik, MPTC for Open RN is licensed under CC BY 4.0\" id=\"return-footnote-202-11\" href=\"#footnote-202-11\" aria-label=\"Footnote 11\"><sup class=\"footnote\">[11]<\/sup><\/a><\/sup> for an illustration comparing the QI process to the nursing process.<\/p>\n<figure id=\"attachment_201\" aria-describedby=\"caption-attachment-201\" style=\"width: 549px\" class=\"wp-caption aligncenter\"><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-201\" title=\"\u201cComparison_QI Process_Nursing Process.jpg\u201d by Amy Tyznik, MPTC forOpen RN is licensed under CC BY 4.0\" src=\"https:\/\/pressbooks.ccconline.org\/accphysicalgeology\/wp-content\/uploads\/sites\/225\/2025\/02\/unnamed-1.png\" alt=\"Image showing comparison of the Q I Process and the Nursing Process, with textual labels\" width=\"549\" height=\"307\" srcset=\"https:\/\/pressbooks.ccconline.org\/accnursing2030\/wp-content\/uploads\/sites\/225\/2025\/02\/unnamed-1.png 512w, https:\/\/pressbooks.ccconline.org\/accnursing2030\/wp-content\/uploads\/sites\/225\/2025\/02\/unnamed-1-300x168.png 300w, https:\/\/pressbooks.ccconline.org\/accnursing2030\/wp-content\/uploads\/sites\/225\/2025\/02\/unnamed-1-65x36.png 65w, https:\/\/pressbooks.ccconline.org\/accnursing2030\/wp-content\/uploads\/sites\/225\/2025\/02\/unnamed-1-225x126.png 225w, https:\/\/pressbooks.ccconline.org\/accnursing2030\/wp-content\/uploads\/sites\/225\/2025\/02\/unnamed-1-350x196.png 350w\" sizes=\"auto, (max-width: 549px) 100vw, 549px\" \/><figcaption id=\"caption-attachment-201\" class=\"wp-caption-text\">Figure 9.6 Comparison of the QI Process and the Nursing Process (Source: Amy Tyznik, MPTC)<\/figcaption><\/figure>\n<p>It is important to note that quality improvement is different from nursing research. QI evaluates processes in place and determines if changes are needed, whereas the goal of research is to identify new innovations in nursing practice.<sup><a class=\"footnote\" title=\"Agency for Healthcare Research and Quality. (2013, May). Module 4. Approaches to quality improvement. Practice facilitation handbook. https:\/\/www.ahrq.gov\/ncepcr\/tools\/pf-handbook\/mod4.html\" id=\"return-footnote-202-12\" href=\"#footnote-202-12\" aria-label=\"Footnote 12\"><sup class=\"footnote\">[12]<\/sup><\/a><\/sup><\/p>\n<h2>Barriers to Quality Improvement<\/h2>\n<p>Barriers to quality improvement (QI) in health care organizations can be multifaceted, arising from a range of systemic, cultural, and practical challenges. One of the primary barriers is resistance to change among health care professionals. This resistance can stem from a lack of understanding of QI principles, fear of additional workload, or skepticism about the effectiveness of new practices. Overcoming this barrier requires robust education and training programs that highlight the benefits of QI initiatives and provide staff with the skills and knowledge needed to implement changes effectively. Also, having transparent conversations, discussing the process steps, and engaging staff questions are paramount.<sup><a class=\"footnote\" title=\"Giannitrapani, K., Satija. A., Ganesh, A., Gamboa, R., Fereydooni, S., Hennings, T., Chandrashekaran, S., Mickelsen, J., DeNatale, M., Spruijt, O., Bhatnagar, S., &amp; Lorenz, K. A. (2021). Barriers and facilitators of using quality improvement to foster locally initiated innovation in palliative care services in India. Journal of General Internal Medicine, 36(2), 366-373. https:\/\/doi.org\/10.1007\/s11606-020-06152-y.\" id=\"return-footnote-202-13\" href=\"#footnote-202-13\" aria-label=\"Footnote 13\"><sup class=\"footnote\">[13]<\/sup><\/a><\/sup><\/p>\n<p>Another significant barrier is inadequate data management systems. Quality improvement relies heavily on accurate and timely data to identify areas for improvement, track progress, and measure outcomes. However, many health care organizations struggle with fragmented or outdated information systems that hinder data collection and analysis. Investing in modern, integrated health information technologies can facilitate better data management and support QI efforts. It also saves significant manpower and staff resources, allowing for more rapid identification of issues and trends.<sup><a class=\"footnote\" title=\"Giannitrapani, K., Satija. A., Ganesh, A., Gamboa, R., Fereydooni, S., Hennings, T., Chandrashekaran, S., Mickelsen, J., DeNatale, M., Spruijt, O., Bhatnagar, S., Lorenz, K. A. (2021). Barriers and facilitators of using quality improvement to foster locally initiated innovation in palliative care services in India. Journal of General Internal Medicine, 36(2), 366-373. https:\/\/doi.org\/ 10.1007\/s11606-020-06152-y.\" id=\"return-footnote-202-14\" href=\"#footnote-202-14\" aria-label=\"Footnote 14\"><sup class=\"footnote\">[14]<\/sup><\/a><\/sup><\/p>\n<p>Resource constraints also pose a substantial challenge to quality improvement in health care. Financial limitations, staffing shortages, and limited time can impede the ability to implement and sustain QI initiatives. Organizations may find it difficult to allocate the necessary resources for training, process redesign, and continuous monitoring. Addressing this barrier often requires strategic planning, prioritization of QI projects, and seeking external funding or partnerships to support initiatives. Many organizations may have quality departments while others may utilize nursing staff to complete QI initiatives.<sup><a class=\"footnote\" title=\"Alexander, C., Tschannen, D., Argetsinger, D., Hakim, H., &amp; Milner, K. A. (2022). A qualitative study on barriers and facilitators of quality improvement engagement by frontline nurses and leaders. Journal of Nursing Management, 30(3), 694-701. https:\/\/doi.org\/10.1111\/jonm.13537.\" id=\"return-footnote-202-15\" href=\"#footnote-202-15\" aria-label=\"Footnote 15\"><sup class=\"footnote\">[15]<\/sup><\/a><\/sup><\/p>\n<p>Cultural factors in health care organizations can also impede quality improvement. Organizational culture that does not prioritize client safety and continuous improvement can undermine QI efforts. This barrier can be addressed by fostering a culture of transparency, accountability, and collaboration. Leadership plays a crucial role in setting the tone and demonstrating a commitment to quality improvement. Engaging all levels of staff in QI processes and celebrating successes can help build a positive culture that supports ongoing improvement.<sup><a class=\"footnote\" title=\"Alexander, C., Tschannen, D., Argetsinger, D., Hakim, H., &amp; Milner, K. A. (2022). A qualitative study on barriers and facilitators of quality improvement engagement by frontline nurses and leaders. Journal of Nursing Management, 30(3), 694-701. https:\/\/doi.org\/10.1111\/jonm.13537.\" id=\"return-footnote-202-16\" href=\"#footnote-202-16\" aria-label=\"Footnote 16\"><sup class=\"footnote\">[16]<\/sup><\/a><\/sup><\/p>\n<p>Lastly, regulatory and policy constraints can limit the scope and flexibility of QI initiatives. Health care organizations operate within a complex regulatory environment that can sometimes create barriers to innovative practices. Navigating these regulations while attempting to implement QI can be challenging. Advocacy for policy changes that support QI, along with a thorough understanding of existing regulations, can help organizations find ways to work within or adapt to these constraints.<sup><a class=\"footnote\" title=\"Alexander, C., Tschannen, D., Argetsinger, D., Hakim, H., &amp; Milner, K. A. (2022). A qualitative study on barriers and facilitators of quality improvement engagement by frontline nurses and leaders. Journal of Nursing Management, 30(3), 694-701. htttps:\/\/doi.org\/10.1111\/jonm.13537.\" id=\"return-footnote-202-17\" href=\"#footnote-202-17\" aria-label=\"Footnote 17\"><sup class=\"footnote\">[17]<\/sup><\/a><\/sup><\/p>\n<hr class=\"before-footnotes clear\" \/><div class=\"footnotes\"><ol><li id=\"footnote-202-1\">Institute of Medicine (US) Committee on Utilization Management by Third Parties, Gray, B. H., &amp; Field, M. J., (Eds.). (1989). <em>Controlling costs and changing patient care? The role of utilization management.<\/em> National Academies Press. <a href=\"https:\/\/www.ncbi.nlm.nih.gov\/books\/NBK235000\" target=\"_blank\" rel=\"noopener\">https:\/\/www.ncbi.nlm.nih.gov\/books\/NBK235000<\/a> <a href=\"#return-footnote-202-1\" class=\"return-footnote\" aria-label=\"Return to footnote 1\">&crarr;<\/a><\/li><li id=\"footnote-202-2\">\u201c<a href=\"https:\/\/commons.wikimedia.org\/wiki\/File:Analyzing_Financial_Data_(5099605109).jpg\" target=\"_blank\" rel=\"noopener\">Analyzing_Financial_Data_(5099605109).jpg<\/a>\u201d by <a href=\"https:\/\/www.flickr.com\/people\/37387065@N05\" target=\"_blank\" rel=\"noopener\">Dave Dugdale<\/a> is licensed under <a href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/2.0\/deed.en\" target=\"_blank\" rel=\"noopener\">CC BY-SA 2.0<\/a> <a href=\"#return-footnote-202-2\" class=\"return-footnote\" aria-label=\"Return to footnote 2\">&crarr;<\/a><\/li><li id=\"footnote-202-3\">QSEN Institute. (n.d.). <em>QSEN competencies: Quality improvement (QI).<\/em> <a href=\"https:\/\/qsen.org\/competencies\/pre-licensure-ksas\/#quality_improvement\" target=\"_blank\" rel=\"noopener\">https:\/\/qsen.org\/competencies\/pre-licensure-ksas\/#quality_improvement<\/a> <a href=\"#return-footnote-202-3\" class=\"return-footnote\" aria-label=\"Return to footnote 3\">&crarr;<\/a><\/li><li id=\"footnote-202-4\">AMIA. (n.d.). <em>Informatics: Research and practice.<\/em> <a href=\"https:\/\/amia.org\/about-amia\/why-informatics\/informatics-research-and-practice\" target=\"_blank\" rel=\"noopener\">https:\/\/amia.org\/about-amia\/why-informatics\/informatics-research-and-practice<\/a> <a href=\"#return-footnote-202-4\" class=\"return-footnote\" aria-label=\"Return to footnote 4\">&crarr;<\/a><\/li><li id=\"footnote-202-5\">\u201c<a href=\"https:\/\/pixabay.com\/ko\/illustrations\/%ec%a0%95%eb%b3%b4%ed%95%99-%ea%b8%b0%ec%88%a0-%ec%a0%95%eb%b3%b4-%ec%84%9c%eb%b9%84%ec%8a%a4-1322241\/\" target=\"_blank\" rel=\"noopener\">informatics-1322241_1920.jpg<\/a>\u201d by <a href=\"https:\/\/pixabay.com\/ko\/users\/mariojsantos-2351841\/\" target=\"_blank\" rel=\"noopener\">mariojsantos<\/a> at <a href=\"http:\/\/Pixabay.com\" target=\"_blank\" rel=\"noopener\">Pixabay.com<\/a> is licensed under <a href=\"https:\/\/creativecommons.org\/share-your-work\/public-domain\/cc0\/\" target=\"_blank\" rel=\"noopener\">CC0<\/a> <a href=\"#return-footnote-202-5\" class=\"return-footnote\" aria-label=\"Return to footnote 5\">&crarr;<\/a><\/li><li id=\"footnote-202-6\">Otokiti, A. (2019). Using informatics to improve healthcare quality. <em>International Journal of Health Care Qual Assurance, 32<\/em>(2), 425-430. <a href=\"https:\/\/doi.org\/10.1108\/ijhcqa-03-2018-0062\" target=\"_blank\" rel=\"noopener\">https:\/\/doi.org\/10.1108\/ijhcqa-03-2018-0062<\/a> <a href=\"#return-footnote-202-6\" class=\"return-footnote\" aria-label=\"Return to footnote 6\">&crarr;<\/a><\/li><li id=\"footnote-202-7\">Montalvo, I. (2007). The National Database of Nursing Quality Indicators (NDNQI). <em>The Online Journal of Issues in Nursing, 12<\/em>(3). <a href=\"https:\/\/ojin.nursingworld.org\/MainMenuCategories\/ANAMarketplace\/ANAPeriodicals\/OJIN\/TableofContents\/Volume122007\/No3Sept07\/NursingQualityIndicators.aspx\" target=\"_blank\" rel=\"noopener\">https:\/\/ojin.nursingworld.org\/MainMenuCategories\/ANAMarketplace\/ANAPeriodicals\/OJIN\/TableofContents\/Volume122007\/No3Sept07\/NursingQualityIndicators.aspx<\/a> <a href=\"#return-footnote-202-7\" class=\"return-footnote\" aria-label=\"Return to footnote 7\">&crarr;<\/a><\/li><li id=\"footnote-202-8\">Study.com. (n.d.).<em> What is economics? - Definition, history, timeline &amp; importance<\/em> [Video]. <a href=\"https:\/\/study.com\/academy\/lesson\/what-is-economics-definition-history-timeline-importance.html\" target=\"_blank\" rel=\"noopener\">https:\/\/study.com\/academy\/lesson\/what-is-economics-definition-history-timeline-importance.html<\/a> <a href=\"#return-footnote-202-8\" class=\"return-footnote\" aria-label=\"Return to footnote 8\">&crarr;<\/a><\/li><li id=\"footnote-202-9\">QSEN Institute. (n.d.). <em>QSEN competencies: Quality improvement (QI)<\/em>. <a href=\"https:\/\/qsen.org\/competencies\/pre-licensure-ksas\/#quality_improvement\" target=\"_blank\" rel=\"noopener\">https:\/\/qsen.org\/competencies\/pre-licensure-ksas\/#quality_improvement<\/a> <a href=\"#return-footnote-202-9\" class=\"return-footnote\" aria-label=\"Return to footnote 9\">&crarr;<\/a><\/li><li id=\"footnote-202-10\">\u201c<a href=\"https:\/\/commons.wikimedia.org\/wiki\/File:Model_for_Improvement.jpg\" target=\"_blank\" rel=\"noopener\">Model_for_Improvement.jpg<\/a>\u201d by <a href=\"https:\/\/commons.wikimedia.org\/w\/index.php?title=User:Cliffnorman&amp;action=edit&amp;redlink=1\" target=\"_blank\" rel=\"noopener\">Cliffnorman<\/a> is licensed under <a href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/4.0\/deed.en\" target=\"_blank\" rel=\"noopener\">CC BY-SA 4.0<\/a> <a href=\"#return-footnote-202-10\" class=\"return-footnote\" aria-label=\"Return to footnote 10\">&crarr;<\/a><\/li><li id=\"footnote-202-11\">\u201cComparison_QI Process_Nursing Process.jpg\u201d by Amy Tyznik, MPTC for <a href=\"https:\/\/www.cvtc.edu\/landing-pages\/grants\/open-rn\" target=\"_blank\" rel=\"noopener\">Open RN<\/a> is licensed under <a href=\"https:\/\/creativecommons.org\/licenses\/by\/4.0\/\" target=\"_blank\" rel=\"noopener\">CC BY 4.0<\/a> <a href=\"#return-footnote-202-11\" class=\"return-footnote\" aria-label=\"Return to footnote 11\">&crarr;<\/a><\/li><li id=\"footnote-202-12\">Agency for Healthcare Research and Quality. (2013, May). Module 4. Approaches to quality improvement. <em>Practice facilitation handbook.<\/em> <a href=\"https:\/\/www.ahrq.gov\/ncepcr\/tools\/pf-handbook\/mod4.html\" target=\"_blank\" rel=\"noopener\">https:\/\/www.ahrq.gov\/ncepcr\/tools\/pf-handbook\/mod4.html<\/a> <a href=\"#return-footnote-202-12\" class=\"return-footnote\" aria-label=\"Return to footnote 12\">&crarr;<\/a><\/li><li id=\"footnote-202-13\">Giannitrapani, K., Satija. A., Ganesh, A., Gamboa, R., Fereydooni, S., Hennings, T., Chandrashekaran, S., Mickelsen, J., DeNatale, M., Spruijt, O., Bhatnagar, S., &amp; Lorenz, K. A. (2021). Barriers and facilitators of using quality improvement to foster locally initiated innovation in palliative care services in India. <em>Journal of General Internal Medicine, 36<\/em>(2), 366-373. <a href=\"https:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC7878595\/\" target=\"_blank\" rel=\"noopener\">https:\/\/doi.org\/10.1007\/s11606-020-06152-y<\/a>. <a href=\"#return-footnote-202-13\" class=\"return-footnote\" aria-label=\"Return to footnote 13\">&crarr;<\/a><\/li><li id=\"footnote-202-14\">Giannitrapani, K., Satija. A., Ganesh, A., Gamboa, R., Fereydooni, S., Hennings, T., Chandrashekaran, S., Mickelsen, J., DeNatale, M., Spruijt, O., Bhatnagar, S., Lorenz, K. A. (2021). Barriers and facilitators of using quality improvement to foster locally initiated innovation in palliative care services in India. <em>Journal of General Internal Medicine, 36<\/em>(2), 366-373. <a href=\"https:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC7878595\/\" target=\"_blank\" rel=\"noopener\">https:\/\/doi.org\/ 10.1007\/s11606-020-06152-y<\/a>. <a href=\"#return-footnote-202-14\" class=\"return-footnote\" aria-label=\"Return to footnote 14\">&crarr;<\/a><\/li><li id=\"footnote-202-15\">Alexander, C., Tschannen, D., Argetsinger, D., Hakim, H., &amp; Milner, K. A. (2022). A qualitative study on barriers and facilitators of quality improvement engagement by frontline nurses and leaders. <em>Journal of Nursing Management, 30<\/em>(3), 694-701. <a href=\"https:\/\/pubmed.ncbi.nlm.nih.gov\/34969172\/\" target=\"_blank\" rel=\"noopener\">https:\/\/doi.org\/10.1111\/jonm.13537<\/a>. <a href=\"#return-footnote-202-15\" class=\"return-footnote\" aria-label=\"Return to footnote 15\">&crarr;<\/a><\/li><li id=\"footnote-202-16\">Alexander, C., Tschannen, D., Argetsinger, D., Hakim, H., &amp; Milner, K. A. (2022). A qualitative study on barriers and facilitators of quality improvement engagement by frontline nurses and leaders. <em>Journal of Nursing Management, 30<\/em>(3), 694-701. <a href=\"https:\/\/pubmed.ncbi.nlm.nih.gov\/34969172\/\" target=\"_blank\" rel=\"noopener\">https:\/\/doi.org\/10.1111\/jonm.13537<\/a>. <a href=\"#return-footnote-202-16\" class=\"return-footnote\" aria-label=\"Return to footnote 16\">&crarr;<\/a><\/li><li id=\"footnote-202-17\">Alexander, C., Tschannen, D., Argetsinger, D., Hakim, H., &amp; Milner, K. A. (2022). A qualitative study on barriers and facilitators of quality improvement engagement by frontline nurses and leaders. <em>Journal of Nursing Management, 30<\/em>(3), 694-701. <a href=\"https:\/\/pubmed.ncbi.nlm.nih.gov\/34969172\/\" target=\"_blank\" rel=\"noopener\">htttps:\/\/doi.org\/10.1111\/jonm.13537<\/a>. <a href=\"#return-footnote-202-17\" class=\"return-footnote\" aria-label=\"Return to footnote 17\">&crarr;<\/a><\/li><\/ol><\/div><div class=\"glossary\"><span class=\"screen-reader-text\" id=\"definition\">definition<\/span><template id=\"term_202_448\"><div class=\"glossary__definition\" role=\"dialog\" data-id=\"term_202_448\"><div tabindex=\"-1\"><p>An investigation by insurance agencies and other health care funders on services performed by doctors, nurses, and other health care team members to ensure money is not wasted covering things that are unnecessary for proper treatment or are inefficient.<\/p>\n<\/div><button><span aria-hidden=\"true\">&times;<\/span><span class=\"screen-reader-text\">Close definition<\/span><\/button><\/div><\/template><template id=\"term_202_449\"><div class=\"glossary__definition\" role=\"dialog\" data-id=\"term_202_449\"><div tabindex=\"-1\"><p>Using information and technology to communicate, manage knowledge, mitigate error, and support decision-making.<\/p>\n<\/div><button><span aria-hidden=\"true\">&times;<\/span><span class=\"screen-reader-text\">Close definition<\/span><\/button><\/div><\/template><template id=\"term_202_450\"><div class=\"glossary__definition\" role=\"dialog\" data-id=\"term_202_450\"><div tabindex=\"-1\"><p>The science and practice integrating nursing, its information and knowledge, with information and communication technologies to promote the health of people, families, and communities worldwide.<\/p>\n<\/div><button><span aria-hidden=\"true\">&times;<\/span><span class=\"screen-reader-text\">Close definition<\/span><\/button><\/div><\/template><template id=\"term_202_451\"><div class=\"glossary__definition\" role=\"dialog\" data-id=\"term_202_451\"><div tabindex=\"-1\"><p>A systematic process using measurable data to improve health care services and the overall health status of patients.<\/p>\n<\/div><button><span aria-hidden=\"true\">&times;<\/span><span class=\"screen-reader-text\">Close definition<\/span><\/button><\/div><\/template><\/div>","protected":false},"author":32,"menu_order":3,"template":"","meta":{"pb_show_title":"on","pb_short_title":"","pb_subtitle":"","pb_authors":[],"pb_section_license":""},"chapter-type":[48],"contributor":[],"license":[],"class_list":["post-202","chapter","type-chapter","status-publish","hentry","chapter-type-numberless"],"part":191,"_links":{"self":[{"href":"https:\/\/pressbooks.ccconline.org\/accnursing2030\/wp-json\/pressbooks\/v2\/chapters\/202","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/pressbooks.ccconline.org\/accnursing2030\/wp-json\/pressbooks\/v2\/chapters"}],"about":[{"href":"https:\/\/pressbooks.ccconline.org\/accnursing2030\/wp-json\/wp\/v2\/types\/chapter"}],"author":[{"embeddable":true,"href":"https:\/\/pressbooks.ccconline.org\/accnursing2030\/wp-json\/wp\/v2\/users\/32"}],"version-history":[{"count":2,"href":"https:\/\/pressbooks.ccconline.org\/accnursing2030\/wp-json\/pressbooks\/v2\/chapters\/202\/revisions"}],"predecessor-version":[{"id":571,"href":"https:\/\/pressbooks.ccconline.org\/accnursing2030\/wp-json\/pressbooks\/v2\/chapters\/202\/revisions\/571"}],"part":[{"href":"https:\/\/pressbooks.ccconline.org\/accnursing2030\/wp-json\/pressbooks\/v2\/parts\/191"}],"metadata":[{"href":"https:\/\/pressbooks.ccconline.org\/accnursing2030\/wp-json\/pressbooks\/v2\/chapters\/202\/metadata\/"}],"wp:attachment":[{"href":"https:\/\/pressbooks.ccconline.org\/accnursing2030\/wp-json\/wp\/v2\/media?parent=202"}],"wp:term":[{"taxonomy":"chapter-type","embeddable":true,"href":"https:\/\/pressbooks.ccconline.org\/accnursing2030\/wp-json\/pressbooks\/v2\/chapter-type?post=202"},{"taxonomy":"contributor","embeddable":true,"href":"https:\/\/pressbooks.ccconline.org\/accnursing2030\/wp-json\/wp\/v2\/contributor?post=202"},{"taxonomy":"license","embeddable":true,"href":"https:\/\/pressbooks.ccconline.org\/accnursing2030\/wp-json\/wp\/v2\/license?post=202"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}