6.2 Quality Improvement Measures

Measuring Outcomes

An important aspect of quality improvement is the use of measures, also referred to as metrics, to identify the level of change on specific elements of the project.  The Institute for Healthcare Improvement(IHI) provides a white paper on Whole System Measures (Martin et al., 2007). The IHI white paper identifies a system of existing metrics that impact quality in a health system.  These metrics are unique to each health system and should be considered as the leader selects measures for their specific project. Depending upon the scope of the project, multiple measures are utilized.

IHI identifies three types of measures that are used in for improvement efforts. They include outcomes measures, process, measures and balancing measures (IHI, n.d.).

For this textbook, we are focusing on Outcome and Process measures examples from the IHI. Process measures can be considered indicators that are measured at specific intervals of the project. Process measures are vital for success of a project as they can inform leaders of the need to change the direction throughout the project, as opposed to waiting until the end of a change project.

Process Measures (IHI, 2019)

Are the parts/steps in the system performing as planned? Are we on track in our efforts to improve the system?

  • For diabetes: Percentage of patients whose hemoglobin A1c level was measured twice in the past year
  • For access: Average daily clinician hours available for appointments
  • For critical care: Percentage of patients with intentional rounding completed on schedule

Outcome measures are those that indicate change at the end of a specified period of time.

Outcome Measures (IHI, 2019)

How does the system impact the values of patients, their health and wellbeing? What are impacts on other stakeholders such as payers, employees, or the community?

  • For diabetes: Average hemoglobin A1c level for population of patients with diabetes
  • For access: Number of days to 3rd next available appointment
  • For critical care: Intensive Care Unit (ICU) percent unadjusted mortality
  • For medication systems: Adverse drug events per 1,000 doses

Use of existing measures is ideal so change can be tracked over a period of time. This box shares some examples of existing measures.  Additional measures are described in further detail in the pages below.

Examples of Existing Measures (IHI, 2019)

  • Patient/client satisfaction surveys
  • Length of stay
  • Adverse events
  • Staff turnover rates
  • Staff-to-patient ratio
  • Infection rates
  • Employee satisfaction surveys

Utilization Review

Health care agencies are reimbursed from Medicare, Medicaid, and private insurance based on their quality performance measures. A utilization review 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 patients’ needs. Information from patients’ medical records is analyzed, along with patient demographics, to evaluate resource allocation, efficiency, and quality of health promotion initiatives (Institute of Medicine, 1989).

Using Informatics to Promote Quality

Utilization review relies on the collection of meaningful data from health records to determine if quality metrics are being met. Informatics refers to using information and technology to communicate, manage knowledge, mitigate error, and support decision-making (QSEN, n.d.). Informatics allows members of the health care team to share, store, and analyze health-related information. Nurses have an important role in informatics. Nursing informatics is the science and practice of integrating nursing knowledge with information and communication technologies to promote the health of people, families, and communities worldwide (AMIA, n.d.). It is a nursing specialty with certification available from the ANCC.

These are several benefits of using informatics in health care (Otokiti, 2019):

  • Improvement of Patient Safety: Informatics allows for up-to-date information sharing by both the patient and members of the health care team. Using informatics can help to reduce the occurrence of medication errors, as well as monitor patient side effects and overall health status. For example, barcode scanning has reduced medication errors by ensuring the correct dose is administered to the correct patient at the correct time.
  • Reduction of Delays in Care: Some health care informatics systems allow for direct communication between health care team members and patients. 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.
  • Reduction of Waste: 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, patients can request their records be shared with health providers from other health organizations, which reduces duplication and unnecessary spending across the nation.
  • Promotion of Patient-Centered Care: Many informatics systems have “patient portal” options where the patient and/or designated personnel are able to be active participants in the care planning and health promotion processes. Informatics offers an inclusive environment for patients to communicate and share directly with their care team regardless of physical location and timing.
  • Support of Quality Improvement: 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.

Quality Indicators

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 (Montalvo, 2007):

  • Nursing Care Hours Per Patient Day
  • Hospital-Acquired Pressure Injuries
  • RN Job Satisfaction

Nurses use quality indicators to support practice changes with evidence directly related to improved patient outcomes.

Learn More

Read about current quality measures promoting clinical excellence at the Press Ganey website.

Next: 6.3 Spotlight Application



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Leading Change in Health Systems: Strategies for RN-BSN Students Copyright © 2023 by Kathy Andresen DNP, MPH, RN, CNE is licensed under a Creative Commons Attribution 4.0 International License, except where otherwise noted.

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