9.3 Measuring and Improving Quality
Now that we have discussed the various ways that quality health care is defined, let’s discuss how quality care is measured, evaluated, and improved.
Utilization Review
Thinking back to value-based reimbursement models discussed in the “Health Care Economics” chapter, recall how 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 clients’ needs. Information from clients’ medical records is analyzed, along with client demographics, to evaluate resource allocation, efficiency, and quality of health promotion initiatives.[1] See Figure 9.3[2] for an illustration of utilization review related to costs.
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.[3] 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.[4] It is a nursing specialty with certification available from the ANCC. See Figure 9.4[5] for an artistic rendition of informatics.
These are several benefits of using informatics in health care[6]:
- Improvement of Client Safety: 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.
- Reduction of Delays in Care: 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.
- 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, clients can request their records be shared with health providers from other heal