Total quality management (TQM) and continuous quality improvement (CQI) continue to be commonly encountered approaches to quality management and improvement [4]. TQM is an important process for staff nurses and administrators alike. It is useful to staff nurses in two ways: it provides them with feedback about the nature of their individual practice and provides them with opportunity to influence patient care in their organization. Administrators use it to assess the general quality of patient care provided within their organizations and as a process to receive and communicate opportunities to enhance patient care and organizational effectiveness.

A process of establishing and maintaining organizational effectiveness (i.e., the quality of care provided to patients), TQM is an institutional plan of action to empower staff to influence corporate achievement of the highest possible standards for patient care. The delivery of patient care is monitored by all staff to ensure that established standards are met or surpassed. Implicit in the concept of TQM is the ongoing evaluation of the standards themselves, thus ensuring that they reflect current norms and practices in healthcare. Organizations use a variety of formal and informal means to gather information to evaluate the quality of care provided to patients. The formal means are encompassed in a quality assurance program. Information needs associated with quality assurance might include patient care databases, patient evaluations of care received, nurses’ notes on the chart, patient care plans, performance appraisals, and incident reports. These sources of information are reviewed by either a concurrent or retrospective audit. Concurrent nursing audits occur during the patient’s stay in the hospital, whereas retrospective nursing audits occur after the patient leaves the hospital. Audit reviews are a major tool for any TQM program.

The literature referring to the development of quality in healthcare ranges from 30 years to 3,000 years as identified by historians. The impetus for the establishment of quality assurance programs emerged during the 1970s as the result of rising consumer awareness, increasing healthcare costs, and the growing professionalism of nursing [5]. An additional factor was the desire of governments to monitor the cost and quality of care associated with its healthcare programs. Almost simultaneously, three things happened: professional standards review organizations were established in a number of countries such as the United States, Canada, and Australia (as available at organizations including the Canadian Nurses Association www.​cna-aiic.​ca, Nursing World www.​nursingworld.​org, or the Australian Nursing & Midwifery Federation www.​anf.​org.​au), standards of practice were developed and published by nursing organizations, and accreditation organizations were created. For example, the American Joint Commission on Accreditation for Hospitals established the requirement for medical and nursing audits. This resulted in organizations requiring the collection of massive amounts of data. Transforming this data into information for multiple purposes added pressure to the entire quality assurance process, which became dependant on the timely processing and review of this data, in turn consuming enormous amounts of nursing time. As these audits were done, healthcare professionals gained an increased awareness of the variability in documentation practices and its link to data quality. This resulted in improved documentation in the form of nursing care plans and patient records, and further increased the volume of information to be reviewed and evaluated in the nursing audits.

As the pressure continued to increase regarding enhanced data quality, documentation comprehensiveness and the need for timely health information to assist clinicians in delivering healthcare, integrated hospital information systems made their entry into the healthcare delivery system. Quality assurance/improvement programs in nursing needed two things to succeed: standardized terminology and standardized care plans. These two elements were also required if information systems were to be any help to nurses in providing nursing care regardless of the health care setting while ensuring seamless delivery of care across the continuum of care. The standardization of terminology required for computerized documentation of nurses’ notes, and the development of standardized care plans, coincided with the need for standardized terminology, development of patient care standards and quality improvement programs (see Chap.​ 7). Quality assurance or quality improvement programs are now implemented in most healthcare organizations and are key for management at all organizational levels.

Health information terminology for clinical documentation is an important component of the EHR [6]. One implementation aspect of these terminology standards is the development and use of minimum data sets (MDS). MDS have been developed and used to document clinical information across all health care settings and specialities. The Resident Assessment is an example of a minimum data set standardized tool. These Resident Assessments have been developed to collect assessment information in different clinical settings such as long term care, nursing home, rehabilitation, complex continuing, and mental health. The report “Highlight of 2012–2011 Inpatient Hospitalizations and Emergency Department Visits” published by the Canadian Institute for Health Information (CIHI) is an example on how data can be used [7]. In Canada, the Data Set C-HOBIC (Canadian Health Outcomes for Better Information and Care) includes standardized terms and concepts linking nursing practice and patient outcomes in the EHR (see the Canada Health Infoway, https://​www.​infoway-inforoute.​ca/​index.​php/​programs-services/​standards-collaborative/​pan-canadian-standards/​canadian-outcomes-for-better-information-and-care-c-hobic and C-HOBIC, http://​c-hobic.​cna-aiic.​ca/​default.​aspx websites).

The ability of a computer to retrieve, summarize, and compare large volumes of information rapidly has proven useful for managers charged with the responsibility of implementing quality assurance programs. The first obstacle to using computers for this purpose was the lack of widespread availability of integrated hospital information systems. The second obstacle was the lack of a widely implemented common nursing vocabulary and methods of coding nursing diagnoses and interventions (see Chap.​ 7). Both obstacles are being overcome with the integration of sophisticated information systems. Taxonomies for nursing diagnoses, interventions, and contributions to patient care outcomes have been developed [8]. Some of the taxonomies include NANDA (www.​nanda.​org), Nursing Intervention Classification (NIC), and Nursing Outcomes Classification (NOC). (For more information, see the following website: http://​www.​nasn.​org/​PolicyAdvocacy/​PositionPapersan​dReports/​NASNPositionStat​ementsFullView/​tabid/​462/​ArticleId/​48/​Standardized-Nursing-Languages-Revised-June-2012). Unfortunately, much of this work has not yet received widespread implementation in the nursing profession and its different practice settings. It is only starting to be incorporated as a framework for the organization of nursing databases by developers of information systems.

Another challenge associated with computerized quality assurance programs is the limitations of the data entry tools. Consequently, much effort has been focused on the process aspects incorporated in the TQM concept. Unfortunately, the vendors of computer software have not given high priority to the information needs related to TQM or the development of clinical software packages for healthcare organizations. This situation has created a major barrier to the effective, widespread use of information systems for quality monitoring in hospitals. Several organizations have developed TQM programs that incorporate procedures for conducting concurrent chart audits. These organizations use a manual concurrent audit conducted by staff nurses with special training in concurrent clinical auditing during the delivery of health care services (www.​currentnursing.​com) on the patient care units. The data from the completed audit forms are then put into the computer for tabulation, summarization, and analysis. This combination of manual and computer methods partially reduces the labour-intensive process associated with totally manual audits. As healthcare technologies and standards are being deployed in healthcare organizations, this is assisting managers to support quality improvement processes. The data collected, when transformed into information, has provided valuable insight in use of services within health care organizations. The reports “Highlights of 2010–2011 Selected Indicators Describing the Birthing Process in Canada” and “Highlight of 2010–2011 Inpatient Hospitalizations and Emergency Departments Visits” published by the Canadian Institute for Health Information (CIHI) are examples of how data can be used.

There is a growing emphasis on patient care outcomes as the major focus of nursing TQM programs. Similarly, there is a growing trend away from the problem resolution model to a planning model as the major criterion for measuring quality assurance. Simultaneously, there is an increasing demand from the public for better resource management in the healthcare sector, and the public has an increasing awareness of quality as a cost component of healthcare. As nursing leaders, we need to process, analyze, and make timely decisions ranging from practice to management and planning perspectives. These factors are creating a demand for more sophisticated computerized information systems that are able to handle and process data which can be transformed into information to will support decision making.