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James Gayle, Amanda Larkins  Abduselam Sheka, Madison Stribling, Jamison Walker

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Overview of Quality Safety Measures in Organizations

A quality dashboard is a graphic representation highlighting trends, performance measures, issues, and risks related to the saftey of patients. Dashboards are used to evaluate everything going on within the healthcare system.  “It is thought that the visualizations provided by quality dashboards can lead to the identification of previously unnoticed patterns in data 8 , informing quality improvement initiatives, and more efficient and effective decision making 9 .” (Randell, 2020 pg. 735) At an organizational level dashboards are used worldwide to monitor the quality of care provided by every hospital and are in turn used to improve quality care. “Healthcare organizations worldwide are increasingly using quality dashboards as a way of monitoring the quality of care they provide and as the basis for quality improvement initiatives” (Randell,2020 pg. 735) At a unit level, quality dashboards are used to monitor exactly what is taking place on that unit, focus on quality of care, issues within that unit and provide adjustments based on the data collected by the dashboard.  " dashboards provide clinical leaders with continuous information that is timely and focused on both internal performance and marketplace comparisons that enable leaders to put their internal data in comparative perspective."  A quality indicator is a measure that provides feedback for the saftey, effectiveness, and quality of care provided.  “quality indicators are defined as quantitative measures that provide information about the effectiveness, safety and/ or people-centredness of care.” (Busse, 2019 pg.33) A performance measure indicates how well the unit/hospital is performing and can indicate areas of improvement and highlight areas of success.  Performance measurement is another area that lends itself to synergy between clinical guidelines and healthcare data. More and more guideline groups develop quality indicators along with the recommendation sets (Blozik et al., 2012)." (Busse, 2019 pg. 254) Data is collected by what is entered through the computer system, based on reports, charting, and electronic data entered in the computer.  “The question of how to obtain data to feed the  dashboard  largely depends on fiscal, privacy and infrastructure constraints. Options include anything from manual chart review to electronic data warehouse sampling.” (Barnum, 2019) The importance of quality dashboards are to improve the quality of care within the unit levels and overall organizational levels, in every hospital. It helps healthcare providers to identify what works and what needs to be adjusted within the system.  “Healthcare organizations worldwide use quality dashboards to provide feedback to clinical teams and managers, in order to monitor care quality and stimulate quality improvement.” (Randell, 2020 pg. 735)

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Interpretation of Individual Indicator Using Assigned Indicator on Dashboard.

Two types of indicators are  important in monitoring CAUTI. Incidence, which is the number or percentage of people developing CAUTI while at the facility. Prevalence rate, which is the number or percentage of people having CAUTI in the unit at a given time. Quality indicators are tools that measure system performance and health care quality and demonstrate the extent to which improvement efforts have led to desirable changes (Santana, 2019) Incidence rate captures only new CAUTI developing during an admission. Whereas prevalence rate include all CAUTI present in a group of patients.  Performance measure is done by examining the rates of incidence over period  of time and then looking for any trend over time. This evaluation is done to assess if there is an improvement or not.  Then root cause analysis is performed  to determine the trend. If the rate of incidence is increasing, contributing factors are addressed and further training is needed to be  implemented. Such assessment provide the chance to assess current short coming in order find a better clinical guidelines that will addressee the contributing factors.  Systematically developed, evidence-based clinical guidelines are important tool to inform decision-making in the context of health emergency as they can allow for evidence-based recommendations (Florez, 2018) Addressing indicators in advance before the occurrence of any adverse events is an important factor in a health care setting because this minimizes the chance of patients being exposed to harm. Harms that can be caused by CAUTI includes patient discomfort, increased mortality, longer length of hospital stay and higher healthcare coast. Most CAUTI can be prevented if evidence-based practice guidelines for indwelling urinary  catheter care are followed (Ferguson, 2020) Knowledge of indwelling CAUTI contributing factors such as proper indwelling catheter care use and other CAUTI prevention interventions that include staff education have a positive impact on minimizing the number of CAUTI in a health care settings ( Andrioli  et al., 2016)   CMS measure, and private insurance penalties play a major role in patients' outcome. Rewarding those health care providers with a greater satisfaction rating and penalizing those with poor rating will force health care providers to focus on patients' satisfaction instead of addressing the root cause of their disease.  CMS reimbursement policy is not related to reduction of nursing-sensitive hospital-acquired adverse events. Hospitals with a greater proportion of patient's discharges paid to Medi-Care reported  a greater likelihood for occurrence of pressure ulcer, infections from urinary catheter and vascular catheter associated infections. (Sung-Heui Bea 2016)

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Investigation how CAUTIs occur and ways to prevent CAUTIs

It is important to take a deeper look into catheter associated urinary tract infections due to the increasing occurs of CAUTIs and the complications that could occur. Knowing why CAUTIs occur can allow us to then practice ways to prevent CAUTIs from occurring.  CAUTI can cause several different health complications.    CAUTIs can lead to a secondary bloodstream infection (Flores-Mireles; 228). CAUTIs of prolonged urinary catheterization results in ongoing epithelial irritation and persistent inflammation and has been linked with development of proliferative pathologies including squamous carcinoma, keratinizing squamous carcinoma, or cystitis granularize (Flores-Mireles; 230).   Catheter associated urinary tract infections occurs for various reasons such as improper hygiene, break of sterile field, and prolonged use of a catheter.  Bacteria are usually introduced to the urinary tract either during catheter placement or after placement (McNeill; 204). Bacteria can also be due to inadequate cleansing of the perineal area prior to insertion of the catheter (McNeill; 204). It is important to keep the tap of the bag clean when draining because it not bacteria can enter this way (McNeill; 204). Another cause of CAUTIs is poor hygiene compliance (Gesmundo; 16).  It is also important to leave catheter for the shortest amount of time possible because the longer they are in place increases the risk for infection.  If health professional provide the proper hygiene before, during, and after catheters this significantly decreases the chance of a CAUTI. Making sure that catheters are also in places for the correct time needed play an important role in decrease CAUTIs.  After 30 days with an indwelling catheter the risk for a CAUTI is 100% (McNeill; 206).  Implications that can be made are that if proper procedures aren't followed, the risk of CAUTI's increases. For instance, if health professional can implement the practice of proper hygiene before placing a catheter, or prior to cleaning a catheter, then this action can reduce the risk of a CAUTI.  "eight out of ten healthcare associated UTI of due to poorly managed urinary catheters (Gesmundo; 15)." Why health professional need to be aware of CAUTIs. It is important that health professionals understand why CAUTIs are such a big deal. Without proper education, and training implemented health professionals can increase the client's risk for more serious infections. Causing this hospital acquired infection can result in the hospital paying out millions of dollars. If nurses can make sure that catheters are being properly cared for this can reduce the risk of deaths and cost for the hospital.   "CAUTIs are the most common healthcare associated infection worldwide (Gesmundo; 15)." Health professional should also be aware that "the risk for a CAUTI increases 3-7 % each day after placement (Flores-Mireles; 230)." It is also important to note that CAUTIs can lead to deaths and cost hospitals millions of dollars. Healthcare associated CAUTI result in around13,000 deaths and increase hospital cost by an estimated $450 million a year (McNeill; 204).

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Possible Changes that Can Be Made to Improve the Indicator.

Five evidence based, best practice interventions to address the indicator on the dashboard include, Appropriate use: assess the need for an indwelling catheter and use alternatives when available (McNeill, 2017) How to address: Most catheters that are inserted are not necessary and can lead to development of an infection. “Catheters are often placed for non-critical reasons (i.e., incontinence or nursing staff convenience) and may be left in place because providers inadvertently forget to order catheter removal. In fact of the five million catheters placed annually in the U.S., 50% are not medically necessary” (McNeill, p205, 2017). Why effective? By assessing appropriate use this reduces rates of unnecessary catheters and reducing the chance of receiving a CAUTI. “Rather than requesting an order for catheter placement when a patient is incontinent, nurses should consider more frequent bathroom rounds, intermittent catheterization, or the use of external catheters” (McNeill, p205, 2017). Proper technique when inserting catheter, following guidelines and use of aseptic technique (McNeill, 2017). How to address:  Implementation of proper training and education on catheter insertion and guidelines are essential to limiting infection. “Education was provided for all staff regarding indwelling urinary catheter insertion techniques via hands on demonstration to ensure consistency of practice. Education also included draining the catheter bag at 350 ml to 500 ml or every four hours and prior to patient transport, ambulation, or transfer” (Maxwell, p40, 2018). Why effective? Proper aseptic technique can lead to effective results without cause of infection if education is provided effectively and catheters are kept track of. “In the majority of cases, a nurse inserts the catheter; therefore, use of a nursing policy or guideline for catheter insertion, education, nursing competencies, and random audits of catheter insertion may be helpful in promoting correct placement and adherence to protocol” (McNeill, p205, 2017) . Use of appropriate catheter tracking data by documenting catheter information including date of insertion, indications, and removal date ( Elpern , 2016) How to address: As nurses it is important to communicate when giving report to another nurse on shift change. Vital information such as when the catheter was placed and when it was removed can improve the patients well-being and promote self -activity. Why effective? Documentation can help nurses pay attention to how long indwelling catheters have been placed for and if they are still necessary. It’s important to check daily and use your judgement as a nurse to remove a catheter if necessary. “Daily, review the necessity for catheter continuation for all patients with urinary catheters. Develop systems to ensure prompt removal of catheters when no longer indicated; consider nurse driven removal protocols” ( Elpern , p10, 2016). Proper maintenance of catheter (McNeill, 2017). How to address: Making sure we are providing proper maintenance for a catheter is another way we can prevent CAUTI’s. We do this by using   evidence-based guidelines for catheter management while in place such as: hand-washing and glove use when handling catheter, proper securing of catheter to leg, maintaining closed system and unobstructed flow, and daily  pericare  (McNeill, 2017). Why effective? Following proper maintenance will decrease the chance of developing an infection due to stringent protocols set in place. One example is keeping tubes from becoming kinked, which will help prevent bacterial growth and urinary backflow. Timely removal of indwelling catheter (McNeill, 2017). How to address: As a nurse we don’t want to leave the catheter in for long periods of time. This can lead to the likelihood of acquiring an infection, which in turn will increase hospital stay. “The risk of developing a bacteriuria is as high as 3% to 10% per day of catherization, reaching close to 100% after placement for 30 days” (McNeill, p 206, 2017). Why effective? Removing the catheter when no longer needed is extremely important and can aid in time a patient can recover in. There have been interventions introduced in which a nurse can decide when to remove the catheter regardless of written order. “These protocols have been shown to reduce the length of time an indwelling catheter is in place, resulting in a decrease in the CAUTI rate” (McNeill p 206, 2017). Evidence based protocols from the guidelines of the CDC are relevant to our practice because they show a decrease in CAUTI infections. “The CDC guidelines for prevention of CAUTI(2009) was used as the source for EBP and PI. Interventions focused on processes included: a two-person urinary catheter insertion checklist (wingman), non-invasive alternatives to urinary catheters, daily audits of bundle compliance and device removal (nurse driven protocol), urinary retention protocol, and guidelines for indications for urine culturing. After implementing these interventions, the number of CAUTIs was measured. Interventions (wingman, audits, guidelines, and protocols) decreased CAUTIs from 15 to 2” ( Stancovici  & Galvan-Anderson, p 13, 2019)   Changes can be made by utilizing different protocols such as: collecting urine specimens when inserting new catheters, clean catheters every 12 hours, having 2 registered nurses present when inserting a catheter to ensure sterile technique, adopting CDC changes of EHR orders for indwelling catheters, and a new nurse driven protocol for removal of indwelling catheters.   The recommendations above were actually implemented and are proven as in the case with an ICU/IMCU in Colorado. “After one year CAUTI free, the ICU/IMCU celebrated the accomplishment with “Zero” candy bars and a banner hung in the department recognizing the effectiveness of their hard work” (Maxwell, p 41, 2018).

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How the EHR Can Be Used in the Monitoring of Quality Indicators.

As more known best practices produce continued positive outcomes; providers can be guided via purposefully  implimented  EHR input fields in order to guide their actions based upon QI recommendations.  Forced system  reuirements  for the attending physician to select an indication for catheter insertion from a pre-established list and force-pushed notifications of a recommendation for discontinuation of an established catheter via the daily information input by the nurse regarding urinary concerns have both been shown to help greatly reduce the  prevolance  of CAUTI incidents.  " Through these measures, the device utilization ratio for urinary catheters (catheter-days/patient-days) was reduced by 28% to 0.51 in the ICUs and 0.13 in the non-ICUs—lower than the national reported rates of 0.60 for ICUs and 0.17 for non-ICU wards in 2013. 18"   (Sampathkumar et al., 2016) User Interface adaptations to a more streamlined approach with a reduction in redundant selections/prompts results in a more positive outcome of patient condition.  By managing these types of information points, providers were able to prevent the occurrence of a CAUTI to a higher degree.  EHR systems such as those used at the Mayo Clinic have initiated a user  inferface  system based on the  follwing :  " Three changes to the EHR were implemented to support compliance with the bundle, as follows: Documentation of catheter/perineal care was standardized. This meant that these data could be retrieved from the EHR and feedback on compliance provided to nursing units. A protocol to facilitate ordering of bladder scans by nurses was created. This was aimed at minimizing unnecessary irrigations in patients with low urine output. Changes to the process of ordering urine cultures were made. These made it mandatory for providers to select from a list of appropriate indications, which resulted in a 50% decrease in urine cultures."  (Sampathkumar et al., 2016). The constant analyzation of data from CDSS systems is a key factor in CAUTI prevention via EHR utilization. The presence of a CDSS system in all reviewed articles was essential for the presence of force-pushed notifications for recommended care and discontinuation times as noted in Rhee et al.  " We educated the staff on the new policy and decision tree and designed the EHR to drive practice, in which the EHR provided a clinical decision support system, with indications for insertion, continuation, and discontinuation of urinary catheters embedded in the documentation work flow of the nurses. The forced function that we embedded in the EHR drove the staff to assess the indications for urinary catheter continuation on a daily basis."  (Rhee et al., 2016). Forced prompts/alerts/reminders ensure that all staff attending to the patient in question are aware of continued changes and recommendations in care based on facility protocols  embeded  within the CDSS of the EHR.  Force push and required data input fields ensure that all providers see the  relavent   inforamtion  that has been established by the  anylization  of the input data into the EHR. This requires a streamlined trial and error phase to ensure facility protocol compliance as stated in the Mayo Clinic report: ' Implementation of an ordering screen that required providers to select from a list of appropriate indications when ordering a urine culture was successful at reducing  unneccesary  urine cultures—but this success was short lived as residents found ways to bypass the screen. Additional changes to the EHR were needed to eliminate the residents’ workarounds.'     (Sampathkumar et al., 2016) Continued data analysis from the EHR will continually track patient condition changes from start to finish by proper CDSS utilization.  By utilizing a comprehensive  discision  support system, the continued influx of information into the EHR helps to guide the nurse to the proper course of action by recognizing the signs of changes in condition based on the pre-established computing  algorythm . Through this, the nurse is alerted through a system of prompts, alerts, and reminders.  (Walker-Czyz, 2016)

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Role of the BSN Nurse and Leadership skills

When facilitating the change to improve quality, it is important to have strong leadership in the BSN nursing roll. Not only having a strong sense of leadership, but the willingness to understand, and implement a project to create the change needed . “The key to transformational change or any change is to have leadership that is able to understand it, support it, explain it, and move the organization to commit to it. That is 95% of the success of any change. (Gesme p. 257) • The change process is impacted based on the nurse's ability to organize and commit fully to change. This will create an environment where ideas are shared for the best implementation of change of practice within the healthcare system.     “Nurse managers and leaders play an important role to create an environment that fosters and encourages innovation. Nurse leaders must create environments and opportunities for staff innovation; communicate expectations concerning time commitments and acceptable levels of risk; and allow for failures (Boston-Fleischhauer, 2016)” • Direct change comes from proper communication, organizational tactics, and encouragement from leaders to team members. Having the ability to inspire team members to adapt to the changes in a positive manner will reinforce the changes being made. “A number of key characteristics of team-based leadership have been identified – power, focus on outcomes, relationships, valuing of others, responsibility and accountabilities (Orchard and  Rykhoff  2015: 80). The unique elements in collaborative team-based practice relate to interdependency in tasks, sharing in responsibilities for outcomes, viewing themselves as part of a cohesive group and having the ability to manage their relationships across boundaries (Orchard 2015: xviii).” The involvement of the change process includes the leader, physicians, and team members involved. This shared vision should be communicated to everyone and should be continually emphasized on the importance of the change.  “An appropriate leadership structure, in-  cluding  a leader and physicians who are committed to the vision and willing to support it, is key to transformative change. All of the physicians in the practice need to be team players, including taking responsibility for the entire practice and being willing to recognize the leader’s authority (Gesme, p.257)”  Using technological advances in today’s society can help track whether or not a change has made a positive, or negative impact. Monitoring these changes in data collection can help healthcare providers understand where their strengths, and flaws, are within the system during change. It is important for the leader to note whether or not improvement has been made after the change has been in place.  “Walker-Czyz (2016) researched how quality of nursing care was impacted by utilization of an integrated EHR and reported that nurses can utilize integrated EHRs with computerized documentation at the bedside to improve patient care. (Thomas, 2016). ”

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Informatics plays a huge roll when it comes to overall patient outcomes. Being able to use widespread data to help facilitate positive change can create a safer environment for patients. “The widespread adoption of electronic health records (EHR) has produced large amounts of data that can be queried to elucidate patterns and trends that may have been previously unrecognized (Stifter et al., 2015).” By acknowledging data input about catheter associated urinary tract infections, healthcare providers can observe what causes a rise, or decrease, with this infection specifically. If there is no measurement on this type of data, how will improvements be made?  “Taking this one step further, if providers and staff do not have access to outcomes data, then they will not understand what needs to be improved (Barnum, 2019)”  By having a comparison of negative, and positive, trends through widespread data access can help ensure that the safest, and most up to date, practices are in place for the client.  "Big data analysis using machine learning techniques enables the investigation of unknown patterns and relationships among numerous factors. Because there are many factors associated with HA-CAUTIs. it is important to look at each factor’s association in addition to the interactions of those factors (Park, p.9)”  Being able to find trends that are directly related to catheter-associated urinary tract infections, and adjusting the practice, can minimize the infection rate. Narrowing the infection rate of CAUTI as minimally as possible is the ultimate goal. “If we are able to identify factors that are associated with the development of CAUTIs, we will then be able to modulate our preventive strategy, accordingly, specifically modifying the standard of care for hospital practice as well as implementing targeted electronic alerts, such as alerting at a higher frequency for  paedi -  atric  patients (Letica-Kriegel, p.4)” The correlation of the data-knowledge-wisdom continuum, and informatics is simply a critical component in the reform of healthcare. Having the usability of the electronic health record to access data can provide an overall level of care that benefits the client in the safest way possible.  “The widespread adoption of EHRs was intended to address long-standing issues related to cost, quality, and access to health care services in the United States (Nation, 2019).”

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A performance measure is used to reflect on the care being provided and indicates flaws within the system or guidelines being misinterpreted.  "While these are usually primarily intended as general performance measures (i.e. the guideline, as a summary of best knowledge, informs the choice of indicator), a closer look at measurement results can provide insights on the extent to which practice reflects guideline recommendations (i.e. the indicators inform  Monitoring for performance deficit is key in order to see where flaws are within the system, and for change of practices to be implemented. This also ensures healthcare providers are using the most up to date, safe practices for the clients. Without seeing a deficit in performance, how can something be improved upon?  According to a systematic review from the Agency for Healthcare Research and Quality (AHRQ), health information technology (HIT) systems, especially EHRs, can enhance guideline-adherent care delivery, improve quality of care through clinical monitoring, and reduce medical error rates in a cost-effective and viable way (Chaudhry et al., 2006; Linder, Ma, Bates, Middleton, & Stafford, 2007)  Utilizing best practices improves the deficit by increasing techniques that are proven to work. Educating on the use of the CAUTI bundle and the CAUTI maintenance tool is a prime example. " A PowerPoint presentation (Appendix D) was created which highlighted the CAUTI bundle guidelines along with the CAUTI bundle maintenance tool. Education was provided to the nursing staff on all the sub-section of the maintenance tool by applying Knowles’s Malcolm theory. De-identified data was provided for over a month post education. The result showed zero CAUTI rates in February" "(Ali, p30, 2018). The financial implications for CAUTI amongst hospitals ranges anywhere from hundreds, to thousands of dollars per client. This amount of money quickly adds up and is replaced with billions by the end of the year.  In 2016 U.S. dollars, the reported attributable costs of CAUTIs were $876 (inpatient costs to the hospital for additional diagnostic tests and medications); $1,764 (inpatient costs to Medicare for non-ICU patients); $7,670 (inpatient and outpatient costs to Medicare); $8,398 (inpatient costs to the hospital for pediatric patients); and $10,197 (inpatient costs to Medicare for ICU patients). ( Hollenbeak , p.5)" The EHR, and informatics are key aspects in implementing safer practices in healthcare by finding positive, negative, and hidden trends within a set of particular data. The use of compiling collected accurate data, and analyzing what changes needed to be made can provide insights for the most up-to-date, and efficient, methods in healthcare  "Large sample sizes and the integration of multiple data sources using a KDDM approach have advantages in discovering hidden information from data and adding new predictors such as social, behavioral, and environmental factors to the analysis. It allows nursing researchers to generate new insights and knowledge and to create evidence-based guidelines for the clinical field. (Park, p.3)"

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Ali, Y. (2018). Decreasing CAUTI rates by educating staff on reinforcing the CAUTI bundle.  Decreasing CAUTI rates by educating staff on reinforcing the CAUTI bundle , 1. Andrioli , E. (2016). Catheter-associated urinary tract infection after cardiovascular surgery: Impact of a multifaceted intervention.  American Journal of Infection Control. ,  44 (3), 289– 293. Doi: 10.1016/j.ajic.2015.09.030 Barnum, T. J., Vaez, K., Cesarone, D., & Yingling, C. T. (2019). Your Data Looks Good on a Dashboard.  Online Journal of Nursing Informatics,  23(3), 10-11. Busse, R.,  Klazinga , N., Panteli, D., & Quentin, W. (Eds.). (2019).  Improving healthcare quality in Europe: Characteristics, effectiveness and implementation of different strategies . European Observatory on Health Systems and Policies. Elpern , E. (2016). Prevention of catheter-associated urinary tract infections in adults.  Critical Care Nurse ,  36 (4), e9–e11.  https://doi.org/10.4037/ccn2016208 Ferguson, A. (2020). Implementing a CAUTI Prevention Program in an Acute Care Hospital Setting.  Med-Surg Matters ,  29 (2), 4–12. Flores-Mireles, A., Hreha, T. N., & Hunstad, D. A. (2019). Pathophysiology, Treatment, and Prevention of Catheter-Associated Urinary Tract Infection.  Topics  in Spinal Cord Injury Rehabilitation ,  25 (3), 228–240.  https://doi.org/10.1310/sci2503-228   Florez, I. (2018). Development of rapid guidelines: 2. A qualitative study with WHO guideline developers.  Health Research Policy and Systems. ,  16 (1). Gesme, D., & Wiseman, M. (2010). How to implement change in practice.  Journal of oncology practice ,  6 (5), 257–259.  https://doi.org/10.1200/JOP.000089 Gesmundo, M., King, A., & Stewart, L. (2016). Prevention of catheter-associated urinary tract infections.  Nursing Review (1173-8014) ,  16 (5), 15–17.

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Hollenbeak , C. S., & Schilling, A. L. (2018). The attributable cost Of catheter-associated urinary tract infections in the United states: A systematic review. American Journal of Infection Control ,  46 (7), 751–757.  https://doi.org/10.1016/j.ajic.2018.01.015 Letica-Kriegel, A. S.,  Salmasian , H., Vawdrey, D. K., Youngerman, B. E., Green, R. A., Furuya, E. Y., Calfee, D. P., &  Perotte , R. (2019). Identifying the risk factors for catheter-associated urinary tract infections: a large cross-sectional study of six hospitals.  BMJ open ,  9 (2), e022137.  https://doi.org/10.1136/bmjopen-2018-022137 Maxwell, M., Murphy, K., & McGettigan, M. (2018). Changing ICU culture to reduce catheter-associated urinary tract infections.  Canadian Journal of Infection Control, 33 (1), 39–43. McNeill, L. (2017). Back to Basics: How Evidence-Based Nursing Practice Can Prevent Catheter-Associated Urinary Tract Infections.  Urologic Nursing ,  37 (4), 204–206.  https://doi.org/10.7257/1053-816X.2017.37.4.204   Nation, J., &  Wangia -Anderson, V. (2019). Applying the Data Knowledge-Information-Wisdom framework to a Usability Evaluation of Electronic Health Record System for Nursing Professionals.  Online Journal of Nursing Informatics, 23,  1. Orchard, C. A.  Sonibare , O., Morse, A., Collings, J., & Al-Hamad, A. (2017). Collaborative Leadership, Part 1: The Nurse Leader’s Role within Interprofessional Teams.  Nursing Leadership   (1910-622X), 30(2),  14-25.  http://doi.org/10.12927/cjnl.2017.25258 Park, J. I., Bliss, D. Z., Chi, C. L., Delaney, C. W., & Westra, B. L. (2020). Knowledge Discovery With Machine Learning for Hospital-Acquired Catheter-Associated Urinary Tract Infections.  Computers, informatics, nursing : CIN ,  38 (1), 28–35. https://doi.org/10.1097/CIN.0000000000000562 Randell, R., Alvarado, N., McVey, L., Ruddle, R. A., Doherty, P., Gale, C., Mamas, M., & Dowding, D. (2020). Requirements for a quality dashboard: Lessons from National Clinical Audits.  AMIA ... Annual Symposium proceedings. AMIA Symposium ,  2019 , 735–744.

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Rhee, C., Phelps, M. E., Meyer, B., & Reed, W. G. (2016, November 16).  Viewing Prevention of Catheter-Associated Urinary Tract Infection as a System: Using Systems Engineering and Human Factors Engineering in a Quality Improvement Project in an Academic Medical Center . The Joint Commission Journal on Quality and Patient Safety.  https://www.sciencedirect.com/science/article/abs/pii/S155372501642060X . Sampathkumar, P., Barth, J. W., Johnson, M., Marosek, N., Johnson, M., Worden, W., … Thompson, R. (2016, November 16).  Mayo clinic Reduces catheter associated urinary tract infections through a Bundled 6-c approach .  https://www.sciencedirect.com/science/article/abs/pii/S1553725016420337 . Santana M, Ahmed S, Lorenzetti D , et al  Measuring patient-centered system performance: a scoping review of patient-centered care quality indicators BMJ Open  2019; 9:  e023596. Doi:10.1136/bmjopen-2018-023596 Stancovici , A., & Galvan-Anderson, B. (2019). Taking every precaution – an Inter-professional approach to reducing catheter associated urinary tract infections in an acute care medical center.  American Journal of Infection Control, 47 , S13.  https://doi.org/10.1016/j.ajic.2019.04.165 Sung-Heui Bae. (2016). CNE SERIES. The Centers for Medicare & Medicaid Services Reimbursement Policy and Nursing-Sensitive Adverse Patient Outcomes.  Nursing Economic$ ,  34 (4), 161–181. Thomas, T.W., Seifert, P.C., Joyner, J.C., (September 30, 2016) "Registered Nurses Leading Innovative Changes"  OJIN: The Online Journal of Issues Nursing  Vol. 21, No. 3, Manuscript 3. Walker-Czyz, A. M. (2016, July 8).  The Impact of an Integrated Electronic Health Record... : JONA: The Journal of Nursing Administration . LWW. https://journals.lww.com/jonajournal/Fulltext/2016/07000/The_Impact_of_an_Integrated_Electronic_Health.5.aspx?casa_token=t691KB-SH5kAAAAA%3AagA0O_6TbfItJNSG4-D5lzcuXs7Qp_b124MlJBR3yihyVQkTg-0mJw8UkiMDJy-9Kgouy_PAFLxLl2WK0GSOsStvqpM.