The World Health Organization recognizes access to quality and timely healthcare services as a fundamental human right. As such, all citizens should be able to access health services without discrimination. Therefore, governments are obligated to ensure they put in place measures that ensure patients receive cost-effective, timely, and high-quality healthcare services (World Health Organization, 2023).  This paper will discuss concepts of healthcare systems such as access, cost, quality of the quality environment, and the recent quality initiatives implemented to improve healthcare systems and service delivery. It will also highlight the relationship between quality measures and evaluation and role development, including how a lack of effective quality measures affects the role of Advance practice nurses (APNs).
Access, Cost, and Recent Health Initiatives.
The Institute of Medicine (IOM) defines access to healthcare as the ability to have timely use of healthcare services to achieve the best health outcomes possible. It can also be defined as the ability to obtain health or related services such as prevention, diagnosis, and treatment when needed. Access encompasses four components: coverage, timeliness, workforce, and services. These components influence the ability of an individual to access health services when they need them (Agency for Healthcare Research and Quality, 2023). Coverage relates to health insurance and facilitates the ability of an individual to enter the healthcare system. In a time when healthcare is extremely expensive, having health insurance ensures that individuals can obtain health services when needed since insurance covers most of the costs. Individuals who lack coverage are less likely to have access to healthcare systems and often have poor health outcomes. Services and timeliness components define the availability of a usual health facility where patients can seek care services when needed and the ability to provide/receive the appropriate healthcare interventions when a health need is recognized, respectively. Workforce components refer to the availability of qualified and culturally competent care providers. Underserved communities/societies tend to have limited access to healthcare due to the unavailability of care providers, which leads to poor health outcomes in these societies (Agency for Healthcare Research and Quality, 2023).
Cost in healthcare is defined differently based on the individual paying for the services. However, it can be generally defined as the amount paid or charged to receive a service or a product. Cost in a healthcare system is viewed from three perspectives: the payers or insurers, the healthcare provider, and the patients. From the insurer’s perspective, the cost of healthcare includes the reimbursements made to the healthcare providers for the services delivered to individuals covered by the insurer (Getzen & Kobernick, 2022). There are two types of health insurance in the U.S.: public and private. Public health insurance is provided by the federal government, and it includes Medicare, Medicaid, and children’s health insurance programs. The government also provides optional programs for visitors and international students (Getzen & Kobernick, 2022). Private insurance is provided by other agents who offer different plans from which their customers can choose. From a health provider’s view, the cost of healthcare involves the expenses incurred directly and indirectly during the provision of healthcare services. This can include the cost of equipment used in providing care services, the cost of medication, utilities such as energy, and administration costs, among other expenses (Getzen & Kobernick, 2022).
From the patient’s view, healthcare costs include deductibles, co-payments, amounts payable by the patients for services that the insurer does not cover, and costs incurred by patients when they seek services from out-of-network providers and co-insurance. Patients without insurance coverage must incur all the costs, which are extremely expensive and limit access to healthcare services (Getzen & Kobernick, 2022).
Quality of healthcare services is defined by the extent to which the services increase the chance of achieving the desired outcomes and aligns with the existing recommended scientific evidence. WHO suggests that quality healthcare must be effective, safe, and people-centered. The effective component involves the delivery of evidence-based care services to the patients; safe comprises ensuring that the intervention does not cause any harm to the patients, while the people-centered component requires that care services provided to the patients must align with the preferences, needs, and values (World Health Organization, 2023). Qualities of high-quality healthcare include timely delivery of services; health interventions should not be delayed to prevent the advancement of diseases, which contributes to poor outcomes. The care services must be equitable; the quality of services should not vary based on one’s gender, cultural background, socioeconomic status, or geographic location. Healthcare providers should always maintain the same level of professionalism when interacting with patients and should make the appropriate changes when necessary to meet the individual needs of the patients (World Health Organization, 2023). The care services should be integrated, which involves providing a full range of healthcare services throughout the course of life. Individuals should be able to access healthcare services from infancy to the other stages, including the geriatric stage. The services should also be efficient; the resources within the healthcare industry are limited. Therefore, healthcare providers must ensure that available resources are used for maximum benefit with minimal wastage. High-quality care services benefit patients by increasing the likelihood of better outcomes and reducing the likelihood of developing complex illnesses (Center for Medicaid and Medicare Services, 2021).
Recent Quality initiatives
There are several initiatives implemented to improve the quality of healthcare services. Hospital quality initiative (HQI) is among the initiatives launched by the Center for Medicare and Medicaid (Medicaid.gov, 2023). The initiative aims to improve the quality of healthcare services delivered and provide clear objective data on the hospital’s performance. This will allow patients to have access to hospitals’ performance records and hence make better decisions on where to seek healthcare services and provide incentives for high-performing facilities (Medicaid.gov, 2023).
The Maternal and infant health initiative (MIHI) by Medicaid is one of the initiatives to improve the quality of care for women and infants. The initiative was first introduced in 2014, and the second phase was initiated in 2020. The initiative seeks to improve the access and quality of care for pregnant and postpartum women and their infants. The initiative also collaborates with healthcare facilities to improve their knowledge and capacity to deliver quality postpartum care, reducing low-risk cesarean births and improving well-child infant visits (Medicaid.gov, 2023). The joint commission also has several initiatives, such as ORYX®, which gathers data on facility performance and compares it to the set standards during the accreditation process. This ensures that organizations that seek to be accredited or to maintain the accreditation status maintain the set quality of healthcare service delivery to their patients. State government and healthcare facilities also run their quality improvement initiatives (Center for Medicaid and Medicare Services, 2021). For example, L.A.’s healthcare plan seeks to provide care services to vulnerable and low-income families in the county. The improvement plan, which runs from 2022-2024, will enable the authorities to monitor the quality, safety, and equity of care services delivered to its members. Health facilities’ quality improvement initiatives focus on improving and maximizing the care delivery processes for better patient outcomes (Center for Medicaid and Medicare Services, 2021).

Relationship between quality measures and evaluation and role development
Quality measures are standards used to assess the performance of healthcare facilities, including patient outcomes, healthcare processes, and patient perception. Quality measures are critical in ensuring patient safety and guard against abuse and misuse of healthcare resources. They are also critical in identifying healthcare areas where interventions are needed to improve the delivery process and patient outcomes (Moody-Williams & Moody-Williams, 2020). Quality measures are categorized into four, including outcome measures that assess a patient’s health status. Process quality measures evaluate the level of compliance with the recommended practice guidelines and the actions that healthcare providers take to improve patient outcomes. Structural measures evaluate the capacity of healthcare facilities to provide quality care services. Balancing measures are used to evaluate the impact of quality improvement projects in healthcare settings (Moody-Williams & Moody-Williams, 2020).
Evaluation is a systematic and intentional process that includes gathering and analyzing qualitative and quantitative data to inform decision-making or process improvement. Role development involves increasing one’s capacity and competence to deliver efficient and quality healthcare services to the patient population (BRYKCZYNSKI, 2022). Nurses have a critical role in improving the healthcare process, systems, and the delivery of healthcare services to ensure safe and quality care. Evaluating the various quality measures in a healthcare setting allows the nurses and other healthcare providers to identify the status of processes and procedures used in the facility (BRYKCZYNSKI, 2022). They can also determine the impact of the care services on the patients, including the patient outcomes. Using the knowledge gained from evaluating quality measures, nurses can identify areas of weakness in the healthcare systems that require more skills. Nurses can then focus on improving their capacity and competence in relation to the needs of the healthcare systems and processes. For example, suppose a quality measure evaluation indicates that the policies used in the facility are ineffective in guiding the delivery of care. In that case, nurses can use that information to advance their knowledge of policy development (BRYKCZYNSKI, 2022).
How the role of the APN might change without effective quality measures.
Advanced practice nurses (APNs) are critical in delivering quality healthcare services to their patients and the public in general. To be able to continuously deliver quality healthcare services, it is critical that APNs have appropriate measures that clearly indicate their level of performance. Having effective quality measures enables APNs to accurately determine their level of effectiveness and therefore make appropriate decisions on improving care. Ineffective quality measures give inaccurate results on the performance of APNs. This deters the APNs from detecting the challenges in the care delivery process and patient outcomes. APNs are, therefore, unable to execute their role effectively, which leads to unsafe healthcare environments and poor patient outcomes (BRYKCZYNSKI, 2022).
Conclusion
Access, cost, and quality healthcare environment are critical components of the healthcare system. Access is the ability to obtain health services when needed; cost is the amount charged for receiving or delivering health services. Cost affects access, and individuals from low socioeconomic status and those without coverage often have limited access to healthcare services. Quality measures play a critical in assisting healthcare providers to evaluate their performance and therefore make appropriate decisions on how to improve the delivery process. APNs can also use it to advance their knowledge and careers in nursing. However, it is critical to ensure effective quality measures are used in the evaluation to generate accurate data that can inform the decision-making process.