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H H S Department of Health and Human Services
U.S. Department of Health and Human Services
Health Resources and Services Administration

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Quality Improvement

Part 1: Quality Improvement (QI) and the Importance of QI

Part 2: Before Beginning - Establish an Organizational Foundation for QI

Part 3: QI Programs - The Improvement Journey

Part 4: Supporting the QI Program - Keep the Momentum Going

Part 5: References

Part 6: Additional Resources


Part 2: Before Beginning - Establish an Organizational Foundation for QI 

An effective QI program requires changes in an organization's culture and infrastructure to overcome its traditional barriers and works toward a common goal of quality. This occurs when all staff embraces the philosophy of QI and understands their roles in supporting an organization-wide focus on QI. Hierarchical roles that are important in clinical settings, and include licensure and appropriate supervision, are different from roles that support effective QI. Therefore, a paradigm shift is needed from their standard care-team roles to those that also include quality improvement.

Each of these foundational topics needs to be discussed within the management team before beginning a quality program and then periodically thereafter. Assessing leadership support of quality, staff engagement in the quality process, and the ability of an organization to manage change, provides the context for an effective QI program that may evolve over time. An organization may step back to reflect on these topics annually or, at minimum, conduct a biennial review.

The Role of Organizational Leadership

The leader's role in promoting and developing QI begins with creating and sustaining a personal and organizational focus on the needs of internal and external customers. Through actions, a leader demonstrates a clear commitment to the organizational mission, values, goals, and expectations that promote quality and performance excellence. The customer-oriented mission, vision, values, and goals of an organization are best integrated into all aspects of management through effective leadership.

An organization that experiences success in the development and implementation of its QI program understands that the organization's chief officer or senior leader creates energy, synergy, and focused leadership for the QI program. Under his or her leadership, all other managers or leaders work together to:

  • Set the direction for QI by creating a strong patient focus
  • Create clear statements that define the organization's mission and values, and identify operational objectives, and short- and long-term expectations
  • Demonstrate continuous commitment to achieving the organization's QI goals

Achieving high levels of performance requires that an organization's leaders develop a strategic quality plan to fulfill the mission of integrating QI into their organization. A strategic quality plan provides guidance for delivering safe and quality care. The plan is often updated annually by clinical, administrative, and executive leadership to ensure the organization is continuously making improvements to meet the needs of its patients and families. The strategic quality plan:

  • Identifies clear goals that define expected outcomes of the overall QI effort
  • Is fact-based using indicators to measure progress
  • Includes systematic cycles of planning, execution, and evaluation
  • Concentrates on key processes as the route to better results
  • Focuses on patients and other stakeholders

In addition to the vision and strategy, a leader needs to create and support an infrastructure that organizes and supports the work. Successful leaders found these actions helpful in creating their quality infrastructures:

  • Become a QI champion and actively support the team; i.e., strong endorsement, support, participation, and resources from organizational leadership to facilitate ongoing QI activities
  • Cultivate a spirit of QI within the organization that encourages continuous improvement of services and programs
  • Identify internal experts or external consultants with experience and training in QI to help get teams started
  • Develop staff members' skills in data collection and analysis
  • Develop staff members' skills in information retrieval, such as, conducting literature searches and accessing databases
Key Staff Roles in a QI Program

For quality to be effectively managed, individuals and groups in an organization should have a clear understanding of their roles and responsibilities relative to QI. Each staff member has a role in ensuring that QI objectives set by the organization are met. Ideally, all contributions are equally valued on the QI team. Although the medical assistant may be supervised by the physician when providing patient care, the medical assistant's perspective and input within the context of the QI team are very important. Since individuals on the QI team work in fundamentally different ways when doing improvement work compared with actual patient-care delivery, it is important to formalize their roles within the committee. Common roles within a QI team include:

  • Day-to-day leader organizes and drives the ongoing work, measurement, and team. This person needs to work effectively with the executive leadership and members of the improvement team. The day-to-day leader also serves as the "key contact" responsible for coordinating communication on the progress on a QI project to the overall organization, staff, and board of directors.

  • Data entry person carries out the data-entry function, and needs sufficient time and computer access to enter data and submit reports regularly. It is often recommended to train a backup person, who also learns to aggregate monthly and quarterly reports, so that reporting is not interrupted for vacations, illnesses, or other unexpected events.

  • Provider champion is an essential member of the QI team due to the clinical nature of the work. The provider champion works regularly with those patients whose care is directly affected by QI efforts. As a leader to help drive change, the provider needs to be an individual who is well-respected and influential among the medical staff, works well with management, and is open to change and new approaches.

  • Operations person is integrally involved in current processes and needs to be part of the team, because much of the innovative work involves designing new processes and streamlining old ones. Operations personnel may include: nurses, nutritionists, social workers, pharmacists, or others. The appropriate specialty of the operations person becomes apparent when areas for improvement in the current processes are identified.

  • Data specialist collects and analyzes data, and uses QI tools. The person selected does not necessarily need to work in a QI department or hold a specific title as long as he or she is well-versed in QI concepts and tools.

Depending on the focus of improvement, other individuals in an organization may bring valuable insight to the process. Any individual may be considered a candidate for a QI team if he or she is willing to be part of a team that is committed to improving quality. In a smaller organization, one person may engage in multiple roles.

While the role of the team in a QI program is significant, total quality commitment involves all levels of an organization's structure. An organization needs to build ongoing training opportunities for staff and teams into its QI framework to sustain and advance its QI efforts. Quality patient care services are achieved through positive interactions among departments that work together to build a dynamic mechanism for continuously improving processes and outcomes of health care services. Additional information, including tools and resources to assist an organization with developing and supporting a QI team, can be found in the Improvement Teams module.

Readiness Assessment - Preparing for Change

Successful implementation of a QI program begins with an honest and objective assessment of an organization's current culture, and its commitment to improving the quality of its care and services. An organization may ask its staff to participate in the assessment process to determine their level of understanding about its existing QI processes. Understanding an organization's strengths and weaknesses around QI is a good starting point to assess its readiness for change. Questions that an organization may want to consider in determining its readiness are:

  • Does the organization have a structure to assess and improve quality of care?
  • Do providers and staff have a basic understanding of QI tools and techniques?
  • Do providers and staff understand their roles, responsibilities, and expectations regarding QI activities?
  • Does the organization routinely and systematically collect and analyze data to assess quality of care?
  • Does the organization have resources dedicated to QI activities?
  • Has the organization identified barriers to fully implement a QI program?

The questions above are provided as examples to demonstrate the assessment process; however, a team may list others specific to its organization. A key point is for an organization to understand that assessing readiness for change increases its ability to support its identified QI goals.

When assessing an organization's readiness to undertake organization-wide practice and culture changes for QI, consider traits fundamental to the success of QI, such as:

  • Organizational commitment to QI
  • Leadership's knowledge of QI principles, methodologies and change management
  • Communication channels between leadership, staff and teams that are effective and functional
  • Teamwork



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