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

Quality Improvement (QI)

Quality improvement (QI) consists of systematic and continuous actions that lead to measurable improvement in health care services and the health status of targeted patient groups. The Institute of Medicine's (IOM) Exit Disclaimer. which is a recognized leader and advisor on improving the Nation's health care, defines quality in health care as a direct correlation between the level of improved health services and the desired health outcomes of individuals and populations (1).

Principles of QI

When quality is considered from the IOM's perspective, then an organization's current system is defined as how things are done now, whereas health care performance is defined by an organization's efficiency and outcome of care, and level of patient satisfaction. Quality is directly linked to an organization's service delivery approach or underlying systems of care. To achieve a different level of performance (i.e., results) and improve quality, an organization's current system needs to change. While each QI program may appear different, a successful program always incorporates the following four key principles (2):

  • QI work as systems and processes
  • Focus on patients
  • Focus on being part of the team
  • Focus on use of the data

The next subsections describe these four QI principles in more depth.

QI Work as Systems and Processes 

To make improvements, an organization needs to understand its own delivery system and key processes. The concepts behind the QI approaches in this toolkit recognize that both resources (inputs) and activities carried out (processes) are addressed together to ensure or improve quality of care (outputs/outcomes). A health service delivery system can be small and simple, such as, an immunization clinic, or large and complex, like a large managed-care organization. QI can assume many forms and is most effective if it is individualized to meet the needs of a specific organization's health service delivery system. Figure 1.1 shows how a health care delivery system consists of resources, activities, and results; these key components are also called inputs, processes, and outputs/outcomes:

Figure 1.1: Inputs, Processes and Outputs/Outcomes.
Source: Donabedian (1980)
Figure 1.1: Inputs, Processes and Outputs/Outcomes

Activities or processes within a health care organization contain two major components: 1) what is done (what care is provided), and 2) how it is done (when, where, and by whom care is delivered). Improvement can be achieved by addressing either component; however, the greatest impact for QI is when both are addressed at the same time.

Process mapping is a tool commonly used by an organization to better understand the health care processes within its practice system. This tool gained popularity in engineering before being adapted by health care. A process map provides a visual diagram of a sequence of events that result in a particular outcome. By reviewing the steps and their sequence as to who performs each step, and how efficiently the process works, an organization can often visualize opportunities for improvement. The process mapping tool may also be used to evaluate or redesign a current process. Additional information, including tools and resources to assist an organization that wants to adopt process mapping as an improvement strategy, can be found in the Redesigning a System of Care to Promote QI module.

Specific steps are required to deliver optimal health care services. When these steps are tied to pertinent clinical guidelines, then optimal outcomes are achieved. These essential steps are referred to as the critical (or clinical) pathway. The critical pathway steps can be mapped as described above. By mapping the current critical pathway for a particular service, an organization gains a better understanding of what and how care is provided. When an organization compares its map to one that shows optimal care for a service that is congruent with evidence-based guidelines (i.e., idealized critical pathway), it sees other opportunities to provide or improve delivered care.

In this module, improvement strategies are presented based on what has worked for other health care organizations. Changes are applied throughout an existing critical pathway so it works more effectively. QI strives to enable an organization to achieve the ideal critical pathway, which is one that allows the care team and patient to interact productively and efficiently to achieve optimal health outcomes.

The following illustrative example reinforces the benefits of understanding systems and key processes in approaching a performance improvement project:

Focus on Patients

An important measure of quality is the extent to which patients' needs and expectations are met. Services that are designed to meet the needs and expectations of patients and their community include:

  • Systems that affect patient access
  • Care provision that is evidence-based
  • Patient safety
  • Support for patient engagement
  • Coordination of care with other parts of the larger health care system
  • Cultural competence, including assessing health literacy of patients, patient-centered communication, and linguistically appropriate care
A health care facility decided to target the accuracy of its medication lists as a way to improve patient safety. Based on its research, the facility staff understood the benefits of implementing information technology as an input or resource to improve the consistency and completeness of its medical documentation. The staff noted that technology adds more value when the focus also includes key processes or activities, such as, developing an effective workflow and staff proficiency in using the technology. The health care facility purchased an electronic medical record (EMR) system as its key component for input and also focused on processes; i.e., how the staff uses the system to improve the quality of medication documentation (outcome).

Focus on Being Part of the Team

At its core, QI is a team process. Under the right circumstances, a team harnesses the knowledge, skills, experience, and perspectives of different individuals within the team to make lasting improvements. A team approach is most effective when:

  • The process or system is complex
  • No one person in an organization knows all the dimensions of an issue
  • The process involves more than one discipline or work area
  • Solutions require creativity
  • Staff commitment and buy-in are needed

In other words, virtually all QI projects involve a team process. Whether an organization is seeking to improve patient wait times, telephone service, diabetes care, or other goals it deems important, a team effort helps an organization to achieve significant and lasting improvements.

It is the responsibility of each individual to be an active and contributing member of the team. Each person on a team brings a unique perspective to the process; i.e., how things work; what happens when changes are made, and how to sustain improvements during daily work. Contributions are made from each individual's skill set and the team's synthesis of ideas. Additional information, including tools and resources to assist an organization in developing and supporting a QI team within its organization, can be found in the Improvement Teams module.

In addition to staff, a key component of a well-functioning QI team is an effective infrastructure, such as, leadership, and policies and procedures to organize and facilitate the work of the team. Infrastructure support affords the team with tools, resources, clear expectations, and a forum for communication. More detail is provided in The Role of Organizational Leadership. This level of infrastructure helps a team to stay on a clear path, while being mindful of an organization's available resources and its goal.

Focus on Use of the Data 

Data is the cornerstone of QI. It is used to describe how well current systems are working; what happens when changes are applied, and to document successful performance. Using data:

  • Separates what is thought to be happening from what is really happening
  • Establishes a baseline (Starting with low scores is ok)
  • Reduces placement of ineffective solutions
  • Allows monitoring of procedural changes to ensure that improvements are sustained
  • Indicates whether changes lead to improvements
  • Allows comparisons of performance across sites

Both quantitative and qualitative methods of data collection are helpful in QI efforts. Quantitative methods involve the use of numbers and frequencies that result in measurable data. This type of information is easy to analyze statistically and is familiar to science and health care professionals. Examples in a health care setting include:

  • Finding the average of a specific laboratory value
  • Calculating the frequencies of timely access to care
  • Calculating the percentages of patients that receive an appropriate health screening

Qualitative methods collect data with descriptive characteristics, rather than numeric values that draw statistical inferences. Qualitative data is observable but not measurable, and it provides important information about patterns, relationships between systems, and is often used to provide context for needed improvements. Common strategies for collecting qualitative data in a health care setting are:

  • Patient and staff satisfaction surveys
  • Focus-group discussions
  • Independent observations

A health care organization already has considerable data from various sources, such as, clinical records, practice management systems, satisfaction surveys, external evaluations of the population's health, and others. Focusing on existing data in a disciplined and methodical way allows an organization to evaluate its current system, identify opportunities for improvement, and monitor performance improvement over time.

When an organization wants to narrow its focus on specific data for its QI program, one strategy is to adopt standardized performance measures. Since performance measures include specific requirements that define exactly what data is needed for each measure, they target the data to be collected and monitored from the other data that is available to an organization. The clinical quality measures identified in this toolkit are examples of standardized measures that an organization, such as a safety net provider, may consider for adoption. They are designed to measure care processes that are common to safety net providers and are relevant to populations served. They narrow an organization's choices of what data to collect and measure.

Additional information, including tools and resources to assist an organization with effective data collection, use, and analysis are found in the Performance Management and Measurement and Managing Data for Performance Improvement modules.

Examples of specific data considerations for clinical quality measures can be found in the modules below specific measures:


What Is a QI Program?

A QI program involves systematic activities that are organized and implemented by an organization to monitor, assess, and improve its quality of health care. The activities are cyclical so that an organization continues to seek higher levels of performance to optimize its care for the patients it serves, while striving for continuous improvement. A QI program typically envelops all QI activities within an organization. Clinically-related QI initiatives and activities to improve an organization's operations and finance are common examples. A QI program in a health care organization often begins with leadership considering these questions:

  • Why is a QI program important to an organization?
  • What does an organization need to know as it develops a QI program?
  • How does an organization start its development of a QI program?
  • How do QI processes work to support the success of the QI program?

The rest of this module provides a high-level discussion that assists an organization with answering these questions. This important content highlights:

  • The importance of a QI program
  • Considerations for building an infrastructure that supports quality
  • Key components of the QI process

The module provides additional information for specific topics and can be accessed by clicking on their links.

Why Is a QI Program Essential to a Health Care Organization?

An organization that implements a QI program experiences a range of benefits:

  • Improved patient health (clinical) outcomes that involve both process outcomes (e.g., provide recommended screenings) and health outcomes (e.g., decreased morbidity and mortality).

  • Improved efficiency of managerial and clinical processes. By improving processes and outcomes relevant to high-priority health needs, an organization reduces waste and costs associated with system failures and redundancy. Often QI processes are budget-neutral, where the costs to make the changes are offset by the cost savings incurred. Additional information, including tools and resources to assist an organization with improving processes and outcomes can be found in the Redesigning a System of Care to Promote QI module.

  • Avoided costs associated with process failures, errors, and poor outcomes. Costs are incurred when nonstandard and inefficient systems increase errors and cause rework. Streamlined and reliable processes are less expensive to maintain.

  • Proactive processes that recognize and solve problems before they occur ensure that systems of care are reliable and predictable. A culture of improvement frequently develops in an organization that is committed to quality, because errors are reported and addressed.

  • "Improved communication with resources that are internal and external to an organization, such as, funders, civic and community organizations. A commitment to quality shines a positive light on an organization, which may result in an increase of partnership and funding opportunities. When successfully implemented, a QI infrastructure often enhances communication and resolves critical issues.

When an organization implements an effective QI program, the result can be a balance of quality, efficiency, and profitability in its achievement of organizational goals.

When an organization implements an effective QI program, the result can be a balance of quality, efficiency, and profitability in its achievement of organizational goals.

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