Continuous Quality Improvement

Issues of Concern

Projects should be targeted at specific, quantifiable patient care or operational outcomes. Projects should be designed in line with institutional interests, values, and key stakeholders. Failure to understand these interests and institutional political dimensions can result in the project's failure.[5] Outcomes should be measured through definable metrics designated as primary and secondary. Primary metrics are measurements of the outcome sought. Secondary metrics ensure that the error or deficiency is not transformed into a new problem by the project's interventions. For example, if the primary metric is to see more patients each day in a clinic, a reasonable secondary metric would be the number of patient care errors. This ensures that deficiencies are improved through the changes, not just transitioned into a new deficiency.[3] 

Many CQI initiatives focus on improving 1 or more areas. Common CQI goals include:

• Cost reduction
• Decreased appointment wait time
• Reduced in-department wait time
• Higher patient volume
• Decreased cycle time
• Reducing defects
• Increased patient and/or staff safety
• Increased patient and/or staff satisfaction [6] 

Clinical Significance

In its seminal 1999 report, "To Err is Human," the Institute of Medicine detailed the impact of medical errors in healthcare in the United States. At that time, estimates were that between 44,000 and 98,000 people died each year due to preventable medical errors. The focus of this report was not on bad people, but on inadequate systems in place to keep patients safe while delivering high-quality medical care. It called upon the medical community to evaluate healthcare delivery systems and practices to improve patient safety and develop better systems to reduce errors.[7] For example, after implementing a CQI strategy, a large healthcare consortium in Alabama serving HIV patients was able to decrease the missed-visit rate of its HIV patients by a statistically significant margin compared to a control group.[8] A systematic review examining the application of Six Sigma and Lean methodologies in surgery noted improvement or benefit in over 88% of studies.[9] Though the researchers noted this might be influenced by systemic bias and imprecision in the definition of improvement. Another large systematic review looked at CQI applications in radiology. Across 23 studies, all noted improvements in 1 or more areas, including cost savings, reduced appointment wait time, decreased in-department wait time, higher patient volume, decreased cycle time, reduced defects, or increased patient or staff safety and satisfaction.[6] There are numerous other examples of CQI delivering clinically significant results, and the modern healthcare provider should be aware of its importance in improving their healthcare delivery model.

Nursing, Allied Health, and Interprofessional Team Interventions

Specific goals for CQI projects can be developed through benchmarking, in which performance is compared with that of similar institutions or against core measures. Each goal should have metrics that are tracked to determine the outcomes of interventions. A successful CQI initiative is the result of a careful, thoughtful, structured planning approach. For example, once clear goals have been established, various methodologies can be used to develop interventions. Before implementing CQI, careful planning and "groundwork" needs to be done, which may include articulating CQI goals, identifying specific clinical outcomes and administrative outcomes for the organization's future state, evaluating current processes to identify what functions and does not function in the organization's current state, understanding how healthcare information technology can help your organization meet its goals, and developing a plan to collect data going forward and compare progress to benchmarks. After this framework is set and the organization is 'fit' for CQI, organizations can utilize CQI strategies.

Strategies for Interventions

• Lean: Developed by Toyota Corporation, the Lean methodology is a process for improving value to customers and employees, with a focus on reducing waste. Kaizen is a core concept of lean and is concentrated on continual improvement. Lean defines 7 types of waste, ie, transport, inventory, motion, waiting, overproduction, over-processing, and defects. The goal is to reduce non-value-added activities, thereby increasing the time and effort spent on value-added tasks.[1][10]
• Six Sigma: Developed at Motorola by Bill Smith in 1980, Six Sigma methodologies are focused on reducing error rates. Six Sigma refers to 6 standard deviations from the mean. If a process reaches Six Sigma, error rates should be less than 3.7/million opportunities. The process proceeds through 5 phases: define, measure, analyze, improve, and control (DMAIC).[11]
• PDSA: Plan-Do-Study-Act, also known as the Deming cycle, is a 4-step process for quality improvement. During the planning stage, objectives and desired outcomes are defined. The 'do' phase allows for the implementation of the plan from the first stage. During the 'study' phase, results are gathered and analyzed to determine the plan's effect. Finally, during the 'act' stage, if the process has achieved the goal, it is controlled to ensure continued compliance; if it has not, a new PDSA cycle is implemented to better meet the outcomes.[1][12]
• Baldrige Award Criteria: This methodology focuses on improving the entire organization and instituting and nourishing a culture focused on CQI. It evolved from an award for organizational excellence through self-assessment into the methodology as implemented across the industry. The Baldridge Criteria focuses on enterprise-level improvement through improved communication, productivity, and effectiveness in 7 categories: leadership, strategic planning, customer focus, measurement (including analysis and knowledge management), workforce focus, operations focus, and results. An important caveat to the Baldrige Criteria is that each of the 7 criteria requires an internal champion to lead and manage improvement. This is because the Baldrige Criteria are suited for enterprise-level improvement rather than a single business or service entity.[13][14]

It should be noted that no single CQI methodology, including Lean, Six Sigma, PDSA, or Baldrige, is considered superior to the others. Rather, the selection of a methodology should incorporate the organization's goals, the feasibility of the data and other resources, the skill sets of those involved, and, ultimately, the strategy that best fits the organization.