What is quality improvement?

The Department of Health and Human Services defines quality improvement (QI) as “systematic and continuous actions that lead to measurable improvement in health care services and the health status of targeted patient groups.” Within this definition, three words should be emphasized. The systematic approach of QI helps create effective interventions that lead to sustainable improvement without leading to adverse effects elsewhere in the system. The continuous nature of QI recognizes that the work is never done and embraces the merits of constant improvement. Lastly, the emphasis on measurement in QI ensures that actions taken lead to demonstrable change for the better.

Background

Quality improvement as a concept rose to prominence in the mid- and late-20th century as part of a shift in manufacturing management philosophy that focused on improving product quality while reducing production costs. The concept reached national prominence in health care in the early 2000s following the release of two landmark reports from the National Academy of Medicine (To Err is Human and Crossing the Quality Chasm). The reports highlighted the gap between what we define as high-quality care and what patients actually experience, providing a call-to-action around health system redesign.

As in manufacturing, quality improvement in health care is one part of a larger strategy around leadership, management, and policy reform. For the purposes of this series, we will focus specifically on quality improvement as an approach to local improvement.

Methods

In health care, we often have little trouble identifying outcomes we wish to improve—patient falls, medication errors, readmissions, etc.—but struggle to implement effective, sustainable solutions. Often, the problems we face are complex, and are not easily addressed with simple interventions. Or interventions that we previously deployed fail. Structured quality improvement approaches—or improvement methods—provide processes and tools for measuring and managing your efforts in a way that helps sustain improvements in your local environment.

You may have heard of different models for quality improvement, like Lean, DMAIC, or the Model for Improvement/PDSA cycle.

At the University of Utah, we use the Value Framework, which incorporates principles from all of these models. The use of a systematic approach is more important than the particular method you use.

When to use quality improvement

Quality improvement excels when one is faced with complex problems, but it is not appropriate in all situations.

Below are three common improvement scenarios you will encounter in the health care setting.

Use it to solve complex problems

Complex problems (👍): In our case example above, Karli identified a problem—overutilization of telemetry—but initially struggled to find a solution. As a physician educator, she naturally turned to education, but found it was minimally effective and unsustainable without continuous effort on her part. Solving the telemetry problem required collaboration among her peers, residents, nursing, data analysts, and others to sustain. Truly a complex problem with no easy solution.

Don't use it to solve simple or research problems

Simple problems (👎): Karli had to use a systematic approach because the problem of overutilization of telemetry was complex and failed to improve with simple solutions. If only a few providers were ordering telemetry inappropriately, her initial approach of education alone might have proved sufficient. Any quality improvement effort will require an investment of time and resources. Save that investment for those problems that are important to you and your organization and are complex enough to require a collaborative, longitudinal commitment to develop interventions that stick.

Research problems (👎): Telemetry overutilization is a well-known phenomenon, and Karli could point to well-established guidelines regarding appropriate use. Rather than discovering new knowledge, she brought existing knowledge into practice to improve care for her patients. Quality improvement is not the same as research, and differentiating between the two can be confusing.

If your primary intent is to contribute to generalized knowledge, a research approach may be more appropriate. If your primary intent is to improve delivery of care or health outcomes for a local population, a quality improvement approach may be right.

More information on the difference between improvement and research here.

How to get started

If you’re thinking about leading or participating in a quality improvement effort, here are three concrete steps to get started:

1. Continue your independent learning

• Explore other lessons on Accelerate
• Take the Value Improvement Leaders course (internal resource)
• Explore external resources (like IHI Open School)

2. Find a mentor or coach

• Talk to your manager, program director, and/or colleagues to learn about mentors, projects, training, and other opportunities unique to your area
• Contact U of U Health’s Value Engineering for information on their coaching methods (internal resource)

3. Have a plan

• Try using the Project Readiness Assessment, a 13-question guide to help think through your project

Conclusion

When used effectively, quality improvement can create lasting and meaningful change for patients, families, and those who work in health care. It’s empowering to have the knowledge, skill and ability to make care better. Learn how and when to drive improvement in your local health care environment.

Originally published January 2019