11/1/24, 3:12 PM Continuous Quality Improvement - StatPearls - NCBI Bookshelf
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Continuous Quality Improvement
Authors
Brian O'Donnell1; Vikas Gupta2.
Affiliations
1 Hofstra Northwell School of Medicine
2 South Carolina Dept of Mental Health
Last Update: April 3, 2023.
Definition/Introduction
Continuous Quality Improvement (CQI) is a progressive incremental improvement of processes, safety, and patient
care. The goal of CQI may include improvement of operations, outcomes, systems processes, improved work
environment, or regulatory compliance. Process improvement may be "gradual" or "breakthrough" in nature. CQI
project development commonly includes defining the problem, benchmarking, setting a goal, then iterative quality
improvement projects. Through the iterative process, improvements are made, the effect of the improvements is
measured, then the process is repeated until the desired outcome is achieved. Common methodologies for
improvement include Lean, Six Sigma, Plan-Do-Study-Act (PDSA) cycles, and Baldrige Criteria.[1][2][3][4]
As the technology for collecting care-delivery data and methods for tracking outcomes becomes more sophisticated
and integrated into healthcare, CQI will become more vital to delivering quality care while maintaining profitability,
healthcare provider satisfaction, and patient satisfaction. Overall, CQI is a quality initiative that repeatedly asks
members of the healthcare team to determine, "How are we doing?" and, "Can we do it better?"
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 failure of the project.[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 changed to a new
problem through the interventions of the project. For example, if the primary metric is to have more patients seen each
day in a clinic, a reasonable secondary metric would be the number of patient care errors that occur. This ensures that
deficiencies are improved through the changes made and not just transitioned into a new deficiency.[3]
Many CQI initiatives focus on improving one or more areas. Common CQI goals include:[6]
Cost reduction
Decreased appointment wait time
Reduced in-department wait time
Higher patient volume
Decreased cycle time
Reducing defects
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Increased patient and/or staff safety
Increased patient and/or staff satisfaction
Clinical Significance
In the seminal report "To Err is Human," in 1999, the Institue of Medicine detailed the impact of medical errors within
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 that there were bad people, but rather there were
inadequate systems in place to keep patients safe while delivering high-quality medical care. It called upon the
medical community to evaluate the systems and practice of healthcare delivery 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-visits rate of its HIV patients by a statistically
significant margin compared to a control group.[8] A systematic review examining the application of Sig 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 either 1 or more areas,
including cost-saving, 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 providing clinically significant results, and the modern healthcare provider should be aware of
CQI's importance for improving their healthcare delivery model.
Nursing, Allied Health, and Interprofessional Team Interventions
Specific goals for CQI projects can be developed through benchmarking, where performance is compared to similar
institutions or 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 and thoughtful structured planning approach. For
example, once clear goals have been established, various methodologies are possible 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, Lean methodology is a process of improving value to customers and
employees with a focus on the reduction of waste. Kaizen is a core concept of lean and is concentrated on continual
improvement. Lean defines 7 types of waste, i.e., transport, inventory, motion, waiting, overproduction, over-
processing, and defects. The goal is to reduce the amount of non-value-added activities, thereby increasing the amount
of 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 six 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 four-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 then gathered and studied to determine what effect the
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plan has had. Finally, during the 'act' stage, if the process has achieved the goal, it is then controlled to ensure
continued compliance, or if it has failed to achieve the goal, a new PDSA cycle is implemented to adjust to better
meet outcomes.[12][1]
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 seven 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 these seven criteria needs a
champion in the organization 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, and Baldrige, is thought to be
superior to the other methodologies. 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.
Review Questions
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Comment on this article.
References
1. Liu JJ, Raskin JS, Hardaway F, Holste K, Brown S, Raslan AM. Application of Lean Principles to Neurosurgical
Procedures: The Case of Lumbar Spinal Fusion Surgery, a Literature Review and Pilot Series. Oper Neurosurg
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2. Valentine EA, Falk SA. Quality Improvement in Anesthesiology - Leveraging Data and Analytics to Optimize
Outcomes. Anesthesiol Clin. 2018 Mar;36(1):31-44. [PubMed: 29425597]
3. Schriefer J, Leonard MS. Patient safety and quality improvement: an overview of QI. Pediatr Rev. 2012
Aug;33(8):353-9; quiz 359-60. [PubMed: 22855927]
4. Gaudreault-Tremblay MM, McQuillan RF, Parekh RS, Noone D. Quality improvement in pediatric nephrology-a
practical guide. Pediatr Nephrol. 2020 Feb;35(2):199-211. [PubMed: 30612204]
5. Langley A, Denis JL. Beyond evidence: the micropolitics of improvement. BMJ Qual Saf. 2011 Apr;20 Suppl
1(Suppl_1):i43-6. [PMC free article: PMC3066842] [PubMed: 21450770]
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27209599]
7. Institute of Medicine (US) Committee on Quality of Health Care in America. To Err is Human: Building a Safer
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(DC): 2000. [PubMed: 25077248]
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A, Parmar J, Raper JL, Mugavero MJ. Data for Care (D4C) Alabama: Clinic-Wide Risk Stratification With
Enhanced Personal Contacts for Retention in HIV Care via the Alabama Quality Management Group. J Acquir
Immune Defic Syndr. 2019 Dec;82 Suppl 3:S192-S198. [PubMed: 31764254]
9. Mason SE, Nicolay CR, Darzi A. The use of Lean and Six Sigma methodologies in surgery: a systematic review.
Surgeon. 2015 Apr;13(2):91-100. [PubMed: 25189692]
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Knechtges P, Decker MC. Application of kaizen methodology to foster departmental engagement in quality
improvement. J Am Coll Radiol. 2014 Dec;11(12 Pt A):1126-30. [PubMed: 25444067]
11. Ahmed S. Integrating DMAIC approach of Lean Six Sigma and theory of constraints toward quality
improvement in healthcare. Rev Environ Health. 2019 Dec 18;34(4):427-434. [PubMed: 31314742]
12. Nicolay CR, Purkayastha S, Greenhalgh A, Benn J, Chaturvedi S, Phillips N, Darzi A. Systematic review of the
application of quality improvement methodologies from the manufacturing industry to surgical healthcare. Br J
Surg. 2012 Mar;99(3):324-35. [PubMed: 22101509]
13. Asif M, Jameel A, Sahito N, Hwang J, Hussain A, Manzoor F. Can Leadership Enhance Patient Satisfaction?
Assessing the Role of Administrative and Medical Quality. Int J Environ Res Public Health. 2019 Sep 03;16(17)
[PMC free article: PMC6747509] [PubMed: 31484308]
14. Karash JA, Ferenc J. Baldrige Award process drives new patient tower planning. Memorial Hermann Sugar Land
uses quality techniques in expansion. Health Facil Manage. 2017 Feb;30(2):6. [PubMed: 29490130]
Disclosure: Brian O'Donnell declares no relevant financial relationships with ineligible companies.
Disclosure: Vikas Gupta declares no relevant financial relationships with ineligible companies.
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