Chapter 2: Applying Quality Improvement in Practice

Introduction

The gaps in care delivery are well recognized by policy makers, patients, and healthcare providers. In the seminal Institute of Medicine (IOM) Report, Crossing the Quality Chasm, six specific aims for quality improvement were identified: healthcare should be safe, effective, patient-centered, timely, efficient, and equitable.¹ Rapid-cycle quality improvement methods, which have been effective in diverse fields, including business, engineering, and agriculture, are now being used in healthcare with great success. This chapter will provide an overview of an approach for quality improvement based on the Model for Improvement (see Figure 2-1).² The key elements will be:

• ▪ Using the Model for Improvement as a framework for improvement

• ▪ Selecting an important domain for improvement

• ▪ Forming the quality improvement team

• ▪ Identifying metrics to track improvement

• ▪ Developing interventions to improve quality

• ▪ Conducting small Plan-Do-Study-Act cycle tests

• ▪ Wide-scale testing

• ▪ Implementation for sustainability

Using the Model for Improvement as a Framework for Improvement

The answers to the three questions of the Model for Improvement help frame the improvement project. The first section of this chapter will address each of the following essential components in planning the improvement project: selecting the domain for improvement, forming the quality improvement team, identifying key stakeholders, establishing a shared goal—both with a global aim and specific aims, developing metrics, understanding the existing process by creating a process map, identifying barriers, constructing a key driver diagram to frame a specific aim with complex processes into manageable drivers, and designing focused interventions to actualize these drivers.

Selecting the Domain for Improvement

There is no process that with attention cannot be improved. However, not all processes are equally important and some processes cannot be readily improved. For novice quality improvement teams, we recommend focusing on problems that can be readily modified in order to achieve some preliminary successes. Over time, as the team matures, more challenging topics can be addressed. Ultimately, the goal of quality improvement is to achieve the “triple aim”: improving the health of populations, improving patient experiences, and decreasing per capita costs. However, it is unlikely that any one particular project will achieve all the three aims. Over time, as more healthcare providers engage in quality improvement, this overarching goal will be met.³

The pediatric quality indicators developed by the US Agency for Healthcare Research and Quality (AHRQ)⁴ can provide a good starting point for selecting a domain for quality improvement. Improvement on these indicators can reduce morbidity and mortality. These quality indicators are ...