What is continuous quality improvement?

Continuous quality improvement (CQI) is a deliberate, defined process driven by the philosophy that anything can be improved.

CQI rejects the idea that the “status quo” is good enough. Instead, it strives to constantly improve things. It’s a systematic process of identifying strengths and problems with processes, analyzing them, testing potential improvements, and implementing those that work.

The CQI approach encourages contribution, trust, respect, communication, collaboration, responsibility, empowerment, and recognition between employees at all levels of an organization. It discourages fear and blame.

The cycle of improvement never ends and becomes part of an organization’s culture.

For many years, quality and safety efforts in healthcare focused on the individual responsibility of nurses and other medical professionals. Today, CQI makes safety and quality a system priority.

CQI recognizes that most problems relate to how things are done (processes) and not an individual’s actions. It leverages all team members in a health system or hospital—from chief marketing officers to physicians and shift nurses—in planning and implementing ongoing improvement strategies and practices.

Quality improvement professionals review patient and other medical data and analyze the processes used to provide care. They then use the information to identify areas for improvement and areas of excellence. The work aims to improve patient outcomes, achieve efficiency in medical care delivery, optimize patient experiences, meet regulatory requirements, and reduce healthcare costs.

Essentially, CQI steers you away from the “We’ve always done it this way” philosophy toward a fresh, self-analytical, and self-critical outlook. It encourages each team member to continuously ask, “How are we doing?” and, “Can we do it better?”. This allows them to discover the fundamental causes of system and process issues and develop solutions.

Lives are at stake in hospitals and other healthcare organizations, so standards must be met. They must therefore be held accountable for excellence more than your typical organization. It’s not possible to overstate the significance of purposeful rethinking for reliable, cost-effective, and long-term quality enhancement.

CQI programs in healthcare are critical because they drive:

• Improved patient outcomes

• Error reduction

• Improved staff efficiency and performance

• Less waste caused by process failures

• Delivery of high-quality patient care

• Heightened morale, productivity, and accountability among team members

• Reduced healthcare costs for providers and patients

• Creativity and the creation of solutions

• Being more adaptable to changes

• Improved processes, information management, and documentation

A CQI program often aims to look more closely at a wide range of processes within a healthcare organization. However, it also focuses on specific aspects of the operation. One way to differentiate that focus is to categorize a program either as a CQI process study or a CQI outcomes study.

A CQI process study looks at the effectiveness of a healthcare delivery process, focusing on how an organization performs a specific task. The task is typically non-clinical but may relate to a clinical procedure. You would look at the effectiveness of existing processes and determine how to improve their facilitation and efficiency. For example, you could do a CQI process study on how patients are scheduled and informed about follow-up appointments.

A CQI outcomes study analyzes patient care, establishes measurements that effectively assess outcomes, and monitors those measurements to determine if the organization is achieving the expected results. For example, the study can help determine if patients are getting the right care or are worsening after treatment. It can also determine how patients are doing within a set time frame after a specific procedure.

There are several models for CQI in healthcare, and each is unique. Before implementing a CQI framework, consider where you are in the process and choose the most effective option for your specific objectives and organizational culture. You might need to combine methods to get what you want. But, what ultimately matters is that you see your chosen method through to the end without quitting.

Here are some common CQI models:

Six sigma

Six sigma works to improve efficiency by minimizing variability in a process. It then locates and corrects errors. As errors decrease, so does variability. 

Six sigma consists of two methodologies: define-measure-analyze-improve-control (DMAIC), which focuses on improving existing processes to meet the customers’ needs, and define-measure-analyze-design-verify (DMADV), which focuses on creating new strategies and policies.

Lean

The lean model is one of the most popular CQI frameworks in healthcare. It identifies valuable processes and focuses on increasing customer value while optimizing operations. 

To improve healthcare delivery, lean helps reduce activities that don’t add value, decrease the risk of mistakes, and cut waste. For example, you can use a lean model to optimize workflows, make patient transfers more efficient, help physicians with triage, and distribute personnel more effectively across departments.

Plan-do-study-act (PDSA)

Plan-do-study-act (PDSA) presents a cyclical model for problem-solving. Teams can quickly cycle through the following steps: identifying areas that need change, prospective changes, rapid implementation, review to establish whether any of the changes are positive, adjust if needed, and restart the process. 

It works well when a swift response to changing circumstances is required, enabling teams to adapt quickly with minimal risk and interruption to clinical work. Having a mechanism to try and refine ideas and ensure they are plausible before implementing them can help teams respond to challenges.

CARE

The CARE model emphasizes upfront care and creates a system where more productive interactions take place between patients and healthcare providers during the care process. According to the CARE model, patient care should be safe, effective, timely, efficient, equitable, and patient-centered.

Members from all levels of the organization should be part of your CQI team. The team needs to be a diverse group of individuals with different roles and perspectives on patient care or other processes under consideration. It should include, whenever possible, input from the end user—the patient.

The Institute for Healthcare Improvement (IHI) recommends including at least one member with a clinical role, technical expertise, day-to-day leadership, and project sponsorship.

The optimal size of a CQI team is between five and eight individuals, but this may vary by practice.

Here are some potential members of a CQI team:

• Chief executive officer, operations manager, or director

• Medical directors

• Physicians and physician assistants

• Nursing staff

• Medical assistants

• Patient representatives

• Health educators

• Community health workers

• Peer mentors

• Patients

• Community representatives

• Directors of clinical services

• Practice managers

• Medical records staff

• Receptionists

• Lab technicians

• Pharmacy or dispensary staff

• Case managers

• Billing department staff

• Finance director

CQI initiatives can be clinical, financial, and operational. Examples of CQI in healthcare include initiatives to:

• Shorten the average length of hospital stays

• Reduce postoperative infections

• Reduce hospital readmissions

• Improve care coordination among departments

• Decrease medication administration errors

• Improve electronic medical record documentation

• Reduce medication-related adverse events

• Optimize sepsis care

• Increase patient and/or staff safety

• Increase patient and/or staff satisfaction

• Decrease the number of urinary catheter infections

A CQI qualification is provided by the Chartered Quality Institute. It’s an internationally recognized qualification that provides an understanding of what quality means in an organizational context and the parts of the quality management process, including disciplines, systems, and quality management techniques.

Continuous quality improvement and quality assurance (QA) work together to improve clinical care, patient safety, and healthcare operations. However, that’s where their similarities end.

Here are some common differences between CQI and QA:

• Processes vs. individuals: unlike CQI, which focuses on systems first and individual performers second, QA tends to be defensive with a focus on human error and identifying and eliminating poor performers. It ensures individuals follow set policies, procedures, and protocols. Meanwhile, CQI tries to ensure these processes make sense and meet the patient’s evolving needs.

• Goal setting: CQI uses system-wide goal setting to improve quality, while QA mostly relies on individual performance evaluation and personal improvement plans.

• Proactive vs. reactive: CQI monitors improvements in care quality through continuous review, so it’s more proactive than QA. QA is reactive and relies on periodic audits and inspections. CQI focuses on ways to prevent errors or variations from standards.

• Communication: CQI focuses on breaking down communication barriers throughout all levels of the organization. Meanwhile, QA requires effective communication between the individuals concerned.