Improving a system as critical and complex as a healthcare system is no small task, but as organizations seek to provide better care at lower costs, continuous quality improvement in healthcare is essential.
What is Continuous Quality Improvement?
Continuous Quality Improvement, or CQI, is an institutionalized program aimed at improving outcomes and lowering the costs for care on a constant basis through systematic adjustments. This process-oriented approach is informed by data analytics, and centered around ongoing improvements to operations, processes and activities to achieve the end goal of improving health for populations, reducing the cost of healthcare and improving the patient experience.
Less formally, CQI asks every professional in the healthcare system to ask continuously, “Can we do this better?” By cultivating a culture centered on continuous improvement, the organization ensures every player begins to look for ways to boost efficiency, increase timeliness and improve effectiveness.
At a system level, CQI is implemented as a cycle, according to the U.S. Department of Health and Human Services (HHS). First, organizations identify, describe and assess strengths and issues. Then, they test, implement, learn from, and adjust solutions to the problems uncovered in the first stages. In practice, this continuous cycle may result in minor corrections rather than large-scale transformations, but over time, the organization adapts to issues revealed through data collection and review.
CQI in Healthcare
CQI can help healthcare organizations become more efficient and patient-centered. With any CQI methodology, healthcare organizations should adhere to several best practices to ensure their CQI strategy is effective.
Why Is CQI Important For Healthcare?
The healthcare system is extensive and beholden to stakeholders in many roles: patients, healthcare providers and insurers. While it may be cumbersome to introduce change, getting it right can remarkably influence outcomes. For example, according to a meta-analysis published in Frontiers in Public Health, CQI lowered hospital admissions for patients with chronic conditions and reduced the number of visits older patients had to emergency departments. Resources can be used more effectively when real-time data enables organizations to manage availability better.
This kind of efficiency and effectiveness, while important in any industry, is acutely critical in the healthcare industry. Where an imperfect process in manufacturing may result in an incorrect shipment, poor process in healthcare could result in an incorrect operation – or at worst, a fatality.
Models for CQI
Healthcare institutions can choose from several models for CQI, including Six Sigma, Lean, PSDA and the Care Model to implement a CQI framework. Each model is unique, and healthcare organizations should consider where they are in the process of implementing a CQI culture to guide which framework will be most effective for the specific CQI objectives and the organizational culture.
Six Sigma focuses on reducing waste and errors, building a network of specialists in the methodology through Six Sigma certifications that range from beginner Green Belts to advanced Black Belts. These experts can guide the organization through the quality improvement process, which focuses on statistical analysis and quality assurance.
Six Sigma uses five principles known as DMAIC:
- Define, a mapping stage to outline the process, its desired outcome, process inputs and the scope of the project itself.
- Measure the performance of the process and its outcome through data. Depending on the process, this may be electronically captured or more manually collected through observation or survey.
- Analyze the data and assess how the process is doing. Measuring the process before launching the improvement initiative can help establish a baseline to test against.
- Improve based on the results. If the data doesn’t demonstrate an improvement, the changes to the process were ineffective.
- Control the process moving forward by regularly monitoring and reviewing for new ways to optimize.
Six Sigma can be used in tandem with Lean, called Lean Six Sigma, or on its own, and works well for CQI in healthcare when trying to reduce wait times or superfluous appointments in a process. Healthcare organizations may leverage Lean Six Sigma to:
- Reduce the amount of time a patient is in care
- Minimize wait times for lab results to speed up diagnosis
- Reduce hospital stays to improve overall outcomes
The core focus of Lean methodology is eliminating waste, and as a result, increasing efficiency. The practice, which stemmed from Toyota’s Production System, strives to eliminate inconsistencies with a process that pulls services through based on demand, rather than pushes them out. Using Lean principles, healthcare organizations would:
- Identify value from all perspectives: patients, providers, insurers. The process will dictate who is involved and where value lies. For example, if an organization is assessing its scheduling process, patients may appreciate less time sitting on hold, while providers appreciate receiving all necessary information upfront.
- Specify where value comes from, understanding both services that add value and services that don’t. At this stage, the question is which activities directly add value and which can be streamlined or eliminated.
- Examine the process. The process flow for an activity should be directed and established to flow as smoothly as possible.
- Identify push/pull activities. Rather than, for example, sending all patients through a set of unnecessary routine tests, a healthcare organization could move to pulling this information through by waiting for the demand from a provider or other stakeholder.
- Eliminate wasteful activities. Once waste is eliminated in the process, the overall value stream can be adapted and then tested to ensure it is as effective and efficient as possible.
Lean simplifies processes that are too complex, pulling together and refining disparate processes or workflows, but is less adept at small, nuanced changes. Lean’s core focuses are to eliminate or reduce overproduction, waiting, transportation, processes that don’t add value, inventory, movement and costs. Often, this is a good fit for projects and changes on larger scales.
As Florida Tech instructor Dev Rajeha puts it, “Hospitals need to implement Lean principles that improve quality.”
“My book, Safer Hospital Care, is on rapid quality improvement using risk analysis tools to predict defects before they happen, a most effective, proactive approach to quality. I teach Lean methods as part of the risk analysis because the risk of high cost to the hospitals and patients can be minimized using the same tools of defect prevention. The idea is that high-quality care must also lower the costs. We need to use more of such methodology.”
The Institute for Healthcare Improvement (IHI) Model can be leveraged to speed up improvement processes given its emphasis on goal setting and team building for change.
In this model, teams ask three core questions:
- What do we want to achieve?
- How will we recognize an improvement as a result of a change?
- What changes can we make that can realize improvements?
Within a framework of Plan-Do-Study-Act (PDSA), teams quickly cycle through prospective chances, rapidly deploy them, and review. The cycle includes seven steps:
- Create the team to include the right experts who can identify areas that need change.
- Establish goals to clearly outline what the team hopes to achieve.
- Create measurements. This will enable the team to review changes in a data-driven manner and assess them.
- Test changes to confirm the goal is achieved, as well as note anything learned in the test.
- Implement the changes more broadly if effective.
- Disseminate to the organization.
This model works well when changes can be gradual and aren’t bogged down with details, and is also valuable for delivering immediate, quick wins.
The Care Model emphasizes upfront care, promoting prevention and disease management through fruitful interactions between all parties in the system, both patients and providers alike.
This model establishes six critical aspects of care, according to the HHS. These focuses include ensuring that care is:
- Safe for patients
- Effective, based on scientific study
- Patient-focused, at an individual level to guide each care decision with respect to the individual’s values, needs and preferences
- Timely to reduce potentially harmful delays and wait times
- Efficient to avoid wasting time, resources, energy and supplies
- Equitable for every individual, regardless of geography, socioeconomic status, religion, gender, age or any other characteristic.
This model expects all parties to participate in improving the system, including the patients.