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• Continuous Quality Improvement (CQI)


  A structured organizational process for involving personnel in planning and executing a continuous flow of improvements to provide quality health care that meets or exceeds expectations
• Factors contributing to the exponential evolution of CQI since the new millennium

  • Increased customer awareness
  • Technological advancements
  • Greater competition
• Role of national and international developments in driving and shaping the evolution of CQI in healthcare services

  • Driving the evolution of CQI in healthcare services on a global scale
• Significance of institutionalizing CQI in public health

  • Extension of lessons learned from medical and hospital care
  • Influences from national and local accreditation efforts
  • Implications for future health improvement models
• Continuous quality improvement (CQI) has evolved over time and across countries
• Substantial progress has been made in the diffusion of CQI in health, e.g., in public health
• The need for greater diffusion of CQI continues, particularly due to greater complexity in health care systems
• Quality and safety problems persist in health care and new techniques are available to address these
• Quality in Health (WHO definition)


  The extent to which health care services provided to individuals and patient populations improve desired health outcomes. In order to achieve this, health care must be safe, effective, timely, efficient, equitable and people-centered.
• Components of Health (WHO)

  • Safe
  • Effective
  • Timely
  • Efficient
  • Equitable
  • People-centered
• Quality Assurance (QA)


  Focuses on conformance quality, which is defined as conforming to specifications; having a product or service that meets predefined standards
• Common Characteristics of CQI

  • Link to key elements of the organization's strategic plan
  • Quality council made up of the institution's top leadership
  • Training programs for personnel
  • Mechanisms for selecting improvement opportunities
  • Formation of process improvement teams
  • Staff support for process analysis and redesign
  • Personnel policies that motivate and support staff participation in process improvement
  • Application of the most current and rigorous techniques of the scientific method and statistical process control
• Cost of Poor Quality Care


  Poor quality care has a direct impact on the patients directly affected, the services which provide that care, and society at large. It includes the costs of identifying errors, correcting them, and making up for the customer dissatisfaction that results.
• Improving the Quality of Care


  • Improving the experience of care
  • Improving the health of populations
  • Reducing the per capita costs of health care
• Rationale for Implementing CQI in Health Care

  • Engagement in true process improvement
  • Give customers (patients) the quality care they deserve
  • Accreditation requirements
  • Cost control
  • Competition for customers
  • Pressure from employers and payers
• Characteristics and Functions of CQI in Health Care

  • Understanding and adapting to the external environment
  • Empowering clinicians and managers to analyze and improve processes
  • Adopting a norm that the term customer includes both patients and providers and that customer preferences are important determinants of quality in the process
  • Developing a multidisciplinary approach that goes beyond conventional departmental and professional lines
  • Adopting a planned, articulated philosophy of ongoing change and adaptation
  • Setting up mechanisms to ensure implementation of best practices through planned organizational learning
  • Providing the motivation for a rational, data-based, cooperative approach to process analysis and change
  • Developing a culture that promotes all of the above
• CQI: Philosophy and Process


  CQI is simultaneously a management philosophy and a management method. It is distinguished by the recognition that customer requirements are the key to customer quality and that customer requirements ultimately will change over time because of changes in evidence-based practices and associated changes in education, economics, technology, and culture. In health care such changes, in turn, require continuous improvements in the administrative and clinical methods that affect the quality of patient care and population health.
• Elements of CQI in Health Care

  • Philosophical Elements
  • Structural Elements
  • Health Care Elements
• Philosophical Elements of CQI

  • Strategic focus
  • Customer focus
  • Systems view
  • Data-driven (evidence-based) analysis
  • Implementer involvement
  • Multiple causation
  • Solution identification
  • Process optimization
  • Continuing improvement
  • Organizational learning
• Structural Elements of CQI

  • Use of process improvement teams
  • Use of CQI tools
  • Creation of parallel organization (Quality Council) to monitor CQI
  • Gain commitment from top management
  • Utilize statistical analysis
  • Develop and review customer satisfaction measures
  • Use benchmarking
  • Engage in redesign of processes
• Examples of CQI Tools

  • Flow charts
  • Run charts
  • Control charts
  • Cause and effect diagrams
  • Frequency charts
  • Checklists
  • Pareto charts
• Healthcare Elements of CQI

  • Use of epidemiological and clinical studies (evidence based medicine)
  • Involvement of staff in governance and peer review
  • Use of risk-adjusted outcome measures
  • Use of cost-effectiveness analysis
  • Use of quality assurance and risk management data and techniques
• Evolution of CQI


  1. From Japan (post-WW II) to US (1960s) to the World (21st century)

  2. Most recently: to low and middle income countries

  3. From TQM to CQI (that changes are improvements and that the improvement processes are ongoing, requiring learning and involvement in the process at all levels, from the individual to the organization level)
• Pioneers of CQI


  • Deming (14 points) - devised for management to improve quality (focus was always on processes rather than organizational structures)
  • Shewhart
  • Juran
  • Feigenbaum
  • Crosby
  • Donabedian
• Continuing Evolution in Japan

  • Taguchi
  • Ishikawa
  • Cross Disciplinary Thinking
  • Cross-Disciplinary Strategic Thinking
  • Industrial Versus Health Care Quality
• Cons of CQI in Healthcare

  • Ignores complexities patient-practitioner relationship
  • Downplays competencies and motivation of the practitioner
  • Ignores quality-cost trade-offs
  • Gives less to clinical activities than to supportive ones
  • Limited perspective on mechanisms for influencing professional behavior such as "education, retraining, supervision, encouragement and censure"
• Pros of CQI in Healthcare

  • Importance of health care quality traditions
  • Greater attention to consumers
  • Greater attention to system designs and processes
  • Expansion of self-monitoring, self-governing tradition to all staff
  • Greater role by management in CQI
  • Development of appropriate applications for health care monitoring
  • Greater education and training in CQI for all staff
• Evolution of CQI in Health Care

  1. From hospitals to all segments of healthcare

  2. From doctors and managers to all staff

  3. From specialized knowledge to generalized competencies

  4. From localized activities to national and international regulatory and accreditation agencies
• The Big Bang of CQI

  • Institute of Medicine
  • To Err is Human (2000)
  • Crossing The Quality Chasm (2001)
  • Data already know, but these report galvanized the press, the public, professional groups and regulators
  • Increased demands for accountability and professional responsibility
  • Transfer of concerns from managerial responses, to across the board responsibility
  • Revised Boynton & Victor Model for Health Care
• Mass Personalization


  Personalization must not be mixed up with customization. While customization relates to changing, assembling or modifying product or service components according to customers' needs and desires, personalization involves intense communication and interaction between two parties namely customer and supplier.
• Personalization in Health Care

  • Increased accessibility of data and information leading to increased patient and family participation in decision making
  • Possibility of personalized medicine - right drug at the right dose at the right time
  • Focus on individual rather than (chronic) condition, including evidence based medicine and self management
• Recent Evolutionary Trends in CQI

  1. The integration of CQI into public health activities

  2. The integration of CQI into nursing education (QSEN)

  3. The expanding role of accreditation

  4. The global spread of CQI across countries and health services

  5. Greater understanding and use of broad–based applications and methods
• The Scientific Method of CQI

  PDSA (Plan-Do-Study-Act) cycles provide a structure for iterative testing of changes to improve quality of systems. The pragmatic principles of PDSA cycles promote the use of a small scale iterative approach to test interventions, as this enables rapid assessment and provides flexibility to adapt the change according to feedback to ensure fit-for-purpose solutions are developed.
• FOCUS-PDCA


  FOCUS-PDCA creates common language and an orderly sequence for implementing CQI. It focuses on the answers to 9 questions.
• Guidelines for Strengthening PDSA Applications

  • Is the quality improvement study pertinent and relevant?
  • Are the results valid?
  • Are appropriate criteria used to interpret the results?
  • Will the study help you with your practice or organization of care?
• Since the advent of the new millennium CQI has continued to evolve in an exponential manner
• Globally and across sectors of health care, leading to innovations and paradigm shifts
• Examples of broader applications in low and middle income countries, institutionalization of CQI in Public Health, and continued successful use of broad-based CQI approaches/methods
• Continued success in using these methods requires care
• Recommendations have been presented for greater emphasis on the fidelity of the applications and fuller understanding, and consideration of the context, in which project-specific results are obtained and generalized