chap 2 cqi

• Continuous Quality Improvement (CQI)


  A dynamic programmatic innovation within a health care setting
• CQI is utilized across health care sectors (including primary and preventative care) as well as across geographic and economic boundaries
• The need for CQI is increasing
• One reason: the safety and quality of care has shown improvement since 2000 but further improvement is needed and improvement should be part of everyone's goal in health care: clinicians, managers, researchers, and patients and their families
• Greater complexity and new technology are increasing the demand for higher quality
• External forces like accreditation and legislation (e.g. the ACA in the U.S) are increasing the demand for higher quality
• Despite the continuing evolution and spread of CQI in health care in the 21st century, some important questions remain about the adaptation and diffusion of quality improvement methods, especially in regard to the central role of individual health care providers
• Important questions about CQI implementation

  • Why aren't more health care providers using CQI tools and processes?
  • Why is the gap between knowledge and practice so large?
  • Why don't clinical systems incorporate the findings of clinical science or copy the "best known" practices reliably, quickly, and even gratefully into their daily work simply as a matter of course?
  • How to expand further the implementation of CQI in health care?
• CQI methodology is constantly being refined and tested: it is an evolutionary quality improvement mechanism
• CQI applications develop via continuous, ongoing learning and sharing among disciplines about ways to use CQI philosophies, processes and tools in a variety of settings
• A decade after the Institute of Medicine To Err is Human (2000) and Crossing the Quality Chasm (2001) and despite best efforts, improvement in quality and safety remains limited
• While progress has been made in understanding and implementing CQI, new challenges have arisen, and old challenges persist. For example, despite incentives for prevention, significant challenges remain in reducing medical errors
• Two key issues have been associated with the lack of improvement in the quality and safety of care in the U.S.: Complexity and cost (Dr. Donald Berwick)
• The complexity of the healthcare system is both a challenge and a source of ideas for how to make improvements (Plsek & Greenhalgh 2001)
• Health care is described as a complex adaptive system (Rouse 2008)
• Implications of healthcare as a complex adaptive system


  • Health care can only be designed to a certain extent
  • Cannot be designed around minimizing costs
  • Requires a focus on maximizing value
  • There is a need to be proactive - designing the system required, rather than continuing to let it evolve
• Leadership is critical and there need to be incentives for improvement
• The U.S. Healthcare system is much more expensive, but not significantly better than other healthcare systems around the world (Leonhardt 2009)
• There are no simple answers about how to move CQI innovations into the mainstream of health care more quickly and efficiently
• A common element to all complex systems is the difficulty surrounding diffusion of innovation
• Diffusion theory provides one way of understanding the barriers and facilitators of CQI in healthcare
• Innovation may not be able to be managed, but organizational conditions can be designed and controlled in a way that "enhance the possibility of innovation occurring and spreading" (Greenhalgh et al. 2005, p.80)
• Factors which facilitate conditions for innovation

  • Leadership
  • The creation of a receptive and even enthusiastic culture (e.g. the development of quality improvement collaboratives)
• Factors related to the process of adopting checklists are examples of factors related to diffusion of innovation
• Characteristics affecting change


  • Relative advantage
  • Compatibility
  • Simplicity
  • Trialability
  • Observability
• In the SSC example, compatibility (how closely do the change ideas align with the existing culture and environment) and trialability (the evidence base for whether the change can be adapted and tested in the new environments in which they are being spread) were most pertinent
• Berwick's 7 rules for dissemination of innovation in health care

  • Find sound innovations
  • Find and support innovators
  • Invest in early adopters
  • Make early adopter activity observable
  • Trust and enable reinvention
  • Create slack for change
  • Lead by example
• Fundamental levers of CQI

  • Reinvention
  • Trust
  • Leadership
• Reinvention hinges on cross-disciplinary learning, driving CQI's evolution globally. It's not a top-down mandate but a shared vision embraced by all, requiring trust, leadership, teamwork, and Deming's 'constancy of purpose'
• While top leadership sets the vision, buy-in from opinion leaders at all levels is crucial for successful reinvention
• CQI cannot be a top-down mandate. It must be part of the vision of an organization and accepted by all who must implement CQI - requiring trust at all levels
• Trust comes from leadership and teamwork and Deming's concept of "constancy of purpose."
• Top leadership must be involved and support and communicate the vision for innovation and change
• The participation, buy-in and support from opinion leaders at all levels within an organization are critical for successful implementation, and the process to reinvention
• One size will not fit all. As described by Berwick (2003, p.1974) "To work, changes must be not only adopted locally, but also locally adapted." Berwick asserts that for this to happen requires reinvention. "Reinvention is a form of learning, and, in its own way, it is an act of both creativity and courage. Leaders who want to foster innovation … should showcase and celebrate individuals who take ideas from elsewhere and adapt them to make them their own"(Berwick, 2003, p.1974)
• Health care is complex and requires diligence to spread the improvement process. Equally complex quality improvement strategies are required, slow adaptation - Simple PDSA cycles, have enjoyed broad success
• Review of a study by Foy et al. (2002) – a prospective study of the attributes of 42 clinical practice recommendations in gynecology
• Social marketing has been documented as being an effective tool for understanding ways to improve the impact of innovations in health care in general
• Business case for a health care improvement intervention

  The entity that invests in the intervention realizes a financial return on its investment (ROI) in a reasonable time frame, using a reasonable rate of discounting. This may be realized as "bankable dollars" (profit), a reduction in losses for a given program or population, or avoided costs
• A business case may also exist if the investing entity believes that a positive indirect impact on organization function and sustainability will accrue within a reasonable time frame