QI Series Part 2 | What is “Quality” in health care and how do we achieve it?

In Education & Quality Improvement by Shawn.MondouxLeave a Comment

This article is the second in a three-part series on quality improvement in health care. The first article, “What is Quality Improvement?”, defined this field of study and provided a brief history of its origins.  In this article, we will define “quality” and briefly describe tools often used to achieve improved quality in health-care delivery.

What do we mean by “high-quality” care?

Health-care organizations around the country are striving to improve the care they deliver to patients, covering numerous areas of quality. In Ontario where we work, we have seen the creation of Health Quality Ontario, the ever increasing number of conditions targeted by Quality Based Procedures, and a proliferation of Quality Standards for care delivery.   Saskatchewan recently trialed a province-wide application of Lean in the healthcare setting.  All British Columbia surgical centers are also enrolled in the National Surgical Quality Improvement Project (NSQIP), which originated at the American College of Surgeons in the U.S. Although most health-care providers agree that increasing quality in health care is important, few understand the definition of quality.

In 2001, the Institute of Medicine published Crossing the Quality Chasm”. 1 It remarked that there existed a large gap between the current care and the highest quality care that could be provided to patients.  It also laid out six domains that defined quality.  Each of these would have to be addressed to achieve the highest possible performance.

The Agency for Heatlhcare Research and Quality (AHRQ) 2 summarizes the six domains as follows:

  1. Safe: Avoiding harm that originates from care that is meant to help patients.
  2. Effective: Providing services based on scientific knowledge to all who could benefit and refraining from providing those services to patients not likely to benefit (avoiding underuse and misuse, respectively).
  3. Patient-centered: Providing care that is responsive to and respectful of individual patient preferences, needs and values, and ensuring that patient values guide all clinical decisions.
  4. Timely: Reducing waits and sometimes harmful delays for both those who receive and those who give care.
  5. Efficient: Avoiding waste including waste of equipment, supplies, ideas, and energy.
  6. Equitable: Providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status.

This definition of quality is thorough while remaining broad.  We should view this as a compass, one that provides us with an overall direction in which we need to steer health care.  It is important to note is that quality improvement projects do not necessarily require clear deliverables in each domain but, as a minimum requirement, should speak to one.  Importantly, they also should not advance a domain at the expense of another.

It should be remarked that these domains were developed in the American health-care climate, in which “equitable care” and “patient-centered care” may specifically address discrepancies in care delivery between socio-economic classes in the U.S.  Some have commented on the omission of resource stewardship from the IOM’s domains of quality of care. Indeed, within publicly funded health-care systems, the best possible care may only be delivered on a population level if changes to improve quality also consider the resource utilization of such initiatives.  It is our position that this must be weighed and considered as part of any quality improvement project.

Tools to increase quality

Quality experts and improvement advisors have come to view their training and skillset as one which begins with the effective application of improvement tools to clinical problems.  These tools come in many shapes and sizes, and are referred to by many names.  They have all grown from a particular need in a particular sector in which quality gains were sought. Judicious and appropriate application of individuals tools, with the help of application experts, is most likely to increase quality gains.

  • The Model for Improvement
  • Lean / Value Stream Mapping
  • Six Sigma

The Model for Improvement

This is the most commonly used model for healthcare improvement projects and is currently endorsed by the Institute for Healthcare Improvement (IHI).  It has immortalized the PDSA cycle (Plan-Do-Study-Act) as the de-facto tool in rapid-cycle change. 3

Model for Improvement


The term Lean refers to a manufacturing production system which originated at Toyota.  Its development progressed over decades (1948-1975), and has now become a management philosophy also referred to as the Toyota Production System (TPS).  Lean is also the origin of many tools used in improvement methodology including value stream mapping (VSM) as well as kaizen activities. Its principal goal is to eliminate waste in a process, such as the process of delivering health care.  More specifically, Lean/TPS has identified seven areas of waste: 4

  • Overproduction (delivering too much product or delivering it too early)
  • Waiting (for providers, resources or patients)
  • Over-processing (doing more work than the customer values)
  • Inventory (providing the work environment with less or more product than needed at inappropriate times)
  • Motion (more movement than required in the process to complete the task – “staff movement”)
  • Defects (significant rate of defective equipment and care in the process)
  • Transportation (limiting the movement of information and materials necessary to the delivery of care — “stuff”)

Six Sigma

Six Sigma is a manufacturing statistical process which seeks to reduce variability in the end product.   It originated at Motorola in 1986.  Sigma is a reference to the lower-case Greek letter σ, which means   ‘standard deviation’.  The goal here is to eliminate defects through decreased variability, by ensuring that products within six standard deviations from the mean meet product specification standards.  This means that 99.99966% of all processes and products produced will meet the desired specifications (or that there are fewer than 3.4 defective features per million opportunities).  It differs from other modalities in that it seeks to narrow the range of “products” produced rather than eliminate waste within the process.

Putting it all together

These are the guiding principles and the major tools used in quality improvement (QI) work.  Only those projects that are true to the IOM domains of quality should be called QI projects. The QI expert adequately and iteratively applies these tools in the most appropriate circumstances and understands the breadth and depth with which to apply them.   As might be the case in any trade, the appropriate use of a tool allows a more efficient completion of the work at hand.

Application of principles to an ED case

Your ED leadership team is looking to reduce the time between patient triage and assessment by a physician (physician initial assessment – PIA time).  Your group has several motivations for this which include increased patient satisfaction, quicker intervention on decompensated cases, and additional funding due to improvement on government metrics. 

Your goal is to see 90% of CTAS 2-3 patients within 1 hour of triage.

An audit should occur to understand which domains of quality are being targeted:

Patient-centered — responsive to patient perception

  • Timely — quicker access to physician
  • Safety — eliminate harm of antiquated system of triage and registration first
  • Efficiency — eliminates waste/duplication within the system
  • Equitable — may reduce LWBS rates in the ED, especially within certain populations

The next step would be to map (value stream mapping — LEAN) out the current process from the time the patient walks into the ED to the time they are seen by a physician.  This should be done by all members that have a hand in these processes including but not limited to EMS, nurses, triage, registration clerks, physicians, charge nurses, porters, PATIENTS, etc.  This same group should then settle on an ideal state map.  This should be guided by a QI advisor to ensure that the domains of quality are kept in mind and addressed. 

The ED group needs to then run a short test of the new model and document the bottlenecks, problems, issues that occur as a result of the change.  PIA times and stakeholder perceptions  should be monitored throughout the test.  Based on the learnings gathered, modifications should be made and a second short test should be conducted (PDSA cycles from the Model for Improvement).  Once the short tests are running well and accepted by stakeholders, implementation can be considered, using the same methodology.   Success should be measured by PIA principally.  A family of measures should also be established to ensure there are no negative effects of this intervention.

Take-home points:

  1. The Institute of Medicine (IOM) provided an often-utilized definition for high-quality health care in 2001.
  2. Six domains of quality exist within health care (safety, timeliness, effectiveness, efficiency, equitability, patient-centeredness), and quality improvement projects should seek to improve the patient experience in at least one of these domains.
  3. Quality Improvement science is about being comfortable with the application of many tools from many different industries, with the goal of understanding and improving the processes of delivering health care.

This post was copyedited and uploaded by Jesse Leontowicz (@jleontow)


Crossing the Quality Chasm. The National Academies Press; 2001. doi: 10.17226/10027
The Six Domains of Health Care Quality | Agency for Healthcare Research & Quality. AHRQ.gov. https://www.ahrq.gov/professionals/quality-patient-safety/talkingquality/create/sixdomains.html. Accessed March 20, 2017.
Science of Improvement: How to Improve . ihi.org. http://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementHowtoImprove.aspx. Accessed March 20, 2017.
Bercaw R G. Taking Improvement from the Assembly Line to Healthcare. CRC Press; 2011.


Dr. Shawn Mondoux is an emergency physician at Hamilton Health Sciences (HHS) and faculty at McMaster University in Hamilton, Ontario. He obtained a masters of Quality Improvement and Patients Safety (QIPS) at the University of Toronto and serves as QI advisor to all projects within the ED. He has a strong interest in clinical QI work as well as the education of PGME learners in QI principles.

Lucas Chartier

Dr. Lucas Chartier is an emergency physician and Deputy Medical Director for the University Health Network (UHN) emergency department (ED). He is also UHN's inaugural Medical Director of Quality and Safety, the ED Lead for the Toronto Central Local Health Integration Network (TC LHIN) and the Chair of the Quality Improvement and Patient Safety (QIPS) Committee of the Canadian Association of Emergency Physicians. With training at McGill (MD CM), University of Toronto (FRCPC) and Harvard (MPH), he now tries to spread the QIPS gospel in all the ways possible!