As physicians involved in Quality Improvement (QI) work, we are often asked by colleagues and learners, “What is QI exactly?” And this makes sense, given that few resources exist for those unfamiliar with the concepts and goals of QI. Here, we hope to provide any health-care professional with the introductory knowledge to better understand how and why QI became so important in healthcare, and what this means for the future of health-care delivery.
A (real brief) history of QI
In 1999, the Institute of Medicine (IOM) in the United States released a now famed report entitled “To Err is Human: Building a Safer Health System.”1 This report received international attention in mainstream media in large part due to the claim that the rate of death in US healthcare due to medical error matched that of a jumbo jet crashing every day. Suddenly, academics and administrators alike took greater interest in the question of medical error and patient safety.
Shortly after the release of “To Err is Human”, the IOM released “Crossing the Quality Chasm: A New Health System for the 21st Century”,2 which received much less media attention but was to become the founding document of QI and patient safety (PS) in health care. It defined the six domains of “Quality Care” (safe, timely, efficient, effective, equitable and patient-centered), and acknowledged that only the patient experience and outcomes should be the true measure of quality.
Preceding the IOM’s reports, the Institute for Healthcare Improvement (IHI) – a US-based health-care improvement and innovation organization – had been pushing the envelope in the spheres of QI and PS3. They have been responsible for the popularizing of the Model for Improvment,4 which has become the cornerstone of health-care improvement methodology and which is being used around the globe to improve patient care.
In 2004, the Canadian Adverse Events Study5 was published by Baker and colleagues and established that approximately 7.5% of all hospital admissions were subject to an adverse event. It was estimated that 37% of these were preventable, which would represent nearly 70,000 events in Canada every year. The study was repeated in 2012 in pediatric centers6 in which it was determined that adverse events occurred in 9.2% of admissions and approximately 45% were deemed preventable.
All of the above publications (and more) led governments to place value on the quality of health care, led hospital administrators to look for leadership in the field of QI, and led clinical departments to seek out and develop expertise within their groups. Over 30 years after its inception, QI in health care is now experiencing its coming of age.
QI and QA – it’s the same thing, right?
Many of our (well-intended) colleagues often approach us to discuss our “work in QA”. It’s QI, not QA… There are fundamental differences between quality assurance (QA) and QI. Quality Assurance (QA) is an audit or review, that is, a process to assess compliance with an established standard. It aims to bring up the care provided up to a known standard. An assessment of the percentage of patients with acute coronary syndromes (ACS) who receive Aspirin (ASA) in your emergency department (ED) is a good example. It establishes performance (it should be 100%!), but does little to propose a solution (i.e. improve) if rates are suboptimal.
Auditing practices are common in the healthcare setting, whereby deviance is established and solutions are quickly proposed and implemented top-down. Despite this, we have all observed scenarios in which the proposed “fixes” are ineffective (or downright dangerous). For example: front-line staff do not “buy” into the changes, new processes are not sustained over the long-term, or new (and bigger) problems may have been created by the change process.
Whereas QA brings up the care up to a known standard, QI aims to break the “ceiling” and move above and beyond the current standard. QI begins where QA ends. In our example, QI would seek to understand why the compliance rate for ASA in ACS is suboptimal in your local ED, and engage clinicians to make useful changes for them (e.g., order set, medical directive, reminders, education, etc). QI’s perspective is to look at care delivery problems almost exactly as we would approach a patient’s diagnostic and treatment journey. The quality problem requires a careful history to understand its nature, diagnostic tests to uncover its cause, treatments directed at the underlying etiology, and monitoring of treatment as time goes forward. This diligent approach defines QI.
Proposing a solution to a clinical quality problem without understanding its nature and assessing its cause would be akin to treating all chest pain patients presenting to the ED with anticoagulation in one centre or antibiotics in another. Although both pulmonary embolism and pneumonia are plausible causes for chest pain, the proposed solutions are entirely unreasonable. So too would be uninformed process changes to important clinical quality problems. In other words, you must understand the system at play and its own specific challenges before you make some changes.
QI and CQI – Well that must be the same then, right?
CQI, or Continuous QI, refers to a health-care delivery and management philosophy, not only a toolkit for change. CQI posits that the improvement journey will never come to an end and that perpetual change, with the goal of achieving better outcomes for the customer/patient, should be the only constant within the organization. An important goal of CQI is to change the institutional culture to accept experimentation and change cycles in the name of QI. So although intimately related, QI and CQI are not the same. The former is the process or methods, while the latter is the spirit embodied by them.
Imagine a large national corporation making a one-time big financial donation to your city with the goal of reducing homelessness. You might consider this to be both generous and socially responsible. A second organization in your community has a sustained community presence not limited to financial donations, which actively seeks the many causes of this complex problem and engages in activities to address these. Although both will hopefully contribute to reducing homelessness, the second organization clearly operates with a different mandate and culture. This broad approach and commitment would be akin to a hospital engaged in CQI work.
It is important to recognize that the current “novelty” surrounding QI is simply because this field is new to the average healthcare practitioner. But QI has been alive for over 3 decades and slowly proving its worth in health delivery systems across the world. QI is fundamentally about changing process and people to make the patient experience better and the best QI is not an activity, but an attitude.
Take Home Points:
- Quality Improvement (QI) science in health care has been alive since 1986 and patient safety studies in the late 1990s and early 2000s established the need for its application more broadly.
- Quality Assurance (QA) audits are a process aimed to increase quality up to an established standard. QI is a toolkit to address the problems when the standard is not attained or when we seek to elevate performance above and beyond to a new standard.
- Continuous Quality Improvement (CQI) is an institutional philosophy and culture which relies on the ongoing and everlasting need to embrace change processes to improve patient care.
This article is the first of a three-part series. The second article in this three-part series will address the definition of quality and different methods used to achieve improvement gains. The final article will differentiate between the QI and Clinical Epidemiology (aka research) approach to problem solving and the objectives of dissemination for both streams of work.