The History of CQI in Health Care Essay

Continuous quality improvement (CQI) is a concept that is applied in various spheres of life. The health care system is not an exception. The implementation of CQI in health care has been an issue on the agenda of the health care institutions since the 1980s. To be precise, the discussions of the necessity of changes in the health care system started in 1987 when the Joint Commission for Accreditation of Health care Organizations (JCAHO) launched an “Agenda for Change” (Radawski 1999).

The reform in medical education was initiated in 1991 (Radawski 1999). The reform was caused by the necessity of providing efficiency in the CQI implementation. The medical personnel might have been informed about the changes. It might have been provided with all the necessary information about the CQI. The process of CQI implementation in health care institutions moved to another level in 1995 when the initial stage of adapting JCAHO standards to the system of CQI ended. At that period, the organization obliged the health care facilities to have a structural division responsible for CQI (Radawski 1999).

The progress in the Quality Implementation Plan was achieved on 30 June 1989. According to the plan, it was intended to pilot and evaluate the “Patient Commitment Card System” in the fall of the same year. The History of CQI in Health Care Essay.  Besides, it was planned to identify and evaluate community sources for QI assistance. In July 1989- June 1990, the plan was revised. In particular, it assumed the implementation of the practice methods, integration of quality improvement action plans, and establishment of the regular quality reviews.

It was decided to evaluate the effectiveness of the existing policies and guidelines. The results of the evaluation provided the background for suggestions for improvement. The implementation of the program was monitored throughout the year. The IV Documentation Team was formed in 1990. The quality reviews and assessments had been initiated the same year.

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Reference

Radawski, D. (1999). Continuous Quality Improvement: Origins, Concepts, Problems, and Applications. Perspective on Physician Assistant Education, 10(1), 12-16.

The quest to use health information technology (IT), specifically EHRs, to improve the quality of health care
throughout the health care delivery continuum is a consistent goal of health care providers, national and local
policymakers, and health IT developers. The seminal Institute of Medicine (IOM) report, Crossing the Quality
Chasm: A New Health System for the 21st Century (IOM, 2001), was a call for all health care organizations
to renew their focus on improving the quality and safety of patient care in all health care delivery settings.
Since the IOM report, the health care industry has emphasized the design and implementation of health IT
that supports quality improvement (QI) and quality monitoring mechanisms in all levels of the health care
delivery system. Many QI strategies currently used in health care, including Continuous Quality Improvement
(CQI), have been adopted from other industries that have effectively used QI techniques to improve the
efficiency and quality of their goods and services. Experience and research have shown that CQI principles,
strategies, and techniques are critical drivers of new care models such as Patient-Centered Medical Homes
(PCMHs) or Accountable Care Organizations (ACOs).The History of CQI in Health Care Essay.  As practice leaders and staff learn more about CQI
strategies and identify what works best for the desired type and level of changes in the practice setting (i.e.,
moving from the current state to the desired future state), they will recognize the value in designing an EHR
implementation to meet both the Meaningful Use requirements and their own QI goals.
This Primer provides an overview of CQI concepts and processes and will:
• Define CQI and how it applies to EHR implementations and practice improvement strategies;
• Identify a conceptual framework to consider when implementing CQI techniques in a practice setting;
• Explore tools, techniques, and strategies that health care and other service industries use to guide and
manage CQI initiatives;
• Guide the selection of the most appropriate CQI technique or strategy for the type and scale of
improvements the practice is considering; and,
• Provide tips to help the practice leaders tailor the approach, tools, methods, and processes to the
unique CQI initiative and practice setting.
1.2 WHAT IS CONTINUOUS QUALITY IMPROVEMENT?
Put simply, CQI is a philosophy that encourages all health care team members to continuously ask: “How are
we doing?” and “Can we do it better?”(Edwards, 2008). More specifically, can we do it more efficiently? Can
we be more effective? Can we do it faster? Can we do it in a more timely way? Continuous improvement
begins with the culture of improvement for the patient, the practice, and the population in general.
Besides creating this inquisitive CQI culture in an organization, the key to any CQI initiative is using a
structured planning approach to evaluate the current practice processes and improve systems and
processes to achieve the desired outcome and vision for the desired future state. Tools commonly used in
CQI include strategies that enable team members to assess and improve health care delivery and services.
Applying CQI to a practice’s EHR implementation means that the health care team must understand what
works and what does not work in the current state and how the EHR will change care delivery and QI aims. The History of CQI in Health Care Essay.
The CQI plan identifies the desired clinical or administrative outcome and the evaluation strategies that
enable the team to determine if they are achieving that outcome. The team also intervenes, when needed, to
adjust the CQI plan based on continuous monitoring of progress through an adaptive, real-time feedback
loop.
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1.3 HOW CAN CQI HELP A PRACTICE MAKE THE MOST OF MEANINGFUL
USE?
Meaningful Use is an important means to achieving the triple aims of health care—improving the experience
of patient care, improving population health, and reducing per capita costs of health care (Berwick et al.,
2008). The Centers for Medicare and Medicaid Services’ EHR Incentive Program provides eligible
professionals, eligible hospitals, and critical access hospitals incentive payments that support the optimal use
of technology for health care (Incentive Programs—Regulations and Guidance). Although a practice can
implement an EHR without addressing Meaningful Use, practices that do so are less likely to realize the full
potential of EHRs to improve patient care and practice operations (Mostashari, Tripathi, & Kendall, 2009).
Attesting to Meaningful Use, although it is an important milestone for a practice, is not an end unto itself.
Practices that can achieve Meaningful Use will be able to use their EHR to obtain a deep understanding of
their patient population and uncover aspects of patient care that could be improved. Using a planned,
strategic approach to CQI will help a practice move from reporting the requirements for Meaningful Use to
improving patient care and meeting other practice goals. The literature shows a strong link between an
explicit CQI strategy and high performance (Shortell et al., 2009). Thus, applying CQI principles and
strategies will transform numbers on a spreadsheet or a report into a plan for action that identifies areas of
focus and the steps and processes needed to improve those areas continually and iteratively.
To establish an effective CQI strategy, a practice should (Wagner et al., 2012)
• Choose and use a formal model for QI.
• Establish and monitor metrics to evaluate improvement efforts and outcomes routinely.
• Ensure all staff members understand the metrics for success.
• Ensure that patients, families, providers, and care team members are involved in QI activities.
• Optimize use of an EHR and health IT to meet Meaningful Use criteria.
Put together, CQI and Meaningful Use can move a practice from its current state to a more desirable future
state. As depicted in Exhibit 1, CQI begins with a clear vision of the transformed environment, identification
of necessary changes to achieve that vision, and input from engaged team members who understand the
needs for the practice. In short, the journey to the desired future state involves a transformation of people,
process, and technology. Meaningful Use of health information and an explicit commitment to CQI can help a
practice establish that clear vision and implement it successfully.
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Exhibit 1. Using CQI to Move From Current State to Future State
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1.4 WHAT DOES CQI LOOK LIKE IN PRACTICE?
In undertaking any CQI initiative, a practice must consider three components: (1) structure, (2) process, and
(3) outcomes (Donabedian, 1980). Exhibit 2 builds on these three components within the context of health
information technology and illustrates the basic premise of CQI: any initiative involving an EHR to improve
patient care must focus on the structure (especially technology and people) and process that lead to the
expected outputs and then ultimately to the desired outcomes.
Exhibit 2. CQI Framework Model
Structure. Structure includes the technological, human, physical, and financial assets a practice possesses
to carry out its work. CQI examines the characteristics (e.g., number, mix, location, quality, and adequacy) of
health IT resources, staff and consultants, physical space, and financial resources.
Process.The History of CQI in Health Care Essay.  The activities, workflows, or task(s) carried out to achieve an output or outcome are considered
process. Although CQI strategies in the literature focus more commonly on clinical processes, CQI also
applies to administrative processes. The EHR functions that meet Meaningful Use Stage I Core Objectives
support key clinical and administrative processes (see this link: MU Objectives).
Output. Outputs are the immediate predecessor to the change in the patient’s status. Not all outputs are
clinical; many practices will have outputs tied to business or efficiency goals and, accordingly, require
changes to administrative and billing processes.
Outcome. Outcomes are the end result of care (AHRQ, 2009) and a change in the patient’s current and
future health status due to antecedent health care interventions (Kazley, 2008). Desired changes in the cost
and efficiency of patient care or a return on investment in the EHR can also be considered outcomes.
Feedback Loop. In Exhibit 2, a feedback loop between the output/outcome and the CQI initiative represents
its cyclical, iterative nature. Once a change to the structure and process is implemented, a practice must
determine whether it achieved the intended outcome and, if not, what other changes could be considered. If
the outcome is achieved, the practice could determine how to produce an even better outcome or achieve it
more efficiently and with less cost.
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It’s not just a model: CQI in action
Consider structure, process, and outcomes and how they apply to a CQI initiative to improve
obesity screening and follow-up in an adult primary care practice that has attested to Meaningful
Use (MU) Stage 1.
• The structural assessment of an obesity screening CQI initiative would examine the
functionality of the EHR for weight management tasks; staff’s knowledge and expertise to
counsel overweight and obese patients; and the adequacy of the space and materials to provide
education and social support. The CQI initiative might also consider the acquisition of a
separate Adult Body Mass Index (BMI) Improvement module that would randomly survey patient
charts at two different times to monitor BMI changes in the clinic’s overweight and obese patient
population. The History of CQI in Health Care Essay.
• A process assessment of an obesity screening CQI initiative would ensure that the EHR can
record and chart vital signs such as BMI (MU Core Measure # 8) so providers can easily
capture, monitor, and trend a patient’s weight from visit to visit. The CQI initiative would also
assess the clinical summaries given to the patient (MU Core Measure # 13) and whether these
summaries effectively educate patients about what they need to do between visits to maintain or
reduce their BMI.
• An output leading to an improvement in BMI could be ensuring that BMI is recorded in the EHR
at each visit for every patient so that the provider can track the patient’s progress. Another
output might be to ensure that every patient receives nutrition and exercise counseling between
office visits.
A primary outcome for an obesity CQI initiative is reducing BMI by a certain amount within a
specified time frame that the provider/patient believes is achievable. Longer term outcomes for the
individual patient are improved quality of life and a longer life. For the practice that is part of an
ACO or PCMH, reducing BMI in its patient panel may result in better reimbursement and receipt of
financial incentives. A CQI initiative supported by an EHR allows the practice to monitor progress
towards the outcome for a patient. Equally important, however is the ability to monitor the progress
of the practice’s obese population by establishing a disease registry. Thus, a practice can monitor
changes in BMI for each patient, estimate the proportion of patients in the practice that are
overweight and obese, and identify patients who are outliers. These powerful data can transform
how a provider chooses to care for these patients.
If the obesity CQI initiative reveals that efforts to screen and counsel are successful in reducing
BMI in patients, the next question is whether the enhanced screening works for everyone equally
well. A closer look at the data may reveal, for example, that screening had almost no effect on older
male patients. These insights would be used to consider additional modifications to the structure
and process of the screening to help older male patients achieve weight management goals.
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2 Strategies for CQI
2.1 LEADING CQI STRATEGIES IN HEALTH CARE
Fortunately, a practice can choose many well-established CQI programs and strategies to achieve its QI
aims. The specific strategy a practice selects depends on several factors. For example, a practice
incorporating CQI in an initial EHR implementation will have different goals and objectives than a practice
that has already achieved Stage 1 Meaningful Use and wants a more targeted CQI effort directed at
Meaningful Use Stage 2. The following sections briefly describe four strategies for CQI widely used in the
health care industry today. The descriptions cover the basic principles of each strategy followed by the
specific action steps each strategy recommends. An accompanying case study illustrates the use of the
strategy in a practice setting.The History of CQI in Health Care Essay.  This section concludes with a side-by-side comparison of the strategies and
guidance on selecting the appropriate strategy. Again, the final CQI strategy the practice uses could be a
combination of tools, methods, and processes that best meet the practice culture and the unique CQI
initiative.
2.1.1 The Institute for Healthcare Improvement (IHI) Model for Improvement
Exhibit 3. IHI Model for Improvement
The IHI Model for Improvement is a simple strategy that many
organizations currently use to accelerate their improvement
strategies. A CQI initiative based on the IHI Model for
Improvement focuses on setting aims and teambuilding to
achieve change. As depicted in Exhibit 3, it promotes
improvement by seeking answers to three questions:
• What are we trying to accomplish?
• How will we know that a change is an improvement?
• What changes can we make that will result in
improvement?
Principles
To answer these questions, a CQI initiative uses a Plan-DoStudy-Act (PDSA) cycle to test a proposed change or CQI
initiative in the actual work setting so changes are rapidly
deployed and disseminated. The cycle involves the following
seven steps:
Form the team. Including the appropriate people on a process
improvement team is critical to a successful effort. The practice
(or provider) must determine the team’s size and members.
Practice staff persons are the experts at what works well in the
practice and what needs to be improved. Include them in
identifying and planning the implementation of any CQI
initiative.
Set aims. This step answers the question: What are we trying to accomplish? Aims should be specific, have
a defined time period, and be measurable. Aims should also include a definition of who will be affected:
patient population, staff members, etc. For practice transformation, the aims should ideally be consistent with
achieving one or more of the triple aims previously discussed.
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Big Sandy Health Care in Eastern
Kentucky used the Plan-Do-Study-Act
cycle to develop and test a new
patient portal. The staff first identified
the priority functions for the portal and
the workflow changes involved. Then,
staff received training and pilot tested
the portal with volunteer patients.
Issues from the pilot testing were
addressed before the rollout, and a
patient survey on the portal provided
feedback to aid further improvements.
When to use. The IHI Model for Improvement is best used for a CQI initiative that requires a
gradual, incremental, and sustained approach to QI so changes are not undermined by excessive
detail and unknowns (Hughes, 2008).
To find out more:
http://www.ihi.org/knowledge/Pages/HowtoImprove/ScienceofImprovementHowtoImprove.aspx
Establish measures. This step answers the question: How will
we know that a change is an improvement? Outcome measures
should be identified to evaluate if aims are met. Practices
should select measures using data they are able to collect.
Select changes. This step answers the question: What
changes can we make that will result in improvement? The
team should consider ideas from multiple sources and select
changes that make sense.

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Test changes. First, the changes must be planned and
downstream impacts analyzed to assess whether they had the
desired outcome or output. Once the changes are
implemented, the results should be observed so that lessons
learned and best practices can be used to drive future changes.
Implement changes. After testing a change on a small scale, learning from each test, and refining the
change through several PDSA cycles, the team may implement the change on a broader scale—for
example, for a pilot population or on an entire unit.
Spread changes. After successful implementation of a change(s) for a pilot population or an entire unit, the
team can disseminate the changes to other parts of the organization.
2.1.2 Lean
Lean is a continuous improvement process that gained international recognition when Womack, Jones and
Roos published a book on the Toyota Production System. Many hospitals have borrowed the key Lean
principles of reducing non-value added activities, mistake-proofing tasks, and relentlessly focusing on
reducing waste to improve health care delivery. The History of CQI in Health Care Essay. Lean helps operationalize the change to create work flows,
handoffs, and processes that work over the long term (see Exhibit 4). A key focus of change is on reducing
or eliminating seven kinds of waste and improving efficiency (Levinson & Renick, 2002):
• Overproduction
• Waiting; time in queue
• Transportation
• Nonvalue-adding processes
• Inventory
• Motion
• Costs of quality, scrap, rework, and inspection
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Exhibit 4. Lean Principles for Operational Efficiency1

1
http://www.pmvantage.com/leanbusiness.php
Principles
A Lean CQI initiative focuses mainly on alleviating overburden and
inconsistency while reducing waste to create a process that can
deliver the required results smoothly (Holweg, 2007). Teams
frequently use these principles once they know what system change
will result in an improvement.
Identify which features create value. Identifying value is
determined through both internal and external perspectives. For
example, patients might value reduced phone time on hold, while
providers value having all the information at hand available when
making an appointment. The specific values depend on the process
being streamlined.
Identify the value stream (the main set of activities for care).
Once value is determined, practice leaders should identify activities
that contribute value. The entire sequence of activities is called the
value stream. Activities that fall outside. The History of CQI in Health Care Essay.