Introduction to Quality Improvement

Side profile of a male surgeon washing his hands.


Learning Objectives

After reading this chapter, you should be able to do the following:

Describe potential benefits that quality improvement can bring to healthcare organizations.

Discuss the history of quality improvement and the use of its methods as a new concept for the healthcare industry.

Analyze the global, national, regional, and state efforts toward healthcare quality improvement.


Josh Nahum was a skydiving instructor in Colorado in 2006 when he fractured his skull and broke his leg in an accident that occurred while doing what he loved best—jumping out of airplanes.

Amazingly, he survived his injuries and was on the mend in the hospital when he caught an antibiotic-resistant bacterial infection. Within weeks, the once healthy, active college student, who had dreams of becoming a child psychologist, was dead. He was 27 years old.

During his almost six-week stay in a hospital intensive care unit (ICU), Nahum developed a healthcare-associated infection called methicillin-resistant Staphylococcus aureus, also known as MRSA, which is a contagious staph bacteria that can be difficult to treat because it is resistant to many commonly used antibiotics. Doctors treated the infection with antibiotics and eventually Nahum was doing well enough to be transferred to a rehabilitation facility to continue his recovery. However, just as he was recuperating, he began to run a fever that spiked at 103 degrees. An infection caused by what’s called antibiotic-resistant gram-negative bacteria—one that is resistant to treatment with virtually every antibiotic medication—was found in his cerebral spinal fluid. Despite efforts to treat the infection, it spread rapidly, causing pressure around his brain, paralyzing him, and making him a permanent quadriplegic dependent on a ventilator to breathe. He died two weeks later.

His family, hoping to alert others to the dangers of healthcare-associated infections and the need for better infection control practices, education, and solutions, told his story on the website of the Infectious Diseases Society of America (Nahum & Nahum, 2010). His parents say the family has never recovered from his death.

When people think about hospitals or other healthcare organizations, many think of them as safe places where people go to get well or help ensure that they stay well. But in reality, hospitals and other healthcare facilities can pose risks to patients. A patient can go into a hospital or surgery center for elective surgery (or, like Josh Nahum, for treatment after an accident) and end up with a dangerous, even life-threatening, infection. Hospitals house sick patients, many of them with illnesses and germs that can spread to other patients and even staff members.

It may amaze you to know that one of the key actions that can help prevent the spread of these healthcare-associated infections is a simple one: hand hygiene. But surely, you think, doctors and nurses are constantly washing their hands or using a hand sanitizer. Maybe—but perhaps they aren’t washing them properly or in every circumstance that they need to, such as after direct contact with each patient.

Therefore, one major initiative in hospitals and healthcare facilities around the country is to ensure that doctors, nurses, and all their workers comply with hand hygiene guidelines, such as those developed by the World Health Organization (WHO) or the U.S. Centers for Disease Control and Prevention (CDC). Proper hand hygiene is the best way to reduce the risk of healthcare-associated infections and keep patients safe.

Quality improvement teams in thousands of hospitals are looking at the problem of making sure staff members follow proper hand hygiene and coming up with ways to promote improved hand hygiene practices to reduce transmission of germs to patients and personnel in healthcare settings. Hands are the conduit for almost every transfer of potential pathogens from one patient to another, from a contaminated object such as a bed tray or bed rail to a patient, or from facility staff to a patient.

Healthcare organizations want to ensure that staff follow proven guidelines to reduce infections. What are some of the steps they are taking? They range from prohibiting staff who have direct patient contact from wearing artificial fingernails, which can harbor germs, to requiring staff to wear gloves whenever they may come into contact with blood or other potentially infectious materials.

It’s not only doctors and nurses who need to wear gloves. What about housekeeping staff who may be called to clean up an operating room or emergency department where blood has dripped on the floor? Or food service staff who pick up used trays from patient rooms following meals?

Once hospitals have measures in place to promote good hand hygiene, they must check to ensure that people are following them. Supervisors may be assigned to watch for proper hand hygiene among staff. Did Dr. Smith clean his hands before providing patient care? What about after caring for the patient? Did he clean his hands after removing his gloves or other protective equipment, such as a gown and mask? Failure to follow these kinds of steps can spread an infection from one patient to another.

Hospitals are monitoring for compliance with their hand hygiene program and tracking their infection rates. How well are they doing protecting patients from healthcare-associated infections? Their financial well-being, accreditation survey, public image, and liability risks may depend on it. That’s why hand hygiene and other quality improvement projects are so critical to healthcare organizations.

1.1 Focus on Quality

Quality has become a major focus within healthcare. Over the last 15 years or so, healthcare organizations have become more focused than ever on providing safe, quality care to patients. After all, patients are consumers and want to get the best possible care they can. Patients, communities, insurance companies, and government agencies are demanding excellence from healthcare institutions, and healthcare organizations are striving to do the best job they can in caring for their patients. As this focus continues, it is important that everyone working in healthcare organizations has an understanding of quality improvement (QI) and why it matters.

There is a simple way to think about quality improvement. Quality improvement encourages all members of an organization to continuously ask the questions “How are we doing?” and “Can we do it better?”

By asking, “How are we doing?” a healthcare organization will undoubtedly uncover problem areas that should be made better. Data that healthcare organizations collect can pinpoint problem areas. A hospital may find that a large number of patients discharged from its facility need to be readmitted within 30 days for reasons that are avoidable. An ambulatory surgery center may discover a high rate of surgical site infections in its patients. A nursing home may find that its elderly residents have a much higher rate of falls and subsequent injuries than other facilities in the state.

Quality improvement is also the way to answer the second question, “Can we do it better?” The purpose of continuous quality improvement (CQI) programs is to improve healthcare by identifying problems, implementing and then monitoring the corrective actions an organization puts in place, and studying the effectiveness of those improvements. Ultimately, the question is: Do they work?

The hospital with high readmission rates may discover that its staff members need to take more time to educate patients when they are discharged so they understand the need to take their medications as prescribed and plan for follow-up visits with their primary care physicians. Or perhaps hospital social workers can better coordinate post-hospital care and services so that patients have the home care they need and won’t need another hospital visit.

The ambulatory surgery center may need to better educate health workers who are involved in surgical procedures, as well as the patients themselves, about the importance of preventing infections and ways to do that. The nursing home may need to better assess residents who are at a risk of falling and put safety measures in place, such as lowering beds and putting stars or other identifiers on doors that alert staff members to at-risk residents.

Why Quality Improvement Matters

A female doctor talking to a senior couple in a hospital room.


Responsive quality improvement programs ensure that patients receive the best care possible.

It is important that healthcare organizations implement a quality improvement program that is responsive to patients, the community, and customers who demand and deserve excellence. If healthcare organizations do not care about quality, patients will suffer. Quality improvement is a concept that has taken hold in many industries; certainly, in healthcare the consequences could not be greater. Quality in medicine can be a matter of life or death for patients. Failing to ensure quality in the airline industry or in the pharmaceutical industry can also cost lives if a plane crashes or a contaminated drug hits the market. But quality may not be a matter of life and death for every industry; for example, a book publishing company or paperclip manufacturer may make errors that harm no one. However, if a physician doesn’t order the proper tests for a patient with diabetes, that patient may lose his eyesight. A housekeeper who doesn’t thoroughly clean a bed before a new patient occupies the hospital room may leave behind germs that cause severe diarrhea in an elderly patient that takes weeks to cure.

Quality improvement is the responsibility of all individuals at all levels of the delivery system. Whether those working in healthcare serve patients directly or support those who do, they must be committed to continuous quality improvement and excellence.

Quality improvement is also a management tool that can help achieve that excellence so that patients receive the best possible care and service. It is about evaluating the quality of an organization’s care and services, setting a high standard, and continuously improving on each patient’s behalf. Quality improvement can apply to almost any process or product and can improve patient care and customer service.

A Look Ahead

In this chapter, we will introduce you to quality improvement and its importance in the healthcare field. Subsequent chapters will delve more deeply into how healthcare organizations can carry out quality improvement projects.

Chapter 2 will provide a more detailed overview of quality in healthcare.

Chapter 3 provides a look at continuous quality improvement, which must be an ongoing effort to strive to do a better job.

Chapter 4 considers how accreditation, regulatory agencies, and other organizations have an impact on quality improvement.

Chapter 5 looks at data resources—the data that pinpoint problems and can lead to solutions and better care.

Chapter 6 covers data measurement and the ways to demonstrate improvement in quality.

Chapter 7 details how two of the most popular quality improvement models, Six Sigma and lean theory, work.

Chapter 8 looks at real-world aspects of quality improvement.

This book will introduce you to concepts that will help you understand and implement quality improvement in a healthcare organization. After all, quality improvement is everyone’s job when it comes to the healthcare field.

Questions to Consider

What do you think is the primary reason that quality improvement is so important in the healthcare industry?

Can you think of a problem in the healthcare industry that a quality improvement project might address?

1.2 A New Concept for Healthcare

As important as quality improvement is in healthcare, its history is quite short. Quality improvement has its roots in industry and came to the forefront as a way to improve manufacturing in post-World War II Japan, but its application is relatively new to healthcare. To be clear, improving the quality of patient care and processes is not a new concept for healthcare organizations, but the use of these methods is quite new.

While the focus on quality improvement in industry is on efforts such as preventing product failures and work-related injuries, in the healthcare world the focus is often on reducing medical errors and protecting patients from bad outcomes—although quality improvement encompasses every aspect of the healthcare operation.

Applying these methods of continuous quality improvement to the delivery of healthcare did not become widely established until quite recently. It wasn’t really until the 1990s that healthcare organizations began undertaking these formal quality improvement projects. These projects were prompted by the increasing focus on performance improvement standards by The Joint Commission, the leading accreditor of hospitals, and the creation of the National Committee for Quality Assurance, a major accreditor of health plans and physician groups.

Since the 1990s, there has been an explosion of interest in quality improvement in healthcare. Some of that interest was spurred by the critical eye that was turned on the healthcare industry, which found shortcomings that the public, government agencies, and patient safety advocates demanded organizations address. Organizations have researched ways to improve care and delivery of services—from the way the facility functions, to how the billing office operates, to the clinical care of the sickest patients. Healthcare organizations have begun sharing best practices and solutions to problems that are widespread in the industry. While some of the most widely publicized quality improvement projects involve clinical care, every department in a healthcare organization can become involved in quality improvement. For instance, efforts to ensure air quality in hospitals where there are patients with airborne transmitted infectious diseases may involve air quality and engineering professionals, facility management, and infection control professionals working together to address issues.

The Patient Safety Movement and Improving Systems

Quality improvement was certainly spurred on by the patient safety movement. Two major reports published by the Institute of Medicine (IOM) put the spotlight squarely on patient safety. To Err is Human, released in 1999, created public demand for change with the rather shocking news that medical errors cause 44,000 to 98,000 patient deaths in the United States annually (Institute of Medicine, 1999). The report found that more deaths occur in hospitals each year from preventable medical mistakes than occur from motor vehicle accidents, breast cancer, and AIDS. However, given the fact that healthcare is a human-driven system and people do make mistakes, it’s important to recognize that there will always be some errors. The goal of quality improvement is to minimize the errors to the lowest possible level, but it is unrealistic to expect that healthcare organizations can ever eliminate every medical error.

The IOM’s Crossing the Quality Chasm report in 2001 made the argument that quality comes from having appropriate systems in place (Institute of Medicine, 2001). The report states that people will always make mistakes, but systems can help prevent those errors. For example, computerized physician order entry systems can minimize medication errors that result from illegible physician handwriting. By having hospital staff enter medication orders via computer linked to prescribing error prevention software, the computer can catch mistakes, such as a high dosage of a medication that could sicken or even kill a patient. Such systems have been shown to reduce serious prescribing errors by more than 50% (Bates et al., 1998). Healthcare organizations need to build such systems and ensure they focus on delivery of high quality care and services.

Quality improvement is a formal approach to the analysis of performance (i.e., how are we doing?) and systematic efforts to improve that performance. There are numerous models used in quality improvement. Two of those models, Six Sigma and lean theory, are discussed in detail in Chapter 7.

A doctor typing a prescription on a computer.

Ajpfilm/age fotostock/SuperStock

Entering prescription orders on a computer rather than writing them out by hand can minimize errors resulting from illegible handwriting.

The purpose of quality improvement is to measure where an organization is and determine ways to make things better. It is not about attributing blame for an error, but about creating systems to prevent errors from happening. These efforts look to find the defect in the system. For instance, wrong-site surgeries, in which a surgeon might replace the right knee instead of the left, can be prevented by simple steps, such as staff members or the patient marking the site prior to the operation.

Current thinking in quality improvement acknowledges the importance of individual performance and competence, but concludes that individual competence is insufficient to ensure consistently high quality. Rather, it is the system that must be evaluated and improved. Better strategies and ways of doing things can avert failures and errors. The result has been a vast national effort to discover the best strategies to develop quality improvements and share that information. For example, how can hospitals and nursing homes keep patients and residents from developing bed sores? Can technology help prevent medication errors? Can decreasing patient wait time help improve their overall satisfaction with a physician’s office?

Healthcare has not had to reinvent the wheel. Organizations are adopting quality theories from the pioneers who brought quality improvement to industries and applying them in the healthcare field to improve their own processes. The automobile industry was the first to institute CQI and its methods were adapted in many other industries. Many ideas that have translated to healthcare initiatives have come from the aviation and nuclear power industries. For instance, similar to how pilots use a standardized checklist to ensure a plane is safe and ready for takeoff, surgeons and other operating room personnel use a checklist to ensure they are ready to proceed with a surgical procedure.

One of the best-known quality improvement models is Dr. William Edwards Deming’s Plan-Do-Study-Act (PDSA) cycle. Many consider Deming the father of quality improvement; PDSA is the one model that various other quality improvement methods stem from. (Students of quality improvement will sometimes see this model referred to as Plan-Do-Check-Act [PDCA]—and then Repeat is added to the sequence, since it is meant to be a continuous process.) Deming changed the model in the 1980s from PDCA to PDSA. As the model evolved, Deming amended his description of PDCA to emphasize the importance of not just checking, but studying and using the knowledge gained to better understand the process being improved. Under the old model, some organizations could be confused about how to apply the “C” or “check” stage of the model. Some organizations thought it meant that they were to measure the improvement and move on to “Act.” The intention was actually to analyze or “study” the results of the measure—to take what you learned about the system and use that new information to improve it. To avoid misinterpretation, Deming changed the name of the stage to “study” and the model became known as PDSA . Sometimes PDCA is still used, but we will refer to PDSA throughout this book (Strongin, 2014).)

Consider the quality improvement efforts to improve hand hygiene and thus cut the number of infections that can threaten patients’ health and lives. A healthcare organization will need to plan the steps it wants to implement to achieve its goal of reducing infections, such as requiring staff to change gloves during patient care if moving from an infected body site to a clean body site. The organization can then create a policy that outlines the exact actions it expects its workers to follow. The organization will then implement its plan and policy, requiring its staff to do these things to help protect patients. Then it will track infection rates and other data for the subsequent study phase, in which it will analyze the information and determine the success or failure of various interventions. For instance, are all nurses following the organization policy? If not, why not? Is more education needed? Is the hand hygiene policy unclear? In the act phase, the organization will make modifications or corrections to the initial plan if necessary. Perhaps it will need to hold in-house educational sessions on each floor to make sure staff members understand when they must wash or sanitize their hands and when gloves should be worn. Perhaps it will need to rewrite its policy in clearer, simpler language that staff members will not be likely to misinterpret. (Readers will find more information on PDSA in Chapter 5.)

In recent years, attention has also focused on the satisfaction of patients and their families. That is another factor driving quality care. Healthcare leaders have looked at how patient satisfaction is a factor in better health outcomes, fewer lawsuits, and lower costs.

Reputations and Public Disclosure of Quality Measures

Healthcare organizations’ reputations, as well as those of individual physicians, are tied to the quality care they provide for patients. Today, consumers have more information than ever on which to base decisions about where they will have open heart surgery, where to place an aging parent who is no longer safe living independently, or which physician they want to go to. But it’s not just a hospital’s national or worldwide reputation, the word-of-mouth knowledge of which nursing home is the best in town, or a neighbor’s opinion about who is a good doctor that consumers rely on.

Now there is the public disclosure of quality data and outcomes, which consumers can use to select a physician, hospital, nursing home, or other healthcare provider. The Medicare website includes processes and outcome data that allow consumers to compare hospitals, home health agencies, nursing homes, physicians, and dialysis facilities (https://data For example, a consumer can find out how the nursing homes in a community compare in terms of urinary tract infection rates, treating pain, numbers of residents who develop bed sores, or how many lose too much weight. Or consumers can view a physician’s individual page, which has information such as board certifications, residencies, and hospital affiliations. Consumers are also able to check quality reports to help them choose a physician, as report cards are available through the majority of major health plans.

The Leapfrog Group, a consortium of public and private organizations that provide healthcare benefits, also posts ratings information about hospitals, disclosing how well they comply with an array of quality processes on its website ( Information is included for about 1,300 hospitals that voluntarily complete a standardized survey intended to capture performance in patient safety, quality, and resource use.

Accreditors also provide quality information about organizations that they review and accredit. The Joint Commission publishes on its website measures similar to those that Medicare publishes for hospitals, as well as scores that demonstrate how well organizations comply with its National Patient Safety Goals, which focus on problems in healthcare safety and how to solve them. For example, the goals for hospitals include efforts to prevent infections, prevent mistakes in surgery, and properly identify patients so they receive the correct medicine and treatment. The NCQA, which accredits health plans and physician groups, also publishes quality information on its website (

Then there are private companies, such as Healthgrades, that publish information about providers, including hospitals and physicians ( Healthgrades, one of the best-known private sites, says it evaluates hospitals solely on clinical outcomes—data on risk-adjusted mortality and in-hospital complications. It says its analysis is based on approximately 40 million Medicare discharges for the most recent three-year time period, with data measuring 31 common procedures and conditions and adjustments made for each patient’s age, gender, and medical condition.

Healthgrades also rates individual physicians, based in part on patient satisfaction surveys. For instance, a consumer who lives in Anytown, USA, can find a list of physicians in his or her area that specialize in treating Parkinson’s disease or a host of other medical conditions. The consumer can narrow the search for only doctors who are board certified in neurology. The consumer can then view an individual physician’s page to see a patient satisfaction rating based on factors such as the ease of scheduling urgent appointments or the level of trust in the doctor’s decisions. However, the patient satisfaction rating may be based on a limited number of patient surveys (perhaps only a handful), as patients are asked on the website to complete a review of their physician. There’s also information on the physician’s experience, the quality of the hospital he or she is affiliated with, and whether any sanctions or board actions were reported.

Along with Healthgrades, there are other websites that offer physician ratings. Lifescript ( offers reviews on 720,000 doctors nationwide. RateMDs ( has free reviews and ratings for doctors, dentists, and other health professionals based on patient comments. Vitals ( has profiles on doctors, dentists, and medical facilities, as well as doctor ratings and reviews.

It’s important to note that using a directory or ratings site is one type of resource that consumers can use to help choose a doctor or hospital, but it shouldn’t be the only one. Some websites are there only to make money for their owners, and consumers should carefully review the usefulness of the information and its source.

As you can see, there is great interest in quality ratings for hospitals, physicians, and other healthcare providers in the United States. However, interest in quality improvement is not limited to the United States, and there are efforts to improve the quality of healthcare in institutions worldwide.

Questions to Consider

What factor do you think was most critical in spurring the explosion of interest in quality improvement in healthcare?

How might quality information influence your selection of a healthcare provider, whether it is a hospital or physician?

1.3 Global, National, Regional, and State Systems

While many U.S. healthcare organizations have adopted continuous quality improvement processes, there is also worldwide interest in quality that has given rise to professional bodies, scientific publications, and organizations dedicated to sharing ideas and innovations in quality improvement. Organizations such as the Institute for Health Care Improvement and the Robert Wood Johnson Foundation bring people and organizations together to learn from each other.

Global Efforts

Quality improvement is spreading globally. There are numerous projects to improve the quality of healthcare in countries around the world, including some of the poorest countries where healthcare needs are among the greatest. Some of those projects are focused on HIV/AIDS, tuberculosis, control and prevention of malaria, and reducing infant mortality.

The World Health Organization has promoted quality improvement efforts, including improving the safety of surgical care around the world, by ensuring adherence to proven standards of care in all countries. For example, the WHO has promoted use of a surgical safety checklist that includes having a patient confirm his or her identity, surgery site, procedure, and consent, as well as to having a nurse verbally confirm the completion of instrument, sponge, and needle counts before a surgeon closes up a patient. And as previously mentioned, the WHO has established hand hygiene guidelines to help prevent healthcare-associated infections.

One organization active in developing countries is the Council on Health Research for Development (COHRED), a global, non-profit organization whose goal is to maximize the potential of research and innovation in order to deliver solutions to the health and development problems of people living in low- and middle-income countries.

An illustrated AIDS prevention guide distributed in Africa.


HIV/AIDS prevention is one example of global efforts to improve the quality of healthcare.

While the problems are sometimes different in other countries, the quality improvement concepts work the same way. An example of this involves a case of a quality improvement team in a small clinic in a remote African village (Smits, Leatherman, & Berwick, 2002). The team assessed whether children were taking a medication called choloroquine that was part of a standard treatment plan for a common infectious disease, malaria. The team found compliance was poor.

Why wouldn’t children take a drug that could protect them against this potentially fatal disease? Looking for a reason, the team discovered the bad taste of the medication was a major problem. Working with mothers in the village, the team identified foods that could be used to conceal the bad taste. In the clinic waiting area, they put up a poster showing how to use the foods to disguise the taste. When they checked again in the next test cycle, compliance with the treatment protocol had increased from 48% to 70%, meaning many more village children were now protected (Smits et al., 2002).

The Efforts of Various Individual Countries

Many industrial countries are using quality improvement processes to help ensure high quality care, better outcomes, and cost-effective treatments. Examples of institutions supporting these efforts include the U.S. Agency for Health Care Research and Quality, the U.K. National Institute for Health and Care Excellence (NICE), and the Dutch College of General Practitioners. The United Kingdom has also established the National Patient Safety Agency, an agency that has become part of the National Health Service, whose goal is to reduce risks to patients and improve safety.

NICE, for example, publishes clinical guidelines that recommend appropriate treatment and care of people with specific diseases and conditions based on the best evidence available in order to improve the quality of care. NICE (2014b) has urged healthcare providers to take further steps to tackle the risk of heart attacks and strokes, suggesting physicians should consider many more patients to be at risk of cardiovascular disease, which causes one in three deaths in the United Kingdom. It has suggested the wider use of statins, drugs that can lower the risk of heart attacks by lowering cholesterol levels. NICE (2014b) says up to 8,000 lives could be saved every three years by offering statins to anyone with a 10% risk of developing cardiovascular disease within a decade. The agency’s public health guidance has aimed at tackling some of the biggest problems facing the country, including obesity, lack of physical exercise, and smoking.

One guidance from NICE concerned adequate staffing at the country’s acute care hospitals. The guidance (NICE, 2014a) resulted from a public inquiry into the so-called Stafford Hospital scandal, which revealed poor care and high mortality rates among patients at the hospital in Stafford, England, in the late 2000s. The scandal came to national attention following an investigation into the hospital’s operation after reports of high mortality rates in patients who were admitted as emergencies. The investigation resulted in a report that criticized management of the hospital and detailed poor conditions and inadequacies.

NICE issued its guidance at the request of the country’s Department of Health and the National Health Service after the issue of staffing levels was raised in the report on failings in Stafford Hospital and others, with neglect allegedly resulting in unnecessary deaths. While it didn’t set minimum staffing levels for the country’s hospitals, the guidance outlined “red flag events,” intended to set off warnings whereby nurses in charge of hospital shifts must act immediately to ensure that they have enough staff to meet the needs of patients on that ward.

Red flag events include lapses in basic care, such as patients not getting medications at the time they should be given, patients having to wait more than 30 minutes to receive pain relief, vital signs not being taken when they should be, or regular checks not being done (such as helping patients get to the bathroom) (NICE, 2014a).

When there is not enough nursing staff to provide that basic level of care, the hospitals are expected to provide more skilled nurses or increase numbers of staff. The guidance is designed to help ensure safe and efficient nursing staffing levels on all acute hospital wards that provide overnight care for adult patients in England.

The red flag events are so serious they should trigger an instant investigation to check if staffing levels are adequate, with extra nurses sent to a floor if shortages are found. A staffing check should also occur if any ward has fewer than two registered nurses working at any one time.

Regional Efforts

The quality improvement movement has also resulted in a number of regional health improvement organizations. The Network for Regional Health Improvement (NRHI) was formed in 2004 in the United States to bring together leaders of regional healthcare coalitions into a network of regional health improvement collaboratives. The collaboratives are made up of healthcare providers (i.e., physicians, medical practices, hospitals, and health systems), healthcare payers (i.e., health insurance plans and public programs such as Medicaid), healthcare purchasers (i.e., employers who purchase health insurance for their employees), and healthcare consumers and organizations that represent consumer interests.

The collaboratives are governed by individuals and organizations from all four of these key groups and address quality and cost issues across a broad range of patients and providers. They establish their direction through consensus among their members and implement their efforts through voluntary cooperation of the members, rather than through government mandates or financial rewards or penalties. The group now has over 30 members across the United States, from California to Massachusetts. Regional coalitions can lead and implement initiatives based on their understanding of local marketplace issues and ability to mobilize local energy for change (Mosser, Karp, & Rabson, n.d.).

For example, in Maine, “community care teams,” which include a registered nurse and physician, among other team members, are calling elderly patients with chronic health conditions in their homes to check on factors such as medications, blood pressure, and diet (Japsen, 2014). This effort is part of a statewide Patient-Centered Medical Home Pilot, launched in 2010 by a purchaser-led collaborative called the Maine Health Management Coalition, a Maine state agency called the Dirigo Health Agency’s Maine Quality Forum, and Maine Quality Counts, a regional healthcare collaborative funded by the Robert Wood Johnson Foundation’s Aligning Forces for Quality initiative.

The program has improved the quality of life for patients and their families and also eliminated unnecessary and expensive hospital admissions and emergency room visits. At Eastern Maine Medical Center, the attention to chronic heart failure patients from registered nurse care coordinators has helped the hospital reduce its readmission rate for Medicare patients to 12% from almost 20% in 2009 (Japsen, 2014). Primary care practices are supported by these multidisciplinary community care teams that include nurse care managers, social workers, health coaches, and pharmacists. If the pilots are successful in Maine, the federal government wants to roll them out nationwide to help seniors across the country.

Numerous healthcare alliances are also involved in promoting performance measures, public reporting, and other quality improvement tools. The alliances or collaboratives do their work in markets that range from combined metropolitan areas or multi-country regions to entire states. They are made up of various stakeholders.

State Efforts

There are also state organizations that promote quality improvement. These include the Medicare system’s Quality Improvement Organizations (QIO) that currently operate in each state to champion improvement in the healthcare system. The Centers for Medicare & Medicaid Services (CMS) contracts with one organization in each state to serve as that state’s QIO contractor. There are also provisions in the Medicare Modernization Act that provide for bonuses, so-called pay for performance, partly based on quality metrics.

QIOs are private, mostly not-for-profit organizations, staffed by professionals, mainly doctors and other healthcare professionals, who are trained to review medical care and help Medicare beneficiaries with complaints. While they are currently state-based, CMS may change that set-up in the future. In May 2013, the agency sought comment about options it may use to divide work among a number of QIO contractors, setting up jurisdictions or regions focused on quality improvement-related work only. CMS has said that starting in August 2014, it will launch the next round of QIO program contracts with a new approach to operations and the service areas for QIOs.

States also contract with independent entities called External Quality Review Organizations (EQRO). Federal regulations require that states that contract with Medicaid managed care organizations (MCO) or Prepaid Inpatient Health Plans (PIHP) conduct an external quality review (EQR) of each entity to ensure it is providing quality care. States can perform the EQR directly or contract with these EQROs to conduct the review to ensure the quality, timeliness, and access to healthcare services that an MCO or PIHP furnishes to Medicaid recipients. EQROs must validate performance improvement projects and performance measures, as well as review the MCO or PIHP to determine its compliance with state standards for access to care, structure and operations, and quality measurement and improvement.

State governments and organizations in various states are also involved in quality improvement efforts. For example, the Iowa Health Collaborative (IHC), which focuses on quality improvement, is a partnership of the Iowa Hospital Association and the Iowa Medical Society. Among its recent initiatives to improve healthcare quality in the state, the IHC has partnered with the Iowa Department of Public Health and the University of Iowa College of Public Health to improve stroke triage, treatment, and outcomes for patients in that state. With funding from a grant, the partnership is focused on increasing the quality of care in hospitals and that provided by emergency medical services. The partnership is promoting the adherence to best practice guidelines, and improving communication between providers, patients, and families. The emphasis is on transitions of care—providing quality from the first responders who arrive by ambulance to treat a stroke patient though the patient’s discharge from the hospital. The Iowa Coverdall Stroke Registry is collecting stroke data from participating healthcare systems, which will be analyzed and used to improve current stroke treatment practices. The ultimate goal of the registry is to use the data to improve stroke protocols throughout the state.

Many states are also posting quality improvement measures to allow consumers to compare healthcare organizations. For example, in Massachusetts, hospitals report data such as the number of patient falls and adverse drug events to the PatientCareLink, a healthcare quality and transparency collaborative comprised of hospitals, nursing leaders, and home healthcare agencies (

Questions to Consider

What kinds of quality improvement issues might affect healthcare in countries around the globe, regardless of their wealth or resources?

How can quality improvement efforts benefit from collaboration among countries, regions, and states?

Summary & Resources

Chapter Summary

The healthcare field has become more focused than ever on improving quality. Patients, communities, insurance companies, and the government are demanding excellence from healthcare organizations. It’s a life and death issue, since poor quality care can harm and even kill patients.

While most healthcare organizations have always cared about providing quality care, the methods of quality improvement—founded in industry—are relatively new to this field. Methodologies, which have their roots in the Plan-Do-Study-Act model, are now being applied by healthcare facilities to improve the quality of the entire patient experience.

The patient safety movement, including two monumental IOM reports that turned a critical eye on the healthcare field, created a surge of quality improvement initiatives. No longer will people settle for hospitals, physicians, and other healthcare providers who do not provide quality care.

With quality measures in the public domain, the reputations of healthcare organizations and physicians are at stake. Their “report cards” are now on display for all to see. The quality improvement movement extends beyond the United States to other individual countries and to global, international efforts to improve healthcare.

Mini Case Study

Harry had a seizure and crashed his car into a tree, crushing both of his legs. When he arrived at the hospital, x-rays showed that his right leg could be saved, but his left leg would have to be amputated. Unfortunately, the x-ray technician mislabeled the films, mixing up the left and the right. The orthopedic surgeon amputated Bill’s good right leg.

The Joint Commission, the largest accreditor of hospitals in the United States, has made the prevention of wrong-site surgery one of its main safety goals. It requires hospitals, as well as ambulatory surgery centers and office-based surgery sites, to establish protocols to prevent wrong-site surgeries.

The Joint Commission mandates the standardization of preoperative procedures to verify that the correct surgery is performed on the correct patient and at the correct site. Guidelines include marking the surgical site, involving the patient in the marking process when possible, and having all members of the surgical team double-check information in the operating room.

Despite these efforts, wrong-site surgery occurs about 40 times a week nationwide, a 2011 Joint Commission Center for Transforming Healthcare study found. The center involved eight hospitals and ambulatory surgery centers in a study to determine the risks that contributed to wrong-site surgery. What did they find were the factors contributing to the risk? Problems with scheduling and preoperative/holding processes, as well as ineffective communication and distractions in the operating room, created risks for patients. The risk also increased if all key people in the operating room did not fully participate in a “time out” prior to beginning surgery to check all information and decide on how they would proceed (The Joint Commission, 2013d).

One of the biggest problems was inadequate information about the patient. For instance, often information is taken by a staff member in the surgeon’s office, who may be dealing with several hospitals, all with different protocols, which can result in confusion. One solution is to create a standardized method of collecting information, as the Joint Commission recommended.

Discussion Questions

What steps should Harry’s healthcare providers have taken to prevent the amputation of his good leg?

How can the Plan-Do-Study-Act model be used to reduce the occurrence of wrong-site surgery?

The Joint Commission recommended a “standardized method of collecting information” to prevent wrong-site surgery. What do you think should be involved in such a process?

Key Terms

continuous quality improvement (CQI)

The process-based, data-driven approach to improving the quality of a product or service.


The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.

quality improvement (QI)

A process using quantitative and qualitative methods to improve the effectiveness, efficiency, and safety of, as well as human resources’ performance in, healthcare delivery.

Critical Thinking Questions

How can the Joint Commission help prevent wrong-site surgeries and improve the performance of healthcare organizations?

How do medical staff contribute to the problem? What about non-medical staff?

Despite all efforts, wrong-site surgeries continue to occur. Why do you think that is the case? In your opinion, what is the best way to prevent this medical error?

Suggested Websites

Infectious Diseases Society of America (IDSA):

An organization that represents physicians, scientists, and other healthcare professionals who specialize in infectious diseases.

The World Health Organization (WHO):

The directing and coordinating authority for health within the United Nations system, providing leadership on global health matters.

U.S. Centers for Disease Control and Prevention (CDC):

U.S. government agency responsible for protecting America from health, safety, and security threats, both foreign and domestic.

The Joint Commission (TJC):

An independent, non-profit organization that provides accreditation and certificates to healthcare organizations and programs in the United States and overseas.

National Committee for Quality Assurance (NCQA):

A non-profit organization making efforts to improve healthcare quality through accrediting and certifying a wide range of healthcare organizations.

Medicare website includes data that allow consumers to compare hospitals, home health agencies, nursing homes, physicians, and dialysis facilities.

The Leapfrog Group’s Hospital Ratings:

The Leapfrog Group Hospital Ratings provide comparative information about several quality indicators for hospitals.


A private company that provides online information, including ratings, on hospitals and physicians.

Council on Health Research for Development (COHRED):

A global, non-profit organization whose goal is to maximize the potential of research and innovation to deliver sustainable solutions to solve the health and development problems of people living in low and middle income countries.

National Institute for Health and Care Excellence (NICE):

A public body that provides national guidance and advice to improve health and social care in the United Kingdom.

The Network for Regional Health Improvement (NRHI):

A national organization representing over 30 members; each member is a regional health improvement collaborative working in its region to improve healthcare delivery.