Quality Improvement: First Steps
QI can bring about substantial, lasting, positive change in your practice. It all begins with identifying the opportunities.
Fam Pract Manag. 1999 Mar;6(3):23-26.
The mere mention of the words quality improvement (QI) can evoke dread in the minds of many physicians. It's sometimes (mistakenly) thought of as little more than extra work and has often been confused with quality assurance, or looking for the “bad apples.”
But QI is much more rewarding and positive than perhaps you've realized. In particular, it can empower you and your staff to make great strides toward quality, and it can energize your work as it removes inefficiencies, improves processes, decreases your frustration and boosts everyone's satisfaction — including yours.
Quality improvement is focused on making processes better.
The first step is finding your practice's key problems.
You then need to identify and prioritize potential change projects.
What is QI?
Very simply, QI is a method of continuously examining processes and making them more effective. It's an idea that started in the business community as companies looked for better ways to produce better products and services for their customers. Over the last decade, the idea has spread into the medical community as more and more physicians have turned to QI theories to improve both the clinical and operational aspects of their practices. Its principles have helped family physicians increase the use of preventive services, improve coding accuracy, improve phone access and decrease patients' waiting times, among other successes.1–4
The principles of QI stem from work by W. Edwards Deming, PhD, a statistician who revolutionized management theories in Japan and the United States. The principles include these:
A strong focus on customers — in our case, patients;
Continuous improvement of all processes;
Involvement of the entire organization in the pursuit of quality;
Use of data and team knowledge to improve decision making.
Because QI is concerned with making the process better (versus blaming individuals), it requires that physicians understand the nature of the core processes used to provide care. Ambulatory practice is highly complex, involving many subsystems, such as scheduling, triage, test-results flow and medical records management, to name just a few. While no individual in a practice knows everything about the practice, working as a team a staff can understand each of these subsystems and how they interrelate.
The QI model requires that you identify your aim (i.e., what you want to accomplish or change), your criteria for judging whether improvements have been made and the changes you plan to make.5 Once you've thought through those issues, you can bring about the desired change using the plan-do-study-act cycle:
Plan: Analyze the process, determine what changes would most improve the process, and establish a plan for making the improvement;
Do: Put your change into motion on a small scale or trial basis;
Study: Check to see whether the change is working;
Act: If the change is working, implement it on a larger scale. If the change is not working, refine it or reject it and begin the cycle again.6
In this article, we will focus on the preliminary stages of any QI project: finding key problems, identifying potential changes and prioritizing the opportunities for change. Subsequent articles in this series will complete the QI cycle.
Finding key problems
Identifying your practice's problems can be more difficult than it sounds. While people in most practices have a general sense that certain processes or systems aren't working well, they can't always pinpoint the real problem or what to do about it. To get your practice started on the path toward finding its opportunities for improvement, you can use any of the following methods.
1. Ask your “customers.” Ask your patients, staff and colleagues for their ideas about how your practice might improve. You can survey your patients or use postcards and suggestion boxes to encourage their comments. The same goes for your staff. If you can identify the things that cause dissatisfaction among employees, you'll have rich fodder for knowing which changes might be meaningful to your practice. Here are some questions to ask: What makes your day more difficult than it should be? What are the reasons things don't work right around the office? What wastes time? What could be improved? You might even want to bring people together for a discussion of these questions.
2. Look for muda. Muda is a Japanese word that Taiichi Ohno, the former leader of quality efforts at Toyota Motor Corp., used to refer to uselessness and futility. It is manifest in any activity that has no added value.
Examine your practice by taking a stroll through the office looking for muda from the patient's point of view. A patient experiences muda while waiting in the reception area, waiting on the phone, waiting for someone to find test results, filling out the same demographic information more than once or receiving unclear instructions from the doctor.
Now go through the office again, this time looking for muda from the point of view of your staff members. If you find activities that involve a “waste of time” (such as making repeat calls to get the same information, looking for charts that are not filed or rescheduling patient visits because of physicians' scheduling changes), you might discover areas for improvement.
Don't forget to look for muda from your own point of view. Do you spend too much time trying to find patient-education materials? Do you have unused exam rooms? Your observations also may suggest possible improvements.
3. Do an internal review. A relatively simple way to identify areas for improvement is to review patients' complaints and explore the possible reasons behind them.
If you want to identify problems with care delivery, you can do a quick chart audit. For example, have your staff help you review 20 geriatric charts at a staff meeting and see how many of the patients received flu shots. You may find that you need to devise a system to improve preventive services.
Your practice probably receives financial statements that report on traditional measures such as charges, collections, expenses and age of accounts receivable. Pay attention to other statistics, too. For example, by studying the average number of patients seen in the office, you may find clues that you need to increase productivity. By studying the percentage of patients in capitated plans and their average number of visits per month, you may find that you should increase or decrease the number of capitated patients you accept.
4. Consult external reviews. Third-party payers frequently provide profiles of doctors' performance as well as comparisons with the performance of other physicians. Ask yourself whether the reports provide any clues about areas for improvement. For example, is the care you provide more costly than others? Is your use of referrals greater than necessary? Your profile may even give you data about Health Plan Employer Data and Information Set measures, such as the percentage of diabetic patients referred for dilated eye exams or the number of pediatric patients whose immunizations are up-to-date. The reports may also include results of patient-satisfaction surveys. How your practice compares with other practices can provide insight into ways that you might improve.
5. Find out what others have done well. Exploring clinical and administrative best practices is another way to find how your practice could be doing better. A good way to find these best practices is to do a literature review. Online databases can give you access to information on every area of medical practice, from the business side to evidence-based clinical policies. Other good resources include the Improvement Guides and Eye on Improvement newsletter published by the Institute for Healthcare Improvement (see “A leader in QI”), as well as the Joint Commission Journal on Quality Improvement.
You may also benefit from asking physicians from other practices whether they have found ways to improve their operations. Similarly, having people from your practice participate in medical management societies, such as the Medical Group Management Association, often gives you access to information about best practices. As you explore these sources, ask yourself whether you see gaps between what others have been able to do in their practices and what you are doing in yours.
A leader in QI
The Institute for Healthcare Improvement (IHI), founded in 1991 as an independent, nonprofit organization, is involved in some of the most innovative quality improvement efforts in the health care industry. IHI's mission is to identify and disseminate information about innovations that have demonstrably improved health care quality. Two IHI initiatives are particularly noteworthy:
IHI's Breakthrough Series Collaboratives brings together health care organizations and a team of quality experts to improve specific clinical or operational areas over six to eight months. The program has achieved success in improving asthma care, improving end-of-life care, reducing adverse drug events and medical errors, and reducing delays and waiting times, to name a few areas.
At the end of each project, IHI hosts a national congress and publishes an “Improvement Guide” offering step-by-step instructions for improving the area addressed by the project.
In 1998, IHI launched the Idealized Design of Clinical Office Practices initiative, a three-year project in which a team of quality experts will work with up to 40 practice sites throughout the country to design, test and deploy new models of office-based practice. The initiative seeks to make improvements in several areas, including clinical care, information management, access to care, office efficiency, documentation and human resources.
For more information, visit IHI's web site at http://www.ihi.org, or contact the organization at 617-754-4800.
Identifying potential changes
Once you have explored any of these methods, you will probably have a list of several problem areas in your practice, as well as a few ideas about how you might make changes. You now need to put those ideas onto paper and create a list of the potential changes that you could initiate in your practice. Your goal at this point is not to work out the details of a solution but simply to generate thoughtful ideas about how you might address each problem area. (In part two in this series, we'll dig deeper into these issues using some common quality improvement tools, such as flowcharts and control charts.) A sample list of change projects aimed at specific problems might look like this:
To reduce no-shows, place reminder calls to all patients the night before their appointments;
To decrease time wasted looking for patient-information sheets, organize a file of patient-education handouts about the 20 most common complaints;
To increase revenue, each week resubmit patient billings that have been denied;
To improve clinical prevention, include smoking status as a vital sign.
Prioritizing the opportunities
After you've created your list of potential change projects, you'll want to prioritize them. First, develop a list of the criteria by which you'll judge the projects' importance. For example, are you more interested in projects that will improve patient care or cut costs? Do you have the resources to tackle a complex problem, or do you need to begin with a project that is relatively easy to implement? Also consider your ability to measure the performance of the process you want to change, the potential for benefits outweighing costs, the availability of data, the chances for success and the elimination of rework or muda. Finally, make sure each project is aligned with your practice's overall vision (see “Beginning With a Vision”).
Once you've identified the criteria that are most important to your practice, aim for consensus about which project (or projects) should be tackled first. One way to do this is to present the list of projects to all staff members and ask them to distribute 100 points among the options, keeping in mind the group's vision and criteria for judging the projects' importance. A person could assign all 100 points to one project or could give 20 points to five different projects, so long as the points added up to 100. You would then total the points for each project. The projects with the highest totals would be your top priorities.
You have now completed the first steps in QI: finding the key problems in your practice, identifying potential changes and prioritizing them. While you may see a lot of work ahead of you, celebrate the significant step forward that you've taken. Your efforts will result in better processes that will boost your practice's performance and bring greater satisfaction at the end of the day. The key is to continue moving forward, and in our second article — which will explore a team approach to planning and implementing a change project — we'll do just that.
This article is the first in a series on quality improvement (QI) in medical practices. The series will lead you through the QI process by addressing these areas:
Editor's note: The authors wish to acknowledge James M. Giovino, MD, Suzanne E. Landis, MD, MPH, John E. Rowe, MD, Miriam Schwarz, MPA, and Kathryn Stewart, MD, for their assistance with this article.
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2. Zazove P, Klinkman MS. Developing a CQI program in a family medicine department. Jt Comm J Qual Improv. 1998;24(8):391–406.
3. Ornstein SM, Jenkins RG, Lee FW, et al. The computer-based patient record as a CQI tool in a family medicine center. Jt Comm J Qual Improv. 1997;23(7):347–361.
4. Anctil B, Winters M. Linking customer judgments with process measures to improve access to ambulatory care. Jt Comm J Qual Improv. 1996;22(5):345–357.
5. Langley GJ, Nolan KM, Nolan TW, et al. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. San Francisco: Jossey-Bass Publishers; 1996.
6. Nelson EC, Batalden PB, Ryer JC. Clinical Improvement Action Guide. Oakbrook Terrace, Ill: Joint Commission on Accreditation of Healthcare Organizations; 1998.
Copyright © 1999 by the American Academy of Family Physicians.
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