continuous quality improvement (CQI) or total quality management (TQM)

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Introduction

A framework for monitoring & enhancing the outcomes of medical care.

Based on Plan-Do-Study-Act cycles to test changes in systems of care

Providers offer input into the clinical care processes

10 step process (JCAHO)

  • assign responsibility
  • define scope of care
  • consider important aspects of care
  • develop key indicators
  • determine evaluation thresholds
  • collect & organize data
  • evaluate the care
  • initiate problem-solving actions
  • assess the results of those actions
  • communicate relevant information

Features

  • goals: identify & control variability in outcomes
  • data collection
    • timing: real time & continuous
    • performance: hands-on staff
  • data analysis:
    • more sofisticated searching for causes of problems or outlyers
  • feedback to staff: regular to all staff
  • staff training:
    • on the job
    • specific training in outcome monitoring & analysis of work process
  • staff involvement:
    • high
    • includes staff suggestions for improvement
  • motivation for improvement
    • staff participation in process & acheiving improved outcomes
    • consumer feedback

Keys to successful CQI projects

  • don't underestimate how hard it is to implement & maintain CQI projects
  • obtain support of facility leadership
  • communicate the CQI model clearly to all staff & obtain their buy-in
  • pick one area of interest at a time that is of importance to leaders, staff, residents & their families
  • don't re-invent the wheel
    • use relevant guidelines & experience of others where applicable
  • minimize paperwork
  • use computers
  • obtain resident & family feedback
  • work with inspectors & provide them specific examples of CQI projects

CMS has outlined five elements of QAPI programs

  • design & scope
  • governance & leadership
  • feedback, data systems, & monitoring
  • performance improvement projects
  • systematic analysis & systemic action[7]

More general terms

More specific terms

Additional terms

References

  1. Medical Knowledge Self Assessment Program (MKSAP) 11, 16, 17. American College of Physicians, Philadelphia 1998, 2012, 2015
  2. Ouslander, JG: In: Intensive Course in Geriatric Medicine & Board Review, Marina Del Ray, CA, Sept 12-15, 2001
  3. Chassin MR, Loeb JM, Schmaltz SP, Wachter RM. Accountability measures--using measurement to promote quality improvement. N Engl J Med. 2010 Aug 12;363(7):683-8 PMID: https://www.ncbi.nlm.nih.gov/pubmed/20573915
  4. Morley JE. Rapid cycles (continuous quality improvement), an essential part of the medical director's role. J Am Med Dir Assoc. 2008 Oct;9(8):535-8. PMID: https://www.ncbi.nlm.nih.gov/pubmed/19083284
  5. Fan E, Laupacis A, Pronovost PJ, et al. How to Use an Article About Quality Improvement. JAMA. 2010;304(20):2279-2287. PMID: https://www.ncbi.nlm.nih.gov/pubmed/21098772
    Curtis JR, Levy MM. Improving the Science and Politics of Quality Improvement. JAMA. 2011;305(4):406-407. PMID: https://www.ncbi.nlm.nih.gov/pubmed/21248160
  6. Varkey P, Reller MK, Resar RK. Basics of quality improvement in health care. Mayo Clin Proc. 2007 Jun;82(6):735-9. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/17550754
  7. 7.0 7.1 Centers for Medicare and Medicaid Services. QAPI Five Elements. https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/Downloads/qapifiveelements.pdf