Continuous Quality Improvement (CQI)

The term continuous quality improvement (CQI) is frequently used in the literature on health care quality and patient safety. Its has two different but related interpretations. The first, more encompassing, use of CQI is as a synonym for total quality management (TQM) or quality management (QM). Here, it represents the entire set of principles, methods, and tools that constitute a quality management organizational initiative. Such principles typically include top management leadership, customer/patient focus, the development of customer–supplier relationships, and more, but perhaps the most important of these is the continuous improvement of processes. It is this latter sense of CQI, as the core of the “CQI movement,” that is more fully discussed here.

Quality management holds that every product, service, and patient outcome is the output of a process. Thus, if the quality of the process output is deficient on some dimension (such as time, cost, clinical outcome, or patient [Page 103]satisfaction), then the process must be improved. Further, in a dynamic world of emerging technologies, shifting patient and employer expectations, regulatory change, and competitive developments, processes must be continuously improved. W. Edwards Deming's famous chain reaction illustrated that process improvements (reductions in rework, scrap, and errors) lead to improved efficiency and decreased costs. The initial emphasis of industrial quality control was largely directed toward these ends. The quality gurus offered rather uniform prescriptions to enhance process improvement. These included an emphasis on teamwork so that complex and cross-functional processes could be addressed; the injunction to “drive out fear/blame” so that the problem of false data could be minimized; and the study of variation because of the information it furnishes on the state of the process.

An organization's processes are especially improved when the organization uses a systematic effort rather than haphazard change directed by hunches and intuition. To promote effective process change, organizations need to use a structured approach or template to guide each improvement project. This guide is the scientific method or some variant thereof such as the PDSA/PDCA (Plan-Do-Study-Act/Plan-Do-Check-Act) cycle (championed by Walter Shewhart and Deming), the diagnostic and remedial journeys of Joseph Juran, or the Seven-Step Method (Hitoshi Kume, Brian Joiner, and others).

In a wonderfully succinct description, George Box defined quality management as the democratization of the scientific method. Unfortunately, many workers would have difficulty in defining the scientific method, much less in operationalizing the definition (translating it into operations), so the models of process improvement just described were created. The models serve as practical guides for an inexperienced person or team and emphasize the use of data and the analytical tools of process improvement such as flowcharts, Pareto charts, and cause-and-effect diagrams. Intermountain Health Care, under the leadership of Brent James, has been a pioneer in applying CQI principles to clinical processes. Success stories there include a 50% reduction in adverse drug reactions, 80% reduction in the decubitus-ulcer rate, and an improvement in complete breast cancer pathology reports from 84% to 99%. CQI case studies can be found regularly in the Joint Commission Journal on Quality Improvement, the Institute for Healthcare Improvement's Web site (at http://www.ihi.org/resources/successstories), and the National Association for Healthcare Quality's Web site (go to http://www.nahq.org/journal, then click on “On-Line Articles”).

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