Key Principles and Framework

The Fundamental Principle of Improvement

The central idea underlying modern quality improvement is captured in the words of D. M. Berwick: "Every system is perfectly designed to achieve exactly the results that it achieves." The level of performance (results) is a characteristic of any given system of work. A system left unchanged can only be expected to continue to achieve the same results it has been achieving. To achieve a different level of performance, it is essential to change the system in ways that enable it to achieve a different level of performance. QI methodology identifies unnecessary, redundant, or incorrect parts of processes, and then changes processes in ways believed to yield improvements. However, because not every change is necessarily an improvement, a change must be tested and studied to determine whether it has actually resulted in improvement.

The Principles of Quality Management

There are four main principles of quality improvement.

Focus on the client. Services should be designed to meet the needs and expectations of clients and community. An important measure of quality is the extent to which customer needs and expectations are met.

Understanding work as systems and processes. Providers need to understand the service system and its key processes in order to improve them. Using tools of process engineering allows simple visual images of these processes and systems.

Teamwork. Because work is accomplished through processes and systems in which different people fulfill different functions, it is essential to involve in the improvement representatives of the people who fulfill these functions. This brings their insights to the understanding of changes that need to be made and to the effective implementation of the appropriate processes, as well as to the development of ownership of the improved processes and systems.

Focus on the use of data. Data are needed to analyze processes, identify problems, and measure performance. Changes can then be tested and the resulting data analyzed to verify that the changes have actually led to improvements.

The Framework for Improving Clinical Quality

Improvement looks at two major components: what is done (content) and how it is done (process of care). Either component could lead to improvement, but the most powerful impact occurs by addressing both simultaneously. A key advancement in the use of this framework has been to develop norms, standards, protocols, and guidelines based on clinical evidence. In so doing, the literature on clinical practices is reviewed and the content developed based on the highest levels of evidence available. Where evidence for practices is weak or inconclusive, this is also acknowledged. This concept¹ is illustrated in Figure 1.

1 Adapted from P.B. Batalden and P.K. Stoltz. 1993. A framework for the continual improvement of healthcare: Building and applying professional and improvement knowledge to test changes in daily work. The Joint Commission Journal, 424_52.