Quality Improvement


Key Points:

  • Significant gaps in healthcare quality exist.
    • Predominantly underuse, overuse and misuse
  • High quality healthcare systems are safe, effective, equitable, efficient, timely, and patient-centered.
  • Many different performance metrics can be used including safety, service, outcomes, finances, and administrative goals.
  • PDSA = Plan, Do, Study, Act
  • Value = Outcomes + Safety + Service / Cost
  • Lean focuses on increasing value by decreasing waste.
    • Waste types: waiting, inventories, overproduction, re-prioritization, unnecessary motion, defects, over-processing, transportation, mis-utilization of skills
  • Six Sigma is a data-driven approach to eliminating defects.
    • Achieving six sigma is defined as no more than 3.4 defects per million opportunities.
    • Uses DMAIC framework: Define, Measure, Analyze, Improve, Control
  • Change Management, often using the ADKAR model, is an essential element to quality improvement.
    • Awareness of need to change
    • Desire to participate and/or support change
    • Knowledge on how to change
    • Ability to implement required skills and/or behaviors
    • Reinforcement to sustain change



  • Articulate why quality improvement in healthcare is important
  • Identify opportunities for quality improvement in your area
  • Use established quality improvement methodologies and tools
  • Sustain long term improvements in quality, safety and service


Recommended Resources: 

Brief Review


Quality Improvement in Healthcare. DocMikeEvans. 11 minutes.

Defining Quality: Aiming for a Better Health Care System. IHI Open School. 4 minutes.

Lean Healthcare. Why Lean? Why now? David Daisher. 10 minutes.

Six Sigma Training Videos. Sixsigmamoneybelt. 7 video playlist, each video less than 7 min.

Lean Training Videos. Sixsigmamoneybelt. 10 video playlist, each video less than 7 min.


Blumenthal D, McGinnis JM. Measuring Vital Signs: An IOM Report on Core Metrics for Health and Health Care Progress. Viewpoint. JAMA. 2015 Apr 28. doi: 10.1001/jama.2015.4862. PubMed PMID: 25919301.

Institute of Medicine. Vital Signs: Core Metrics for Health and Health Care Progress. Washington, DC: National Academies Press; 2015.

Road Map for Quality Improvement: A Guide for Doctors by Manoj Jain MD

Hoffman RL, Medbery RL, Vandermeer TJ, Morris JB, Kelz RR. The Educational Toolbox: Kick Start Your Educational Program in Quality Improvement. J Surg Educ. 2015 Apr 14. pii: S1931-7204(15)00030-6. Review. PubMed PMID: 25887503.

Balasubramanian BA, Cohen DJ, Davis MM, Gunn R, Dickinson LM, Miller WL, Crabtree BF, Stange KC. Learning Evaluation: blending quality improvement and implementation research methods to study healthcare innovations. Implement Sci. 2015 Mar 10;10(1):31. PubMed PMID: 25889831.

Portela MC, Pronovost PJ, Woodcock T, Carter P, Dixon-Woods M. How to study improvement interventions: a brief overview of possible study types. BMJ Qual Saf. 2015 May;24(5):325-336. doi: 10.1136/bmjqs-2014-003620. Epub 2015 Mar 25. Review. PubMed PMID: 25810415.


Mayo Clinic Quality Academy Educational Resources. 12 free modules introducing quality improvement, patient safety, evidence-based medicine, and health policy. Certificates can be printed for each completed module.

Starting Lean Health Care. AMA STEPSforward. Free online educational module. 0.5 hour AMA PRA Category 1 Credit™.

Djuricich A. A Continuous Quality Improvement (CQI) Curriculum for Residents. MedEdPORTAL Publications; 2007. This curriculum includes a format for teaching continuous quality improvement to residents as a module during an ambulatory rotation. It includes explicit goals and objectives, a required "project", tests (both pre and post), lecture handouts, evaluation materials, and an extensive bibliography. In addition, there is a DVD of the didactic of teaching CQI to residents.

Hanson E, Rosenbluth G, McPeak K. QI Olympics: A Game-Based Educational Activity in Quality Improvement. MedEdPORTAL Publications; 2013.


In-Depth Review


Transforming Healthcare through Quality Improvement and Innovation: The Time is Now! Prathibha Varkey. University of California Television. 46 minutes.

Integrating Quality Improvement and Patient Safety Across the Continuum of Medical Education. AAMC webinar.

Advanced Six Sigma Tools. Sixsigmamoneybelt. 7 video playlist, each video less than 5 minutes.


Lean Healthcare Deployment and Sustainability by Mark L. Dean. 240 pages. 2013.

Practical Lean Six Sigma for Healthcare - Using the A3 and Lean Thinking to Improve Operational Performance in Hospitals, Clinics, and Physician Group Practices by Todd Sperl, Rob Ptacek, and Jayant Trewn. 280 pages. 2013

High Performance Healthcare: Using the Power of Relationships to Achieve Quality, Efficiency and Resilience by Jody Hoffer Gittell. 288 pages. 2009.


Reed D, Wittich C, Drefahl M, McDonald F. A Quality Improvement Curriculum for Internal Medicine Residents. MedEdPORTAL Publications; 2009. This resource includes a comprehensive users' guide with background and rationale, all materials needed to teach the 3-year curriculum including step-by-step guides to modules with hand-outs and references, learner assessment and curriculum evaluation information, and detailed instructions for faculty.

Take the Lead on Healthcare Quality Improvement. Coursera, Case Western Reserve University.

Teaching for Quality (Te4Q) Program. AAMC. Faculty development program that trains clinical faculty how to effectively teach quality improvement and patient safety (QI/PS) to medical students, residents, and other clinicians. Through a combination of assessments, an on-site workshop, the development of an educational project, and expert mentoring, Te4Q equips clinical faculty to lead, design, and evaluate effective learning in quality improvement and patient safety across the continuum of medical education. Upon successful completion of the program, participants earn the AAMC’s Te4Q Certificate.

American Society for Quality. Web-based quality training courses. $ Fee required

Standards for Quality Improvement Reporting Excellence (SQUIRE) International Writing Conference. Given annually in Hanover, NH. $ Fee required