SECTION 1: EVIDENCE-BASED QUALITY IMPROVEMENT, PRINCIPLES, AND PERSPECTIVES Quality Improvement Methods in Clinical Medicine

This article surveys the methods and tools of quality improvement used today in health care. Specifically, we describe how clinicians can use these methods to impact the clinical practice of medicine. Improvement teams from a variety of health care organizations have reported the successful use of basic methods such as group work, flowcharting, data collection, and graphical data analysis. In addition to these incremental, problem-solving methods borrowed from the industrial practice of improvement, we have also seen the use of specific process design methods in health care applications such as care path development. The pace of change in health care has also led to the practical development of newer methods for rapid cycle improvement. We will review the basic approach behind these methods and illustrate key elements such as the ideas of change concepts and small-scale tests of change. Unfortunately, whereas these methods have been very successful and highly appealing to improvement practitioners, they may also have inadvertently widened a gulf between these practitioners and traditional health-services and clinical researchers. We offer an assessment of this issue and suggest ways to narrow the communication gap. Measurement has also traditionally been a part of the thinking about quality assurance and improvement in health care. We review the new philosophy of measurement that has emerged from recent improvement thinking and describe the use of control charts in clinical improvement. Benchmarking and multiorganizational collaboratives are more recent innovations in the ways we approach improvement in health care. These efforts go beyond simple measurement and explore the why and how associated with the widespread variation in performance in health care. We explore a variety of health care examples to illustrate these methods and the lessons learned in their use. We conclude the article with an overview of four habits that we believe are essential for health care organizations and individual clinicians to adopt to bring about real improvement in the clinical practice of medicine. These are the habits for: 1) viewing clinical practice as a process; 2) evidence-based practice; 3) collaborative learning; and 4) change. Pediatrics 1999;103:203–214; quality improvement methods, clinical medicine, benchmarking, collaboration, rapid cycle improvement. ABBREVIATIONS. RDS, respiratory distress syndrome; IVH, intraventricular hemorrhage; PDSA, Plan-Do-Study-Act; OB/GYN, obstetrics/gynecology; IHI, Institute for Healthcare Improvement. Structured quality improvement—the use of systems thinking, data analysis, and teams to bring about better outcomes, higher satisfaction, improved processes, and reduced variation—is now widely practiced in health care. Whereas early efforts were primarily directed at administrative and service processes, the techniques are increasingly being applied to clinical issues as well.1–5 In this article we will examine how clinicians can use the methods of quality improvement to impact the practice of medicine. We will survey the methods of improvement science from general industry and describe the newer models of rapid cycle improvement. We will also show how clinicians are using the statistical methods associated with control charts to improve care for patients. Finally, we will describe how health care leaders are using benchmarking and multiorganizational collaboratives to take advantage of existing variation in practice as an opportunity for learning. MODELS AND TOOLS IMPORTED INTO HEALTH CARE FROM INDUSTRIAL QUALITY