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Introduction to Health Care Quality and Safety

Nationally, a gap exists between the quality of care that is possible and the actual quality of care delivered. Annually between 44,000 and 98,000 Americans die annually as a result of medical errors; the total U.S. health care cost of injury due to medical errors ranges from $17 billion to $29 billion. The explosion of knowledge and technology, and the failure to translate that scientific knowledge into clinical practice, has resulted in massive variation in practice. In addition healthcare needs are increasingly complex, the processes and systems for complex multidisciplinary healthcare delivery outdated, and resources are often wasted. Our grim economic reality looms: that of a >$10 trillion US debt resulting in extraordinary and unprecedented pressure to control medical costs. The result is an ongoing shift in traditional health care practices and an evolving transformation of care delivery processes to achieve better patient outcomes; specifically, to improve safety, efficiency and family experience and focus on value across the care continuum. Development of expertise in and experience with effective, systematic quality improvement methods and tools is essential to achieve this healthcare transformation.

Quality improvement (QI) is defined as the systematic approach to measuring and identifying gaps between actual and desired quality of care and applying tools and improvement methods to make changes to the system that result in measurable and sustainable improvements (i.e., “closing the gap”). QI at all levels of the health care system and it is important to have physician involvement at each level. In 2001 the Institute of Medicine issued a report—Crossing the Quality Chasm—which identified 6 quality aims for healthcare—safe, timely, effective, efficient, equitable and patient-centered (STEEEP).

This webpage is designed to provide the basic resources needed to conduct a successful quality improvement initiative, including multiple QI tools to help gather and accurately interpret data. In addition we have provided a sections on Patient Safety, Key Publications, Publishing QI, Guidelines and Pathways, Department of Pediatrics QI efforts, and links to internal and external QI websites, resources and training sites for more comprehensive information.

Meaningful and sustained improvement requires careful planning and organization and a systematic approach. So, let’s get started! Familiarize yourself with the Quality Improvement Roadmap which provides an outline of the key steps essential in a quality improvement project. Useful QI tools for several of the steps are listed. Stay organized from the beginning using the Project Planning Form or the Project Tracking Sheet. Assemble your team, develop your Improvement Project Charter and begin to explore the concern you are trying to address. Tools that are useful during this discovery phase include: Fishbone Diagram, Modeling Processes (Juran’s Diagnostic Journey section) and Flow Chart/Process Flow Diagram. Often during the discovery phase multiple opportunities for improving a process or addressing an issue will be identified. It is best to narrow down these opportunities to those that are manageable, within your sphere of influence and which provide the greatest return on effort. A Pareto Chart is useful to facilitate this prioritization process.

You are now ready to begin to focus on developing, testing and implementing solutions. A Key Driver Diagram may be useful to assist with defining your improvement aim and to determine the key drivers-the “what” you need to accomplish that aim and the interventions—the “how”—change concepts to achieve the “what.” Modeling Processes (Juran’s Remedial Journey section) and the PDSA Worksheet are useful to define and organize the key elements of each intervention. Data collection is critical to provide an objective view of the process or issue you are working to improve. Data is essential to establish a baseline to measure improvement, to validate or dispel assumptions, to understand a problem or how a process is performing and to avoid implementing ineffective, costly solutions. Prior to collecting data measures should be defined and a measurement plan determined; use the Measurement Plan Form to assist you in defining the measure and your data collection plan. Are you confused about measuring for improvement? If so, review Measurement-3 Faces. Data alone tells us nothing; to understand and learn from data requires accurate analysis and presentation. In addition contextual knowledge is essential for data to evolve into information that is useful for decision-making. Tools to analyze data include: Chart Guide, Pareto Chart, Scatter Plot, Histogram, Run Chart and Control Chart.

You may be considering publishing or presentation the results of your improvement work. The SQUIRE guidelines outline the key items that authors should consider when writing manuscripts describing formal studies of quality improvement. We have also included a listing of suggested Journals to submit Q&S manuscripts to.

As you begin your quality improvement work keep the following tips in mind.

  • Use a structured framework to conduct your project
  • Clearly define team member roles and responsibilities
  • Set timelines
  • Track progress. Keep ongoing records of activities
  • “Bite off what you can chew.” Focus efforts in areas that are in your sphere of influence
  • Use data to generate “light;” avoid “hunches”
  • Communicate effectively with team members and all people affected by the project

To access comprehensive information about patient safety, an essential aim of quality healthcare, use the link to AHRQ Patient Safety Primers. Patient Safety Primers guide you through key concepts in patient safety; each primer defines a topic, offers background information on epidemiology and context, and highlights relevant content. Tools to analyze and learn from errors and devise prevention strategies found on this webpage include: the System Analysis of Clinical Incidents, MERP Med Error Classification Index and Error Classification algorithm.

Next: Introduction to Quality Improvement

Dept. of Pediatrics Mission and Vision


The Department of Pediatrics at the University of North Carolina at Chapel Hill seeks to improve the health of children in North Carolina and beyond through excellence in the care of patients and families, in research, and in the education of clinicians and scientists.


To be the leading department of pediatrics in the southeast, within the nation’s leading public medical school.

Next: Introduction to Quality Improvement