Milestone 19 Summary

Description: Practice uses an organized approach (e.g. use of PDSAs, Model for Improvement, Lean, FMEA, Six Sigma) to identify and act on improvement opportunities.

What does success look like?


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Practice does not incorporate standard improvement methodology to execute change ideas in the practice setting. Practice has decided on a standard QI methodology and is planning the implementation process. Practice is beginning to incorporate regular improvement methodology to execute change ideas in the practice setting but the methodology has not yet been implemented in all areas of the practice. The practice fully incorporates regular improvement methodology to execute change ideas in the practice setting.

Note: numbers are PAT scores

Why is this important?

Our healthcare delivery system is among the most complex in the world, and with continuous demands for improved health outcomes and cost savings, intentional and strategic planning for constant improvement is necessary. Quality improvement (QI) is not one methodology; rather, it is a management process and set of tools that is necessary for achieving transformational change within a system or individual practice. One QI definition states that it is “a continuous and ongoing effort to achieve measurable improvements in the efficiency, effectiveness, performance, accountability, outcomes, and their indicators of quality in services or processes which achieve equity and improve the health of the community.”1 QI activities are helpful for understanding processes, identifying areas for improvement, assessing capabilities, assessing why results may not occur as intended, and choosing and institutionalizing appropriate and feasible solutions.2 There are dozens of QI activities to accomplish these goals, with some of the most common being cause and effect diagrams, failure modes and effect analysis, run charts and control charts, and Plan-Do-Study-Act cycles.3 QI programs are most successful when they consider the entire system being impacted, focus on the impacts that changes have on patients (and include patients in planning), focus on team processes, and meaningfully use data.4 Small incremental changes, when intentionally embedded within a larger vision for transformational change, can be powerful tools for improving processes for both patients and providers.

Potential Tactics

  • Establish an interdisciplinary quality improvement committee to champion QI efforts. Include a physician champion and at least one patient representative
  • Complete the Institute for Healthcare Improvement Open School curriculum
  • Use the Model for Improvement to structure QI goals
  • Develop a plan to train key staff in QI methods
  • Systematically train and provide feedback to involved staff about ongoing progress
  • Test one change at a time


Tools and Resources


What might this look like in practice?

A practice has been challenged with long patient wait times leading to patient dissatisfaction and duplication of work. To better understand the cause of this problem, a Medical Assistant (MA) was trained to conduct a time-motion study recording the time it took for a patient to walk through each step from clinic check-in to time seen by the physician. After two days of tracking, this data was reviewed by the entire team observed who identified inefficient workflows between the front desk check-in and rooming of patients. A standardized work flow was developed to allow for immediate notification of the MA upon patient check-in and communication with the nursing team regarding room availability. Using a Plan-Do-Study-Act (PDSA) approach, this new standard work was piloted for 2 weeks. Each time the patient touched a new practice staff member, the time was recorded. This allowed for review of results at the end of the 2-week period. The newly implemented work flow reduced time from check-in to rooming by 5%. The group found ways to further optimized the standard work, extending it to immediate notification of the physician upon patient rooming and tracked this impact for a month. Patient wait times were reduced and this new standard work flow was integrated into the routine processes of all staff.



  1. Riley WJ & Moran JW. Defining quality improvement in public health. J Public Health Management Practice. 2010;16(1):5-7.
  2. Nunes JW, Seagull FJ, Panduranga R, Segal JH, Mani NA & Heung M. Continuous quality improvement in nephrology: A systematic review. BMC Nephrol. 2017;17:190.
  3. Institute for Healthcare Improvement. QI Essentials Toolkit. Cambridge, Massachusetts. 2017
  4. U.S. Department of Health and Human Services Health Resources and Service Administration. Quality Improvement. 2011. Retrieved from