Milestone 20 Summary

Description: Practice builds quality improvement (QI) capability in the practice and empowers staff to innovate and improve.

What does success look like?


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Practice recognizes the need for QI capacity and has developed or identified training programs for staff in QI skills and tools. A limited number of practice staff/providers have QI skills and are involved in the practice’s QI initiatives. Practice is actively building QI capability within the practice through approaches such as including QI skills in orientation for all new staff and ensures that all staff participates in QI training. Practice has developed QI capability within the practice and empowers staff/ providers to participate in QI activities by allocating time for QI activities, including QI within defined job duties, recognizing and rewarding innovation and improvement.

Note: numbers are PAT scores

Why is this important?

As practices work toward achieving the quadruple aim, it is important to identify key staff members capable and willing to champion quality improvement (QI) efforts. Champions may not always be leaders by title but should be respected by their peers. It is up to these leaders to set the expectation that improvement should be part of everyone’s role and to provide enabling structures that allow professional development and opportunities to implement improvement activities. It is well documented that clinician commitment to quality-improvement activities leads to improved safety and quality across practices.1 A handful of key elements from high performing health systems that are critical to clinician engagement in QI capacity include: engaged leadership, clinician compact (e.g. an explicit agreement regarding clinician and organizational expectations), appropriate financial compensation to protect time for clinicians to engage in QI activities, availability of data on clinical performance and safety that are transparently shared within the practice, and opportunities for promotion that consider clinician involvement in QI activities where applicable.1

Practices must find ways to eliminate barriers to staff participation in QI activities, including time, overcoming institutional culture and a history of autonomy in practice, and lack of training and QI skills.1,2 Once the practice determines strategies for engaging and training staff in QI, it must also ensure these changes are maintained over time. Many tools exist to help teams sustain QI projects, such as performance boards, standard work flows, and daily improvement huddles.3 The Agency for Healthcare Research and Quality recommend three tips for facilitating a QI processes. The first priority should be to examine the microsystem—focus on the engagement and participation of all stakeholders affected by QI activities, including patients and families. Second, start with small-scale demonstrations rather than jumping off with large-scale changes, and finally, allow the process to be an iterative one that builds upon lessons learned along the transformation journey.4

Potential Tactics

  • Establish an interdisciplinary quality improvement committee to champion QI efforts. Include a physician champion and at least one patient representative
  • Require staff to complete the Institute for Healthcare Improvement Open School curriculum
  • Develop a plan to train key staff in QI methods and provide opportunities for ongoing professional development
  • Build QI activities into official job descriptions
  • Incorporate QI goals into practice long-term strategic and business plans
  • Create monthly reports to share data on practice and provider level quality of care, patient experience and utilization data. Provider data can be de-identified. Reports are shared with staff and available to patients.


Tools and Resources


What might this look like in practice?

A primary care practice has identified its QI transformation team, which is led by one physician and includes the practice manager, a nurse, and a medical assistant. In developing their plans for developing QI capacity and skills throughout their practice, they held a planning meeting where they discussed questions including4:

  • What areas are of highest need for improvement?
  • Who will be affected, and how?
  • Who can/should lead these initiatives?
  • What resources and training will be needed?
  • What are possible barriers, and how can they be overcome?
  • How will we measure progress and success?
  • What is our timeline?
  • How will we share our plans and progress?

The team identified basic QI knowledge and skills that all staff should possess and are developing training materials starting with the Model for Improvement and Plan-Do-Study-Act cycles. This information is also added to new employee orientation. Time is allocated at each monthly staff meeting to share information on the status of a select few QI projects and for all staff members to recommend ideas they have for future QI efforts. Staff members are encouraged to actively participate in improvement activities and they are incentivized to do so via annual reviews. The practice has added two questions to the patient surveys about quality improvement activities and is recruiting for a patient advisor to join the QI team.



  1. Taitz JM, Lee TH & Sequist TD. A framework for engaging physicians in quality and safety. BMJ Qual Saf. 2012;21(9):722-8
  2. Silver SA, Harel Z, McQuillan R, Weizman AV, Thomas A, Chertow GM, et al. How to begin a quality improvement project. Clin J Am Soc Nephrol. 2016;11(5):893-900
  3. Silver SA, McQuillan R, Harel Z, Weizman AV, Thomas A, Nesrallah G, et al. How to sustain change and support continuous quality improvement. Clin J Am Soc Nephrol. 2016;11(5):916-924
  4. Agency for Healthcare Research and Quality. Section 4: Ways to approach the quality improvement process. 2017. Retrieved from