Protocol Development and Quality Improvement

Quality improvement (QI) consists of systematic and continuous actions that lead to measurable

improvement in health care services and the health status of targeted patient groups.

Health care performance is defined by an organization’s efficiency, outcome of care, or level of patient

satisfaction. Using benchmarks may help with measurements/goals/outcomes.

To achieve a different level of performance (i.e., results) and improve quality, an organization’s current

system needs to be challenged/evaluated.

Key components of a successful QI program:

QI works as systems and processes.

Keeps the intended outcome as the central focus

Embraces a team approach

Focuses on processes versus specific people’s actions

Improvement strategies

Understand the delivery system and key processes.

Recognize that resources (inputs) and activities carried out (processes), including the work around

for the actual defined processes, are addressed together to ensure or improve the quality of care

(outputs/outcomes).

Quality management or performance improvement departments within a health care institution often

share data with risk and regulatory departments.

QI programs within an institution

Executive steering committee

Various departments involved in QI initiatives:

Performance improvement

ii.

Pharmacy department

iii.

Nursing

iv.

Medical staff

Respiratory

vi.

Quality department

vii.

Medical ethics committee

viii.

P&T committee

ix.

Data reporting

Medication safety committee

xi.

Compliance department

xii.

Critical care/clinical specialty committee

Analyzing the quality assurance (QA)/QI program

A normal level (upper and lower control limit) should be established for a process to operate.

The process is evaluated, and the results are compared with the normal level expected. Control

charts can show the variance of the output of a process over time. The process is considered

in control if the variance between measurements is the normal random variation considered

inherent in the process. If the variance falls outside the limits or has a run of non-natural points,

the process is considered out of control.

Example: Established process for daily sedative interruption for mechanically ventilated patients.

The preestablished expected level of daily sedative interruption was established when the protocol

was considered initiated. The QA data collected evaluate the frequency by which the assessments

are being performed over a time interval.