Choosing a Focus for a Quality Improvement Activity

The following article is written by Naomi Kuznets, PhD, senior director and general manager of the AAAHC Institute for Quality Improvement, and comes from the AAAHC Institute for Quality Improvement "IQI Insights" publication. It is copyrighted and being published with the explicit permission of the AAAHC Institute for Quality Improvement.


From the 2011 AAAHC Accreditation Handbook for Ambulatory Health Care, an organization that can be accredited:


Develops and implements a quality improvement program that is broad in scope to address clinical, administrative and cost-of-care performance issues, as well as actual patient outcomes, i.e., results of care, including safety of patients. Characteristics of the program must include but are not limited to: development of processes to identify important problems or concerns that are appropriate to address for improving the quality of services provided by the organization [Standard 5.II.A.5, page 35].


The focus of this article is choosing a topic for a quality improvement activity: why this is so important, some criteria that may help organizations do this and potential areas to consider. Although there is an extensive literature on quality improvement/benchmarking, this column is designed to review a limited number of issues.


Why is identifying an appropriate topic for quality improvement so important?

An effective QI program can improve clinical, administrative and financial aspects of organizational performance. Investing the resources (time, personnel, etc.) necessary for QI may lead to benefits such as:

  • Improving patient health and safety
  • Increasing patient satisfaction and retention
  • Obtaining greater efficiencies of care
  • Using "lessons learned" in multiple applications


These benefits are dependent on identifying a good topic or focus for your QI activity. A poor choice can result in wasted resources and frustration.


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Important criteria to consider when choosing a topic for quality improvement

What are the criteria for a "good" QI topic?

A. You have had adverse events, near misses, complaints.

1. Patient or provider harm (e.g., administration of a medication to which the patient has a known allergy; sharps injuries), or expressions of dissatisfaction (e.g., "providers don't listen to or spend enough time with patients") are clear opportunities for change and improvement.

2. These are "problems" that scream for a "solution." Ignore these at your own peril — including potential liability and loss of business.

3. These issues take precedence over other potential topics for quality improvement.


B. There is something you do or see a lot (prevalence/incidence).

1. Your day-to-day business (e.g., chronic diseases that affect a high proportion of your population or your most commonly performed procedures) is important to your organization.

2. You will have the opportunity to collect enough data in a short period of time to have some confidence in your results.

3. You will have the chance to make relatively wide ranging changes.


C. There is something that costs a lot to you, your patients, or payors (think of short- and long term, direct and indirect costs).

1. Now, more than ever, high costs make an issue important to all of us.

2. As the criterion wording suggests, cost needs to be considered in broader terms than immediate, direct costs.

  • In the present economy, we have all become more aware that small, short-term costs add up rapidly (e.g., supplies used daily such as rubber gloves and gauze pads).
  • It may not be high cost to you directly, but with more than 17 percent of the U.S. gross national product (2010) devoted to healthcare ( and continued economic ups and downs, the cost to someone else has a way of coming around to you (e.g., your staff health insurance rates, your ability to contract, the increased scrutiny of the cost of what you do, etc.)

3. There is an opportunity to decrease costs substantially if there is high cost.


D. You suspect or have noticed variations in practice (i.e., nobody does a task exactly the same way). The idea is not to make your providers into "robots" rather, it is to see if:

1. One provider is more effective than another (e.g., prescribes medications of dose/duration that decrease recurrence rates for a particular infection or uses an anesthesia that is associated with less post-operative nausea and vomiting).

2. One provider is more efficient (has comparable results but at less expense) than another (e.g., uses a less expensive medication [given dose and duration] that is associated with the same rate of recurrence for a particular infection or uses a less expensive anesthesia that is associated with the same level of PONV).

3. One provider is more compliant with evidence-based guidelines than another (e.g., the provider always provides immunizations as recommended or the provider always orders prophylactic antibiotics as recommended).


Note: Criteria E and F actually supersede all previous criteria, but are listed last because they cannot be applied until a tentative topic is chosen.

E. You believe you can accomplish change on this issue. Certain factors (e.g., regulation, payment policies, and "market factors") may create difficult and sometimes insurmountable barriers to quality improvement.

1. Quality improvement activities that will require legislation, and/or change in payor policy or certain market factors have less promise of success than those that do not.

2. Your organization can have the best of intentions, and a great potential QI project, with regard to improving influenza immunization rates, but success will be unlikely if necessary vaccines are not available.

3. Another example of inability to effect positive change is trying to increase the proportion of patients with cataracts and presbyopia who receive intra-ocular lenses (IOLs) that correct for presbyopia. At present, the success of this effort would be limited by the number of Medicare patients who have out-ofpocket funds available for the extra cost of these IOLs.


F. You believe you can get/already have participation on this topic choice from across the organization. Organizational support and participation will prevent a QI study from becoming an "uphill battle."

1. Decreasing variation (in response to Criterion D above) can hit roadblocks when providers are unwilling to consider making changes, or there is not support from the governing body.

2. Adequately defining the study topic, the factors that impact the topic and the data collection requires participation by those on the frontline (often staff and providers).

3. Dissemination of study results and changes in policy/procedure must be supported by the authority to make the changes happen (i.e., the resources, enforcement and rewards).


Areas to Consider

Many organizations will choose a topic that meets Criterion B (something you do or see a lot, e.g., asthma management or colonoscopies) or Criterion C (cost of asthma management or cost of colonoscopies). However, organizations may not know how to proceed from these very large topic areas. Finding specific issues within a larger topic will be less overwhelming and increase your chances for success. The following lists describe potential processes and outcomes to measure:




Selected additional sources of information on criteria for choosing a QI topic (or performance measure) include:

  • Agency for Healthcare Research and Quality (AHRQ). National Quality Measures Clearinghouse ( and National Guideline Clearinghouse (
  • Institute of Medicine (IOM). Committee on Quality of Health Care in America. Crossing the quality chasm: a new health system for the 21st century. Washington DC: National Academy Press. 2001.
  • National Quality Forum:


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