Module 1: Introduction to Quality Improvement and Data Analytics

Quality Timeline

Items in Green and bolded are related to healthcare quality

Items in Blue (not bolded) are related to general quality concepts, originally applied
primarily to manufacturing

1855 Florence Nightingale is among the first to introduce quality assurance

techniques in healthcare, documenting hospital conditions and deaths of soldiers
during the Crimean War. View graphic.
1910 Surgeon Ernest Codman proposes hospital standards and suggests
tracking patient progress to determine efficacy of treatment.
1911 Frederick Winslow Taylor publishes Principles of Scientific Managementa
seminal work in management.
Frank Bunker Gilbreth and his wife launch a management consulting company focused
on increasing efficiency through time and motion studies
1918 The American College of Surgeons launches voluntary on-site hospital
inspections.
1924 Walter Shewhart applies statistical methods to the problem of quality control. His
seminal work with statistical process control charts launches a quality revolution.
1937 Joseph Juran develops the Pareto Principle. He becomes an influential figure in
the field of quality improvement.
Pareto Principle: 80% of a problem is caused by 20% of the factors/sources. A Pareto
chart helps identify problems that offer the greatest potential for improvement, by
showing the relative frequency or size of different problems. View example of a Pareto
chart.
Pareto Chart: The green line below shows the cumulative percentage of the total
number of falls. It highlights the items at the left that are most important to address. So,
you can see that because the number of falls in wards 24L and 25L constitute 45% of all
falls, those would be the areas you would want to address first.

1946 The American Society for Quality (at that time called the American Society for
Quality Control) is established to sustain and advance quality improvement techniques.

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1950s - W. Edward Deming introduces statistical quality control methods in Japan. He
also develops the DMAIC method to reduce defects (initially in manufacturing) by
finding root causes, eliminating them, and maintaining the resulting level of
improvement.
Define: Identify the problem or opportunity for improvement
Measure: Establish baseline performance metrics and determine how you will
measure improvement
Analyze: Analyze the data; identify, validate and select root cause for elimination
Improve: Identify, test, and implement improvement solutions
Control: Determine how you will ensure that gains are sustained, including type
of monitoring to be implemented

1950 Kaoru Ishikawa develops the cause and effect diagram.

Also called a fishbone diagram, the process of developing these charts helps
individuals to think through and identify causes of a specific event or outcome.
View Fishbone diagram
1951 - The Joint Commission on Accreditation of Hospitals is established as a
non-profit organization to provide hospital accreditation, on a voluntary basis,
based on meeting certain minimum quality standards.
1960 The aerospace industry develops the Failure Modes and Effects Analysis
(FMEA) approach. FMEA is a systematic, proactive method for evaluating a process to
identify where and how it might fail, in order to identify the parts of the process that are
most in need of change. It is also described as a reliability evaluation technique to
determine the relative impact of different system and equipment failures. Additional
information on FMEA.
1966 - Dr. Avedis Donabedian publishes Evaluating the Quality of Medical Care,
establishing a model for examining care quality that includes the structure
(factors that impact the context of healthcare delivery, e.g., buildings, equipment,
HR policies), the process (e.g., transactions between patients and providers), and
the outcomes (e.g., effects of healthcare on patients). View additional information
1970 The National Academy of Sciences establishes, with a congressional
charter, the Institute of Medicine (IOM)--a non-profit, non-governmental
organization to serve as an independent scientific advisor to improve the nations
health.
1972 - Medicares Professional Standards Review Organizations (PSROs) are
established. They focused on reviewing health services submitted for Medicare
reimbursement to ensure that they were medically necessary and met
professionally recognized quality standards.
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1979 The National Committee for Quality Assurance (NCQA) is established. They
offer accreditation to health care entities that meet certain standards. According
to their website, NCQAs programs and services reflect a straightforward
formula for improvement: Measure, Analyze, Improve, Repeat.
1983 PSROs are replaced by Peer Review Organizations (PROs), focused on
improving quality and containing costs.
1985 The US Navy uses the term Total Quality Management (TQM) to refer to its
adoption of Edward Demings approach to quality to assess the Navys operational
effectiveness. Read a brief definition of TQM.
1989 The National Agency for Health Care Policy and Research, which would
eventually become the Agency for Healthcare Research and Quality (AHRQ), is
established, with a focus on improving clinical effectiveness, treatment outcomes, and
practice guidelines.
1990 The Healthcare Financing Administration (HCFA) launches the Health Care
Quality Improvement Program (HCQIP) to improve the quality, efficiency, and
effectiveness of services received by Medicare and Medicaid patients.
1990 James Womack publishes The Machine That Changed the World, popularizing
the term Lean Production.
Lean Process Improvement is a systematic method involving a collaborative team effort
to improve performance by removing waste and inefficiencies. It was originally applied
to manufacturing. There are eight different types of waste associated with the Lean
approach. Required Viewing: Watch a 6 minute video on 8 wastes in healthcare
1. Defects Time spent inspecting for and correcting problems
2. Transportation Unnecessary, avoidable movement of products (or
patients) and equipment
3. Inventory Costs of storage, possible degradation of goods
4. Motion - Unnecessary movement of employees
5. Waiting - Waiting for the next step in the production process, interruptions or
bottlenecks to workflow
6. Overproduction - Production ahead of demand, going beyond what is
needed and provides value to the customer
7. Overprocessing Unnecessary extra work created because of inadequate
tools or ineffective processes
8. Human potential Lost employee productivity due to ineffective management
1991 - The Institute of Healthcare Improvement (IHI) is founded.

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1999 The Institute of Medicine publishes To Err Is Human: Building a Safer
Health System.
This report shocks the nation with statistics indicating the magnitude of
mortality attributed to medical errors. An estimated 44,000 to 98,000 deaths
per year and other serious adverse events are described. The report lays
out a comprehensive strategy by which government, health care providers,
industry, and consumers can reduce preventable medical errors. (from the
IOM website). Optional Reading: 6-page summary of the IOM report.
2001 The Institute of Medicine publishes Crossing the Quality Chasm: A New
Health System for the 21st Century
Conclusion: The U.S. health care delivery system does not provide
consistent, high quality medical care to all people and change is needed.
This report from the committee on the Quality of Health Care in America
makes an urgent call for fundamental change to close the quality gap,
recommends a redesign of the American health care system, and provides
overarching principles for specific direction for policymakers, health care
leaders, clinicians, regulators, purchasers, and others. (IOM website)
Required Reading: IOM Crossing the Quality Chasm Report Brief
2012 The Institute of Medicine (IOM) publishes Best Care at Lower Costthe
Path to Continuously Learning Health Care in America.
Achieving higher quality care at lower cost will require fundamental
commitments to the incentives, culture, and leadership that foster
continuous learning, as the lessons from research and each care
experience are systematically captured, assessed, and translated into
reliable care (excerpt from IOM website). Optional Reading: IOM Best Care
at Lower Cost Report Brief

References
American Society for Quality. (n.d.). Quality glossary - T Retrieved from
https://asq.org/quality-resources/quality-glossary/t
American Society for Quality. (n.d.). Who we are. Retrieved from http://asq.org/about-
asq/who-we-are/history.html
Best, M., & Neuhauser, D. (2006). Walter A Shewhart, 1924, and the Hawthorne
factory. Quality and Safety in Health Care, 15(2), 142-143. Retrieved from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2464836/

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Centers for Medicare & Medicaid. (n.d.) How to use the fishbone tool for root cause
analysis. Retrieved from https://www.cms.gov/medicare/provider-enrollment-and-
certification/qapi/downloads/fishbonerevised.pdf.
Donabedian, A. (2005). Evaluating the quality of medical care. Milbank Quarterly. Dec,
2005, p 691729.
FMEA-FMECA.com. (2006). What is a FMEA? Retrieved from http://www.fmea-
fmeca.com/what-is-fmea-fmeca.html
Gagel, B. (1995). Health care quality improvement program: A new approach. Health
Care Finance Review, 16(4),15-23. Retrieved from
http://www.ncbi.nlm.nih.gov/pubmed/10151886
Institute for Healthcare Improvement. (2016). Failure modes and effects analysis (FMEA) tool.
Retrieved from
http://www.ihi.org/resources/pages/tools/failuremodesandeffectsanalysistool.aspx

Institute of Medicine (US). (2001). Crossing the quality chasm: a new health system for
the 21st century. Crossing the quality chasm a new health system for the 21st
century. Washington, D.C.: National Academy Press. Retrieved from
http://www.nationalacademies.org/hmd/~/media/Files/Report
Files/2001/Crossing-the-Quality-Chasm/Quality Chasm 2001 report brief.pdf
Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (Eds.). (2000). To err Is human:
Building a safer health system. Washington, D.C.: National Academies Press.
Retrieved from http://iom.nationalacademies.org/reports/1999/to-err-is-human-
building-a-safer-health-system.aspx
LeanFoxSolutions (2012). Lean Thinking-Eliminating Waste in Healthcare-Lean
Fox.mov. [Video file]. Retrieved from
https://www.youtube.com/watch?v=NfdnbrDh3Fw
Marjoua, Y. and Bozic, K. (2012). Brief history of quality movement in US healthcare.
Current Reviews in Musculoskeletal Medicine, 5(4), 265273. Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3702754/
Mouradian, G. (2002). The quality revolution: A history of the quality movement.
University Press of America: Lanham, MD.
National Committee for Quality Assurance. (n.d.) About NCQA. Retrieved from
http://www.ncqa.org/about-ncqa.
Neuhauser, D. (2003). Florence Nightingale gets no respect: as a statistician that is.
Quality and Safety in Health Care, 12:317. Retrieved from
http://qualitysafety.bmj.com/content/12/4/317.full

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NHS. Scotland. (2016) Pareto chart. Retrieved from https://asq.org/quality-
resources/quality-glossary/t
Smith, M., Saunders, R., Stuckhardt, L. & McGinnis, J. (Eds). (2012). Best care at
lower cost: The path to continuously learning health care in America.
Washington, D.C. National Academies Press. Retrieved from
http://iom.nationalacademies.org/Reports/2012/Best-Care-at-Lower-Cost-The-
Path-to-Continuously-Learning-Health-Care-in-
America.aspx?_ga=1.106879299.1114197746.1446580541

Images
Nightingale, F. (1858) Diagram of the causes of mortality in the army in the East.
Adapted from Notes on Matters Affecting the Health, Efficiency, and Hospital
Administration of the British Army: founded chiefly on the experience of the
late war. Retrieved from
http://understandinguncertainty.org/files/Coxcombs.jpg

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