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    Janis Coffin, DO, FAAFP, PCMH CCE, FACMPE

    Understanding the nature of continuous quality improvement (CQI) is increasingly important in the age of performance-based reimbursement under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Starting in fiscal year 2019, practices will have their reimbursements altered based upon performance scores tabulated in the 2017 performance year scoring period.

    Both reimbursement pathways under MACRA — advanced alternative payment models (APMs) or the Merit-Based Incentive Payment System (MIPS) — require some form of demonstrable quality improvement efforts. Year-over-year performance metrics and advancement within some program’s subtiers, whether stated outright or implied, require advanced performance scores. Familiarization with CQI paradigms is crucial for practices and organizations seeking to adapt successfully to the requirements placed upon them under these new systems.

    Common CQI strategies in healthcare

    Although many CQI strategies in use today have foundations in the manufacturing sector, many have found a place in healthcare over time. Figure 1 highlights these CQI paradigms commonly used in a variety of healthcare settings. Although some of these models, such as Lean and Six Sigma, still maintain much of the original manufacturing perspective regarding CQI methodology and just as much of the original terminology, others such as the Institute for Healthcare Improvement (IHI) Model for Improvement are specifically crafted variants designed for use in healthcare settings.

    Choosing a CQI strategy

    The adoption of a specific CQI is highly contingent on an organization’s goals and ability to adhere to the established principles characteristic of any particular CQI. Organizations that lack necessary experience with statistical methodologies may find adoption of CQI models such as Lean Six Sigma or Six Sigma to be a difficult endeavor without appropriate investment in both time and resources. Thus, it is important for any organizational stakeholders seeking to adopt a CQI to familiarize themselves with the basic tenets of the CQIs under consideration.

    The organization's data collection capabilities, be it predominantly manual or electronic, also need to be taken into consideration when choosing a CQI strategy. For most organizations that participate in the Centers for Medicare & Medicaid Services (CMS) EHR Incentive Program and demonstrate Meaningful Use, many of these electronic capabilities are inherent to the system utilized. For organizations still predominantly reliant on paper charting without electronic data collection, any collection of data necessarily inherent to any relevant CQI strategies may require additional investment in terms of infrastructure or workforce. Serious consideration may need to be given to data acquisition, be it electronic automated data collection or manual documentation, and which is most appropriate given costs and resource usage. For any Medicare-accepting organization, avoidance of electronic systems may not be feasible financially given the inherent changes mandated under MACRA.1

    All CQI strategies require a certain amount of stakeholder buy-in. Thus, organizational culture and ability to adapt to change also must be taken into consideration when choosing a model. Every CQI model requires some amount of organizational culture shift to embrace the necessary changes required to properly execute each strategy. This culture shift often requires a commitment of both time and resources on behalf of the organizational leadership, as leadership commitment to organizational change is critical for stakeholder buy-in at other levels in the organization.

    Providing all pertinent stakeholders information and promoting transparency in the CQI adoption process often helps to alleviate some of the organizational anxiety associated with any major change. With that said, some of the previously mentioned CQI models require more adaptation to adhere to basic principles than others. Most notably, the IHI model serves as a suitable entry point for many healthcare organizations seeking to embrace CQI methodologies.

    With these factors taken into consideration, any one or combination of the CQI strategies can be chosen, though they have key differentiating factors as related to complexity and the settings most conducive to success (see Figure 2).

    CQI adoption best practices

    Often, adoption of CQI methodology focuses on adopting best practices at the onset based on industry standards and model organizations. Thus, it is important to understand the best practices that promote optimal adoption and appropriate leveraging of a CQI paradigm to help meet organizational goals.

    Data management is a critical aspect of CQI adoption, especially for those models that are heavily reliant on quantitative approaches. It is important to determine what the sources of each data set will be and how to optimize collection both effectively and efficiently. If data has to be collected outside of an electronic record, it is important to assess how this data will be collected otherwise. It is also important to ensure that electronically collected data accurately reflects what it is presumed to reflect. This may require training personnel on proper data entry. Just as importantly, data must be stored in a usable fashion. Ideally, data will be stored in databases that are easily queryable for analysis. It is also important to conduct periodic audits to ensure the data collection and output are accurate.

    Metric management is also important at the onset to establish appropriate measures that assess structure, process and outcomes throughout the organizational unit adopting the CQI methodology. These measures can be based on industry standards or predetermined indicators built into the electronic system. It is important to set target and benchmark metrics to evaluate performance both periodically and among other organizations, if those data are available.

    For a CQI initiative to be successful, it also requires an appropriate amount of time and resource investment to support stakeholder efforts. This requires investment in the necessary infrastructure such as organizational investments in data collection equipment, training and time allotment. Dedicating the necessary resources, establishing finite timelines and assigning staff help to create a sense of ownership and accountability for the CQI initiative and can help spur necessary affective commitment to help foster a shift in organizational cultural acceptance of the initiative. If the CQI is too complex for the organization to implement properly, breaking the initiative into smaller, more digestible pieces may help foster necessary buy-in to promote acceptance by organizational stakeholders. Establishing goals and celebrating their achievement is critical to promoting staff participation and recognizing outstanding performance.

    Understanding the fundamentals of multiple CQI strategies for a healthcare organization can be a critical advancement for those seeking to adopt a well-described, quality improvement initiative to meet the reimbursement requirements of MACRA.2 By choosing a CQI model that best fits the goals, culture and structure of the organization, stakeholders seeking to implement a quality improvement initiative are more likely to find success rather than simply choosing one at random. By leveraging best practices within the industry regarding adoption, organizations are also more likely to find success in the age of CQI under MACRA.


    1. Self RH, Coffin J. "The components of the Merit-Based Incentive Payment System." Journal of Medical Practice Management. 2017. 32(3):173-6.
    2. Medicare Access and CHIP Reauthorization Act (MACRA), Pub. L. No. 114-10, 129 Stat. 87 (codified at 42 U.S.C. 1305 (2015)).

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