Table of Contents

        Overview – The Quality Improvement Process

  1. Deciding What to Work On
    1. Some Things to Consider
    2. Begin to Collect Data
    3. Tools to Help You Get Started
  2. Building an Improvement Team (Who to Involve & How)
    1. Assembling an Improvement Team
    2. Coordinating an Improvement Team
  3. Finding Out What’s Going On
    1. Observation Using a Tally Sheet
    2. Other ways to Collect, Analyze and Display Data
    3. What You Can Learn from Your Baseline Data
  4. What We Might Do
    1. Generating Alternatives
    2. What Are Others Doing? (Benchmarking)
    3. Selecting One Change to Test
  5. Crafting and Testing an Intervention
    1. The PDSA Cycle
  6. What’s Next?
    1. What Have You Learned from Your Test Data?
    2. Where Do You Go From Here?

        Appendix – Partnering with Other Practices

        Worksheets & Instructions



Chances are you are in a busy practice with limited staffing and you are hard pressed to keep up. You’re checking out this Healthcare Improvement Skills Center website and this manual because your practice or healthcare system has decided everyone has to do a quality improvement project this year, or – more likely– because your medical specialty board has indicated that you have to do at least one “Part 4” Maintenance of Certification project – a quality improvement project – in your practice every three years or so. They are asking you to demonstrate your competence in practice-based learning and improvement and you want to brush up your QI skills.

Medical specialty boards, healthcare systems, the ACGME,* the Joint Commission** and CMS,*** among others know that practice-based learning and improvement is what clinicians do on an ongoing basis. With this new requirement, various entities are seeking to encourage medical professionals, all of us, to become a bit more systematic in our improvement efforts. They know that regardless of specialty, sub-specialty, or professional role we need a common set of concepts and methods, and a common language, to easily and efficiently communicate with one another and to effectively work together in multi-disciplinary improvement project teams. The purpose behind all these “QI” (quality improvement) requirements, seemingly coming from every direction, is that straightforward.

We have put together this “Concise Practice Improvement Manual.” to provide a very brief, hopefully inviting introduction to quality improvement. It is intended to quickly give you the big picture. The balance of Healthcare Improvement Skills Center exercises, case-driven learning modules and activities will provide you with a good deal more about various aspects of QI.

In the “My QI Project” area of this website, you will find a more detailed version of this manual (“Concise Practice Improvement Manual – Unabridged”). The longer version of the manual includes some highlighted tips and additional resources. It’s purpose is to actually walk you and your colleagues through the steps of a modest QI project, once you begin to apply these skills in your own, particular practice setting.

Using This Manual – You can read it all the way through or use its various parts selectively, as needed.

*American Council on Graduate Medical Education;
**Joint Commission on Accreditation of Healthcare Organizations
***Centers for Medicare and Medicaid Services