The Institute of Medicine (IOM) defines quality as the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. Various IOM reports issued over the past decade have identified serious problems with quality in health care. Quality improvement (QI) is a continuous process involving assessment of quality and efforts to increase quality, with follow-up reassessment of quality and further efforts to improve it if needed. In the past, the acronym CQI (continuous quality improvement) was often used to reflect the continuous nature of the process. Performance improvement (PI) is sometimes used as a synonym for QI.

Quality Department staff perform a variety of quality functions and there is a role for the pharmacy department in the performance of these functions: compliance with accreditation and regulatory requirements, ensuring that patients receive medically-appropriate and evidence-based care, minimizing risk and maximizing patient safety, and preparing internal and external reports of various measures that reflect the appropriate and timely use of medications (among other things). QI initiatives pertaining to medication use cross service lines and care settings and require a multidisciplinary approach to be successful. The expertise of the pharmacist provides for a large impact on quality when addressing the appropriate use of medications in the management of specific conditions (e.g., acute myocardial infarction, heart failure) and the prevention of surgical infection.

Pharmacist activities might include proactive identification of “outliers” using evidence-based metrics, providing metric-based feedback to change clinical practice, targeting improvement opportunities via data mining and audits, and promoting compliance through the development of order sets, alerts, care bundles, guidelines, practice variation exposure (i.e., patterns), and adoption of best practices to elevate the overall standard of care.

Quality management is a core job responsibility of the executive leadership. CEOs are provided incentives to understand and influence practice patterns so that the organization is aligned with evidence-based best practices. Multidisciplinary efforts are under way in the organization to drive a constant flow of information and analysis, continuous improvement as a core strategy, standardization of critical processes, and real time problem solving. As medication experts, pharmacists should be engaged in designing, implementing, and tracking organizational QI initiatives that impact appropriate medication use, such as the timing of initial administration and discontinuation of antibiotic prophylaxis for surgical patients, antibiotic selection and timeliness of antibiotic administration for patients with pneumonia, and ordering of aspirin and beta blockers for patients with acute myocardial infarction. Pharmacists are critical to the success of QI initiatives and tangible results (e.g., a reduction in mortality) through their QI participation and by extrapolating and sustaining improvements that result in a high level of organizational performance for all evidence-based measures.

The goal of research is to generate new knowledge.  The research process may involve random assignment of subjects to a control group or intervention group, be doubled-blinded, use a fixed hypothesis, focus on the elimination of bias, and consist of a large, formal test.  The goal of QI efforts is improvement.  The QI process may involve an observable test, some stable bias, just enough data (e.g., 30 chart reviews a month), some adaptation, and sequential tests of change.  The QI model answers these three questions:

• What are we trying to accomplish?
• How will we know that a change is an improvement?
• What change can we make that will result in an improvement?

Pharmacists should have some knowledge of process flow mapping, problem identification, and statistical process control.  Data are generally displayed as a run chart for the following reasons:

• To study observed data for trends over time
• To compare performance prior to and following implementation of a solution to measure the impact
• To focus attention on changes/variation in the process