HiQuiPs: QI Frameworks Part 1: A Call for the Strategic Deployment of Improvement Modalities

Authors: Shawn Mondoux, Camilla Parpia, Matthew Hacker Teper, Sasha Litwin

Quality Improvement (QI) is in the middle of a “market surge”. Over the last few years, QI has gained increasing presence in academia, hospital operations, and science. A plot of Pubmed articles with the search criteria “quality improvement” OR “QI” yield a very flat slope between 1948 and 2009. However, between 2010 and 2020, the number of QI articles grew nearly 5 times from 3200 to 15000 per year. (Figure 1) Healthcare institutions are now promoting clinicians by the value of the work they have done to improve care through QI. Hospitals are increasingly purchasing or adopting systems of continuous quality improvement (CQI) and hiring directors or executives that have demonstrated abilities or certifications in QI. (1)(2) QI’s relevance to modern medicine can no longer be doubted. QI has been adopted across healthcare settings relatively quickly. Its rapid expansion has been aided by highly regarded organizations like the Institute for Healthcare Improvement who have taught and legitimized the discipline to clinicians and administrators.

Figure 1: Plot of Articles on Pubmed including the term "Quality Improvement" from 1948 to present (Source: Pubmed)

A variety of change modalities have been used with success in healthcare and more broadly. Tools such as Design Thinking have combined elements product design and process design. The National Health Service (NHS) has adopted a model called Experience Based Co-Design (EBCD). (3) Other organizations have demonstrated healthcare successes using tenets of strategic foresight. While others still are solving important healthcare problems with Artificial Intelligence (AI) or Machine Learning (ML). And finally, we must not forget that clinical trials (RCTs and their kin) are often the only viable method to demonstrate effect and improvement in areas such as therapeutics.

What is most remarkable is that, in a sector with almost unparalleled process complexity, we seem to have a need to identify a singular modality which is most likely to deliver extensive gains of improvement. This idea is wishful thinking. Whilst disciples of each improvement modality are adept and describing the limitations of others, the reality is that all of the Clinical Improvement Sciences (yes this is a new term -- coined here on HiQuiPs!) have applications in which they shine and others in which they would be misapplied. Like with any discipline, it’s important to choose the right technique for the right problem. Being an exclusive strong disciple of a single improvement modality prevents you from reaping the benefits of the other improvement modalities. In essence, we haven’t yet determined how best to select an improvement modality given the constraints and realities of the problem which is to be solved.

Therein lies the future of improvement. A “shark tank” of techniques, approaches and philosophies in which the next healthcare problem is dropped, to be consumed by the most suitable science. Health systems that invest in understanding the full gamut of clinical improvement sciences, beyond QI and clinical research, will be more successful in achieving more thorough and rapid change. The future of clinical improvement is likely one in which different sciences are applied at different stages throughout the process, leveraging the advantages and abilities of each at a time where these traits are most needed.

The key in all of the clinical improvement sciences is to completely understand the problem, from all of its angles. The tools deployed to get from that point to an effective solution are different. In some problems, several approaches may be independently effective. Yet what is clear is that health systems that use a variety of approaches are likely to solve more complex problems. Academic centers need to value clinical scholarship (scholarship of engagement) rather than singular improvement modalities. Publishing avenues need to be created for all of the clinical improvement sciences. Perhaps most topically, all of the people looking to improve healthcare, under any modality, need to realize they have more in common than they like to admit.

Summary of key article takeaways (source: Camilla Parpia)

In the coming posts, we’ll be discussing different clinical improvement sciences including design thinking, quality improvement, and systems thinking. We’ll teach you about their foundations, and how to apply them to different problems. We look forward to your comments and critiques. Let’s move towards the next generation of improvement!

Senior Editor: Shawn Mondoux

Copyedited by: Camilla Parpia


  1. Zonsius MC, Milner KA. Continuous Quality Improvement. Res Adv Pract Nurses, Fourth Ed From Evid to Pract [Internet]. 2021 Apr 7 [cited 2022 May 17];70–90. Available from: https://www.ncbi.nlm.nih.gov/books/NBK559239/

  2. Hill JE, Stephani AM, Sapple P, Clegg AJ. The effectiveness of continuous quality improvement for developing professional practice and improving health care outcomes: A systematic review. Implement Sci [Internet]. 2020 Apr 19 [cited 2022 May 17];15(1):1–14. Available from: https://implementationscience.biomedcentral.com/articles/10.1186/s13012-020-0975-2

  3. Donetto S, Pierri P, Tsianakas V, Robert G. Experience-based Co-design and Healthcare Improvement: Realizing Participatory Design in the Public Sector. http://dx.doi.org/102752/175630615X14212498964312 [Internet]. 2015 [cited 2022 May 17]; Available from: https://www.tandfonline.com/doi/abs/10.2752/175630615X14212498964312

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