Never forget the fundamental elements of a successful quality improvement program, experts say, even as your attention may be drawn away by complex data analysis. The basic, essential elements of quality improvement are necessary for any initiative to succeed.

Governance in decision-making can be an important component of any successful quality improvement program, says Leslie M. Jurecko, MD, MBA, senior vice president for quality, safety, and experience at Spectrum Health, based in Grand Rapids, MI. This can mean deferring to experts with more knowledge, which often will be those most directly involved with the issue, she says. Spectrum operates under a governance structure that includes about 100 expert teams that determine the proper clinical pathways for multiple subjects such as sepsis, wounds, and heart failure.

“You need a governance structure around those decisions, meaning those closest to the front line need to decide the best practice and also how to hold people accountable to that practice,” Jurecko says. “That gets the front line engaged, because they are not decisions handed down from on high by executives who don’t actually care for these patients.”

However, governance-by-expert teams is not always easy to achieve. Jurecko notes that it can be challenging to gather subject matter experts in a room at the same time to discuss quality issues. Simply scheduling different people at the hospital for a meeting can be difficult, but then the quality improvement department has to provide them with useful data.

“We also have to provide them a quality improvement specialist who understands improvement methodology,” Jurecko explains. “We have to have a clinical nurse specialist and often a pharmacist. Even if physicians are leading the discussion, this is still a team effort. Just getting all of those critical roles and multidisciplinary representatives together can be a challenge because no one has any extra time for meetings.”

Spectrum addresses some of those challenges with virtual meetings and other technology that does not require gathering everyone in person, Jurecko says.

Aligned goal-setting can be critical to the success of quality improvement projects, Jurecko notes. “A key to good quality improvement is clarification and simplification of goals. Often in a physician leadership structure, they will have certain goals they want to achieve; a corporate structure will have other goals. In a risk-based reimbursement agreement, there will be still other goals,” Jurecko says. “Finding the alignment and simplifying the message around all of these different goals is going to be very important for the future. Healthcare systems that can do that are going to make providers a lot happier. Right now, they are getting disparate messages coming at them from all different angles, both internally and externally.”

At Spectrum, Jurecko tries to align any incentive goals with its quality system goals, its risk-based reimbursement agreement, and the system’s ongoing professional practice evaluations. Those practice evaluations summarize data to assess a practitioner’s clinical competence and professional behavior.

“All of that has to align so that we don’t have four or five different goal-setting systems coming at our frontline physicians,” Jurecko says.

Shared ownership is another crucial component of successful quality improvement programs, Jurecko says. Quality cannot just live in the quality improvement department; rather, it must be a focus of the entire hospital, a culture in which everyone feels responsible for improving quality.

“Even if you name a chief quality officer and give them a big team of folks, that is not what is going to drive improvement,” Jurecko explains. “You need shared ownership across physician leaders and operational leaders so they see quality as their number two job, right behind ... caring for patients. They have to see quality as the way to improve their performance in their number one job.”

Successful quality improvement programs also employ specific improvement methodology to issues, which requires training in that discipline, Jurecko says. Not all quality department employees are sufficiently trained on how to apply change management to a project.

“There are physicians who are interested, but that’s another challenge to find the time required to teach them and give them the tools that will allow them to lead these projects most effectively,” she says.

A review of the most successful quality improvement programs will show that they all include a robust process improvement process, says Kristen Geissler, managing director with Berkeley Research Group in Baltimore.

“This means they are not just looking at numbers and putting them in a report,” she explains. “They are actually doing something with those numbers, actively engaging a multidisciplinary group to find better processes, removing variations and waste.”

Leadership support also is essential, she says. Quality improvements will not be successful without hospital or health system leadership endorsing the effort and holding the organization accountable for reaching high expectations of quality. “It also is critical to be a data-driven organization,” Geissler says. “If you can’t measure it, you can’t improve it. That is especially true in healthcare quality improvement.”

Most of these essential elements are dependent on the organization’s culture, she notes. Without the right culture, even the best quality improvement efforts can stall. “We’ve seen organizations that have a great process improvement program on paper, but the culture isn’t there down through the frontline staff to encourage them to think about how to do things better and even to raise their hands when they see concerning issues related to patient care,” Geissler says.

The culture can be more important than the size of the quality department or the available resources, Geissler notes. “Hospitals that have very small quality shops can still manage to have very good quality scores. We’ve seen hospitals with very large quality shops that don’t have great quality scores,” she says. “The culture can be the link. Even if you have a large quality department, and you’re throwing a lot of money and effort at a problem, it can all be wasted if the people caring for patients don’t have the mindset to receive your efforts in the right way and apply those improvements.”

Leadership rounds can be effective in promoting the right culture, but Geissler says the way in which leadership rounds are conducted can be a bellwether for the success of a quality improvement program.

Some leaders participate in the rounds but see them only as a way to check off a box for interacting with staff, Geissler says. Others may round at inopportune times or move through too quickly, with little or no interaction with staff and patients. “With the organizations that don’t have an effective, engaged leadership rounding process, that often is an indicator of issues that lead to lower quality scores and lower employee support of quality improvement projects,” Geissler notes.

Conflicting data also can undermine quality improvement efforts, she says. It is not uncommon for one set of data to show a quality rate that conflicts with another set of data. Presenting both data sets to frontline staff can undermine improvement projects, she says.

A better approach is to designate a data steward who can sort through the conflicting data and present a uniform picture of where the hospital stands. “Otherwise, you run the risk of people latching on to one set of data or other, and then you have people running in different directions or forming a different idea of the seriousness of the issue,” Geissler cautions.


  • Kristen Geissler, Managing Director, Berkeley Research Group, Baltimore. Phone: (443) 391-1046. Email:
  • Leslie M. Jurecko, MD, MBA, Senior Vice President, Quality, Safety, and Experience, Spectrum Health, Grand Rapids, MI. Email: