in an organization. CQI assumes that most examples of poor quality are due to correctable systematic problems rather than to individual incompetence or irresponsibility. It often incorporates routine collection and monitoring of information to assess quality so that the organization can identify and respond to problems in a timely fashion. CQI generally uses interdisciplinary teams both to identify inefficiencies that increase errors and to institute checks that make errors easier to prevent and catch (Berwick, 1989; Kritchevsky and Simmons, 1991). For example, a group of cardiothoracic surgeons practicing in three states used CQI and other techniques to improve their practices and found a 24 percent reduction in their combined mortality rates (O'Connor et al., 1996).

A hospital that finds medication errors might review the many steps involved in the process by which physicians, nurses, pharmacists, and others provide medications to patients. Solutions might include having nurses and pharmacists double-check doses, using standardized doses for patient weight ranges to reduce calculation errors, and having a standard location for documentation of all drug allergies (Leape et al., 1995). Prevention of medication errors is particularly important for cancer chemotherapy, and efforts have been initiated to improve safeguards (Cohen et al., 1996).

While there are concrete examples of the success of some CQI efforts, some health care experts do not believe that the movement has made a sizable impact on the U.S. health care system (Blumenthal et al., 1998).

Practice Guidelines

Practice guidelines are systematically developed recommendations about some or all aspects of decision making for a particular condition or clinical situation (IOM, 1990). The development of guidelines usually involves a review of the relevant research and clinical literature. The best guidelines make explicit the methods used to develop them, including how evidence was used to support recommendations. Clinical practice guidelines can be judged according to several attributes, for example, their validity, reliability, and clarity (Table 6.3).


Institute of Medicine List of Desirable Attributes of Clinical Practice Guidelines




Lead to health and cost outcomes projected for them


Given the same evidence and methods, another set of experts would produce essentially the same statement


Explicitly state the population to which they apply


Identify specific exceptions


Use unambiguous language and precise definition of terms

Multidisciplinary process

Involve participation by representatives of key affected groups

Scheduled review

Indicate when they should be reviewed


All procedures, participants, evidence, assumptions, and analytic methods must be documented and described


SOURCE: IOM, 1990.

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