“How would you design a great hospital quality improvement program?”

A distinguished gentleman who looks to be in his 60s is asking the question. He and I are sitting across from each other at the end of a long, dark mahogany conference table.

great hospital quality improvement program board room

I don’t remember how I came to be here. I probably look a bit confused.

“John. Tell me… How would you do that?”

Now I remember. I’m interviewing for the position of Chief Quality Officer (CQO). I’m ten minutes into an interview with the Chair of the Board of Directors. His name is Samuel.

That’s quite a broad question, Sam.

Clarify the question for me. You want me to describe how I would build an ideal quality improvement program? For a hospital like this? Are there any financial constraints?

“I’d just like to hear your opinion on what a really good program looks like. Let’s not worry too much about budgets. But keep it within the realm of possibility.”

A Great Hospital Quality Improvement Program


OK. I’ll tell you what I think. And I’ll try to keep it brief and fairly high level.

I’m making the following assumptions:

  • We’re talking about the quality program at a stand alone general full-service hospital.
  • I am going to include patient safety as part of overall quality program.
  • I’m assuming that this program will need to meet all of the required reporting demands of CMS and other regulatory bodies.

“That sounds good,” Sam replies.

OK, then let me start with the basics.

great hospital quality improvement program cycle

First, I’ll define what I mean by quality improvement.

We’re talking about a program designed to support the hospital’s efforts to deliver medical care to patients that is:

  • Undeniably effective and evidence-based,
  • Timely, and
  • Error free.

I’ll describe my design of a basic quality program. However, in the real world, the design process would be collaborative. It would involve multiple conversations with stakeholders from the local community, and possibly some outside experts.


The underpinnings of the program will start with the culture of the organization. Quality and safety must be built into the fabric of the culture of the hospital.

That means that the hospital mission addresses quality and safety. And the values of the organization will also include a commitment to quality.

Furthermore, the QI program itself would have its mission, values and vision. They would be defined by the hospital leadership, with input from all stakeholders, including patient representatives.

The Board of Directors will approve them. And everyone working at the hospital will need to acknowledge and sign off on the mission, vision and values. That includes the employees and non-employed medical staff members and independent contractors working at the facility.

The cultural aspects must include evidence that teamwork and effective communication are valued. We will implement the list of Safe Practices from the National Quality Forum.


Next, we will ensure that team members believe in quality and continuous learning. Hiring will involve an assessment of the commitment of potential hires to quality and safety.

Of course, all necessary licensing and credentialing will be followed.  An excellent quality program starts by involving motivated and engaged team members. Whether it's environmental services, phlebotomists, CNAs, lab and imaging technologists, nurses, pharmacists, or physicians, we will ensure that they all have the best credentials and a demonstrated ability to provide excellent care.

That sets the stage for building a great program.


A great hospital quality improvement program has the ability to measure, report and improve important measures of quality and safety. So, next, I would define for the organization how quality is going to be quantified. 

We will need to implement tools to monitor our performance. In order to clearly define the tools we need, the expertise we need, and the structure to put this program in place, we need to define the metrics that will demonstrate our success or failure.

great hospital quality improvement program reports

Ideally, we will track every outcome and process measure that experts agree define quality in the hospital setting. Off the top of my head, the following are generally recognized as important outcomes to track and report:

  • Overall mortality rate, expressed as mortality index.
  • Mortality rate for high volume conditions like heart failure, COPD and pneumonia. The top 20 by volume would be a good start.
  • Complication rates for the top 20 procedures (by volume), such as total joints and other inpatient procedures.
  • 30-day readmission rates for the top 20 medical, and top 20 surgical, diagnoses.
  • Compliance rates for process measures (such as CMS core measures and other important lead measures).
  • Selected patient safety measures (including Sentinel Events and Never Events).
  • Selected AHRQ Inpatient Quality Measures.
  • Length of Stay (overall, and for specific high volume diagnoses).
  • Medication Errors.
  • Additional measures, as indicated by comparing the Leapfrog National Measures Crosswalk and other published guidelines to what is already in place.

Measurement Tools

Given the list of measures that we must monitor, I will lead a team to identify the best measurement tools. If there are tools that can integrate with our EMR, I will focus on those. Otherwise, I will find tools(s) that will provide as much of the needed data as possible. The tools will need to provide risk-adjusted outcomes and rates for process measures. It will need to be as affordable as possible.

Such tools might include those provided by The Advisory Board, Premier, Quantros and others. Without automation of these measurements, they become very difficult to follow and compare to benchmarks.


In addition to leadership by the CMO or CQO, we will need an experienced, knowledgeable, clinical expert to lead the quality and safety department or division. He or she will have the appropriate attitude, experience and training to ensure success in this position.

great hospital quality improvement program engaged staff

Other expertise needed within the department will include:

  • Regulatory (CMS, TJC or DNV, and state regulatory departments);
  • Quality processes, including process improvement, quality improvement, and patient safety;
  • Sentinel events and root cause analysis;
  • Infection prevention;
  • Medication safety;
  • Data analysis, decision support and statistical analysis;
  • Continuing medical education;
  • Super-user for any measurement tools installed; and,
  • Coding and documentation as it relates to quality and safety reporting.


We will need to assign the activities to the appropriate teams and create a REPORTING structure. We can start with a structure that looks like this, and adjust it to suit our needs:

great hospital quality improvement program org chart


In a small facility, one person might handle multiple duties. As the organization gets larger, the duties will need to be managed by a larger team.

I will place management of continuing medical education as part of the QI division. In this way, the majority of educational content for physicians will be designed to address gaps in care or patient safety.


The Quality Committee, which is a subcommittee of the Board, will oversee all of the activities. So, there will need to be several scorecards that the board can review in order to easily monitor our performance.

The membership of the committee will include select board members, the CEO, COO, CQO, CMO, QI & PS Director, Pharmacy Director, Nursing Director, representatives from CME and  Infection Prevention, and members of the medical staff from each of the large departments (e.g., medicine, surgery, etc.).

Several subcommittees will report directly to the QI Committee:

Each of these subcommittees will be monitoring outcomes and creating teams to address specific gaps in performance. The subcommittees might need specific teams for certain projects or for certain high risk units.

Here is how the COMMITTEE structure might look:

great hospital quality improvement program committee structure


Each SUBCOMMITTEE and TEAM will develop its own scorecards for reporting the ongoing performance being addressed. Minutes of each meeting and scorecards for each TEAM will be sent to its SUBCOMMITTEE. Each SUBCOMMITTEE, in turn, will report to the Quality and Safety Committee.

The CQO will present quarterly quality and safety reports to the senior executive team and the Board of Directors.

That structure ensures accountability of the organization to the community, via the Board.

Peer Review

Notice, Sam, that this model has not addressed the formal physician peer review process. But that must be included as part of the re-credentialing process for physicians.

My recommendation is that medical staff peer review be done by a multidisciplinary committee, with members from each medical staff department appointed by the chair. Cases will be reviewed, based on screening criteria for each department. Also, cases can be referred to the peer review committee as needed.

Some of those cases will also be reviewed through the sentinel event or QI process as well. The physicians will be invited to participate when their case is being discussed.

So, Sam, that’s what I consider to be a starting point for a good program.

In addition to the what I've already mentioned, we will:

  • address new opportunities as they arise,
  • focus on continually improving the quality of the care,
  • take a multidisciplinary approach,
  • integrate education into the process, and
  • evaluate the culture through regular cultural surveys.

Wrapping Up a Great Hospital Quality Improvement Program

Sam replies, “That sound like a really sound plan. Thanks for taking the time to describe it.

“I think we’re out of time, so I’ll bring you to your next interview. Best of luck and thanks for coming in to meet with us today.”

I'm walking toward the door when, suddenly, I hear a distant ringing. The ringing becomes louder and louder.

Where is it coming from?

I open my eyes. The alarm on my cell phone is ringing. And I’m in my pajamas, in bed. I'm so preoccupied with my upcoming job search that I was dreaming about an interview!

Some of those ideas about a quality program were pretty good, though.

I jump out of bed to find a pen and paper to jot the ideas down!

Next Steps

What have I forgotten in my dream-induced quality plan? Let me know in the Comments.

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