New Framework for Quality Improvement


Improving healthcare means taking an efficacious intervention from one setting and effectively implementing it somewhere else.

Image Credit: Shuttershock.com

Image Credit: Shuttershock.com

“It is this key element of adapting what works to new settings that sets improvement in contrast to clinical research. The study of these complex systems will therefore require different methods of inquiry,” according to a recently published paper in the International Journal for Quality in Health Care titled “How Do We Learn about Improving Health Care: A Call for a New Epistemological Paradigm.”

“In biomedical sciences, we’re used to a golden standard that is the randomized controlled trial,” says lead author M. Rashad Massoud, MD, MPH, senior vice president, Quality & Performance Institute, University Research Co., LLC. “Of course, the nature of what we’re trying to do does not lend itself to that type of evaluation. It means that we can’t have an either/or situation where we either continue as we are or we go to flip side—which then inhibits the very nature of improvement from taking place, which is very contextual, very much adaptive in nature. There has to be a happy medium in between, where we can continue to do the improvements without inhibiting them and, at the same time, improve the rigor of the work.”

A new framework for how we learn about improvement could help in the design, implementation, and evaluation of QI by strengthening attribution and better understanding variations in effectiveness in different contexts, the authors assert.

“This will in turn allow us to understand which activities, under which conditions, are most effective at achieving sustained results in health outcomes,” the authors write.

In seeking a new framework for learning about QI, the authors suggest that the following questions must be considered:

  • Did the improvements work?
  • Why did they work?
  • How do we know that the results can be attributed to the changes made?
  • How can we replicate them?

“I think hospitalists would probably welcome the idea that not only can they measure improvements in the work that they’re doing but can actually do that in a more rigorous way and actually attribute the results they’re getting to the work that they’re doing,” Dr. Massoud says.


  1. Massoud MR, Barry D, Murphy A, Albrecht Y, Sax S, Parchman M. How do we learn about improving health care: a call for a new epistemological paradigm. Intl J Quality Health Care. doi:10.1093/intqhc/mzw039.

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