How to Improve: Model for Improvement: Selecting Changes

Model for Improvement: Selecting Changes

Model for Improvement question: What change can we make that will result in improvement?

While all changes do not lead to improvement, all improvement requires change. The ability to develop, test, and implement changes is essential for an individual, group, or organization that wants to improve.

System-level improvement usually requires fundamental changes to the design of the system that result in improved performance and outcomes without increasing costs — not just quick fixes to bring a system back into control or to a previous level of performance.

To answer the third question in the Model for Improvement — What change can we make that will result in improvement? —the following might be helpful:

Careful examination of the existing system (using flowcharts, for example)
Exploration of the current system attributes that get in the way of better performance (a cause and effect diagram might be useful)
Investigation of best practices inside and outside your organization to understand what is possible

When generating ideas for change that will result in improvement, subject matter expertise is valuable. Ideas may come from the literature, point-of-care staff, customers of the system being improved, researchers, and other experts, and should be adapted for the local context. Developing a theory (or conceptual model sometimes represented in a driver diagram, for example) that organizes and describes how the changes will result in improvement in the system is a key part of getting started.

Another useful set of tools for identifying changes are “change concepts” — general notions or approaches to change that have been found to be useful in developing specific ideas for changes that lead to improvement. Creatively combining these change concepts with knowledge about specific subjects can help generate ideas for tests of change.

Wherever you find your ideas for change, run Plan-Do-Study-Act (PDSA) cycles to test a change or group of changes on a small scale to learn how they work in your local environment and see if they result in improvement. If they do, expand the tests and gradually incorporate larger samples and under a variety of conditions until you are confident that the changes can and should be implemented and adopted more widely.

The change concepts included here were developed by Associates in Process Improvement (see The Improvement Guide [Langley GJ, Nolan KM, Nolan TW, Norman CL, Provost LP. San Francisco: Jossey-Bass Publishers, Inc.; 2009] for a list of 72 change concepts, as well as examples of how they were applied in process improvement, both inside and outside of health care).

Examples of Categories of Change Concepts

Eliminate Waste

In a broad sense, waste can be considered as any activity or resource in an organization that does not add value to an external customer. Some possible examples of waste are materials that are thrown away, rework of materials and documents, movement of items from one place to another, inventories, time spent waiting in line, people working in processes that are not important to the customer, extra steps or motion in a process, repeating work that has previously been done by others, over-specification of materials and requirements, and more staff than required to match the demand for products and services.

Toyota is famous for focusing improvement on the following "seven wastes":

Waste of overproduction
Waste of waiting
Waste of transportation
Waste of processing itself
Waste of inventory (stock)
Waste of motion
Waste of producing defective parts or products

Improve Workflow

Products and services are produced by processes. How does work flow in these processes? What is the plan to get work through a process? Are the various steps in the process arranged and prioritized to obtain quality outcomes at low costs? How can we change the workflow so that the process is less reactive and more planned? A flowchart is a great tool for understanding your existing processes and envisioning improvement in workflow.

Optimize Inventory

Inventory of all types is a possible source of waste in organizations. Inventory requires capital investment, storage space, and people to handle and keep track of it. In manufacturing organizations, inventory includes raw material waiting to be processed, in-process inventory, and finished goods inventory. For service organizations, the number of skilled workers available is often the key inventory issue. Extra inventory can result in higher costs with no improvement in performance for an organization. How can we reduce costs associated with the maintenance of inventory? Understanding where inventory is stored in a system is the first step in finding opportunities for improvement.

The use of inventory pull systems such as "just-in-time" is one philosophy of operating an organization to minimize the waste from inventory. In a pull system of service, the timely transition of work from one step in the process to another is the primary responsibility of the downstream (i.e., subsequent) process. This is in contrast to most traditional push systems, in which the transition of work is the responsibility of the upstream (i.e., prior) process.

Change the Work Environment

What would make the environment better able to support improvement? Examples of change concepts to change the work environment include the following:

Invest more resources in improvement
Give people access to information
Conduct training
Implement cross-training
Develop alliances and cooperative relationships

Producer/Customer Interface

To benefit from improvements in quality of products and services, the customer must recognize and appreciate the improvements. Many ideas for improvement can come directly from a supplier or from the producer's customers. Many problems in organizations occur because the producer does not understand the important aspects of the customers’ needs or customers are not clear about their expectations from suppliers. The interface between producer/provider and their customers presents opportunities to learn and develop changes that will lead to improvement.

Manage Time

This age-old concept provides an opportunity to make time a focal point for improving any organization. An organization can gain a competitive advantage by reducing the time to develop new products, waiting times for services, lead times for orders and deliveries, and cycle times for all functions in the organization. Many organizations have estimated that less than five percent of the time needed to manufacture and deliver a product to a customer is actually dedicated to producing the product. The rest of the time is spent starting up or waiting.

Focus on Variation

Everything varies! But how does knowing this help us to develop changes that will lead to improvement? Many quality and cost problems in a process or product are due to variation. The same process that produces 95 percent on-time delivery or good product is the same process that produces the other 5 percent of late deliveries or bad product. Reduction of variation in such cases will improve the predictability of outcomes (may actually exceed customer expectations) and help to reduce the frequency of poor results.

Error Proofing

Errors occur when our actions do not agree with our intentions even though we are capable of carrying out the task. Often, we have to act quickly in a given situation or are required to accomplish a number of tasks sequentially or even simultaneously. Making these slips is part of being human. We might do such things as:

Forget to enter information or enter it incorrectly
Leave out a step in a process or do them in the wrong sequence
Include the wrong merchandise in a shipment
Try to use something in the wrong way
Put something together wrong

Although these errors or slips are the result of human actions, they occur because of the interaction of people with a system. Some systems are more prone to error than others. We can reduce errors by redesigning the system to make it less likely for people in the system to make errors. This type of system design or redesign is called error proofing.

Focus on the Product or Service

What improvements can you make to the design of the product or service? Examples of change concepts that focus on the product or service include the following:

Mass customize
Reduce the number of components
Change the order of process steps
Differentiate using quality dimensions

How to Improve: Model for Improvement: Establishing Measures

Model for Improvement: Establishing Measures

Model for Improvement question: How will we know that a change is an improvement?

Measurement is a critical part of knowing if we have made a difference, what the impact of the changes are, if we have met our aim, and future action to take. When selecting measures, it is vital to include the people whose lives will be impacted by the improvement to have a voice in deciding what measures are important from their perspective. While aims often center around a quantitative aim or target, it’s important to measure your improvement work using quantitative and qualitative data.

Measurement for improvement should not be confused with measurement for research. This difference is outlined in the table below.

	Measurement for Research	Measurement for Learning and Improvement
Purpose	To discover new knowledge	To bring new knowledge into daily practice
Tests	One large "blind" test	Many sequential, observable tests centered on learning
Biases	Control for as many biases as possible	Design data collection to stabilize bias
Data	Gather as much data as possible, "just in case"	"Just enough" data gathered through small sequential samples

Three Types of Measures

Use a set of measures (typically 4 to 10) in order to track change and learning over time across different areas of the system (or processes). The three types of measures commonly used include: outcome, process, and balancing measures.

Disaggregating data (stratification) to show potential systemic inequities can be an important strategy for ensuring that improvement efforts close rather than maintain or widen equity gaps (e.g., race, ethnicity, ancestry, language, sexual orientation, gender identity).

Outcome Measures

Linking back to the numeric goal within the aim statement, the outcome measure indicates how the system is working, specifically the impact on the customers/patients. Typically there is one outcome measure for an improvement initiative, and at times, there may be a need for two.

Examples:

For diabetes: Average hemoglobin A1c level for BIPoC patients with diabetes
For access: Number of days to 3rd next available appointment
For critical care: Intensive Care Unit (ICU) percent unadjusted mortality
For medication systems: Adverse drug events per 1,000 doses
For population health: Number of children under 10 years old experiencing hunger

Process Measures

Are the parts/steps in the system performing as planned? Are we on track in our efforts to improve the system?

Examples:

For diabetes: Percentage of BIPoC patients whose hemoglobin A1c level was measured twice in the past year
For access: Average daily clinician hours available for appointments
For critical care: Percent of patients with intentional rounding completed on schedule
For population health: Number of children under 10 years old receiving school meals

Balancing Measures (looking at a system from different directions/dimensions)

Are changes designed to improve one part of the system causing new problems in other parts of the system?

Examples:

For reducing time patients spend on a ventilator after surgery: Make sure reintubation rates are not increasing
For reducing patients' length of stay in the hospital: Make sure readmission rates are not increasing

Tips for Effective Measures

Plot Data Over Time

Improvement requires change, and change is, by definition, a temporal phenomenon. Much information about a system and how to improve it can be obtained by plotting data over time, such as data on length of stay, volume, patient satisfaction — and then observing trends and other patterns. Tracking a few key measures over time is the single most powerful tool a team can use. [See additional information below.]

Seek Usefulness, Not Perfection

Remember, measurement is not the goal; improvement is the goal. In order to move forward to the next step, a team needs just enough data to know whether changes are leading to improvement. Also, try to leverage existing measures the team is already collecting data for and reporting on so it’s also easier and not additional work.

Use Sampling

Sampling is a simple, efficient way to help a team understand how a system is performing. In cardiac surgery, the patient volume is typically low enough to allow tracking of key measures for all patients. However, sampling can save time and resources while accurately tracking performance. For example, if accurate data is not easily available through automated administrative databases, instead of monitoring the time from catheterization to cardiac surgery continuously, measure a random sample of 10 to 20 cardiac surgery patients per month.

Example: Use Sampling

Below is an example of using sampling in measuring the time for transfer from the emergency department (ED) to an inpatient bed.

Rapid movement from the ED after a decision to admit the patient is critical flow for entry to the entire system for emergent patient care. It represents the ability of patients with various illnesses to get into the system through the most common admission route.

Sampling approach: The measurement will consist of 6 weekly data collections of 25 patients each. The patients can be sampled in several ways, such as in one of the three ways described as follows:

5 patients per day for 5 days of the week (patients must be consecutive and at least one day must be a weekend day)
25 consecutive patients regardless of any specific day, except that it must include some weekend admissions
If there are fewer than 25 admissions for a week, the total admissions for the week should be included in the sample

The time is measured from the decision to admit to the physical appearance of the patient into the inpatient room. The destination cannot be a "holding area" but must be a "real inpatient bed." The sample collection should be done in real time, so a data collection process needs to be worked out by members of the team to achieve this goal. The collections must be done weekly and summarized as the percentage of patients in the sample that achieved the goal for that week. Six weeks of data needs to be collected and six data points placed on a run chart.

Integrate Measurement into the Daily Routine

Useful data are often easy to obtain without relying on information systems. Don’t wait two months to receive data on patients’ average length of stay in the hospital from the information systems department. Develop a simple data collection form and make collecting the data part of someone’s job. Often, a few simple measures will yield all the information you need.

Use Qualitative and Quantitative Data

In addition to collecting quantitative data, be sure to collect qualitative data, which often are easier to access and highly informative. For example, ask the nursing staff how weaning from medications is going or how to improve the sedation protocol. Or, in order to focus your efforts on improving patient and family satisfaction, ask patients and their families about their experience of the cardiac surgery process.

Plotting Data Over Time

Plotting data over time using a run chart is a simple and effective way to determine whether the changes you are making are leading to improvement. Annotate the run chart to show the changes you made.

Run Chart Example: How to Improve Establishing Measures

How to Improve: Model for Improvement: Setting Aims

Model for Improvement: Setting Aims

Model for Improvement question: What are we trying to accomplish?

The three fundamental questions in the Model for improvement can be addressed in any order, although teams typically start with the first question — What are we trying to accomplish? — to guide them in setting aims.

Answering the model’s three questions is an iterative process — the team moves back and forth between them as changes in thinking in one question or learning from PDSA cycles results in changes in thinking in another.

Setting an initial aim is essential to starting an improvement initiative. An organization will not improve without a clear and firm intention to do so.

Elements of an effective aim:

What we are improving
By what date and how much we want to improve: Time-bound and measurable (how much? by when?)
For/with whom are we doing this work: Define the specific population whose lives will be affected by the improvement effort
Where the improvement is taking place

Agreeing on the aim is crucial, as is allocating the people and resources necessary to accomplish the aim. Engage the individuals who will most benefit from the improvement on the improvement team and in defining the aim.

To help develop improvement project aims, health care organizations often use the six overarching "Aims for Improvement" outlined in the 2001 report, Crossing the Quality Chasm: A New Health System for the 21st Century:

Safe: Avoid injuries to patients from the care that is intended to help them.
Effective: Match care to science; avoid overuse of ineffective care and underuse of effective care.
Patient-Centered: Honor the individual and respect choice.
Timely: Reduce waiting for both patients and those who give care.
Efficient: Reduce waste.
Equitable: Close racial and ethnic gaps in health status.

Tips for Setting Aims

Co-Design the Aim

Ensure that individuals who will most benefit from the improvement are members of the team that is defining the aim(s). “Customers” of the process, individuals with lived/living experience, and stakeholders in the community that receive care all have insights into the experience of care, what is likely to be successful, and know how to engage people in change that the health system cannot access alone.

Choose Aims That Explicitly Close Equity Gaps

Look at why one group of individuals may be experiencing different outcomes than other groups. Explicitly call out systemic barriers like racism, ageism, primary language, and other factors that have led to the inequitable outcomes that you seek to address with the improvement project. Remember that improving for all may lead to equality but not to equity, while improving for those with the worst outcomes will benefit everyone.

State the Aim Clearly

Teams make better progress when their aims are specific, clear, and simple. The essential elements of an aim statement include:

What we are improving
By what date we want to see improvement, ideally expressed as month and year (e.g.,“by October 2028”) rather than as a general timeframe (e.g., “within 10 months”)
How much we want to improve (what success would look like), stated in numerical goals
For/with whom are we doing this work
Where we are doing the work
Sometimes explaining why is also helpful

Include Numerical Goals When Possible

Teams are more successful when they have unambiguous, focused aims, ideally with numeric goals that clearly signal what success would look like. This helps to create a burning platform for change from the current performance to improved performance.

For example, the aim "Reduce preterm births among Black birthing people" is not as effective as "Reduce preterm births among Black birthing people from 15% to 9% by August 2025." The numerical goals also help team members begin to think about what their measures of improvement will be, what changes they might test, and what level of support they will need.

However, numerical goals must be established rationally — there should be a clear line of site between the theory of what changes are likely to result in improvement, the resources allocated, the measurement system, and the numerical goals stated in the aim.

Set Stretch Goals

A "stretch" goal is one to reach for within a certain time. Setting stretch goals in an aim statement — such as "Reduce preterm births among Black birthing people from 15% to 9% by August 2025" — communicate immediately and clearly that maintaining the status quo is not an option.

Effective leaders make it clear that the goal cannot be met by simply tweaking the existing system. Once this is clear, people begin to look for ways to fundamentally redesign the current system and overcome current barriers to achieve the stretch goals. Be sure to align stretch goals with the system identified, the scope of the change ideas, and the resources available to the team.

Be Careful of Aim Drift

Once the aim has been set, the team needs to be careful not to back away from it deliberately or "drift" away from it unconsciously. The initial stretch goal "Reduce preterm births among Black birthing people from 15% to 9% by August 2025" can drift to become "Reduce preterm births among Black birthing people to 12%” — or the focus can shift to something different and less explicit, such as “Improve the experience of Black birthing people.” Revising the initial aim isn’t necessarily a bad thing, as long as the change is acknowledged explicitly by the team and relevant stakeholders and the revised aim includes best-practice elements.

To avoid drifting away from the aim, repeat the aim continually. Start each team meeting with an explicit statement of aim — "Remember, we’re focusing on reducing preterm births among Black birthing people from 15% to 9% by August 2025" — and then review progress quantitatively over time.

Be Prepared to Refocus the Aim

Every team needs to recognize when to refocus its aim. If the team’s overall aim is at a system level (e.g., "Increase access to cancer care for Latinx patients by reducing waiting time for appointments from 4 weeks to 2 weeks by January 2026"), team members may find that focusing for a time on a smaller part of the system (e.g., "Increase access to breast cancer screening for Latinx patients by 30% by May 2025") will help them achieve the desired system-level goal.

Note: Don’t confuse aim drift or backing away from a stretch goal (which usually isn’t a good tactic) with consciously deciding to work on a smaller part of the system (which often is a good tactic).

Examples of Effective Aim Statements

Improve the patient experience during delivery for Black birthing persons as measured by an increase in patients reporting they were listened to from 25% to 75% by June 2024
Increase colon cancer screening rates among patients ages 50+ who identify as Chinese from 50% to 70% by May 2025
Reduce harm from use of anticoagulants from the current rate of 1.8 per thousand admissions to less than 1.4 by January 2025 and less than 1 per thousand admissions by January 2026
Reduce waiting time to see a physician for all patients ages 65+ who identify as Black, Indigenous, or people of color to less than 15 minutes by July 2024
Increase the percentage of patients whose primary language is not English that are transferred from the emergency department to an inpatient bed within 1 hour of the decision to admit from 25% to 50% by March 2024
Increase the percentage of patients ages 50+ who self-identify as Black, Indigenous, or people of color that are transferred from the inpatient facility to a long-term care facility within 24 hours, after the patient is deemed ready to transfer, from 58% to 75% by April 2026
Reduce average ventilator days by 2 to 4 days per discharge by November 2024
Reduce adverse drug events (ADEs) per ICU day by 75% (or absolute number of less than 0.10 ADEs per ICU day) by December 2026

How to Improve: Model for Improvement: Forming the Team

Model for Improvement: Forming the Team

Improvement work thrives with a team. People involved in parts of the process or system that you are trying to improve will bring diverse perspectives and expertise to fuel more effective ideas for change that are more likely to be sustained while building will to make improvements.

Improvement teams vary in size and composition. Each organization forms teams to suit its own needs and the needs of the specific improvement effort.

First, review the purpose of the improvement initiative (you may or may not have a specific aim, yet, when you pull the team together).

Second, consider the system that relates to that purpose: What are the boundaries of the system that will be affected by the improvement efforts?

Third, ensure that the team includes members who are familiar with all the different parts of the process — leaders, managers, and administrators as well as those who work in the process, including physicians, pharmacists, nurses, point-of-care staff, and other subject matter experts.

Consider which “customers” or individuals with lived and living experience are most likely to benefit from the improvement and engage them as members of the team.

When forming an improvement team, it is vital to apply an equity lens. Some questions to ask with an equity lens include the following:

Who is invited to contribute input to the improvement effort to identify the desired outcome, measures, and change ideas?
Whose expertise is valued? The people who are most affected by the improvement opportunity need to be represented in the team that is designing the work and ideally throughout the lifespan of the improvement effort.
Are people who are engaged in different parts of the process represented? Who is missing?

Finally, each team needs an executive sponsor who takes responsibility for aligning the project to the organizational strategy, relieving bottlenecks, allocating resources, and supporting the improvement opportunity.

Team Roles

Effective teams include members representing different knowledge and experience of the system: system leadership, technical/subject matter expertise, day-to-day leader or process owner, and user/customer experience. There may be one or more individuals on the team with each kind of expertise, or one individual may have expertise in more than one area, but all areas should be represented on the team to successfully drive improvement.

Experience in the Process/System

Include team members who have knowledge of the process or system that is being improved and who represent a range of perspectives (e.g., patients, providers). Think about the end user and co-design with those individuals instead of for them. The team also needs someone with enough authority in the organization to test and implement a change and who understands both the clinical implications of proposed changes and the consequences such a change might have in other parts of the system.

Day‐to‐Day Leader or Process Owner

The process owner is usually the day-to-day improvement team leader. A day-to-day leader is the driver of the project, assuring that tests are implemented and overseeing data collection. It is important that this person understands not only the details of the system, but also the various effects of making change(s) in the system. After the improvement project ends, the process owner continues to be involved in implementing and maintaining the improvement.

Experience with Improvement Methods

At least one team member should have experience with improvement methods, such as through participating in past quality improvement (QI) initiatives or through formal QI training. A team member with improvement methods expertise can provide additional technical support by helping the team determine what to measure, assisting in design of simple, effective measurement tools, and providing guidance on collection, interpretation, and display of data.

Technical/Clinical/Subject Matter Expertise

Subject matter experts have expertise in areas relevant to the improvement project. They may not be able to attend all team meetings (in health care, this is especially true for busy clinicians), but should be consulted and engaged to the extent they are willing and able.

Project Sponsor (System Leader)

In addition to the working members listed above, a successful improvement team needs a sponsor, someone with executive authority who can provide liaison with other areas of the organization, serve as a link to senior management and the strategic aims of the organization, provide resources and overcome barriers on behalf of the team, and provide accountability for the team members. The sponsor is not a day-to-day participant in team meetings and testing, but needs to review the team's progress on a regular basis.

Example Team: Improving Care in Office Practices

Aim: We will improve care for all patients with chronic illness by making improvements in our clinic such that measures of patient experience (specifically percent reporting they are listened to and treated with respect) for patients who self-define as Black, Indigenous, or people of color increases from 25% to 75% within 18 months.

Team:

Technical Expert: ____, MD, Physician at downtown primary care clinic
Day-to-Day Leader: ____, RN, Manager of downtown primary care clinic
Team Members:
- Patient educator
- Medical assistant
- Clerk/scheduler
- Quality expert
- Two to five patients who self-define as Black, Indigenous, or people of color and their family members
Sponsor: ______, MD, Medical Director for primary care practices

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Content on IHI.org may include links to external websites, which are evaluated for inclusion on IHI.org using the following guidelines: The website provides clinical- and/or improvement-related information or content (e.g., resources and tools) that is entirely, or at least in part, freely available to users. IHI.org does not include links to websites or organizations that are commercial or product-based; pharmaceutical or medical products organizations or services; consulting services; or other types of organizations or websites, as determined by IHI's sole discretion. Links to external websites do not constitute an endorsement or sponsorship by us of such websites or the information, content, products, services, code, or other materials presented on or through such websites and/or services. The inclusion of any link to such sites on IHI.org does not imply our endorsement or recommendation of that site and we do not represent or warrant that the contents of any third party website and/or service is accurate, compliant with state or federal law, or compliant with copyright or other intellectual property laws. Although we are selective about the organizations we link to, WE DO NOT ASSUME ANY RESPONSIBILITY FOR ANY WEBSITES THAT ARE LINKED TO OUR SITE OR THAT YOU BROWSE AFTER FOLLOWING A LINK FROM IHI.org.

While we welcome your feedback on IHI.org, we reserve the right to make the final decisions about the content that is posted on the site and to remove such content in our unfettered discretion for any reason or no reason. If you believe that your work has been used on IHI.org in a way that constitutes copyright infringement, please contact our Copyright Agent by following the procedures described below. To register other types of complaints, you can use the “Report This” or “Contact Us” features or any other feedback link on our site to send us comments and criticisms, but IF YOU ARE DISSATISFIED WITH OUR RESPONSE OR WITH THE CONTENTS OF IHI.org, YOUR ONLY REMEDY IS TO STOP USING THE WEBSITE.

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Policy on Using and Sharing IHI.org Content

IHI’s goal is to make the content posted on IHI.org free and open to all, as often as possible, and for our users around the world to access our resources in order to promote the improvement of health care quickly and broadly.

In keeping with our mission, we invite registered users of IHI.org to download, learn from, and share the content on IHI.org, as permitted under these Terms of Use.

Unless otherwise prohibited, you may look at IHI.org content online; download individual documents; print or email pages of content; download tools to your personal or handheld computer for later reading or use; and print a reasonable number of copies of pages for yourself or your colleagues, provided that:

You may not modify the content or any copyright notices or source indications.
You may NOT post the content directly into another website. Instead, because we update the content on IHI.org frequently and want to make sure people are using the most up-to-date information, you should link to the content on IHI.org.
You must always credit IHI (and any other sources specified for a specific piece of content) as the source of the material, as follows: “[Name of content item]. Boston, Massachusetts: Institute for Healthcare Improvement; [Year]. (Available on www.IHI.org)”
You may not repackage our content for commercial purposes or otherwise offer it for sale.

Note that some content posted on IHI.org originates from outside sources that have granted IHI permission to post this content to our website only. Any further permissions for this content must be sought directly from the content owners.

You may be required to register and/or pay to access or use certain content on IHI.org. You will be informed of any additional or modified terms governing your use of such content at the time of registration or purchase, and your access to and use of such content will be subject to those additional or modified terms. If you register or pay for an individual account, you may not share your user name or password with anyone else. If you register or pay for an organizational account, you may not share the organization’s user name or password with anyone outside of the organization.

We reserve all other rights not expressly granted under these Terms of Use.

To request permission to use IHI.org, including its content, in a manner other than as permitted under these Terms of Use, please send an email to info@ihi.org. Although we will try to respond in a timely manner, we are not always able to do so, and you do not have permission to vary your use of IHI.org, including its content, unless and until we give you explicit permission to do so.

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Content That You Submit to IHI.org

Unless we tell you that something will be treated confidentially, when you submit content to IHI.org, including but not limited to documents, web page text, tools, reports, studies, comments, ratings, and postings to discussion boards, blogs and wikis, you are giving us a royalty-free, world-wide, irrevocable, perpetual, nonexclusive license to use, reproduce, create derivative works from, modify, publish, edit, translate, distribute, perform, and display such content in any medium, form, format, or forum whether presently existing or developed later, and to sublicense such rights to others. For example, you give us the right to display an item of content, such as a document or comment that you provide to us or post in one of our discussion groups, blogs, wikis, or the Resources section, for as long as we want. We will consider requests to remove content that you make publicly available on IHI.org on an individual basis, but IHI will make the final decision whether or not to remove such content.

For our policies regarding information you place on IHI.org that will be treated confidentially, please see our Privacy Policy.

You may not post any content, links or code that would be, in the sole and absolute determination of IHI, misleading, false, defamatory, vulgar, inappropriate, or harmful. We disclaim any liability for moderating such content, but reserve the right to remove any such content at any time without your consent.

In consideration for your use of IHI.org, you agree to provide true, accurate, and complete information. If you provide any information that is untrue, inaccurate or incomplete, we may decline to permit your continued use of IHI.org and may remove the content that you provided or posted.

If you submit or post any content or intellectual property to IHI.org or IHI, you represent and warrant that your submission or posting does not infringe the rights of the owner of such content or intellectual property or any other third party. You further represent and warrant that the owner of such content or intellectual property has expressly granted, or allowed you to grant, to IHI a royalty-free, world-wide, irrevocable, perpetual, nonexclusive license to use, reproduce, create derivative works from, modify, publish, edit, translate, distribute, perform, and display such content or intellectual property in any medium, form, format, or forum whether presently existing or developed later, and to sublicense such rights to others.

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Procedure for Making and Responding to Claims of Copyright Infringement

IHI respects the rights of all copyright holders and has adopted and implemented a policy that provides for the termination in appropriate circumstances of users who post materials on IHI.org that infringe the rights of copyright holders. If you believe that your work has been copied in a way that constitutes copyright infringement, please provide our Copyright Agent the following information required by the Online Copyright Infringement Liability Limitation Act of the Digital Millennium Copyright Act, 17 U.S.C. § 512:

A physical or electronic signature of a person authorized to act on behalf of the owner of an exclusive right that you claim is infringed;
Identification of the copyright work that you claim has been infringed, or, if multiple copyrighted works at a single online site are covered by a single notification, a representative list of such works at that site;
Identification of the material that you claim to be infringing or to be the subject of infringing activity and that is to be removed or access to which is to be disabled, and information reasonably sufficient to permit us to locate the material;
Information reasonably sufficient to permit us to contact you, including your address, telephone number, and email address;
A statement that you have a good-faith belief that use of the material in the manner complained of is not authorized by the copyright owner, its agent, or the law; and
A statement that the information in the notification is accurate, and under penalty of perjury, that you are authorized to act on behalf of the owner of an exclusive right that is allegedly infringed.

To contact our Copyright Agent for notice of claims of copyright infringement on or regarding IHI.org: Customer Service (info@ihi.org) at Institute for Healthcare Improvement, 53 State Street, 18th Floor, Boston, MA 02109, USA.

If you believe that your user submission that was removed (or to which access was disabled) is not infringing, or that you have the authorization from the copyright owner, the copyright owner’s agent, or pursuant to applicable law, to post and use the content in your user submission, you may send a counter-notice containing the following information to our Copyright Agent:

Your electronic or physical signature;
A description of the content that has been removed or to which access has been disabled;
A description of where the allegedly infringing material is located on the website;
Your address, telephone number, and email address, and a statement that you consent to the jurisdiction of Federal District Court for the judicial district in which the address is located, or if your address is outside of the United States, for any judicial district in which IHI.org may be found, and that you will accept service of process from the person who provided notification under subsection 17 U.S.C. § 512(c)(1)(C) or an agent of such person;
A statement by you that you have a good faith belief that the content was removed or disabled as a result of mistake or a misidentification of the content; and
A statement by you made, under the penalty of perjury, that the above information in your counter-notice is accurate and that you have authorization from the copyright owner, the copyright owner’s agent, or pursuant to applicable law to post and use the content in your user submission.

Please send such notice to our Copyright Agent at: Customer Service (info@ihi.org) at Institute for Healthcare Improvement, 53 State Street, 18th Floor, Boston, MA 02109, USA.

If a counter-notice is received by IHI, IHI may send a copy of the counter-notice to the original complaining party informing that person that IHI may restore the removed content or cease disabling it in 10 business days. Unless the copyright owner files an action seeking a court order against the member or user, the removed content may be restored, or access to it restored, in 10 to 14 business days or more after receipt of the counter-notice, at the sole discretion of IHI.

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Questions or Concerns

For questions or concerns about these Terms of Use, please email info@ihi.org.

Revision date: September 2023

Privacy Policy

As health care organizations in the US and around the world strive to improve the quality of their care, a credible, easily accessible resource is necessary to provide them with trusted content and a forum to collaborate with their peers. Patients are demanding better care, and clinicians and managers, confronting a system that is under great stress, need to know how to provide it. Among the most important forms of support are access to improvement knowledge, routes to new practices, and ways to connect with experts and colleagues who have led change. IHI.org will help make these interactions possible.

We at the Institute for Healthcare Improvement (“IHI”), producers of IHI.org, believe that you have the right to know how your personal information may be used or disclosed. You take your privacy seriously, and we respect your concerns. Accordingly, we have created this Privacy Policy in order to describe how we collect information, what we do with it, and what controls you have. Please read it carefully, and if you have any questions or concerns, please send us a comment at compliance@ihi.org. Unless otherwise indicated, this Privacy Policy applies to your use of the IHI.org website, as well as the related domains and subdomains, including but not limited to my.ihi.org, education.ihi.org and community.ihi.org (collectively, "IHI.org").

If you receive a communication from IHI indicating that your Information has been collected by IHI or that you have been registered for IHI.org, your use of IHI.org means that you agree to the terms of this Privacy Policy. “Information” means information about you that is personally identifiable like your name, address, email address, phone number, areas of interest or data related to your improvement work, your medical condition, medical diagnosis or medical treatment, photographic or video images of you, credit card information, and other information about you that is not otherwise publicly available. This policy does not apply to the practices of companies that IHI does not own or control, or to people that IHI does not employ or manage.

Policy

Gathering of Information

Access to Information

Registration

We collect Information when you register for IHI.org. This Information may be updated by you at any time. We will not disclose the Information you submit when you register except as provided in this Privacy Policy or the Terms of Use.

By registering, you agree that we may make certain Information (“Public Profile Information”) visible when you contribute content to IHI.org, and when you use or participate in certain site features and tools, including but not limited to user communities, blogs, ratings and comments, groups, and CPPS Certificants page as more fully described below. Public Profile Information includes: First Name, Last Name, Photo (if you provide one), Credentials (e.g., MD, MPH, MBA), Job Title, Organization Type, Organization Name, City, Country, State/Province/Region, and Areas of Expertise. If you enroll in an IHI conference such as the IHI Forum or International Summit, we may share your Public Profile Information and your Address and Zip/Postal Code with organizations that exhibit their products or services (Exhibitors) at these events.

If you are a student, you may check a box and give details about your graduation year, which we will use to determine whether you receive free access to the IHI Open School courses and other potential benefits relevant to student users, which may include eligibility for discounts and scholarships to attend IHI programs.

We may use your Information to send you a newsletter or email messages with updates and notices concerning new content posted to the site and/or products or services that might be of interest to you. Completing the registration information allows us to better understand you, your position, your organization type and interests. If at any time you would like to stop getting general email information you can do so by updating your Profile. However, IHI, its contracted faculty, or its employees may still contact you via email with an individual message or about a IHI Offering in which you are participating or enrolled even if you have opted out of receiving email updates from IHI.

Contributing Content to IHI.org

IHI.org encourages your participation through submitting content and participating in the interactive functionality on the website including blogs, wikis, discussion boards, search features, interactive tools, rating or commenting on content, and sharing audio and video content, improvement stories, resources, and tools. If you contribute any content to IHI or IHI.org, including but not limited to trainings, presentations, documents, stories about your medical condition, diagnosis, and treatment, improvement stories, tools, testimonials, and other resources, or if you comment on or rate content on the site, or otherwise post content to IHI.org, you agree to allow us to make your Public Profile Information publicly available on IHI.org in connection with your activity and to share your name, experience, and credentials in connection with any such contribution.

Please remember that the text you submit to IHI.org in a discussion board or as a comment on content is immediately viewable on the site by the general public.

You should exercise caution when deciding to disclose any sensitive Information on IHI.org. We recommend that you never give out your address, phone number, date of birth, or social security number. You may not give out Information about an organization, a patient, or another person or submit other content if you do not have the express authority or permission to share that Information publicly. If you are a clinician or health care professional and submit information regarding treatment of patients, you must only share information that is fully de-identified in accordance with the Health Insurance Portability and Accountability Act of 1996 and its implementing regulations ("HIPAA") and all other applicable federal and state laws and regulations. We may edit or return Information provided to IHI.org from a clinician or health care provider that contains patient identifying information.

IHI.org also has certain rights to republish content that originally was published elsewhere. IHI.org may disclose the name, experience, and credentials of any individuals associated with such republished content.

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Site Usage Statistics, Cookies, Advertisements and Web Beacons

When visiting IHI.org, your browser sends information to the site's hosting server identifying the Internet protocol (“IP”) address of your computer (or the proxy server you use to access the World Wide Web), your computer or mobile device operating system and the browser you are using, email patterns, your Internet Service Provider or mobile carrier, the page you last visited, the page you are currently visiting, and the next page you navigate to. We log this Information. We may also track and catalog the search terms that you enter in search forms. We make use of a standard feature of browser software called a "cookie" (including flash cookies) that helps us recognize you when you visit. We store your email address in a cookie file and place the file on the hard drive of your computer. Most browsers accept cookies. However, if you wish, you can usually set your browser to refuse cookies. If you set your browser to refuse cookies, you will need to login to the site each time you visit, and certain features may not work correctly.

To increase the effectiveness of IHI.org and tailor your experience of IHI.org, we may include a file, called a web beacon, within IHI.org. The web beacon allows IHI.org to provide anonymized, aggregated auditing, research and reporting of use of IHI.org.

We partner with Microsoft Clarity and Microsoft Advertising to capture how you use and interact with our website through behavioral metrics, heatmaps, and session replay to improve our website and services. Website usage data is captured using first and third-party cookies and other tracking technologies to understand user interactions and enhance site functionality. Additionally, we use this information for site optimization, fraud/security purposes, and to support our mission of healthcare improvement. For more information about how Microsoft collects and uses your data, visit the Microsoft Privacy Statement.

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Contacting Us

If you have any questions or comments about this Privacy Policy, please email us at compliance@ihi.org or send a letter to:

Institute for Healthcare Improvement
53 State Street, 18th Floor
Boston, MA 02109

Revision date: September 2023

Improvement Topics

Explore Improvement Topics to discover learning opportunities to build your knowledge and skills, free resources and tools to support your improvement work, and IHI leadership and expertise in these topics.

Artificial Intelligence in Health Care

While artificial intelligence (AI) applications in health care hold much promise, they also present serious potential risks that must be considered and addressed prior to more widespread implementation.

Climate and Health

The imperative for health care organizations to tackle climate change is clear: The health care sector both contributes to climate change — accounting for 4.4 percent of global greenhouse gas emissions — and also must contend with its effects on human health.

Health Equity

Improving health and health care worldwide requires a focus on equity — equity of access, treatments, and outcomes. We will achieve health equity when each individual has a fair opportunity to achieve their full health potential.

Improvement Capability

The science of improvement provides concepts, methods, and tools to envision, achieve, and sustain positive change. Equipping ourselves with these essential quality improvement skills helps us to identify improvement opportunities, test and implement effective changes, and scale-up and sustain better ways of working.

Maternal and Infant Health

Improving maternal and infant health by eliminating inequities and reducing mortality is possible by implementing evidence-based and promising clinical and social practices for all population.

Patient Safety

IHI aims to advance a total systems approach to safety, grounded in evidence and the science and methods of improvement, to ensure that every person receives safe, reliable, effective, and equitable care.

Population Health

Advancing an integrated approach to the health of populations is critical to achieving our mission of improving health and health care worldwide.

Quintuple Aim

Rooted in the original IHI Triple Aim, IHI’s updated and expanded framework explicitly incorporates the crucial improvement areas of workforce well-being and health equity.

Triple Aim

The IHI Triple Aim framework serves as the foundation for optimizing health for individuals and populations by simultaneously improving the patient experience of care (including quality and satisfaction), improving the health of the population, and reducing per capita cost of care for the benefit of communities.

Whole System Quality

Whole System Quality is a more holistic approach to quality management that integrates quality planning, quality control, and quality improvement activities across the organization, supported by leadership practices that foster a culture of learning.

Workforce Safety

Health care workforce safety — physical, psychological, and emotional — is inextricably linked to patient safety, outcomes, and experience of care.

Workforce Well-Being and Joy in Work

IHI partners with experts and collaborates with health care organizations around the world to apply and adapt the most impactful strategies that enable the health care workforce to not just persevere, but to thrive.

Fellowship Program

IHI Fellowship Program

The IHI Fellowship Program is designed for worldwide health care professionals in quality and safety roles who are looking to take their strategic, operational, and thought leadership skills to the next level.

Man and woman in business attire shaking a hand and smiling

Take Your Quality and Safety Leadership Skills to the Next Level

Ideal candidates for the IHI Fellowship Program have strong foundational knowledge and experience in quality, safety, and quality improvement capability. Candidates seek to hone their knowledge and skills to effectively institute impactful change and achieve organizational goals in today's complex health care environment.

Application Information

IHI Fellowship: A 14-Month Program

The Institute for Healthcare Improvement (IHI) Fellowship Program, offered to select health care professionals worldwide, is designed for those in quality and safety roles who are looking to take their strategic, operational, and thought leadership skills to the next level.

The 14-month program will support a closely-knit cohort of participants from around the globe and will include smaller affinity groups. It offers a unique virtual learning opportunity, and includes experiential learning through the leadership of strategic, impactful work within participants' home organizations. This work within home organizations will help to firmly cement the strategic improvement knowledge and new ways of thinking gained throughout the program.

Ideal candidates will have strong foundational knowledge and experience in quality, safety, and quality improvement capability. They will seek to hone their knowledge and skills to effectively institute impactful change and achieve organizational goals in today's complex health care environment.

View a recording from our most recent informational call

The deadline for the 2025–2026 cohort has been extended: Program applications and scholarship applications are now accepted until August 15, 2025.

IHI Fellow Gillian Smith discusses how the IHI Fellowship Program has been valuable to her.

Class picture of fellows from the IHI Fellowship Program — Class Picture of IHI Fellows

Fellowship participants:

Bring new ways of thinking and innovative ideas for improving the quality of patient care, reducing harm, and patient-centered outcomes back to their organization
Make a direct impact on their system while pursuing a strategic project with metrics tied to strategic organizational goals
Deepen their knowledge in quality and safety science
Learn how to lead system changes in quality, safety, and culture, including how to engage, influence, and impact culture change

Support and networking opportunities include:

A dedicated mentor providing continuous feedback and support
Access to and guidance from renowned IHI leaders and faculty, including health care quality and safety experts, and innovative leaders who have improved systems in other industries
A lasting and meaningful global network of peers and faculty, allowing for an exchange of advice, ideas, and support in the long term (this includes an exclusive alumni network)
Senior sponsorship and active engagement from your home organization’s executive team, including quarterly sponsor progress check-ins

Learn more about applying for the IHI Fellowship Program

Additional Information

Background on the IHI Fellowship Program

2024–2025 Fellows

IHI Fellowship Alumni

Apply for the IHI Fellowship Program

The IHI Fellowship Program is designed for those in quality and safety roles who are looking to take their strategic, operational, and thought leadership skills to the next level.

Application Information

Need Help or Have Questions?

Email the IHI Fellowship Team at fellowship@ihi.org

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Model for Improvement: Selecting Changes

Model for Improvement question: What change can we make that will result in improvement?

Examples of Categories of Change Concepts

Eliminate Waste

Improve Workflow

Optimize Inventory

Change the Work Environment

Producer/Customer Interface

Manage Time

Focus on Variation

Error Proofing

Focus on the Product or Service

Related Content

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Model for Improvement: Establishing Measures

Model for Improvement question: How will we know that a change is an improvement?

Three Types of Measures

Outcome Measures

Process Measures

Balancing Measures (looking at a system from different directions/dimensions)

Tips for Effective Measures

Plot Data Over Time

Seek Usefulness, Not Perfection

Use Sampling

Example: Use Sampling

Integrate Measurement into the Daily Routine

Use Qualitative and Quantitative Data

Plotting Data Over Time

Related Content

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Model for Improvement: Setting Aims

Model for Improvement question: What are we trying to accomplish?

Tips for Setting Aims

Co-Design the Aim

Choose Aims That Explicitly Close Equity Gaps

State the Aim Clearly

Include Numerical Goals When Possible

Set Stretch Goals

Be Careful of Aim Drift

Be Prepared to Refocus the Aim

Examples of Effective Aim Statements

Related Content

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Model for Improvement: Forming the Team

Team Roles

Experience in the Process/System

Day‐to‐Day Leader or Process Owner

Experience with Improvement Methods

Technical/Clinical/Subject Matter Expertise

Project Sponsor (System Leader)

Example Team: Improving Care in Office Practices

Related Content

Help / Contact Us

My IHI Account/Profile

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