Massachusetts Medical Society: How to Run a Quality or Process Improvement Project

How to Run a Quality or Process Improvement Project

Vital Signs September 2013

Your Practice

Financial incentives are being increasingly tied to improvements in quality and efficiency scores as the environment continues to shift toward alternative payment models. As a result, many practices are seeking new opportunities to improve quality and efficiency in the practice setting. Practices that want to improve in these areas may want to consider running a quality or process improvement project to help boost their scores. Here are some steps that may help you get started:

Pick an Area of Focus

The first step in running a quality and/or process improvement project is to pick an area of focus. Appointment wait times, post-appointment follow-up contact, and ease of accessing information are some potential areas for improvement that are correlated with patient experience scores, for example. Practices that want to engage in an improvement project should first determine which area they want to focus on.

Set SMART Goals

Once a topic has been determined, set a clearly defined SMART goal. A SMART goal is specific, measurable, attainable, relevant, and time-based. An example of a SMART goal for reducing wait times is: “Reduce mean wait time for primary care patients by 5 minutes from when they check in to when they are called into the exam room. This will be achieved within six months of project implementation.” You may need to conduct an initial assessment of your practice in order to determine a goal that is attainable. In this example, you should know the current average wait time and what factors influence wait time in your practice.

Design a Process

Consider the steps necessary to achieve your SMART goal:

  • Conduct a baseline data analysis.Measure the process, examine the current data, and determine what the targeted improvement should be.
  • Analyze the process. Determine how the current process is working and whether there are unnecessary steps that can be streamlined.
  • Determine the opportunity for improvement.Consider the opportunities for process redesign or extra step elimination. Consider whether there are resources that are necessary to make things more efficient and whether or not workarounds have been created over time.
  • Create an action plan. Outline the steps that you will take to improve the process and define who is responsible for undertaking the necessary actions.
  • Implement.Move forward with redesigning the process within a targeted timeframe according to your action plan.
  • Monitor the process and review the data. Make sure that the implemented actions had the desired effect of improving the process.
  • Measure your progress and adjust accordingly.Ask questions such as: What has worked? What has not worked? What should be done differently moving forward based on findings? Include your staff in every step of the decision-making process.
  • Continue to monitor the process post-implementation.Don’t miss additional opportunities to streamline even after changes have occurred.

A successful quality or process improvement project will likely have many positive benefits on your practice, from financial rewards to improved satisfaction of patients and staff. If you would like more details about how to implement a quality and/or process improvement project, visit or contact PPRC Consulting Services at (781) 434-7702 or

– Georgia Feuer

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