Summer 2016 (Volume 26, Number 2)

Top Ten Things Rheumatologists Should (And Might Not) Know
About Quality Improvement

By Shirley Chow, MD, FRCPC, MSc (QIPS); and
Kaveh G. Shojania, MD

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This year’s annual meeting of the CRA had “optimizing quality” as its theme. With many recent innovations and changes in best practices, as well as increasing calls for accountability, rheumatologists must know how to address quality problems in their practices. The following list will help rheumatologists understand quality improvement and how they can proceed.

1. Work smarter, not harder: Change the system.
Most problems call for fixing the system in which we work, not asking people to work harder or “be more careful.” We need to redesign processes such that the right way to do something becomes the easy way to do it.1

2. Do not rush to a solution: Understand the problem first.
Too often, people rush to creating a checklist, guideline, new order set, or educational material. Each of these strategies presupposes a certain type of problem or lever for change, one which may not apply to your problem.2 Using a reminder implies that everyone agrees that such-and-such is the right thing to do, but they forget to do it. Sometimes that is true. Other times, though, it may be that you are “reminding” people of something they either disagree with or do not like to do.

3. Achieving an improvement requires a clear and concrete goal.
“I want to improve the care of patients with rheumatoid arthritis (RA)” is so vague as to be pointless. Something specific, such as aiming for low Clinical Disease Activity Index (CDAI) scores by one year, is better. Ideally, one would articulate a measurable improvement such as an increase of X% in RA patients achieving low CDAI by one year.

4. Take aim at appropriate targets.
Pick your battles. Consider not just the importance of the problem but also the likelihood of success. Key factors contributing to a problem may fall outside your control or the solutions tried by others either have not worked to date or have produced unintended consequences. Before wasting hours of your time in a valiant but doomed effort to, for example, ensure your patients never develop infections, consider a more modest but feasible target, such as ensuring every inflammatory patient has their immunizations up to date.

5. Rapid cycle change should be rapid.
You do not need to review 100 charts to demonstrate a problem or see how your intervention is working. You need just enough information on a process to evaluate if there is a problem, implement a change, measure its effect, and study how to refine or discard your process (a Plan-Do-Study-Act cycle).3-5 The Super Bowl is not won by planning the perfect first game, but by constantly making small improvements. This is the basis of continuous quality improvement.

6. Reflection is important.
Take time to reflect on what was learned in each cycle and how to build on it.

7. Anticipate what can go wrong and take steps to mitigate these issues.

8. All improvement is change but not all change is improvement.
Physicians have often been labeled as resistant to change; however, no one categorically resists all forms of change. Winning a lottery involves change, but who would say, “Go ahead and keep the money – I hate change.” People resist change when the change involves loss – loss of control, change to comfortable routines, increases in work, decreases in reward, and so on. In light of this reality, develop changes that take into account the stakes for people affected by the change and do not chalk up all complaints to knee-jerk resistance to change.

9. Do not forget your stakeholders.
Stakeholders are anyone affected by a problem, and anyone who will be involved with and/or affected by the change. This could include other physicians, inter-professional teams, patients, administrative staff, and other departments. Creating a culture of change is critical, so engaging stakeholders early in the development process will help to really understand the problem, inform the change, and build commitment for the change. Having a champion in a leadership position acknowledge, for example, that there is waste and over-ordering of serological tests, will help remove barriers and encourage others to help to tackle this problem.

10. Quality improvement differs from traditional research.
Academics may want to publish the results of a successful quality improvement project. This is a complex topic. However, it is no longer true that, just because you might publish something, you need to obtain research ethics approval. Some institutional ethics committees are more familiar with this change than others; a good reference tool is the Alberta Research Ethics Community Consensus Initiative, providing useful guidance and a screening tool to indicate the need for ethics approval on a given project.6


1. Berwick DM. A primer on leading the improvement of systems. BMJ 1996; 312(7031):619-22.

2. Davidoff F, Dixon-Woods M, Leviton L, et al. Demystifying theory and its use in improvement. BMJ Qual Saf 2015; 24(3):228-38.

3. Etchells E, Ho M, Shojania KG. Value of small sample sizes in rapid-cycle quality improvement projects. BMJ Qual Saf 2016; 25(3):202-6.

4. Reed JE, Card AJ. The problem with Plan-Do-Study-Act cycles. BMJ Qual Saf 2016; 25(3):147-52.

5. Ogrinc G, Shojania KG. Building knowledge, asking questions. BMJ Qual Saf 2014; 23(4):265-7.

6. ARECCI Ethics Screening Tool. Available at:

Shirley Chow, MD, FRCPC, MSc (QIPS)
Assistant Professor,
Division of Rheumatology,
University of Toronto,
Toronto, Ontario

Kaveh G. Shojania, MD
Vice Chair,
Quality & Innovation,
Department of Medicine
University of Toronto
Centre for Quality Improvement and Patient Safety,
Sunnybrook Health Sciences Centre
BMJ Quality & Safety
Toronto, Ontario