Background: Efforts to implement continuous quality improvement (CQI) principles in ambulatory or primary care settings still lag behind efforts in the hospital setting. Many physicians view the concept of CQI with unconcealed skepticism; the process of ambulatory care is very different from that of hospital-based care; and the data necessary to guide CQI efforts are often either missing or inaccurate in the outpatient setting. Since fall 1995, the Department of Family Medicine (DFM) at the University of Michigan (Ann Arbor), including approximately 35 faculty members at seven family practice sites, has been engaged in CQI projects.
Planning and implementation: The CQI committee had a six-month deadline to lay out a plan for educating all faculty and staff in the importance of the CQI approach to problems; design methods for all faculty and staff to buy in to the concepts; and develop a plan to address basic clinical CQI activities, administrative systems change and work environment improvement, and larger ad hoc projects in clinical care, educational programs, and research programs.
Implementation: CQI activities were incorporated into the routine monthly business agendas at each clinical site, each of which had a functioning local committee and had begun development of at least one CQI project.
Projecting into the future and conclusions: Cost cutting has further moved CQI from the sideline to center stage in the DFM's activities. An effective CQI program can be a major asset in the current competitive health care market, but designing and implementing an outpatient CQI program is a difficult and complex process. Three major problems--the ongoing resistance to change, the slow pace of adding CQI projects to already overburdened work schedules, and the need to conduct the program with ever-decreasing resources available-persist.