Hospitals and health care systems increasingly are engaging in diverse improvement efforts: in individual units, across hospitals and beyond the walls of their facilities. Value-based purchasing and public reporting make quality and patient safety improvements more critical than ever before. New incentives to address population health and mandates for more meaningful community benefit programs have created new imperatives to expand improvement efforts beyond traditional hospital-based projects.

Faced with so many diverse opportunities for improvement, leaders need a framework to identify the skills, tools and teams that are needed to successfully execute a wide range of initiatives, from eliminating health care-acquired infections to preventing obesity in communities they serve.

The Improvement Continuum

To succeed in a rapidly changing environment, health care leaders must develop the ability to implement improvement projects across four levels:

Topic or microsystem projects address specific, well-defined challenges within a single care unit. Examples include preventing surgical-site infections and reducing the incidence of hospital-acquired pressure ulcers.

Care coordination projects span multiple units or departments and include efforts to reduce readmissions or increase appropriate discharges to hospice.

Defined population projects include efforts to improve the health of a given population, such as reducing emergency department visits for asthma patients.
Community health projects engage multiple partners in initiatives to improve health outcomes for people in a particular geographic area. Examples include preventing obesity and reducing gun violence. 

Projects at each of these levels require different skills, tools and people to be successful, and the levels build on one another. Projects at the care coordination level build on the skills, tools and teams developed at the microsystem level; projects that target defined populations build on the skills, tools and teams at both the care coordination and microsystem levels, and so forth. Mastery of basic improvement science skills and project management techniques provides the foundation for all projects.

As projects expand beyond the unit and topic level and become increasingly complex, this framework, which we call the Improvement Continuum, guides leaders by clearly identifying the additional competencies needed at each level. Many excellent toolkits and models for improvement already exist. The Improvement Continuum is intended to supplement existing resources. It is described in detail with several case examples in the Hospitals in Pursuit of Excellence guide, "Leading Improvement Across the Continuum: Skills, Tools and Teams for Success."

A Health System Applies the Framework

St. Charles Health System in Bend, Ore., is using the Improvement Continuum framework for strategic planning and for specific project implementation.

One health system team is using the framework for a medication reconciliation project. Improving medication reconciliation systemwide involves coordinating efforts among multiple entities: surgical departments, EDs, pharmacy and other hospital units. Such a project utilizes the skills identified at the topic/microsystem level — project management and improvement science — but also collaboration and health information technology skills required at the care coordination level.
Medication reconciliation is a care coordination project that demonstrates how tools and skills from previous levels (i.e., topic/microsystem) are expanded upon. Kyle Johnson, administrative fellow, describes the medication reconciliation project as "a perfect example of a complex problem that needs to be managed both as a project at the macro level of our health system and as a conglomeration of Plan-Do-Study-Act cycles at the microsystem level." The Improvement Continuum framework guides leaders through these multiple levels of improvement activity.

In addition, Alisha Fehrenbacher, director for strategic improvement, and her team at St. Charles are using the Improvement Continuum to "develop strategic aims and big dot measures." According to Fehrenbacher, "The continuum provides an integrated framework that is helping us achieve Triple Aim results."

Sustaining Improvement across the Continuum

The Improvement Continuum emphasizes both project management skills and improvement science skills. This dual emphasis is crucial for today's leaders who are working to improve complex, adaptive systems like health care organizations. The Improvement Continuum provides an alternative to the one-size-fits-all mentality that many organizations adopt when designing improvement projects. According to Johnson, with this framework, the project drives the improvement systems and tools used, not vice versa. "The framework outlines things that are intuitively known, but blends both the strategic thinking and specific tools that are needed across different projects. It is a great framework for planning," Johnson says.

To achieve significant and sustainable improvements across all aspects of health care, hospitals must expand their improvement efforts beyond traditional, unit-based initiatives. The Improvement Continuum provides a framework to ensure that leaders can build projects with the skills, tools and teams needed for success.

For more information about implementing this framework, as well as the Leadership Action Model for sustaining improvement, visit the Hospitals in Pursuit of Excellence website to download the guide "Leading Improvement Across the Continuum: Skills, Tools and Teams for Success."

Maulik Joshi, Dr.P.H., is president of the Health Research & Educational Trust and senior vice president for research at the American Hospital Association. Natalie D. Erb, M.P.H., is an administrative fellow at HRET.