Quality Improvement Model Research Articles

Applying Lean Kaizen to improve timely CT scan appointments for oncology patients in a safety-net hospital.

e18627 Background: Timely radiographic studies are essential to oncology care. At our institution, a safety net hospital in a large metropolitan area, baseline assessment determined that the overwhelming majority of outpatient computed tomographic (CT) scans for oncology patients were overdue for scheduling. We applied the Lean Kaizen quality improvement model to improve on-time scheduling of CT scans in our hematology-oncology clinic. Lean Kaizen is centered around eliminating waste, improving productivity, and maintaining sustained improvement through collaborative efforts from multiple departments to analyze system workflow inefficiencies in a stepwise fashion. Methods: In collaboration with our Kaizen Promotion Office, we conducted a series of interdisciplinary meetings including staff from radiology, oncology, scheduling, and administration. All aspects of the scheduling workflow were critically reviewed and barriers to scheduling were identified using an Ishikawa root-cause diagram and the Kaizen principle of gemba (“go and see the work”). A new workflow was developed in which clinic staff scheduled patients for CT scans prior to clinic discharge. To implement the new workflow, we employed the principles of shojinka (“create flow”) and nagara (“eliminate waste”). We developed and distributed workflow guides, conducted simulation events, and provided one-on-one training to ensure a successful rollout. Three months after our initial meeting, the new workflow was launched. The workflow was refined based on feedback from daily pre-clinic team meetings. Results: Preliminary data were gathered approximately 3 weeks following implementation of our new workflow. Since our intervention, the percentage of CT scans overdue for scheduling decreased from 87% (65 of 75 CT scans) to 17% (9 of 53 CT scans). Conclusions: Our study showed that the Lean Kaizen QI model was successful in improving the rate of oncology patients scheduled for CT scans in a timely fashion. This study demonstrated the importance of interdepartmental collaboration and continuous monitoring for improvement. Given the success of this project, this workflow will be expanded to other services within our institution following the Kaizen principle of yokoten (“sharing knowledge”).

The Organizational Effectiveness Model for Quality Improvement of Madrasah: A Case Study of State Madrasah Tsanawiyah in Indonesia

The present study aims to comprehend what enables Madrasahs at MTSN in Jambi City to be effective by developing a substantive theory of school effectiveness that can be applied to schools that have not been effective in managing education under the same conditions to achieve effectiveness. The Sequential Exploratory Design of mixed method is applied in this study. The methodology begins with the first phase namely collection and analysis of qualitative data. Thus it followed by the second phase namely collection and analysis of quantitative data which construct based on the interview result selected through purposive sampling. The participants of qualitative method consist of teachers, school principals, and committees. Meanwhile for the qualitative method the participants consisted of ± 266 teachers. The result elaborated the Madrasah organizational effectiveness model for improving school quality was the most important, namely collaboration and communication, vision and goals as well as conformity with standards were the main or determining factors in realizing madrasa effectiveness in the context of Jambi City. Implications of findings are implies for the stakeholder of Madrasah. Recommendations were made to increase efforts to make public Madrasah in Jambi City more effective.

The Organizational Effectiveness Model for Quality Improvement of Madrasah: A Case Study of State Madrasah Tsanawiyah in Indonesia

The Organizational Effectiveness Model for Quality Improvement of Madrasah: A Case Study of State Madrasah Tsanawiyah in Indonesia

Risk prediction of 30-day mortality after stroke using machine learning: a nationwide registry-based cohort study

BackgroundsWe aimed to develop and validate machine learning (ML) models for 30-day stroke mortality for mortality risk stratification and as benchmarking models for quality improvement in stroke care.MethodsData from the UK Sentinel Stroke National Audit Program between 2013 to 2019 were used. Models were developed using XGBoost, Logistic Regression (LR), LR with elastic net with/without interaction terms using 80% randomly selected admissions from 2013 to 2018, validated on the 20% remaining admissions, and temporally validated on 2019 admissions. The models were developed with 30 variables. A reference model was developed using LR and 4 variables. Performances of all models was evaluated in terms of discrimination, calibration, reclassification, Brier scores and Decision-curves.ResultsIn total, 488,497 stroke patients with a 12.3% 30-day mortality rate were included in the analysis. In 2019 temporal validation set, XGBoost model obtained the lowest Brier score (0.069 (95% CI: 0.068–0.071)) and the highest area under the ROC curve (AUC) (0.895 (95% CI: 0.891–0.900)) which outperformed LR reference model by 0.04 AUC (p < 0.001) and LR with elastic net and interaction term model by 0.003 AUC (p < 0.001). All models were perfectly calibrated for low (< 5%) and moderate risk groups (5–15%) and ≈1% underestimation for high-risk groups (> 15%). The XGBoost model reclassified 1648 (8.1%) low-risk cases by the LR reference model as being moderate or high-risk and gained the most net benefit in decision curve analysis.ConclusionsAll models with 30 variables are potentially useful as benchmarking models in stroke-care quality improvement with ML slightly outperforming others.

An initiative to reduce medication errors in neonatal care unit of a tertiary care hospital, Kolkata, West Bengal: a quality improvement report

BackgroundMedication errors are an emerging problem in various hospital settings, especially in neonates. A study conducted in the neonatal care unit of a tertiary institute in Kolkata as baseline over...

Coaching and mentoring skills: a complement to the professional midwifery advocate role

Workload pressures within midwifery have magnified because of the global pandemic, causing anxiety and stress for healthcare professionals across all settings. The prediction of the retirement time bomb, combined with midwives leaving the profession as a result of burnout, is having a considerable impact on maternity service provision. There is additional recognition of stress factors caused by the changing landscape within maternity services, one of which has been identified as the national implementation of the continuity of care model. The support framework for midwives and student midwives and the continuous improvement process that the advocating for education and quality improvement model is designed to achieve is needed now more than ever in what have become known as unprecedented times. The author is passionate regarding support for student midwives and prior to lockdown, commenced a postgraduate course in coaching and mentoring. The rationale for undertaking this qualification was to enhance professional midwifery advocate skills further. This proved to be beneficial to the development of the professional midwifery advocate services.

Respiratory Therapist-Driven Extubation Readiness Testing in a Single Pediatric ICU.

There is currently no standardized way to determine suitability for extubation of pediatric ICU (PICU) patients, potentially resulting in prolonged duration of mechanical ventilation. We aimed to design and implement a protocol for screening all intubated PICU patients for extubation readiness. We adopted the quality improvement (QI) Model for Improvement with Plan-Do-Study-Act (PDSA) cycles to achieve this aim. This QI project was conducted over 11 months in a multidisciplinary PICU. Outcome measures included the (1) development of a standardized extubation readiness test (ERT) that was acceptable and safe; (2) performance of ERT on > 80% of all mechanically ventilated subjects; and (3) maintenance or reduction in mechanical ventilation duration, extubation failure (non-elective re-intubation within 48 h of extubation), and need for rescue noninvasive ventilation (NIV). Balancing measures were to ensure (1) no compromise of the subject's clinical status; and (2) acceptability of the ERT workflow by medical, nursing, and respiratory therapist (RT) teams. Four PDSA cycles were necessary to achieve the aims of this study. During the QI period, 438 subjects were admitted to the PICU. The ERT was championed by the RTs who conducted the test during office hours. ERT performance increased from 0% (baseline) to 90% (fourth PDSA cycle). Extubation failure rate after implementing ERT was reduced compared to baseline (4/31 [12.9%] vs 3/127 [2.4%], P = .01), whereas need for rescue NIV (3/31 [9.7%] vs 10/127 [7.9%], P = .74) and duration of mechanical ventilation (2 [1-7] d vs 1 [1-3] d, P = .09) were unchanged. PICU length of stay was reduced after implementing ERT (5 [3-10] d vs 3 [1-6] d, P = .01). No subject was destabilized as a result of ERT, and PICU staff found the workflow acceptable. An acceptable and safe ERT protocol was implemented and found to improve outcomes in PICU subjects on mechanical ventilation.

Exploration on the Reform Strategy of Teaching Quality Evaluation System in Chinese Vocational Colleges

The teaching quality evaluation of vocational education is not only an important way to meet the national identification of technical talents, but also an objective reflection of the comprehensive management level and college running quality of vocational colleges. However, the teaching evaluation of vocational education in China has not formed a unified and standardized management system framework. Therefore, in the new era of Xi Jinping, China's research on the evaluation of teaching quality of occupation technology education is more important. PDCA cycle is Deming Cycle, which is a model of continuous quality improvement, including four repeated steps: Plan, Do, Check and Act. This is exactly the same as the process of teaching quality evaluation in vocational colleges. Based on the concept of PDCA cycle theory, this paper attempts to use PDCA method to increase the innovative potential of teaching quality evaluation, and construct a set of closed-loop evaluation management scheme of teaching quality in the whole process and all-round spiral dynamic cycle mode-a five in one pluralistic structural teaching quality evaluation and management system of vocational colleges, families, enterprises, third-party institutions and society. This paper also discusses how PDCA method will affect the design and reform of teaching quality evaluation of vocational education in China, and deeply analyzes the problems and countermeasures that vocational colleges may face after trying to implement the pluralistic structural teaching quality evaluation and management system.

Building High-Performance Team Dynamics for Rapid Response Events in a US Tertiary Hospital: A Quality Improvement Model for Sustainable Process Change.

Hospital rapid response systems are designed to reduce unmet patient needs and prevent clinical deterioration. Rapid response teams are the principal component of a rapid response system and require teamwork to function optimally; poor communication among team members can result in substandard patient care. The authors describe a process for developing and implementing standardized communication and a teamwork structure for rapid response events (RREs) at a large academic hospital. The multidisciplinary team developed a project charter and key driver diagram, developed a "communication bundle," used quality improvement methodology, monitored adherence to the changes, and reported these data to key stakeholders on a weekly basis. By project end, the team met the goal of having 70% or more of adult RREs include the use of the "communication bundle." The balancing measure demonstrated that the introduction of a formalized communication framework did not significantly increase the duration of RREs.

Quality Improvement Interventions in the Delivery Room to Improve the Early Initiation of Breastfeeding in Healthy Neonates: A Tertiary Hospital-Based Study

Background: The low-middle income countries continue to contribute to a high proportion of neonatal and child mortality globally. The reduction in mortality rates requires low-cost interventions such as early initiation of breastfeeding (EIBF). The study objective was to improve the rate of EIBF in all the healthy term newborns born in our institute from a baseline rate of 10% to at least 70% over 3 months through a quality improvement (QI) approach. Methods: This study was conducted in the labor room and operation theatre of a tertiary care center in Uttar Pradesh. All the healthy term mother-newborn pairs born in the study period were included and the Point Of Care Quality Improvement model was followed. After the baseline assessment of the problem, a QI team was formed which did the root-cause analysis and generated the change ideas to be implemented by small Plan-Do-Study-Act (PDSA) cycles initially then systematically expanded to the larger level. Outcome Measure: The effect of a PDSA cycle was measured by the percentage of newborns breastfed within the first hour of birth at the end of each cycle. Results: The EIBF improved from the baseline rate of 10% to 70.5% at the end of 5 PDSA cycles and was maintained at 70.7% during the sustainability phase. Conclusion: The QI approach can be utilized to improve EIBF, while the sustainability depends on continuous efforts like education programs, counselling, and supportive supervision. The inclusion of simulation-based training for staff can build confidence and improve results.

Elementary School Teacher Quality Improvement Model Based on Literacy and Technology

The Industrial Revolution 4.0 and Society 5.0 were concepts that first developed in Japan. This concept has an impact not only on Japan but also for all countries in the world. Every country is required to be able to adapt technology, including Indonesia. Technology that is growing will even affect the development of each generation. This is proven by the discovery of the baby boomers to the alpha generation as a result of the development of technology and information. Therefore, every parent and even educator must have the skills to be able to educate generation Z and alpha who are currently very exposed to technology. This is even exacerbated by the Covid-19 pandemic which is currently still spreading in Indonesia. The government has started to encourage Distance Learning to break the chain of virus spread. Teachers and parents are required to be able to collaborate in educating children. In fact, teachers must be able to present interesting learning models so that they are not boring for students. Therefore, various kinds of skills are needed so that teachers are able to adapt to these conditions. And of course, those who need this the most are teachers in marginal areas of Indonesia who have many limitations. The general objective of this research is to compile basic data and develop a Literacy and Technology-based Elementary School Teacher Development model in Indonesia's Marginal Region, which is named TELEPATI (TEacher LEadership Program Towards Excellent Indonesia). TELAPATI is an integrated program to improve the quality of Indonesian teachers by optimizing their leadership abilities as themselves, teachers and educators. This model is dedicated to helping improve the quality of teachers who are able to educate the Indonesian generation in today's digital era. This model integrates coaching and mentoring using the 24h-Self Controlling system.

Application of a Nursing Data-Driven Model for Continuous Improvement of PICC Care Quality.

A PICC catheter maintenance network was established and managed to monitor the maintenance of catheters in placed patients throughout the process, providing homogeneous PICC catheter continuity of care for patients. Model-driven thinking is an idea for simulation system development. Model-driven architecture (MDA) is a design methodology that implements model-driven thinking and is widely used in simulation system development. Based on the requirements of nursing, the data-driven model is mainly divided into interface layer and functional service layer; this study adopts MDA technology which can detach the functions of the system from the platform, based on domain knowledge, and the metamodel adopts XSD-based data model to generate the PIM model, which is stored in the model library. The results showed that the number of nurses at maintenance sites increased from 79 to 232, the PICC placement rate for oncology patients increased from 35.0% to 76.0%, the nurse maintenance operation pass rate increased from 53.9% to 88.4%, and the maintenance default rate decreased from 40.0% to 10.9%.

Simulation‐based training module on urosepsis improves knowledge and skills of urology nurses in Karachi, Pakistan: A brief project report

AbstractSimulation‐based training has become an essential part of medical and healthcare education. The purpose of this project was to evaluate the improvement in knowledge and skills of nurses by introducing a new training methodology simulation‐based training module. A ‘cause and effect’ tool was used to identify care concerns and learning needs experienced by urology nurses in patient care settings. Early identification and management of sepsis/urosepsis was identified as a learning theme. A timeline was set and the Institute for Healthcare Improvement Quality Improvement Model, methodology was used to enact a plan‐do‐study‐act cycle to develop a strategy for project execution. To improve care provided by urology nurses and to improve the clinical outcomes, a biannual traditional training course for urology nurses was refurbished converting it into a simulation‐based training module. Via this module nursing staff gained knowledge about a standard sepsis protocol and were able to perform focused assessment on a high fidelity SimMan 3G® simulator. Staff were further able to identify early signs of urosepsis and demonstrate an ability in its initial management. Participants had skills signed off at the end of simulation‐based training session. Improvement in knowledge was assessed by multiple choice questions following pre and post‐tests. An online evaluation form was filled by each participant to assess effectiveness of module and strengths, weaknesses opportunities, threats (SWOT) analysis was done. Fifty four out of 93 nurses within a Nephrology‐Urology service participated. Improvement in knowledge was calculated by pre‐test average score about recognition and early management of sepsis which was 59%, with an average post‐test score of 75%. Besides this, nurses were evaluated for skills sign off with at least a ‘satisfactory’ performance. At the end of the session evaluation forms were completed by the participants to determine the perceived usefulness of the training. A SWOT analysis identified the main strength of the project which was that it offered hands‐on skills to identify early warning signs of sepsis along with the opportunity to practice the management of these issues efficiently. Simulation‐based module significantly improved the knowledge and skills of urology nurses and participants demonstrated a positive attitude toward this new pedagogy.

The Michigan Radiation Oncology Quality Consortium: A Novel Initiative to Improve the Quality of Radiation Oncology Care

Numerous quality measures have been proposed in radiation oncology, and initiatives to improve access to high-complexity care, quality, and equity are needed. We describe the design and evaluate effect of a voluntary statewide collaboration for quality improvement in radiation oncology initiated a decade ago. We evaluate compliance before and since implementation of annual metrics for quality improvement, using an observational data set with information from more than 20,000 patients treated in the 28 participating radiation oncology practices. At thrice-yearly meetings, experts have spoken regarding trends within the field and inspired discussions regarding potential targets for quality improvement. Blinded data on practices at various sites have been provided. Following Standards for Quality Improvement Reporting Excellence guidelines, we describe the approach and measures the program has implemented. To evaluate effect, we compare compliance at baseline and now with active measures using mixed effects regression models with site-level random effects. Compliance has increased, including use of guideline-concordant hypofractionated radiation therapy, doses to targets or normal tissues, motion management, and consistency in delineating and naming contoured structures (a precondition for quality evaluation). For example, use of guideline-concordant hypofractionation for breast cancer increased from 47% to 97%, adherence to target coverage goals and heart dose limits for dose increased from 46% to 86%, motion assessment in patients with lung cancer increased from 52% to 94%, and use of standard nomenclature increased from 53% to 82% for lung patients and from 80% to 94% for breast patients (all P < .001). Although observational analysis cannot fully exclude secular trends, contextual data revealing slow uptake of best practices elsewhere in the United States and qualitative feedback from participants suggests that this initiative has improved the consistency, efficiency, and quality of radiation oncology care in its member practices and may be a model for oncology quality improvement more generally.

Implementing a Treat-to-Target Approach for Rheumatoid Arthritis During the COVID-19 Pandemic: Results of a Virtual Learning Collaborative Program.

ObjectiveA treat‐to‐target (TTT) approach improves outcomes in rheumatoid arthritis (RA). In prior work, we found that a learning collaborative (LC) program improved implementation of TTT. We conducted a shorter virtual LC to assess the feasibility and effectiveness of this model for quality improvement and to assess TTT during virtual visits.MethodsWe tested a 6‐month virtual LC in ambulatory care. The LC was conducted during the 2020–2021 COVID‐19 pandemic when many patient visits were conducted virtually. All LC meetings used videoconferencing and a website to share data. The LC comprised a 6‐hour kickoff session and 6 monthly webinars. The LC discussed TTT in RA, its rationale, and rapid cycle improvement as a method for implementing TTT. Practices provided de‐identified patient visit data. Monthly webinars reinforced topics and demonstrated data on TTT adherence. This was measured as the percentage of TTT processes completed. We compared TTT adherence between in‐person visits versus virtual visits.ResultsEighteen sites participated in the LC, representing 45 rheumatology clinicians. Sites inputted data on 1,826 patient visits, 78% of which were conducted in‐person and 22% of which were held in a virtual setting. Adherence with TTT improved from a mean of 51% at baseline to 84% at month 6 (P for trend < 0.001). Each aspect of TTT also improved. Adherence with TTT during virtual visits was lower (65%) than during in‐person visits (79%) (P < 0.0001).ConclusionImplementation of TTT for RA can be improved through a relatively low‐cost virtual LC. This improvement in TTT implementation was observed despite the COVID‐19 pandemic, but we did observe differences in TTT adherence between in‐person visits and virtual visits.

Analysis of Surgical Mortalities Using the Fishbone Model for Quality Improvement in Surgical Disciplines.

The healthcare industry is complex and prone to the occurrence of preventable patient safety incidents. Most serious patient safety events in surgery are preventable. This study was conducted to determine the rate of occurrence of preventable mortalities and to use the fishbone model to establish the main contributing factors. We reviewed the records of patients who died following admission to the surgical wards. Data regarding their demography, diagnosis, acuity, comorbidities, categorization of death and contributing factors were extracted from the Research Electronic Data Capture (REDCap) database. Factors which contributed to preventable and potentially preventable mortalities were collated. The fishbone model was used for root cause analysis. The study received prior ethical clearance (M190122). Records of 859 mortalities were found, of which 65.7% (564/859) were males. The median age of the patients who died was 49years (IQR: 33-64years). The median length of hospital stay before death was three days (IQR: 1-11days). Twenty-four percent (24.1%) of the deaths were from gastrointestinal (GIT) emergencies, 18.4% followed head injury and 17.0% from GIT cancers. Overall, 5.4% of the mortalities were preventable, and 41.1% were considered potentially preventable. The error of judgment and training issues accounted for 46% of mortalities. Most surgical mortalities involve males, and around 46% are either potentially preventable or preventable. The majority of the mortality were associated with GIT emergencies, head injury and advanced malignancies of the GIT. The leading contributing factors to preventable and potentially preventable mortalities were the error of judgment, inadequate training and shortage of resources.

Fuzzy decision-making model for process quality improvement of machine tool industry chain

Industry 4.0 has fostered innovation in industries around the world. Manufacturing industries in particular are advancing towards smart manufacturing by integrating and applying relevant technologies. The output value of machine tools in Taiwan is among the top of the world and the central region is a key area for this industry chain, which supplies manufacturers in Taiwan and their international downstream customers. To support innovation in this industry, the current study used the Six Sigma quality indices for smaller-the-better, larger-the-better, and nominal-the-best quality characteristics to construct a fuzzy decision-making model. Based on this model, we propose a process quality fuzzy analysis chart (PQFAC) for process quality improvement. Our use of fuzzy decision values to replace lower confidence limits decreases the probability of misjudgment made by sampling errors. The proposed fuzzy model also offers a more accurate assessment of process improvement requirements. We provide a real-world example to demonstrate the applicability of the proposed approach. Machine tool manufacturers can apply the platform and proposed model to evaluate their process capabilities for the vital parts suppliers and downstream customers, determine optimal machine parameter settings for processes with inadequate accuracy or precision, establish more suitable machine repair and maintenance systems, and combine the improvement experiences of customers to create an improvement knowledge base. This will enhance product value and industry competitiveness for the entire machine tool industry chain.

Implementing Large-Scale Data-Driven Quality Improvement in Assisted Living.

Develop and evaluate the implementation of a proposed model for large-scale data-driven quality improvement in assisted living. We conducted a mixed-methods evaluation of the implementation of a large-scale data-driven quality improvement collaborative of Wisconsin assisted living communities (ALCs). The model has been voluntarily implemented by 810 Wisconsin-licensed ALCs serving >20,000 residents. The model was codesigned iteratively 2009-2012 by a public-private multistakeholder advisory group. Using system usage statistics and project records, we evaluated implementation outcomes: appropriateness, acceptability, adoption, feasibility, fidelity, penetration, and sustainability. Implementation for ≥1 quarter was feasible for 92% of the 810 ALCs that enrolled. The model has been deemed appropriate and acceptable by public-private stakeholders representing residents, providers, regulators, and payers, and appropriateness for ALCs serving different populations has been iteratively improved through targeted workgroups. The model is currently adopted in Wisconsin by 31% of the 1573 ALCs in provider associations. Among adopters, 88% on average implemented the model with fidelity to key membership rules per quarter. The model achieved demographic and institutional penetration by currently reaching 24% of Wisconsin ALC residents and by leveraging initial grant funding to become integrated in Wisconsin's annual Medicaid budget and being central to Wisconsin's incentive program to managed care organizations. Model implementation for 8years has been sustained by member enrollment for nearly 4years on average, with 71% of members enrolled >2years and sustained early adopters representing 37% that have been enrolled >5years. This is the first implementation study of large-scale data-driven quality improvement in assisted living, despite its demonstrated value in other health care sectors. The article proposes a model with core components and implementation strategies drawing on a decade-long public-private collaboration. The implementation study findings establish a promising path and future directions for wider implementation.

Development of patient-centered outcomes for labour and birth: a qualitative study

Background: Current quality improvement models in obstetrics focus on prevention of adverse perinatal outcomes. The development of these metrics was based on expert opinion that did not account for patients’ values. The ultimate aim of our research is to develop performance indicators for labour and birth that reflect the patient perspective. Methods: A qualitative interview design was used to engage a convenience sample, of recent (&lt;1 year) postpartum patients, in semi-structured interviews, where they shared their experiences of their recent birth. Patients were also asked to assess descriptions of adverse perinatal outcomes for readability and comprehension, towards developing accurate unbiased descriptions for a subsequent survey of patients to weight complications. Responses were recorded, transcribed, coded and analyzed using thematic analysis. thematic analysis. Results: Five themes emerged during the analysis: (1) desire for patient-centred care, (2) improved communication, (3) labour/birth, expectations and outcomes, (4) care team support during labour and birth, (5) continuing emotional and physical postpartum care. Conclusions: Patient-centred care and good health outcomes were the major values expressed by the patients in this study. Good communication and shared decision making led to patients describing their labour and birth as a satisfying experience. This study lays the foundation for developing a quality tool to measure the outcomes of birth and adverse outcomes from the patients’ perspective.

Programa de melhoria da qualidade nos cuidados em serviços de saúde: estudo de reflexão

The aim was to reflect on the potential of applying the continuous quality improvement model, disseminated by the Institute for Healthcare Improvement (IHI) in health services. This is a reflective study on the application of the continuous quality improvement model in national and international research. The purpose of the model is to improve healthcare outcomes and the patient experience through changes in the behavior of healthcare professionals and institutions and by systematically applying changes to complex processes and systems. Furthermore, the model consists of three fundamental questions that are combined with the PDSA cycle (Plan-Do-Study-Act). The impacts of these cycles on care processes and patient safety were also presented. Studies that used this methodology showed a reduction in adverse events and improvement in care processes in health services. Thus, the continuous quality improvement model should be widely used in clinical practice and research to improve care provided to all patients and at all levels of health care with limited resources and without great costs.