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  • Define quality improvement (QI).

  • Define goals for applying QI to reduce health-care inequities.

  • Describe how QI can affect health-care inequities

  • Review the importance of collecting data on race, ethnicity, language, and social and behavioral risk factors.

  • Review the importance of patient safety for vulnerable patients.

  • Describe the “Triple Aim” QI framework.

  • Describe the eight steps of a QI initiative.

Olivia has worked for 3 months at a community health center that serves a vulnerable patient population. The staff is wonderful, with many dedicated people, but some are worn down by chronic staffing shortages and overwhelming patient needs. The patients are very poor with many psychosocial stressors. Some have no telephone or are homeless; others cannot afford bus fare to the clinic; about at third speak little or no English. A small yet significant number of patients use illicit drugs. Olivia has been given 10% “QI time” in her job description to help the clinic tackle long-standing quality of care issues and to start making some operational and clinical improvement. While finding the task somewhat daunting, she is excited to dive in. However, she is not sure how to begin.


Even the most dedicated and idealistic practitioners can be daunted in their quest to care for complicated patients in limited resource settings. Health-care delivery systems can support the individual practitioner in that quest. Those systems that focus on continually improving patient health (outcomes) define improved care (performance) as requiring the constant, combined efforts of everyone in the system. System-based approaches to improving patient outcomes and care can follow formal methods of analysis and strategies for progress.

Quality Improvement (QI) is one system-based approach borrowed from other industries that has been applied to health care. The Agency for Healthcare Research and Quality defines QI as “a multidisciplinary, systems-focused, data-driven method of understanding and improving the efficiency, effectiveness, and reliability of health processes and outcomes of care.”1,2 While interest in QI has exploded in the United States over the past two decades, the extent to which those efforts have improved health care for vulnerable patients is unclear. This chapter addresses the specific challenges of quality improvement in safety-net settings with vulnerable patient populations. We present an eight-step approach to designing, implementing, and evaluating QI efforts, emphasizing data-driven and team-based approaches, adapted from the Institute for Healthcare Improvement. We describe concrete steps that can be used to guide QI efforts, with advice about how to adapt or expand their use in safety-net settings.


Since the publication of the Institute of Medicine (IOM) report “Crossing the Quality Chasm,”3 a report that documented the ways in which the US health-care system not only failed to deliver high quality care but actually harmed patients, the United States has experienced a surge in QI activities. ...

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