Are quality improvement activities increasingly becoming a reactive game, or is our external health care environment becoming more effective (and influential) in "cueing" us about important clinical areas on which to focus?

Quality improvement (QI) activities and the functions supported by QI departments have long had a traditional "core." This core list of activities includes quality planning, education, measurement, analysis, and improvement activities. It also includes department-specific monitoring; pharmacy and drug-related review; investigation, monitoring, and improvement of occurrences, accidents, and errors; and multiple other efforts related to regulation/accreditation or related to internally identified concerns.

Priorities of quality departments today are increasingly being triggered from outside the organization. Patient safety initiatives are a case in point. While patient safety has always been important, never before has so much attention been paid, so much literature written, nor has it been so visible to the public and on the lips of so many legislators. Activities catalyzed by the Institute of Medicine report of 1999 have quickly assumed primary focus in quality departments.

HCFA's voluntary clinical improvement projects carried out state by state have likewise raised the expectations for improvement with specific clinical populations and specific measures of their care. Whereas in the past, internal priorities were the first considered in how a quality department dedicated its efforts and resources, the visibility of these projects is reordering priorities in many sites.

State and local quality improvement initiatives are also increasingly emerging in today's environments. Special interest groups addressing a given disease state, population, or project are encouraging health care organizations to participate in their efforts, submit data toward a collaborative improvement project, or follow a given protocol. The risk of not participating in such projects is to give the appearance to the community that an organization is uncommitted to quality or the cause.

These scenarios demonstrate a rising specter of quality, which is overall a very good thing. Furthermore, most of the initiatives described are grounded in evidence-based care, and carry the potential of significantly improving patient care.

It is critical in the context of many opportunities, however, that quality directors make good decisions about which projects should hit their priority list, or opportunities in which to participate. Obviously, participating in all is impossible, or at best might diffuse the organization's focus so as not to be effective in improving anything. Limited resources also prevent a quality director from paying attention to multiple additional efforts. At times, waiting for completion of selected efforts may set the stage for success, because appropriate attention can be paid without the complication of competing priorities.

So, the watchwords of the day are to keep one's finger on the pulse of the external health care environment, and understand the implications of the emerging opportunities (?mandates)[horizontal ellipsis] but always, always make conscious and grounded decisions regarding participation, capacity and timing.

-Patricia Schroeder MSN, MBA, RN

Journal Editor