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Need and the Conceptual Model for Continuous Quality Improvement (CQI) System in Hospital Industry
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(January 30, 2019)


Quality standards implementation system in hospitals provides insight into the structure, process, outcome and serve as instrumental indicators to improve health care services. As a consequence, evaluating the quality systems in the hospital is important and implement ways of continuous quality improvement (CQI) more efficiently in order to reduce the differences in the operational process, its outcome, and sustainability of quality systems. Continuous quality improvement is a continuous “lifting of the bar” of quality system in the hospital. It leads to Service excellence.

Overall hospital continuous quality improvement should be a goal and the main objective of hospitals to achieve success in their healthcare services beyond the accreditation. Continuous quality improvement system cannot be implemented in a short period. It is a long journey of a hospital. It should not be forced by anybody. It should be accepted, engaged, learned and facilitated by every healthcare provider, leader and the management of the hospital. The leadership culture should be progressively nurtured within the hospital. Processes improvement, smooth operations, patient satisfaction, and employee satisfaction can be achieved through the implementation of quality systems and the continuous quality improvement system in the hospital. Few hospitals management need implementing the quality system is just for getting accreditation, other hospitals want to be leading providers of the world-class healthcare services through their continuous quality improvement efforts.



Quality systems are needed for high-quality care and patient safety by credential healthcare professionals. There should be a Structured Quality improvement programme based on the continuous monitoring of patient care services by designated employees in the quality department, management, staff in all the functions and at all the levels. Quality improvement includes analysis of the performance and the systematic efforts to improve the performance. Continuous quality improvement system provides the continuous patient satisfaction rates, employee’s satisfaction through continuous learning, skill development, better working environment, gaining leadership skills and ownership of processes.

There is an increasing attention on enhancing the quality of life through the Quality Council of India, and hospitals accreditation in India through the International organization for Standardization (ISO) and National accreditation board for hospitals and healthcare providers (NABH), a major focus on quality systems implementation and quality Improvement by hospital managers and healthcare providers is the key to enhance the quality and safety of healthcare services. Once the hospital is quality services certified, it is very important that it should focus on sustainability of quality systems and that the hospital staff should be continuously motivated for continuous quality improvement to reach higher levels of healthcare quality. The training frequency for personnel on Quality management systems needs to be augmented. Similarly monitoring frequency should be increased which brings out continuous quality care and in turn proves that the quality system is in place.



As per Insurance Regulatory and Development Authority of India (IRDA) notification on 29-07-2016, All such providers offering cashless services for allopathic treatment shall meet with the pre-accreditation entry-level standards laid down by National accreditation board for hospitals and healthcare providers (NABH) or such other standards or requirements as may be specified by the authority from time to time within a period of two years from the date of notification. Then only maximum hospitals started implementing quality systems.

-    Insurance regulatory and development authority of India (IRDA) came up with the recent change of guidelines where it has directed about 33,000 empanelled hospitals to obtain the NABH entry-level certification and this has to be done in the next two years. Since NABH accreditation is completely voluntary, only a few hospitals choose to obtain the quality certification. NABH was established in 2006.

-    This is an important step to ensure quality. For patients, it means increased safety and better quality. So far this was only voluntary but by ensuring accreditation, it is a regulatory guideline that has been mandated. One has to fulfil basic requirements at the entry level to be able to empanel themselves under various insurance schemes. As of now, all over India, only 450 hospitals have been empanelled under NABH. Stakeholders in the industry say that it is not only safe for patients but also for employees, since it certifies that the hospital is a safe place to work in. The entry-level rules are very basic and fundamental and expected to be followed by all hospitals.


    This paper is to address a conceptual model which includes intangible processes and tangible resources as a base to formulate Standard operating procedures (SOPs) which results in achievement and maintenance of Continuous Quality Improvement (CQI) in hospitals through regular monitoring.


Processes in the hospital involve both clinical and managerial tasks, large volumes of data, a large number of patients and employees. Processes in the hospital are complex and dynamic. Hospital processes require the coordination of all the department's employees including doctors.

Intangible processes include factors such as Leadership, team supervision, processes, procedures and practices, services, key indicators, safety, and effective communication. Efforts for Processes improvement are necessary because they play a major role in reducing costs and enhancing work efficiency. To achieve quality improvement, hospitals need to implement and follow standard processes.


Tangible resources include the factors of hospital equipment and safety systems, training, selection, placement, and manpower monitoring. To achieve quality improvement, hospitals need to utilize standard resources.


Hospital tries to provide the best possible healthcare services to its patients. Standard operating procedures (SOPs) of each department constitute a manual which significantly determines the standard functions of a hospital. As a base of intangible processes and tangible resources, the hospital leaders or the quality personnel and the management together should create Standard operating procedures (SOPs) based on the hospital functions to be implemented across the hospital. Once they have been implemented, it is the responsibility of all the departmental heads to continue and modify any changes required as per the hospital functions. Standard operating procedures (SOPs) categorized into technical, strategic and structural factors.


Continuous quality improvement (CQI) can be achieved through regular monitoring and by proper follow up of intangible processes, tangible resources and Standard operating procedures (SOPs). This leads to the best clinical quality, patient experience, and patient satisfaction, PDSA cycle progress, quality improvement, and organizational development. It is the responsibility of all departments HODs to follow up the continuity and regularly monitor the work status as per the implemented SOPs. The head of the hospital needs to involve the head of all departments (HODs) in planning the implementation.



    The literature review is the first step to identify the most important factors for Continuous Quality Improvement (CQI). Based on a thorough review and synthesis of information from Continuous Quality Improvement (CQI) literature, 16 critical areas of managerial planning and actions to achieve effective Continuous Quality Improvement (CQI) were identified.  





Intangible Processes

Leadership & Team Supervision

Ross Miller (2013), Kristiina Hyrkas et.al. (2003)


Anne Cleven et.al. (2016), Clare et.al.  (2000)


Sara Melo (2016)


Sandra C. Buttigieg et.al. (2016), Pavol Gejdos (2015), Ross Miller (2013)

Key Indicators

Anke Bramesfelda, b, (2016)


Charles R. Gowen III (2012), Rudolph P. Valentini (2017)

Team Work and Effective Communication

Mark White et al. (2014),

Catherine Dingley et al. (2008)

Tangible Resources

Security Practices and Office Environment

Andrei Ion Hohand et.al. (2015)

Training and selection, placement and Manpower monitoring

D. Daugherty Jill et al. (2013), Ann Elizabeth et.al. (2012)



Procedures (SOPs)


Sun Hee Lee et.al. (2002)


John Beesant and David Francis (1999)


Ross Mlller (2013)



Quality Improvement (CQI)

Clinical Quality

Anne Cleven et.al. (2016)

Patient Experience and Patient Satisfaction

Cheng Shuag et.al. (2017)

PDSA Cycle Progress

Eleanor Nicholson et.al. (2017)

Quality Improvement

Rudolph P. Valentini (2017),

Organizational Development

Ross Miller (2013)



    Implication involved in Continuous quality improvement in NABH pre-accredited entry level hospitals can be drawn from the findings generated in this research. Based on the factors, a range of strategies can be adopted by healthcare providers with the aim of Continuous quality improvement which helps them to achieve patient satisfaction, employee satisfaction, and the hospital development in a sustainable manner.


Factors which have been employed in this study can be empirically tested and the relationship between variables can also be tested among NABH pre-accredited entry level hospitals.



In the present economic scenario, the demand for healthcare quality is increasing amongst the general people of India. Therefore, healthcare providers are concerned about the quality standard of their service to ensure patient satisfaction. Overall hospital continuous quality improvement should be a goal and the main objective of hospitals to achieve success in their healthcare services beyond the accreditation.

This paper concludes that the Continuous Quality Improvement (CQI) in hospital industry is more important to sustain the quality standards for healthcare excellence through a set of factors which includes leadership, team supervision, processes, procedures, services, key indicators, safety, teamwork, effective communication, security practices, office environment, training, selection, placement and manpower monitoring, technical, strategical and structural factors, clinical quality, patient experience and patient satisfaction, PDSA cycle progress, quality improvement, organizational development.



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About the Authors:

Ms Divya Deepthi Panditi- PhD Healthcare Research Scholar, School of Management, Hindustan University,  Chennai- 603103

Dr.M.K. Badri Narayanan- Professor, School of Management, Hindustan University, Chennai: 603103