Please Wait a Moment

Innovation Blog

Blog posts are written by Russell Kohl, MD, FAAFP. Dr. Kohl is the Chief Medical Officer and Chief Operating Officer at TMF Health Quality Institute. He works across the company to support quality improvement efforts, leads the Innovation Team and has served as lead physician for the Comprehensive Primary Care initiative.


ORIGINAL (border added to reveal white stripe) /portals/0/Images/Staff/DrRussellKohl.jpg ADJUSTED & TRIMMED TO 230x300 /portals/0/Images/Staff/DrRussellKohl_230x300.png ADJUSTED & RESIZED TO 115x150 /portals/0/Images/Staff/DrRussellKohl_115x150.png ADJUSTED & RESIZED TO 77x100 /portals/0/Images/Staff/DrRussellKohl_77x100.png

The Third Dimension of Quality Improvement

Jul 6 2021 - Russell Kohl, MD, FAAFP

Quality improvement (QI) efforts have long been modeled as an interplay between “competency” and “commitment.” In this model, a subject is evaluated for their knowledge-based attributes (the knowledge or technical gaps that must be addressed in order to move forward), called their “competency,” and their attitudinal attributes (the cultural traits or belief systems around both the topic and change), called their “commitment.” However, the last year has shown an additional dimension, called “competition,” which should be included in the model. The ability to maintain ongoing QI efforts during COVID-19 presented a great challenge to many health care organizations. These organizations hadn’t lost competency and they remained just as committed to achieving the best for their patients as they were before the pandemic. They simply couldn’t maintain their prior “full-time” health care work in addition to the expanded demands of the pandemic. The competing priority of the pandemic entered into the dynamic, which requires us to reflect on our mental model of competency versus commitment in quality improvement.

To imply that the competition for resources required during COVID-19 is new, would be fallacy. Every health care organization has done this sort of mental triage for years. The difference is that the “normal” timeline of QI projects (and even the conceptualization of QI as a “project”) has historically led to these triage decisions being attributed to the “commitment” domain. As QI projects were proposed, the health care organization historically decided it couldn’t commit to it, based on capacity. During 2020, though, many organizations found themselves having to set aside ongoing projects that they continued to feel strongly about. While stopping a project effort versus not starting one are generally the same from an ethical perspective, they certainly don’t feel like it from a humanist point of view. Ongoing QI projects with positive results had to sometimes be set aside to return to the survival stage of Maslow’s Hierarchy of Needs. What can we learn from these situations and how should this affect our conceptualization of quality improvement moving forward?

My immediate recognition was the impotence of many of our current methodologies for defining quality. Instead of a holistic, patient-oriented approach to QI measurement, we have continued to perpetuate a disease- and procedure-based measurement and evaluation system. How do we reconcile quality when the disease we were measuring ceases to be the patient’s greatest risk factor for premature mortality and morbidity? Is it really “poor quality” to change our focus to the higher risk (such as spread of a virus like COVID-19) and place our previous QI work on hold? Is the organization really “plateaued” when its measures aren’t improving, but its patients’ mortality/morbidity risks are decreasing due its actions? These challenging questions, and the sheer scope of the COVID-19 pandemic, refuse to allow us to return to a QI model that doesn’t adequately consider competing demands. We can’t let competing challenges (like those presented in a pandemic) be swept into the domain of “commitment,” where we view patient oriented prioritization as a “lack of commitment to improvement.” We are left with a profound, but simple question: “How do we determine what’s most important to care for patients at this moment?”

Too often, this question is answered based on finances. While acceptable if we are certain that financial incentives are correctly aligned, experience would suggest that they are frequently not. Patient preferences could be an additional criteria, however this criteria may challenge the entire premise of population health. How, then, do we determine prioritization of efforts for quality improvement? While I don’t yet know that answer, the importance of recognizing prioritization as a separate driver of QI efforts is the first step towards identifying all dimensions of quality improvement.

1 2Next
The Science Behind Vaccines, Antibodies and Herd Immunity
Mar 24 2022
COVID-19 Booster Update and Overview of the Pfizer Vaccine for Children Ages 5 to 11
Nov 11 2021
COVID-19 Medical Minute
Sep 1 2021
COVID-19 Update: The Delta Variant, Boosters and Vaccine Requirements
Aug 23 2021
The Third Dimension of Quality Improvement
Jul 6 2021
Delayed Gratification
Dec 7 2020
What’s in Your Lab Coat: Using the Tools in Your Pocket to Gather Credible Online Data
Nov 16 2018
May Is Mental Health Month
May 23 2018
No Single Raindrop Believes It Is Responsible for the Flood
Nov 9 2017
The Art of Aerial Combat and Quality Improvement
Aug 3 2017
1 2Next

There appears to be a licensing issue. Please login as Host to correct this.

Send Us Your Feedback:

Please keep in mind that all content will be reviewed for appropriateness. TMF Health Quality Institute has the right to reject and approve posts at their discretion. The user should not post patient information that would violate The Health Insurance Portability and Accountability ACT of 1996 (HIPAA) and understands that comments violating HIPAA will not be shared.


There appears to be a licensing issue. Please login as Host to correct this.