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9. Quality Assurance/Improvement

9.1 Quality assurance: what is it?

The Institute of Medicine defines quality of care as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”[649] In addition to whether care for a particular condition achieves desired health outcomes, other considerations in gauging quality of care include accessibility, the quality of the patient experience when receiving care, and how the processes of care delivery are structured in a manner to constrain health care costs.[650][652] Quality assurance is a process whereby a health care organization can ensure that the care it delivers for a particular illness meets accepted quality standards.[640],[649],[650] Inherent characteristics of this process include:

  • Existence of evidence-based clinical guidelines for the illness of interest, and from which quality of care performance indicators can be derived. These indicators can refer to structures, processes, or outcomes of care.[653],[654]
  • Development and maintenance of a health information database representative of the patients/illness served by the health care organization. The database can be audited and benchmarked against the performance indicators to assess the quality of care.
  • Development of mechanisms to address care deficiencies identified in the database audit and improve the quality of care.
  • Repeated database audits to assess the effectiveness of measures taken to improve care delivery, and to ensure the ongoing delivery of quality care.
  • Placement of a system aimed to monitor patient safety and provide processes to address safety-related issues that become apparent.

A review of the large body of literature regarding quality assurance and safety is beyond the scope of this section. Instead, we address issues specific to quality care in the HF population with additional details in sections 9.2-9.7 of the Supplementary Material, and in Table 44.


176. We recommend that health care systems should provide for quality assurance in the process as well as content of care provision (Strong Recommendation; High-Quality Evidence).

177. We recommend that quality assurance programs should include the following elements to allow for assessment of patient, provider, and health care institutional outcomes (Strong Recommendation; Moderate-Quality Evidence):

i. Measurement of evidence-based key performance indicators to assess system performance and outcomes.

ii. Robust measurement of important clinical and system of care outcomes.

iii. Intervention supports such as clinical tools to facilitate best practices.

iv. Performance feedback and education to HF care professionals and administrators.

Practical Tip

Selection of performance indicators with outcome data from randomized clinical trials, such as those listed in the CCS Quality Indicators E- Library-Heart Failure ( HF_V2.pdf), is preferred.

Institutional quality improvement strategies that include the following features have been shown to improve outcomes:

  • Reliance on a set of multimodal rather than single interventions
  • Administrative and change management support Provision of quality assurance personnel support
  • Emphasis on persistent/sustainable rather than temporary interventions
  • Resource support, during and after the period of practice change
  • Administrative as well as physician champions

It is unclear if any single intervention is superior to another. Use of multiple simultaneous interventions provides a larger effect size.

Examples of interventions with the highest quality of evidence for outcome improvement at a system level include:

  • Use of therapies proven to improve clinical outcomes in randomized clinical trials
  • Interdisciplinary and longitudinal approach to chronic disease care including with repeated visits, case management, home visits, and multimodal communication methods
  • Comprehensive hospital and postacute care in combination
  • Timely and accurate communication between health care providers

Examples of isolated interventions with limited evidence for improved process measure outcome improvement at a system level include:

  • Practice audits with multifaceted feedback
  • Reminder or decision support tools
  • Health care provider education
  • Patient/family education
  • Pay for performance programs
  • Telemedicine/telemonitoring programs

Broader regional, provincial, and national frameworks are required to promote and facilitate quality assurance initiatives at all levels of HF care.


649. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press (US), 2001.

650. Fishman PA, Hornbrook MC, Meenan RT, Goodman MJ. Opportunities and challenges for measuring cost, quality, and clinical effectiveness in health care. Med Care Res Rev 2004;61:124S-43S.

651. Rubin HR, Pronovost P, Diette GB. The advantages and disadvantages of process-based measures of health care quality. Int J Qual Health Care 2001;13:469-74.

652. Mant J. Process versus outcome indicators in the assessment of quality of health care. Int J Qual Health Care 2001;13:475-80.

653. Campbell SM, Braspenning J, Hutchinson A, Marshall MN. Research methods used in developing and applying quality indicators in primary care. BMJ 2003;326:816-9.

654. Donabedian A. Quality assessment and assurance: unity of purpose, diversity of means. Inquiry 1988;25:173-92.

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