CCPP Module 9, Section 4: Quality Audits and Process Optimization
Module 9: Workflow Design and Clinical Operations

Section 9.4: Quality Audits and Process Optimization

An introduction to the principles of continuous quality improvement (CQI). Learn how to define key performance indicators (KPIs) for your practice, audit your performance, and use that data to make your workflow smarter and more effective.

SECTION 9.4

Quality Audits and Process Optimization

From “Doing the Work” to “Improving the Work”: The Science of Getting Better.

9.4.1 The “Why”: Good Intentions Don’t Guarantee Good Outcomes

You have designed a brilliant workflow. You have crafted a masterful schedule. You have written impeccably clear SOPs. You have, in effect, built a high-performance clinical engine. But even the most finely engineered engine requires a diagnostic system. It needs sensors to monitor performance, gauges to display the results, and a mechanic who knows how to interpret that data and perform a tune-up. Continuous Quality Improvement (CQI) is the science of being that mechanic for your own practice.

In healthcare, it is dangerously easy to confuse activity with accomplishment. We can feel incredibly busy—seeing patients, writing notes, communicating with providers—and assume that this busyness equates to high-quality care. This is a fallacy. Being busy simply means you are expending effort; it offers no proof that your effort is efficient, effective, or even safe. The only way to know if you are truly delivering on the promise of your practice is to systematically measure your performance, compare it against established standards, and use that information to drive meaningful change. This is the essence of CQI.

Quality audits and process optimization are not punishments or “gotcha” exercises. They are the tools of a mature professional who has moved beyond ego and defensiveness to a state of constant, humble inquiry. The fundamental mindset of CQI is not “Am I doing a good job?” but rather, “How can we, as a team, do an even better job tomorrow?” It is a proactive, data-driven, and blameless approach to excellence. It replaces assumptions with data, anecdotes with trends, and guesswork with a structured methodology for improvement.

This section will equip you with the foundational principles and practical tools of CQI. You will learn how to define what “success” looks like in tangible, measurable terms by setting Key Performance Indicators (KPIs). You will learn how to conduct a simple but powerful quality audit to see how your real-world performance stacks up against your goals and your SOPs. Most importantly, you will learn how to use the results of that audit not as a report card, but as a treasure map—a guide that reveals the hidden opportunities to make your practice safer for patients, more efficient for your team, and more valuable to your healthcare system. Embracing CQI is the final step in becoming not just a clinical practitioner, but a true clinical leader.

Pharmacist Analogy: The Medication Use Evaluation (MUE)

Throughout your pharmacy education and career, you have likely participated in or at least learned about Medication Use Evaluations (MUEs), a cornerstone of hospital pharmacy practice. An MUE is a formal, systematic process for improving patient outcomes by ensuring medications are used in a safe and effective manner. Think about the steps of a classic MUE for, say, appropriate vancomycin dosing:

  1. PLAN: Establish Criteria. You and the P&T committee decide what constitutes “good” vancomycin use. You set clear, evidence-based criteria: Was an appropriate loading dose given based on weight? Was a trough level drawn at the correct time? Was the dose adjusted appropriately based on the trough and renal function?
  2. DO: Collect Data. You perform a retrospective chart review of 20-30 patients who received vancomycin. You use a data collection form to see how often the actual practice met the criteria you established.
  3. STUDY: Analyze the Results. You analyze the data and find that in 60% of cases, the first trough was drawn too early, leading to potentially incorrect dose adjustments. You have identified a performance gap.
  4. ACT: Implement an Intervention. You don’t just point out the problem; you fix it. You might provide education to the nursing and phlebotomy staff, or better yet, you work with IT to build a new order set in the EMR that defaults the first trough draw to the correct time. You then plan to re-measure in 6 months to see if your intervention worked.

Continuous Quality Improvement is simply applying the MUE philosophy to your own clinical operations. Your workflow, scheduling, and SOPs are your “medications.” Your KPIs are your “dosing criteria.” A quality audit is your “chart review.” And your process optimizations are your “interventions.” You already know how to do this. You have the scientific mindset and the analytical skills. CQI is the framework that allows you to turn that powerful lens of evaluation away from a single drug and onto the performance of your entire practice.

9.4.2 The Engine of Improvement: The PDSA Cycle

Continuous Quality Improvement is not a random walk towards “better.” It’s a structured, iterative process guided by a simple yet powerful model: the PDSA Cycle. PDSA stands for Plan, Do, Study, Act. It is a four-stage scientific method for testing a change. By repeatedly cycling through these four stages, you can refine your processes based on real-world data, ensuring that your changes actually lead to improvement.

The PDSA Cycle for Continuous Quality Improvement

1. PLAN

Identify a goal or problem. Formulate a theory for improvement and make a plan to test it. What do you predict will happen?

2. DO

Implement the test on a small scale. Carry out the plan and collect data on the results.

3. STUDY

Analyze the data. Compare the results to your predictions. What did you learn? What went wrong?

4. ACT

Based on what you learned, either adopt the change, adapt it for the next cycle, or abandon it. What are you going to do next?

The cycle then repeats, with the “Act” stage of one cycle forming the “Plan” stage of the next, leading to continuous improvement.

9.4.3 If You Don’t Measure It, You Can’t Improve It: Defining Your KPIs

The entire CQI process is fueled by data. Before you can conduct an audit or run a PDSA cycle, you must first define what you are going to measure. Key Performance Indicators (KPIs) are specific, quantifiable measures that you use to track the health and performance of your practice. A good KPI is like a vital sign for your clinic—it gives you an objective reading of how you are doing in a critical area. Your practice should have a balanced “dashboard” of KPIs that measure performance across three key domains: Clinical Quality, Operational Efficiency, and Financial Viability.

The Danger of a Single Metric

Focusing on only one type of KPI can be disastrous. For example, if you only measure financial KPIs like “visits per day,” you might be incentivized to rush through appointments, causing your clinical quality to suffer. Conversely, if you only measure clinical quality without regard to efficiency, your practice might become financially unsustainable. A balanced set of KPIs is essential to ensure that improvements in one area do not come at the expense of another.

Masterclass Table: A Balanced Scorecard of KPIs for a CMM Practice
KPI Category Example KPI How to Measure It (The Formula) Data Source(s) Why It Matters
Clinical Quality
Are we improving patient health?		 % of Diabetes Patients at A1c Goal (Number of patients with DM managed by CPP with A1c < 8%) / (Total number of patients with DM managed by CPP) EMR Problem List, Lab Results, Practice Patient Panel List Directly measures your impact on a key clinical outcome. This is a powerful way to demonstrate value to providers and administrators.
% of HFrEF Patients on Guideline-Directed Medical Therapy (GDMT) (Number of HFrEF patients on all 4 pillars of GDMT) / (Total number of HFrEF patients) EMR Problem List, Medication List, Echocardiogram Reports Shows your ability to close evidence-to-practice gaps and implement complex, life-saving medication regimens.
Medication Discrepancy Rate (Number of patients with >1 unintended medication discrepancy identified at initial visit) / (Total new patients seen) Pharmacist’s documentation in the initial visit note. Quantifies your direct impact on patient safety by catching and resolving medication errors during transitions of care.
Operational Efficiency
Are our processes working smoothly?		 Referral-to-Visit Lag Time Average number of days from the date a referral is received to the date the patient’s initial visit occurs. Referral Tracking Spreadsheet (requires logging both dates). A key indicator of patient access. Long lag times can lead to patient frustration, worsening clinical status, and poor relationships with referring providers.
New Patient No-Show Rate (Number of scheduled new patient visits where the patient did not show) / (Total number of scheduled new patient visits) Scheduling System Reports High no-show rates are a major source of lost revenue and wasted clinical time. This KPI helps you diagnose problems with your intake and confirmation process.
Note Co-sign Rate / Recommendation Acceptance Rate (Number of pharmacist recommendations accepted or co-signed by provider) / (Total number of recommendations made) EMR Task Lists, Chart Audits of pharmacist notes. A direct measure of your credibility and collaborative effectiveness. A low acceptance rate is a critical signal that your communication or recommendations need to be improved.
Financial Viability
Is our practice sustainable?		 Billable Encounters per FTE per Month (Total number of billable encounters completed in a month) / (Your Full-Time Equivalent status) Billing Reports, Scheduling System The most basic measure of productivity. It’s essential for justifying your position and planning for future growth.
Claim Denial Rate (Number of claims denied by payers) / (Total number of claims submitted) Billing Department Reports (Remittance Advice) A high denial rate indicates problems with your documentation, coding, or insurance verification processes, leading to lost revenue and rework.

9.4.4 How to Look in the Mirror: Conducting a Simple Quality Audit

Once you have your KPIs and your SOPs, you have the tools you need to conduct an audit. An audit is simply a structured process for collecting data to see if your practice is conforming to your own established standards. It doesn’t have to be a massive, intimidating project. A small, focused audit can yield incredible insights.

The 5-Step Mini-Audit Playbook

  1. Step 1: Choose ONE Process and ONE KPI. Do not try to boil the ocean. Start with a single, high-priority area. Example: Let’s audit our “New Patient Intake” process, and our KPI will be “Referral-to-Visit Lag Time.” Our goal, as stated in our (hypothetical) SOP, is for this to be ≤ 10 business days.
  2. Step 2: Create a Simple Data Collection Tool. This can be a simple spreadsheet. The columns should represent the key data points you need to measure your KPI and look for the root cause of any problems.
  3. Step 3: Pull a Random Sample. You don’t need to review every chart. A random sample of 10-20 recent patients is usually enough to reveal patterns. Use your Referral Tracking Spreadsheet to select the last 20 patients who completed a new visit.
  4. Step 4: Conduct the Audit & Collect the Data. Go through the EMR and your tracking logs for each patient in your sample and fill out your spreadsheet. This is the “DO” phase of your PDSA cycle.
  5. Step 5: Analyze and Visualize the Results. This is the “STUDY” phase. Calculate your overall performance. Look for trends. Where are the delays happening? Create a simple chart to make the findings clear.
Example Audit: “Referral-to-Visit Lag Time”

Audit Tool (Spreadsheet):

MRN Referral Date Date Triage Complete Date All Records Rx’d Date Pt First Called Date Visit Scheduled Date of Visit Total Lag (Days) Delay Point? (e.g., Records, Pt Contact)
1234510/1/2510/2/2510/8/2510/9/2510/9/2510/16/2510Records (6 days)
6789010/2/2510/2/2510/3/2510/4/2510/10/2510/20/2512Pt Contact (6 days)
… (18 more rows) …

Analysis of Results (“STUDY”):

After auditing 20 charts, you find:

  • The Average Referral-to-Visit Lag Time is 14.5 days. (We are not meeting our goal of ≤ 10 days).
  • Only 30% (6/20) of patients were seen within the 10-day goal.
  • By analyzing the “Delay Point” column, you discover that 70% of the total delay across all patients occurred between “Date Triage Complete” and “Date All Records Rx’d.”

Conclusion: We have a significant bottleneck in our process for obtaining medical records from other offices. Our patient contact and scheduling process seems to be efficient, but we are being held up waiting for paperwork.

9.4.5 From Data to Action: The “Act” Phase and Process Optimization

The audit has given you a diagnosis. Now it’s time to prescribe the treatment. The “Act” phase of the PDSA cycle is where you use your findings to implement a targeted change to improve the process. A key technique to ensure you are fixing the right problem is to perform a simple Root Cause Analysis.

Root Cause Analysis with the “5 Whys”

The “5 Whys” is a simple but powerful technique for getting past the surface-level symptoms of a problem to find its underlying cause. You simply state the problem and then ask “Why?” five times (or as many times as it takes to get to a root process issue).

Problem: Our Referral-to-Visit Lag Time is too long (14.5 days).

  1. Why? Because we have long delays in getting medical records.
  2. Why? Because our technicians have to make multiple phone calls and send multiple faxes to the referring offices.
  3. Why? Because the referring offices often don’t send the records with the initial referral.
  4. Why? Because the referral form they use doesn’t clearly state what records are required, and there’s no easy way for them to attach them.
  5. Why? (The Root Cause) Because our referral process is entirely passive and places the entire burden of data gathering on our team after the fact.

This analysis shows that the problem isn’t that your staff is slow; the problem is that your system is poorly designed. Now you can develop a targeted intervention.

Masterclass Table: From Root Cause to Action Plan (The “ACT” Phase)
Audit Finding / Problem Identified Root Cause Proposed Intervention (The “ACT”) How to Measure Success
Referral-to-visit lag time is 14.5 days, exceeding 10-day goal. Our referral process is passive and creates rework for our staff.
  1. Redesign the Referral Form: Create a new, one-page PDF referral form that includes a clear checklist of the required records (last note, labs, etc.).
  2. Educate Referrers: Visit the top 3 referring clinics, provide them with the new form, and explain that sending a “complete packet” will result in faster scheduling for their patients.
  3. Update SOP: Revise SOP-ADM-001 to state that if an incomplete referral is received, the technician will immediately contact the office and request the complete packet using the new form as a guide.
 Re-audit in 3 months. Our goal is to reduce the average lag time to < 10 days and increase the percentage of referrals arriving with all necessary records from (e.g.) 20% to 75%.