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AHRQ: Agency for Healthcare Research and Quality

Approaches to Quality Improvement

Quality improvement is a "systematic, formal approach to the analysis of practice performance and efforts to improve performance."1 In practice, this term means improving the practice's operations in a way that provides the best care possible while causing the least strain on staff due to errors, slowdowns, and confusion. To successfully implement new practices, such as medications for OUD, build a practice culture that supports quality improvement and integrate these efforts into the practice's standard processes.1

Note. The rest of this module may be more practical for larger practices that provide more comprehensive, whole-person treatment for OUD or for practices that conduct clinical research.

You can use or adapt several different models or approaches to quality improvement based on your individual needs and capacity. For example:

Each of these models is based on a similar set of principles that could help guide your practice's quality improvement efforts as you implement medications for OUD. The Playbook does not endorse one model over another but rather highlights some of the core principles of quality improvement that are common among different approaches.

Not all primary care practices that treat people with OUD are able to implement rigorous quality improvement practices or initiatives. However, at a minimum, try to identify realistic and feasible improvements given the context of your practice.

The practice continually identifies opportunities to improve the performance, quality of patient care, and confidence of clinicians and staff in their own operations and teamwork. The practice uses the data generated by patient care to monitor and improve performance.

Systematically tracking quality measures (also known as "performance measures") will help identify areas in need of improvement; set measurable goals for change; and evaluate the effectiveness of a new policy, process, or procedure.1 Measures can be used for quality improvement initiatives, benchmarking against other providers or organizations, and accountability.2 Performance measures can also be similar, if not the same, as those used for Tracking Patient Progress and simply used for additional purposes.

Consider the practice's strengths and weaknesses, and identify areas for improvement such as issues related to access, implementation, and outcomes:

Access: Patients may experience gaps in service coverage or other barriers to care, as evidenced by long waits for care, high no-show rates or loss to follow-up. Consider tracking measures related to the number of patients on a waiting list, time elapsed between first contact and patient's first treatment services, time elapsed between follow-up visits, and similar measures.

Implementation: Practices may need to improve their processes to identify patients with OUD, attitudes toward those with OUD or other SUDs, capacity to serve patients with OUD, or confidence in team function and shared workflows. Related performance measures may include:

  • Number of providers and staff trained to understand OUD and treatment best practices;
  • Number of new patients started on medications for OUD;
  • Percentage of patients being prescribed medications for OUD among those with an OUD;
  • Number of patients served by the practice;
  • Proportion of eligible providers who are willing to prescribe medications for OUD;
  • Proportion of providers actively prescribing medications for OUD;
  • Proportion of providers prescribing medications for OUD to at least XX patients, where XX can be any minimum number of patients of interest; and
  • Average caseload (of patients with OUD) per prescriber.

Outcomes: Additional areas for improvement related to the impact of the MOUD practice on patient outcomes include reduction in opioid and other substance use, retention in treatment, patient functioning, follow-up and engagement with external referrals, overdose rates, utilization of hospital services, impact of co-occurring conditions, and other health outcomes among more complex patients. To measure progress in these areas, providers may consider monitoring:

  • Retention rates (30-day, 60-day, 90-day, 6-month, 1 year);
  • Continuous MOUD refills;
  • Health-related quality of life scores;
  • Functional outcomes;
  • Patient satisfaction;
  • Form: Patient Health Questionnaire-2 (PHQ-2) scores;
  • Pain, Enjoyment, and General Activity (PEG) scores (among patients with chronic pain);
  • Participation in counseling or other recovery supports; and
  • Mortality rates.

The measures used will vary based on the practice's goals, model, and capacity for analysis. When selecting measures, consider the time and resources needed to collect and analyze these data. It is best to start by selecting one or more measures that are both important to the practice or patient population and reasonable to measure with existing resources.3

How will data be collected? Determine the intervals at which data will be collected for each measure they focus on at any given time. When choosing quality measures, consider the burden on providers, staff, and patients to collect the data as well as how data will be stored (e.g., electronic health record system, care registry, separate database, or spreadsheet). Use data from existing sources whenever possible. Note that some of the phone- or computer-based apps designed to provide treatment and support recovery for people with OUD or other SUDs include patient reported outcome measures that can be shared with the provider with patient consent. The apps can thus provide a low-burden approach to obtaining helpful outcome data.

How will data be analyzed and reported? Decide how frequently to conduct data analysis and summarize the results. Consider whether performance indicators will be reported across the entire practice that treats OUD, by care team, or specifically by provider.

When undertaking quality improvement initiatives, consider any barriers to change in the practice, such as internal resistance due to negative attitudes, a lack of understanding, or competing priorities. The Network for the Improvement of Addiction Treatment (NIATx) recommends picking a powerful change leader with the respect, authority, and time to help with these quality improvement activities.4 Also, involving stakeholders from across the practice in the planning and implementation of any changes will provide unique insight from members with different roles and will encourage staff buy-in.

Some practices may also need additional external support from other individuals or organizations to help with quality improvement efforts, such as5:

  • Data feedback and benchmarking: Offers feedback on key quality indicators and allows practices to compare performance with other practices and providers. It can identify areas for improvement and provide motivation to change.
  • Practice facilitation or practice coaching: Helps build the practice's skills and internal capacity for quality improvement through sharing of tools, resources, and expertise.
  • Expert consultation: Encourages adoption of best practices by sharing knowledge and experience.
  • Learning collaboratives: Creates a community to collaborate among peers, share lessons learned, and promote a culture of quality improvement.

These external supports may come from a variety of sources such as quality improvement organizations, practice-based research networks, professional organizations, and public or private insurers.6 Check for local organizations, state practices, or federally funded initiatives that may be available.

"While all changes do not lead to improvement, all improvements require change. The ability to develop, test, and implement changes is essential for any individual, group, or organization that wants to continuously improve."7

Whenever possible, change your practice based on data collected and analyzed by your practice. After selecting an area for improvement, create goals or objectives for the desired changes. These goals should be SMART (S-Specific, M-Measurable, A-Achievable, R-Realistic/Relevant, T-Timely).

Plan-Do-Study-Act (PDSA) Cycles: Changes can be implemented and tested with a process such as the PDSA cycle. PDSA is a series of short, rapid cycles in which changes are tested first on a small scale, adjusted if needed, and then fully implemented when the results indicate significant improvement. This incremental method of implementing and testing changes helps minimize resources invested until a change has demonstrated significant impact. Starting on a small scale also allows practices to make changes in a manner that is less disruptive to clients and staff and less likely to encounter staff resistance.8

The stages of a PDSA Cycle are:9

  • Plan—Identify the purpose and goal of the change. Develop a plan to test the change, including who should be involved and how data will be collected and analyzed.
  • Do—Implement the change on a small scale. Collect data and document any problems or unexpected observations.
  • Study—Analyze the data and compare the results with your predicted outcome. Summarize and reflect on what you have learned so far.
  • Act—Plan for the next steps you will take based on the results of the test. Consider whether the change should be adopted (implement and test on a larger scale), adapted (modify the change and begin a new PDSA cycle), or abandoned (stop testing this change idea).

Lean Management Principles: The focus of lean management principles is eliminating waste and maximizing value to the patient by streamlining processes and workflows. This approach has been used effectively in manufacturing companies for decades, particularly in Japan. Learn more about lean management principles in the Institute for Healthcare Improvement's white paper Going Lean in Health Care.

Communicating the Results: Share successes of quality improvement efforts with providers and staff in your practice. It can create a positive feedback loop in which seeing discernible changes and improvements will help gain staff buy-in for future quality improvement initiatives.

  • Don't forget that quality improvement is an ongoing process, not a singular initiative.
  • Don't jump right in and make a change. Collect baseline data first so you can see if the change has a measurable effect.

1. American Academy of Family Physicians. Basics of Quality Improvement. AAFP. 2025. Accessed April 29, 2025. https://www.aafp.org/family-physician/practice-and-career/managing-your-practice/quality-improvement-basics.html

2. American Academy of Family Physicians. Quality Measures. AAFP. Accessed March 11, 2025. https://www.aafp.org/family-physician/practice-and-career/managing-your-practice/quality-measures.html

3. Six Building Blocks. Measuring success metrics. Published online 2018. https://depts.washington.edu/fammed/improvingopioidcare/wp-content/uploads/sites/12/2018/05/Measuring-success-metrics_2018-05-16.pdf

4. University of Wisconsin-Madison. NIATx as an Evidence-based Practice. NIATx. 2025. Accessed April 29, 2025. https://niatx.wisc.edu/niatx-as-an-evidence-based-practice/

5. Agency for Healthcare Research and Quality. The EvidenceNOW Model: Providing External Support for Primary Care. AHRQ. 2025. Accessed April 30, 2025. https://www.ahrq.gov/evidencenow/model/index.html

6. Agency for Healthcare Research and Quality. Quality Improvement in Primary Care. AHRQ. 2020. Accessed April 29, 2025. https://admin.ahrq.gov/research/findings/factsheets/quality/qipc/index.html

7. Institute for Healthcare Improvement. How to Improve: Model for Improvement: Selecting Changes. IHI. Accessed April 30, 2025. https://www.ihi.org/how-improve-model-improvement-selecting-changes

8. Institute for Healthcare Improvement. How to Improve: Model for Improvement: Testing Changes. IHI. Accessed May 2, 2025. https://www.ihi.org/how-improve-model-improvement-testing-changes

9. Institute for Healthcare Improvement. Quality Improvement Essentials Toolkit. IHI. Accessed April 29, 2025. https://www.ihi.org/resources/tools/quality-improvement-essentials-toolkit