Background
Continuous quality improvement (CQI) initiative is a crucial initiative aimed at enhancing quality in the health system that has gradually been adopted in the healthcare industry. In the early 20th century, Shewhart laid the foundation for quality improvement by describing three essential steps for process improvement: specification, production, and inspection [
1,
2]. Then, Deming expanded Shewhart’s three-step model into ‘plan, do, study/check, and act’ (PDSA or PDCA) cycle, which was applied to management practices in Japan in the 1950s [
3] and was gradually translated into the health system. In 1991, Kuperman applied a CQI approach to healthcare, comprising selecting a process to be improved, assembling a team of expert clinicians that understands the process and the outcomes, determining key steps in the process and expected outcomes, collecting data that measure the key process steps and outcomes, and providing data feedback to the practitioners [
4]. These philosophies have served as the baseline for the foundation of principles for continuous improvement [
5].
Continuous quality improvement fosters a culture of continuous learning, innovation, and improvement. It encourages proactive identification and resolution of problems, promotes employee engagement and empowerment, encourages trust and respect, and aims for better quality of care [
6,
7]. These characteristics drive the interaction of CQI with other quality improvement projects, such as quality assurance and total quality management [
8]. Quality assurance primarily focuses on identifying deviations or errors through inspections, audits, and formal reviews, often settling for what is considered ‘good enough’, rather than pursuing the highest possible standards [
9,
10], while total quality management is implemented as the management philosophy and system to improve all aspects of an organization continuously [
11].
Continuous quality improvement has been implemented to provide quality care. However, providing effective healthcare is a complicated and complex task in achieving the desired health outcomes and the overall well-being of individuals and populations. It necessitates tackling issues, including access, patient safety, medical advances, care coordination, patient-centered care, and quality monitoring [
12,
13], rooted long ago. It is assumed that the history of quality improvement in healthcare started in 1854 when Florence Nightingale introduced quality improvement documentation [
14]. Over the passing decades, Donabedian introduced structure, processes, and outcomes as quality of care components in 1966 [
15]. More comprehensively, the Institute of Medicine in the United States of America (USA) has identified effectiveness, efficiency, equity, patient-centredness, safety, and timeliness as the components of quality of care [
16]. Moreover, quality of care has recently been considered an integral part of universal health coverage (UHC) [
17], which requires initiatives to mobilise essential inputs [
18].
While the overall objective of CQI in health system is to enhance the quality of care, it is important to note that the purposes and principles of CQI can vary across different contexts [
19,
20]. This variation has sparked growing research interest. For instance, a review of CQI approaches for capacity building addressed its role in health workforce development [
21]. Another systematic review, based on random-controlled design studies, assessed the effectiveness of CQI using training as an intervention and the PDSA model [
22]. As a research gap, the former review was not directly related to the comprehensive elements of quality of care, while the latter focused solely on the impact of training using the PDSA model, among other potential models. Additionally, a review conducted in 2015 aimed to identify barriers and facilitators of CQI in Canadian contexts [
23]. However, all these reviews presented different perspectives and investigated distinct outcomes. This suggests that there is still much to explore in terms of comprehensively understanding the various aspects of CQI initiatives in healthcare.
As a result, we conducted a scoping review to address several aspects of CQI. Scoping reviews serve as a valuable tool for systematically mapping the existing literature on a specific topic. They are instrumental when dealing with heterogeneous or complex bodies of research. Scoping reviews provide a comprehensive overview by summarizing and disseminating findings across multiple studies, even when evidence varies significantly [
24]. In our specific scoping review, we included various types of literature, including systematic reviews, to enhance our understanding of CQI.
This scoping review examined how CQI is conceptualized and measured and investigated models and tools for its application while identifying implementation challenges and facilitators. It also analyzed the purposes and impact of CQI on the health systems, providing valuable insights for enhancing healthcare quality.
Discussion
In this review, we examined the fundamental concepts and principles underlying CQI, the factors that either hinder or assist in its successful application and implementation, and the purpose of CQI in enhancing quality of care across various health issues.
Our findings have brought attention to the application and implementation of CQI, emphasizing its underlying concepts and principles, as evident in the existing literature [
31‐
36,
39,
40,
43,
45,
46]. Continuous quality improvement has shared with the principles of continuous improvement, such as a customer-driven focus, effective leadership, active participation of individuals, a process-oriented approach, systematic implementation, emphasis on design improvement and prevention, evidence-based decision-making, and fostering partnership [
5]. Moreover, Deming’s 14 principles laid the foundation for CQI principles [
109]. These principles have been adapted and put into practice in various ways: ten [
19] and five [
38] principles in hospitals, five principles for capacity building [
38], and two principles for medication error prevention [
41]. As a principle, the application of CQI can be process-focused [
8,
19] or impact-focused [
38]. Impact-focused CQI focuses on achieving specific outcomes or impacts, whereas process-focused CQI prioritizes and improves the underlying processes and systems. These principles complement each other and can be utilized based on the objectives of quality improvement initiatives in healthcare settings. Overall, CQI is an ongoing educational process that requires top management’s involvement, demands coordination across departments, encourages the incorporation of views beyond clinical area, and provides non-judgemental evidence based on objective data [
110].
The current review recognized that it was not easy to implement CQI. It requires reasonable utilization of various models and tools. The application of each tool can be varied based on the studied health problem and the purpose of CQI initiative [
111], varied in context, content, structure, and usability [
112]. Additionally, overcoming the cultural, technical, structural, and strategic-related barriers. These barriers have emerged from clinical staff, managers, and health systems perspectives. Of the cultural obstacles, staff non-involvement, resistance to change, and reluctance to report error were staff-related. In contrast, others, such as the absence of celebration for success and hierarchical and rational culture, may require staff and manager involvement. Staff members may exhibit reluctance in reporting errors due to various cultural factors, including lack of trust, hierarchical structures, fear of retribution, and a blame-oriented culture. These challenges pose obstacles to implementing standardized CQI practices, as observed, for instance, in community pharmacy settings [
85]. The hierarchical culture, characterized by clearly defined levels of power, authority, and decision-making, posed challenges to implementing CQI initiatives in public health [
41,
86]. Although rational culture, a type of organizational culture, emphasizes logical thinking and rational decision-making, it can also create challenges for CQI implementation [
41,
86] because hierarchical and rational cultures, which emphasize bureaucratic norms and narrow definitions of achievement, were found to act as barriers to the implementation of CQI [
86]. These could be solved by developing a shared mindset and collective commitment, establishing a shared purpose, developing group norms, and cultivating psychological preparedness among staff, managers, and clients to implement and sustain CQI initiatives. Furthermore, reversing cultural-related barriers necessitates cultural-related solutions: development of a culture and group culture to CQI [
41,
86], positive comprehensive perception [
91], commitment [
85], involving patients, families, leaders, and staff [
39,
92], collaborating for a common goal [
80,
86], effective teamwork [
86,
87], and rewarding and celebrating successes [
80,
90].
The technical dimension barriers of CQI can include inadequate capitalization of a project and insufficient support for CQI facilitators and data entry managers [
36], immature electronic medical records or poor information systems [
36,
86], and the lack of training and skills [
86‐
88]. These challenges may cause the CQI team to rely on outdated information and technologies. The presence of barriers on the technical dimension may challenge the solid foundation of CQI expertise among staff, the ability to recognize opportunities for improvement, a comprehensive understanding of how services are produced and delivered, and routine use of expertise in daily work. Addressing these technical barriers requires knowledge creation activities (training, seminar, and education) [
39,
42,
53,
69,
86,
90,
91], availability of quality data [
86], reliable information [
92], and a manual-online hybrid reporting system [
85].
Structural dimension barriers of CQI include inadequate communication channels and lack of standardized process, specifically weak physician-to-physician synergies [
36], lack of mechanisms for disseminating knowledge and limited use of communication mechanisms [
86]. Lack of communication mechanism endangers sharing ideas and feedback among CQI teams, leading to misunderstandings, limited participation and misinterpretations, and a lack of learning [
113]. Knowledge translation facilitates the co-production of research, subsequent diffusion of knowledge, and the developing stakeholder’s capacity and skills [
114]. Thus, the absence of a knowledge translation mechanism may cause missed opportunities for learning, inefficient problem-solving, and limited creativity. To overcome these challenges, organizations should establish effective communication and information systems [
86,
93] and learning systems [
92]. Though CQI and knowledge translation have interacted with each other, it is essential to recognize that they are distinct. CQI focuses on process improvement within health care systems, aiming to optimize existing processes, reduce errors, and enhance efficiency.
In contrast, knowledge translation bridges the gap between research evidence and clinical practice, translating research findings into actionable knowledge for practitioners. While both CQI and knowledge translation aim to enhance health care quality and patient outcomes, they employ different strategies: CQI utilizes tools like Plan-Do-Study-Act cycles and statistical process control, while knowledge translation involves knowledge synthesis and dissemination. Additionally, knowledge translation can also serve as a strategy to enhance CQI. Both concepts share the same principle: continuous improvement is essential for both. Therefore, effective strategies on the structural dimension may build efficient and effective steering councils, information systems, and structures to diffuse learning throughout the organization.
Strategic factors, such as goals, planning, funds, and resources, determine the overall purpose of CQI initiatives. Specific barriers were improper goals and poor planning [
36,
86,
88], fragmentation of quality assurance policies [
87], inadequate reinforcement to staff [
36,
90], time constraints [
85,
86], resource inadequacy [
86], and work overload [
86]. These barriers can be addressed through strengthening leadership [
86,
87], CQI-based mentoring [
94], periodic monitoring, supportive supervision and coaching [
43,
53,
87,
92,
95], participation, empowerment, and accountability [
67], involving all stakeholders in decision-making [
86,
87], a provider-payer partnership [
64], and compensating staff for after-hours meetings on CQI [
85]. The strategic dimension, characterized by a strategic plan and integrated CQI efforts, is devoted to processes that are central to achieving strategic priorities. Roles and responsibilities are defined in terms of integrated strategic and quality-related goals [
115].
The utmost goal of CQI has been to improve the quality of care, which is usually revealed by structure, process, and outcome. After resolving challenges and effectively using tools and running models, the goal of CQI reflects the ultimate reason and purpose of its implementation. First, effectively implemented CQI initiatives can improve leadership, health financing, health workforce development, health information technology, and availability of supplies as the building blocks of a health system [
31,
48,
53,
68,
98]. Second, effectively implemented CQI initiatives improved care delivery process (counselling, adherence with standards, coordination, collaboration, and linkages) [
48,
53,
65,
68]. Third, the CQI can improve outputs of healthcare delivery, such as satisfaction, accessibility (timely access, utilization), continuity of care, safety, efficiency, and acceptability [
52,
54,
55,
76,
78]. Finally, the effectiveness of the CQI initiatives has been tested in enhancing responses related to key aspects of the HIV response, maternal and child health, non-communicable disease control, and others (e.g., surgery and peritonitis). However, it is worth noting that CQI initiative has not always been effective. For instance, CQI using a two- to nine-times audit cycle model through systems assessment tools did not bring significant change to increase syphilis testing performance [
116]. This study was conducted within the context of Aboriginal and Torres Strait Islander people’s primary health care settings. Notably, ‘the clinics may not have consistently prioritized syphilis testing performance in their improvement strategies, as facilitated by the CQI program’ [
116]. Additionally, by applying CQI-based mentoring, uptake of facility-based interventions was not significantly improved, though it was effective in increasing community health worker visits during pregnancy and the postnatal period, knowledge about maternal and child health and exclusive breastfeeding practice, and HIV disclosure status [
117]. The study conducted in South Africa revealed no significant association between the coverage of facility-based interventions and Continuous Quality Improvement (CQI) implementation. This lack of association was attributed to the already high antenatal and postnatal attendance rates in both control and intervention groups at baseline, leaving little room for improvement. Additionally, the coverage of HIV interventions remained consistently high throughout the study period [
117].
Regarding health care and policy implications, CQI has played a vital role in advancing PHC and fostering the realization of UHC goals worldwide. The indicators found in Donabedian’s framework that are positively influenced by CQI efforts are comparable to those included in the PHC performance initiative’s conceptual framework [
29,
118,
119]. It is clearly explained that PHC serves as the roadmap to realizing the vision of UHC [
120,
121]. Given these circumstances, implementing CQI can contribute to the achievement of PHC principles and the objectives of UHC. For instance, by implementing CQI methods, countries have enhanced the accessibility, affordability, and quality of PHC services, leading to better health outcomes for their populations. CQI has facilitated identifying and resolving healthcare gaps and inefficiencies, enabling countries to optimize resource allocation and deliver more effective and patient-centered care. However, it is crucial to recognize that the successful implementation of Continuous Quality Improvement (CQI) necessitates optimizing the duration of each cycle, understanding challenges and barriers that extend beyond the health system and settings, and acknowledging that its effectiveness may be compromised if these challenges are not adequately addressed.
Despite abundant literature, there are still gaps regarding the relationship between CQI and other dimensions within the healthcare system. No studies have examined the impact of CQI initiatives on catastrophic health expenditure, effective service coverage, patient-centredness, comprehensiveness, equity, health security, and responsiveness.
Limitations
In conducting this review, it has some limitations to consider. Firstly, only articles published in English were included, which may introduce the exclusion of relevant non-English articles. Additionally, as this review follows a scoping methodology, the focus is on synthesising available evidence rather than critically evaluating or scoring the quality of the included articles.