Measuring and improving quality of care in an academic medical center.

The Donabedian definition of quality—structure, process, and outcome—provides a useful framework. A relentless focus on measuring process adherence and outcome is critical. Systemic improvements usually require teams to plan and to implement them. The lean or Toyota production system for process improvement is one useful method of organizing work, although different approaches are often necessary at the physician, practice unit, and statewide level. Challenges include scalability of the change (ie, rolling them out across the institution or system), tailoring the information technology tools, and building systems for sustainability.