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Management eBrief No. 195

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Management eBriefs
Issue 195 February 2022

The report is a product of the VA/HSR&D Evidence Synthesis Program.

Continuous Quality Improvement (CQI) for Clinical Teams: A Systematic Review of Reviews

Continuous quality improvement (CQI) frameworks are system-level approaches to improving the quality and safety of healthcare with three essential features: systematic data-guided activities, iterative development and testing of processes, and designing with local conditions in mind. In December 2019, the Deputy Under Secretary for Health issued a directive outlining the deployment of a new VA-wide program for Systems Redesign and Improvement. As part of this directive, Lean Management was designated as the primary CQI framework to be used across the VA healthcare system. However, there is uncertainty as to whether Lean is superior to other CQI frameworks, such as Six Sigma or Clinical Microsystems. There is also uncertainty as to whether certain intervention-level or health system-level factors affect the success or failure of specific CQI methodologies, such as rigorous training of staff or health system academic affiliation.


Lean Management (Lean) – a process adapted from a 1930s manufacturing model by the Toyota Corporation that seeks to increase efficiencies and reduce waste – has been applied to a variety of medical and industrial settings and is one of the most popular CQI frameworks in healthcare settings.

VA’s Evidence Synthesis Program (ESP) Center in West Los Angeles, CA, conducted a systematic review of reviews to determine whether any CQI framework is superior to others and what Consolidated Framework for Implementation Research (CFIR) factors contribute to success or failure of CQI initiatives. Investigators searched PubMed (1/1/2010 – 3/18/21), CINAHL and Cochrane (1/1/2010 – 3/30/2021), and DARE (1/1/2010 – 3/31/2015) databases. From 136 articles that were given a full-text review, 36 met study inclusion criteria. Of these reviews, 29 used traditional systematic review methodology and were assessed using the modified AMSTAR2 (A Measurement Tool to Assess systematic Reviews) tool.

Summary of Findings

  • This systematic review of reviews found that no CQI method is preferred, but many studies have shown success for different CQI frameworks in specific contexts, such as operating rooms and emergency departments.
    • Of the 36 included reviews, only one compared the effectiveness of different frameworks. This review found no evidence that any single CQI strategy was more effective than any others in quality or safety improvement and concluded that the local context should guide which framework is ultimately implemented. None of the other 11 reviews of more than one CQI method compared effectiveness between different frameworks.
  • Few systematic reviews had high ratings on a modified AMSTAR2 tool, leading to the conclusion that the overall certainty of evidence related to these topics is low to moderate.
  • Evidence gaps remain regarding whether any CQI strategy is superior to others or how any such methodology should be implemented on a large scale within the VA healthcare system.
  • No systematic reviews discussed healthcare workers’ reactions, learning, or behavior changes related to participating in CQI. Similarly, while some systematic reviews mentioned aspects of the Consolidated Framework for Implementation Research (CFIR) factors of intervention characteristics, characteristics of individuals, and inner settings of organizations, no review compared the success or failure of different CQI frameworks based on differences in these factors.
  • No studies discussed whether either the CFIR factors of outer setting or specific processes during implementation of a CQI framework contributed to either the success or failure of implementation of any methodology.

Implications for VA

Several studies included work done within VA as part of their larger reviews. However, across included reviews, there were limited data on intervention and setting characteristics to compare to the overall VA population. Nevertheless, the findings likely have applicability to any large healthcare system seeking to implement a multi-site improvement methodology. Further, within VA, there are several ongoing initiatives that use CQI methodologies or frameworks with CQI elements, such as the VA Quality Enhancement Research Initiative (QUERI) Evidence-Based Quality Improvement (EBQI) Training Hub and The Learn. Engage. Act. Process. (LEAP) Program, in addition to the focus on Lean in systems redesign. These current efforts may not be represented universally in the published literature, nor were any of these initiatives specifically identified in the systematic reviews that comprised this review of reviews, but these initiatives may provide opportunities for future comparative evaluations of CQI methods.

This current review of reviews was requested by the VA Office of Systems Redesign and Improvement (SRI), which is charged with partnering with Veterans Integrated Service Networks (VISNs) in implementing the aforementioned 2019 Directive. This report will be used to identify effective CQI frameworks and conditions necessary for their success for dissemination and training across VA by the SRI.

Future Research

Future work should emphasize comparative designs for CQI methodologies. Available resources at VA may help facilitate such work in the future. Overall, this comprehensive review identified several gaps in the current evidence that warrant future investigation, even across studies with higher AMSTAR2 ratings. The most notable of these gaps is a lack of comparative studies analyzing multiple CQI methodologies within healthcare settings. As noted above, current VA efforts from resources such as the EBQI or LEAP programs may provide opportunities to promote such comparative investigations.




Boggan JC, Shekelle PG, Mak SS, Burton J, Begashaw MM, Miake-Lye IM. Continuous Quality Improvement (CQI) for Clinical Teams: A Systematic Review of Reviews. Los Angeles: Evidence Synthesis Program, Health Services Research and Development Service, Office of Research and Development, Department of Veterans Affairs. VA ESP Project #05-226; 2021. 

To view the full report, go to vaww.hsrd.research.va.gov/publications/esp/continuous-qi.cfm (Intranet only)

ESP is currently soliciting review topics from the broader VA community. Nominations will be accepted electronically using the online Topic Submission Form. If your topic is selected for a synthesis, you will be contacted by an ESP Center to refine the questions and determine a timeline for the report.



This Management e-Brief is provided to inform you about recent HSR&D findings that may be of interest. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs. If you have any questions or comments about this Brief, please email CIDER. The Center for Information Dissemination and Education Resources (CIDER) is a VA HSR&D Resource Center charged with disseminating important HSR&D findings and information to policy makers, managers, clinicians, and researchers working to improve the health and care of Veterans.

This report is a product of VA/HSR&D's Evidence Synthesis Program (ESP), which was established to provide timely and accurate synthesis of targeted healthcare topics of particular importance to VA managers and policymakers –; and to disseminate these reports throughout VA.

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