Another key feature of the QI definition is measurable. If something cannot be measured, it cannot be improved. A usable taxonomy of health-care quality was first developed by Avedis Donabedian, who divided it into structure, process , and outcome [7]. Structural elements include, for example, whether all physicians in a practice are board certified, or whether a hospital offers advanced treatments such as transjugular intrahepatic portosystemic shunt (TIPS). Processes reflect evidence-based medical decision making and health-care-related activity, such as prescribing antibiotics for secondary prophylaxis of spontaneous bacterial peritonitis (SBP). Outcomes can be intermediate endpoints such as re-bleeding rate after endoscopic hemostasis of varices, or more distal measures such as mortality or health-related quality of life. Although the ultimate goal of medicine is to improve quality and/or quantity of life, outcome measurement is susceptible to confounding variables, statistical error, provider manipulation, and may depend on many factors—many of which are not under the control of health-care providers [8]. In addition, with distal outcomes such as mortality, it is often difficult to determine what changes should be implemented to create improvement. Therefore, most quality measurement focuses on either processes or intermediate outcomes. Kanwal et al. have proposed a set of 41 process measures for cirrhosis [9]. These measures, which were developed from the literature review and input from a multidisciplinary expert panel, provide a useful starting point for QI efforts—some examples are provided in Table 33.1.

Additional quality measures of importance include patient-centered measures, such as knowledge, self-efficacy, and satisfaction with care. Most medical interventions require an engaged patient to carry them out, and the extent to which a clinician educates and involves the patient in the decision-making process (i.e., shared decision making) is an important feature of quality care. We surveyed patients in our practice, and found that many lacked the critical basic knowledge to manage their disease; for example, 58 % thought that a low-sodium diet included the use of sea salt! Patients’ knowledge about their condition and its management improved significantly after implementing a structured education program in our practice (Fig. 33.2) [10].

There are numerous approaches to QI, such as Six Sigma or Lean [11]. Most of these philosophies come from the manufacturing sector, and consultants can be hired to advise physicians and practices on QI. However, not only can this be costly but hiring external consultants also goes against the principles that QI needs to be continuous and driven by those doing the daily work. Therefore, in many instances, a provider group may be better served to develop their own system. The following steps outline a practical approach: