Process Improvement Engagement is the Key to Operational Excellence: A Pilot Study

Authors: Jeff Blake, RPh, BCSCP; Lisa Siefert, RPh, FASHP, ASQ-CMQ/OE; Amanda Bardwell, RN; Aubrey Hersch, PharmD; KayCee Harmon, RN, CRNI

Background

Quality management standards from CMS and accrediting bodies require organizations to integrate operational, clinical, and safety practices. This analysis examines whether engagement in a structured Performance Improvement (PI) program within a national specialty and home infusion pharmacy correlates with stronger internal audit performance and indicators of operational excellence.

Discussion

Improved PI engagement, clearer expectations, and accreditation‑aligned training strengthened audit performance, expanded high‑performing locations, and demonstrated PI participation as a key driver of sustained quality and operational excellence.

• Enhanced PI participation strengthened overall audit reliability and consistency
• PI engagement emerged as a key lever for sustaining long‑term organizational excellence
• Growth in ≥90% scoring locations reflects maturing quality practices organization‑wide
• Apply pilot insights to guide expansion of the study.

Purpose

This analysis evaluates whether engagement in Performance Improvement (PI) activities by both location leadership and frontline teams correlates with stronger internal audit outcomes. Findings will guide targeted training, resource allocation, and future support strategies across clinical operations.

Methods

The Clinical Services team conducted a three-year retrospective review of Performance Improvement data from 2023-2025. Engagement was scored using:

• Only locations participating in both internal audits and PI activities were included. Q4 2025 data were excluded due to unavailability.
• All locations are fully accredited, internal audits include measures of operating process compliance, which can be more rigorous than accreditation standards.  

2025 engagement correlated with audit performance (r = 0.73; 0.59)

• 5.2% Increase in Engagement Scores
• 14.8% Improvement in Total Audit Performance
• 31.6% improvement in PI-specific audit scores

Conclusions

The organization’s leadership engagement in its PI program is associated with improved internal audit outcomes, including a notable increase in locations achieving ≥90% on both PI‑specific and total audit scores. Higher PI engagement shows positive associations with both PI‑focused and overall audit performance, reinforcing the value of consistent participation and timely review completion. These results underscore the importance of the Clinical Services team’s efforts to develop resources that support education for new team members and managers on PI expectations and activities.

Authors of this presentation disclose the following concerning possible financial or personal relationships with commercial entities that may have a direct or indirect interest in the subject matter of this presentation: Nothing to disclose.

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