











































MANUSCRIPT TYPE


EDITORIAL 

 

3 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                              Volume 3 – Issue 2 – June 2020 
 

 
 

Rethinking Quality Improvement in Athletic Health Care  
Matthew J. Rivera, DAT, LAT, ATC & Kenneth E. Games, PhD, LAT, ATC 
Indiana State University, Terre Haute, IN 
 
 
Key Phrases 
Continuous Improvement, systems-level, individual 
process improvement 
 
Correspondence 
Dr. Matthew Rivera, Indiana State University, 567 N. 
5th Street, Terre Haute, IN 47809. 
Email: Matthew.Rivera@indstate.edu 
Twitter: @Matt_RiveraDAT  
 
 
Full Citation 
Rivera MJ & Games KE. Rethinking quality 
improvement in athletic health care. Clin Pract Athl 
Train. 2020;3(2): 3-5. 
https://doi.org/10.31622/2020/0002.2.     

 
 
EDITORIAL 

The concept of continuous quality improvement 
(CQI) has gained more recognition within the 
profession of athletic training in recent years. 
With the new transition into the professional-level 
master’s degree and the Commission on 
Accreditation of Athletic Training Education 
standards related to quality assurance in health 
care, it is no surprise that we are starting to talk 
about CQI more seriously. The purpose of this 
editorial is to speak frankly to our audience 
about how potentially unattainable large-scale, 
systems-level CQI is for an individual athletic 
trainer. From a behavioral change perspective, 
we are asking athletic trainers to equivocally 
overtake a mountain with no training. Our goal is 
to make CQI achievable for each athletic trainer 
in their own system, on their own terms. Some 
may question this philosophy, but because we 
are relative infants in this world of quality 
improvement, we propose an alternative. 

Forms of CQI can vary, which may cause 
confusion, especially since formal training has 
been omitted in athletic training education to this 

point. Currently, a majority of the literature that 
exists in athletic training that focuses on CQI 
involves broad-level, large systems process 
improvement. Here, practicing athletic trainers 
serve to enter data into large databases such as 
the Athletic Training Practice-Based Research 
Network (ATPBRN); High School Reporting 
Information Online (High School RIO), National 
Athletic Treatment, Injury, and Outcomes Network 
(NATION); or NCAA Injury Surveillance Program. 
This evidence and information is meaningful and 
informs clinical practice in a way that can help us 
align our practice with best evidence. But, this 
asks athletic trainers not to reflect on their own 
practice or system, but to enter data to inform 
the larger profession. Meaningful, but not the 
fuel necessary to create change within their own 
practice. 

There is a need for athletic trainers to share their 
experiences and data that they gather both in 
individual and systems level CQI processes. By 
sharing these experiences through dissemination, 
other athletic trainers can become aware of 
these individual CQI processes and improve their 
own practice. This identification and initial 
process improvement at the individual level is 
what will aid in athletic trainers becoming 
involved in process improvement within their 
organization at a system-level (Figure 1). 
Imagine an athletic trainer at a secondary school 
performs a small scale improvement project with 
a specific patient panel that they provide care 
for. They implement incremental change and 
track outcomes to make data driven decisions on 
the improvement project. This athletic trainer can 
then share their findings with another athletic 
trainer at the secondary school or at a similar 
school within the same system (e.g. healthcare 
system). They collaborate to expand the project. 
This shared project can then continue to grow 
between schools and eventually become a 

mailto:Matthew.Rivera@indstate.edu
https://doi.org/10.31622/2020/0002.2


Rethinking Quality Improvement in Athletic Health Care    

 

4 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                              Volume 3 – Issue 2 – June 2020 
 

project that is implemented within the whole 
system. This is the eventual goal of CQI on the 
system-level. However, these progressive steps 
remain grounded in individual action.   

Systems-based evaluation of clinical outcomes is 
the pinnacle of CQI, but there are many 
different frameworks, theories, or approaches to 
CQI in health care, most of which require action 
down to an individual level. Regardless of the 
patient care or process that is the target for 
improvement, individual actions will lead to 
overall, sustainable change within the system. It is 
these individual actions that can build upon one 
another, spread across multiple providers that 
can lead to larger process improvement and 
larger change. This initiation of CQI at an 
individual level can fuel the momentum into 
larger systems-level change. 

There are many different CQI practices that 
athletic trainers can begin to implement on either 
an individual or systems-level. We have 
summarized a small portion of these in Table 1 
to help begin to expose athletic trainers to these 
methods. Of particular interest within athletic 
training is the practice of checklist or standard 

work. By creating tools such as checklists for the 
processes within an athletic training clinic 
individual athletic trainers can help mitigate 
errors or make requirements explicit can help 
ensure quality of care. Further, by standardizing 
the processes or the work in individual clinics 
athletic trainers can ensure that work is done in a 
consistent way, leading to improvements in care.  

With the addition of quality assurance in the 
CAATE Standards as well as the push for CQI in 
health care it is important we continue to 
disseminate the findings of athletic trainers from 
various settings using various CQI methodologies. 
Therefore we are excited to announce the 
expansion of our Quality Improvement Section to 
include more methods than the Model of 
Improvement (Plan, Do, Study, and Act (PDSA) 
cycle) to include various CQI methodologies 
examining improvements in practice. Readers can 
find the new expanded section at our Manuscript 
Guidelines. We encourage authors to consider 
submitting their work in CQI for consideration for 
publication to continue to disseminate their 
experiences and help other athletic trainers learn 
and engage with improvement measures.  

Figure 1. Translation of Individual PDA Cycles to Systems-Level Approach 

http://clinat.indstate.edu/index.php/clinat/qi
http://clinat.indstate.edu/index.php/clinat/qi


Rethinking Quality Improvement in Athletic Health Care    

 

5 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                              Volume 3 – Issue 2 – June 2020 
 

  

Table 1. Continuous Quality Improvement Practices  
Tool Brief Description and When to Use 

Affinity Diagram1 

Affinity diagrams are the organized output of brainstorming with a group 
of individuals.  Affinity diagrams can be used when: 
• A problem must be solved at all costs 
• An easy solution is not found 
• Time is needed to analyze the problem 
• Participation of individuals promotes mutual understanding 

Waste Reduction2 

Waste reduction is a strategy to improve the function of a system by 
eliminating waste.  Common examples of where waste can be found 
include overproduction (e.g. unnecessary referrals), waiting, unnecessary 
processing, staff movement, defects, transportation, and inventory. 

Checklist3 

The idea of a checklist is a simple tool.  Critical quality control steps are 
sometimes overlooked without checklists. Many healthcare functions 
benefit from the use of checklists which makes explicit the requirements 
for quality.  A good checklist assures that the work has been done 
correctly and completely. 

Standard Work4 

Good quality requires that work be done in a consistent way. 
Interventions to develop a better way will only have an impact on 
practice if the new practice results in change that is consistent and 
reliably implemented. Standard work is a written description which is 
communicated and followed by all staff involved in a specific process. 

REFERENCES  

1. Lepley, CJ. Problem-solving tools for 
analyzing system problems: The affinity 
map and relationship diagram. J Nurs 
Admin. 28(12). 1998. 44-50. 
https://doi.org/10.1097/00005110-
199812000-00014.  

2. Berwick, DM & Hackbarth, AD. Elimiting 
Waste in US Health Care. JAMA. 
2012;307(25):1513-1516. 
https://doi.org/10.1001/jama.2012.362
.  

3. Thomassen et al. Implementation of 
checklists in health care; learning from 
high-reliability organisations. Scand J 
Trauma Resusc, Emerg Med. 
2011;53(19). 

https://doi.org/10.1186/1757-7241-19-
53.  

4. Ng, D et al. Applying the Lean principles 
of the Toyota Production System to 
reduce wait times in the emergency 
department. CJEM. 2010;12(1):50-57. 
https://doi.org/10.1017/s14818035000
12021.  

 

 

https://doi.org/10.1097/00005110-199812000-00014
https://doi.org/10.1097/00005110-199812000-00014
https://doi.org/10.1001/jama.2012.362
https://doi.org/10.1001/jama.2012.362
https://doi.org/10.1186/1757-7241-19-53
https://doi.org/10.1186/1757-7241-19-53
https://doi.org/10.1017/s1481803500012021
https://doi.org/10.1017/s1481803500012021

