The 4 I’s of quality improvement in veterinary medicine

Banfield Pet Hospital’s chief medical officer offers practical steps to pursuing quality improvement in your practice.

Content sponsored by Banfield Pet Hospital

Quality improvement (QI) in veterinary medicine is a systematic effort to improve delivery of care to patients. It often entails instituting systems-based improvements and standardizing processes to reduce variation and achieve predictable results. Continuously analyzing and seeking to enhance performance leads to better outcomes that benefit pets, people, and practices alike.

Here we outline a 4-part framework for pursuing QI, where each component starts with an “I”: identify opportunities, investigate root causes, introduce best practices, and involve the team. We also describe how we applied the 4 I’s in a case study.

Identify opportunities

Opportunities for QI may present after adverse events, or you can proactively identify aspects of your practice that could be safer or more efficient. Banfield’s Domains of Quality (Figure 1) articulate the elements of quality care we try to achieve. Adapted from the Agency for Healthcare Research and Quality,1 and first created by the National Academy of Medicine,2 this framework is used by Banfield Pet Hospital to assess quality care. Ask yourself whether your practice could better model one of them. Compare your practice performance with your ideal standards to identify any gaps.

Investigate root causes

After identifying a QI opportunity, investigate the factors that contribute to the problem, otherwise known as the root causes. Various approaches can be used in root cause analysis, including the 5 Whys.3 This exercise begins by stating the problem and asking why it occurs. The answer is the topic of the next “why?” and so on, drilling down until the root causes are revealed. For a printable, full-size 5 Whys worksheet, visit

Introduce best practices

A useful counterpart to the 5 Whys are the 5 Hows,4 which is a similar iterative exercise to tease out steps to mitigate the root causes of a problem. Mitigation efforts can include changes to processes, structures, training, culture, or reporting. Seek evidence from the literature or your own practice to distinguish which potential steps are most appropriate for your QI initiatives.

Involve the team

Make sure your team is aware of and comfortable with the best practices or mitigation steps to be implemented and understand the whys behind them. Daily huddles with the whole team—not just a subset of the team—offer regular opportunities to discuss new opportunities and ongoing QI initiatives. Identify quality champions on your team who might be willing to lead QI initiatives themselves.

Putting the 4 I’s into practice

Identify opportunities

We focused on anesthesia, one of the highest-risk services in a veterinary practice. Rates of anesthesia-related mortality have been reported to be between 0.1% and 0.2% in healthy dogs and cats and between 0.5% and 2% for sick animals.5 A 2017 Banfield study6 demonstrated that Banfield’s mortality rate associated with anesthesia was comparable with or lower than mortality rates previously reported in the industry. Although mortality rates associated with anesthesia were already low, we felt a responsibility to patients and clients to dig deeper and uncover information that could potentially further reduce the mortality rate.

Investigate root causes

Root causes of anesthesia mortality were identified by reviewing available literature and performing our own internal analysis on data from our medical records.

Introduce best practices

We established evidence-based medical quality care standards to mitigate the risk factors we identified, consisting of clinical essentials and best practices. These resources helped our associates operationalize the standards for procedures, equipment, and communication.

Involve the team

We devised a robust communication plan to disseminate the quality standards and expectations for their implementation to our teams. We also set up an annual quality audit program to investigate compliance with the standards and identify ongoing areas of opportunities for continuous improvement. Job aids were regularly reviewed and discussed with the teams to keep everyone up-to-date on recommended practices.


After applying the 4 I’s framework, we have seen a consistent, durable, and ongoing decrease in anesthesia-related mortality. At the end of 2021, we had the lowest anesthesia mortality rate ever recorded at Banfield, helping to protect the lives of hundreds of pets since the start of the program.

The principles and concepts behind QI and the approaches mentioned are available in more detail in the full report, “Implementing Safety and Quality Improvements in Veterinary Medicine.”7 This report is the latest in the series of Banfield’s Veterinary Emerging Topics (VET) reports, created in partnership with the North American Veterinary Community. VET reports combine the power of data with open, solution-based dialogue to help improve patient outcomes.


  1. Six domains of health care quality. Agency for Healthcare Research and Quality. Reviewed November 2018. Accessed February 17, 2022.
  2. Institute of Medicine (US) Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. National Academies Press (US); 2001
  3. Five whys tool for root cause analysis. Centers for Medicare and Medicaid Services. Accessed February 17, 2022.
  4. Five whys and five hows. American Society for Quality. Accessed February 17, 2022.
  5. Brodbelt D. Perioperative mortality in small animal anesthesia. Vet J 2009;182(2):152-161. doi:10.1016/j.tvjl.2008.06.011
  6. Matthews NS, Mohn TJ, Yang M, et al. Factors associated with anesthetic-related death in dogs and cats in primary care veterinary hospitals. J Am Vet Med Assoc. 2017;250(6):655-665. doi:10.2460/javma.250.6.655
  7. The 2022 Veterinary Emerging Topics (VET) report: implementing safety and quality improvements in veterinary medicine. Banfield Pet Hospital Exchange. Accessed February 17, 2022.

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