Additional Resources and References

If you are new to continuous quality improvement (QI), there are many useful QI tools that can assist you in your efforts. For example, the Institute for Healthcare Improvement (IHI) provides a number of QI tools that support its Model for Improvement. Their Quality Improvement Essentials Toolkitexternal icon is a good primer for those beginning their quality improvement journey. It includes the Improvement Project Planning Formexternal icon to help teams think systematically about their improvement project and the PDSA Worksheet for testing changeexternal icon, which walks the user through documenting a test of change. These resources may be helpful for planning, assigning responsibilities, and carrying out small tests of change for improving CR utilization.

Another useful QI reference and toolkit is the Guide to Improving Care Processes and Outcomes in Health Centersexternal icon, available from the Health Resources and Services Administration (HRSA), which supports the U.S. health care safety net. This resource includes worksheets, such as the Clinical Decision Support-enabled Quality Improvement Worksheet word icon[Word – 702K]external icon, for analyzing current workflows and information flows and considering improvements for targets such as increasing CR utilization. CRCP can help identify promising, evidence-based approaches to enhancing care processes to achieve this goal.

Finally, the Healthcare Information and Management Systems Society (HIMSS) publishes a guidebook seriesexternal icon on improving care delivery and outcomes with clinical decision support (CDS).23,24 These guidebooks can help you apply the CDS Five Rights framework to ensure that all the right people (including patients) get the right information in the right formats via the right channels at the right times to optimize health-related decisions and actions. The guidebooks help health care practices and their partners set up programs that reliably deliver outcome-improving CDS interventions. They also provide detailed guidance on how to successfully develop, launch, and monitor such interventions so that all stakeholders benefit.


AACVPR: American Association of Cardiovascular and Pulmonary Rehabilitation
ACC: American College of Cardiology
AHA: American Heart Association
AMI: Acute myocardial infarction
BP: Blood pressure
CDC: Centers for Disease Control and Prevention
CDS: Clinical decision support
CME: Continuing medical education
CMS: Centers for Medicare & Medicaid Services
CR: Cardiac rehabilitation
CRCP: Cardiac Rehabilitation Change Package
ECG: Electrocardiogram
EHR: Electronic health record
EMR: Electronic medical record
HFrEF: Heart failure with reduced ejection fraction
HHS: Department of Health and Human Services
HIMSS: Healthcare Information and Management Systems Society
HRSA: Health Resources and Services Administration
ICU: Intensive care unit
IHI: Institute for Healthcare Improvement
ONC: Office of the National Coordinator for Health Information Technology
PAD: Peripheral artery disease
PDSA: Plan-Do-Study-Act
QI: Quality improvement
SET: Supervised exercise training

  1. Ades PA, Keteyian SJ, Wright JS, Hamm LF, Lui K, Newlin K, et al. Increasing cardiac rehabilitation participation from 20% to 70%: a road map from the Million Hearts® Cardiac Rehabilitation Collaborative. Mayo Clin Proc. 2017;92(2):234–42.
  2. Smith SC Jr, Benjamin EJ, Bonow RO, Braun LT, Creager MA, Franklin BA, et al. AHA/ACCF secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular disease: 2011 update; a guideline from the AHA and ACC Foundation endorsed by the World Heart Federation and the Preventive Cardiovascular Nurses Association [published correction appears in J Am Coll Cardiol. 2015;65(14):1495]. J Am Coll Cardiol. 2011;58(23):2432–46.
  3. Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE Jr, et al. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non–ST-elevation myocardial infarction. J Am Coll Cardiol. 2007;50:e1–157.
  4. Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, et al. 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention. A report of the ACC/AHA Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. J Am Coll Cardiol. 2011;58(24):e44–122.
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  6. Eagle KA, Guyton RA, Davidoff R, Edwards FH, Ewy GA, Gardner TJ, et al. ACC/AHA 2004 guideline update for coronary artery bypass graft surgery. A report of the American College of Cardiology/American Heart Association task force on practice guidelines. J Am Coll Cardiol. 2004;44(5):e213–310.
  7. Sibilitz KL, Berg SK, Tang LH, Risom SS, Gluud C, Lindschou J, et al. Exercise-based cardiac rehabilitation for adults after heart valve surgery. Cochrane Database Syst Rev. 2016;3:CD010876.
  8. Heran BS, Chen JM, Ebrahim S, Moxham T, Oldridge N, Rees K, et al. Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Database Syst Rev. 2011;(7):CD001800.
  9. Taylor RS, Brown A, Ebrahim S, Jolliffe J, Noorani H, Rees K, et al. Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials. Am J Med. 2004;116(10):682–92.
  10. Anderson L, Oldridge N, Thompson DR, Zwisler A-D, Rees K, Martin N, Taylor RS. Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Database Syst Rev. 2016;67(1):1–12.
  11. Rejeski WJ, Foy CG, Brawley LR, Brubaker PH, Focht BC, Norris JL 3rd, Smith ML. Older adults in cardiac rehabilitation: a new strategy for enhancing physical function. Med Sci Sports Exerc. 2002;34(11):1705–13.
  12. Oldridge N, Streiner D, Hoffmann R, Guyatt G. Profile of mood states and cardiac rehabilitation after acute myocardial infarction. Med Sci Sports Exerc. 1995;27(6):900–5.
  13. Suaya JA, Shepard DS, Normand SL, Ades PA, Prottas J, Stason WB. Use of cardiac rehabilitation by Medicare beneficiaries after myocardial infarction or coronary bypass surgery. Circulation. 2007;116(15):1653–62.
  14. Fang J, Ayala C, Luncheon C, Ritchey M, Loustalot F. Use of outpatient cardiac rehabilitation among heart attack survivors — 20 states and the District of Columbia, 2013 and four states, 2015. MMWR. 2017;66(33):869–73.
  15. Park LG, Schopfer DW, Zhang N, Shen H, Whooley MA. Participation in cardiac rehabilitation among patients with heart failure. J Card Fail. 2017;23(5):427–31.
  16. Beatty AL, Truong M, Schopfer DW, Shen H, Bachmann JM, Whooley MA. Geographic variation in cardiac rehabilitation participation in Medicare and veterans affairs populations: an opportunity for improvement? Circulation. 2018;137(18):1899–1908.
  17. Bachmann JM, Shah AS, Duncan MS, Greevy RA Jr, Graves AJ, Ni S, et al. Cardiac rehabilitation and readmissions after heart transplantation. J Heart Lung Transplant. 2018;37(4):467–76.
  18. Institute for Healthcare Improvement. The Breakthrough Series: IHI’s Collaborative Model for Achieving Breakthrough Improvementexternal icon . IHI Innovation Series white paper. Boston: IHI; 2003.
  19. Thomas RJ, Balady G, Banka G, Beckie TM, Chiu J, Gokak S, et al. 2018 ACC/AHA clinical performance and quality measures for cardiac rehabilitation: a report of the American College of Cardiology/American Heart Association task force on performance measures. J Am Coll Cardiol. 2018;71(16):1814–37.
  20. Montoye CK, Eagle KA, Michigan ACC-GAP Investigators, ACC-GAP Steering Committee, American College of Cardiology. An organizational framework for the AMI ACC-GAP project. J Am Coll Cardiol. 2005;46(10 Suppl):1–29.
  21. Thomas RJ, King M, Lui K, Oldridge N, Piña IL, Spertus J. AACVPR/ACC/AHA 2007 performance measures on cardiac rehabilitation for referral to and delivery of cardiac rehabilitation/secondary prevention services. J Am Coll Cardiol. 2007;50:1400–33.
  22. Ali-Faisal SF, Benz Scott L, Johnston L, Grace SL. Cardiac rehabilitation referral and enrolment across an academic health sciences centre with eReferral and peer navigation: a randomised controlled pilot trial. BMJ Open. 2016;6(3):1–8.
  23. Osheroff JA, Teich JM, Levick D, Saldana L, Velasco F, Sittig D, et al. Improving Outcomes with Clinical Decision Support: An Implementer’s Guideexternal icon. 2nd ed. Chicago: HIMSS; 2012.
  24. Osheroff JA, ed. Improving Medication Use and Outcomes with Clinical Decision Support: A Step-by-Step Guideexternal icon. Chicago: HIMSS; 2009.
Page last reviewed: October 24, 2019