In the late 1980s, with the beginning transition from fee for service to a prospective payment plan, healthcare organizations were fi rst challenged to evaluate their ineffi ciencies. With further changes in the fi nancing of healthcare to rein in costs (e.g., capitation and contracting by large insurers and managed care organizations), hospitals began to recognize the competitive nature of healthcare and that ineffi ciency cut into profi ts. Healthcare organizations began to shift from quality assurance, a retrospective review of individual's compliance with policies and procedures, to proactive analysis of system's processes and outcomes called quality improvement (QI;Colton, 2000).In addition to fi nancial factors, several sentinel events accelerated the evolution of QI in healthcare organizations. Th e National Demonstration Project in QI in Health Care examined whether or not the industrial QI paradigm was transferable to healthcare organizations (Colton, 2000). Th e industrial QI paradigm was based on the founding work of Walter Shewhart, W. Edwards Deming, and Joseph Juran and results supported the use of this paradigm to drive patient safety and quality care in healthcare organizations (Burda, 1988). Bolstered by these results, co-author and physician Donald Berwick, made the case, in the New England Journal of Medicine, for using industrial-based QI methods to improve American healthcare (Berwick, 1989). Another sentinel event was Th e Joint Commission's Agenda for Change that included the use of QI in hospitals and included input from key stakeholders (e.g., patients, healthcare workers, and hospital administrators) to achieve its goal of rewriting its accreditation standards (Colton, 2000). Th e new standards focused on the QI process and included the use of run charts, Pareto charts and statistical process control to evaluate and improve systems to achieve better outcomes.Th e Institute for Healthcare Improvement (IHI) emerged from the National Demonstration Project on QI in Health Care in 1991 in Cambridge, Massachusetts (IHI, n.d.). Th e creators of the IHI envisioned clinicians in healthcare systems using QI methods to fi x unreliable common care practices (Berwick et al., 1990). Th e IHI recognized the need to build capacity for change in the U.S. healthcare system by creating an organization that would engage in knowledge sharing and training on performance improvement.From 2005 to the present, the IHI has been establishing patient safety initiatives in the United States and abroad (IHI, n.d.). As part of this work, the IHI launched the Triple Aim in 2006 with a call to enhance the patient experience, improve population health, and reduce costs to optimize health system performance (Berwick et al., 2008). Clinicians in primary care practices across the United States have adopted the Triple Aim framework; however, stressful work life has interfered