QUALITY IMPROVEMENT PROCESS PLANNING TEMPLATE 2

Quality Improvement Process Planning Template

HLTH325 Quality Improvement Process Planning Template

Action Plan for Leaders to Support a QI Team and Sustain a “QI Culture”

Department:

I. Current Condition

QI Project and Team QI Culture

 What strengths does your QI team have that will make them
successful?
The team has a clinical leader who understands how changes will
impact the clinical care process and the effects of these changes
on other areas within the organization.
The team also has technical expertise, thus has in-depth
knowledge of the QI processes.
Effective day-to-day leadership that will ensures that tasks
allocated to the team are completed. The leadership ensures
that the team understands the impact of its activities
The team’s membership is diversified with different members
playing different roles and perspectives on patient care and
other areas and processes under consideration.
Further, the team has an improvement advisor who has
expertise in quality improvement methods and will be resourceful to
the lead team and experts.
 What barriers or challenges will the QI team encounter?
The team will encounter challenges in identifying areas within the
system that can be refined and coming up with new ways of
doing things.
Lack of motivation can be a challenge to the members who are
asked with a challenging process (Agency for Healthcare
Research and Quality, 2019).

 What specific support will the QI team need to ensure they are
successful?

 What is your agency doing well to support a culture of QI?
Helping the QI team in the development of systems that will help them
track progress in line with the achievement of their improvement goals
by setting up data systems that will be used in the production of
performance reports on major quality metrics that will be done on a
monthly basis.

 What two areas would you most like to improve?
Increase accountability of members of staff within the organization
Have members of staff take more refresher courses to ensure that they
are up-to-date with care practices

 Why is it important to improve these areas?
Accountability will improve the members commitment to their duties
as well as the quality of care provided to patients
Refresher courses on the other hand will add on the expertise that
members of staff already have in their area of specialization and ensure
that they remain up-to-date with emerging practices in the medical

field II. Measures: What Will Indicate Progress?

QI Project and Team QI Culture

 List two measures that will show the team is moving in the right
direction toward success.
By June 2019, the team will …

1. Come up with of achieving higher rates of dialysis nurse
   satisfaction
2. Come up with ways of reducing central venous catheter
   infection rates

 List two measures that will show the agency is moving in the right
direction toward success.
By June2019, the agency will …

1. Have facilitated the creation of a quality improvement
   plan
2. Have provided the necessary resources for the plan to be
   implemented

QUALITY IMPROVEMENT PROCESS PLANNING TEMPLATE 3

III. Action Plan
List at least 3 things you can you do to support your team and ensure they are successful in completing a QI project.
Supporting the QI Project and Team
Activities/Tasks Who is Responsible? By When? Status/Progress
Identifying improvement opportunities

All team members By the start of
the project

Opportunities identified

Create a sense of urgency for change All team members By 7 th July ongoing
Solicit experiences of other patients patients 15 th July Done
Provide ideas of change to redesign
systems of care (Nelson, 1990).

nephrologists 30 th June Ongoing
Develop a system to track progress Technical team By 20 th June Done
Develop a standard template such as a
QI dashboard for recording
performance reports

Technical team By 20 th June Accomplished

List at least 3 things you can do to help your agency begin to change the culture.
Sustaining a QI Culture
Activities/Tasks Who is Responsible? By When? Status/Progress
Facilitate refresher courses Human Resource
Department

Ongoing exercise By end of June, five nephrologists and ten dialysis
nurses had attended refresher courses

Provide funding Finance manager 30 th June done
Help the team develop a system to tract
progress

Technical staff 30 th June done

IV. Review/Reflect on Results: What Happened?
This section is for post-action review; it defines the actual outcomes and captures learning.

QI Project and Team QI Culture

 How is the QI team progressing? The progress is
commendable
 What things am I doing to support the team’s success? Help
in the recording of the QI dashboard for easy tracking of
progress
 What things am I doing to hinder the team’s success? none
 What additional things do I need to do to help the team be
more successful? Put in more effort to help the team
compile reports in good time so that the progress report is
ready by the end of each month

 How is the QI Culture progressing? More physicians are
signing in for refresher courses and members of staff are
embracing the additional courses being provided.
 What things am I doing to support the progress? I have
attended a refresher course and have registered for the next
one early next year
 What things am I doing to hinder progress? none
 What additional things do I need to do to ensure progress?
Be committed and help the team gain more expertise by
attending more refresher courses

Research & Quality. Retrieved from https://www.ahrq.gov/professionals/prevention-chronic-care/improve/system/pfhandbook/mod14.html


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References

Agency for Healthcare Research and Quality. (2019). Module 14. Creating Quality Improvement Teams and QI
Plans | Agency for Healthcare
Nelson, E. C. (1990). Using outcome measures to improve care delivered by physicians and hospitals.
In Effectiveness and outcomes in health care: Proceedings of an invitational conference by the Institute of
Medicine.