Quality Improvement Plan Page 9
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15Assessment. Assessment is accomplished by comparing actual performance on an
indicator with:
Self over time.
Pre-established standards, goals or expected levels of performance.
Information concerning evidence based practices.
Other clinics or similar service providers.
(List here the assessment strategies you will use. See APPENDIX A, attached, for examples of
performance improvement tools.)
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Section 5
Quality Improvement Initiative
Once the performance of a selected process has been measured, assessed and analyzed,
the information gathered by the above performance indicator(s) is used to identify a
continuous quality improvement initiative to be undertaken. The decision to undertake the
initiative is based upon clinic priorities. The purpose of an initiative is to improve the
performance of existing services or to design new ones. The model utilized at Name of
Clinic is called Plan-Do-Check-Act (PDCA). (Modify the following as appropriate for your
program. If you choose a model other than PDCA, describe the model here.)
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# Plan - The first step involves identifying preliminary opportunities for improvement.
At this point the focus is to analyze data to identify concerns and to determine
anticipated outcomes. Ideas for improving processes are identified. This step
requires the most time and effort. Affected staff or people served are identified, data
compiled, and solutions proposed. (For tools used during the planning stage, see
sections “a” thru “k” in APPENDIX: A. )
# Do - This step involves using the proposed solution, and if it proves successful, as
determined through measuring and assessing, implementing the solution usually on a
trial basis as a new part of the process.
# Check - At this stage, data is again collected to compare the results of the new
process with those of the previous one.
# Act - This stage involves making the changes a routine part of the targeted activity. It
also means “Acting” to involve others (other staff, program components or
consumers) - those who will be affected by the changes, those whose cooperation is
needed to implement the changes on a larger scale, and those who may benefit from
what has been learned. Finally, it means documenting and reporting findings and
follow up.
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