On Quality Improvement Action Planning --

Welcome back to what is now Part 3 in my description of Quality Improvement Action Planning®.

My last post ended with Plan 2—Plan to get data. So I'll start this one with completing Step 2—What is causing the problem?

Our team has developed a list of possible root causes and then carried out the plan to get data. At this point in the process, they analyze the gathered data to determine whether they have identified the most important root causes and what the data tells them about how to solve the problem.

This analysis involves reviewing all data, categorizing it in relationship to the problem and the possible root causes, and answering the question, “What have we learned about this problem?”

Once the team has analyzed root causes, Step 3 can be completed—answering the question, “What is the goal?”

A single problem might lead to the identification of multiple root causes. Each root cause might lead to several goals.

This is why it is so important to take your time and define the problem well. Otherwise, the whole process can become unwieldy and hard to manage. Keep the problem narrow enough so that when multiple root causes are identified, and each of those has several goals, the team can successfully implement and track its results. Too many goals is a set-up for trouble. If need be, prioritize the root causes and act on the top three, then the next set, and so forth as you are successful.

Goals should be stated clearly. This means that each goal should address only one thing the team wants to change. If necessary, you can state several goals for one root cause. Just don’t bunch several things into one goal because it will be impossible to measure.

I don’t think goals always have to have end dates, but they should be stated in such a way that you will know when you have achieved them. “There are sufficient equipment and supplies to carry out scheduled activities” is a good goal; and might also need to be partnered with a goal that says, “All staff know where equipment and supplies are stored, what is available, and how to access it;” and perhaps also a goal such as, “A cleaning and maintenance schedule for equipment and supplies will be in use.” These goals, while they do not have end dates, are clearly stated, each one addressing a different aspect of root causes of equipment availability, and it would be easy for anyone to tell whether they have been achieved.

Now that the goals are clear, the team moves to Plan 3—Plan to act. This plan answers the question of Step 4—What actions will we take to reach our goals?

Action steps are basically the bridges between the problem (where we are now) and the goal (where we want to be). Each action step must have a champion (an individual, not a group) and an end date by which the action step will be completed.

The Plan to act should paint a picture of the actions that staff are taking to reach the goal in such a way that an evaluator can come in at any point and tell exactly where the group is in the process. This part of the QIAP process is what is generally called “action planning.” As you can see, the problem identification, root cause analysis, and goal setting that come before it set the stage for an action plan that is more comprehensive and likely to yield robust results.

Finally, based on the action steps it has written, the team or leader can now develop Plan 4—Plan to validate.

Plan 4 has two distinct parts, Step 5—How will we know staff are following the plan? And Step 6—How will we know the plan is working.

• Validation is about ensuring that the action steps are being implemented and also that they are having the desired impact on the problem.
• Actions to be taken for validation should have a person assigned, and also a due date by which the analysis will be completed. Generally, data is brought back to the leader or team at some point so that decisions can be made to change the action steps or conduct more staff training, or to correct the course in some way in order to ensure that the goals are met.

This should be built into Plan 4:

• Who will review what data and when
• How the plan itself will be changed if it is not working or if staff are not able to implement it as it was planned.
• Addressing the overall effectiveness of the plan and when the plan is considered to have been successful. Often, teams set a threshold (such as, “When this goal is achieved at 100% compliance for three consecutive months”), and then refer the oversight to the CQI or PI Committee (such as “the CQI Committee will continue to monitor audits until it determines that the goals have been met”). This brings the plan into the purview of the QA or CQI committee so that oversight can be broader.  It involves leadership and often physicians in the process of oversight, further reinforcing the success achieved.

My one last piece of advice on this—notice your successes and celebrate with all staff who contributed to the solution. I’m not sure who it was who said, “Nothing builds success like success” but it is certainly true. Keeping people encouraged, letting them know what they have done to be part of a significant achievement, and involving them in celebration of success will entice them to jump in more and more as you use Quality Improvement Action Planning to create lasting, meaningful solutions to complex problems. People who use this process consistently learn that no problem is unsolvable if they invest in doing the job right.