Phase 3: Drive Performance Improvement (Months 4-9)
Objective: To translate data into meaningful action by adopting a standard improvement methodology and conducting regular internal assessments.
- Standardize Improvement Methodology: Select and implement a consistent performance improvement approach that fits the organization’s culture, such as Plan-Do-Study-Act (PDSA) or Lean.
- Launch Performance Improvement Teams: Charter multidisciplinary teams to address specific improvement opportunities identified through data analysis.
- Conduct Internal Assessments: Implement a robust internal assessment program that includes tracers, mock surveys, and environment of care rounds to proactively identify issues.
- Manage Assessment Findings: Develop a formal process to document findings, assign responsibility, and track corrective actions to completion.
What would you like me to fetch?
Phase 3: Drive Performance Improvement (Months 4-9)
Step 4: Develop Your Performance Improvement Methodology
Data without action is just information. You need a systematic approach to improvement.
Common Improvement Methodologies
Choose an improvement approach that fits your organization’s culture:
1. Plan-Do-Study-Act (PDSA)
- Simple, intuitive framework
- Good for rapid testing of changes
- Easy to teach to staff at all levels
2. Lean
- Focuses on eliminating waste
- Emphasizes standardization
- Strong on process mapping and workflow improvement
3. Six Sigma
- Data-driven approach to reducing variation
- Uses DMAIC (Define, Measure, Analyze, Improve, Control) framework
- Requires more statistical expertise
4. IHI Model for Improvement
Combines PDSA with three fundamental questions:
- What are we trying to accomplish?
- How will we know if a change is an improvement?
- What changes can we make that will result in improvement?
Structuring Improvement Projects
For each improvement initiative:
- Form a multidisciplinary team with appropriate expertise
- Define the problem clearly with baseline data
- Set specific, measurable goals with timeframes
- Identify and test changes using your chosen methodology
- Implement successful changes
- Monitor results to ensure sustained improvement
- Document and share learnings
Step 5: Create a Robust Document Control System
Accreditation surveys heavily focus on documentation. A well-organized document control system is essential.
Policy and Procedure Management
Establish a standardized approach to:
- Policy development and review
- Approval processes and signatures
- Formatting and numbering conventions
- Revision tracking
- Distribution and access
- Archiving of retired policies
Essential Quality Program Documents
Ensure you have these key documents:
- QAPI Plan
- Annual QAPI Evaluation
- Committee charters and minutes
- Performance improvement project reports
- Patient safety plan
- Infection control plan
- Emergency operations plan
- Risk management plan
- Department-specific quality plans
Document Review Schedule
Implement a regular review cycle:
- Annual review of all key plans
- Biennial review of policies and procedures
- Ad hoc reviews when regulations or standards change
- Post-event reviews after significant incidents
Step 4: Develop Your Performance Improvement Methodology
Download our Performance Improvement Project Template to guide your team through the improvement process.
Step 5: Create a Robust Document Control System
Download our Policy and Procedure Template designed specifically for healthcare organizations.