Performance Improvement Project

(15 minute presentation)

Performance Improvement Indicators

Safety—avoid injury to patients from the care that is intended to help them

Timeliness—reduce waits and harmful delays

Effectiveness—provide services based on scientific knowledge to all who could benefit and refrain from providing services to those not likely to benefit (avoiding overuse and underuse, respectively)

Efficiency—avoid waste

Equitability—provide care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographical location, and socioeconomic status

Patient centeredness—provide care that is respectful of and responsive to individual patient preferences, needs, and values

1. Increase in Turn Around Time for the interpretation of Echocardiograms

2. Increase in patient stolen property in the ER

3. Increase in the patient’s blood type mismatch in the Laboratory

4. Increase in nosocomial infections in the Critical Care Units

5. Decrease in revenue in outpatient imaging centers

Define Goals and Objectives

Once the QI plan is set and the priorities have been identified, the performance measures must be determined in order to put the plan into motion. Performance measures are designed to serve as yardsticks on which to measure quality. In order to measure a particular element of care, process, or outcome, indicators are selected to assess performance within a particular area of focus. Indicators are quantitative measures that can be used to assess and improve performance. While not a direct measure of quality, indicators are tools that can be used to direct attention to potential performance issues that may require more intense review.

Clinical Goals

Clinical goals are generally set based on clinical performance measures and are derived from evidence-based clinical guidelines. Measurement allows an evaluation of an important outcome of care for a designated population of patients, and it is a proxy to understand the effectiveness of the underlying systems of care. Just as there are evidence-based care guidelines for many conditions, there also are established measures that indicate how effectively guidelines are translated to practice. National organizations carefully considered these measures, and it is advisable to adopt an established measure.

Data Collection and Analysis

Planning Within an organization’s QI Plan, managing data is an essential part of performance improvement. It involves collecting, tracking, analyzing, interpreting, and acting on an organization’s data. Measuring a health system’s inputs, processes, and outcomes is a proactive, systematic approach to practice-level decisions for patient care and the delivery systems that support it. Data management also includes ongoing measurement and monitoring. It enables an organization to identify and implement opportunities for improvement


Generally an evaluation of the progress an organization makes toward the goals identified in the QI plan will occur annually. Senior leadership and stakeholders will evaluate if the objectives for the QI plan have been met or if further refinement is required. However, in QI, collecting data on an annual basis does not support quality improvement methodology. A more frequent plan for data collection and analysis is strongly encourage. In short, if an organization plans to collect and analyze data quarterly, they can quickly identify if a particular performance measure has slipped in progress toward goals. They are then well suited to apply improvement methodologies as outlined in the module Testing for Improvement, and continue to make progress toward their identified goal. Although the frequency of data collection is not prescriptive, the frequency of data collect should be outlined clearly in the QI Plan. This should also include a plan if an organization finds that an identified performance measure is not meeting the progress they expected. This plan does not need be extensive but could simply refer the measure for attention by the QI Team who initially focused on improving the measure.

Identify Opportunities for Improvement

The next phase of data collection and analysis or data management t involves two distinct albeit related processes: 1. Analyzing data is the review of performance data to determine if it meets the desired quality level; it is used to define a performance plan. 2. Interpreting data is the process of assigning meaning or determining the significance, implications, and conclusions of data collected; it is used to evaluate and improve activities, identify gaps, and plan for improvement. Analysis and interpretation of data are used in concert when an organization reviews its performance. When the organization has a process in place to collect and display performance data, it ensures sufficient time is reserved to review the data and learn from it. A organization begins this phase by reviewing the current performance and comparing it to the previous performance of the organization. . This analysis gives a general sense of progress toward the performance goal as identified in the QI Plan. The interpretation process provides knowledge of the changes applied to the systems, special events with a potential impact, and lessons learned from the time period data was collected. It also helps to form the next steps to apply interventions for improvement. An organization may evaluate its performance against available benchmark data, which is beneficial when compared to the performance goal developed in the QI Plan. Additional information on benchmarking including resources to available organizations to gain benchmark data can be found in the module Managing Data for Performance Improvement.


Process to Apply Interventions for Improvement

The Plan-Do-Study-Act (PDSA) cycle is integral to rapid-cycle change methodology with emphasis on the “S” or study part of the cycle. Once data is collected, study is the analysis and interpretation phase, and when it is completed, an organization can proceed to “A” or acting on the data. A organization’s analysis and interpretation of the data drives its subsequent actions on performance. Once an organization has completed the analysis of the data they may determine a specific measure requires attention. Once the measure is identified, senior leadership may refer the measure back to the QI Team who initially focused on the improvement of a measure so they may apply improvement strategies with the goal of improvement. Additional information on improvement strategies can be found in the module Testing for Improvement. Additional information on QI teams can be found in the module Improvement Teams.

Implementing a QI Plan

Successful implementation of QI in an organization requires a process for identifying organizational problems and solving them, a process for providing ongoing education and training for all staff of the organization in principles, tools, and techniques of continuous improvement. Furthermore, all staff within the organization should understand clearly the mission and vision of the organization and be committed to quality improvement as part of their daily routine activities. Highlighted below are a few organizational processes to assist in the successful implementation of a QI Plan

Annual Evaluation and Work Plan Development

The QI Evaluation is often an annual evaluation of the prior year’s quality improvement activities, which includes recommendations for the next year. This process generally includes updating the QI plan and gaining approval annually


Leave a Reply

Your email address will not be published. Required fields are marked *