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H H S Department of Health and Human Services
U.S. Department of Health and Human Services
Health Resources and Services Administration

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Developing & Implementing a QI Plan

Part 1: Introduction

Part 2: Structure and Leadership

Part 3: Fictional Case Study: Using Different QI Charts / Diagrams 

Part 4: Developing a QI Plan

Part 5: Implementing a QI Plan

Part 6: Related Resources

Part 1: Introduction 

The goal of this module is to highlight the important role of an effective QI plan in improving performance of your organization’s health care systems. The module provides examples of how your organization can establish a QI plan and describes the basic elements necessary for the successful development and implementation of an organizational QI plan.

What is a Quality Improvement Plan?

A QI plan is a detailed, and overarching organizational work plan for a health care organization's clinical and service quality improvement activities. It includes essential information on how your organization will manage, deploy, and review quality throughout the organization. A QI plan is generally developed by executive and clinical leadership and, in many organizations, must be approved by the organizations governing body such as a Board of Directors. It is updated regularly to reflect what your organization is doing to improve quality. A QI plan generally outlines the specific clinical focus areas for the current and subsequent calendar years. Often, it is developed as an outgrowth of the evaluation of the previous year's QI activities, organizational priorities and organizational program requirements.

Elements of an Effective QI Plan

An effective QI plan includes the following key elements:

  • Description of organizational mission, program goals, and objectives
  • Definition of key quality terms/concepts
  • Description of how QI projects are selected, managed, and monitored
  • Description of training and support for staff involved in the QI process
  • Description of quality methodology (such as PSDA, Exit Disclaimer. Six Sigma Exit Disclaimer.) and quality tools/techniques to be utilized throughout the organization
  • Description of communication plan of planned QI activities and processes, and how updates will be communicated to the management and staff on a regular basis
  • Description of measurement and analysis, and how it will help define future QI activities
  • Description of evaluation/quality assurance activities that will be utilized to determine the effectiveness of the QI plan’s implementation
How do I begin a QI Plan?

Before developing a QI plan, it is important to have an understanding of your organization’s current status regarding quality improvement. An assessment of current activities in your organization will help you identify strengths and weaknesses as well as barriers to sustain QI efforts.

Some of the commonly identified barriers to sustaining a QI project are:

  • lack of an adequate Quality Management (QM) organizational structure to support improvements over time;
  • lack of resources;
  • lack of ongoing communication and feedback to providers and staff;
  • lack of periodic re-monitoring and feedback to providers and staff;
  • staffing changes without sufficient training of new staff; and
  • changing priorities and lack of interest.

Below are key points that will help address these barriers.

Identify Quality Policies and External Requirements

Identify the external requirements your organization may need to fulfill before developing a QI plan. These external requirements may be the funding organization’s quality requirements or standards for obtaining accreditation.  For HRSA grantees there are often key deliverables based on program requirements. If your program is currently funded by HRSA, you should consult its Web site and links to Bureaus and Offices for required guidelines and measures when developing the organization’s QI plan. See the links below for performance measure information specific to that bureau or office:

There are a number of organizations that survey and accredit a wide range of health care organizations that meet their quality and safety standards/requirements. The accreditation requirements can be found in the organizations’ links listed below:


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