Appendix 4

U.S. Department of Health and Human Services Recommendations to the Secretary - FOCUS-PDCA Performance Improvement Process

This is the heart of any Performance Improvement (PI) process. Each letter represents a piece of the PI puzzle. When all the pieces are put together, positive results usually occur. The following will take you through this process.

Find an opportunity to improve. In this stage you identify a process to be improved. For example, you have identified a process may not be effective. Ask yourself if the current process is tied to the hospital's mission and priorities? Question the productivity of the process. Ask yourself if it can be improved and who will benefit from improvement. Now you are ready for O.

Organize a team who understands the process. Here, you gather a team of employees who are closest to, or have ownership in the process. They are the one's on the "front lines" and really know if something is working or not.

Clarifying the current knowledge of the process is the next step. In this stage, you are gathering the "who, what, when, and where" information you need in examining the issue chosen.

Understanding the cause of process variation. Here, you ask yourself the "why" question. In other words, now you know the process by clarifying the elements, why isn't it working effectively.

You are at the halfway mark in the process. Now it gets fun.

Select the process improvement. The team selects the most appropriate solution keeping in mind the cost and difficulty of implementation. Again, your selection is based on successfully completing the two previous steps. Rushing to selection will not improve the outcomes, so before you select an intervention, make sure you have done the groundwork.

Plan the improvement. This next step involves deciding how the improvement will be made. Action plans are developed for how the process will be implemented within the targeted area. A plan for data collection to monitor the effects of the change is also addressed at this stage.

You are now ready to implement the change.

Doing the improvement is the next step. Here, the focus is on collection of baseline data and information that will determine how the process performs prior to, and following any improvement efforts. In this stage, monitor the process closely. Are there any surprises? If so, why did they occur, and what can the team do about it?

Checking the results is the next to last step. Here, you are evaluating to see if the process changes were actually implemented as planned. The team monitors the effects of the change, and most importantly, a comparison of predicated results versus actual changes are analyzed. If results are not as the team hoped, a review of the prior steps are in order. If everything checks out, you have successfully modified or changed a existing process for the better, and are at the last step.

Act to hold the gain. Here, the team creates a strategy for holding improvements and working toward further improvements.

These simple steps are to be part of every PI team here at SVMC. Following the process is crucial in order to have a successful team, as well as not wasting the time of the folks who are involved. Good luck, and let the process begin!

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