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Developing & Implementing a QI Plan

Part 4: Developing a QI Plan 

What should go into the plan itself?

The key elements of a QI plan include:

  1. A description of purpose, priorities, policies and goals of the QI program;
  2. A description of the organizational systems needed to implement the program, including QI committee structure and functions, descriptions of accountability, roles and responsibilities;
  3. The process for gaining consumer input;
  4. Core measures and measurement processes; and
  5. A description of the communication and evaluation plan.

Each of these components is described in brief below:


Describe the purpose of the QI plan, including the organization’s mission and vision, policy statement, the types of services provided, etc.


Define the key concepts and quality terms used in the QI program/project so that there is a consistent language throughout the organization regarding quality terms.

  • Quality Improvement (QI) refers to activities aimed at improving performance and is an approach to the continuous study and improvement of the processes of providing services to meet the needs of the individual and others.
  • Continuous Quality Improvement (CQI) refers to an ongoing effort to increase an agency’s approach to manage performance, motivate improvement, and capture lessons learned in areas that may or may not be measured as part of accreditation. It is an ongoing effort to improve the efficiency, effectiveness, quality, or performance of services, processes, capacities, and outcomes.
  • Quality Assurance (QA) refers to a broad spectrum of evaluation activities aimed at ensuring compliance with minimum quality standards. The primary aim of quality assurance is to demonstrate that a service or product fulfills or meets a set of requirements or criteria.  QA is identified as focusing on “outcomes,” and CQI identified as focusing on “processes” as well as “outcomes.”

Organizational System

Describe the organizational structure, roles and responsibilities, timeline for reporting findings and improvement strategies, and training/support provided for project staffs. Describe how leadership provides support to QI activities:

  • Organizational structure is a formal, guided process for integrating the people, information, and technology of an organization, and serves as a key structural element that allows organizations to maximize value by matching their mission and vision to their overall strategy in quality improvement. Implementing a QI plan requires a clear delineation of oversight roles and responsibilities, and accountability. The QI plan should clearly identify who is accountable for QI processes, such as evaluation, data collection, analysis education and improvement planning.
  • The specific organizational structure for implementing a QI plan can vary greatly from one organization to another. Generally, responsibility for Quality begins with Board that authorizes the Executive Director to provide resources to support quality program and assigns responsibility for QI program to lead clinical and QI staff (e.g., the Medical Director if your organization has one). A Quality Coordinator is assigned to support the medical director/chair of the committee and for day-to-day activities.
  • Depending on the size of the organization, who participates in QI activities may vary. For example, in small clinics with a primary care provider, nurse, and support staff, most of the staff members are involved in all aspects of QI work. In larger organizations such as a hospital, usually a Quality Committee is established that includes senior management, designated QI staff if there are any, and other key players in the organization with the expertise and authority to determine program priorities, support change, and if possible, allocate resources. The main role of this group is to develop an organizational QI plan, charter team, establish QI priorities and activities, monitor progress towards goal attainment, assess quality programs and conduct annual program evaluation.

Identify Areas for Improvement

List and prioritize QI projects: 

Areas for improvement can be identified by routinely and systematically assessing quality of care. QI projects may be identified from self-assessment, customer satisfaction surveys, or formal organizational review that identifies gaps in services. Staff from all levels should be included to brainstorm and develop a list of changes that they think will improve the process. Consumer input on the experience of care delivery is extremely important to identify areas that need improvement. The QI projects that are selected and prioritized should show alignment with the organization’s mission.

Goals and Objectives

Define key program goals and objectives for the current year:

This list should be tailored to the program and include specific objective(s) that need to be accomplished to successfully achieve the goal. The objective(s) for each of the selected goals need to be Specific, Measurable, Achievable, Relevant and Time-framed (SMART objectives) so that you will be able to clearly determine whether the objectives have been met at the end of the year by using a specified set of QI tools. 

For example,

By December 29, 2011 (time bound), increase the number of training sessions given for QI staff on “QI concepts and tools” (specific & relevant) from 6 to 10 (measurable & achievable).

Generally, the QI Committee identifies and defines goals and specific objectives to be accomplished each year.  These goals may include training of clinical and administrative staff regarding both CQI principles and specific quality improvement initiative(s).  Progress in meeting these goals and objectives are an important part of the annual evaluation of QI activities.

Performance Measurement

Describe how the Quality program is measured, data is collected, monitored and analyzed:

  • Performance Measurement (PDF - 9 pages) is used to monitor important aspects of an organization’s programs, systems, and processes; compare its current performance with the previous year’s performance, as well as benchmarks and theoretical test performance measures, and identify opportunities for improvement in management, clinical care, and support services. The basic steps are to:
  1. Determine performance measures and develop indicators to measure performance;
  2. Define measurement population;
  3. Describe data collection plan as well as data collection method such as chart  abstraction (a process where a trained clinician reviews a chart and pulls out data elements for the purposes of research), interviews; and
  4. Describe an analysis plan
  • Confidentiality requirements including the Health Insurance Portability and Accountability Act of 1996 (HIPAA) policies should be strictly followed when dealing with data that includes personal health information. 
  • Some of the measures organizations may elect to use include, structural, process, outcome, and patient experience measures. You should use nationally recognized  and standardized measures that have already been developed and tested, whenever possible. Examples of general sources of clinical measures include:
  • NCQA Health Plan Employer Data and Information Set (HEDIS) Measures – This tool provides a set of standardized inpatient and ambulatory performance measures in the health care industry.
  • AHRQ Clearinghouse of Clinical Measures – This is a database and Web site for information on specific evidence-based health care quality measures and measure sets.
  • National Quality Forum (NQF) – This website includes a directory of endorsed performance measures and NQF endorsed standards which can be used by hospitals, healthcare systems, and government agencies like the Centers for Medicare & Medicaid Services for public reporting and quality improvement.
  • Healthy People 2020 – This website provides a 10-year agenda for improving the Nation’s health. It provides health measures on General Health Status, Health-Related Quality of Life and Well-Being, Determinants of Health, and Disparities.
  • For further information on Performance Measurement, see the Performance Measurement and Management module. 

QI Initiative

Identify the QI methodology and quality tools/techniques to be utilized throughout the organization. Describe the process:

  • The purpose of a QI initiative is to improve the performance of existing services or to plan new ones. Strategies for improvement in the existing process can be identified by using QI tools such as benchmarking, fishbone diagram, root-cause analysis, etc.
  • The PSDA (Plan-Do-Study-Act)  cycle is one of the widely used QI methodology in health care for testing a change on a small scale—by planning change and collecting baseline data, testing the change and collecting data, observing the results and analyzing the data, and acting on what is learned. If the change did not result in improvement in the process, try another strategy. If the change resulted in improvement, adopt the change, monitor the process periodically, and implement the change on a larger scale.
  • A number of other QI approaches have also been used in healthcare.  Based on your organizational priorities, the QI committee can choose a preferred approach.
    • Six Sigma's (Define, Measure, Analyze, Improve, and Control)
    • FADE (Focus, Analyze, Develop, Execute, and Evaluate)


Describe how quality is communicated throughout the organization on a regular basis:

Once a QI initiative is launched, it is important to have regular communication on quality improvement to all staff including the board and stakeholders.  Regular updates on how the QI plan is being implemented, training activities being conducted, and improvement charting are important parts of any communication plan. The progress in QI projects can be documented using activity logs, issue identification logs, meeting minutes, etc.  Improvement efforts can be communicated through the various methods, such as: kick-off meetings or all-employee meetings; story boards and/or posters displayed in common areas; sharing organization’s annual QI plan evaluation; e-mails, memos, newsletters and/or handouts; and informal verbal communication.

Approval of QI Plan and Annual Evaluation

Describe how evaluation will be done, when it will be done, who will be responsible for developing it, how the results will be documented and communicated; and who is responsible for reviewing and approving it:

A QI plan should be evaluated on an annual basis for effectiveness in achieving the goal. A QI committee will annually review and make suggested revisions to the QI plan. Based on an ongoing review, priorities will be set and opportunities for improvement identified for the next year. A report summarizing review process, findings, QI initiatives taken, suggested modifications, projects in progress, and recommendations for changes, will be compiled and forwarded to the Board for review.

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