Module 3: Part 1 Developing and Implementing a QI Plan: Understanding the QI Plan Adapted from: The Health Resources and Services Administration (HRSA) Quality Toolkit

Learning Objectives Module 3 Discuss the important role of an effective QI plan in improving performance

A Quality Improvement Plan Is a detailed work plan for quality improvement activities Includes essential information on how you will manage, deploy, and review quality Is developed by executive and clinical leadership May need approval by a governing body, such as a Board of Directors

A Quality Improvement Plan Is updated regularly to reflect what you are doing to improve quality Outlines focus areas for the current and subsequent calendar years Is developed based on the evaluation of the previous year's QI activities, priorities and program requirements

Operations Manual

connectheartfailure.org Strategic Objective Current Standing Opportunity Action Plan 1.1 Key facility stakeholders are invested in the improvement of HF patient care   1.2 Facility has a quality improvement team focused on HF patient management and improving outcomes 1.3 Facility has a well-defined multidisciplinary team who manages the HF patient 1.4 Facility has a team that meets regularly to discuss HF and HF readmission issues 1.5 Facility completes multidisciplinary rounds daily with HF patients (Monday-Friday at a minimum) 1.6 LOS and GLOS are tracked for the HF patient and available on whiteboard in the patient’s room 1.7 Yearly mandatory plan to educate physicians and staff on latest GMDT for HF

PDSA = Plan Do Study Plan Act Act – Adopt the change, abandon it, or run through the cycle again Plan a change or test, aimed at improvement Do – Carry out the change or the test Study the results. What did we learn? What went as planned? Why?

Elements of an Effective QI Plan Includes a description of: Organizational mission Program goals Objectives Definition of key quality terms/concepts Description of: How QI project is selected, managed, and monitored

Elements of an Effective QI Plan (cont) Description of: Measurement and analysis, and how it will help define future QI activities Evaluation/quality assurance activities that will be utilized to determine the effectiveness of the QI plan’s implementation

Before developing a QI plan How to Begin a QI Plan Before developing a QI plan Understand your organization’s current status regarding quality improvement An assessment of current activities in your organization will help you: Identify strengths and weaknesses Identify barriers to sustain

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 Examples: Regulatory agencies Accreditation requirements

Establish Support and Confirm Commitment from Leadership Successful QI effort = engagement and buy-in from leadership Leadership plays an important role in improving quality by: Setting priorities Providing structure to support the improvement effort Modeling core values Promoting a learning atmosphere Acting on recommendations Advocating for supportive policies Allocating resources for improvement

Commit Resources to Support QI Activities What is needed to achieve your QI priorities: People Funding Equipment Space Training/development Adequate resources should be allocated to: - Staff time - Ongoing training of employees and medical staff - Technical assistance - Materials or equipment - Technical support, such as management information system

The Key Elements of a QI plan A description of: Purpose, priorities, policies, and goals of the program A description of the organizational systems needed to implement the program, including: QI committee structure and functions Descriptions of accountability Roles and responsibilities

Summary Quality improvement plan Is a detailed, and overarching organizational work plan for an organization's clinical and service quality improvement activities To be successful organizations must have: Leadership support and commitment Commit resources Educate staff