HLTH325: Quality Improvement Process Planning Action Plan for Leaders

This report outlines a quality improvement (QI) action plan designed for healthcare leaders to support a QI team and foster a sustainable "QI Culture." The plan begins by assessing the QI team's strengths, such as effective communication and a shared vision, and identifies potential barriers, like employee resistance to change. It details specific support needed by the team, including employee acceptance and proactive engagement. The report then defines measures to indicate progress for both the QI project and the overall QI culture, such as patient feedback and statistical reports. An action plan is provided, listing activities, responsible parties, and timelines for supporting the team and changing the organizational culture, including tasks like preparing questionnaires, creating meeting agendas, and promoting a positive work environment. The report concludes with a review of results, assessing the team's and culture's progress, identifying supporting and hindering factors, and outlining additional steps needed for success, such as improved time management and the creation of engaging training materials. The goal is to improve patient satisfaction, enhance communication, and foster holistic care within the healthcare setting.

HLTH325 Quality Improvement Process Planning Template
Action Plan for Leaders to Support a QI Team and Sustain a “QI Culture”
Department:
I. Current Condition
QI Project and Team QI Culture What strengths does your QI team have that will make them
successful?
The QI team is effective and comprises of dedicated and enthusiastic
team members who work together in order to reinforce innovation
within the healthcare organization. The QI team comprises of a
number of strengths that include effective communication, fostering
a healthy work environment, effectively identifying the barriers and
adapting measures to remove the barriers and making use of
coaching and training to the workforce to promote quality. In
addition to this, the QI team within the organization has a strong set
vision that aspires to promote continuous improvement in terms of
quality.
 What barriers or challenges will the QI team encounter?
While introducing a change within the organization, a number of
hindrances can be encountered in terms of resistance from
employees. This is on account of a difference in opinion between the
workforce and the management. This case hold true for the QI team
of the Eastern Memorial Hospital as well. On introducing a change,
for instance, implementation of a new electronic health system or a
new technology, the first step adapted by the QI team is to conduct
training. On multiple occasions, a number of obstacles have been
encountered from employees who are unwilling to absorb the critical
nuances of using a new system and do not prefer training. These
situations hinder the process of quality improvement.
 What specific support will the QI team need to ensure they are
successful?
The specific support required by the QI team would include ready
acceptance from the employee workforce. In addition to this, it
would also need a proactive approach from the employee workforce
to work collectively in order to live up to the vision and mission of the
hospital.
 What is your agency doing well to support a culture of QI?
The organization aspires to promote continuous quality
improvement. This is done by the organization by establishing a
strong QI team and regularly conducting quality evaluation of the
ongoing work process.
 What two areas would you most like to improve?
The organization has faced a few issues of patient dissatisfaction and
compromised quality of care in the past. In order to foster
improvement in these areas, the healthcare organization would need
to improve in the following areas:
1. Establish a strong therapeutic relationship with the patients
2. Improve communication between patients and care
professionals.
 Why is it important to improve these areas?
It is extremely important to improve the above mentioned areas so as
to improve the quality of care in order to acquire positive patient
outcome. In addition to this, improving upon the mentioned areas
would also help in fostering holistic care and promoting a smooth work
process.
II. Measures: What Will Indicate Progress?
QI Project and Team QI Culture
 List two measures that will show the team is moving in the right
direction toward success.
By March 2014, the team will …
1.
The team will receive constructive feedback from
patients discharged from the hospital
The team will provide compulsory feedback to the care
professionals and monitor the performance of the
employees based upon key performance indicators
(KPIs)
2.
 List two measures that will show the agency is moving in the right
direction toward success.
By March 2014, the agency will …
1.
The agency would present a statistical report based upon
the level of patient satisfaction
2.
The agency would present a comparison report based
upon the patient satisfaction level with data collected
from the previous 2 years

Author:
Version and date:
This is a living document; revise the plan as you work and learn
III. Action Plan
List at least 3 things you can you do to support your team and ensure they are successful in completing a QI project.
Supporting the QI Project and Team
Activities/Tasks Who is Responsible? By When? Status/Progress
Prepare a questionnaire feedback form
for the patients which would be
distributed to them during the time of
discharge in order to retrieve response
about their level of satisfaction with the
service
The QI team is responsible
for reflecting upon the key
areas that determine
patient satisfaction level
and makes use of those
aspects to draft the
questionnaire feedback
form
By the end of the
week
At present, the team is reviewing the list of
patient complaints and drafting a draft
questionnaire feedback form
Prepare an agenda of the meeting I am responsible for
preparing the agenda of
the meeting
By the end of the
week
Once, the review of the patient complaints is
complete, a meeting would be conducted by the
care professionals and I would then be drafting
the agenda of the meeting
Prepare day to day activity schedule
which would encompass of the key areas
to be addressed during the training
session
The leader of the QI team
would plan the activity
schedule of the training
session
By the end of two
weeks
Once the meeting is conducted, the training
process would be started.
Document the minutes of the meeting
after the completion of the meeting and
each training session
I am responsible for
documenting the minutes
of the meeting as well as
the training sessions
At the end of
meeting and at
the end of every
training session
The minutes would be documented after the
completion of the listed activities. This would
help in monitoring the progress level.
List at least 3 things you can do to help your agency begin to change the culture.
Sustaining a QI Culture
Activities/Tasks Who is Responsible? By When? Status/Progress
Promote a positive work environment The leader End of the week One on one session is being held with workers
Create a grievance redressal unit The leader End of the week Finalizing committee
Induce motivation The leader End of week Leader is taking motivational sessions
IV. Review/Reflect on Results: What Happened?
This section is for post-action review; it defines the actual outcomes and captures learning.
QI Project and Team QI Culture
 How is the QI team progressing?
Things are progressing at a steady rate and are expected to
induce a positive change within the employee workforce
 What things am I doing to support the team’s success?
I am helping with the documentation process and at the
same time marinating a positive work environment and
making sure that there are no internal conflicts
 What things am I doing to hinder the team’s success?
I am unable to address the tasks quickly, which is leading to
poor time management
 What additional things do I need to do to help the team be
more successful?
I need to help the team create training materials that would
be absorbed well by the employees
 How is the QI Culture progressing?
The QI is progressing at a steady rate but is showing positive
results
 What things am I doing to support the progress?
I am helping in fostering an optimistic environment and
ensuing that there is no negativity within the team
 What things am I doing to hinder progress?
I need to prioritize tasks and manage time so as to ensure
accelerated progress
 What additional things do I need to do to ensure progress?
I need to come up with interactive materials that could
make the training session interesting for the employees