Quality Improvement Plan: Project Management

Quality Improvement Plan Project Instructions: Quality Improvement Plan: Project Management

Use the Grading rubric as a guide for the information and what to include in the QIP

Review the QIP ppt slides and the resources listed in this document to better understand the Model for Improvement (MP) that you will use in developing your Quality Improvement Plan (QIP)

The QIP should include the part1 and part 2 of the MP: Three questions for improvement and the PDSA.


  1. 1. What are we trying to accomplish (aim)?

In this section describe the organization for whom your QIP is intended such as “nursing home, physician practice, hospital etc.to provide a context for your targeted population. Then state your aim. Your aim should aligns with the organization’s quality Improvement goal.

The aim should

  • Specify a time time-specific
  • Be measurable (quantitative or qualitative)
  • Applies to a defined patient population
  • Include what will be achieved



Organization’s goal of a physician practice is “To improve preventive care for patients with diabetes”

The QIP Aim may be “We will provide foot exams to 100% of our diabetes patients who came for an office visits by the end of July 31 2016.


  1. How will we know that change is an improvement (measures)?

In this section, describe the measurable outcome(s) you intend to see. You should literature review of the problem, how the problem is been measured.

For example, for the aim listed above, you will provide a background on how foot exam is been measured in the literature. Is a 20% change in foot exam considered a significant improvement? Whose perspective is important, the patient, the management, health plans or reporting agencies. Will an improvement in this measure negatively impact other parts of the organization? Consider any relevant structure, process and outcome measures.



  1. What change can we make that will result in an improvement?

Describe the processes currently in place that may show any gaps.


Identify opportunities for improvement that may exist (Use process analysis tool such as flow chart, matrices (chapter 3 in your textbook) to identify gaps in the processes of your organization, look for causes of problems that have occurred and opportunity for improvement. Identify the cause of the problem and constrains to any proposed solutions.


For example, in the example used above, some questions to consider during brainstorming to determine the change to make are: Is there a checklist of what services should be provided to diabetes patients during office visit? Is foot exam listed on the checklist? If listed, who is responsible?  If foot exam is added to the things the nurse should check when they take vitals, will it cause a lag in the time it takes the nurse to process patients and consequently increase wait times?

After you identify the cause, decide what should be change in the process to achieve your aim. What you decide to change is your intervention, and should be based on your analysis.

  • Review the literature, guidelines and reports to determine what has worked
  • Consider what has worked at other organizations that you can adapt to suit your organization








The information and decisions you obtained in PART 1 will be used in PART 2.

  • Plan it- What exactly are we going to do?
  • Do it –When and how do we do it?
  • Study – What are the results?
  • Act – What do we do with the results (lesson learned)




PDSA ItemActions



1.     What change are you testing with the PDSA cycle(s)?

2.     Who will be involved in this PDSA? (e.g., one staff member or resident, one shift?).

3.     What do you predict will happen and why?

4.     What is the small test of change?

5.     How long will the change take to implement?

6.     What resources will be needed?

7.     What data need to be collected?


List your action steps, who will be responsible (where applicable) and the time frame for completion


Creating a checklist of expected services for diabetes patient for the nurses during an office visit. Foot exam is required for patients with diabetes in addition to checking or getting their A1C data and getting their vitals.

The checklist will ensure that foot exam is performed for all diabetes patient.

A pilot test of the updated checklist will be tested first with two nurses for a month.  This will allow to test the process and determine if the change will result in achieving the aim

No new additional resources is expected for this change beside additional time for the nurses with diabetes patient.

We will collect data on number of patients each nurse worked with? The number with diabetes? Total time spent with each patient. A benchmark of total time spent with and without a foot exam



Carry out the test on a small scale. Document observations, including any problems and unexpected findings.

Collect data you identified as needed during the “plan” stage.

Describe how you will actually ran the test.


In this section describe the process of implementing the test. Describe any potential problems that may occur


Study and analyze the data. Determine if the change resulted in the expected outcome.

Were there implementation lessons?

Summarize what was learned. Look for: unintended consequences, surprises, successes, failures.

Describe how you will prepare the data and analyze the data. What estimates do you plan to get? E.g. the proportion of all patient with diabetes that had foot exam during a visit. A bar chart of the time the nurses spent when foot exam was performed compared to when it was not

What results and lessons do you anticipate?



Based on what was learned from the test: Adapt – modify the changes and repeat PDSA cycle.

Adopt – consider expanding the changes in your organization to additional residents, staff, and units. Abandon – change your approach and repeat PDSA cycle.

Describe what modifications to the plan will be made for the next cycle from what you learned. Describe what you will do with the lesson learned if it was positive (i.e. if the change results in and improvement); and if it was negative (i.e. the aim was not achieved, or cost and time spent was more than expected etc.



Key sections you should note to include in the QIP. Part 1 and Part 2 of the Model for Improvement, and the Team process

  1. Part 1- Evidence-based literature review on the issue, potential solutions and problems, measures to assess and determine if the change will an improvement if implemented; types of data to collect and analysis strategies. Use the APA format for your citation and references.
  2. Part 2- the worksheet for the PDSA cycle, two columns similar to what is in your instructions.
  3. Team Process description: Describe the process the team used in decision making, assigning responsibilities for tasks that contributes to the development and completion of the QIP. Each member’s contribution in completing the QIP.

What strategies implemented in your teach that facilitate the success or otherwise of the processes leading to the development of the QIP?








http://patientsafetyed.duhs.duke.edu/module_a/introduction/introduction.html (great resource with examples on aspects of Model for improvement