Step 3: Team formation, project development and implementation, including repetitive cycles of data collection and sequential interventions
QI efforts should be sustained, involving no fewer than 2-3 linked cycles of improvement efforts including data collection and analysis. Data may be collected and reported as often as necessary, but we will expect that projects should be eligible for approval after 6-12 months of sequential rapid cycles of improvement and data collection (e.g., Plan, Do, Study, Act (PDSA) cycles). Shorter cycles generally are advisable to enable and support rapid improvements in care. The use of one-time pre-and post-data collection is not consistent with quality improvement principles of sequentially testing multiple interventions to improve care.
The data must be of sufficient
quality to permit reasonable conclusions, and to provide guidance to the
project team, and there must be appropriate charting and reporting tools to
document performance over time. Such tools might consist of annotated run
charts and/or statistical process control charts.
An improvement cycle should address the
identified problem, general goals/aims within a measurable timeframe for
achievement, the main underlying root causes of the problem, interventions or
countermeasures to address causes, and operational plans to implement the
interventions. View the Logic Diagram for a Proposed Improvement
Cycle for guidance
in planning cycles.
The first improvement cycle should consist of:
1. Appropriate data collection relevant
to the identified problem.
2. Analysis and review of data to
identify underlying cause(s) of problem.
3. Intervention likely to help address
underlying cause(s) and improve system performance.
Subsequent cycles should consist of:
1. Post-intervention data collection to
assess impact of intervention.
2. Adjustment(s) / second intervention(s)
to address underlying cause(s).
3. Post-adjustment data collection to assess
impact of intervention.