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10 Steps for Analysis of Quality Improvement Projects

The following is a template of 10 steps and guidelines used by Brainerd Lakes Surgery Center in Baxter, Minn., to meet the AAAHC 10-point quality reporting system.

1. Identification of the Purpose of the Activity: You should identify the problem(s) or concern(s) that is/are potential topics for a QI Project (Study) [quality issue addressed] Describe the concern/problem as well as the severity and the source of the problem or concern (i.e. Retrospective clinical record review revealed that verbal orders were not being countersigned). Explain why it is significant to the organization.

2. Appropriateness of the performance goal: Identification of the performance goal against which the organization will compare its current performance in the area of study

3. Data collected (performance measure[s]): What data will be collected in order to determine the organization's current performance

4. Data collection methodology: How was the data collected?

5. Data analyses and conclusions: The data must describe the frequency, severity, and source of the problem.

6. Comparison of initial performance versus performance goal: A comparison must be made between the current performance and the performance goal.

7. The development and implementation of corrective action, and, if necessary, additional corrective action, there should be a change in behavior

8. Re-measurement, and, if necessary, additional re-measurement; included must be a second round of data collection that objectively determines whether the corrective actions have achieved and sustained demonstrable improvement. It should be remembered that when you re-measure, you are expected to use the same measures you used in the first place. There may be a few reasons to change some of the measures; however, these are minimal and should be documented well. You should not change a measure to increase your outcomes.

9. New current performance versus performance goal: If the initial corrective actions did not achieve and/or sustain the desired improved performance, implementation of additional corrective actions and continued re-measurement until the problem is resolved or is longer relevant. Acceptable change is determined in-house. However, external factors may impact the decision of what is acceptable change. Benchmarking may be a helpful tool in developing acceptable change goals.

  • Benchmarking involves comparing a set of products or services against the best and/or like that can be found within the relevant industry sector. Regularly comparing aspects of performance (functions or processes) with best practitioners and/or like practitioners, identifying gaps in performance, seeking fresh approaches to bring about improvements in performance, following through with implementing improvements, and following up by monitoring progress and reviewing the benefits. The involvement of Benchmarking with your QI Study may start at the time you identify the problem(s) and/or concern(s) and begin the development/identification of the performance goals and objectives and continue as you have collected your data and then compare your data as a part of your process for the development of your corrective actions.

10. Methods of communication of the study findings throughout the organization; tt should remembered that the Governing Body is responsible for the operations of the Center and therefore should not only 'hear' the report; however, be involved in the resolution process as necessary. The incorporation of such findings into the organizational educational activities [i.e. "closing the QI loop"]

Thank you to Sandy Berreth, RN, MS, CASC, administrator of Brainerd Lakes Surgery Center, for providing these guidelines.

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