Step 1: Confirm Commitment of Leadership &
Establish Supportive Organizational Structure

• Establish support of program leadership for Quality Management (QM) and confirm commitment.
• Commit resources to support QM activities.
• Provide education about CQI tools and techniques to all levels of staff, including senior leadership.
• Establish a method to inform all levels of staff, including senior leadership and Board of Directors, about QM initiatives.
• Delineate expectations of staff related to QM.
• Delineate specific QM responsibilities of staff.

 Step 2: Establish Quality Management Plan

• Establish Quality Guidance Team, Steering Committee or utilize existing leadership meetings to oversee the QM program.
• Develop an organizational QM plan which delineates goals and objectives for the QM program.[2]
• Establish QM priorities.
• Develop a time line or calendar of activities for the year.
• Select a QM approach, such as PDSA or the Chronic Care Model.
• Clarify QM responsibilities of staff.

 Step 3: Determine Performance Measures &
Collect Baseline Data

• Based on QM priorities, determine performance measures.
• Develop indicators to measure performance.
• Define measurement population and delineate eligibility criteria.
• Create a data collection plan to include: ¨C Sampling strategy ¨C Determine method of data collection, i.e. chart abstraction, interviews
• Create data collection tools ¨C Create instructions for data collection tools ¨C Train personnel who will collect data ¨C Conduct pilot test of tool
• Establish process of communicating with staff about measurement process
• Collect data

 Step 4: Analyze Data

• Analyze data and review the results.
• Identify areas where additional data is required.
• If historical data are available, compare for trends.
• Display and distribute data to communicate findings and results.
• Identify areas for improvement and select a quality improvement project.

 Step 5: Develop Project-Specific CQI Plan

• Establish project-specific QM team that represents all staff integral to the service or issue.
• Identify a team leader or sponsor.
• Delineate specific goals for the team.
• Allocate time and resources for the team.
• Delineate team responsibilities.
• Develop timeline for reporting findings and improvement strategies.

 Step 6: Study and Understand the Process

• Analyze the root causes.
• Utilize CQI tools and techniques to understand the process, such as flow charts, facilitated brainstorming, cause & effect diagrams, fishbone, etc.
• Document and track progress by using activity logs, issue identification logs, meeting minutes, etc.
• Report progress to senior leadership and staff on a regular, defined basis.

 Step 7: Develop and Implement an Improvement Plan

• Identify potential solutions to make improvement to the systems of care.
• Recognize quick fixes and longer term solutions.
• Try a small test of change and analyze results.
• Refine improvement plan.
• Develop timeline for implementation of plan.
• Delineate team responsibilities.
• Implement changes.
• Track changes and improvement actions.

 Step 8: Remeasurement

• Determine interval for remeasurement.
• Remeasure indicator after change has been implemented.
• Look for incremental improvement.
• Communicate results to team, staff and leadership.
• Determine need for and/or level of remeasurement on an ongoing basis.
• Develop a plan for sustained improvement.

 Step 9: Celebrate Success

• Communicate results of the project to all levels of the organization, including consumers when appropriate.
• Congratulate team in public forum, i.e. staff meetings, Board of Director meetings.
• Select a new project and begin at Step 3.