Tools for Grantees: Quality Management Manual < Previous | Home | Next >  III. Step-By-Step Quality Management Guide: Nine Critical Steps   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 and track changes and improvement actions.

Identify potential solutions to make improvement to the systems of care.  TOP

Once you have identified an area for improvement, analyzed the root causes, and understood the processes involved, it is time to develop and implement your improvement plan. Just as you were thorough in your process to identify root causes, you should be equally thorough in determining your improvement strategy. The team brainstorms to develop a list of changes that they think will improve the process. The team leader will need to manage this process to assure that consensus is reached regarding the plan.

Recognize quick fixes and longer term solutions. TOP

There will be some improvements that can be accomplished very easily and without pretesting. These quick fixes can be a nice jump start for the team and can be very motivating. Other improvements require pretesting, longer term planning, or require a major work redesign.

Try a small test of change and analyze results.  TOP

Most purposeful improvements will require a systematic approach to achieve the goal. Test your changes on the small scale before they are widely implemented to assure that the change will be effective. We have all been involved in improvement strategies that did not achieve the desired improvement and yet were fully adopted from the start. As there are generally multiple root causes, there may be multiple changes needed to improve the process. You will be relying on multiple cycles to achieve your overall aim. Include conditions in your test that will affect your change in the future. Collect data over time to measure the impact of your change under differing conditions.

During the change process you will need to recognize that staff, providers, and clients react differently to change. Changes should be discussed at a minimum with all individuals involved in the process being addressed, and ideally with all program staff. Lack of communication at this stage can undermine a successful strategy. Expect some resistance but utilize your team members to help decrease negative reactions or behavior that can hinder the change process. Team members are the most influential agents for change. Part of their role will be to bring their colleagues along, answer questions, and show enthusiasm. This can help limit resistance from other staff.

By all means, use common sense. By now, you have already developed a good sense of what strategies will be most effective to improving your process. Use those strategies first, that will maximize your ability to implement an immediate improvement to your program or service. From the list of all possible solutions, review your list with a keen eye and make sure that you sequence your steps in a logical manner that will give you the best result.

Once improvements have been implemented fully, consistent ways of doing the work need to be formalized. This could involve establishing standard ways of performing work activities in a department procedure, standard training for new staff, documentation and ongoing measurement to ensure that the change becomes the normal way things are done.

Below are questions to keep in mind while you are implementing your improvements:

1. What are you trying to accomplish? Be sure to provide an aim for the improvement effort that will guide and keep the effort focused.

2. How will you know that a change is an improvement? Criteria or measures need to be identified to answer this question. The effectiveness of the effort to improve depends in part on the ability to measure these criteria.

3. What changes can be made that will result in improvement? Changes that can lead to improvement need to be identified and tested. In order to implement a change, you will need to identify “who” will do “what,” “when,” and “where.”

Source: Langley, G., Nolan, K., Nolan, T., Norman, C. & Provost, L. (1996). “The Improvement Guide.” Joessey-Bass Publishers San Francisco.

A helpful strategy is to test change on a small scale instead of trying to implement a change throughout an entire system. For instance, if you would like to revise the clinical flowsheet, make a few changes and ask one (1) provider to test the revised flowsheet during one (1) clinic session. Once you receive feedback, make other changes as needed and test it again with three (3) providers over the course of a week. Continue making changes as needed and testing with a group of providers. After these small tests of change have been completed, the revised flowsheet will be ready for widespread implementation.

A widely used framework for testing change on a small scale is the Plan-Do-Study- Act cycle (PDSA) or Shewhart cycle named after the individual who developed it. Use this framework to test your improvement ideas prior to full implementation. (See references for more information on this tool.)

The PDSA Cycle

The PDSA Cycle – The PDSA cycle above is showing the four steps required to assess change within your organization.

Source: Institute for Health Care Improvement, Health Resources and Services Administration (HRSA), HIV/AIDS Bureau (HAB). HIV/AIDS Bureau Collaboratives: Improving Care for People Living with HIV/AIDS Disease, publication supported by grant number 54 U69 HA 00042-03 from the Health Resources and Services Administration.

Refine improvement plan.  TOP

Testing the plan on a small scale can help you understand what works and what doesn’t. Set up a feedback loop including additional data collection to determine if the change was successful. This refinement process may take some time, and you may need to re-test the changes prior to full implementation.

	Develop timeline for implementation of plan.  TOP
	Delineate team responsibilities.
	Implement and track changes and improvement actions.

Once you are sure that the plan is ready for full scale implementation, you will need to develop a timeline and again communicate to all key stakeholders. The improvement plan and timeline are to keep the team focused on their progress. They should include the who, how, what and when.

As much as possible, give team members responsibilities that are closely related to their jobs. They may be able to tap into information and knowledge about their programs and use it in the QM effort.

Below are two formats to document your plan which you may find helpful. Improvement Plan (1) organizes the plan by action item; Plan (2) by the source of the change. The plan should include a timeline as well as responsible individuals for each improvement. The plan should be updated regularly and can be used to communicate to key stakeholders and individuals not on the project team. Within the improvement plan, specific staff responsibilities should be delineated. (See Appendix F for an additional Project Workplan, which will help you document your progress.)