Appendix J - Sample Quality Improvement Plan Action(s) Problem or Baseline Root and Time Evaluation Process to Measure Goal(s) Result Cause(s) Person(s) Frame Process Improve Responsible Measure Enter the Enter cause(s) For each Enter the goal For each action Describe how identified for baseline that have been identified cause, to be achieved step, indicate the facility will improvement. (current) result identified by describe the including date the beginning continuously for measure your facility action step(s) (e.g., date (date evaluate each “To including date that the facility will improve our action step action step and %. contribute(s) to use to achieve baseline of was started) taken to see if the facility’s improvement. % to and the end improvement is current Indicate who in date (date being achieved. % by . performance your facility is action step to (e.g., tracking rate. (Enter responsible for be completed). tools, meetings, each cause on a each action step. monitoring) separate line Include who will below). be responsible for evaluation and compliance. Dialysis facility The percentage Only 3 out of 8 Infrequent Use Quarterly To increase 9/1/11 The social unaware of of nursing nursing home communication Update Tool to percentage of worker will disaster plans home patients patients had with nursing document disaster conduct for nursing with disaster plans nursing home for nursing audit of End: 12/1/11 home patients, documented documented in plans. home patients charts for and no disaster plans. chart (38%). documented in nursing home documentation patient chart to patients in No assigned of plans in 90%. December to member to Social worker Numerator: # patient chart. determine obtain and will be of nursing progress. If goal document responsible for home patients not met, the information reviewing and with social worker from Nursing documenting documented will review and Home. contact with plan revise actions. Nursing Home and disaster Denominator: plans. Total # of nursing home patients Date QIP Developed: ___________________________________ Facility: ___________________________________
Appendix J - Sample Quality Improvement Plan Problem or Process to Improve Measure Baseline Result Root Cause(s) Action(s) and Person(s) Responsible Goal(s) Time Frame Evaluation Process Measure identified for improvement. Enter the baseline (current) result for measure including date and %. Enter cause(s) that have been identified by your facility that contribute(s) to the facility’s current performance rate. (Enter each cause on a separate line below). For each identified cause, describe the action step(s) the facility will use to achieve improvement. Indicate who in your facility is responsible for each action step. Enter the goal to be achieved including date (e.g., “To improve our baseline of % to % by . For each action step, indicate the beginning date (date action step was started) and the end date (date action step to be completed). Describe how the facility will continuously evaluate each action step taken to see if improvement is being achieved. (e.g., tracking tools, meetings, monitoring) Include who will be responsible for evaluation and compliance. Dialysis facility unaware of disaster plans for nursing home patients, and no documentation of plans in patient chart. The percentage of nursing home patients with documented disaster plans. Numerator: # of nursing home patients with documented plan Denominator: Total # of nursing home patients Only 3 out of 8 nursing home patients had disaster plans documented in chart (38%). Infrequent communication with nursing No assigned member to obtain and document information from Nursing Home. Use Quarterly Update Tool to document nursing home plans. Social worker will be responsible for reviewing and documenting contact with Nursing Home and disaster plans. To increase percentage of disaster for nursing home patients documented in patient chart to 90%. 9/1/11 End: 12/1/11 The social worker will conduct audit of charts for nursing home patients in December to determine progress. If goal not met, the social worker will review and revise actions. Date QIP Developed: ___________________________________ Facility: ___________________________________