Creating a Quality Improvement Model

Develop a quality improvement plan that is based on the scenario by doing the following:
Note: You may present your plan as a chart, graph, multimedia presentation, or outline.
A. Discuss how to initiate a quality improvement project for this clinical problem.

  1. Identify the areas of focus for quality improvement in the scenario.
  2. Select a model for the process.
  3. Identify the types of data needed for objective information.
  4. Identify how you would gather the data.
    B. Identify the team members who would contribute to the team.
  5. Describe these team members’ professional roles.
  6. Explain why the team members’ participation would benefit the project.
  7. Discuss the qualities the team needs in order to facilitate project success.
    C. Discuss how you would communicate your ideas for quality improvement project
    implementation to organizational leaders.

Creating a Quality Improvement Model

There is an identified problem concerning the care services being offered in the clinic
case study. The problem is caused by the various shortcomings especially in the way the various
departments’ staff carry out their duties. Although there is a laid out programs in the clinic where
each section is aware of what is expected o them and when they are expected to deliver these
services, the various departments are not working closely together as a whole. Since the clinic is
a whole function failure in one department is likely to affect the program of other departments
and the overall quality of services delivered.
Areas of focus for quality improvement in the scenario include coordination between the
therapy staff and the nursing staff, barriers to internal communication, and adherence to

schedules. Delays are caused by the poor coordination between the two departments. Proper
coordination is the key consideration to addressing the problem (Jha & Zaslavsky, (2014).
Nurses need to adhere better to schedules to avoid affecting the therapy sessions. Internal
communication is not effective and often results in arguments.
Areas of Focus

Lack of Coordination: In order for the clinic to improve coordination between the
different departments, there must be strong processes on the part of the organization and
commitment on the part of the staff (Gillam & Niroshan Siriwardena, 2013). To collaborate the
efforts of the entire clinic, the management need to have proper policies and code of ethics that
will promote systematic integration of the various functions through accountability and
commitment. The processes developed must also be capable of detecting early symptoms of lack
of coordination in order to alleviate the problems before they can affect quality of care services.
Adherence to Work Schedules: An analysis of the clinic problem shows a lack of
adherence to schedules especially among the nursing staff. There are numerous complaints from
the therapy department concerning the low degree to which the nursing staffs are able to stick to
the laid down schedule of releasing patients for therapy (Jha & Zaslavsky, (2014). As such, the
whole daily program at the clinic gets delayed eating into the time that patients are supposed to
have their therapy. Besides, less time spent on therapy means a compromise to the quality of the
care service being offered to patients and damage on the reputation of the clinic.
Barriers to Internal Communication: The problem in the clinic is also closely associated
with poor internal communication between the various staff members. Some of the barriers

include role and bias. These barriers cause poor communication and conflicts as seen in the clinic
where therapy staffs are always quarrelling with the nursing staff.
As a result of these identified challenges, three areas of focus were identified; poor
quality of care services being offered to patients, overworking of the patients, and shortage of
Overworking of Patients
Overworking of the patients was identified as emanating from the lack of coordination
and proper communication causing wastage of the time patients require to undertake the normal
therapy. Therapists have little time to spend with patients causing overworking.
Understaffing of Nurses
Notably, most of the nurses have cited that delays are normally caused by the large
number of tasks that they have to undertake implying that they are understaffed. This is the root
cause of all the delays and lack of motivation being experienced in the nursing department.
Focus in this area should be in assessing the workload of each employee to identify signs of
Patient Care
The overall implication is that patients receive a raw deal. The care being offered to
patients especially in terms of therapy is not sufficient. This compromises the quality of the care
services as well as on the healing process of the patients. The QI must, therefore, focus on
addressing these three areas of focus (Wiig et al., 2014).


Model Process for Addressing the Clinical Problem

The best-suited model for the QI project is the Plan-Do-Study-Act (PDSA) model for
improvement. According to Jha and Zaslavsky, (2014) the PDSA model for improvement
involves eight stages; introduction, forming a team, setting aims, identifying measures, deciding
on the changes, testing changes, and spreading changes.

(Adapted from: Davis et al., 2014)

The model involves planning for change to be implemented, implementing the plan,
evaluation is necessary during and after the project implementation, and the final stage involves

full implementation or continuation of the changes (Wiig et al., 2014). The plan stage entails
identifying the objectives and aims of the project and formulating a theory to guide action,
defining success metrics. The Do step is undertaken by putting the plans into action. The Study
step entails monitoring the outcomes of the plan in order to test its viability and to identify signs
of success or areas of weakness for improvement. Finally, the Act step proceeds by integrating
the learning generated through the project as a basis for adjustments where necessary (Davis et
al., 2014). The four steps then becomes a continuous process of improvement in the organization.
The model will enable the team test out changes before full implementation. It will also
give all the stakeholders in the case; nurses, CEO, supervisors, physical therapist, transporters,
and schedulers to establish if the proposed QI change will work. By involving all the
stakeholders in the clinic, the project will enjoy high levels of ownership which will make
success more likely.

Types of Data Required

To achieve objective information, the project requires evaluation of both primary and
secondary data (Wiig et al., 2014). These sources will provide both quantitative and qualitative
data as follows:

 Patient records (records on drugs administered and therapies and discharge notes)
 Therapy notes (concerning the frequency, duration, and progress of therapies)
 Treatment progress data(gathered while treatment is being conducted)
 Generalization probe data (measures of a variety of patient behaviours in relation
to treatment goals)


 Control data
 Communication and Shift Records (employees weekly/monthly reports should
contain this information)
 Staff work schedules and timetables (for each department and employee)
 Focus group discussion findings.
 Patient and staff satisfaction surveys
 Frequencies of timely access to care and health screening
 Percentages of appropriate care services and treatment
The combination of the qualitative and quantitative data gathered will close any gaps that
could cause the information to be subjective (Wiig et al., 2014).
Ways of Gathering the Data
 Evaluating clinic database for patients and staff records such as therapy notes will be used
to evaluate the effectiveness of the care programs (Gillam & Niroshan Siriwardena,
2013). The data base will be accessed to gather information concerning record of
treatment and therapy done for each patient as well as the duration for each program. This
can be achieved by calculating the frequencies of patients’ timely access to care and the
percentages of appropriate care services and treatment. this will be helpful in assessing
the quality of care given.
 The report should also consider employees’ personal timetables and work schedules to
establish how they plan their activities and possible challenges such as overworking.

Timetables will be evaluated by identifying how daily tasks are planned and the time
allocations to these tasks to offer insight into the issue of overworking.
 Brainstorming and discussion sessions are an effective source of information and ideas
(Wiig et al., 2014). Analysis should be done to identify patterns in ideas raised in terms
of the common issues, concerns, and suggestions.
 Another source is by conducting staff interviews and questionnaires to get opinions from
staff. Interview should be conducted with selected representations of the staff to collect
ideas, opinions, and recommendation concerning the problem.
Team Members to Contribute to the Team

The team will be comprehensive by including members from across all departments in the
centre to ensure that all aspects of the problems are objectively identified and addressed.
 Rehabilitation department – rehabilitation supervisor
 Health information management supervisor
 Surgery department – supervisor
 Schedulers – team leader
 Nursing department – supervisor
 Would care team – team leader
 Transporters – team leader
 Social work department – supervisor
 Project team leader
The nursing department supervisor will help unravel the mystery of how programs are
organized and to offer insight into the cause of the delays and confusion being experienced in

their department. The HIM supervisor will facilitate the process of gathering information both
from the clinical database and the respondents. Additionally, they will be instrumental in
analyzing the data for interpretation by the members. The team leaders representing the
schedulers and the transporters are important for the group since they will shed light on what
causes them to delay in handing over and transporting patients to the therapists. The supervisors
from the wound care unit, social work department, and surgery department would be
instrumental in offering insights into the status of their various areas. The team leader will offer
leadership through organizing, direction, motivation, and planning.

Contributions of the Members of the Team to the Project

 Rehabilitation supervisor is expected to offer information concerning therapies including
schedules, length of stay of patients in therapy sessions.
 Health information management supervisor is needed to facilitate the process of
gathering information both from the clinical database and the respondents and in
analyzing the data.
 Surgery supervisor will offer insight on the length of period spent on surgery
 Schedulers’ team leader will report on the assigned time for patients in every session
from nursing to therapy.
 Nursing supervisor will report on the dynamics of the nursing department including time
spent on would care and any identified causes for delays.
 Transporters’ team leader will be required to report on challenges and issue concerning
transporting of patients.
 Social work supervisor is to report on the way their department has organized its
counselling sessions in accordance with other programs.

 The team leader will offer leadership through organizing, direction, motivation, and

Qualities needed by the Team

 The team members must demonstrate reliability whereby the team will work better if
members who get work done (Wiig et al., 2014).
 Members of the team need to communicate constructively and effectively (Lemak et al.,
 Members should be willing to listen to others actively. Good listeners are very essential
for the effective functioning of the team (Davis et al., 2014).
 To be successful, the team needs active open and willing sharing. People must be willing
to share information, experience, and knowledge pertaining to the problem in question
(Lemak et al., 2013).
 The group needs members to be flexible problem solvers. Members should be able to
change with conditions of the team (Davis et al., 2014).
Professional Roles

 Leadership – the team requires a member who can offer strong leadership and motivation
 Monitoring and evaluation – the project needs to be monitored to ensure success
 Rehabilitation supervisor therapies should collaborate with other in identifying the
problems and solutions leading to delays

 Health information management supervisor will be required to facilitate gathering of
information both from the clinical database and the respondents and in analyzing the data.
 Surgery supervisor should also contribute to identifying and addressing the problems
causing delays.
 Team leaders for schedulers and transporters will report on the assigned time for patients
in every session from nursing to therapy.
 Nursing supervisor is a very important player in the team in offering information
concerning schedules, staffing, and cooperation with other departments.
 Social work supervisor is to report on the way their department has organized its
counselling sessions in accordance with other programs.

Communication Strategies

It is important that the ideas generated in the team are communicated effectively to the
project implementation organizational leaders. The first step of the presentation will be a review
of the report by the selected team before it is presented (Lemak et al., 2013). The team will
discuss on the appropriateness of the report. The team will ensure that the report is relevant in
terms of the aim and objectives, methods and procedures, recommendations, and any other
relevant presentation documents. Presentation of the team’s proposed QI project will be one in
form of a report to be presented to the Board of Directors/leadership. Subsequent updates of the
QI project progress will be done to the leadership regularly in for of activity logs, issue
identification logs, and meeting minutes. In addition, improvement efforts will be communicated
through all-employee meetings and newsletters (Gillam & Niroshan Siriwardena, 2013).


Requirements for Proceeding with the Quality Improvement Project
There is an identified problem of quality of the care being offered to patients and as such
there is a need for a QI project. Projects need facilitation in terms of resources (Davis et al.,
2014). The project will need facilities such as offices in which to hold meetings on the progress
of the project or staff trainings. Financial resources are needed in supporting the activities of the
project. There is also a need in terms of time on the part of the team steering the implementation
of the project given that they have other daily duties to attend to. There is a need for a team of
the staff members to oversee the implementation of the project. The project needs a steering
committee that will oversee the step-to-step stages of the project’s implementation. There should
also be a team for ongoing evaluation of the implementation progress of the project. Approval of
the QI recommendations by the leadership is very essential. The project must earn the support
and commitment of the management to secure continuation.



Aghaei Hashjin, A., Ravaghi, H., Kringos, D. S., Ogbu, U. C., Fischer, C., Azami, S., &
Klazinga, N. S. (2014). Using Quality Measures for Quality Improvement: The
Perspective of Hospital Staff. Plos ONE, 9(1), 1-13. doi:10.1371/journal.pone.0086014.
Davis, M. V., Mahanna, E., Joly, B., Zelek, M., Riley, W., Verma, P., & Solomon Fisher, J.
(2014). Creating Quality Improvement Culture in Public Health Agencies. American
Journal Of Public Health, 104(1), e98-e104. doi:10.2105/AJPH.2013.301413.
Gillam, S., & Niroshan Siriwardena, A. A. (2013). Commissioning for Quality
Improvement. Quality in Primary Care, 21(6), 339-343.
Jha, A., & Zaslavsky, A. (2014). Quality Reporting that Addresses Disparities in Health
Care. JAMA: The Journal of the American Medical Association, 312(3), 225-226.
Lemak, C., Cohen, G. R., & Erb, N. (2013). Engaging Primary Care Physicians in Quality
Improvement: Lessons from a Payer-Provider Partnership. Journal of Healthcare
Management, 58(6), 429-443.
Wiig, S., Robert, G., Anderson, J. E., Pietikainen, E., Reiman, T., Macchi, L., & Aase, K. (2014).
Applying Different Quality and Safety Models in Healthcare Improvement Work:
Boundary Objects and System Thinking. Reliability Engineering and System Safety, 134.