Improvement Project Worksheet – CLINICAL PROJECT
Project
Goal: ___________________________________________________________________________________________
Keep in mind the IOM Quality Goals: Safe, Timely, Efficient, Effective, Equitable, Patient Centered (STEEEP)
Team
Members: __________________________________________________________________________________
Sponsor: mentor at your facility to help you complete your project; administrator: make sure you have a manager on board; expert: staff member
close to the process with expertise that you need for the project e.g. information technology or housekeeping.
Step 1 - Problem Identification & Baseline Data
My global aim is to ____________________________________________________________________
Global Aim – fill in the blanks
in the _______________________. I expect that by working on this problem, we will
______________________________________________________. It is important for us to work on this
because _____________________________________________________________________________.
Data to support - What are some
observations you have made? What
are some of the factors that stand in
the way? Explain your detailed plan
for data collection here. For
example, conduct a survey or an
interview.
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Outcome Data – How prevalent is
the problem? Provide results here
Step 2 - Link Current Evidence & Benchmarking Best Processes
Evidence from literature – what evidence in the
literature supports or informs your goals?
Provide the following for TWO sources of literature: title,
author, intervention, sample, details, results & your own
comments.
Evidence from industry – Find evidence from other
institutions or the industry: what are others doing that
would support your goals?
Provide the following for TWO sources: title,
hospital/organization, intervention, population, details,
results & your own comments.
Step 3A – Understanding the Process (Context – readiness to change, evidence of teamwork, quality culture)
Directions: Review each principle that determines readiness for change. Score a principle “yes” if you have established support and readiness. If you have
not, score it “no” and define required action steps. When you have implemented the action steps, feel free to re-evaluate and re-score. If you have not
achieved support, redefine your opportunity and realign your strategies. (Note: re-evaluating and re-scoring is not necessary for the assignment, but it
would benefit your project.)
When all criteria is scored as a “yes” you should proceed with your improvement strategy. As you continue, remember to:
1. Use the PDSA process with a focus on continuous evaluation and reflection.
2. Follow the implementation process as a team
3. Measure effectiveness continuously
4. Market the outcomes to your team and the organization 5. Celebrate success
Define agreed upon project & goals: Do you
have senior leadership buy-in? Yes or no?
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Step 3A Continued
Customer Focus: Have you clearly defined the
customer who will benefit from the
improvement? Yes or no?
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Eliminate Blame: Have you defined the
process (not the people) that requires
redesign? Yes or no?
Rely on Data: Have you defined data needs
and required support for data management
and analysis? Yes or no?
Team Approach: Have you defined an
interprofessional team creating a neutral
problem solving environment? Yes or no?
Include all levels of employees: Have you
defined all employees involved in every level
of process? Yes or no?
Economic Support: Have you identified
economic needs of the project, including time,
personnel and financial support? Yes or no?
Step 3A Continued
Celebrate Success 1: Have you identified
ideas for various levels and types of team
success? Yes or no?
Celebrate Success 2: Have you obtained buyin for celebration of success? Yes or no?
Step 3B – Understanding the Process (Diagnosis of system performance, process map, fishbone diagram)
Fishbone Diagram - We use fishbone diagrams to help identify what caused a particular event to occur. Begin by placing the event at the head of the fish.
Then think about the causes of this event as they relate to each of six categories: People, Methods, Machines, Materials, Measurements, and Environment.
People:
Process:
Equipment:
Problem:
Materials:
Environment:
Management:
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Step 3B Continued
Process Map – Make a process map any way you can, save it as a picture, and include it below. Click the grey box to insert a picture.
Step 4 – Specific Aim & Timeline
Specific Aim – What are we trying to
accomplish? Make sure your aim is SMART:
Specific, Measurable, Achievable, Realistic,
and Timely.
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Step 5 - Measures
Survey or interview guide: Create a short
survey or interview guide (2 -3 questions) to
collect additional information from the people
who you work with regarding the process you
are trying to change.
On the right answer: 1) What was one
question you asked? 2) What did you find out?
Outcome Measure: Identify the outcome
measure: what are the desired results?
Outcome Measure: Identify the operational
definition: how will you measure?
Process Measure: Identify the process
measure: are the parts of the system
performing as planned?
Process Measure: Identify the operational
definition: how will you measure?
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Step 5 Continued
Balancing Measure: Identify the balancing
measure: are changes to improve one part of
the system causing new problems in other
areas?
Balancing Measure: Identify the operational
definition: how will you measure?
Step 6 – Identify and Choose Change Idea (What changes can we make that will result in an improvement?)
Directions: Fill out the table below. Enter a change idea then answer yes or no to each question in that row. Give a point for each “yes” response and
include the total number of points for the change idea in the “total” column.
Change Idea
Evidence to
Support?
Available
Resources?
Easy to
Implement?
New
Innovation?
Advantage
Over Current
Process?
Total
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