Our QI Process

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OUR Process FOR

Quality Improvement Projects

01

Define the Problem & Aim

Problem Statement: Draft a clear, data-driven description of the current issue. Define where and when the problem happens and why it should to be improved.
Aim Statement: Create a measurable SMART goal (Specific, Measurable, Achievable, Relevant, Time-bound)

05

Test & Refine Using PDSA Cycles

Test the change ideas from your driver diagram using Plan-Do-Study-Act (PDSA) Cycles.
Plan: Note your prediction for a specific intervention you want to test.
Do: Test this on a small scale and note your observations.
Study: Analyze the data from your test and compare it to your predictions.
Act: Decide whether to adapt the change and run another PDSA cycle, adopt it into the workflow, or abandon it.

02

Map & Analyze the Current State

Process Mapping: Create a flowchart to outline each step of the current process from start to finish.
Root Cause Analysis: Use tools like the “5 Whys” or a Fishbone Diagram to dig down past surface symptoms and identify the underlying causes of the problem.

06

Review Results

Run Charts or Control Charts: Plot your data over time using run charts or control charts to determine if you have true improvement.

03

Establish Measures

Include:
Outcome Measures: Tracks the overall goals of the project
Process Measures: Monitor whether the interventions you’re testing are leading to improvement.
Balancing Measures: Account for any unintended side effects or negative consequences of your interventions.

07

Sustain & Spread Success

Standardization: Embed changes that lead to improvement into standard operating procedures.
Ongoing Monitoring: Set up a plan to track metrics over time and prevent backsliding.
Spread: Scale successful interventions to other areas.

04

Create a Driver Diagram

Create this tool to visually represent the Aim (your ultimate goal), the
Primary Drivers (the high-level system components required to achieve the aim), the Secondary Drivers (sub-components influencing the primary drivers) and the Interventions (actionable interventions that will be tested.)