Develop a quality improvement plan

Project plan template

Part 1: Define the project

Identify what you are trying to accomplish. Think of a project you would like to be involved in, or
are currently involved in. Later in the template, you will develop the plan in more detail

A. Project name: Reducing skin tears in older people

B. Specify project identification tools:

Which tools will you use to gather valid and reliable evidence to identify the need for this quality
improvement plan? (for example, clinical audit, chart reviews, complaints, benchmarking and
brainstorming). Why do you think these would be appropriate?


 Clinical indicators-skin tears
 Brain storming with staff about causes of skin tears
 Satisfaction surveys of older people and family members regarding their satisfaction with
skin care
 Review of complaints regarding skin care and skin tears
 Focus group with staff regarding implementation process

C. Specify project parameters:

What process or problem should the team study? What are the boundaries of the team’s work?
What part/s of this process or problem should the team NOT study?

Benchmarking revealed higher incidence of skin tears in older people admitted to one unit.

Boundaries: Project will not include other acute or chronic wounds or decubitus ulcers and will
not include people under the age of 65 years

D. Importance of the project:

Why is the project important? What needs of customers, the organisation, or the work area will
be addressed? Why is it important to your workplace?

Skin tears have been associated with poor quality of life, increased pain and discomfort,
decreased mobility and self esteem in older people. The latest evidence-based practice guidelines
outline a range of interventions that can decrease the risk of skin tears in older people. Data
relating to the incidence of skin tears on one unit was benchmarked with data from other units-
this indicated a higher incidence of skin tear rate in the unit where the Quality Improvement Plan
will be implemented. Complaints data and information from satisfaction surveys indicated that
older people and their families were concerned about the quality of skin care provided to the
older people and the incidence of skin tears on the unit.
 E. Outline project goals:
Write the project objectives here in one or two sentences. Ensure they are specific, measurable,
aligned, ambitious, realistic, time framed and trackable.

The incidence of skin tears in older people on one unit will reduce by 50% from baseline data

F. Specify quality standards:

Define the resources, evidence based best practices, frameworks and legislations that you will
benchmark your project on.

Joanna Briggs Institute of Evidence Based Practice

Nurses’ code of practice

Privacy legislation

OHS legislation

Relevant organizational policy and procedure

Sussman, G & Golding, M 2011, ‘Skin tears: Should the emphasis be only their management?’,
Wound Practice and Research, vol. 19, no. 2, pp 66-71

G. Outline project scope:

What is the desired end result of your project? Define how big or small your project is and what it
encompasses. Outline the work involved to reach the project outcome.

By the end of this project skin tears in the unit will be reduced by 50% from baseline data. This
project encompasses analysis of baseline data at the commencement of the project and on going
clinical indicator data collection throughout the duration of the project. Process measures are
gathered using focus groups with staff, and satisfaction of stakeholders with the project will be
gathered using a satisfaction survey. A team approach is utlised and education will be provided to
team members and unit staff on a range of topics related to skin care in older people, skin tear
prevention, team work, data collect and communication.

H. Define project timelines:

What is the length of the project? When will the project begin? What is the target date for
completion?

Project length: 8 months

Begin: January 2018

Completion: August 2018

 I. Define resources:
Will the team need financial resources? What department(s) or division(s) will provide support?
What limitations are there on budget? Can the team request additional financial support? From
whom? Define other resources (technical support, equipment, supplies, personnel) that this team
will need.

 Back fill for team members to undertake data collection and analysis; attend meetings;
participate in education
 Purchase of skin care products such as emollients and limb protectors
 Cost of using external education consultant
 Cost of stationery and supplies
 Lunch and refreshments provided to staff attending meetings and education
 Computer, internet connection, microphone, camera
 Subscription to the Joanna Briggs Institute of Evidence-Based Practice
 Skype connection

Additional financial support can be requested from the NUM of the unit.

J. Define any training needs:

What training will team members need? In what skills? Who will provide the training?

 Data collection and analysis skills

 Age related changes to the integumentary system
 Prevention and management of skin tears
 Working in teams
 Effective team communication
Running successful meetings

K. Identify stakeholders:
Anyone having a legitimate interest in the outcome of the project (for example, patients, NSW Health Care
Complaints Commission , Joanna Briggs Institute )
 NSW Health
 Board of Directors of the organisation
 Older people and their families
Unit staff

L. Select the team:

Select people who can give a range of experiences, perspectives, skills and knowledge to help the
team achieve its goal. Identify What work areas or technical specialties must be represented for the
team to accomplish its mission?
Coach/quality advisor: Quality manager

Team leader: NUM

Members of the team: (include their area of expertise and role in the team if applicable) 3 unit
staff members, older people, family members

When, where, how often and for how long will the team meet: Monthly meetings on the unit
third Thursday of the month 1pm-2.30pm

As with any team, gather a range of experience, perspectives, skills and knowledge to help the
team achieve its goal. The members can be full time, part time, casual or a mixture, or you can
have core members with supplementary members who you bring in to advise and assist as
needed. Include less experienced people in the team, because they can challenge assumptions
that those with more experience take for granted and they can ask the ‘silly’ , sometimes
insightful questions.

M. Develop operating guidelines:

Define the team’s operating guidelines within the project:
What methods of communication will you use with the team members and stakeholders
during the project?
 What methods of communication will you use with the team members and stakeholders
during the project?
 Minutes of meetings
 Meeting agenda
 Posters of monthly skin tear statistics
 Face to face
 Skype
 Phone
Email
Brochures

How will conflict situations be dealt with?

 Polling
 Pros and Cons list
Majority rules

How will resistance to change be managed?

 Acknowledge people’s concerns and fears about change
 Provide education on the change
 Involve everyone in feedback about change
 Engage everyone in the change process
 Encourage everyone to be flexible and learn
Facilitate feedback to all

How will the team be able to bring up issues?

 Contact the team leader who will add the issue to the meeting agenda
Verbally to the team leader
 What are the ground rules of behavior and operation?
No discrimination, no bullying, participate and support other team members, be
respectful, complete actions prior to the next meeting, only one person at a time speaks
during the meeting

Who will people report to? Use a chart to describe people’s roles and responsibilities:
Board of Govenors

Director of Nursing

NUM

Team Leader

Team members

What decision – making authority will the team have? What authority will the team have
to call in coworkers or outside experts, request equipment or information normally
inaccessible to them and make changes to the process?
The team leader will report to the NUM who reports to the DON if further resources are required.
Team leader will have direct access to data, policies, procedures and other relevant
documentation. Team leader can request assistance from the Manager of Quality in head office
whenever required.

N. Identify the stakeholders whom you need to check with to ensure your project is
acceptable

Stakeholder Information Required When required Format

NUM/Director of Project aim/scope/budget December 2017 Report

Nursing

Regional Quality Project/aim/scope/budget December 2017 Report

Manager

Part 2: Developing a quality improvement plan

Step 1 Restate project purpose statement with more detail

By when: August 2018

Deliver what: Reduction by 50% in skin tear rate in the unit

To whom: Director of Nursing

In order to – why: Improve the quality of life for older people in the unit and reduce length of
admission and associated costs

Step 2 What do we expect to happen?

50% reduction in skin tear incidence, decreased length of stay and decreased costs

Step 3 Determine what data you will need to collect and what tools will you use to collect them…

 Clinical indicators- skin tears

 Stakeholder satisfaction survey
 Complaints data review
Staff focus group

Step 4 Identify:

Who will collect the data? Unit staff and NUM

When will the data be collected?

 Clinical indicators- monthly

 Satisfaction survey- 4 monthly
 Complaints review- monthly
 Focus group- at completion of project

Where will the data be collected? On the unit

Step 5 Identify:

Who will analyse the data?

NUM
When will the data be analysed?

Onset of project, then at 3 months, then 6 months and at end of project

How will the data be analysed?

Quantitative data from patient notes

Step 6 Brainstorm on the tasks/deliverables required for the project – Flow chart your quality
improvement issue

 Get sign off for project from NUM/DON

 Finalise and review project plan
 Obtain baseline data
 Establish schedule for the project
 Establish and communicate meeting times and dates
 Arrange education sessions for team members and staff
 Arrange and advertise access to relevant websites for team members and staff
 Develop and implement interventions
 Evaluate interventions
Write up final report

Step 7 Put the tasks/deliverables in rough order

See step 6

Step 8 Choose from a selection of charts and diagrams.

Which method would you deem most appropriate for presenting the data that you will be
collecting for your QI plan?

Provide rationales for your choices.

Cause and effect diagrams

Histograms
Run charts
Ideal for quantitative projects
Step 9 Suggest interventions for the issues you have detected based on your data

Look for a range of views so data does not appear biased

Step 10 Allocate a time frame for each task (that you’ve put in order). Estimate how long each
task will take, include who you’ll delegate each task to.

Item Duration Milestone Responsibility

Date

Analyse baseline 4 hours Jan 2018 Team leader

data

Education for 2 days Jan 2018 Team leader/external education

team members consultant

Education for 2 days Feb 2018 Team leader/external education

team members consultant

Part 3: Change
Step 11 Evaluate the process, impact and outcomes of change. Complete the checklist for
managing organization change from Skinner (2005, pp. Checklist 1-3):

Preparation 1. Has the need for change been carefully ❏

considered?
Have discussions addressing the following
questions been conducted?
• Have any shortcomings been
identified?
 • What / who is driving the change (i.e.,
what is the rationale for change)? Is this
legitimate?
• Is there a shared perspective that
change is necessary?
• Is change occurring anyway (i.e., in an
unplanned, uncoordinated manner)?
• How does the change relate to the
organisation’s goals and mission?
• What is the evidence that the change
will result in the desired outcomes?
• Do the advantages of change outweigh
the disadvantages?
 Are there sufficient resources to
successfully implement the change?
2. Has a change committee / work group been ❏
established?
3. Does the change committee have a clear role ❏
and function?
For example:
• Evaluating the need for change
• Communication with workers
• Developing an implementation plan
• Conducting or overseeing trials
 • Evaluating implementation of the
change.
4. Does the change committee include ❏
representatives from:
• Frontline workers (non-supervisory /
managerial roles)?
• Workers in supervisory and managerial
roles?
• External bodies such as unions?
 • Different professional groups or roles
within an organization (e.g.,
administration, nurses, researchers,
GPs)?
Unfreezing 5. Has a communication strategy been developed? ❏
6. Does the communication strategy contain ❏
messages that address the following six points?
• Necessity of change
• Discrepancy between current and
desired level of functioning
• Appropriateness of desired change
• Capacity of the organisation to achieve
the change
• Support of informal and formal
organisational leaders
 • Benefits and advantages of the
change (for organisation and individual
workers).
 7. Does the communication strategy include a ❏
range of channels?
For example:
• Face-to-face communication from CEO
/ management (i.e., speeches,
meetings)
• Face-to-face communication from
immediate supervisors
• Emails / letters
• Posters
 • Articles in organisational newsletters.
8. Does the communication strategy include ❏
providing messages on multiple occasions (i.e.,
more than just once or twice)?
9. Does the communication strategy include face- ❏
to-face meetings between workers and
supervisors?
10. Does the communication strategy include ❏
recognition of workers’ investment in current
work practices?
 • Have workers been given
opportunities to discuss the pros and
cons of current work practices?
Changing 11. Have managers / supervisors been briefed on ❏
the change process so they can answer
workers’ questions on:
• Goal / purpose of change?
• Benefits of change?
• Process of implementing the change?
• Implications for individual workers’
roles, responsibilities and job security?
• Opportunities for input into the change
process?
 • Evaluation strategy for the change
process?
12. Are workers given opportunities to participate ❏
in the change process?
For example:
• Participating in regular meetings
• Representation on organisational
change committees
• Having regular informal discussions
 • Participating in attitude and opinion
surveys.
13. Are workers provided with regular constructive ❏
feedback on the performance of new work
practices?

14. Do managers / supervisors recognise and ❏

reward workers’ achievements in changing their
work practice?

Confirming/supporting
15. Has professional development been offered (if ❏
required) to assist workers to learn new work
procedures and practices?
16. Has a trial of the proposed change been ❏
organised (if appropriate)?
Is the trial adequately resourced?
• Have workloads been adjusted for staff
participating in the trial (if necessary)?
 Have resources been allocated to
monitor and evaluate the results of the
trial?
17. Has the trial identified the need for modifi- ❏
cations to the new work practices (or the
process of implementing the change)?
 Have these modifications been made?
18. Have the outcomes of the trial been ❏
communicated to workers?
19. Has an evaluation plan been developed to ❏
assess the:
• Process of change?
 Outcomes of the change process?
20. Does the evaluation include input from a range ❏
of stakeholders?
21. Has a plan been developed to provide ongoing ❏
support to workers?
For example:
• Plans for future “check-up” meetings /
group discussions
 • Results of the evaluation process
discussed with workers

Comments: NA

Step 12 Project risk assessment of your QI plan.

What can go wrong? What is the likelihood of that happening? How will it be managed ? Outline
strategies…

Risk Level (high/Medium/Low) Management Strategy

Project runs over time and Low Team leader monitor

over budget progress and reports to NUM
if more resources/time
required
Part 3: Administer and monitor your project
Step 13 Benchmarking

What methods will use to collect the baseline data and subsequent comparative data? Review at
3 months, 6 months and end of project. As per onset of project data

How the data will be analysed? Quantitative review comparision with baseline

How the data will be presented? Run sheets, Histograms

Strategies you will use to communicate information gathered from the comparison of baseline
with subsequent data to members of your team and health care consumers.

Meetings, newsletters

Step 14 Monitor the project

How will you know when the change has occurred? (Performance indicators, outcomes, quality
standards)
Decrease in skin tears evident from data collected
Step 15 Evaluate the project
Have you succeeded in producing the required change?
Still to be evaluated

Step 16 Issues and Risks Summary

Summarise here the issues/risks that arose during the lifecycle of the Project and what action was
taken to resolve them.

Two key members of the project team were transferred to another unit and were no longer
available to participate in the project. A replacement for one of the team members was found and
took their place on the team. This new team member had to be educated and informed of the
team progress in order to become an active participant on the team.

Step 17 Lessons learned

For each Project Milestone or Phase, identify what worked, what didn’t work and ways to improve
the process the next time.

What Worked What didn’t work Ways to improve

Milestone/Phase
Analysis of baseline Project team leader Increase the amount
data was relieved from of education the
their normal duties project team leaders
to undertake receives on data
analysis in work collection and
hours analysis

Education of team Not all staff could Ensure variety of

members and staff attend face to face modes of education
lectures due to delivery
 rostering
constraints

Education for older Education for older Ensure variety of

people and their people and their modes of education
families families not delivery for older
included in the people and their
original project plan families

Step 18 Recommended improvements

Outline how you will apply the key lessons learned for the actual/future roll out of this project.

 Ensure education is available for all relevant stakeholders using a variety of education
modes eg face to face lectures, on-line learning resources, self paced learning activities
 Ensure work load is distributed among all team members
Provide template for reporting at the beginning of the project

Part 4: Project sign-off

__________________________________ ____________________

Project Manager Project Sponsor

__________________________________ ____________________

Project Client/Owner Other