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Ann Marie T. Sullivan, M.D., Acting Commissioner
Governor Andrew M. Cuomo

Quality Improvement Plan Template
Quality Improvement Plan

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New York State Office of Mental Health
Office of Quality Management

Quality Improvement Plan
Name of Clinic
Date of the Current Plan

Section 1 – Introduction

Introduction: Mission, Vision, Scope of Service
(Describe briefly the clinic program that will be covered by this Plan, including the clinic’s mission and vision, the types of services provided, its relative size, etc,)

The following Quality Improvement Plan serves as the foundation of the commitment of the this clinic to continuously improve the quality of the treatment and services it provides.

Quality services are services that are provided in a safe, effective, recipient-centered, timely, equitable, and recovery-oriented fashion.

( Clinic name ) is committed to the ongoing improvement of the quality of care its consumers receive, as evidenced by the outcomes of that care.  The organization continuously strives to ensure that:

Quality Improvement Principles.
Quality improvement is a systematic approach to assessing services and improving them on a priority basis.  The (Name of Clinic)  approach to quality improvement is based on the following principles:

Continuous Quality Improvement Activities.
Quality improvement activities emerge from a systematic and organized framework for improvement.  This framework, adopted by the hospital leadership, is understood, accepted and utilized throughout the organization, as a result of continuous education and involvement of staff at all levels in performance improvement. Quality Improvement involves two primary activities:

The tools used to conduct these activities are described in Appendix A, at the end of this Plan.

Section 2 – Leadership and Organization

The key to the success of the Continuous Quality Improvement process is leadership.  The following describes how the leaders of the (Name of Clinic) clinic provide support to quality improvement activities.

The Quality Improvement Committee provides ongoing operational leadership of continuous quality improvement activities at the clinic. It meets at least monthly or not less than ten (10) times per year and consists of the following individuals:  (List titles of committee members. The membership should include a recipient/family member for adult settings and a family member for children settings. Indicate the Chairperson of the Committee.)

The responsibilities of the Committee include:

The Board of Directors also provides leadership for the Quality Improvement process as follows:

(Describe how leadership will support clinic’s QI Program.)

The Leaders support QI activities through the planned coordination and communication of the results of measurement activities related to QI initiatives and overall efforts to continually improve the quality of care provided. This sharing of QI data and information is an important leadership function.  Leaders, through a planned and shared communication approach, ensure the Board of Directors, staff, recipients and family members have knowledge of and input into ongoing QI initiatives as a means of continually improving performance.

This planned communication may take place through the following methods;          

Please describe your clinics method and/or mechanism for communication to recipients, staff and leadership.

Section 3 – Goals and Objectives

The Quality Improvement Committee identifies and defines goals and specific objectives to be accomplished each year.  These goals include training of clinical and administrative staff regarding both continuous quality improvement principles and specific quality improvement initiative(s).  Progress in meeting these goals and objectives is an important part of the annual evaluation of quality improvement activities.

The following are the ongoing long term goals for the   (Name of Clinic)  QI Program and the specific objectives for accomplishing these goals for the year ______ . (Indicate the current year.)

List here your goals and objectives for the current year.  Selection of your goals may be taken from the list provided above.  You do not need to select all of these goals.  The list should be tailored to your program and include specific objectives - ways in which these goals will be accomplished. The objective(s) for each of your selected goals need to be specific and measurable.  Specific and measurable means that you will be able to clearly determine whether the objectives have been met at the end of the year by using a specified set of QI tools.  (See Appendix A.)  At least one of the goals and its corresponding objective(s) should concern staff education related to your quality improvement activities.

Section 4 – Performance Measurement

Performance Measurement is the process of regularly assessing the results produced by the program.  It involves identifying processes, systems and outcomes that are integral to the performance of the service delivery system, selecting indicators of these processes, systems and outcomes, and analyzing information related to these indicators on a regular basis.  Continuous Quality Improvement involves taking action as needed based on the results of the data analysis and the opportunities for performance they identify.

The purpose of measurement and assessment is to:

Measurement and assessment involves:

Selection of a Performance Indicator.
A performance indicator is a quantitative tool that provides information about the performance of a clinic’s process, services, functions or outcomes.  Selection of a Performance Indicator is based on the following considerations:

Characteristics of a Performance Indicator.
Factors to consider in determining which indicator to use include;

(Describe the factors which you will consider in selecting a measure of quality.)  

The Performance Indicator Selected for the (Name of Clinic) Quality Improvement Plan.
For purposes of this plan, an indicator(s) comprises five key elements: name, definition, data to be collected, the frequency of analysis or assessment, and preliminary ideas for improvement.  The following Table presents each performance indicator currently in use by the clinic, along with the corresponding descriptors.

Measure of Service Quality (Complete this table for each indicator which is selected.  Note that only one indicator is required during the first year of the agreement.)
Name Name.  Usually a brief two or three word title.
Definition Definition.  With detail, explain the name by including the data elements and the type of numerical value to be used to express the indicator (percentage, rate, number of occurrences etc.).
Data Collection Describe how the data will be collected as well as the method and frequency of collection, and who will collect the data.
Assessment Frequency State how often the Quality Improvement Committee will assess information associated with the indicator.

Assessment is accomplished by comparing actual performance on an indicator with:

(List here the assessment strategies you will use.  See APPENDIX A, attached, for examples of performance improvement tools.)

Section 5 – Quality Improvement Initiative

Once the performance of a selected process has been measured, assessed and analyzed, the information gathered  by the above performance indicator(s) is used to identify a continuous quality improvement initiative to be undertaken. The decision to undertake the initiative is based upon clinic priorities. The purpose of an initiative is to improve the performance of existing services or to design new ones.  The model utilized at  Name of Clinic  is called Plan-Do-Check-Act (PDCA)(Modify the following as appropriate for your program.  If you choose a model other than PDCA, describe the model here.)

Section 6 – Evaluation

An evaluation is completed at the end of each calendar year. The annual evaluation is conducted by the clinic and kept on file in the clinic, along with the Quality Improvement Plan.  These documents will be reviewed by the Office of Mental Health as part of the clinic certification process.

The evaluation summarizes the goals and objectives of the clinic’s Quality Improvement Plan, the quality improvement activities conducted during the past year, including the targeted process, systems and outcomes, the performance indicators utilized, the findings of the measurement, data aggregation, assessment and analysis processes, and the quality improvement initiatives taken in response to the findings.

Appendix AQuality Improvement Tools 

Following are some of the tools available to assist in the Quality Improvement process.

  1. Flow Charting:  Use of a diagram in which graphic symbols depict the nature and flow of the steps in a process.  This tool is particularly useful in the early stages of a project to help the team understand how the process currently works.  The “as-is” flow chart may be compared to how the process is intended to work.  At the end of the project, the team may want to then re-plot the modified process to show how the redefined process should occur.  The benefits of a flow chart are that it:
    1. Is a pictorial representation that promotes understanding of the process
    2. Is a potential training tool for employees
    3. Clearly shows where problem areas and processes for improvement are.
      flow chart symbols

      Flow charting allows the team to identify the actual flow-of-event sequence in a process.

  2. Brainstorming:  A tool used by teams to bring out the ideas of each individual and present them in an orderly fashion to the rest of the team.  Essential to brainstorming is to provide an environment free of criticism.  Team members generate issues and agree to “defer judgement” on the relative value of each idea.  Brainstorming is used when one wants to generate a large number of ideas about issues to tackle, possible causes, approaches to use, or actions to take.  The advantages of brainstorming are that it:
    1. Encourages creativity
    2. Rapidly produces a large number of ideas
    3. Equalizes involvement by all team members
    4. Fosters a sense of ownership in the final decision as all members actively participate
    5. Provides input to other tools: “brain stormed” ideas can be put into an affinity diagram or they can be reduced by multi-voting.
  3. Decision-making Tools:  While not all decisions are made by teams, two tools can  be helpful when teams need to make decisions.
    1. Multi-voting is a group decision-making technique used to reduce a long list of items to a manageable number by means of a structured series of votes.  The result is a short list identifying what is important to the team.  Multi-voting is used to reduce a long list of ideas and assign priorities quickly with a high degree of team agreement.
    2. Nominal Group technique-used to identify and rank issues.
  4. Affinity Diagram:  The Affinity Diagram is often used to group ideas generated by brainstorming.  It is a tool that gathers large amounts of language data (ideas, issues, opinions) and organizes them into groupings based on their natural relationship.  The affinity process is a good way to get people who work on a creative level to address difficult, confusing, unknown or disorganized issues.  The affinity process is formalized in a graphic representation called an affinity diagram.
    This process is useful to:
    1. Sift through large volumes of data.
    2. Encourage new patterns of thinking.
      As a rule of thumb, if less than 15 items of information have been identified, the affinity process is not needed.
  5. Cause and Effect Diagram(also called a fishbone or Ishakawa diagram):  This is a tool that helps identify, sort, and display.  It is a graphic representation of the relationship between a given outcome and all the factors that influence the outcome.  This tool helps to identify the basic root causes of a problem.  The structure of the diagram helps team members think in a very systematic way.  The benefits of a cause-and-effect diagram are that it:
    1. Helps the team to determine the root causes of a problem or quality characteristic using a structured approach
    2. Encourages group participation and utilizes group knowledge of the process
    3. Uses an orderly, easy-to-read format to diagram cause-and-effect relationships
    4. Indicates possible causes of variation in a process
    5. Increases knowledge of the process
    6. Identifies areas where data should be collected for additional study.
      cause and effect diagram

       Cause and effect diagrams allow the team to identify and graphically display all possible causes related to a process, procedure or system failure.

  6. Histogram:  This is a vertical bar chart which depicts the distribution of a data set at a single point in time.  A histogram facilitates the display of a large set of measurements presented in a table, showing where the majority of values fall in a measurement scale and the amount of variation.  The histogram is used in the following situations:
    1. To graphically represent a large data set by adding specification limits one can compare;
    2. To process results and readily determine if a current process was able to produce positive results assist with decision-making.
  7. Pareto Chart:  Named after the Pareto Principle which indicates that 80% of the trouble comes from 20% of the problems.  It is a series of bars on a graph, arranged in descending order of frequency.  The height of each bar reflects the frequency of an item.  Pareto charts are useful throughout the performance improvement process - helping to identify which problems need further study, which causes to address first, and which are the “biggest problems.”  Benefits and advantages include:
    1. Focus on most important factors and help to build consensus
    2. Allows for allocation of limited resources.
      event rate 12 month

        The “Pareto Principle” says 20% of the source causes 80% of the problem. Pareto charts allow the team to graphically focus on the areas and issues where the greatest opportunities to improve performance exist.

  8. Run Chart:  Most basic tool to show how a process performs over time.  Data points are plotted in temporal order on a line graph.  Run charts are most effectively used to assess and achieve process stability by graphically depicting signals of variation.  A run chart can help to determine whether or not a process is stable, consistent and predictable.  Simple statistics such as median and range may also be displayed.
    The run chart is most helpful in:
    1. Understanding variation in process performance
    2. Monitoring process performance over time to detect signals of change
    3. Depicting how a process performed over time, including variation.

      Allows the team to see changes in performance over time.  The diagram can include a trend line to identify possible changes in performance.

  9. Control Chart:  A control chart is a statistical tool used to distinguish between variation in a process resulting from common causes and variation resulting from special causes.  It is noted that there is variation in every process, some the result of causes not normally present in the process (special cause variation).  Common cause variation is variation that results simply from the numerous, ever-present differences in the process.  Control charts can help to maintain stability in a process by depicting when a process may be affected by special causes.  The consistency of a process is usually characterized by showing if data fall within control limits based on plus or minus specific standard deviations from the center line.  Control charts are used to:
    1. Monitor process variation over time
    2. Help to differentiate between special and common cause variation
    3. Assess the effectiveness of change on a process
    4. Illustrate how a process performed during a specific period.

      Using upper control limits (UCLs) and lower control limits (LCLs) that are statistically computed, the team can identify statistically significant changes in performance. This information can be used to identify opportunities to improve performance or measure the effectiveness of a change in a process, procedure, or system.

  10. Bench Marking:  A benchmark is a point of reference by which something can be measured, compared, or judged.  It can be an industry standard against which a program indicator is monitored and found to be above, below or comparable to the benchmark.
  11. Root Cause Analysis:  A root cause analysis is a systematic process for identifying the most basic factors/causes that underlie variation in performance.