PEPFAR Quality Control and Method Validation Activity 13 Handout 4: Quality Improvement Project Plan

Handout 4: PDCA Plan 1307 148 Quality Improvement Project PlanXC30 PLAN Use all the resources available to you to try and understand the problem, propose solutions and develop an action plan. SECTION A- Identifying the problem I. State the apparent problem: ________________________________________________________________________________ ________________________________________________________________________________ II. Collect Baseline Data: What data will be collected? ______________________________________________________ Method - How will the data be collected? ____________________________________________ Who is responsible for collecting data? ______________________________________________ What are the tools/forms/checklists to be used? _______________________________________ Over what period of time will the data be collected? ____________________________________ When will the data be reviewed? ___________________________________________________ III. Analyze the baseline data: What is wrong? ________________________________________________________________ Where is it happening? __________________________________________________________ When is it happening? ___________________________________________________________ Who is involved? _______________________________________________________________ IV. Identify possible causes: _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ V. Propose possible solutions: _____________________________________________________________________________ _____________________________________________________________________________ HILS1746 Effective Date: 12/6/2016 Handout 4: PDCA Plan 1307 149 SECTION B: Action Plan I. Identified problem: ______________________________________________________________ II. AIM Statement (overall goal of this project) _________________________________ _____________________________________________________________________________ III. Actions to be implemented (following brainstorming of possible solutions). Action item Responsible Timeline Signature Person IV. Select and Define ELEMENT TO BE MEASURED (to monitor effectiveness of implemented actions) ____________________________________________________________ V. Results of element measured at baseline ___________________________________ VI. Acceptable results (target for this measure) ________________________________ VII. Data Collection How will the data be collected? ____________________________________________________ Who is responsible for collecting data? ______________________________________________ What are the tools/forms/checklists to be used? _______________________________________ How often will the data be collected? _______________________________________________ How often will the data be reviewed? ________________________________________________ How often will the data be analyzed to monitor effectiveness of implemented actions? _____________________________________________________________________________ HILS1746 Effective Date: 12/6/2016 Handout 4: PDCA Plan 1307 150 DO IMPLEMENT Action Plan Collect data on element to be measured (to be done throughout the implementation period; document problems and unexpected observations) Summary of data collected on element to be measured Date of Review Results Depending on the element measured, results may be presented in a different format than table above e.g. before and after pictures. Monitor how the plan is being executed. Action item Responsible Person Timeline Signature Action Plan review R 1 R 2 R 3 CHECK Was change effective? _____________________________________________________________ If yes, how easy or difficult was it to achieve results? ______________________________________ ________________________________________________________________________________ ________________________________________________________________________________ Unexpected Observations: ________________________________________________________________________________ ________________________________________________________________________________ ACT If successful develop and implement plans to standardize the process, communicate changes and train as necessary. If unsuccessful, use information collected during DO and CHECK for problem analysis (Repeat PDCA) PLAN-DO-CHECK-ACT (Next Cycle ) Plan & Implement Cycle II of Improvement Project: Proposed date to begin Cycle II of improvement project ____________________________________ Signature of Reviewer _____________________________ Date _________________________ Laboratory Director _______________________________ Date _________________________ HILS1746 Effective Date: 12/6/2016