Introduction

Using objective tools of measurement—a process of continuous appraisal and self-analysis—is characteristic of a progressive, consumer-centric organization. Although many programs and organizations develop programs to meet external regulatory standards, organizations that wanted to distinguish themselves in the marketplace in the latter part of the 20th century and early 21st century developed continuous improvement programs based upon quality as a core value. Organizations use data gathered by their quality and performance improvement programs to develop improvement opportunity plans that enhance the care and services delivered to individuals and populations.

This module presents a framework or performance improvement process for identifying and addressing improvement opportunities in your organization. The model used is FOCUS-PDCA, which was developed by the Hospital Corporation of America, and is based on earlier work by Walter A. Shewhart, the father of statistical quality control. Various tools and techniques are also described to lead you through the process.

The first step in any improvement effort is to secure the support of leadership in your organization. Once leadership supports your embarking on an improvement journey, you can get started. You will want to assemble a team that has the necessary resources to accomplish the improvement task. This team may be made up of process owners and staff who actually perform the process on a daily basis. Make sure that these team members can devote a certain number of hours every week or month to work on the project. Leadership can help ensure that their schedules allow for this.

Once you've assembled your team, follow the process steps below.

• Find a Process to Improve
• Organize
• Clarify Current Knowledge of the Process
• Uncover Causes of Process Variation or Poor Quality
• Start PDCA
• Plan the Improvement Process
• Do the Improvement, Data Collection, and Analysis
• Check the Results and Lessons Learned
• Act by Adopting, Adjusting, or Abandoning the Change