Performance

Improvement (PI)
Plan and Template
Approved and adopted 11/2009

by the
Best Practices Committee of the
Health Care Association of New Jersey
4 AAA Drive, Suite 203, Hamilton, NJ 08691
Tel: 609-890-8700
www.hcanj.org

2009. Permission granted to copy documents with attribution to the

Best Practices Committee of the Health Care Association of New Jersey.

HCANJ Best Practices Committee

Performance Improvement (PI) Plan and Template

Table of Contents
Page

I.

Disclaimer

i.

Introduction to the Performance Improvement (PI) Plan and Template

A. General Introduction
B. How to Use the Template

ii. - iii.

Introduction to Performance Improvement

A. Mission Statement
B. Vision Statement
C. Statement of Values
D. Fundamentals of Performance Improvement

1. - 2.

II. Objectives of the Performance Improvement Plan

2.

III. Performance Improvement Plan Participants and Respective Responsibilities

A. Board of Directors/Governing Authority
B. Facility Leaders
C. Performance Improvement Committee
D. Facility Staff
E. Residents and Families
F. Consultants
G. Vendors and Product/Services Suppliers
H. Community Representatives

2. - 3.

IV. Identifying Potential Areas for Improvement

A. Clinical Care/Services Opportunities
B. Non-Clinical Care Opportunities
C. Government, Accreditation and Professional Requirements
D. HCANJ Best Practices

3.

40.

V.

Prioritize Opportunities to Improve

A . Staff and Consumer Participants
B. Selecting Best Opportunities to Improve

3. - 4.

VI. Sources and Collection of Data that Yields Useful Information

A. What to Monitor
B. Sampling: What and How to Sample

4. - 7.

VII. Analysis of Data and Information

A. P I Process Cycle
B. Root cause Analysis (RCA)
C. Benchmarking
D. Presenting Data and Information to Various Stakeholders

7. - 9.

VIII Confidentiality of Data, Information, Findings and Reports

.

IX. Education/Training
A. Senior Management
B. P I Committee Members and Participants
C. All Staff
D. Residents and Families
E. Community Members and Others

9. - 10.

X.

10.
10. - 17.
17.
18. - 20.
21. - 24.
25. - 26.
27. - 32.
33. - 34.
35.
36.
37. - 38.

Appendix
A: Definitions
B: Exhibits, Forms and Tools
1. Design, Measure, Assess, Improve, and Control (DMAIC) Tool
2. Plan, Do, Check, Act (PDCA) Tool
3. Fishbone Diagram
4. Root Cause Analysis (RCA)
5. Cause and Effect Map
6. Failure Mode and Effects Analysis (FMEA)
7. SMART Tool
8. Pareto Analysis Chart (PAC)

XI. Bibliography, Reference Citing and Internet Sites of Interest

39. - 40.

HCANJ Best Practices Committee

Performance Improvement (PI) Plan and Template

Best Practice Guideline
DISCLAIMER: This Best Practice Guideline is presented as a model only by way of illustration. It
has not been reviewed by counsel. Before applying a particular form to a specific use by your
organization, it should be reviewed by counsel knowledgeable concerning applicable federal and state
health care laws and rules and regulations. This Best Practice Guideline should not be used or relied
upon in any way without consultation with and supervision by qualified physicians and other
healthcare professionals who have full knowledge of each particular residents case history and medical
condition.
This Best Practice Guideline is offered to nursing facilities, assisted living facilities, residential health
care facilities, adult day health services providers and other professionals for informational and
educational purposes only.
The Health Care Association of New Jersey (HCANJ), its executers, administrators, successors, and
members hereby disclaim any and all liability for damage of whatever kind resulting from the use,
negligent or otherwise, of this Best Practice Guideline herein.
This Best Practice Guideline was developed by the HCANJ Best Practice Committee (Committee), a
group of volunteer professionals actively working in or on behalf of health care facilities in New
Jersey, including skilled nursing facilities, sub-acute care and assisted living providers.
The Committees development process included a review of government regulations, literature review,
expert opinions, and consensus. The Committee strives to develop guidelines that are consistent with
these principles:

Relative simplicity
Ease of implementation
Evidence-based criteria
Inclusion of suggested, appropriate forms
Application to various long term care settings
Consistent with statutory and regulatory requirements
Utilization of state and federal government terminology, definitions and data collection

Appropriate staff at each facility/program should develop specific policies, procedures and protocols to
best assure the efficient, implementation of the Best Practice Guidelines principles.
The Best Practice Guidelines usually assume that recovery/rehabilitation is the treatment or care plan
goal. Sometimes, other goals may be appropriate. For example, for patients receiving palliative care,
promotion of comfort (pain control) and dignity may take precedence over other guideline objectives.
Guidelines may need modification to best address each facility, patient and familys expectations and
preferences.
Recognizing the importance of implementation of appropriate guidelines, the Committee plans to offer
education and training. The HCANJ Best Practice Guidelines will be made available at www.hcanj.org.
2009. Permission granted to copy documents with attribution to the
Best Practices Committee of the Health Care Association of New Jersey.

i.

HCANJ Best Practices Committee

Performance Improvement (PI) Plan and Template

Best Practice Guideline
INTRODUCTION TO THE PERFORMANCE IMPROVEMENT (PI) PLAN AND TEMPLATE
A. GENERAL INTRODUCTION
This Performance Improvement Best Practice plan and template was developed by the Health Care
Association of New Jerseys (HCANJ) Best Practices Committee, an all volunteer team of practicing
long term care professionals. The plan and template development process included a review of
government regulations, relevant literature, various performance improvement programs, expert
opinions and consensus.
This Performance Improvement (PI) plan guideline is in the form of a template. The templates
design is relatively easy to use and customize. Current, evidence-based criteria for defining,
advancing and sustaining performance improvement strategies have been incorporated into the
document, as well as suggested forms and analytical tools. The template may be used in various
long term care settings, such as, nursing and skilled nursing facilities, sub-acute care facilities,
assisted living facilities and programs, residential care settings and in adult medical day health care
services.
Organizations may use this PI plan template in several ways:
1. Those with well established, effective PI plans may wish to review this template and select
components to incorporate into their pre-existing plan.
2. Those with reasonably complete and effective plans may wish to use this template as the
foundation for their new plan by incorporating selective elements of their pre-existing plan
into this template.
3. Those with no well-established, successful PI plans may elect to use this template to
formalize their new PI plan.
The Best Practices Committee of HCANJ recommends that organizations that intend to use this
template as the foundation for their new or updated PI plan proceed as follows. Designate a
team of knowledgeable senior leaders, day-to-day managers, key clinical care and service
directors/supervisors, front line staff, consumers, community leaders and consultants to carefully
review this plan template and make thoughtful, appropriate, adjustments in the template to produce a
draft comprehensive, organization- specific PI Plan. Then, senior management should review the
draft plan, make appropriate adjustments as needed, and approve the plan.
The Best Practices Committee suggests that each facility/program conduct a formal review and
revision (as needed) of its PI Plan at regular intervals, not to exceed every twelve (12) months.

ii.

B. HOW TO USE THE TEMPLATE

Generally available electronic word processing software will facilitate the users capacity to
customize this template to produce an organization-specific plan. This template is available through
HCANJ (www.hcanj.org) in PDF and Microsoft word formats.
The user is prompted to insert [ INSERT HERE ] organization specific information in various
locations throughout the template, and to remove [ DELETE ] unwanted information, to
generate an up to date PI plan that meets the needs of the organization. To facilitate this process,
text that is intended to remain as part of the PI plan appears in black ink color. Text that the
individual organizations may insert or delete to customize this template appears as black bold ink
color.

iii.

TEMPLATE
[ INSERT NAME OF ORGANIZATION ]
PERFORMANCE IMPROVEMENT PLAN
I. INTRODUCTION TO PERFORMANCE IMPROVEMENT
Effective Performance Improvement emanates from the organization's leaders to instill a
yearning in the hearts of all staff to find and embrace better ways to get the right things done, and
done well. Performance Improvement is more than a task, a program, a process or a committee;
it is the essential bridge to a successful future.
The term Performance Improvement is intended to communicate a company-wide philosophy
and process to regularly identify and implement constructive, cost-effective opportunities to
improve performance. Other commonly used improvement process terms, such as, Quality
Improvement, Quality Assurance, Quality Assessment, Quality Assessment and
Assurance, Quality Control, Quality Management, and Total Quality Management are
believed to be incorporated within the meaning of Performance Improvement.
NOTE: Facilities and programs that prefer to use a term of art other than Performance
Improvement to identify their self-improvement process may edit this document by deleting
Performance Improvement and inserting their preferred, descriptive term of art.

This company-wide performance improvement process includes identifying and implementing

opportunities to improve the quality of resident care and quality of life, as well as other measures
of organizational performance. For example, resident care improvement opportunities may
include fewer resident fall-related injuries and fewer adverse medication events. Organizational
improvement opportunities may include finding a better process to select, screen and orient new
employees, adopting new technology to enhance the capacity of the staff to communicate, and
capital improvements in the building, grounds and equipment to improve the environment of care,
thereby improving the quality of life for residents and quality of the work environment for staff.
A. MISSION STATEMENT (See definition, page 13.)
( Insert organizations Mission Statement here. )
B. VISION STATEMENT (See definition, page 17.)
( Insert organizations Vision Statement here. If none, delete this section. )
C. VALUES STATEMENT (See definition, page 15.)
( Insert organizations Values Statement here. If none, delete this section. )

1.

D. FUNDAMENTALS OF PERFORMANCE IMPROVEMENT

1. Key elements: Organizational performance that achieves and sustains high quality
care and services is a complex, interdependent process. Key elements of the
success of this PI plan include the following:
a) leadership that is competent, committed and stable
b) reliable capital and operational funding sufficient to achieve the mission
c) human resources stable staff
d) an inclusive process supported by all stakeholders
e) selective, focused performance improvement initiatives
2. Limits of the PI plan: Like all plans, this plan is an expression of intent that outlines
a philosophy and a process for self-improvement. As such, this plan is intended
to be flexible and to accommodate timely and appropriate adjustments to address
seen and unforeseen circumstances, while adhering to the fundamental mission,
vision and values of this organization.
3. Effective performance improvement efforts will focus on the development,
maintenance and periodic improvements in systems that influence
organizational outcomes. Systems will be designed and modified to achieve
reliable, efficient outcomes.
II. OBJECTIVES OF THE PERFORMANCE IMPROVEMENT PLAN
A. Improve quality of care thereby enhancing the quality of life
B. Improve quality of work environment
C. Achieve improved outcomes that exceed regulatory standards
III. PERFORMANCE IMPROVEMENT (PI) PLAN PARTICIPANTS AND RESPECTIVE
RESPONSIBILITIES
( Insert Facility Personnel )
A. Board of directors/governing authority
1. Proactive role
2. Oversight and direction
B. Facility leaders
1. Key leaders
2. Performance improvement coordinator
C. Performance improvement committee
1. Role of committee
a) relationship to other committees
2. Members and participants
a) facility staff
2.

b) residents and families

c) consultants
d) vendors and product/services suppliers
e) community representatives
3. Meetings and records
IV. IDENTIFY POTENTIAL AREAS FOR IMPROVEMENT
A. Clinical care/services opportunities
1. Quality of care: Resident receives the necessary care and services to attain or
maintain the highest practicable physical, mental, and psychosocial well being,
in accordance with the comprehensive assessment and plan of care.
2. Quality of life: Creating and sustaining an environment that humanizes and
individualizes and enhances each resident
B. Non-clinical care opportunities
1. Environment of care: Considers the need for appropriate space to provide and
support services that preserve the dignity and privacy of the resident
2. Organizational performance: The actual goals of an organization as measured against
its intended objectives.
C. Government, accreditation and professional requirements
1. Department of Health and Senior Services; survey and certification
2. Ombudsman
3. Other government requirement and findings
4. Accreditation standards
5. Generally recognized standards of care
V. PRIORITIZE OPPORTUNITIES TO IMPROVE
A. STAFF AND CONSUMER PARTICIPATION
1. Include the resident/family and staff who can view the process with a different
perspective.
a) Identifying the opportunities for improvement (What is the problem?)
b) Before making a change to the process, participants will need to know the
whole process from start to finish.
c) Identifying how the process begins
d) Examining the path of the process for weakness and potential problems
e) Brain storming: An exchange of ideas useful in the development of change,
once the participants have identified areas of weakness and risk
f) Basic rules in brainstorming: Allow participants freedom to express their
ideas. Open discussions motivate other views and ideas.
3.

B. SELECTING BEST OPPORTUNITIES TO IMPROVE

1. Prioritizing the weaknesses; factoring the number of events and level of risk
a) Examples:
1) Collect data
2) Analyze data collected
3) Develop actions from the analysis of data. Actions are focused on
preventing problems and strengthening weaknesses.
4) Prioritize the process change, or revision of the process
5) Greatest good
(a) Outcome:
(1) Have the revisions or changes in the process made a
positive impact on resident outcomes?
(2) Have the residents quality of life improved?
6) Sustainability:
(a) Performance improvement is an ongoing cycle of measuring
resident outcomes.
(1) Monitoring results is essential.
(2) Participants should continually look for new ways of
improving the process.
VI. SOURCES AND COLLECTION OF DATA THAT YIELDS USEFUL INFORMATION
A. WHAT TO MONITOR
1. Satisfaction levels of important constituents
a) resident/family satisfaction survey
b) employee satisfaction survey and follow up
c) other stakeholders as appropriate. (e.g. sub- acute, physicians, hospitals)
2. Safety-related parameters
a) falls
b) medication errors
c) polypharmacy
d) elopements
e) employee injury
f) visitor injury
g) job-related employee illness
h) reports of abuse
i) epidemic illness - resident and staff
j) physical plant

4.

3. Resident care outcomes

a) wounds
b) incontinence
c) infection
d) urinary tract infection (UTI)
e) upper respiratory infection (URI)
f) vaccination compliance
g) unexplained functional decline
h) unplanned weight loss
i) restraints
j) unplanned hospital admission
k) unanticipated death
4. Effectiveness of important programs, systems processes
a) alarms
b) generators
c) infection control
d) employee health
e) employee education and training
f) regulatory survey outcomes
g) community involvement and reputation
h) staff retention
i) legal issues
j) dementia care
k) food service
l) laundry
m) activities/recreation
n) resident council
5. Factors that influence compliance with regulations
a) resident/family satisfaction
b) staff competency and productivity
c) administration competency and leadership
d) staff stability and retention
e) staff satisfaction
f) direct supervisors management and competency
g) other factors
h) consistent assignment

5.

6. Building and grounds issues

a) appearance
b) cleanliness
c) safety issues fire alarms and other alarm systems
d) scheduled preventative maintenance and upkeep
e) inspection compliance
f) grounds upkeep and appearance
g) water, ambient control
h) required regulatory inspection compliance
i) parking lot safety
7. Organizational effectiveness and efficiency
a) communication throughout organization
b) leadership support
c) support of corporate to facility
d) table of organization
e) cost control/resource management
f) budget development and management input
g) census management
8. Organizational culture
a) clear, defined, communicated
b) implementation
c) results of satisfaction surveys (residents, families, employees)
d) regulatory survey outcomes
9. Regulatory requirement items to monitor
a) safety committee recommendations
b) satisfaction surveys (residents, families, employees)
c) staff training and education
d) staff retention
e) complaints (residents, families, employees)
f) scheduled maintenance reports and inspections
g) employee personnel files
h) clinical
1) wounds
2) infection control
3) hospitalizations
4) elopements
5) falls
6) clinical documentation audits
6.

7) pharmacy consultant reports and drug regimen review

8) medication errors
9) unexplained weight loss
10) pressure ulcers/wounds
11) incontinence
12) nutrition, hydration and dietician reports
13) restraints
14) immunization card
15) infection control surveillance
B. SAMPLING: WHAT AND HOW TO SAMPLE
1. Reliable and valid tools
a) Press - Ganey
b) Holleran
c) MyInnerview
d) Gallop
e) Web search for others
2. Sample by observation
a) Real-time observation
1) staff competency in relation to residents plan of care
2) medication pass
3) infection control
4) care plan compliance
5) environmental safety
6) others
b) Record review
VII ANALYSIS OF DATA AND INFORMATION
A. PI PROCESS CYCLE (See exhibits listing, page 17.)
1. Plan Do Check Act (PDCA)
2. Strategic, Measurable, Achievable, Relevant, Timely (SMART)
3. PI Cycle: Data, Information, Knowledge, Plan, Act, Evaluate
4. Design Measure Assess Improve Control (DMAIC)
B. ROOT CAUSE ANALYSIS (RCA) (See exhibit, page 26. - 32.)
1. Definition: Root Cause Analysis (RCA) is a structured step-by-step questioning
process that focuses on finding the real cause of a problem/incident/undesirable
trend or event. RCA focuses on prevention, not blame, and should consist of a
systematic search for what really went wrong and not whose fault was it.

7.

2. Purpose of the RCA:

a) Identify the fundamental reasons why something undesirable happened
b) Correctly identify the root causes so appropriate action plans can be
identified and put in place
c) Effectively develop an action plan that will prevent reoccurrence of the
problem/incident/undesirable trend or event
3. Process of the RCA
a) Data collection phase and analysis
1) Begin RCA data collection as soon as possible following occurrence
identification
2) Include each individual involved in the occurrence in the data
collection phase process
3) Appoint a facilitator to guide the RCA process
4) Document each individuals account of the problem/incident/
undesirable trend or event including conditions before, during
and after the occurrence, personnel involvement including all
actions taken, environmental factors and any other information
having relevance to the problem/incident/undesirable trend or
event. Documentation my be on a flip chart for all participants to
view.
5) Sample questions
(a) Were facility/community procedures followed?
(b) Was equipment in good condition?
(c) Was lighting adequate?
(d) What type of surface?
(e) Was assignment excessive?
(f) Was task part of normal duties?
(g) Was individual trained?
(h) Were housekeeping issues a factor?
(i) Was task repetitive?
(j) Was proper personal protective equipment (PPE) used?
b) Analytical phase
(1) Analyze data to identify the most likely causal factors utilizing the
Five Whys technique. Keep asking why five or more times in
order to get to the root cause of the problem.
(2) Examples of root causes may include one or more of the following
areas:
(a) equipment
(b) material
8.

(c) procedure problem not well defined

(d) policy problem
(e) personnel error-judgment errors
(f) design problem: process or system?
(g) training adequate
(h) external factors
(3) Summarize the findings of the data
c) Action plan
(1) Design and document an action/corrective plan
(a) identify an action plan for each cause
(b) identify what changes can be made to the system to prevent
reoccurrence
(i) Redesigning systems may involve (not inclusive)
(a) policy and procedure changes
(b) staff education
(c) new equipment
(d) additional forms
(c) develop and document final action plan for administrative
review
(d) assign responsibility for each action item with a time line
(e) institute follow up for reviewing completion and
effectiveness of action items
d) Fish Bone Diagram (See exhibit, page 25.-26.)
e) Failure Mode & Effects Analysis (FMEA) (See exhibit, page 35.)
C. BENCHMARKING
1. Definition: Benchmarking is the process of comparing the cost, time or
quality of one achievement against another achievement. The result may
indicate an opportunity for making changes in processes and systems to
improve outcomes.
D. PRESENTING DATA AND INFORMATION TO VARIOUS STAKEHOLDERS

VIII. CONFIDENTIALITY OF DATA, INFORMATION, FINDINGS AND REPORTS

(See definition, page 10.)
IX. EDUCATION/TRAINING
A. SENIOR MANAGEMENT
B. PI COMMITTEE MEMBERS AND PARTICIPANTS
9.

C. ALL STAFF
D. RESIDENTS AND FAMILIES
E. COMMUNITY MEMBERS AND OTHERS
X.

APPENDIX
A. DEFINITIONS
Administrative
Review:

the individual or group responsible for final decisions.

Benchmarking:

the process of comparing the cost, time or quality of one

achievement against another achievement. The result may
indicate an opportunity for making changes in processes and
systems to improve outcomes.

Brainstorming:

an idea-generating technique for a group of people to solve

problems:
encourage unrestrained collective thinking
all ideas are welcomed
no single participant dominates the session

Cause and Effect

Map: (Fishbone
Diagram)

offers a structured approach for identifying all possible causes

of a problem.
See Exhibits, page 25. - 26., 33. - 34.

Confidential:

data and information that includes all records and documents

that are made available only to a few, select persons on a need
to know basis. The ability of the organization to produce,
analyze and maintain some performance improvement records
as confidential is vital to the self-improvement process.

Culture:

the established attitudes, beliefs, sentiments, formal and

informal operating principles and behavior of the
organization. See culture change.

10.

Cycle of
Performance
Improvement
(CPI):

the formal process of:

1. gathering meaningful data (relevant, timely, organized and
accurate)
2. transforming the data into information through a process of
evaluation and analysis
3. extracting the information that is most useful to obtain
knowledge of the current systems strengths and weaknesses
4. developing a plan of action to wisely apply the knowledge
gained to improve better results
5. sustaining implementation of the plan of action, and
continuing evaluation of ongoing results by reapplication of
the cycle
Various tools may help businesses apply the discipline required
to follow the cycle of performance improvement, such as the
following: See Exhibits, page 17. - 38.

1. Design, Measure, Assess, Improve, and Control (DMAIC)

Tool
2. Plan, Do, Check, Act (PDCA) Tool
3. Fishbone Diagram
4. Root Cause Analysis (RCA)
5. Cause and Effect Map
6. Failure Mode and Effects Analysis (FMEA)
7. SMART Tool
8. Pareto Analysis Chart (PAC)

Dashboard:

an informative presentation of performance improvement-related

data, information, process adjustments and results, which may or
may not be confidential.

Deficiency:

the failure to meet recognized standards or requirements.

11.

Design, Measure, an approach to the cycle of performance improvement used to

Assess, Improve, improve an existing process.
Control
The basic methodology consists of the following five steps:
(DMAIC):
Step 1. DEFINE

process improvement goals that are

consistent with customer demands and the
organizational strategy.
Step 2. MEASURE key aspects of the current process and
collect relevant data.
Step 3. ANALYZE the data to verify cause-and-effect
relationships. Determine what the
relationships are, and attempt to ensure
that all factors have been considered.
Step 4. IMPROVE or optimize the process based upon data
analysis.
Step 5. CONTROL to ensure that any deviations from target are
corrected before they result in defects.
Pilot test the new process.
See Exhibit, page 18. - 20.

Fail Safe
Methods:

an implementation of methods and warnings to decrease

probability of mistakes.

Failure Modes
and Effects
Analysis
(FMEA):

an approach to the cycle of performance improvement in the

form of a procedure for analysis of potential failure modes
within a system for classification by severity or determination of
the effect of failures on the system.
Failure causes are any errors or defects in process,
design, or item, especially those that affect the customer, and can
be potential or actual.
Effects analysis refers to studying the consequences of
those failures.
See cycle of performance improvement.
See Exhibit, page 35.

12.

Fishbone
Diagram:
(Cause and
Effect Map)

a tool that helps identify, sort and display possible causes of a

specific problem or characteristics of a process. It graphically
illustrates the relationships between a given outcome and the
complex variety of factors that influence the outcome. See
cause and effect map. See Exhibits, page 25. - 26., 33. - 34.

Incident:

is any event, occurrence, situation or circumstance, which is

unusual or inconsistent with the policies, practices and routine
operation of the community. An incident may be an accident or
a situation, which may or may not result in bodily injury and/or
property damage. Note: Physical or mental mistreatment of a
resident is always considered an incident even when an actual
injury has not occurred.

Interviewing:

a technique for identifying problems and collecting information.

It can be used with staff, residents and family.

Mission
Statement:

a brief description of a company's fundamental purpose that

answers the question, "Why do we exist?". The mission
statement articulates the company's purpose both for those in the
organization and for the public.

Monitor:

to intermittently watch, check or observe for a particular

purpose.

Near-miss:

an unplanned event or negative outcome that did not result in

injury, illness, or damage - but had the potential to do so; such as
when a fortunate break in the chain of events prevented a
negative outcome. Although human error is commonly an
initiating event, a faulty process or system invariably permits or
compounds the harm, and should be the focus of analysis and
improvement. Other familiar terms for these events are a "close
call", or in the case of moving objects, "near collision".

Pareto Analysis
Chart:

a bar graph used to arrange information in such a way that

priorities for process improvement can be established.
See Exhibits, page 37. - 38.

13.

Plan Do Check
Act (PDCA):

one approach to the cycle of performance improvement. The

PDCA cycle is a checklist of the four stages which you must go
through to get from problem-faced to problem solved. The four
stages are Plan-Do-Check-Act, and they are carried out in a
cycle. See cycle of performance improvement. See Exhibits,
page 21. - 24.

Problem:

a deviation from expected, desirable results.

Process:

an organized group of related activities that work together to

transform one or more kinds of inputs into outcome(s) that are of
value to customers. A system may contain multiple processes.
See system and protocol.

Protocol:

a formalized process. The term protocol is often applied to

processes that involve clinical care assessments, activities and
outcomes. See system and process.

Quality of Care: care and services that respect the individuals needs and choices,
improve the likelihood of achievable clinical outcomes, and are
consistent with evidence-based knowledge. Quality of care
leads to Quality of life, the goal for long term care residents,
which may be best measured by each individual resident.

Residentcentered:

care and services that are respectful of and responsive to

individual resident preferences, needs, and values to ensure that
residents values guide all clinical/service decisions.

Residentdirected:

care and services that are provided at a time and in a manner that
is directed and controlled by the resident.

14.

Root Cause
Analysis (RCA):

a structured, step-by-step, analytical problem solving process to

help determine the fundamental (root) cause(s) of problems.
This problem identification process helps performance
improvement professionals avoid wasting time fixing
symptoms of a deep rooted problem, and guides them through
steps to identify the root causes. RCA is not about assigning
blame. It is about preventing the reoccurrence of undesirable
outcomes. See Exhibits, page 27. - 32.

Sample:

a selected part, section, or item that is believed to be

representative of the nature of the whole from which it was
taken.

Sentinel Events:

are relatively infrequent, clear-cut events that occur

independently of a patient's condition that result in unnecessary
outcomes for patients.

one that is well defined and consistently followed without

Standardized
Process, Protocol variation. See system, process and protocol.
or System:
Strategic,
Measurable,
Achievable,
Relevant, Timely
(SMART):

a way of assessing objectives to assure that they are written in a

manner that identifies their strategic significance, are
measurable, can be achieved, are relevant to the issues, and are
timely to the needs of the organization. See Exhibit, page 36.

System:

a group of independent processes and people that together

perform a common mission See process and protocol.

Values
Statement:

are grounded in values and defines how people want to behave

with each other in the organization. They are statements about
how the organization will value customers, suppliers, and the
internal community. Values statements describe actions that are
the living enactment of the fundamental values held by most
individuals within the organization. The values of each of the
individuals in your workplace, along with their experience,
upbringing, and so on, meld together to form your corporate
culture.

15.

Variation:

a change in data, characteristics, process or function that may be

caused by one or more of four factors. Before correcting for
variation, performance improvement professionals will likely
want to know the type of variation that occurred. The different
types are as follows:

Common cause variation is a variation that comes from one or

more elements inherent within the process.
For example: The expected process for medication
delivery is that the off-premises pharmacy will deliver
medications to the facility daily between 4 and 6 pm.
Because the defined process has multiple variables that
may influence the actual delivery time, some variation
outside of the expected range (two hours) may occur and
may be attributed to process itself.

Special cause variation is variation that comes from a special

circumstance.
For example: The driver of the car transporting the
medications from the pharmacy to the facility is involved
in a serious accident, the car can not be driven, another/
driver is dispatched, and the delivery of medications is
delayed by three hours. In this example, the variation was
due to special cause the accident.

Structural variations are regular changes caused by seasonal

adjustments or long term trends.
For example: Over time, the traffic congestion along the
route driven by the pharmacy delivery vehicle increased
to a degree that the medications scheduled for a 6 pm
delivery are not delivered until 6:30 pm most days. The
long term trend of increased traffic was a structural
variation.

16.

Tampering is a misguided attempt to adjust a process to

otherwise correct minimal variation that is within acceptable
limits.
For example: The pharmacy delivery schedule is
working well and medications always arrive between the
allotted times 4 to 6 pm. However, the weekend
pharmacy dispatcher decides to improve services and
move up the delivery time to between 4 and 5 pm, by
directing the driver to take a different road route. The
new route caused the driver to get lost and caught in
evening rush hour traffic, and the medications did not
arrive until 7 pm. The dispatcher tampered with a
process that was working within expected standards, and
made it worse.
Vision Statement: sometimes called a picture of your company in the future but
its so much more than that. Your vision statement is your
inspiration, the frame work for all your strategic planning.
Unlike the mission statement, a vision statement is for you and
the other members of your company, not for your customers or
clients. See mission statement.

B. EXHIBITS, FORMS AND TOOLS

Page

1. Design, Measure, Assess, Improve, and Control (DMAIC)

Tool
2. Plan, Do, Check, Act (PDCA) Tool
3. Fishbone Diagram
4. Root Cause Analysis (RCA)
5. Cause and Effect Map
6. Failure Mode and Effects Analysis (FMEA)
7. SMART Tool
8. Pareto Analysis Chart (PAC)

17.

18. - 20.
21. 25. 27. 33. 35.
36.
37. -

24.
26.
32.
34.

38.

DMAIC AND TOOLS

DMAIC stands for: Define, Measure Analyze, Improve and Control
Represents the five steps, starting with the analysis through to project completion.
STEP

OBJECTIVE

TOOLS TO USE

DESCRIPTION

Identify the improvement

opportunities and scope (what
will be included) of the project

Benchmarking
Pareto
Gap analysis
Process Map
(current process)

2. MEASURE How are we doing?

Analyze the process to identify

the problem
Define the expected outcome

5 Whys
Check and Tally
Sheets
Actual timings
against expected
Process Map
(expected process)

1. DEFINE

What is the
problem?

3. ANALYZE What is wrong?

Identify the root causes of the

problem

4. IMPROVE Fix the problem

5. CONTROL Maintain the gains

and publish results

5 Whys
Benchmarking
Root cause analysis
Fishbone diagram
Brainstorming (see
root cause analysis)
Interviewing (use
the 5 whys)

Refine and prioritize the

improvement opportunities

Initiate the project, create a plan

and project manager

Project plan
Project
management

Control measures put in place to

ensure results are achieved and
maintained.
Evaluate the results at the end
of the project (and possibly
again at a later date).
Publish results and thank
participants

Sustainability
Continuous
Improvement

18.

DMAIC AND TOOLS

Define, Measure Analyze, Improve and Control
Follow the five steps, starting with the analysis through to project completion.
Problem:

STEP
1.

DEFINE

2.

MEASURE

3.

ANALYZE

4.

IMPROVE

5.

CONTROL

OBJECTIVE

DESCRIPTION

19.

TOOLS TO USE

Steps of DMAIC
Define, Measure Analyze, Improve and Control
Follow the five steps, starting with the analysis through to project completion.

Step 1 - DEFINE - The problem.

1. This stage is about identifying the improvement opportunities and identifying the
scope (e.g. what will be included) of the project.
2. The business requirements and the customers requirements are established.
3. If there are any shortfalls between the requirements and the process the analysis
moves to the next stage.
Step 2 - MEASURE - How are we doing?
1. The process is analyzed. And the expected performance is determined.
2. Prepare a process map.
Step 3 - ANALYZE - What is wrong?
1. The root causes of the problem are identified.
2. Various analysis is used to obtain data to help work towards a solution.
Step 4 - IMPROVE - Fix the problem
1. The improvement opportunities are refined and prioritized.
2. A business case is usually completed which provides details of the solution and the
benefits to be gained. If there is more than one solution the business case would
usually include details of all solutions and the benefits that each would provide.
3. The pros and cons of each will usually be included together with recommendations
for the best solution.
4. When the solution is agreed and receives approval to proceed, a project is initiated,
implementation is planned and the project is managed.
Step 5 - CONTROL - Maintain the gains and publish results
1. Control is maintained throughout the project to ensure the desired outcomes are
achieved.
2. At the end of the project the process is measured again to ensure the expected
outcomes have been achieved and checks made to ensure the improvements can
be sustained.
3. A further evaluation may be carried out several weeks or months after
implementation to check that the expected improvements have been sustained.

20.

PDCA CYCLE
Plan, Do, Check, Act
Follow the four steps, starting with the analysis through to project completion.

PLAN

Identify and target root

causes of problems
Develop action plan

DO

Determine if improvements
have been met
Refine and expand
solutions
Monitor progress

Pilot the planned

solution
Implement activity

ACT

Measure
Audit
Evaluate outcomes

21.

CHECK

PDCA TOOL
PDCA stands for: Plan, Do, Check, Act
Represents the four steps, starting with the analysis through to project completion.

Problem example: Mrs. Ks recent fall

PLAN

DO

Fall risk assessment is

completed timely
and accurately

All nurses responsible

for admitting a
resident will be inserviced on the fall
risk assessment

Admission
assessment
Complete within
eight hours of
admission
14 day post
admission
30 day post
admission
Post fall
Significant change

CHECK

Euphemize on
eight clinical
conditions
Review of newly
admitted residents
hospital course of
stay
Medication
reconciliation
Time frame in
which to complete
the fall risk
assessment

Admitting nurse
completes fall risk
assessment
Time frame fall risk
assessment
was completed
Accuracy to the
completed fall risk
assessment

22.

Change of shift
Admitting nurse
completes
assessment
within the shift
the resident is
admitted
Supervisor of the
following shift
will review fall
assessment for
completion and
accuracy

ACT

Lunch time dining

room checks
Residents returning
from therapy alarm
checks
Audit?

Reduction in
number of
falls
Continue to
monitor
Continue
random
checks
Continue
education of
staff
Discuss and
report any
changes to the
team

PDCA TOOL
Plan, Do, Check, Act
Follow the four steps, starting with the analysis through to project completion.

Problem:

PLAN

DO

CHECK

Miscellaneous:

23.

ACT

Steps of PDCA
( Plan, Do, Check, Act )
Follow the four steps, starting with the plan through to action and project completion.

Plan Step:
1.
2.
3.
4.
5.

6.
7.

Recognize the problem and establish priorities. Problem may be outlined in very general terms
based on information from several sources.
Form the problem-solving team. Interdisciplinary teams of individuals close to the problem are
best.
Define the problem and its scope clearly. Who, What, Where and When. Pareto Analysis can
be useful in defining the problem. See exhibit on page 37. - 38.
Analyze the problem/process. Process flowcharts can be useful a useful tool.
Determine possible causes. Cause-and-effect diagrams are helpful in identifying root causes of
a problem. Data from the diagrams can be organized using check sheets, scatter
diagrams, histograms, and run charts.
Identify possible solutions. Brainstorm to find solutions. Avoid the temptation to propose quick,
immediate fixes. Goals should be specific, measurable, achievable, and realistic.
Evaluate potential solutions. Focus on solutions that address root causes and prevention of
problem occurrence. Solutions should be cost-effective. Achieving group consensus is
important.

Do Step:
1.

Implement the solution or process change

2.

Monitor results and collect data

Check Step
1.

Review and evaluate the result of the change

2.

Measure progress against milestones

3.

Check for any unforeseen consequences

Act Step - If successful,

1.
2.
3.

Standardize process changes

Communicate to all involved
Provide training in new methods

24.

Fishbone Diagram
Fishbone Template for Root Cause Analysis
What are Fishbone Diagrams? These diagrams are used in identifying and organizing the possible cause of a
problem. Cause-effect diagrams are also called Ishikawa diagrams after their creator, Dr. Kaoru Ishikawa. They are
also referred to as fishbone diagrams because they resemble the skeleton of a fish, with a head, spine and bones.
A Fishbone Diagram is a visual illustration that clearly shows the relationship between a topic and the various
factors related to it. The shape of the diagram looks like the skeleton of a fish. The bones of the fish represent factors
that have been combined or synthesized to form categories. The categories, in turn, come together to form the topic
that is depicted in the head of the fish.

Problem example: Mrs. Ks Verapamil order

Cause
1. Transfer Form
was incomplete

Cause

Cause

Cause

2. Transfer Order 3. Hospital POS

was not clarified or MAR were not
checked

4. Pharmacy did
not question
incomplete order

Cause
5. Pharmacy sent
immediate release
form of drug

Effect
Administered
wrong dose
of
Verapamil

Causes

Cause
1. Pharmacy
instructions for
dosage were
wrong

Cause
2. Nurse changed
MAR to reflect
pharmacy
instructions

Cause

Cause

3. Nurse did not

check original
order (POS) prior
to administering
medication

25.

4. Nurse did not

have adequate
knowledge of
medication being
administered

Cause
5. Policies were
not followed

Fishbone Template for Root Cause Analysis

Problem:

Cause
1.

Cause
2.

Cause

Cause

3.

4.

Cause
5.

Effect
Causes

Cause
1.

Cause
2.

Cause

Cause

3.

4.

Miscellaneous:

26.

Cause
5.

Root Cause Analysis (RCA)

Template for Root Cause Analysis
A.

WHAT IS A ROOT CAUSE ANALYSIS (RCA)? Root cause analysis (RCA) is a class
of problem solving methods aimed at identifying the root causes of problems or
events. The practice of RCA is predicated on the belief that problems are best solved
by attempting to correct or eliminate root causes, as opposed to merely addressing
the immediately obvious symptoms. RCA is a critical feature of any safety
management system because it enables answers to be found to the questions posed by
high risk, high impact events (including near misses) what happened, why it
occurred, and what can be done to prevent it from happening again.

B.

WHEN SHOULD RCA USED? RCA is normally only performed on high risk, high
impact events, such as sentinel events. A reportable near miss sentinel event is
managed using the same processes as an actual event.
Sentinel Events are relatively infrequent, clear-cut events that occur independently of a
patient's condition that result in unnecessary outcomes for patients. See definition,
page 15.
An incident is any event, occurrence, situation or circumstance, which is unusual or
inconsistent with the policies, practices and routine operation of the community. An
incident may be an accident or a situation, which may or may not result in bodily
injury and/or property damage. Note: Physical or mental mistreatment of a resident
is always considered an incident even when an actual injury has not occurred. See
definition, page 13.
Note: All incidents should be reported, investigated, and recorded especially
if there was no adverse outcome.

C.

WHAT ARE THE TIMELINES FOR RCA? The RCA processes should be investigated
as soon as allowable after an incident. The more time elapsed, the less reliable the
account of events by people involved and important information may no longer be
available.
1. A RCA team should be convened within two working days of an incident.
2. A RCA report should be signed off within two calendar months of commencing the
investigation.
3. Notify the appropriate authorities (insurance companies, government agencies, and
internal departments) of the occurrence of all sentinel events per their regulations.
Report investigation findings and submit a risk reduction action plan.
27.

D.

FIVE MAJOR RCA INVESTIGATION PRINCIPLES:

1. Thoroughness: a complete review of all possible causes is required. Focus on systems
and processes (not individual performance)
2. Fairness: in terms of involvement of all staff associated with the incident. (be fair,
thorough and efficient)
3. Efficiency: the time taken to undertake the investigation should be consistent with the
significance of the problem being investigated. (focus on problem solving)
4. Independence: include independent team members to help reduce the impact of bias
(overcome the fear to present information others may not want to hear)
5. Use a scale of effectiveness to develop recommendations. (use recognized analytical
methods)

E.

TEN MAJOR STEPS IN A RCA INVESTIGATION:

1. Verify the incident and define the problem
2. Commission the RCA investigation
3. Map a timeline (event and causal factor chart)
4. Identify critical events
5. Analyze the critical events (cause and effect chart)
6. Identify root causes
7. Support each root cause with evidence
8. Identify and select the best solutions
9. Develop recommendations
10. Write and present the report

F.

COMMISSIONING A RCA INVESTIGATION: The ultimate responsibility for

responding to serious incidents lies with an executive position who has primary
responsibility for the delivery of clinical care. This individual becomes the executive
for the RCA program in verifying the incident and defining the problem.
To brief the commissioning executive and focus the RCA effort, the RCA coordinator
must first define and determine the level of significance of the problem that is to be
investigated.
Defining the problem provides a clear understanding of:
1. the problem the RCA team is required to address
2. the scope of the investigation
3. the consequences of the incident

28.

G.

FORMING THE RCA TEAM

1. A small group of staff, which has expertise either in RCA methodology or in an area
relevant to the incident, conducts the RCA investigation. Organizations should try to
keep the size of the team manageable. Between three and six members is ideal.
2. A RCA facilitator is responsible for facilitating the RCA investigation. This includes
forming the team, mapping the event, ensuring the team meetings occur and follow
the agreed process, and facilitating team meetings. This person might also be the
RCA coordinator.
3. A RCA team leader is usually the head of a clinical unit or another staff member with a
recognized leadership role. Their role involves ensuring clinical participation,
supporting the team facilitator at meetings, and ensuring the clinical content is
relevant and appropriate.
4. RCA team members are those staff who participate in the team meetings and assist with
data gathering. They provide relevant expertise and should be able to provide
impartial input. Team members do not need to be clinical staff. Organizations
should involve staff who are familiar with work practices and systems (for example,
biomedical engineering, security, consumer liaison, and administrative staff).
5. Others: Involve staff who were directly involved with the incident only if their ability
to remain objective is not compromised.

H.

WRITING ROOT CAUSE STATEMENTS

Root cause statements are written as conclusions. Conclusions can be either:
1. Cause and effect statements
Example: Cause and effect - The lack of staff training on the management of
patients with chest pain resulted in the patient being discharged
without appropriate investigations being completed, which
contributed to the patients readmission and subsequent cardiac arrest.
2. Prophetic statements (predictions)
Example: Prophetic - The unavailability of guidelines for the management of chest
pain in the emergency department will continue to contribute to the
delivery of sub-optimal care.

29.

I.

THE FIVE RULES OF CAUSATION

1. Causal statements must clearly show the cause and effect relationship. When describing
why an event has occurred, show the link between the root cause and the undesirable
outcome.
2. Negative descriptors are not used in causal statements. To force clear cause and effect
descriptions (and avoid inflammatory statements) do not use negative descriptors.
3. Each action cause must have a corresponding conditional cause. For every human error
in the causal chain, there must be a corresponding condition cause that combined to
contribute to the undesired effect.
4. Each procedural deviation must have a preceding cause. Identify the cause of a
procedural violation, not the violation.
5. Failure to act is only causal when there was a pre-existing duty to act. The duty to
perform might arise from standards and guidelines for practice or other duties to
provide patient care.

J.

PREPARING RECOMMENDATIONS AND REPORTS

1.
Formulating Recommendations
a) The investigation team writes recommendations after the solutions have
been evaluated for the likelihood of their effectiveness.
Recommendations are suggested actions that management will
consider after the investigation report has been presented to the
executive sponsor.
b) The RCA team will need to consider who to consult when developing
recommendations and be aware of the wider system implications of
actually putting recommendations in place. To be credible,
recommendations should be evaluated against:
1) the root cause (conclusion) statement
2) the RCA method used
3) the level of associated risk
4) the hierarchy of control
5) achievability
6) the perceived value to the organization

30.

2.

Writing a RCA report

a) Reports are written to communicate to management the findings,
conclusions and recommendations pertaining to the initial problem
the RCA team was requested to investigate. The reports
comprehensiveness depends on the significance of the investigation
findings. The report is written after recommendations have been
evaluated for effectiveness.
b) Regardless of the reporting format chosen, the report should include
these three elements:
1) executive summary
2) event and causal factor chart
3) conclusions, supporting evidence and recommendations

K.

RCA POST-INVESTIGATION RESPONSIBILITIES

After signing off the RCA report, it is
1.
the RCA team leaders responsibility to:
a) develop and implement a risk reduction action plan to manage the risks
identified by the RCA team
2.
the RCA program coordinators responsibility for:
a) arranging for the findings to be presented to the people involved in the
incident
b) ensuring organizational reporting requirements are met
c) completing governmental reporting requirements
3.
the team executive is responsible for:
a) ensuring a risk reduction action plan is prepared and implemented
b) monitoring the progress and outcomes of risk mitigation strategies

L.

DEVELOPING THE RISK REDUCTION ACTION PLAN

The causal statements developed in the RCA investigation need to be converted into
risk statements. This should be done in conjunction with staff responsible for
organizational risk management. It requires an assessment of the level and analyses
of the risk. The risk reduction action plan should include a description of:
a) who is accountable for the risk
b) what action is to be taken
c) who is responsible for the action
d) by when the action is to be completed
e) a measurable performance target

31.

M.

RCA DOCUMENT MANAGEMENT

(Note: If investigations were not protected by legal or professional privilege, all
documents are subject to disclosure)
1. Keep a RCA investigation register to provide a record of the investigations undertaken, when
they were done, what problem they were commissioned to solve, and which staff
participated.
2. Keeping a copy of all completed reports, risk reduction action plans and the outcomes
achieved is necessary in case a similar problem occurs and the organization needs to
identify which strategies were ineffective.
3. Documenting risk reduction action plans in a risk register or other action tracking system is
necessary to ensure the monitoring and outcome loop is closed.

32.

CAUSE AND EFFECT MAP

Cause and Effect process mapping shows small steps of a sequence of events leading to an end
result. The process is:
1. Identify the PROBLEM or CRITICAL EVENT. Start up-stream from the perceived area of interest
and move down-stream a bit beyond your area of interest.
2. Identify the steps (ACTION CAUSE) leading to CONDITION CAUSES of the problem or critical
event.
3. Set enough time and boundary levels for each action to achieve a goal without limiting the
performance.
1. DESCRIPTION OF
PROBLEM OR
CRITICAL EVENT

ACTION
CAUSE
ACTION
CAUSE
CONDITION
CAUSE

ACTION
CAUSE
CONDITION
CAUSE

2. TIME AND
BOUNDARIES

ACTION
CAUSE
CONDITION
CAUSE
CONDITION
CAUSE

FINAL OUTCOME:

33.

CAUSE AND EFFECT MAP

The four stages of a cause and effect map helps you to think through causes of a problem or critical event
thoroughly. Their major benefit is to systematically consider all possible actions and causes, rather than
just the most obvious. Follow these four stages to solve a problem or critical event:
1.

STAGE 1: IDENTIFY THE PROBLEM

a) Write down the exact problem in detail (CRITICAL EVENT).
b) Where appropriate, identify who is involved, what the problem is, and when and where it
occurs (DESCRIPTION OF PROBLEM OR CRITICAL EVENT). Leave space to
develop action cause and condition cause ideas.

2.

STAGE 2: WORK OUT ALL MAJOR FACTORS INVOLVED

a) Next, identify the factor(s) or ACTION CAUSE(S) that may contribute to the problem.
b) Draw lines off the spine for each factor or ACTION CAUSE, and label it. These may be
people involved with the problem, systems, equipment, materials, external forces, etc.
c) Draw out as many possible factors or ACTION CAUSE(S) as possible.
d) If you are trying to solve the problem as part of a group, then this may be a good time for
some brainstorming. See brainstorming, page 10.

3.

STAGE 3: IDENTIFY ALL POSSIBLE CAUSES

a) For each of the factors or ACTION CAUSE(S) considered in stage 2, brainstorm possible
causes of the problem or critical event that may be related to the factor (CONDITION
CAUSE).
b) Show CONDITION CAUSES as smaller boxes coming off the factors or ACTION
CAUSE(S). Where a cause is large or complex, break it down into sub-causes. Show these
as lines coming off each cause line.

4.

ANALYZE YOUR DIAGRAM:

a) By this stage you should have a diagram showing all the possible causes of your problem
or critical event of which you can think.
b) Depending on the complexity and importance of the problem or critical event, you can
now investigate the most likely causes further. This may involve setting up several
investigations, carrying out surveys, etc. These will be designed to test whether your
assessments are correct.

34.

FAILURE MODE EFFECT ANALYSIS (FMEA)

A Failure Mode Effect Analysis (FMEA) is a tool for proactively evaluating processes and/or products
and identifying ways to prevent defects. FMEA allows the project to proactively identify potential
problems and implement avoidance or mitigation strategies to minimize any potential adverse effect on
the program. FMEA spots problems before a solution is put into action.

1.

IDENTIFY ALL POTENTIAL AREAS OF FAILURE FOR A PROCESS.

a) This approach most often involves multi-discipline teams, sometimes with customer
involvement, who will use techniques such as brainstorming to identify all the potential
areas of failure for a product or process.
b) From this data the team can then identify the major risks to the product or program and
can develop the most appropriate mitigation and/or avoidance strategies.

2.

FAILURE MODES: SEVERITY, OCCURRENCE AND DETECTION

a) Failure modes may be grouped based on criteria such as systems or sub-systems.
b) Each failure mode is evaluated in terms of the
1) potential impact (Severity)
2) likelihood of it occurring (Occurrence)
3) degree of difficulty to detect (Detection)
c) This process will produce a Risk Priority Number (RPN) which can be used to prioritize
action planning.

TEMPLATE for Failure Mode Effect Analysis (FMEA) tool

Identify all the
For each activity
activities in the
identify all the things
process that is being that could go wrong.
reviewed

For each thing that

Calculate the SOD#
could go wrong,
Severity should the
identify the effects that
event occur
would arise from the
Probability of the
Occurrence
potential failure.
Ability to Detect the
event

1.

2.

3.

35.

Risk Priority Number

(RPN). Produce plans to
minimize the potential
for occurrence, or to
mitigate should the
event occur.

SMART TOOL
( Specific, Measurable, Agreed Upon, Realistic and Time-based )
WHAT IS A SMART TOOL? Once you have planned your project, turn your
attention to developing several goals that will enable you to be successful.
Goals should be S M A R T Specific, Measurable, Agreed Upon,
Realistic and Time-based.
A goal might be to:
1) hold a weekly project meeting with the key participants [Team] and/or
2) organize and run a continuous test program throughout the project.
The acronym S M A R T has a number of slightly different variations, which can be
used to provide a more comprehensive definition for goal setting:
S specific, significant, stretching
SPECIFIC: well defined. Clear to anyone that has a basic knowledge
of the project
M measurable, meaningful, motivational
MEASURABLE: Known if the goal is obtainable and how far away
completion is known when it has been achieved
A agreed upon, attainable, achievable, acceptable, action-oriented
AGREED UPON: Agreement with all the stakeholders what the goals
should be
R realistic, relevant, reasonable, rewarding, results-oriented
REALISTIC: Within the availability of resources, knowledge and time
T time-based, timely, tangible, trackable
TIME-BASED: Enough time to achieve the goal. Not too much time,
which can affect project performance

36.

PARETO ANALYSIS CHART

What is a Pareto Chart? A bar graph used to arrange information in such a way that priorities for
process improvement can be established.
Pareto diagrams are named after Vilfredo Pareto, an Italian sociologist and economist, who invented this
method of information presentation toward the end of the 19th century. The fundamental idea behind the
use of Pareto diagrams for quality improvement is that the first few (as presented on the diagram)
contributing causes to a problem usually account for the majority of the result. Thus, targeting these
"major causes" for elimination results in the most cost-effective improvement scheme.

Why is it important? Pareto charts provide a tool for visualizing the Pareto principle, which
states that a small set of problems (the "vital few") affecting a common outcome tend to occur
much more frequently than the remainder (the "useful many"). A Pareto chart can be used to:
1) decide which subset of problems should be solved first
2) decide which problems deserve the most attention
3) provide a before-and-after comparison of the effect of control or quality improvement
measures
200
100%

180

90 %
160

80 %

140

70 %

120

60 %

100

50 %

80

40 %

60

30 %

40

20 %

20

10 %

0
Missed Dose

Medicine
Decreased

Wrong Patient

Wrong
Medication

Wrong Time

Wrong Dose

37.

0%

Steps of PARETO CHART

DEFINITION:
A bar graph used to arrange information in a way that priorities for process improvement can be
established.
PURPOSE:
1. To display the relative importance of data.
2. To direct efforts to the biggest improvement opportunity by highlighting the vital few in contrast
to the useful many.
HOW TO CONSTRUCT:
1. Determine the categories & units for comparison of the data, such as frequency, cost, or time.
2. Total the raw data in each category, then determine the grand total by adding the totals of each
category.
3. Re-order the categories from largest to smallest.
4. Determine the cumulative percent of each category (i.e., the sum of each category plus all
categories that precede it in the rank order, divided by the grand total & multiplied by 100).
5. Draw and label the left-hand vertical axis with the unit of comparison, such as frequency, cost
or time.
6. Draw and label the horizontal axis with the categories. List from left to right in rank order.
7. Draw and label the right-hand vertical axis from 0 to 100 percent. The 100 percent should line
up with the grand total on the left-hand vertical axis.
8. Beginning with the largest category, draw in bars for each category representing the total for that
category.
9. Draw a line graph beginning at the right-hand corner of the first bar to represent the cumulative
percent for each category as measured on the right-hand axis.
10. Analyze the chart. Usually the top 20% of the categories will comprise roughly 80% of the
cumulative total.
Suggestions:
Create before and after comparisons of Pareto charts to show impact of improvement
efforts.
Construct Pareto charts using different measurement scales, frequency, cost or time.
Use objective data to perform Pareto analysis rather than team members opinions.
If there is no clear distinction between the categories - if all bars are roughly the same
height or half of the categories are required to account for 60 % of the effect - consider
organizing the data in a different manner and repeating Pareto analysis.

38.

XI. BIBLIOGRAPHY
Reference Citing and Internet Sites of Interest

1.

Dennis C. Kinlaw, Ed.D (1992). Continuous Improvement and Measurement for Total Quality: a
team-based approach. Pfeiffer & Company, San Diego, CA, and Business One Irwin,
Homewood, IL.

2.

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40.