1 Quality Improvement Plan Template In this course, you develop an organizational quality improvement (QI) plan for a health care organization of your choice. Organize the plan as you would present it to the organization’s board of directors for approval. Use the following outline as a guide when developing your plan. Executive Summary: A one-page overview of the plan Introduction/Purpose: Introduce the organization and state its mission. Describe the types of services the organization provides. This section must be approximately half a page. Goals/Objectives: Describe what goals the organization has to meet its mission. These are principles that shape how the organization views and achieves quality. Examples may involve the concepts of safety, effectiveness, timeliness, and patient centeredness. This section must be approximately half a page. Scope/Description/QI Activities: Describe what departments, programs, and activities are affected by the plan and why they are involved in its implementation. This section must be approximately half a page. Data Collection Tools: Describe the type of performance data to be collected and why that data is focused on. Describe why each data collection and display tool was selected for the QI plan. This section must range from half a page to a full page. QI Processes and Methodology: Describe the methodology and processes used to implement the plan. This must explain why each methodology and process are in the plan and why they were chosen. This section must range from half a page to a full page. Comparative Databases, Benchmarks, and Professional Practice Standards: Describe what the organization will use as a standard to compare performance. This section must be one paragraph. This may be through a number of methods such as a comparative database or a competing organization’s annual report. Authority/Structure/Organization: Describe the authority structure of the plan’s implementation. This must describe who is responsible for implementing the plan. Include a description of each role involved in the plan. This section must be approximately half a page: · Board of directors · Executive leadership · Quality improvement committee · Medical staff · Middle management · Department staff Communication: Identify who the performance activity outcomes are communicated to and who does the communicating. This describes who is responsible for overseeing data collection and preparing data reports. This section must be approximately one paragraph. Education: Describe how staff will be educated regarding the plan. This covers how each staff member will be initially oriented to the plan and each employee fits into the plan based on job responsibilities. This section must be approximately one to two paragraphs. Annual Evaluation: Describe what elements of the plan are annually evaluated for improvement. This section must be approximately one paragraph. Running head: QI PLAN PART 3 1 QI PLAN PART 3 7 ...

1. 1
Quality Improvement Plan Template
In this course, you develop an organizational quality
improvement (QI) plan for a health care organization of your
choice. Organize the plan as you would present it to the
organization’s board of directors for approval. Use the
following outline as a guide when developing your plan.
Executive Summary: A one-page overview of the plan
Introduction/Purpose: Introduce the organization and state its
mission. Describe the types of services the organization
provides. This section must be approximately half a page.
Goals/Objectives: Describe what goals the organization has to
meet its mission. These are principles that shape how the
organization views and achieves quality. Examples may involve
the concepts of safety, effectiveness, timeliness, and patient
centeredness. This section must be approximately half a page.
Scope/Description/QI Activities: Describe what departments,
programs, and activities are affected by the plan and why they
are involved in its implementation. This section must be
approximately half a page.
Data Collection Tools: Describe the type of performance data to
be collected and why that data is focused on. Describe why each
data collection and display tool was selected for the QI plan.
This section must range from half a page to a full page.
QI Processes and Methodology: Describe the methodology and
processes used to implement the plan. This must explain why
each methodology and process are in the plan and why they
were chosen. This section must range from half a page to a full
page.
Comparative Databases, Benchmarks, and Professional Practice

2. Standards: Describe what the organization will use as a standard
to compare performance. This section must be one paragraph.
This may be through a number of methods such as a
comparative database or a competing organization’s annual
report.
Authority/Structure/Organization: Describe the authority
structure of the plan’s implementation. This must describe who
is responsible for implementing the plan. Include a description
of each role involved in the plan. This section must be
approximately half a page:
· Board of directors
· Executive leadership
· Quality improvement committee
· Medical staff
· Middle management
· Department staff
Communication: Identify who the performance activity
outcomes are communicated to and who does the
communicating. This describes who is responsible for
overseeing data collection and preparing data reports. This
section must be approximately one paragraph.
Education: Describe how staff will be educated regarding the
plan. This covers how each staff member will be initially
oriented to the plan and each employee fits into the plan based
on job responsibilities. This section must be approximately one
to two paragraphs.
Annual Evaluation: Describe what elements of the plan are
annually evaluated for improvement. This section must be
approximately one paragraph.

3. Running head: QI PLAN PART 3
1
QI PLAN PART 3
7
QI Plan Part 3
Implementing a new system in place needs a sense of teamwork
within the staff and leadership of an organization. The leaders
involved in the fulfillment of a quality improvement plan
include the board of directors, the departmental staff, the QI
committee as well as the middle management. It is also essential
to have an efficient communication mechanism amongst all the
leaders and staff in the facility, the vendors, and the end users
as well. Such process will ensure that the new system will
effectively communicate with the current operational system, as
such; data would transfer without any issues or losses.
This paper aims to discuss the criteria, tasks, communications,
education, monitoring and revisions, a well as regulatory and
accreditation involved in a successful creation and
implementation of a quality plan. Comment by Lawrence
Fergus: Good overview and alerting the reader what to expect in
the body of the paper.
Criteria and Tasks
The primary component of any given QI plan must include a
detailed explanation of the goals the purpose as well as the
policies that the organization intends to achieve. It also requires
a detailed outline of the committee’s roles and responsibilities
as well as an account of all the systems and measures needed to
achieve the plan (Health Resources and Services
Administration, 2015). Quality improvement entails some
functions that would need careful delegation to each of the
stakeholders involved. For instance, the leaders play a critical
role since they are in charge of establishing and maintaining a

4. personal as well as an organizational emphasis towards both the
internal and external demands of clients (Health Resources and
Services Administration, 2015). The leader is obliged to display
an unwavering commitment to the purpose, objectives,
expectations, and values of the institution. It must ensure that
the team attains excellent performance as well as promote
quality. The other key roles would include day-to-day leader,
provider champion, data specialist, data entry person and
operations person (Health Resources and Services
Administration, 2015).
Authority, Structure, and Organization
When implementing a quality improvement plan, it is critical
that the organization establishes mechanisms of achieving its
goals and objectives within the authority structure. In that case,
the organization would have to analyze and outline staff body
so that there would be a clear understanding of individual’s
goals and ensuring that they concur with the organizational
goals (Godény, 2012).
An organization chart is an organized system that assimilates
information, the consumers as well as the technology within the
facility to achieve a current goal. The primary objective of
Davis healthcare facility is to provide excellent patient care
experiences. Each discipline is ranging from the board of
directors; employees all have unique roles to play in the
improvement plan (Godény, 2012). The organizational structure
is an essential element that must be well thought during the
implementation of the QI program.
At Davis healthcare, the board of directors has a sole
responsibility of ensuring that all the members of staff are
giving the patients quality care. The board members must know
the relevance of monitoring QI within the healthcare facility,
and they also have a duty to ensure that the employees are
following all the regulations, and quality standards are met
(Godény, 2012). The organization thus needs to involve the
board of directors in the implementation of the QI plan.
The board has a legal responsibility for spearheading and

5. monitoring the improvement of the delivery of high-quality
patient care (Godény, 2012). The board of the health care
facility is responsible for ensuring that the QI plan is designed
so that it can perform the following functions:
· Sufficiently monitor the delivery of patient care services as
well as make it easier to identify any harmful and risky
activities in time (Balestracci & Barlow, 1996).
· Quickly establish opportunities that would drive improvement
into the existing operations and systems.
· Assure that effective links between the various activities in
the facility are well set up to protect the patients from harm as
well as ensure compliance with the current standards of patient
care (Safety, quality, credentialing, infection control, risk
management) (Balestracci & Barlow, 1996).
· Assure that all the effected changes in the QI plan remain in
place through time.
The board of directors has legal obligation related to duty of
care, which arise in two primary contexts; the decision-making
role and the oversight responsibility. In fulfilling the obligation
of care, the board has a responsibility to carry out the due
inquiry, make informed and responsible decisions in addition to
providing appropriate oversight to the healthcare facility
(McLaughlin, McLaughlin, & Kaluzny, 2004). Furthermore, the
board is required to provide quality control to the compliance
program
Adequate supervision of the program of conformity will require
an evaluation of compliance with regulations that govern
hospital acquired conditions, the Reporting Hospital Quality
Data for Annual Program Update, state adverse event reporting
requirements, gain sharing, physician incentives, and outcomes
management initiatives (McLaughlin, McLaughlin, & Kaluzny,
2004). A board of directors of an organization is responsible for
providing guidance, leadership, and support during the creation
and implementation of a quality improvement plan. The board
must approve the final QI plan before execution begins. The
board of directors also has the responsibility to evaluate

6. periodically and review the plan (Health Resources and Services
Administration, 2015). It is the duty of the board to provide and
approve the required resources for attainment. It is important
for the board to demonstrate a continued interest and
involvement in the organization’s quality and improvement
processes:
· Executive Leadership – will organize the plan, by pulling
managers from clinical, financial and administrative teams to
identify potential problems through brainstorming.
· Quality Improvement Committee – will monitor the project to
ensure that early warnings for identifying and avoid potential
liability resulting from actions.
· Medical Staff – will determine the cause of the increase in
medication error over the past 3months and in order to
prevent/reduce medication errors from occurring, will provide
data during the Quality Improvement (QI) process and provide
data to middle management for accuracy (Godény, 2012).
Leadership and structure. A quality improvement plan needs, to
begin with, an individual or committee are responsible for
creating, implementing, and monitoring the program
(McLaughlin, McLaughlin, & Kaluzny, 2004). It is essential for
a clear comprehension of the roles and responsibilities to be
defined as well as accountability. A QI plan consists of
members from executive leaders and clinical staff (Health
Resources and Services Administration, 2015).
Communication. Once a QI plan has been established, it is
critical that the facility sets up routine association on quality
enhancement to all the employees inclusive of the board and all
the prospective stakeholders (Balestracci & Barlow,
1996). There is a need for consistent appraisal on how these
initiatives are established and implemented; the training
activities that is in progress; and the quality improvement
charting; as these are crucial components of any communication
process (Godény, 2012). “The progress in most Quality
Improvement at Davis health care facility will be documented
using event logs, issue identification records, meeting minutes,

7. among others. Development efforts could also be
communicated through the various mechanisms, such as kick-off
meetings or all-employee meetings; storyboards and/or posters
displayed in common areas; sharing organization’s annual QI
plan evaluation; e-mails, memos, newsletters and/or handouts;
and informal verbal communication (McLaughlin, McLaughlin,
& Kaluzny, 2004).”
A QI program should be examined yearly to ensure efficiency in
attaining the purpose. A QI council will evaluate annually and
create recommended modifications to the QI program (Health
Resources and Services Administration, 2015). “Based on an
ongoing review, priorities will be set, and opportunities for
improvement identified for the next year (McLaughlin,
McLaughlin, & Kaluzny, 2004).”
Monitoring relays a method for identifying the comparativeness
of the organization with the first opportunities for improvement
and attaining of set goals and objectives (McLaughlin,
McLaughlin, & Kaluzny, 2004). All areas need control since
any defect in service delivery to a patient would affect the
whole healthcare facility. Leaders determine the specific areas
that require monitoring (Health Resources and Services
Administration, 2015). Monitoring could be aimed at
improvement, ensuring policy compliance or establishing the
procedures and standards in the installation.
Regulatory and Accreditation. The accrediting and regulatory
agencies that would be involved in the Quality improvement
processes include: The Joint Commission on Accreditation of
Healthcare Organizations (JCAHO), the United States
Department of Health and Human Services (HHS) and the
National Committee for Quality Assurance (NCQA) (Health
Resources and Services Administration, 2015). JCAHO is
responsible in assessing the standard of care that patients
receive. The agency requires that all health organizations’
management set expectations, plan and manage the
measurement, assessment, and improvement of all the aspects of
providing healthcare (Health Resources and Services

8. Administration, 2015).
The HHS is usually the representative body for the federally
funded agency, which focuses on improving the quality of
healthcare. The federal government defines and mandates the
specific areas for monitoring Quality (Health Resources and
Services Administration, 2015). Such include preventive care,
chronic disease management, and infection control and fall
rates.
Conclusion
In every successful quality plan, are involved and committed
stakeholders. Stakeholders have their own roles to perform in
order to achieve the ultimate purpose of quality processes, that
which is to provide excellent health care service to those who
are need.
This paper tackled and elaborated the criteria, tasks,
communications, education, monitoring and revisions, as well as
regulatory and accreditation involved in the effective
development and implementation of a quality plan. Comment by
Lawrence Fergus: Well summarized
References
Balestracci, D., & Barlow, J. L. (1996). Quality Improvement:
Practical Applications for Medical Group Practice. Medical
Group Management Assn.
Godény, S. (2012). Quality assurance and quality improvement
in medical practice. Part 3: Clinical audit in medical practice.
Orv Hetil , 153(5):174-83.
Health Resources and Services Administration. (2015). Quality
Improvement. Retrieved from US Human and health services
Department:
http://www.hrsa.gov/quality/toolbox/methodology/qualityimpro

9. vement/part3.html
McLaughlin, C. P., McLaughlin, C., & Kaluzny, A. D. (2004).
Continuous Quality Improvement in Health Care: Theory,
Implementation, and Applications. Jones & Bartlett Learning.
Running head: QI PLAN PART 2
1
QI PLAN PART 2
2
QI Plan Part 2
At Davis healthcare facility, the primary focus is on improving
the quality of patient care in all its aspects. They are delved at
improving the services they offer their patients and reduce the
errors in the cares offered. To achieve the improvement, they
must accurately utilize different mechanisms and strategies for
quality improvement. This paper will tackle information
regarding improvement methodologies; information technology;
and benchmarking geared towards improving safety at Davis
Healthcare. This article will also discuss mission and vision as
well as strategic and operational plans; barriers to improvement;
and lastly, successful implementation of quality measures in the
facility. Comment by Lawrence Fergus: Good lead-in
Quality Improvement Methodologies
The quality improvement plan often focuses on the data
collected and how it can be used to improve quality (Hughes,
2008). Over the years, health care facilities have not had any
quality improvement plan. With increased competition, health
care facilities like Davis Health Care must strive to have well-
defined data collection tools that will focus on improvement of
patient safety.
The management and leadership have an obligation to evaluate

10. and establish information technology; the milestones that will
assist with management as well as the use of benchmarking
strategies to facilitate in the effective progressing of the quality
improvement plan. Health care managers are responsible in
improving the quality of services in health organizations. To
improve the quality of services, they will have to select methods
that have been previously proven successful in the QI process
for healthcare organizations such as the Six Sigma. This method
is used to measure the QI process as it does so by comparing the
baseline process from the initial data and the capability of the
process after the facility has piloted the quality improvement
solutions. The Six Sigma is comprised of five distinct phases
which includes: define, measure, analyse, and improve. It is
commonly designated as the DMAIC approach to quality
improvement. The define phase is the aspect that defines and
establishes the goals and objective once the issues that need
improvement had been identified and the relevant data has been
collected. The measure phase helps in determining the dynamics
of the new process. The collected data is then analyzed
including the plan and improvement.
The pros and cons of the Six Sigma methodology is that it
allows the managers to control the QI processes such it becomes
effective and successful. The methodology uses ‘think’, which
means it utilizes strong leadership as well as statistical thinking
to accomplish quality improvement (Henderson, 2011). In fact,
research has it that it could easily cause overspending and
issues relating to fixing financial problems. The data collected
using the six sigma method may not be beneficial regarding
improvements and may cause the employees to be rigid to
change. However, some health organizations would still benefit
from the Six Sigma method of quality improvements.It provides
a system that easily detects issues in the facility. Health care
systems like Davis healthcare, for instance, require a data-
driven well-organized method. The six sigma model can display
performance quantitatively and has the mechanism to meet the
high demand of organizational data-driven methods.

11. Comment by Lawrence Fergus: Good point
Provision of quality services is a priority for the employees as
well, hence, they also have significant data to contribute to the
betterment of services in the facility. It is also possible to
obtain quantitative data from the members of staff and the
customers and be utilized to make well-informed decisions. The
cons of this method is that it is time as well as cost intensive.
Therefore, in most cases, the organization may not be willing to
give out that required time and financial expenses in utilizing
the method.
Another type of methodology is the product improvement
methodology. It is one of the rigorously utilized methods of
Quality improvement in most organizations. Most organization
use this method because improving the product/services offered
often result in more client satisfaction, which in this case is the
patient satisfaction. One of the pros of using the product
improvement methodology is that it shows that the organization
cares about their patient’s well-being and prioritize their care.
Heath care facilities need continuously to improve other areas
such as employee training, technology, education among others.
Lastly, the people-based improvement method is another
commonly used quality improvement method. It has a great
benefit to Quality improvement since it incorporates all the
stakeholders in the process. It includes everyone ranging from
the managers to the patients themselves. It is an effective
methodology because it uses teamwork and all the stakeholders
play a role in the improvement process. The main pro of the
people-based method is that it encourages full participation of
all the stakeholders in the improvement process. It allows for
opinions from everyone that is linked to the facility.
Information Technology
One primary form of information technology that could be used
at Davis Healthcare is the Electronic Medical Records (EMRs).
Using EMR helps in improving the record-keeping system in the
facility. EMRs allow the health care organizations to keep
accurate patient records in a simpler, easy to retrieve and well-

12. organized manner. Moreover, it allows the physicians and other
healthcare employees who may need information regarding
patients to access it easily and faster.
Another kind of technology that could help improve the services
offered to patients at Davis Healthcare is the Clinical Decision
Support System (CDSS).The CDSS helps the physicians as well
as the nurses to make an accurate diagnosis and effective
treatment recommendation according to the diagnosis.
Another critical technology application that would benefit Dais
healthcare is the Electronic Management Material (EMM). The
EMM technology helps the facility track their inventory
appropriately. All these technologies would help the facility
improve the quality of their services. For instance, the managers
at Davis healthcare facility would be able to look into the CDSS
database and obtain appropriate information and evaluate
warnings relating to drug prescriptions and other clinical
protocols. The EMM would ensure that the facility has adequate
supplies that they would require to provide the best care for
their patients.
Benchmarking and Milestone. Milestones and benchmarks are
often used in organizations where improvement is required. A
potential one for Davis health care facility is updating the EMR
system. Benchmarks and Milestones allow the healthcare
facility to evaluate the quality indicators and compare another
level of performance about their past performance.
Benchmarking also allows the facility to compare their
performance with other healthcare facilities in the area. It
allows the facility to establish whether or not they are
improving regarding performance and service delivery. Data
obtained through benchmarking is often real and practical.
Therefore it usually gives the facility a clear perspective of
their strengths, weaknesses, threats and opportunities. It is a
broader mechanism of the organization to have a SWOT
analysis and determine its position in the industry. Milestones
allow the organization to make small adjustments and attain
success as hey implement the necessary changes that they would

13. need to have to improve their performance. The milestones
would show the organizations the extent to which they have
improved since they started up to the current time. Recently, we
compared our system to the systems of other surrounding
healthcare organizations. We realized that the other
organizations had systems that required upgrades. Davis
healthcare facility could use their milestones to make
significant decisions relating to improvement.
Performance and quality measures are useful in improving the
quality of services in an organization. Performance and quality
have to be in line with the mission and vision of the healthcare
organization. Quality measures are paramount to any
organization. For Davis Healthcare facility, the organization
ensures that all the employees perform their duties in the
required manner such that they deliver quality care to patients
that come into the facility. These measures are meant to help
employees develop appropriate skills and mechanisms to
improve the quality of services that they cater to patients. At
Davis Healthcare, the measures are monitored by the
Information Technology department or a committee which
guarantees that the physicians and nurses address all the quality
improvement needs.
Barriers. It is inevitable to have barriers during the
implementation of a quality improvement plan. Barriers usually
interfere with implementation, but in a case where the members
of staff embrace the philosophy or quality improvement, then
the barriers can be overcome. The paramount factor is that the
employees have to understand the relevance of quality
improvement and understand their respective roles in the
program. For instance, some employees may not fully accept the
changes and may be rigid to incorporate the changes.
Another major barrier is the lack of communication among
stakeholders. If the communication mechanism is not well
established, then the program may encounter a communication
barrier. It is crucial that all the employees get updated on the
quality improvement plan and its progression in order to be

14. aligned with the plan. If there is no proper communication, then
some employees and stakeholders may be left out, and such plan
may not be fully implemented.
Other barriers would be various humanistic factors like single-
sightedness, conflicting priorities, and side-tracking among
others. Single sightedness is whereby the employees are not
willing to wait for the implementation and see the effects. Side-
tracking is whereby management focuses primarily on time and
monetary factors instead of the main concept. All these barriers
have the extensive potential to harm the implementation of the
QI plan.
Conclusion
In summary, the individuals charged with quality improvement
tasks are from top to bottom; that is from the management to the
lower employees. Such involvement and commitment ensures
that the QI plan will be successful in the facility. This paper
tackled information regarding improvement methodologies;
information technology; and benchmarking geared towards
improving safety at Davis Healthcare. This article also
discussed mission and vision as well as strategic and
operational plans; barriers to improvement; and lastly,
successful implementation of quality measures in the facility.
Comment by Lawrence Fergus: Well summarized.
References
Healthcare Quality Improvement Partnership (HQIP). (2015). A
guide to quality improvement methods. Healthcare Quality
Improvement Partnership (HQIP).

15. Henderson, G. R. (2011). Six Sigma Quality Improvement with
Minitab. John Wiley & Sons.
Hughes, R. G. (2008). Tools and Strategies for Quality
Improvement and Patient Safety: Retrieved from NCBI:
http://www.ncbi.nlm.nih.gov/books/NBK2682/
Leebov, W., & Ersoz, C. J. (2003). The Health Care Manager's
Guide to Continuous Quality Improvement. iUniverse.
Lighter, D., & Fair, D. C. (2004). Quality Management in
Health Care: Principles and Methods. Jones & Bartlett Learning.
Running head: QI PLAN PART 1
1
QI PLAN PART 1
6
QI Plan Part 1
The increase utilization of technology in the health care arena
has made it necessary to implement quality improvement
initiatives toward patient’s safety. The measures of the quality
of health care through observation of its processes, outcomes, as
well as structure, are significant in the measurement of quality.
A renowned healthcare institution like Davis Health Care is
dedicated towards the provision of excellent patient care
experience. This paper will discuss
data collection tools, data display, measurement and reporting
focusing on patient safety Comment by Lawrence Fergus:

16. Brief and effective lead-in to the body of your plan.
Data Collection Tools
The quality improvement plan often focuses on the data
collected and how it can be used to improve quality (Hughes,
2008). Over the years, health care facilities have not had any
quality improvement plan. With increased competition, health
care facilities like Davis Health Care must strive to have well-
defined data collection tools that would focus on improvement
of patient safety.
These data collection tools should be mirrored from techniques
of other industries. Thus, it must consider “total quality
management (TQM) that promotes constancy of purpose and the
systematic analysis as well as measurement of process steps that
relates to outcomes and capacity (Hughes, 2008)”. It is worth
noting that even though TQM model does not have data
collection tools to support, it helps the health care facility to
have an organized approach that entails teamwork, systematic
thinking as well as measurement and changes that creates an
environment for improvement (Hughes, 2008). Therefore, the
quality improvement plan should be incorporated TQM with the
aim of committing the health care facility to improve their
quality and achieve desirable results (best patient safety).
Comment by Lawrence Fergus: Quotation mark?
The quality improvement should have a continuous quality
improvement that is interchanged with TQM. The Continuous
Quality Improvement must be used to improve and develop
better clinical practices and identify opportunity for
improvement in the quest for better patient safety in the
organization (Hughes, 2008). The plan must ensure that all the
regulatory measures are factored in and thus, fundamental
processes like documentation, the study of credentialing
processes and review of oversight committees.
Another pillar of quality improvement plan would be the
Clinical Practice Improvement (CPI). “The clinical practice
improvement ensures the safety of the patient through a
multidimensional outcomes methodology that would have a

17. direct application to the management of the clinics and
individual approach (AHRQ, 2014)”. It denotes better
understanding of the health care delivery system and its
complexity, the purpose, collects data, assess the findings as
well as interpretation of the findings for better patient safety.
Comment by Lawrence Fergus: Include page or paragraph
number with quotes - see APA Manual v6 or UOP APA site
material.
The quality improvement plan should be significant since “it
helps the healthcare facilities to have a systematic and yet data-
guided activities to design and bring immediate improvement in
the delivery of health care setting (AHRQ, 2014)”. This quality
improvement plan ensures that intervention founded by data
collection tools are aimed at the reduction of the quality gap for
patients encountered in the routine practices. Therefore, the
data collected would be used to make a significant decision
about the quality improvement in the healthcare facility. The
source of the data should be primary so that the health
organization can count on the results to improve the quality of
the patient safety (AHRQ, 2014).
As an individual planning and organizing a quality improvement
plan, it is fundamental to note that quality improvement plan is
more intense by research (Oster & Braaten, 2016). Therefore,
data collection tools must be selected carefully to ensure that it
suits its purpose. Since the main of the quality improvement is
to focus on improvement of patient safety, the data collection
tools should be more than just observation as done by the
researchers (Oster & Braaten, 2016).
Data Collection Tools: Strengths and Weakness
The data collection tools would assess and define the problem
of patient safety that would be seen as helpful in the
prioritization of safety and quality problems as well an
enhancing of quality (Swanson, 1995). It is also worth noting
that some of the data collection tools complement each other so
that improvement the quality addressed errors and increased the
cost of the collection tool. The quality Improvement plan on

18. patient safety at Davis Health Care would use the following
data collection instruments: “Plan-Do-Study-Act (PDSA),
Failure modes and effects analysis (FMEA) and Health failure
modes and effect analysis (HFMEA) (AHRQ, 2014)”.
The first tool would Plan-Do-Study-Act is a data collection tool
or method that aims at making a positive impact in the
healthcare process like patient safety by affecting the favorable
outcomes. The device is used to medical improvement practices
within the organization. Unlike other others, the “PDSA tool is
often cyclical in nature since it assesses the changes and
accomplishes its purpose in small and frequent steps (Hughes,
2008)”. The goal of this data collection tool is to establish a
function correlation between the alteration in the process and
the results (Hughes, 2008). The processes could be the
capabilities and behaviors of the personnel in charge of
security. The data collection tool often starts with the
determination of the scope and nature of the problem, changes
that should be made, plan for the patient safety changes,
quantities that should be measured to understand its change on
the changes and finally the strategy to ensure that change does
not have a negative impact (Oster & Braaten, 2016).
The second data collection tool is “the failure mode and effects
analysis (FMEA). The FMAE tool is used to analyze data that
help in the avoidance of insecurity event and improve the
quality of care (Oster & Braaten, 2016)”. FMEA is also issued
to “identify potential areas of failure when experimental, and
characterization of the process at the desired speed of change
should be used. Thus, retrospectively to characterize the safety
of the process by the identification of potential areas of failure
about the patient safety process from the medical staff
(Swanson, 1995)”. The data collection method uses flow-chart
that analysis the focus of the team. The information obtained
from the FMEA is utilized to produce information for the
prioritization of enhancement plans that stand as the education
and standard for development plans and undertakings. The
FMEA is an accurate data collection tool since there is always a

19. failure mode in the systems.
The merits of these systems include the use of systematic error
management that is significant to the excellent clinical care in
the sophisticated setting and processes. It is also dependent on a
multidisciplinary method that integrated error report, decision
support, integrated incident, and education of the security
personal as well as standardization of terminology (Swanson,
1995). On the other hand, FMEA tends to be cumbersome and
hectic. It can be ineffective in places where failure modes are
not identified.
Finally, the health failure mode and effects analysis (HFMEA)
provides a detailed discussion of the smaller processes that
results in a recommendation of the larger process. It is a
significant tool since it can be used for the proactive analysis of
health care by facilitating a thorough analysis of its
vulnerabilities in securing safety of patients. The tool is
valuable in the identification of multifactorial nature of errors
and potential risk for error.
Conclusion
Unlike research, the quality improvement includes small
samples adoption of new approaches that are effective as well
as changes of the interventions (Hughes, 2008). As research
attempts to assess the source of the problem and address it in
generalizable fashion, the quality improvement plan would
enable the hospital to improve its practices for the better. Thus,
quality improvement plan would apply the research into
practices, and its primary audience is the organization (Hughes,
2008). The data collected in the quality improvement plan
would help the organization to improve patient safety.
This paper tackled different types of data collection tools and
data display as well as elaborated the measurements and
reporting systems that are geared towards patient safety.

20. References
AHRQ. (2014). 5. Improving Data Collection across the Health
Care System. Retrieved from Agency for Healthcare Research
and Quality: http://www.ahrq.gov/research/findings/final-
reports/iomracereport/reldata5.html
Hughes, R. G. (2008). Tools and Strategies for Quality
Improvement and Patient Safety:. Retrieved from NCBI:
http://www.ncbi.nlm.nih.gov/books/NBK2682/
Oster, C., & Braaten, J. (2016). High Reliability Organizations:
A Healthcare Handbook for Patient Safety & Quality. Sigma
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Swanson, R. (1995). The Quality Improvement Handbook: Team
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