The FOCUS PDCA Methodology

Collected by:

Majdah Shugdar

Executive Director , Admin Affair

Central Board for health care Institution, CBAHI

Majdah Shugdar

Page 1 of 11

The FOCUS PDCA Methodology

Continuous Quality Improvement
Continuous quality improvement (CQI) is a
concept that came out of the business industry.
Rather than creating a culture of blame if things
do not go well, the focus is on a team approach to
improvement that rewards the group when things
get better.
CQI has been adapted for health care in several
ways. One acronym for this is FOCUS-PDCA
work:
FOCUS - PDCA is an extension of the Plan, Do,
Check, Act (PDCA) cycle sometimes called the
Deming or Shewhart cycle.
FOCUS-PDCA: FOCUS-PDCA it is a simple, logical,
and

systematic

approach

to

accomplish

incremental improvement of an existing process, or

to redesign an existing process or design an
essentially new process or in problem solving.
The guidelines for using FOCUS-PDCA are:

If a problem analysis is needed,

If a task is either new or unique. A routine

task normally doesn't necessitate a PDCA
unless a major new factor is introduced,

First, FOCUS on a particular issue.

Find a process to improve

Organize to improve a process
Clarify what is known
Understand variation
Select a process improvement

Then, move through a process improvement plan,

PDCA

Plan: create a timeline of resources, activities,

training and target dates. Develop a data
collection plan, the tools for measuring
outcomes, and thresholds for determining
when targets have been met.
Do: implement interventions and collect data.
Check: analyze results of data and evaluate
reasons for variation.
Act: act on what is learned and determine
next steps. If the intervention is successful,
work to make it part of standard operating
procedure. If it is not successful, analyze
sources of failure, design new solutions and
repeat the PDCA cycle.

The PI project should begin with FOCUS if a

process already exists. If a process does not
exist, begin with PDCA.
Step 1."F"

for Find a problem, process

improvement opportunity. "If no problem is

recognized, there is no recognition of the need for
improvement." Imai
It is important to review and

determined a priority

for your organization. Think through the following

questions: Was the problem identified through a
needs assessment or through a prioritization tool?,
What is your baseline data that indicates an
opportunity? , Who are the internal and external
customers? Write a one or two sentence overview
of the improvements that are needed.
Step 2. "O" for Organize a team that knows
about the problem or process in review.
'Teams provide possibilities for empowerment that
are not available to individual employees."
1.

Do you need to organize a team? Address

why a team is being formed. In order to
assemble the correct team to improve the
process

Majdah Shugdar

or

problem

ask

the

Page 2 of 11

following

2.

questions: Who would be helpful? Who

involved in the problem? How does the

needs to be involved? Who has knowledge

problem impact quality? What is the cost of

on the process or problem? Who would

the

benefit

or

process

break

Identify

the

most

Define

the

problem.

would benefit from the opportunity to be

determined

involved in problem solving, planning or

What is deficient? What is not working?

process monitoring? Who is creative? Who

What is the perception of quality? Have

has organizational skills?.

there been customer complaints, incidents?

Tell the selected team the purpose of the

How big is the problem? Where is the

project. Encourage all team members to be

problem?

from

being

involved

as

job

of teamwork, and that every member is

ask

Is

significant

down?

enrichment or a learning experience? Who

yourself

the

problem.

Once
the

problem

this

is

following:

chronic

or

sporadic?

logical and creative. Stress the importance

3.

Some of the PI tools and techniques

important. Empower the team to make a

developed to help define a process and

contribution.

problem

Teams

often

struggle

to

of their jobs, fall into a sequence of steps

are

flowcharting

and

brainstorming.

understand how the tasks, which are part

3.

problem

4.

Immediate and necessary action should not

(process) or how intricately departments

be ignored. Identify if there are any short-

are related.

term quick and easy improvements.

Once the team members are organized,

5.

If you discovered the process is not being

their roles and responsibilities need to be

followed

identified throughout the duration of the

correct standard operating procedures and

than

re-educate

staff

on

the

project. Plan and decide who is going to be

standardize the best current method.

the leader and organizer, as well as who is

going to write and document the progress

Step 4. "U" for Understand causes of process

to communicate results.

variation

and

uncover

possible

causes

of

problem. Investigate and eliminate unusual

Step 3. "C" for Clarify current knowledge

of

the process/problem. "A problem well stated is a

occurrences. "I have no particular talent, I am

merely inquisitive." Albert Einstein

problem half solved.

1.
1.

Determining the possible underlying causes

Analyze the process to distinguish between

of problems and process variation requires

expected and actual performance. Study

some

the current situation without trying to

analyzing. Do not jump towards a solution

develop long term solutions.

in this step.

To have a

research,

investigating,

and

clear statement of the situation, you must

2.

first do background work. Look carefully at

Sometimes what appears to be the problem

the

interpret

actually turns out to be related to other issues.

evidence. Talk to people involved, review

situation

Some of the questions used in this step to

records about the process and watch the

identify reasons and process variables are as

process first-hand. Recognize the problem.

follows: What are some of the most likely

Define and explain the current situation or

causes of the problem and process variation?

process in question.

What are the probable reasons for deficiencies?

Some of the questions that are asked in

What is the impact on customers? There are

this step are: What is your understanding

many verbal tools and techniques, which can

of how the process should flow? What is

be utilized to help organize the thoughts of a

the background of the problem? Who is

group, in order to analyze problems and

Majdah Shugdar

to

detect

and

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determine

causes.

Some

of

these

are:

based PI tools used in this step are check-

field

sheets, Pareto diagrams, scatter diagrams

analysis, brainstorming, and Ishikawa (cause

and run charts. Pareto analysis helps to

and

quantify the causes of problems. Look at

flowcharting,
effect

storyboarding,
diagramming

force

or

the

fishbone

the available data and stay objective in

diagram).

nature as you review the data.

2.

The Ishikawa or cause-effect diagram is

Examine your processes for variation or

unusual

to find out what is really going on with a

process and problem by asking questions

problem. The purpose of the diagram is to

to find out what happened differently.

determine causes of a problem in order to

Were

solve the problem. The problem analysis

process?

involves diagramming and is also known as

employee

fatigue

schedule?

You

fishbone

diagram

because

of

the

occurrences.

new

Investigate

personnel

Is

the

involved

problem

affected

related

need

in

to

to

the

the
by

on-call

continue

to

pictorial. The effect or problem is first

standardize the processes as much as

drawn as the "head" of the fish on the right

possible by making corrections to unusual

side of the paper. A horizontal line is drawn

causes of problems.

from the head down the entire length of

3.

5.

used as a first step before data gathering

6.

If the problem requires intensive root

the paper. Branches are drawn off the line

cause

on angles. Each line represents a process

variation

related to the problem.

Improvement methodology and not the

The process analysis involves looking at

FOCUS-PDCA.

either standard parts of a process or the

process improvement analysis. Special vs.

specific steps in a flowcharted process to

common cause variation is illustrated with

determine what you do and do not know

the use of control charts and is used in the

about

Process Improvement methodology.

the

process

or

problem.

The

analysis

or

then

measuring
use

Sentinel

the

source
Process

Events

require

M.M.M.M.E. acronym is a way to remember

the standard parts of a process by looking

Step 5. "S"

men (personnel, staffing and training),

materials or items used, the
methods or operating procedures,
machines or equipment such as

improvement

computer

the

intention, sincere effort, intelligent direction, and

and

skillful execution. It represents the wise choice of

at

systems,

environment

such

and
as

sound

workload. Look at each part of the process

for Selects the performance

by

improvement

prioritizing/select

strategy/state

the

an

narrative

goals/start the improvement cycle. "Quality is

never an accident, it is always the result of high

many alternatives." Willa A. Foster

and determine the causes of the problem

by

brainstorming

and

asking

why

1.

your

overall

goal,

process,

or

outcome improvement. Be specific as to

is then diagrammed off the line. You keep

what your project will focus on in order to

asking why until you've reached enough

eliminate the problem or process variation.

detail. The process of asking why is known

as the Five Why's. The causes can then be
4.

Define

problem occurred. Each cause of a problem

Define what change is to be made.

2.

Questions to ask in this step as you aim for

analyzed and sorted.

long-term solutions are as follows: Will the

Measure process variables if necessary and

action eliminate the problem? Will process

evaluate the data. Measurement allows one

variation

to

the

potential action, solution, alternative or

causes of the problems. Examples of data

option that will improve the process then

quantify

Majdah Shugdar

problems

and

confirm

be

decreased?

Identify

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the

assess the following: Is the solution risky?

outlining dependencies between departments. You

What are we trying to accomplish? What

may need to strategically plan for the future by

changes can we make that will result in

determining what needs to be in place to get where

improvement? How will we know that a

you want to be.

change will result in improvement?

3.

Identify the opportunities for improvement

To make improvements in a process you must

by establishing priorities. The goal of this

know all the aspects of the process. Take the

step

alternative

process apart into sequential series. Determine the

actions, in the end choosing the best

basic flow of proposed activities by flowcharting the

solution or first steps towards the solution.

basic steps of the process. Design processes in

Continue to be creative and innovative

order to have a smooth flow of interdependent

solutions should be based on potential in

activities. A flowchart is a graphical tool that shows

order

the

process information. Flowcharts are similar to

problem. Solutions address the cause of

maps. Draw a flowchart, value added flowchart,

the problem, and are cost-effective and

PERT (Planning Evaluation Review Technique) chart

capable of being implemented within a

or Gantt chart of the process or interrelated

reasonable amount of time. Examples of PI

processes. You can draft a flowchart by hand or use

tools and techniques used for prioritization

software

are: prioritization grids, selection grids and

Microsoft Project or Visio.

is

to

to

consider

prevent

many

recurrences

of

programs

such

as

Microsoft

Word,

the Pareto Analysis, 80% of the problems

can be corrected by changing 20% of the

Step 7. Design the measurement plan. "You

systems. Pareto analysis is the process of

can't manage what you can't measure. " A. Banker.

ranking opportunities to determine which

of many potential opportunities should be

Never

pursued first.

improvement-measure-measure-measure.

assume

the

action

will

result

in
A

measurement plan is required to establish the need

"P" for Plan includes steps 6-9. "Planning is

for

future-oriented, and the future will arrive whether

improvement.

the organization is ready or not." Wynn and

needed to assess how well a process is working.

Guditus

Data is the voice of a process. The measurement

improvement,

as

well

Measurement

as

provides

to

assess

the

data

plan is a plan to measure what you plan to do.

Step

6.

Plan

the

action

improvement/process

for

performance

Measurements provide objective data to separate

design/project

opinion from fact. This is essential for valid problem

planning. "People seldom hit what they do not aim

solving. Planning the measurement plan means

at." Henry David Thoreau

planning how an improvement action will be tested

and how data will be collected. The measurement

If you do not have a process in place, begin with

data are used to regulate, modify, monitor, accept

the Plan stage. Plan the implementation and

or reject a process being studied. An understanding

evaluation of the improvement. The most important

of data is necessary before you can develop a

part of problem solving is planning the action you

measurement plan.

are going to take. The action should be directed at

eliminating the cause of the problem.
Are you re-designing an existing process or are

Information on data in general:

Measurement can be obtained either qualitatively

you designing a new process? Your plan may

or

require contingency planning which helps design

measuring with words. Words are grouped into

back ups. Your plan may require critical paths

categories (e.g. like or dislike, agree or disagree,

Majdah Shugdar

quantitatively.

Qualitative

measurement

Page 5 of 11

is

satisfied or dissatisfied.) Quantitative measurement

7.

clinical and,

is measuring solely with numbers.

8.

satisfaction.

Some of the reasons to collect data of your project

Examples of definitions of data are:

are:
9.

patient specific,

To create a baseline if one does not exist

To monitor the process over time

To see the effect of a change in the process

Categories of data: Decide how you want the

To determine the impact of the change or

data categorized in order to be analyzed. Some

what effect the action has

medication system examples are:

To

evaluate

the

11. knowledge based.

effectiveness

of

your

problem resolution and determine whether

change led to the expected improvement

10. aggregate data,

To determine whether or not to continue

working on the process

12. Analyze

by

selection

&

medication

use

procurement,

processes:
ordering

&

prescribing, dispensing, administration or

monitoring
13. Analyze by sub classification: dosage form,

To provide a common reference

duration, rate, time, dose, missed dose,

To provide feedback on the performance of

route of administration, drug, monitoring

a system in the form of data

To provide information for decision making

To

provide

follow-up

data

indicating

measurable improvement.

error,

strength/concentration,

drug

deterioration, patient, technique.

14. Look at what type of employee caused the
error: Nurse, pharmacist, pharmacy tech,
delivery tech
15. Analyze if error was equipment or supply

There are different types, kinds, definitions and

categories of data:

related: pump, tubing, syringe, bag

16. Volume: Look of how many orders are
processed each week. How many orders

Types of data are:

are processed on-call each week?

17. Population size: All orders over time, using

1.

perception of care (opinion) data,

2.

observable

(seeing

what

there

a sample of 100 orders in a week for

is

and

3.

strategic outcome measures, lag indicators

or

results

data

(after

everything

has

performance

Using

sample

of

100

have 1 or more errors?

18. Out of all the orders (in a day, week) how
many errors are caught before shipping?

happened), or
4.

example.

medication orders each week, how many

recording it) data,

driver

measures,

lead

indicators, or process measures (data that

How to collect data: Data can be collected

are early indicators so that the process can

many different ways. Perception of care data is

be

collected on surveys and can be done in person, by

adjusted

occur).

before

undesirable

results

mail, over the phone or in focus groups. Check

sheets are used to record sample observations and

Kinds of data are:

detect patterns.

5.

financial,

How to display data: Data can be visually

6.

operational,

displayed in many different and creative ways to

Majdah Shugdar

Page 6 of 11

help analyze and turn the quantitative data into

There should be a historical summary of all the

information. Pareto charts are horizontal graphs,

action

which run from high (left) to low (right). The

objective.

steps

taken

towards

accomplishing

the

vertical bars illustrate the individual category being

compared. Run charts graph data over time to

Step 10. Implement the improvement "A useful

determine trends. Concentration diagrams display

motto during the start-up phase is, think big-start

data within a picture.

small." Ernst & Young

Step 8. Estimate cost/completion date. "You

Select and implement a solution. Do you need to

can't build a house without hammer and nails."

test a pilot (trial basis) first? It is best to carry out

Hosotani

a small-scale change or project before incurring the

cost of widespread implementation. Pilot projects

Estimate the cost of the project, including cost of

are forgiving. By doing a pilot first, it gives

actions and cost of data collection. Resources are

unforeseen obstacles a chance to surface before the

the supplies, equipment, personnel, etc. required to

real implementation. Do not carry out a full

accomplish the objective.

implementation after a pilot until a successful trial

has been approved in the Check stage. If you do

Determine timelines, milestones and the target

completion

date

to

having

the

not pilot, then implement the action plan.

objective

accomplished.

Set a date of implementation of performance

improvement.

Describe

what

was

used

to

Step 9. Education "QC begins and ends with

implement the plan. Carry out the improvement as

education." Ishikawa

planned.

Some

general

and

specific

education

on

performance improvement may be necessary when

Step 11. Implement data collection "Well begun

is half done." Horace

explaining to the employees how organizations

work in processes to make improvements in daily

Implement the data collection. You may want to

work. Improve learning to advance improvement.

pilot

Before moving from the plan stage to the do stage,

procedures first to make sure that everything is in

train

place.

your

employees

on

purpose

of

project,

the

data

collection,

instruments

and

process changes and data collection. Dont surprise

people with change. Explain the change and its'

Establish baseline data if there is no baseline data.

effects. Who will need to change the way they do

Initiate the data collection in full or pilot the data

their jobs? What are the sampling instructions?

collection process by testing on trial basis. Do Data

What training is needed?

Collection. Collect data to monitor the performance.

Clear criteria need to be established. The use of
common checklist or data collection forms can help

"D" for Do.

to

ensure

consistency

and

reliability

in

data

Do is explained on step 10 and 11. "Employees

collection. Plan how you are going to present the

who

data in a clear and understandable form.

feel

capable

of

solving

problems,

do."

Townsend and Gehardt

"C for Check "Whatever is worth doing is worth
Do is when the action you planned is carried out.

evaluating." Wynn and Guditus

The action could be a trial situation where you

perform the test by implementing the action on a

Check/Study's steps are between 12-14.

small scale or it may be an actual implementation.

Majdah Shugdar

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The Check/Study stage is the analysis. Here we

and check data for customer outcomes. Look at all

judge how well we have accomplished the plan

the

based on information and determine the next steps.

effectiveness of the change according to your plan.

This step is often omitted, which leaves the

Gather

effectiveness of a plan in question.

collection results after implementing solution to

related

data.

data

Monitor

from

key

the

points.

progress

and

Analyze

data

evaluate for process improvement and for customer

Step 12. Results of action " An accepted leader

outcomes. Was your prediction correct? Use the

has only to be sure of what is best to do, or at least

data in your decision making whether or not to

to have made up his mind about it." Winston S.

adopt action. How can you be more cost-effective?

Churchill
Evaluate the solution and the follow up. Check the
Check involves evaluating and analyzing the effect

data collection results after the implementation of

of the action being tested. What did you learn? Is

your plan in order to evaluate improvement. The

the solution you've chosen working? Do you need

solutions

to take corrective action? Do you have the right

accomplished

staff in place? Do any changes need to be made?

however, they don't or they may only partially

What are the pros and cons of the plan? Was there

solve the problem. They may even cause other

any unplanned information you collected? Was your

problems or prove to be too expensive. You need to

prediction correct? Do you need to go back and

check. Now, you must check the solutions to verify

implement another portion of the plan? Results

their effectiveness in solving the problem, to see if

should flow from management to staff for more

they cause other problems, and to see if they are

improvement

to

cost-effective. You can document changes to the

management. At this point there is a choice. You

process by comparing the data before you began

can abandon the idea, repeat to modify the idea, or

the project with data developed at this stage.

go on to the "act" stage to standardize the process

Analyze

if the data validates the solution works.

Measure and assess the effect of the action.

strategy

input

and

back

you

data

have
your

to

developed

may

intentions.

evaluate

the

have

Sometimes,

improvement.

Monitor the progress and effectiveness of the

change according to your plan. Run charts, scatter

Step 13. Results of data :

diagrams, histograms, check sheets, Pareto charts

Data are simply facts; information is the actual

(your hope is that the large category your team

answer to a question. Information is based on data,

worked on is now only a small bar on the Pareto

but simply having data will not provide information.

diagram, or even gone completely.)

Transforming data into information is the key to

Repeat some of the steps if data does not meet

this step.

target.

Continue

to

evaluate

the

data

or

Determine intervals to review data (e.g. daily,

performance improvement evidence to use as

weekly, and monthly.) Check for errors. Was there

information in your decision making. Once data

any unplanned data you collected? Tabulate your

validates the solution will work you can move to the

data. Who is going to review? Looking at your data

Act stage.

requires some evaluation and analysis. Compare

before and after data. Check your data results vs.

Turning data into information by using a bar

target goals. Check your progress vs. plan. Assess

graph

the effect of the action. Analyze and review results.

Example 4.

is

illustrated

in

the

Appendix

as

Determine if the findings meet acceptable limits.

Determine if findings are moving in the right

Step 14 Repeat "It is common sense to take a

direction.

method and try it. If it fails, admit it frankly and try

Are

there

general

trends

towards

improvement? Check data for process improvement

Majdah Shugdar

Page 8 of 11

another. But above all, try something. " Franklin D.

Act is explained from 15 through 20. "Until you

Roosevelt

implement a decision, it is not really a decision at

all." Edward C. Schleh

Have you accomplished your original goal? After

checking the implementation of the plan, you may

ACT: Act on the information. Adopt the change. In

decide that the "do" stage has not accomplished all

standardizing, you do what is required to keep the

you intended it to. Instead of going to "act" you

process going. For example, you may provide

must make an adjustment. Describe how the target

employee training on a new process for continuity.

wasn't met. You can abandon it, or make further

Act

revisions. Does the change idea have potential, or

executing

do you need to abandon the idea and start again

process. Once improvement has occurred, you

with a new idea? Repeat the cycle. If the solution is

must immediately establish controls in order to

not correcting the problem, then the process should

maintain improved performance. Otherwise, you

begin again to determine a better solution. This

probably will not be able to keep the gains made.

means we review our plan and its implementation

Controls are like the "check" the "act" stages in

and search for ways to improve. If results are not

PDCA, because we make deliberate changes. You

where you want them you must go back to make

act based on the results of our check. You modify

an adjustment. You must need to modify or adjust

or plan accordingly, and you do or perform your

your solution. Now is the time to stand back from

service in an improved manner.

means

fully
the

implementing

solution

by

the

action

standardizing

or
the

the problem, rethink it, and possibly develop new

plans. Ask yourself: What has our team tried? What

Use

have you accomplished so far? In what ways does

improvement

our plan fall short? And most important, what do

budgets and resource allocation.

your

findings.

Identify

needs.

training.

Compare

Identify

results.

Guide

you and the team plan to do about it? Go back to

your original analysis and decide if there were some
other possible causes that may be causes. You may
need to go back to any one of the steps as you

Step

write your adjustment plan.

actions/solutions/adopt

15

Implement

effective

change/if

pilot

implement to full "I like the dream of the future

Often times you are not going to try to make all

better than the history of the past." Thomas

your changes at once, because then you could not

Jefferson

measure the effectiveness. The first variable may

be successful, and now you want to try another

Problems are solved only when recurrences do not

process variable working towards achieving the

happen. If a pilot project was successful then

original goal.

implement it on a full scale. The organization's

action plan for improvement is pilot tested and

Continue to improve your measurement plan too.

implemented, if successful and objectives have

been

achieved.

Process

revisions

should

be

Repeat the Plan and Do stages until you've met

finalized. Education is necessary. Determine a

your defined measurement objective. Once the data

completion

date

validates the solution will work you can move to the

Implement

effective

Act stage.

Determine if there are any processes that can be

after

goals

have

actions.

been

Identify

met.

owner.

eliminated. If revision is needed, then go back to

"A" for Act

the necessary stage to revise.

If

no

further

improvement

is

feasible,

complete the project.

Majdah Shugdar

Page 9 of 11

then

Step 16 Follow up/next steps/refine change

"TQM programs provide people with the "freedom
to fail" which enables them to learn from mistakes

It is not enough to find the solution. Deciding how

and accept the responsibility for their results and

and to whom these lessons can be communicated

for preventing repetition of errors: they do not

are important steps of a project. You can share

negatively sanction people and they remove fear

information many different ways. Information can

from the workplace." Allan Sayle

be

shared

either

in

writing

or

verbally.

Documentation is a channel of communication. The

How can the change be refined or revised? What

paperwork produced is one of the most significant

can be done to error-proof the process. Repeat the

channels

cycle and learn from the results to improve the

documentation

process.

worksheets,

Reinforce

the

progress.

Make

of

communication.
are

data

The

Minutes,
collection

forms

action
forms,

of

plans,

summary

improvements when needed. Do any changes need

reports and project files. Written material can be

to be made to the solution? Do any changes need

disseminated throughout an organization in many

to be made in the measurement system? How can

ways such as being sent electronically or posted on

the change and measurement system be refined.

site or on an organization's Intranet site for a

What steps will be taken next?

centralized

form

of

communication.

Verbal

presentations are a very helpful venue to share

Your first improvement action could have been

information as well. Verbal presentations can be

successful and now you can try another action. You

done in person at staff meetings or seminars, or

may try something new or add another measure to

over the phone via a teleconference.

continue

to

make

improvements

and

reduce

variation. After the process has met performance

You need to share information both internally and

goals, the final step is to develop and put in place

externally.

new standards so that the problem stays solved.

important. Do you need to make recommendations

Standardize the processes and systems to ensure

to someone? Was a change made that needs to be

you will maintain and sustain improvements

publicized? The method chosen to publicize the

Communication

on

all

levels

is

solution depends on who is the target audience. Do

The advanced Process Improvement methodology

you need to report the findings to someone? Who

monitors

improvement

might be interested in learning what was learned?

approach

and

using

the

six-sigma
isn't

Has a training plan been developed to train

achieved until minimal variation has been obtained.

personnel on new methods? By sharing information

performance

improvement

in writing you not only provide evidence of your

Step 17 Lessons learned/cost savings "Total

efforts by sharing your progress, but also to open

Quality

of

your efforts for feedback during the process. Within

management processes and systems that create

the organization it is important to share information

delighted

empowered

with all the employees by posting progress results

employees, leading to higher revenue and lower

during the project. At completion, you can help

cost." Juran Institute, Inc.

others learn by telling people how you achieved

Management

(TQM)

customers

is

through

the

set

your goal. You can share what actions were

What lessons were learned? Learn from results.

implemented, how you evaluated the effectiveness

Itemize things you wished you knew before you

of the action, how much did the solution cost, and

started the project for example.

how effective your project turned out to be. What

lessons were learned? What are your follow-up

Documentation/communication

plans? Your team has the opportunity to express

"Nothing has really happened until it has been

any observations, conclusions or recommendations

recorded." Virginia Woolf

that were gained from the problem-solving activity.

Step

18

Majdah Shugdar

Page 10 of 11

What processes or steps in the PI project might be

improved

further?

What

did

you

learn

Bibliography

about

working as a team or about problem solving?

Accreditation Commission for Health Care, Inc. (2002)

Documentation

Home Infusion Accreditation Manual

serves

as

both

historic

record

keeping and as resource material for others.

Information should also be shared externally to

Allen, Roger E., and Stephen D. Allen (1995) Winniethe-Pooh on Problem Solving Penguin Books New York,
NY 10014 (out of print)

enhance your public image. Marketing can promote

your Programs to Referral Sources and customers.
Marketing will have "Bragging Rights" for your
accomplishments.

Carey, Raymond, G. (2002) Measuring Quality

Improvement in Healthcare: A Guide to Managing with
Control Charts De Paul University Quality Institute

Project is completed. Celebrate your success!

Step 19 Sustain performance improvement
"We just couldn't leave well enough alone." Toyota
Motor sales slogan
If your team is satisfied that your solutions have
solved the problem, you must show what has been
done to keep the solutions in place so that the
problem never reoccurs or occurs minimally with
little variation. To keep your staff focused and to
avoid a lapse into old routines and methods,
controls must be put in place to remind people of
the new method. Decide how you want to monitor,
review and re-evaluate periodically. Training may
be

necessary

measures

to

are

maintain
used

to

gains.

to

determine

if

if

the

improvement

Step 20 The PDCA cycle can be repeated again

again;

attempting

to

refine

the

improvement.
Review over time. The PDCA cycle is cyclic not
linear. Even when improvements have been put in
place

and

effective

improvements

Gomes, Helio (1966) Quality Quotes ASQ Quality

Press, Milwaukee, WI
Joint Commission Resources (2001) 2001-2002
Comprehensive Accreditation Manual for Home Care
Joint Commission on Accreditation of Healthcare
Organizations
Joint Commission on Accreditation of Healthcare
Organizations (1994) Framework for Improving
Performance

have

Joint Commission on Accreditation of Healthcare

Organizations (1995) Leadership Skills for Performance
Improvement: Planning for Quality

is

sustained over time.

and

Dusenbury, Diane, and Steven W. Collins, Process

Management: A Method for Achieving Desirable
Healthcare Results Journal for Healthcare Quality Vol.
24, No. 4 July/August 2002

Performance

determine

improvement is sustained. Continue performance

measurement

Brown, Janet A. RN, CPHQ (1986-2001) The

Healthcare Quality Handbook: A Professional Resource
and Study Guide 2001 Sixteenth Annual Edition

been

standardized, process management should not end.

Joint Commission on Accreditation of Healthcare

Organizations (1988) Sentinel Events: Evaluating
Cause and Planning Improvement
Joint Commission on Accreditation of Healthcare
Organizations (1996) Using Performance Measurement
Tools in Home Care and Hospice Organizations
Joint Commission on Accreditation of Healthcare
Organizations (1999) Using Performance Measurement
to Improve Outcomes in Home Care and Hospice
Settings

Variables, such as new technology, change over

time. Accordingly, the improvements should be
reviewed periodically.

Majdah Shugdar

Page 11 of 11