Improvements don’t end with the action plan
A monitoring system to can help ensure success
By Patrice Spath, RHIT
Brown-Spath & Associates
Forest Grove, OR
When a patient care problem or improvement opportunity has been identified, it must be resolved. If the problem is significant, it is important to take action as quickly as possible. Good ideas for resolving the problem are solicited from physicians and staff and the best solutions identified. At this point the improvement project is over, right? Unfortunately, once an improvement initiative has been completed and corrective actions apparently implemented many projects stop here. The final step (follow-up) is where a lot of performance improvement initiatives fail.
The reason for this is that corrective actions don’t get fully implemented and without monitoring some actions fall through the cracks. It is vital to develop a tracking system that will give senior leaders and oversight groups the capability of knowing what corrective items have not been completed. A monitoring system that tracks closure helps to ensure a successful improvement initiative. If the entire system is expected to function properly, then fixing the few problem areas is vital.
Corrective actions are generated as result of improvement projects, root cause analyses, and proactive risk assessment projects. The quality manager often has two different roles to play in the corrective action process: (1) assist in developing the plan; and (2) verify completion of the plan. Neither of the roles involves assuming the responsibility for implementing and evaluating corrective actions. Implementing and monitoring the effectiveness of actions are the responsibility of management of the area or activity being improved.
Quality managers can assist in the corrective action plan by suggesting methods of process improvement. These methods may be based on successful improvement initiatives in other parts of the organization or external best practices. Bear in mind, however, that no one is obligated to follow your recommendations. Even if you offer detailed instructions for improving a process, people may still find their own solutions. The important thing is to have effective corrective actions. Remember also, that the more input you have in developing problem solutions, the greater chance you will have of "owning" the corrective action.
Whatever corrective actions are selected, the plan to be submitted to the leadership group should be well-defined. The quality manager can help with this. Review the proposed actions, the timeline, and measures of success to determine if plans are complete. Work with the PI team leader or process owner to create a comprehensive action plan that documents the steps to be taken, when each action is expected to be done and the accountable people, and the strategies for evaluating the effectiveness of actions.
Verifying completion of corrective actions and impact on problem resolution may take several different forms. The evaluation methods should be part of the corrective action plan so that the quality manager and over-sight individual or group knows up front which methods of verification will be used. The timetable for measuring effectiveness of corrective actions needs to be part of the plan as well.
The organization’s leaders must be kept informed of the status of all improvement activities, whether it is an intra-departmental or cross-functional project. Use a reporting and tracking system to monitor improvement action plans. This can be a paper process — one page per project — such as the form show on page 12. For ease in data entry and retrieval, the same information can be computerized using a spreadsheet or database program. The disadvantage of a paper system for reporting improvement projects is similar to the disadvantage of any paper-based information system — data overload and inflexibility. If improvement project information is computerized, the quality department and other groups can easily excerpt summary information to produce concise project status reports. The projects can be sorted by department, month follow-up is due, important processes, and a variety of other configurations to meet the information needs of different groups.
An improvement project tracking process should provide a means of determining what stage improvements projects might be in at any given time. Make it your ambition to help facilitate the improvement follow-up process, not be the law and order. Department managers and PI team leaders have lots of other work responsibilities and documenting follow-up of action plans may be the last thing on their minds. Use your tracking log to send out reminders approximately one week prior to the due date of follow-up information. When reports are submitted, don’t settle for vague entries. For instance, if a supervisor notes that "procedure changes are in progress," ask for more details. If corrective actions are accomplished within the planned timeline, and the evidence indicates the corrective action works, then the improvement project can be considered closed. However, another follow-up evaluation may be warranted if the issue represented a major problem area or if corrective action was complicated. Build safeguards into your tracking process to prevent incomplete corrective actions or evaluations from dragging on.
No matter what format and process is chosen for reporting the status of improvement projects, it will never be an exact science. Report deadlines may be missed or people may be reluctant to let others know that planned actions have not taken place as expected. To combat these situations, organizations need to set the stage for timely and honest reporting. Pave the way for open communication by establishing a structured, yet simple, format for project status reporting. Status reporting should not be a tedious or time-consuming process. In fact, the simpler, the better. An electronic format of the project status report could be developed for online Intranet use or people could simply be asked to fill in the electronic format and send to the appropriate individual or group via email.
Improvement projects usually get behind schedule a day at a time, not a month at a time. Having a means of documenting and tracking these delays is important for spotting the trends that lead to major setbacks. Bi-weekly status reports from the project leaders to oversight individuals or groups are recommended.
The objective of action planning, implementation, and follow-up is to have effective and sustained performance improvement. Organizations cannot allow people to fall into the trap of believing that once the action plan is written, the job is over. Improvement projects should end only after the process owners and senior leaders are satisfied that the corrective action has met the goals and is effectively implemented.
When a patient care problem or improvement opportunity has been identified, it must be resolved. If the problem is significant, it is important to take action as quickly as possible. Good ideas for resolving the problem are solicited from physicians and staff and the best solutions identified.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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