Quality Improvement Admin Guide

Documentation Index

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Module: GR Core - Quality Improvement (GR-07)
Audience: QI Coordinators, Compliance Officers, Administrators
Last Updated: 2025-12-15

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Overview

This guide covers administration of the Quality Improvement module, including project management, PDSA cycles, metrics tracking, and improvement action management.

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Getting Started

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Prerequisites

1. Ensure QI is enabled in Governance → Settings → Quality Improvement
2. Configure notification settings for reminders
3. Familiarize yourself with the PDSA methodology

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Key Routes

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Creating QI Projects

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From Scratch

1. Navigate to Governance → Quality Improvement
2. Click New Project
3. Fill in required fields:
   • Title: Clear, descriptive name
   • Category: clinical, operational, safety, compliance, or outcomes
   • Description: Problem statement and improvement goal
   • Owner: Person responsible for the project
4. Click Create Project

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From a Compliance Requirement

When a compliance requirement needs improvement:

1. Navigate to the requirement detail page
2. Click Create QI Project
3. The project will be linked to the requirement

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From an Audit Finding

When an audit finding warrants systematic improvement:

1. Navigate to the finding detail page
2. Click Create QI Project
3. The project will be linked to the finding

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Managing PDSA Cycles

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Creating a Cycle

1. Open a project detail page
2. Navigate to the PDSA Cycles tab
3. Click New Cycle
4. Enter the hypothesis and plan details
5. Click Create Cycle

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Advancing Through Phases

Each cycle progresses through four phases:

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Plan Phase

Document:

• What change are you testing?
• What do you predict will happen?
• How will you collect data?

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Do Phase

Document:

• Carry out the test
• Record observations
• Note any problems or surprises

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Study Phase

Document:

• Compare results to predictions
• What did you learn?
• Were there unexpected outcomes?

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Act Phase

Document:

• What will you do next?
• Adopt (implement broadly), Adapt (modify and test again), or Abandon

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Advancing a Cycle

1. Complete documentation for current phase
2. Click Advance Phase
3. Confirm the transition
4. The cycle moves to the next phase

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Completing a Cycle

After the Act phase:

1. Review all documentation
2. Click Complete Cycle
3. Document the outcome and next steps

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Tracking Metrics

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Creating Metrics

1. Open a project detail page
2. Navigate to the Metrics tab
3. Click New Metric
4. Enter:
   • Name: What you’re measuring
   • Description: How it’s measured
   • Category: outcome, process, or balancing
   • Unit: Measurement unit (%, count, days, etc.)
   • Baseline Value: Starting measurement
   • Goal Value: Target to achieve

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Recording Measurements

1. Click Record Measurement on a metric
2. Enter the new value
3. Add any notes about the measurement
4. Click Save

The system automatically calculates trend based on the last 3 measurements.

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Understanding Trends

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Managing Improvements

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Creating Improvement Actions

1. Open a project detail page
2. Navigate to the Improvements tab
3. Click New Improvement
4. Enter:
   • Title: Action to take
   • Description: Detailed steps
   • Responsible Party: Who will do it
   • Due Date: When it should be complete
5. Optionally link to a PDSA cycle or metric

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Tracking Progress

Monitor improvements through:

• Project detail page (per-project view)
• QI Dashboard (organization-wide view)
• My QI page (per-user view)

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Handling Overdue Improvements

1. Check the QI Dashboard for overdue items
2. Contact responsible parties
3. Either extend the deadline or reassign

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QI Dashboard

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Overview Statistics

The QI Dashboard shows:

• Total Projects: All projects in the organization
• Active Projects: Currently in progress
• Active PDSA Cycles: Cycles in planning or execution
• Open Improvements: Not yet completed
• Overdue Improvements: Past due date

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Charts and Breakdowns

• By Category: Distribution of projects by type
• By Status: Project status breakdown
• Metric Trends: Improving vs. stable vs. declining

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Settings Configuration

Navigate to Governance → Settings → Quality Improvement:

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Module Settings

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Notification Settings

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Integration with Other Modules

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GR-03: Compliance Requirements

• Create QI projects from requirements needing improvement
• Link projects to specific regulatory requirements
• Track compliance improvements systematically

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GR-04: Audit Findings

• Create QI projects from audit findings
• Use PDSA methodology for corrective actions
• Document improvement evidence

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GR-05: Risk Assessment

• Address high-risk items through QI projects
• Track risk reduction through metrics
• Document mitigation improvements

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Best Practices

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Project Scope

• Keep projects focused on specific, measurable improvements
• Start small with pilot tests before broad implementation
• Set realistic timelines based on complexity

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PDSA Cycles

• Complete cycles quickly (2-4 weeks typical)
• Test small changes before scaling
• Document thoroughly even when things don’t work

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Metrics

• Choose metrics that directly measure the improvement goal
• Collect baseline data before making changes
• Balance outcome metrics with process metrics

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Improvements

• Assign clear ownership for each action
• Set realistic due dates
• Follow up regularly on progress

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Reporting

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Available Reports

Access through the QI Dashboard:

• Project status summary
• Improvement completion rates
• Metric trend analysis
• Overdue item reports

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Export Options

• Export project lists to CSV
• Generate PDF summaries
• Share dashboard views

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Troubleshooting

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”QI feature not available”

Ensure QI is enabled in GR Settings.

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”Cannot create improvement”

Check that the project is in Active or Planning status.

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”Metric trend not updating”

Record at least 3 measurements for trend calculation.

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Related Documentation

• QI User Guide - Staff guide
• Risk Admin Guide - Risk management
• Audit Admin Guide - Audit management
• Compliance Admin Guide - Compliance tracking

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