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Module: GR Core - Quality Improvement (GR-07)
Audience: All Staff
Last Updated: 2025-12-15

Overview

Quality Improvement (QI) is a systematic approach to enhancing organizational processes, outcomes, and services. This module helps you participate in improvement initiatives, track your assigned actions, and contribute to continuous improvement efforts.

Getting Started

Accessing Quality Improvement

  1. Navigate to Governance → Quality Improvement from the main menu
  2. Or use the direct link: /gr/quality-improvement

My QI Dashboard

Your personal dashboard at Governance → My QI shows:
  • My Improvements: Actions assigned to you
  • My Projects: Projects you own
  • My PDSA Cycles: Cycles you’re participating in

Understanding QI Projects

What is a QI Project?

A QI project is a structured initiative to improve a specific aspect of operations, clinical care, safety, or compliance. Each project follows the PDSA (Plan-Do-Study-Act) methodology.

Project Categories

CategoryDescription
ClinicalImprovements to resident care and clinical outcomes
OperationalProcess efficiency and workflow improvements
SafetySafety enhancements and risk reduction
ComplianceRegulatory compliance improvements
OutcomesOutcome measurement and improvement

Project Status

StatusDescription
PlanningProject is being set up
ActiveProject is underway
On HoldTemporarily paused
CompletedSuccessfully finished
CancelledProject was stopped

PDSA Cycles

What is PDSA?

PDSA stands for Plan-Do-Study-Act, a four-phase cycle for testing and implementing improvements:
  1. Plan: Define the change to test, predict outcomes, plan data collection
  2. Do: Carry out the test, document observations and problems
  3. Study: Analyze data, compare to predictions, summarize learnings
  4. Act: Decide next steps - adopt, adapt, or abandon the change

Participating in Cycles

If you’re assigned to a PDSA cycle:
  1. Review the plan documentation
  2. Execute your assigned tasks during the “Do” phase
  3. Provide observations and feedback
  4. Participate in the “Study” analysis

My Improvements

Viewing Assigned Improvements

Navigate to Governance → My QI to see improvements assigned to you. Each improvement shows:
  • Title and description
  • Related project
  • Due date
  • Current status

Improvement Status

StatusDescription
PlannedImprovement identified but not started
In ProgressWork is underway
CompletedSuccessfully implemented
IneffectiveTried but did not achieve desired results

Completing Improvements

  1. Navigate to the improvement through My QI or the project detail
  2. Update your progress as you work
  3. Mark as complete when finished
  4. Attach evidence of completion if required

Understanding Metrics

What are QI Metrics?

Metrics track measurable outcomes to determine if improvements are working. Each metric has:
  • Baseline: Starting measurement before improvement
  • Goal: Target value to achieve
  • Current Value: Latest measurement
TrendMeaning
ImprovingMoving toward the goal
StableStaying consistent
DecliningMoving away from the goal

Tips for Success

  1. Check My QI Regularly: Stay on top of your assigned improvements
  2. Meet Deadlines: Complete improvements before due dates
  3. Document Everything: Keep notes on what worked and what didn’t
  4. Communicate: Share observations with project owners
  5. Be Honest: Report actual results, even if they’re not what you hoped

FAQ

Q: How do I know if I have QI tasks?

Check Governance → My QI. Any improvements assigned to you will appear there. You’ll also receive notifications for new assignments and upcoming due dates.

Q: What if I can’t complete an improvement by the due date?

Contact the project owner as soon as possible to discuss extending the deadline or reassigning the task.

Q: Can I suggest a new QI project?

Yes! Talk to your supervisor or compliance officer about improvement ideas. They can help determine if a formal QI project is appropriate.

Q: What’s the difference between a QI improvement and a corrective action?

  • QI Improvement: Proactive enhancement to make things better
  • Corrective Action: Reactive fix for an identified problem or audit finding


Need Help? Contact your QI Coordinator or Compliance Officer.