Action Planning

HSAG HQIC will discuss action plans for quality improvement, including their key components and primary uses.

This material was prepared by Health Services Advisory Group (HSAG), a Hospital Quality Improvement Contractor (HQIC) under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services (HHS). Views expressed in this material do not necessarily reflect the official views or policy of CMS or HHS, and any reference to a specific product or entity herein does not constitute endorsement of that product or entity by CMS or HHS. Publication No. XS-HQIC-QI-04242023-02

Transcript

The speaker is Christine Bailey, Quality Improvement Organization Executive Director, HSAG.

Speaker 1 (00:02):

Today, we're focusing on action plans, and our objectives are to talk about what exactly is an action plan. Identify the key components, discuss how to use an action plan, and review an example. What is an action plan? It's really a step-by-step plan or roadmap. And it's really, really important that you start with that good smart goal: That specific, measurable, attainable, relevant and time-bound. Because again, that will keep you focused and keep you from getting scope-creeped. The action plan details your interventions or actions that you're going to take to achieve that goal. And it assigns responsibility for the action items, and that's really important when you have any kind of project to establish accountability for completion of those items, those action items or interventions in a timeframe. So, the last piece of that is really, it incorporates our deliverable dates and assists us in adhering to our project timeline.

Speaker 1 (01:17):

Keep that goal statement in front and center so you make sure you stay within the parameters of that goal and you keep on target. And you know, really when you have this action plan, you can use this as part of your agenda for your meeting. Again, make sure you have the date it was initiated. If you do update your action plan, you know, put that at the top, so it serves as a record for what you've done. So, we're going to kind of tease this apart a little bit. So, the first, you know, titled item, it's really a key area for improvement, kind of like the title for what that action is that you're going to do. With your root cause, it really is going to identify, the part of the root cause that that action is going to address or that intervention is going to address.

Speaker 1 (02:17):

So, once you perform your RCA, you know, sometimes it's multifactorial, so you want to put what part of that root cause that you have identified that that action item or intervention is going to speak to. So, the nexus plan. So, that's actually the action steps to be taken. The strategy really you're going to identify, you know, what you're accomplishing, the improvement in each area identified for change. So, responsibility. Again, this is really important, the individual or group assigned to accomplish the plan or action items. When we work in a group, we always have, you know, I call them our workhorses. They're the folks that are the ones that seem to carry the load and do the work for all of our projects. And, it really gives us, you know, fatigue. When we use that same person over and over again, you think about who you're assigning this to and what their workload looks like.

Speaker 1 (03:24):

Also, look at the area that it impacts the most. So, again, look for that champion that is closest to the area where you are looking to implement that improvement. And, it has to be very clear, very clear responsibilities. Put that team member's name. It just kind of helps with that accountability. So, due date. Set those deadlines, look at your timeline, and put a date when it's due, and then mark when it's completed, as well. It helps you when you look back and kind of, you know, debrief on what went well and what didn't. You know, maybe you had an unrealistic timeframe. But again, when we start talking about accountability, 'cause it's always difficult when you are leading the team and you go, you know, get updates of where everybody is for their piece. You know, make sure you call that person out and say, this is due by such and such a date, and you know, are you on target?

Speaker 1 (04:37):

If not, what are the barriers? So, many times when you call those, call that out in the group, you know, just peer pressure alone helps with accountability. Measurement plan. Describe the plan to collect information to evaluate the results and to monitor the process. So, what are the metrics? Document the metrics to measure and the success or efficiency. You know, look at rapid-cycle improvement. Critical-to-quality tree. Those will help you. Even the data plan will help you identify the metric you want to use to see if the intervention from this action plan is actually doing what we expect it to do. Status. So, document the status updates each time the team meets. So, again, this goes back to accountability. What are you waiting on? How far along are they in implementation? Are we monitoring data to check efficiency and effectiveness?

Speaker 1 (05:43):

So, you know, make sure each time you meet, put a date in and make some kind of comment about it. You know, when this goes up to leadership or, you know, whoever your project sponsors are looks at this, it again, that leadership helps establish that accountability with the folks that are assigned to do a certain task. Results and lessons learned. Was it efficient? Did it move the metric? What worked and what didn't work? Identify changes you would like to make. You know, PDSA your own, your own strategy. And, and again, you know, document the successes and barriers, so you know if we can't get something implemented. So, what are our key takeaways? Again, an action plan is a step-by-step plan to achieve your SMART goal. So, your SMART goal for your project, keep that on the top of that page, so that you can refer back to it.

Speaker 1 (06:49):

So, you know, you don't have that scope creep, where you're looking at solving one problem and you end up, you know, identifying a lot of other issues and maybe barriers. And there may be other projects that you have to address before something can be moved forward. You might have to delay, you know, what you're working on a little bit to address other issues. But again, don't, you know, don't have scope creep for this action plan. And then again, the action plan provides a team or project leader with a tool to design, assign, and track the implementation of a quality improvement initiative. If you do have an existing template, make sure it has, you know, the strategy or intervention designed to achieve your goal, which we call your root cause. The plan. What are the actions. That's where the rubber meets the road. What are the actual action steps you're going to be taking? Responsibility, keep it on time, your measurement plan, your status, and your PDSA for lessons learned.