What is the Quality Improvement Toolkit?
This toolkit consists of four (4) tools – with instructions and examples – for Critical Access Hospitals to use in delivering QI projects.
Each section of this toolkit will walk you through how to use the tool, when to use the tool, examples, and where to find editable copies so that you can successfully use them in your hospital.
Elements of these Tools were introduced at the FL Flex Quality Summit on May 14, 2024. Recordings of the related sessions of the Summit are available here: (Introduction to the QI Toolkit starts at 49 minutes)
If you have any questions about this toolkit, please contact the FL Flex Program Team for more information.
We would like to acknowledge the assistance of Alliant Health Solutions, who are also the current CMS QIN-QIO contractor for our region (including the State of Florida), for advice and use of certain templates in this QI Toolkit.
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SMART goals stand for Specific, Measurable, Achievable, Relevant, and Time-Bound. SMART goals help improve achievement and success.
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This is a four-phase quality improvement model used to test a change through iterative cycles, commonly used by hospitals and endorsed by CMS.
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These tools support the adoption and sustainment of changes introduced through a QI project and include a Stakeholder Matrix, Empathy Mapping and a Communication Plan.
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A tool that helps you plan a project and reflect on the outcomes.
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A Collection of tools and templates used by other hospitals that may be of interest to the FL CAHs
Tool 1: Create SMART Goals
For any successful QI project, it is important to start with a SMART (Specific, Measurable, Attainable, Realistic, Timebound) goal. A SMART goal clarifies exactly what is expected and the measures used to determine if the goal is achieved and successfully completed. SMART goals help improve achievement and success.
In short, a SMART goal frames what the hospital would like to achieve with a QI project.
A SMART goal is:
Specific. When setting a goal, be specific about what you want to accomplish. Think about this as the mission statement for your goal. The goals should articulate what measure or practice this change will enable (ex: reduction in inpatient falls, improve response rates to HCAHPS survey, utilization of teach-back, improving communication about medicines with patients at discharge, etc.)
Measurable. The success toward meeting the goal can be measured. What is our start or end point, what quantifiable and qualitative change would we like to see? There should be a source of information to measure or determine whether a goal has been achieved. Measurement methods can be both quantitative (productivity results, etc.) and qualitative (testimonials, surveys, etc.).
Attainable. The goals can be achieved in the timescale, not aspirational. Goals are realistic and can be achieved in a specific amount of time and are reasonable.
Realistic. The goals are based on available resources, capabilities, and other hospital priorities. The goals are aligned with current tasks and projects and focus in one defined area; include the expected result.
Timebound. The goal has an attainable and realistic time period in which this can be achieved.
Tool 2: Plan-Do-Study-Act (PDSA) Cycle
Plan-Do-Study-Act (PDSA) is a four-phase improvement model used to test a change through iterative cycles, commonly used by hospitals and endorsed by CMS. When using a PDSA, you will want to think about three main questions:
1. What are we trying to accomplish?
2. How will we know that a change is an improvement?
3. What changes can we make that will result in an improvement?
Going through the prescribed four steps, guides the thinking process into breaking down the task into steps and then evaluating the outcome, improving on it, and testing again for each iteration.
Tool 3: Change Management Tools
Quality improvement (QI) is about designing system and process changes that lead to operational improvements. To ensure these changes are implemented, adopted, and sustained in order to deliver the desired results, the following change management tools have been provided to aid CAH QI project teams in planning for and managing the impact to staff and other stakeholders.
Tool 3. A - Stakeholder Matrix
As part of change planning, it is important to consider that some stakeholders have a high level of impact on project success and need targeted forms of communication, outreach, and engagement. A stakeholder is an individual or a group that have an interest or stake in the work you are doing. To guide the development of targeted materials, organizations can use a Stakeholder Matrix template to summarize the key changes and level of impact for each identified stakeholder group.
Tool 3.B Empathy Mapping
An Empathy Mapping tool is designed to help you deepen your understanding about your stakeholders – what are their motivations? Needs? Challenges?
Insights from Empathy Mapping can help inform research needs, personas, change plans, messaging and impact the overall likelihood of connection and adoption.
Tool 3.C - Communication Plan
A Communication Plan provides a framework to organize the types and methods of communication for individuals within your quality improvement (QI) team, as well as other internal and external stakeholders. Regular communication with all stakeholders helps reduce uncertainty when introducing change. A communication plan is designed to engage all stakeholders at the appropriate level of participation and keeping them abreast of project activities. The following communication plan template is a tool that helps to keep track of your communications (and get approval where needed), to your different audiences / stakeholders.
Tool 4: BAR/AAR
A BAR/AAR is a tool that helps you plan a project and reflect on the outcomes. The Goal of a BAR/AAR is to encourage:
Open and honest professional discussion
Participation by everyone on the project team
A focus on results of an event or project
A BAR is held at the beginning point of a project. It is a valuable tool to use as part of your initial planning or kick-off. It can also be used at each new phase of a project. The AAR portion is used to reflect on what went well, what did not go well, what would you keep and what would you change. If you forget to do the BAR portion of the BAR/AAR, that is ok. You can still use the AAR portion as a helpful tool to reflect on how the project went and plan for next time.
