A Self-Assessment Guide for Health Care Organizations - IFC

STEP 5: Develop an Action Plan
The team should develop an Action Plan to close the gaps to meet the
standards. Each measurable element that is scored as “partially met”
or “not met” requires an action.
Quality Gap Analysis
Current
State
Desired
State
Current Standards Met
All Standards Met
Gap between current and desired state
based on self assessment
It is likely that some of the actions that need to be taken will be
straightforward. For example, if a process for checking water quality
is needed, then the action is clear – a procedure needs to be written
identifying who checks the water, when, and how. In some cases,
the way forward is likely to be less clear and the team may need to
collect more information in order to understand the situation. For
example, one hospital that investigated the reason for a higher rate
of incomplete medication orders discovered that this occurred when
new medical interns joined. This finding was clearly important in
determining a solution to the problem.
Some issues arising may be difficult to resolve and require specialist
assistance. In other instances there may well be internal resistance
to change (e.g. relating to new working practices) and will require
sustained, explicit management support. Colored graphs and charts
showing progress on key indicators (e.g. infection rates, patient
satisfaction) over time, displayed in departmental areas are also an
effective way of promoting quality improvement efforts.
Action plans should be as specific as possible, e.g. regarding
responsibilities and timetables.
Example: Action Plan
What needs
to be done
1. Develop a policy
and procedure
regarding obtaining
informed consent.
Who is going
to do it
Winona Amory,
Senior Nurse,
Surgical Ward
When will it
be done
May 15
STEP 6: Communicate the Findings/
Actions
The assessment findings and action plans should be shared with all
key parties. A Communication Plan should include:
1. Who needs the information
List all the individuals or groups that need the information, e.g.
staff, board of directors, committees.
2. What information is needed
Each group has a different need for the information. For instance,
the infection control committee will be interested in the findings
related to specific standards, whereas the board of directors is more
likely to be interested in a summary of the findings.
3. How will the information be delivered
The method that best suits the target group should be used.
A formal report might be sent to the board of directors and a
presentation might be made to the medical staff.
4. Who will convey the information
The person selected for delivering the information must be an
appropriate authoritative figure.
5. When will the information be given
Specific dates need to be assigned so that the plan can be monitored.
Example: Communication Plan
Who needs the information
All clinical staff
What information is needed
Informed consent policy and procedure
How will the information be delivered
Formal presentation
Who will convey the information
Winona Amory, Senior Nurse
When will the information be given
June 30
IFC Self-Assessment Guide for Health Care Organizations 85