Quality Improvement Initiative (QII) Plan

Alliant Quality will evaluate:

  • Acknowledgment of the issue being addressed
  • Specific steps to be taken to address the issue
  • Staff position/title designated to be responsible for the steps
  • Timeline for accomplishment of the steps
  • Specific methodology to be used to evaluate the plan’s success
  • Frequency of monitoring the effects of the plan


In order to demonstrate accomplishment of the above, the components (and examples) noted below might assist you in developing your plan.

 1. Description of Concerns – document the quality of concern issue.

How has the quality of care concern impacted the patient or patient care?

 2. What is the prevalence or baseline rate?

Provide any data that demonstrates other occurrences of the same or related concerns, including a numerator, denominator and time frame during which they occurred. This will serve as the baseline for which subsequent data will be compared and will be the indicator that the selected interventions have resulted in improvement or whether or not changes are required.

 3. What was the root cause analysis (goal of identifying where improvement may be possible)?

This analysis will provide more information related to the processes responsible for the system failure and assist in the development of intervention most likely to result in improvement.

 4. State your measurable goals.

Document desired goals that clearly communicate what desired level of performance is expected. Goals should address process changes as well as outcome related to process changes.

 5.  Interventions & Rationale - Specifically as possible document interventions and how they will address the identified system failure and quality concerns.

These interventions should be evidence- based with references given related to scientific studies, research, best practice guidelines, other national guidelines, etc.

 6. Outcomes - Document process measures and/or outcome measures on the table.

The process measure focuses on the specific process identified for improvement efforts and has a direct impact on the desired outcome. The outcome measure reflects why the process is conducted. Both types of measures require a numerator and a denominator. The numerator generally contains the measure (# of inpatient deaths, # of patient falls) while the denominator contains the population to be studied).

 7. QII Plan implementation date - Provide the date the plan will be implemented.

 8. Describe the overall outcome - Describe how the QII process will result in tangible improvement and accomplishments over a time period that can be linked to the interventions.


Follow-up - Indicate how you intend to maintain and monitor your QII Plan and when you will provide a progress report.

11 SOW Quality Improvement Initiative Plan.pdf

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