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LCSR Performance Improvement Resources


This article contains a continually updated collection of performance improvement (PI) reference material including publications, videos, web articles, and templates. Much of this material was developed by the Institute for Healthcare Improvement (IHI) and Agency for Healthcare Research and Quality (AHRQ) specifically for health care, as well as the ACR for facilities participating in one of the ACR Learning Network’s improvement collaboratives.

PDSA Worksheet

This worksheet provides step-by-step documentation to complete a Plan-Do-Study-Act (PDSA) PI project cycle using the Lung Cancer Screening Registry.

Plan Your Project

The following resources are provided to help you consider important aspects of embarking on a performance improvement initiative as you begin your project planning.

Build the Team

These articles and videos discuss how to create an effective quality improvement team, who to include, the necessary roles, and how to work together to reach your goals.

  • Science of Improvement: Forming the Team (IHI): Describes the roles and expertise needed for effective QI teams with examples.

  • Creating Quality Improvement Teams and QI Plans (AHRQ, 2015): The quality improvement (QI) team or committee is the group of individuals within a practice charged with carrying out improvement efforts. This module covers the formation of QI teams.

  • Working in Teams (ACR Learning Network, 2022): Selecting the right people for the QI team, clarifying roles, and the lifecycle of team development and group dynamics.

  • Communicating Progress and Results (ACR Learning Network, 2022): Best practices for keeping your team engaged and informed throughout the project.

Set a Goal and Analyze Baseline Data

The resources below provide examples and guidance on goal setting and identifying underlying factors that contribute to the current performance level. Downloadable PI templates (diagrams, charts, etc.) and videos explaining their use are included below.

  • Evaluating the Current State (ACR Learning Network, 2022): How to evaluate and map out your existing processes by involving multiple stakeholders and communicating effectively with staff.

  • Flowchart/Process Map (IHI, 2014): (Requires free IHI account.) A flowchart — also known as a “process map” — is a visual representation of the sequence of steps in a process. Understanding the process as it currently operates is an important step in developing ideas about how to improve it. This makes flowcharts especially useful in the early phases of improvement work.

  • Eleven Steps to an Effective Gemba Walk (KaiNexus, 2022): By visiting the place where work is done, leaders gain valuable insight into the flow of value through the organization and often uncover opportunities for improvement and learn new ways to support employees. These are the most important steps you can take to conduct an effective Gemba walk.

  • Science of Improvement: Setting Aims (IHI): Examples of effective PI project aim statements (goals).

  • Root-Cause Analysis and Health Failure Mode and Effect Analysis: Two Leading Techniques in Health Care Quality Assessment (JACR, 2014): The principles and techniques provided in this publication should allow reviewers to better understand the features of root-cause analysis (RCA) and health failure mode and effect analysis (HFMEA) and how to apply these processes appropriately. These principles include how to organize a team, identify root causes, seed out proximate causes, graphically describe the process, conduct a hazard analysis, and develop and implement potential action plans.

  • Cause and Effect Diagram (IHI, 2015): (Requires free IHI account.) Also known as the Ishikawa or fishbone diagram, this tool helps you analyze the root causes contributing to an outcome.

  • Pareto Chart (IHI, 2015): (Requires free IHI account.) Using a Pareto chart helps teams concentrate their improvement efforts on the factors that have the greatest impact. It also helps teams explain their rationale for focusing on certain areas and not others.

Design an Intervention Plan

This section includes articles discussing concepts and models for planning and implementing interventions at your facilities and what is necessary for success.

  • Using Change Concepts for Improvement (IHI): There are many kinds of changes that will lead to improvement, but these specific changes are developed from a limited number of change concepts. This article lists change concepts that can be combined with knowledge about specific subjects to generate ideas for tests of change (interventions).

  • Creating Quality Improvement Teams and QI Plans (AHRQ, 2015): Discusses using key driver models to focus quality improvement plans (intervention plan) with examples, what an improvement plan should include, and how to monitor progress.

Measure Post-Intervention Results

Listed below are articles and charts to support evaluating the results of your intervention(s) against project goals and the establishing measures for tracking improvement progress.

  • Control Chart: The chart displays performance over time and helps to discern which changes in values are due to a true change or typical random variation. The PI Assessment tab of the Facility Comparison Report (see Study section of the PI Project Walkthrough) provides a control chart for your facilities.

Create a Sustain Plan

This section contains information on sustaining improvements at your organization in the long-term, creating a plan, and communicating effectively with staff.

  • Sustaining Improvements (ACR Learning Network, 2022): Video on developing strategies to sustain successful interventions beyond the project sphere into the operational system. (At 3:20-4:33 disregard references to an ACR A3 document as this is specific to the LN program and the PDSA Worksheet should be used with this project. The concepts discussed in this section of the video should still be included in your Sustain Plan, but the format you use to document this is up to you.)

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