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Performance & Quality Improvement “The Relentless Pursuit of Perfection”. PQI is simply the process of constantly looking at what we do, how well we do it, and how we can improve. We don’t believe “if it ain’t broke, don’t fix it”!. Who’s in charge? .

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PQI is simply the process of constantly looking at what we do, how well we do it, and how we can improve. We don’t believe “if it ain’t broke, don’t fix it”!

who s in charge
Who’s in charge?
  • You are! Employees are the lifeblood of this organization. You do the work, so you are the most knowledgeable on how to improve it. We want to empower our workforce so EVERYONE can be a steward for Performance and Quality Improvement – this is CRITICAL to PQI success.

Everyone plays an active roll in PQI!


In God we trust, all others send data!

What data? – Outcome data

Where does outcome data come from - All our reports and surveys.

Such as?

  • Med Error Report
  • Referral/Discharge Report
  • Case Record Review
  • Staff Retention/Turnover Report
  • Facility/Maintenance Report
  • Level of Care Report
  • Census/Bed Days Report
  • Behavior Management Report
  • Employee Satisfaction Surveys
  • Client Satisfaction Surveys
why do we have all this data
Why do we have all this data?

This is the only way to determine our strengths and weaknesses. We can make sure we are:

  • Meeting our goals and objectives of providing our clients with professional, compassionate and effective services.
  • Meeting the needs of our staff through effective training and mentoring
  • Making sure our buildings and grounds are in compliance
  • Finding the opportunities for improvement!

There’s always room for improvement!

what do we do with this data
What do we do with this data?

We need to analyze all this data - where are we strong, where are we weak, where can we improve. To do this, we have a series of meetings.

  • Weekly Progress Review Team Meeting
  • Monthly Staff Meeting
  • Quarterly Roundtable Meeting – Big Kahuna of all our meetings. All information from the other two meetings are combined and brought to the RT meeting.

At these meetings, if we see the need, we can ask ourselves the “three basic questions”.

three basic questions that need to be addressed in any improvement initiative
Three Basic Questions That Need to Be Addressed in Any Improvement Initiative
  • What are we trying to accomplish?
  • How will we know a change is an


  • What change can we make that will

result in improvement?

  • Identify and/or clarify what is not working. Where are we now and where do we want to be.
  • Design a "best-guess" solution--a new process model based on best practices.
  • Research similar service delivery providers to learn what goals to measure performance against.
  • Carry out your change
  • Collect the least amount (yes!) of data that you need
  • Is it increasing or decreasing frustration, productivity, cost or outputs/outcomes?
  • Correct obvious mistakes on the fly.
  • Roll out the new process agency-wide.
  • Mandate feedback from individuals. If they diverge from the new process, why.
  • Change the process based on the feedback until there is 80% conformance.
  • Share data with those doing the work
  • Allow for time to improve performance
  • Monitor for staff doing better or worse, clients unhappy or happy, the process /system working, not working
  • Ask the STAFF for ways to improve the process.

Act on what you have learned.

Continue to make improvements by going through the cycle again and again.

keeping the momentum
Keeping the Momentum
  • To set targets for improvement an organization should implement good ideas as soon as they appear and then check their impact.
  • Think you’ve got an idea? Bring it on!
  • Successful implementation of quality improvement requires commitment, focus and patience, but the rewards are substantial.
reality check we are only human after all
Reality Check – We are only human, after all!

Human behavior. We have to want it to succeed, and most of us only want it to succeed if it saves us time and decreases work & frustration. If it is too cumbersome or costs too much time, we have difficulty maintaining the process even if it does produce better outcomes!