QI Action plan

QI Action plan.

Please complete the attached tables:

This is an individual assignment. Using your assigned case study, create the action plan components of your QI project using the Indicator Worksheet.* After your fishbone diagram (i.e., cause-effect diagram) is created, you will identify items to be changed. List these as steps or key pieces that your clinical practice guideline or systematic review suggests be in place to improve outcomes (i.e., indicators) in “process or indicator” column. In the “what data will be collected” column, identify how you will measure the change (e.g., audit, documentation in system, etc.). Under “plan for improvement,” take out each indicator and create plan by identifying 1) what the indicator is; 2) why it is key for improving outcomes; 3) operational definition; 4) numerator/denominator for ratio/percentage; 6); data collection method, and 7) goal for indicator (this is not the outcome; it is specific to indicator, a benchmark; for example, 100% compliance).

These are components that must completed as part of your final QI Report of Project. Together, these tasks directly relate to course objective “use data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality and safety of healthcare systems.” 

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*item found in QI Project Resources

You should include the following:

  • Submit completed Indicator Worksheet 
  • Example of how to do the tables: 

All patients on med-surg unit B with a catheter in place will have the type of catheter documented in their chart.

Numerator: Patients in unit B with a silver tipped catheter in place.

Denominator: All patients in unit B with a catheter in place.

The benchmark is 100% compliance, 0 CAUTIs 

The intervention table could look something like the following:






And so on…

Silver tipped catheter


Document type of catheter inserted in each patient

The evidence shows that the silver tipped catheters have less risk of infection

When patient is admitted to unit


Because there is a well-established, significant body of evidence demonstrating best practices for CAUTI prevention, we know that there are other interventions besides insertion of silver tipped catheter to be considered. Your case studies also contain nursing problems for which a well-established body of evidence exists in support of best practices. Do the above steps for each intervention that you identify.

QI Action plan

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