Improvement Project

Guidelines based on
FOCUS PDCA
 F- Find the problem

• Explain the data for the previous 4 to 6months

• Identify the issue from the data
• Make the problem statement
• Make definition of the problem statement
• Make the objective of the problem statement
 O- Organize the team
• Team includes
• Team leader: Department head
• Facilitators: -Quality Management & Patient Safety
coordinator
- Quality Management & Patient Safety department director
• Other members:
• Quality coordinator for the departments
• Involved department heads
 C- Clarify the current process

• Explain by step by step process of the actual situation

of the issue
• Should be as flow chart
 U- Uncover the root causes

• Identify the root causes- mention as fish bone

diagram
• Compare the differences from the current process
• Do the brain storming
FISH BONE DIAGRAM
 S- Select remedy
• Make the actions that prevent the occurrence of the
issue
• Prioritize the actions
 P- Plan
• Make the action plan as :
Remarks Due date Responsible Action
person
 D- Do the action

• Follow the action plan and make the progress report

• A pilot study to be done for the period of 2 months
and data will be monitored to detect the
effectiveness of the proposed remedies.
 C- Check the results
• Analyze the effectiveness of the action plan and do
the modifications if necessary
 A- Act
• Final action plan is followed after modification
• The team will keep continuous monitoring over the
process to maintain the gains and ensure
compliance to the modified process changes.
• Make the final report after the analysis