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Tool 2B: Quality Improvement Process

Preventing Falls in Hospitals: A Toolkit for Improving Quality of Care

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Background: This tool will help you and your team identify the extent to which you have the resources for quality improvement (QI) in your organization. The form was developed by the Turning Point Initiative to assess if an organization has the needed systems in place to improve quality and performance.

Reference: Turning Point Performance Management National Excellence Collaborative. Performance Management Self-Assessment Tool. Available at: 

How to use this tool: This tool should be filled out by the Implementation Team leader (or individual designated by the leader) in consultation with the QI department. The "you" refers to your organization as a whole. Check the box that most accurately describes your organization's current resources. If you find that your organization has fully operationalized QI processes, connect the fall prevention initiative with these existing processes. If some processes are missing, advocate for them to be put into place in the context of the fall prevention program.

Quality Improvement Process

Assessment QuestionNoSomewhatYes (fully operational)
1. Do you have a process(es) to improve quality or performance?   
Is an entity or person responsible for decisionmaking based on performance reports (e.g., top management team, governing or advisory board)   
Is there a regular timetable for your QI process?   
Are the steps in the process communicated?   
2. Are managers and employees evaluated for their performance improvement efforts (i.e., is performance improvement in their job descriptions)?   
3. Are performance reports used regularly for decisionmaking?   
4. Is performance information used to do the following? (check all that apply)
Determine areas for more analysis or evaluation.   
Set priorities and allocate/redirect resources.   
Inform policymakers of the observed or potential impact of decisions under their consideration.   
5. Do you have the capacity to take action to improve performance when needed?
Do you have processes to manage changes in policies, programs, or infrastructure?   
Do managers have the authority to make certain changes to improve performance?   
Do staff have the authority to make certain changes to improve performance?   
6. Does the organization regularly develop performance improvement or QI plans that specify timelines, actions, and responsible parties?   
7. Is there a process or mechanism to coordinate QI efforts among programs, divisions, or organizations that share the same performance targets?   
8. Is QI training available to managers and staff?   
9. Are personnel and financial resources allocated to your QI process?   

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Current as of January 2013
Internet Citation: Tool 2B: Quality Improvement Process: Preventing Falls in Hospitals: A Toolkit for Improving Quality of Care. January 2013. Agency for Healthcare Research and Quality, Rockville, MD.