Preventing Falls in Hospitals

Tool 2B: Quality Improvement Process

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Background: This tool was originally part of the Turning Point Initiative and was updated in 2012 as part of the Public Health Performance Management System Framework. It can be used to assess if an organization has the needed systems in place to improve quality and performance.

Reference: Public Health Performance Management System Framework. 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. 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

In public health, the use of a deliberate and defined improvement process, such as Plan-Do-Check-Act, that focuses on activities that address community needs and population health improvement. QI refers to a continuous and ongoing effort to achieve measurable improvements in the efficiency, effectiveness, performance, accountability, outcomes, and other indicators of quality in services or processes which achieve equity and improve the health of the community.

Assessment Question Never / Almost Never Sometimes Always / Almost Always Note details or comments mentioned during the assessment
1. One or more processes exist to improve quality or performance        
   A. There is an entity or person responsible for decisionmaking based on performance reports (e.g., top management team, governing or advisory board)        
   B. There is a regular timetable for QI processes        
   C. The steps in the QI process are effectively communicated        
2. Managers and employees are evaluated for their performance improvement efforts (i.e., performance improvement is in employees’ job descriptions and/or annual reviews)        
3. Performance reports are used regularly for decisionmaking        
4. Performance data are used to do the following (check all that apply)        
   A. Determine areas for more analysis or evaluation        
   B. Set priorities and allocate/redirect resources        
   C. Inform policy makers of the observed or potential impact of decisions under their consideration        
   D. Implement QI projects        
   E. Make changes to improve performance and outcomes        
   F. Improve performance        
5. The group (program, organization, or system) has the capacity to take action to improve performance when needed        
   A. Processes exist to manage changes in policies, programs, or infrastructure        
   B. Managers have the authority to make certain changes to improve performance        
   C. Staff has the authority to make certain changes to improve performance        
6. The organization regularly develops performance improvement or QI plans that specify timelines, actions, and responsible partiesstrong>        
7. There is a process or mechanism to coordinate QI efforts among groups that share the same performance targets        
8. QI training is available to managers and staff        
9. Personnel and financial resources are allocated to the organization’s QI process (e.g., a QI office exists, lead QI staff is appointed)        
10. QI is practiced widely in the program, organization, or system        

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Page last reviewed January 2016
Page originally created January 2013
Internet Citation: Tool 2B: Quality Improvement Process. Content last reviewed January 2016. Agency for Healthcare Research and Quality, Rockville, MD.