SAMPLE POLICY WORK

• Do: Implement the plan on a small scale to test its effectiveness. • Study: Analyze results through data collected and assess whether the goals were achieved. • Act: Based on the findings, adjust the process and institutionalize successful strategies.

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Implementation of Corrective Actions:

– Initiate corrective actions as per the approved action plans. – Ensure that the improvements are integrated into day-to ‑ day operations across all relevant departments. – Communication tools, such as internal bulletins and digital dashboards, disseminate updates to all staff. • Monitoring of Effectiveness: – Following the implementation, continuously monitor the effectiveness of corrective actions using the same KPIs and audit tools. – If desired outcomes are not met, reassess and modify the action plan through iterative cycles. • Documentation and Reporting: – Record the entire improvement process from planning to outcome in a Quality Improvement Log. – Reports are prepared at the end of each PDSA cycle, summarizing the interventions taken and their impact on service quality. – These reports are reviewed by executive leadership and shared with all relevant departments to foster transparency and collective learning.

d. Roles and Responsibilities

Effective execution of the Quality Improvement Plan depends on clear delineation of responsibilities across the organization:

Executive Leadership • Responsibilities:

– Provide overall strategic direction and secure resources for quality improvement initiatives. – Approve all major QI projects and ensure alignment with the agency’s mission and regulatory mandates. – Review quarterly quality reports and initiate high-level corrective actions when necessary. • Key Actions:

– Lead executive QI meetings and incorporate QI into strategic planning sessions.