Collect some baseline data on these measure(s) on a Run Chart, before instituting change(s). When the process is stable (all special causes removed or incorporated), establish control limits in a Control Chart.
Study the variation in the process. Beyond the run/control charts, utilize improvement tools such as Flowcharting, Cause-and-Effect Diagram, Key Drivers, and other tools which will guide needed changes.
Select a CHANGE that will likely cause improvement . This change can come from Tool Kits or what makes good sense to the QI team.
Begin to conduct TESTS OF CHANGE (PDSA CYCLES).Evaluate the impact of the CHANGE by collecting more data and recalculating the Mean and Control Limits.