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Forming the Local Quality Improvement Team

Convening your quality improvement team is a critical first step to success. Typically the ideal core team membership will include 5-8 multidisciplinary members who “own” critical components or are direct stakeholders in the process or processes involved in the improvement project. Suggested team composition includes Project Champion, Physician Champion, Nursing Champion, Unit Medical Director, Unit Nursing Management, Front Line Nursing, Nursing Educators, Nurse Practitioners, Midwives, Physicians, Pharmacists, Patient/Family Members, Patient Safety Officer, Quality Improvement Office, Joint Commission Data Extraction and Reporting Office, CPOE and IT/EMR Implementation Experts. (Other team experts will vary depending on project but might include:  Pharmacy, Anesthesia provider, OR leader, Lactation, PT, etc. )

Team expectations include:

  1. Create a core team, and designate a Day to Day Leader (Key Contact) for day-to-day management of the project.  Each team will need a Physician and Nursing Champion as well as Patient/Family member.
  2. Obtain local executive support for the project and schedule frequent Senior Leader (project Sponsor) updates on project progress, challenges and opportunities.
  3. Obtain local review and approval for QI project initiation and continuation in compliance with local guidelines and policies (e.g. IRB, Quality Council, Practice Board etc.) if required.
  4. Conduct frequent (consider weekly, but at least monthly) team meetings.
  5. Keep up to date on data collection and resolution of potential data entry errors in the AIM system.
  6. Implement changes using a PDSA methodology – ask the 3 questions, then PDSA.
  7. Participate in all TIPQC webinars, and regional and State meetings by sharing your team’s reports and lessons learned from your PDSA implementation of Potentially Better Practices in the Project Toolkit.  Everyone teaches, everyone learns!