Fillable Printable Force Field Analysis: QI
Fillable Printable Force Field Analysis: QI
Force Field Analysis: QI
Public Health Solutions
QI Initiative
AIM WORKSHEET
NAME OF ORGANIZATION: Public Health Solutions District Health Department
Intends to: Revise and document the process for developing and maintaining policies and
procedures such that it reduces problems with access and credibility.
By (date): 9/30/2013
Who: All Staff
Because: Through the beta test for the PHAB accreditation process, the PHS major failings
included inadequate documentation of policies and procedures as well as overall departm ent
decision making. The availability of grant funds from NDHHS provided us with an opportunity
to engage in a quality improvement project. Of the many areas in which such a project could be
done, we chose to improve the policy and procedure process within the PHS.
Our goals include:
• Provide staff with a policy format
• Provide staff with a format for a policy manual: to plac e all policies/procedures in o n e
centralized location, for implementation of staff made policies/procedures, to be able to
change policies/procedures, for all employees to be able to access to policies/procedures,
and to enable an evaluation process of policies/procedures
• To establish a process for documentation of policies/procedures
• To reduce costs associated with new employee orientation/training
• To increase the access to resources on how to do a procedure
• To increase staff work efficiency
• To increase staff knowledge of public health policies
• To better services provided to population served
Fundamental Questions for Improvement
What are we trying to accomplish?
PHS is trying to accomplish a systematic process for developing, storing, maintaining currency
and accessing policies/procedures which enable accreditation and high quality department
operations
How will we know that a change is an improvement?
Through staff feedback
Staff Meetings
Director evaluation
BOH oversight
Meeting accreditation standards related to policies, procedures, and documentation
What changes can we make that will result in an improvement?
Organization of policies
How we train existing employees
How we orient new employees
Cut costs
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Public Health Solutions
QI Initiative
Improvement of quality of programs and services
Checklist of required/desired characteristics of process
9 Singular policy format
9 Centralized location of policies
9 Consistency
9 Ability to use for orientation of new staff
9 Use manual for training of current staff
9 Ability to have direction when employees are absent/leave
9 Policies are organized
9 Up-to-date legally
9 Able to protect staff legally through having the documentation of policies
9 Improvement of services provided
9 Improvement of job output
9 Evaluation
9 Decrease in time spent on staff instruction how to do something
9 Decrease in money spent on training
9
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Public Health Solutions
QI Initiative
FORCE-FIELD ANALYSIS: QI
POTENTIAL USES: QI PROCESS CHANGE
• To explore what is currently going right and what is going wrong
• To explore any opposition to change
• To understand the extent of opposition
• To identify pros and cons of options for change
Update policies, centralize policies in a manual, and use a singular
format for policy development
POSITIVE FORCES ( + ) NEGATIVE FORCES ( - )
Singular Format
Accessibility
Consistency
Protection
Legal
Orientation of New Staff
Training
Knowledge in staff absence
Location
Time Constraints
Staff willingness
People together
Contributions
Future development
Who follows through
Fall through cracks
Amount of work
Change to new process
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Public Health Solutions
QI Initiative
Affinity Chart QI
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Public Health Solutions
QI Initiative
Flow Chart of Current Process
These are drafted based upon
research of existing and
evidence based materials
The need for policies and
procedures is identified by staff
Depending on the level of
authority under which it will be
used, it is approved by me and
or the Board of Health
Draft is circulated to staff and
others as appropriate for
comment
Dates of drafts, revisions and
approvals are recorded
They are stored on the shared
drive for staff reference
Staff BOH
Director
Review of
Process/Policy
Format
S-Drive
QI:
Process
Change
involving
Policies
Effect?
Better Service
Evaluation
BOH
Director
Staff
Staff Com
p
ute
r
Front Office
S
-
Drive
Unintended Changes
Evaluation
Universal useBest Process
Tech P
r
oblems
Unintended Chan
g
es
# reache
d
E
valuation
Oversight
Evaluation
Oversight
Assessment
Follow Through
Time Commitment
Orientation
Accessibility
People within
District
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Public Health Solutions
QI Initiative
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Flow Chart of Changed Process
2) The need for the policy is
recognized, the authority for the
policy is designated (Board or
staff), and people affected by
the policy are identified for
involvement. Legal or program
references cited and
documented Policy drafted with
references and the people that
drafted policy. These are
drafted based upon research of
existing and evidence based
materials
1) The need for policies and
procedures is identified
by staff, BOH, or outside
evaluator.
3) Policy is vetted or reviewed
by those who will be involved in
implementing the policy.
Director review and
Legal or clinical review as
appropriate sign off by director
or Board as appropriate
Depending on the level of
authority under which it will be
used.
5) Whether exempt/non-exempt
consideration for attorney
review
4) All medical policies related to
medical treatment must have
medical consultant review and
those with potential legal impact
or compliance requirements
review as directed by director
6) Consult the director for who
else needs to review the policy
7) Draft is circulated to staff and
others as appropriate for
comment
8) Review by staff affected by
policy and changes made as
necessary with directors
a
pp
roval
9) Policy is sent to director and
a copy is saved on the author’s
computer.
10) Depending on the level of
authority under which it will be
used, it is approved by Director
and/or the BOH
11) Dates of drafts, revisions,
and approvals are recorded and
date of policy revision is added
to the policy review calendar
12) Director or designee adds
policy to restricted folder of all
policies
13) Director or designee adds
policy to manual in the front
office and on the shared folder
