1. Title Presentation Date:

2. Comprehensive Plan Briefly describe your overall quality plan for your department. Describe what areas are important to assure you are delivering a high quality service to the patients you serve. What are your goals?

3. Measure – Indicators List the type of indicators you are measuring to improve quality & safety, improve efficiency, improve satisfaction, etc.

4. Analysis: Areas of Strength List indicators that you have met or exceeded your goal or benchmark Analyze the data – Don’t just report meeting or exceeding benchmark. Try to briefly describe factors that influence the results You may show tables, run charts, bar graphs, etc., of each indicator but that is not necessary Add additional slides if necessary

5. Analysis: Areas of opportunity Display your data for any areas that you have not met your target or goal. Analyze the data – Don’t just report not meeting benchmark. Try to briefly describe factors that influence the results It is up to you how you want to display your data. You may use tables, run charts, bar charts, etc. Add as many additional slides as needed to adequately display your data

6. Act What actions have you put in place to address the overall quality, safety, efficiency or satisfaction of your program? What are your roadblocks and impediments (Process, equipment, culture, etc.) How are you working through roadblocks? What help do you need?

7. Review Are the actions producing the results, any additional actions, are you measuring the right thing, what have you learned, should you continue to monitor? What are your expected improvement targets? By when? What are your plans to adapt if goal attainment falls short?