School of Nursing

Saint Louis University

Worksheets on the following aspects of a quality improvement project:

Worksheet A Identifying Areas for Improvement

Worksheet B Forming a Team Worksheet C
Team Meeting Notes Worksheet D Goal Setting
Worksheet E Current Process Analysis
Worksheet F Root-cause Analysis Worksheet G
Fishbone Diagram Worksheet H Process
Improvement Plan Worksheet I Implementation
Strategy Worksheet J Pilot-Testing Worksheet K
Pilot-Test Evaluation Worksheet L Ongoing
Monitoring

Engelbert C. Manuel, RN, MM-IR/ Quality Improvement Worksheets/ 1st sem/2016/v.1

 School of Nursing
Saint Louis University

WORKSHEET A:
Identifying Areas for Improvement

1. Select one question, issue, or perceived problem to examine further. (You may use the
institutions checklist, policy or manual of operating procedures if applicable)

Question: a.) Are the significant others aware of the Guidelines in Safe Handling of
Hazardous Chemotherapy Drugs?

b.) Are the patients aware of the food they are allowed to eat for their specific
diet (i.e. soft diet, clear liquid diet, diet as tolerated etc.)

2. Randomly select five (or more) records (or other data sources, depending on the question)
to review. Determine a question that will be asked:
Question:
a.) Are the significant others aware of the Guidelines in Safe Handling of Hazardous
Chemotherapy Drugs?

1) Do significant others know how to clean up spilled chemotherapy drugs?

2) Do significant others know the importance of using protective gowns, masks when
visiting their loved ones who are having chemotherapy drugs
3)
4)

b.) Are the patients aware of the food they are allowed to eat for their specific diet (i.e. soft diet,
clear liquid diet, diet as tolerated etc.)

1) Do patients know the examples of food they could consume in their required diet?

3. Collect data:
Data can help you separate what you think is happening from what is really happening.
Data will establish a baseline so you can measure improvement.
Data will help you avoid putting solutions in place that will not solve the problem.

Record findings here:

Case a Yes No
1. We have observed that the
significant others are not
oriented when handling their
loved ones who are having
chemotherapy. Some dont
wear their masks.
2. Some significant others dont
know how to manage spills.
Case b Yes No
1. Some patients miss their
scheduled procedures due to
 the fact that they did not
follow prescribed diet
2. Some significant other s buy
food for the patient that are
not allowed
3. The need to give patients a
list of food for them not to
have a limited choice when
they get hungry.

4. If data is not readily available from medical records, what sources did you use to collect
your data, and what at steps did you take to collect this data?
We had our palliative ward duty last august 11-12 and august 17-19 and we have observed such
signs.

According to Rowe et. al 2009 posters are used as a form of transferring knowledge and that it
needs a greater flexibility in their design and dissemination in order for posters to be effective in
disseminating valuable information.
 School of Nursing
Saint Louis University

WORKSHEET B:
Forming a Team

A team is identified as a small number of people with complimentary skills that are
committed to a common purpose and hold themselves mutually accountable.
A. Identify team members who will work on this project
a. Teams should have 3-4 members that will plan, implement, and evaluate their work.
b. If you already have a team, make sure that they include appropriate members related
to the topic chosen for improvement.
c. Involve staff from different shifts, units and departments.

Name Position Alternates:

CAPUYAN, Josepha Adviser

BALLESTEROS, Rhedge Member
NERONA, Edri Member
TURAS, Vicente Member
DE GUZMAN, Jeremy Member
DIMACJE, Chaya Leader
DUCUSIN, Lyca Member
EL-I, Rio Member
IGNACIO, Christine Member
LAZO, Nickha Member
SOLIS, Genette Member
TIENG, Lou Member

B. Identify time and place for short weekly meetings (no more than 30 minutes)
a. Team does not have to meet at same time and place each week.
b. Meetings can be more or less frequent as needed. Post meeting schedule in a
place accessible to all team members, where appropriate:

Meeting # Date Time Place

1 08/19/17 2: 00pm Palliative ward
2 09/22/17 3:30 pm Student Dorm
3 09/27/17 2:00pm SLU-SON Faculty Room
4 09/30/17 2:00pm Student Dorm
 School of Nursing
Saint Louis University

WORKSHEET C:
Team Meeting Notes

Team Meeting Notes

Team Members:
Team Start Date:
Team Goal: ______

Date Main points of discussion Next step Person responsible Due by:

To plan a strategy to Every member

We were able to identify and promote awareness should search for an
discuss a problem which is on on spill RRL regarding the
spill management i.e. management. RRLs management of
8/19and22 chemotherapy drugs needed. chemotherapy drugs
To plan a strategy to
promote in Safe
We were able to identify a more Handling of
specific topic which is Hazardous
Guidelines in Safe Handling of Chemotherapy
8//27and30 Hazardous Chemotherapy Drugs Drugs via posters

Engelbert C. Manuel, RN, MM-IR/ Quality Improvement Worksheets/ 1st sem/2016/v.1

School of Nursing
Saint Louis University

WORKSHEET D:
Goal Setting

A goal is a clear statement of the intended improvement and how it is to be measured.

Use your goal statement to stay focused, to establish boundaries for what is and is not
included in your teams work.
Post your goal where it is visible at every team meeting (or recite this before start of meeting)

Write a goal for improvement:

Your goal should:
o Answer the question, What do you want to
accomplish? o Be measurable.
o Be short so that everyone can remember it.
Does not include how you will achieve goal.
o May include a beginning and end date.
o Your goal may be taken directly from an item on the institutions checklists. Example:
Increase number of care plans that provide for medication on a regular schedule (e.g.,
around the clock), not just PRN, (for patients with daily pain) from 50% to 75% over
the next two months.

STATE YOUR GOAL/AIM

To promote proper handling of chemotherapy drugs to significant others such as
spill management, handling patients who are going under chemotherapy (i.e. sweat
of patients,
Flushing the toilet 2x, body fluids of patients) by using poster.