Read Me First Performance and Quality Improvement Tool Kit Welcome! This is version 1.02 of COA’s PQI Tool Kit. We hope that you find this information helpful for you and your organization. In order to make appropriate updates, we need your input to tell us what works, what doesn’t work and how we can improve it. We ask that you consider taking a very brief survey about the usefulness of the Tool Kit. It should take no more that 5-10 minutes and will guide the future development and revision of the PQI Tool Kit. Along with improvements, we are also seeking new ideas for tools that can be part of this kit. This initial version includes relatively simple tools to help organizations get off to a great start to PQI. We recognize that some organizations may benefit from more advanced PQI tools. They will appear in future versions, and with some feedback from our stakeholders, we hope to make it an even better resource. Taking the survey is a great way to provide feedback on the PQI Tool Kit. However, you can also email David Haynik @ dhaynik@coanet.org. All feedback is welcome, whether it is technical or related to content. To access the survey, please click the link or go to the website by typing in: http://coa.formassembly.com/232020 Originally released on September 21, 2016 Version 1.02: Revised on November 21, 2016 Revisions include the addition of Section 14 “Additional Guidance” which supports organizations who need to provide additional evidence of implementation to COA. Council on Accreditation The Performance and Quality Improvement Tool Kit Version 1.0 2 Revised on November 21 , 2016 A comprehensive guide to developing a performance and quality improvement program Section 1: Main Document Council on Accreditation www.COAnet.org Version 1.02; Revised November 21, 2016 1 Using the Table of Contents All of the tools and example documents are accessible through the table of contents below. These resources are only available through the PQI Tool Kit table of contents and cannot be obtained through the public Tool Search. Please use the direct links below to access the full list of resources. All tools and examples are available in PDF version only. Table of Contents Performance and Quality Improvement Tool Kit Table of Contents # Title Related Tool Example Tool 1 Introduction None None 2 Culture of Improvement None None 3 Stakeholder Involvement Stakeholder Chart Stakeholder Chart Graphic Completed Stakeholder Chart 4 PQI infrastructure PQI infrastructure Graphic None 5 Model of Change Model of Change Graphic None 6 Impro vement Plans Improvement Plan Plan (page 1) Do (page 2) Check and Act (page 3) Completed Improvement Plan Example 7 Program Indicators Program Indicators Worksheet Completed Program Indicators Worksheets 8 Logic Models Logic Model Goal Logic Model Actual Completed Logic Model example #1 for Programs Completed Logic Model example #2 for Administration 9 PQI Plan None See below 10 Sample PQI Plan Complete Infrastructure Graphic Sample PQI Plan 11 PQI Report None Sample PQI Report 12 Closing the Loop None None Council on Accreditation www.COAnet.org Version 1.02; Revised November 21, 2016 2 1 3 Conclusion & Next Steps None None 14 15 Bibliography None None 16 Print Version Download This PDF document includes all the resources listed above in the table of contents. The resources are organized into section within the PDF document. This allows users to print all resources at once instead of accessing the individual links above. (total of 127 pages; 12 MB) Additional Guidance PQI Evidence Worksheet Tracking Worksheet Mental Health Evidence Example Human Resources Evidence Example Financial Counseling Evidence Example Tracking Worksheet Example Council on Accreditation www.COAnet.org Version 1.02; Revised November 21, 2016 3 Welcome! This tool kit has been developed to assist organizations with implementing a comprehensive Performance and Quality Improvement (PQI) program. The tools that are included in this document are only intended to be guides. The Council on Accreditation does not expect organizations to use them in order to successfully achieve accreditation. However, the tools - when used appropriately and thoughtfully - will lead an organization, agency or program to a successful PQI system. The tools can be used exactly as they are stated, or they can be recreated to capture elements of your organization’s culture and climate. A strong Performance and Quality Improvement Program is intended to improve services to clients. COA’s PQI Standards expect that organizations will always be finding ways to improve their client care, regardless of how successful they currently are. A few notes about this guide: • The recommendations or guidance should not be interpreted as extensions of COA’s Performance and Quality Improvement Standards. For direct guidance on what is expected for successful accreditation in the area of PQI, please see the PQI Standards section for your relative Standards Edition. • The terms “organization,” “program,” and “agency” are typically used interchangeably unless otherwise noted. • The terms “PQI program” and “PQI system” are used interchangeably throughout this guide. Both terms are used to represent the activities, infrastructure, practices, procedures and other elements that relate to performance and quality improvement. • Use of these tools and resources are not a guarantee of accreditation. These resources simply assist organizations with documentation of implementation. While documentation is important, COA accreditation relies upon actual practice. For example, if your organization is utilizing all of the forms in this document, but is not conducting the activities, it will not succeed in achieving accreditation. • The use of this guide is not restricted to organizations seeking accreditation or currently accredited by COA. • Use of this guide is appropriate for large and small organizations. Organizations will have to contextualize the material to their specific needs. 1 Introduction Performance and Quality Improvement Tool Kit TIP: If you are new to developing a PQI system, start with the tools as-is. As you begin implementing the program, you will develop ways that work better for your organization. Those ideas hopefully take the form of new tools that you will create specifically for your organization. Council on Accreditation www.COAnet.org Version 1.02; Revised November 21, 2016 4 Defining Culture of Improvement Defining culture – regardless of context – can be a challenging feat. So how does COA define a culture of improvement? Looking at PQI 1 for the Private Edition Standards, we have some guidance (see below). Understanding that culture is unique to each organization, let’s take a broader look at what culture means and then relate it to improvement. According to The Social Work Dictionary, 6 th Edition 1 , culture is “the customs, habits, skills, technology, arts, values, ideology, science, and religious and political behavior of a group of people in a specific time period.” The group of people referring to the culture is easy: the organization and its stakeholders. To define the time period, we can describe that as present, with lessons from the past and plans for the future. Religious and political behavior may not be appropriate for this exercise, however, organizations can view themselves from the perspective of customs, habits, technology, arts, values, ideology and science. Some of the questions listed below, relating to the definition of culture, may be helpful in assessing if your organization has a culture of improvement. 1. What regular activities do you conduct that provide an opportunity for improvement? (habits and customs) 2. What talents do your staff members possess that contribute to improving practices? (skills) • Do you have staff who are skilled in staff development and morale building? • Are there team members who enjoy evaluation and planning? 3. What systems do you use to foster improvement? (technology) • What programs or software contribute to the organizations ability to measure, track, and aggregate data? 4. How do you use and encourage creativity to improve the services that your clients receive? (arts) • Are there creative means to recognize and encourage contributions to your organization? 1 Barker, R. L. (2003). The social work dictionary (6th ed.). Washington, DC: NASW Press. 2 . Culture of Improvement Performance and Quality Improvement Tool Kit Council on Accreditation www.COAnet.org Version 1.02; Revised November 21, 2016 5 • Do staff feel supported to mention ideas, even if they seem radical? 5. As an organization, how do your values relate to improvement? (values) • Does your mission statement or vision statement relate to improvement? • Is your organization willing to invest in people or ideas that may not have a direct monetary return? 6. How would you describe your organization’s model of change? (ideology) • Does your organization follow a Plan-Do-Check-Act cycle, Six Sigma, or other model of change? 7. What evidence do you use to demonstrate and support improvement? (science) • Are changes based upon evidence or gut feelings? • Are interventions provided because they are proven effective or because they “feel good”? As demonstrated above, defining a culture of improvement for any organization is not straight forward and can often be contextual. There are no “right” answers for the questions above; just an opportunity for critical thinking about how your organization values change. For that same reason, there is no tool or guide that will objectively change the culture of your organization. However, exploring the above questions with your leadership team and other key stakeholders of your organization may provide some insight. Council on Accreditation www.COAnet.org Version 1.02; Revised November 21, 2016 6 Identifying Your Stakeholders The first step to developing your organization’s PQI system is understanding who your stakeholders are and what role they play within your organization as well as in the improvement process. Below are steps to incorporating stakeholders into your PQI Plan and using the Stakeholder Chart Tool. Step 1: Make a list Organizations must identify who their stakeholders are. The list below will look familiar for most organizations. Some additional stakeholder groups that are not included in this list may be student interns, foster parents, government officials, military commanders, or law enforcement. You are encouraged to think critically and creatively about groups of individuals who have a stake in your organization and how to include them in your PQI system. 3 Stakeholder Involvement Performance and Quality Improvement Tool Kit Council on Accreditation www.COAnet.org Version 1.02; Revised November 21, 2016 7 Step 2: Categorize your list Using the Stakeholder Chart Tool, indicate each category of stakeholder that you would like to include in your PQI system. List them in the “Stakeholder Group” box. You can be as detailed as necessary for the reader to gain a full understanding of who has a stake in your organization’s practices. Step 3: Describe each group Once you have outlined each stakeholder group, it is important to briefly describe that group and how they are unique to your organization. For example, all organizations are going to identify “clients” as a stakeholder group. What makes your clients unique? What services do they receive? Perhaps the clients at your organization receive mental health services and typically come from lower socioeconomic households. Or, maybe your organization works with many individuals who have recently been incarcerated and are struggling to find stability in society. They may not be identified as clients at all, and your organization uses the term “consumer” or “customer.” Look at the example below and note that the description is very brief, yet provides the reader with some context. Step 4: What data does the stakeholder provider? To further solidify the readers understanding of how the stakeholder is involved in the improvement process, the next step involves documenting what data the stakeholder provides to the organization. Every stakeholder should be providing some type of data to the organization whether formal or informal. In the same example above, you will notice that the clients in this example provide satisfaction data (formal) through an annual survey, as well as comment cards that are available in the common areas. Clients can even provide informal data through organization employees by simply telling them about how things can improve. When the data is informal, it’s the responsibility of the recipient of the data (the employee) to communicate the data to appropriate staff at the organization. Notice the feedback loop. Data comes from clients and then the information is given back in the form of improvement, summaries and reports. Council on Accreditation www.COAnet.org Version 1.02; Revised November 21, 2016 8 Step 5: What information do you provide to the stakeholder group? Step five of involving stakeholders in the PQI system is “closing the loop.” This theme will be repeated throughout the PQI Tool Kit because it is an important concept and an area where many organizations struggle. Section 12 discusses the concept in greater detail. Closing the loop involves follow-through and follow-up. It reinforces buy-in and ensures that organizations do not simply collect data, but they actually do something with it. For this context, closing the loop means providing information back to the stakeholder. The final box that is included on the Stakeholder Chart asks for how the organization returns information to the stakeholder, as it relates to the data that they initially provided. For example, if clients regularly complete satisfaction surveys, but results are never shared, they may think that it is not worth their time to complete the surveys. By closing the loop and providing clients with a summarized version of the survey results, clients may be more apt to think that the organization is doing something with the data. Furthermore, if an organization shares with clients how they made a change based upon the feedback, clients may feel encouraged to be a part of the organization. In the example above, the organization returns information to the clients by making sure that the PQI Quarterly Report is available to clients and includes information on the areas of measurement that the clients participated in. The Stakeholder Chart is a simple document to help organizations gather their thoughts and practices about stakeholder involvement in one place. Descriptions are limited to simple summaries; the actual evidence would be visible in copies of reports or correspondence that is provided to stakeholders. TIP: It might be helpful to conduct this as a brainstorming activity. This will ensure that you do not leave any group out. Once they are all identified, they can be categorized, as appropriate, then placed in the Stakeholder Chart. Council on Accreditation www.COAnet.org Version 1.02; Revised November 21, 2016 9 Establishing and Maintaining the Capacity to Have a PQI system Every PQI infrastructure is different. It is up to the organization to develop a system that is appropriate to the organization size, availability of resources, and complexity of services. However, there are common elements that make up all successful PQI programs. Step 1: Identify a coordinator The Coordinator can be defined as a point person who is responsible for overseeing the PQI process, organizing efforts and closing open PQI loops (see Section 12) throughout the organization. Some organizations may have a full-time person solely dedicated to this role. Others may have a fraction of a full time person manage the responsibilities of the PQI system. There are also organizations that have an entire department, with a Director. Regardless, this person or persons initially receives the data from stakeholders in the form of surveys, monthly reports, outcomes, dollar amounts, budgets, spreadsheets and many countless other mediums. The Coordinator is typically the collector, sorter and processor of data for the organization. Using existing systems, whether advanced software or simple spreadsheets and databases, the Coordinator has the capacity to organize the information and move it to the next component of the PQI infrastructure in a manner that is accurate, understandable and digestible. Step 2: Develop a PQI committee The PQI Committee works in close collaboration with the PQI Coordinator. Often chaired by the PQI Coordinator, the PQI Committee is a group of employees within the organization from all levels. The Committee has the responsibility of reviewing the information that is provided by the Coordinator from their unique perspective in the organization. For example, direct service staff members are able to view the data and understand how the data relates to the work that they conduct with their clients. The leadership of the organization may have a more macro-level view of the information. Administrative staff are often able to provide an angle on the data that others may simply look past. All perspectives are valuable and provide an opportunity to improve. Some common objectives of PQI Committees include the following: • Review data received across the organization. 4 PQI I nfrastructure Performance and Quality Improvement Tool Kit TIP: Don’t forget to include PQI responsibilities in job descriptions for appropriate individuals. Specifically, if you have a full time employee only with only a portion of their time dedicated to PQI. You will want to reflect those duties in their job description. You may want to even consider adding some duties to the job descriptions of those who serve on the PQI Committee. Council on Accreditation www.COAnet.org Version 1.02; Revised November 21, 2016 10 • Identify and analyze trends in the data. • Brainstorm opportunities for improvement and change. • Recognize staff and stakeholders who have made contributions to positive change in the organization. • Generate excitement and energy around the PQI system in the organization. • Produce reports or dashboards that display the information that they have collected. • Develop improvement plans to address areas of concern or for general projects that support the work. Although PQI committees are typically comprised of staff members, some organizations have been successful at including other stakeholders, such as volunteers, clients, and board members. These organizations demonstrate an ability and willingness to go above and beyond in establishing a culture that values change. Step 3: Define the communication with leadership Organizations already have leadership, but it’s the relationship to the PQI infrastructure that matters in this context. It is expected that the PQI Coordinator has close communication with the leadership group, if the coordinator is not already a member of the leadership at the organization. The leadership’s role within the organization is to support PQI initiatives by: • Allocating appropriate resources to the PQI system. • Carefully considering requests and improvement plans that are developed within the PQI Committee. • Participating in PQI activities, as appropriate. • Supporting and encouraging a culture of excellence and continual improvement. • Inviting and involving external stakeholders in the improvement process, as appropriate. It often helps to provide a diagram or infographic of the PQI structure to help readers understand how information flows. On the following page is an example that organizations can use or adapt to meet their specific needs. This graphic is also available for download. To walk through this graphic, let’s start with the stakeholders on the left side. They provide the data, which you will notice is on the right side of the stakeholders with arrows pointing to the right. The data they provide is collected, reviewed and aggregated by the PQI Coordinator. For large organizations, a team will be completing these tasks. For small organizations, the director of a program or an administrative staff member may be completing these tasks. Once the data is in a more digestible format, it is delivered to the PQI Committee. You’ll see a red arrow that points down, to the committee. There the committee processes the information, identifies trends, areas of concern and improvement plans. That information is provided back to the PQI Coordinator, as demonstrated by another red arrow that points up. This exchange of information may happen multiple times or on an ongoing basis. That same back-and-forth may also occur with the leadership of the organization and the PQI Coordinator. The leadership will want to know the trends, concerns, and improvement plans to provide approval or to just have an awareness. Whatever happens with the data, whether it’s just placed in a report or is the catalyst for an improvement plan, the results and progress are given back to the stakeholders. This flow is demonstrated by the large curved arrow pointing from the PQI Coordinator to the stakeholders on the left. The process is typically ongoing. Council on Accreditation www.COAnet.org Version 1.02; Revised November 21, 2016 11 This diagram is explained on the previous page. It is intended to serve as a model for organizations and can be copied or altered as needed. If copied, be sure to contextualize the model to fit your organization’s specific needs. Identify the flow of information, the roles, committee structure, reporting mechanisms, etc. Council on Accreditation www.COAnet.org Version 1.02; Revised November 21, 2016 12 Describing Your Model of Change When reviewing the various data that is processed through the PQI infrastructure, there will be trends that are identified as needing to change. To demonstrate that your organization implements change in a thoughtful manner, it is necessary to identify a model of change that PQI initiatives are implemented through. Remember, not all data or information needs to go through a model of change. Only data that indicates the need for change requires the use of a model of change. Step 1: Identify a model of change that works for your organization A common model of change that many organizations use, both formally and informally, is the Plan-Do-Check-Act (PDCA) cycle. Some organizations may recognize this by different names such as Plan-Do-Study-Act, Plan-Do-Check-Adjust or the Deming Circle. Regardless of the name used, the concept is the same. It is an organized way to view and structure improvement initiatives. We will provide additional information about the use of this model further in this section. Also, it is important to be aware of other models that might be a better fit for your organization. Below are some examples and links to where you can find additional information: (The hyperlinks are to Mind Tools Inc. There are many resources available online for additional models of change for organizations. 2 The Council on Accreditation does not endorse Mind Tools Inc., nor do they have a financial or business arrangement). • Lewin’s Change Management Model (more information available on www.mindtools.com) • McKinsey 7-S Model (more information available on www.mindtools.com) • Kotter’s 8-Step Model (more information available on www.mindtools.com) • Six Sigma (more information available on www.mindtools.com) Step 2: Identify when change is needed • Every organization will have different ideas about what requires change. As stated in the beginning of this section, not everything that is reported by stakeholders is in need of change; in fact, most information will likely get aggregated and reported back with some additional context. For example, when monthly numbers are collected for Program A, do those numbers need to go through a model of change? No, unless they identify a trend that needs to be addressed. Perhaps they have decreased over the past 4 months, or they have remained the same even though a new staff member has been added to the team. It is the PQI Committee and the PQI Coordinator’s responsibility to identify when the data is actually information that requires change. Otherwise, the information will be part of a greater report and returned to the stakeholder groups with no action taken. 2 Mind Tools: Online Management, Leadership and Career Training. (n.d.). Retrieved September 16, 2016, from https://www.mindtools.com/ 5 Model of Change Performance and Quality Improvement Tool Kit Council on Accreditation www.COAnet.org Version 1.02; Revised November 21, 2016 13 • When change is identified, that is when the model of change is applied. The following section will provide a method for implementing and documenting change using the PDCA model. Step 3: Implement your model of change For the purposes of this document, it will be assumed that you and your organization are selecting the Plan, Do, Check, Act Cycle. 3 4 It is very common and very simple. If your organization chooses another model, please keep that model in mind when PDCA is referenced. Implementing that model of change, specifically using the PDCA cycle often comes down to documentation and being more thoughtful in the change process. The first task is understanding the model and how its use will impact the organization. Most often, graphics are used to demonstrate how the model is used at organizations. The PDCA model is simple to demonstrate through the use of graphics, yet it is also flexible enough to adapt to a multitude of situations and contexts. Below, you will find a simple graphic that helps users visualize how the process works. In fact, many readers may see this cycle and recognize that this is already the process that they use to produce change. It’s intuitive, which is another reason for its common use. 3 Moen, R., & Norman, C. (2006, April). Evolution of the PDCA Cycle. Retrieved September 16, 2016, from http://pkpinc.com/files/NA01MoenNormanFullpaper.pdf 4 PDCA. (n.d.). Retrieved September 16, 2016, from https://en.wikipedia.org/wiki/PDCA Council on Accreditation www.COAnet.org Version 1.02; Revised November 21, 2016 14 Of course, understanding the model of change goes deeper than looking at a graphic. As part of implementing a model of change comes the responsibility of educating organizational staff on its purpose and use. Below is a brief outline of each step in the cycle. PLAN During this phase of the Plan, Do, Check, Act Cycle, preparations are made in order to effectively make the change. This may involve gathering additional data and information to support the need for the change. If collaboration is required for the potential change, the plan phase may involve committee meetings and the development of proposals and work plans. If it is a smaller change, the planning may simply involve brainstorming about the possible implications to all aspects of the organization. Near the end of the planning phase, a work plan is developed to identify specific objectives, responsibilities and indicators of success. DO During the Do phase, the work plan or proposal is acted upon. There should be a mechanism in place for follow up and regular reporting on the status CHECK This phase allows for the work to be assessed, after an appropriate period of time has passed. Those involved review the process and identify the positive aspects of the change and any negative aspects of the change. The group or individual responsible for the change compares the actual results to the expected results. Deviation from the expected result is noted. An assessment of how the change impacts the rest of the organization should also take place. Most importantly, it needs to be determined whether the change was successful or unsuccessful. Even if unsuccessful, the change still has some positive impact, even if that impact is simply a better understanding of the situation. ACT Once the organization has determined if the change was an improvement from the baseline, or prior status, then that change is accepted as part of current practice. The organization maintains the new practice or change. The organization will need to integrate this change into their current culture and environment. If the change was not a positive one, then they may return to the baseline way of operating. The organization, group or individual can start another Plan phase of the PDCA cycle to determine a different method to address the concern. A detail that is easy to miss in the above model of change graphic is the uphill climb, also known as progress. Improvement cycles should always be occurring; organizations can benefit the most from a PQI system when there is always at least one improvement plan being currently implemented. As stated earlier, even when improvement plans do not work as expected, lessons are learned, the organization grows and progress ensues. As per the visual, when there are no improvement plans in progress, the wheel stops spinning and rolls back instead of moving forward. Council on Accreditation www.COAnet.org Version 1.02; Revised November 21, 2016 15 When change is needed As discussed in the previous section, some information is indicative of change. With the Plan, Do, Check and Act cycle as the framework, this section will go through using improvement plans to implement the change. The links below are tools designed to guide organizations through improvement initiatives using the PDCA cycle and documenting it appropriately. Maintaining good records of improvement initiatives - whether successful or not - provides ideal demonstration that change happens and lessons are learned. These worksheets are designed to guide organizations in using improvement plans, consistent with COA’s PQI Standards, specifically PQI 7.01 (Private & Canadian Editions). Page One of the Improvement Plan: Plan Page Two of the Improvement Plan: Do Page Three of the Improvement Plan: Check & Act Step 1: Identify the need to implement an Improvement Plan Improvement plans can be used for a variety of reasons, including: 1. When data collected through an organization’s PQI program indicates that there is an area of concern. 2. For administrative functions that are in need of increased efficiencies. 3. To correct under-performing programs or sites. 4. To provide guidance to staff members who demonstrate performance that is not meeting expectations. 5. For successful programs that an organization would like to further develop. 6. To increase the involvement of the governing body. These are just some examples of how Improvement Plans can be used; however the number of opportunities for their use is unlimited. It is important to talk with staff and stakeholders about the role of Improvement Plans within the organization. While they can sometimes be used to document and improve undesirable behaviors or performance, they are not intended to be punitive. On the contrary, by programs/departments always having a working Improvement Plan in place, it is a demonstration that the organization has a culture of improvement and values change. By reviewing data collected through the PQI program, looking at surveys, talking with staff or meeting with members of the governing body, an organization should be able to identify something that can use improvement. It’s important to have data to support the need for change. If the data is not present, but an organization still recognizes a need for 6 Improvement Plans Performance and Quality Improvement Tool Kit Council on Accreditation www.COAnet.org Version 1.02; Revised November 21, 2016 16 change based on anecdotal information, gathering data to support the change can be part of the planning process. In summary, use data to identify and support the change. In PQI 7.01, the interpretation discusses the use of corrective action plans and Improvement Plans. Corrective action plans are used in response to an identified deficiency and are often more punitive. Improvement plans are more proactive in nature; however, for the sake of simplicity, an improvement plan can also be used as a corrective action plan. If this is the case, it will be important to identify the reason for the plan and the consequences of not successfully completing it. Step 2: Assign a responsible person or persons Now that the opportunity for improvement has been identified, the organization will identify who is responsible for developing the improvement plan and ensuring that the appropriate staff are on track with achieving the objectives as listed in the plan. For many organizations, the individual identified as the PQI Coordinator may be the responsible person for developing and tracking improvement plans. Perhaps for other organizations, each Director and Manager is responsible for creating plans for their respective team or program. Either method is appropriate, as long as there is someone who develops the plans, maintains them, monitors them and provides follow-up when necessary. Let’s turn to the first page of the Improvement Plan document. On the following page, a view of the form is available. Step 3: Plan Complete the Plan form of the Improvement Plan. On this form, you will be asked the following questions: 1. Briefly describe the opportunity for improvement and what information supports this need. 2. Describe the success indicators; how will you know that the proposed actions were effective? 3. What data supports the need for this change? TIP: Start small! If this is a new process for the organization, start with a simple Improvement Plan. When it is fully followed-through and successful, it will contribute to developing buy-in with staff who may have felt apprehensive. Also, it helps to not have the first Improvement Plan as a result of the need for corrective action. Use an opportunity that is proactive and has the support of the organization’s staff. Council on Accreditation www.COAnet.org Version 1.02; Revised November 21, 2016 17 In the example above, notice that the situation is described in detail. It provides you with an overview of the opportunity for improvement and what the organization did to gather more data. Because this is an optional form – a tool – the exact language of what to include is up to you. Complete this information in a manner that will be beneficial not just to COA, but also to your organization and team. Step 4: Develop the work plan Complete page 2 of the Improvement Plan by detailing the specific action items of the initiative. There are six separate categories that organizations should complete: action item, person responsible, cost and resources needed, target completion date, actual completion date and success indicators/comments. Organizations will find more TIP: While organizations that use this tool will most likely use it to meet COA standards or to respond to COA’s Commission Department, COA wants this to be a helpful tool for organizations , not COA If adjustments are needed or if organizations want to create a similar form, but tailored to their unique needs, they are encouraged to do so.