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5. Receive report's from Quality Sub -Committee, if any. 6. Discuss changes needed to indicators. 7: Recommend the chartering of Quality Sub -Committee, if any. 8. Provide input to the QI Cornmittee,from the Strategic Plan, 9. Summarize action items identified at'this meeting. 10. Recommend training/educational ,needs. 11. Evaluabon'of the meeting. Section IV: Action to'Improve A. Once a need for improvement in performance has been identified by the TAG, Care Ambulance Service will be utilizing the FOCUS-PDSA model for performance improvement.'FOCUS-PDSA iinvolves the following steps: 1.. Find a process to improve _ the TAG will identify improvement needs: 2. Organize a team that knows the process — the QI Committee will form QI Sub-Committee(s) as needed and.review process documents.. 3. Clarify currentknowledge of the process - review indicator trends relevantto the process, collect, other information 4. Understand causes of process variation utilizing tools such as fishbone diagrams, .Pareto.analyses, etc. 5. Select process improvement to reduce or eliminate cause(s). 6. Plan — State objective of the test, make predictions, Develop plan to carry out the test (who, what where, when) 7. Do - Carry out the test, document problems and unexpected observations, begin analysis of the data 13. Study - Complete the analysis of the data, compare the test'data to predictions, and summarize what was learned 9. Act - What changes are to be institutionalized? :What will be the objective of the next cycle? What, if any, re-education or training is needed to effect the changes? Once a Performance Improvement Plan has been implemented, the fesults:of the improvement plan will be measured.. Changes to the system willbe standardized and/or integrated.'A plan for monitoring future activities will be established. B. During its Bi -Annual or other meetings, the QI Committee will identify` indicators that signal a need for improvement and make recommendations for chartering a QI �Sub- Committee, if needed. The QI Committee will select members and charter the Task_ Force with a specific objective for1mprovement. Each Task Force will use the; FOCUS-PDSA model to conduct improvement planning and prepare recommendations or a report for review by the QI Committee. The QLCommittee will modify or accept and implement recommendations of the QI Sub -Committee and prepare the report for distribution to the TAG. The QI Committee will -also disband the Quality Task Force at the appropriate time. Notify the Departments and Employees Manager of QAlQI .will put. together a department task force to plan and. implement the indicator under review. If the indicator is_ a clinician documentation improvement issue, 12 250-269