Continual Quality Improvement Resource 1-5

Continual Quality Improvement Resource 1-5

In producing this resource file and Continual Quality Improvement policy information and templates Volunteer South West would like to thank and acknowledge the following people and organisations.
Kris Robertson as the original author of the CQI policy and whose work the CQI section of the file is based upon. Kirby Dotson ECU for her work reviewing the policy and to Lotterywest and the Department for Communities Volunteering Secretariat for funding the program and the resource file. (Download Resource File here).

Rebecca Parker
Community Development Program Coordinator Volunteer South West

The Quality Improvement Cycle  (download this document)
This cycle and diagram provides a framework for implementing Continual Quality Improvement (CQI) into your service and organisation. Each of the nine steps, guided by the Australian Quality Improvement Council, is outlined on the following pages with suggestions for how this could look in your organisation.


1.    Select the opportunity for improvement

Step one of using the CQI framework is ‘selecting an opportunity for improvement’ within your organisation.
Ideally, selection of opportunities should take place through on annual CQI planning process. That said, the annual plan does not exclude activities that arise as a result of staff, customer or community concerns which may occur anytime of the year. In an annual planning process priorities should be set using the Matrix (this can be found in the template section of this guide) for self assessment of the organisation and its services. The template offered within this guide is a directive only and may need adapting for your needs.

The first step of using the matrix is deciding the areas of assessment for your organisation. Volunteer South West use the matrix with four major areas for consideration; Leadership, Planning and Strategies, Data and Performance and Staff Focus which are appropriate areas for your organisation. Other areas may need to be considered for your service or organisation.
Please see the template MATRIX provided in the template section of this manual.
Using the matrix for self assessment will give you a clear result for selecting opportunities for improvement as part of the CQI.
Alternatively, if your organisation chooses not to adopt the ‘Matrix’ you may like to self assess your policies and practices through other means, such as identifying needs through team meetings etc, and then work your way through the 9 steps of the quality improvement cycle.

2.    Select the team

When you have self assessed you need to consider the next stage of ‘selecting the team’.
When selecting your team think about who could support your quality improvement activity from the agency, customer group or community. The team may consist of management committee members, staff members and volunteers. Things to consider for an organisation when it is choosing a CQI Team may include:

  • Relevance – Is this purely an agency activity or is it appropriate to involve consumers or the wider community? Is the CQI for the agency or is it program specific? This may determine your team members.
  • Commitment – Are staff and consumers involved committed to the process?
  • Training – Has adequate training been provided that will enable team members to participate fully?
  • Contribution – Can these people provide feedback and undertake tasks to achieve the desired outcomes?
  • Workload – Has the activity to be undertaken been factored into workloads (as opposed to has the person got the time) – QI needs to be seen as an integral facet of overall service delivery.
  • CQI coordinator – Is it appropriate to have a CQI coordinator as part of the team? This role may be taken on to ensure continual assessment is addressed at management level and changes implemented throughout the agency. Maybe this is a great new role for a volunteer within your agency?

3. Study the current situation

This stage involves the ‘team’ studying the specific issue(s) for improvement.
This process requires a whole team (either agency or program specific) commitment to identifying any perceived gaps, opportunities for improvement and to set priorities.
For example, there may be concerns about people wandering through the building. Who can
raise this as an issue and how do we decide the priority level. How many people are affected? Are there safety issues to consider (if so, risk should be seen as high therefore change priority is high)? Are there security issues to consider (again if so, risk should be seen as high).
Who will take responsibility for driving the process for change and who should be implementing the change?
The current situation should be described on the ‘Continuous Quality Improvement Record’ form with a template for this listed in the template section of this guide. This template is designed listing an issue on each form and keeping for your records for reviewing down the track. It is suggested a file is kept specifically for CQI with spare copies of templates for use as required.
After this step is completed the team should have a good understanding of the issue or issues involved, a vision for desired outcome and the steps needed to be implemented to get to the desired outcome.

4. Analyse the causes

Building on step 3, the team now analyses the causes of the situation or issue.
During this stage the team looks at the causes and contributors of the situation or issue being addressed by asking questions such as those below, and in fact you may add many of your own in team analysis of the cause.

  • What could be contributing to the current situation?
  • How is it that people can walk through the building without staff attending to them?
  • Is it a matter of prior practice?
  • It hasn’t really been seen as an issue until now?
  • Staff levels are inadequate?
  • A gatekeeping / intake process is not in place?

5. Develop a theory for improvement

After analysing the causes for the situation, the next step is to form a plan to implement changes in your organisation.
Using the ‘Continual Quality Improvement Record’ form again, formulate a plan for improvement. Questions the team could be asking themselves in order to achieve this would include:

  • What strategies will be employed to achieve the desired results?
  • Has our theory for improvement (desired outcome) demonstrated its effectiveness or has our activity resulted in further recommendations and needs further review?
  • Who will be responsible for implementing the changes needed?

List all the recommendations for action, with names against each recommendation for the implementation purposes.

6. Implement the Improvement

How to take the idea for improvement and turn it into action!
After a decision is made by the CQI team on how an issue should be addressed within your organisation, a trial period should be used to test if the theory for improvement will work!
Set a date now for the completion of the trial period and review of the changes, as we all know dates can blow out when there is no deadline! Pick a timeline appropriate to your improvement.

For example, in the case of people wandering through the building – four steps for improvement may be taken:

  1. Moving the admin desk to a better position in the building so all people coming in will be seen by admin staffUsing a gate keeping process by admin staff to screen all people coming into the centre, with the specific process being defined and followed.
  2. Using signage to direct people to the admin/reception area upon entry
  3. Keeping the toilets locked so people don’t ‘wander in’ to use them.

Example time period for changes – one month and then reassessed.

From this point the cycle continues. Each implemented action is monitored and evaluated for effectiveness. We do not simply implement change and consider there is no further action required. What works well for one program or situation may not work well for another, and remember all affected by the change have the right to raise concerns or make comments about new improvements – including clients or participants of your service.
One way to do this is by providing a ‘suggestions for improvement box’ somewhere handy and accessible to all in the building. Providing this (or feedback forms for program based activities) will allow customers and clients, staff and other key stakeholders to make comments and suggestions anonymously.

7. Study the results

Following the initial trial an evaluation is the next step of the process – studying the results.

Questions that should be asked at this stage include:

  • Did the changes make the effect we wanted? Did it work?
  • Do we have to modify the changes?
  • Has it improved the overall quality of the service delivery?
  • Do clients benefit from the changes?

A template review form is available to use for this section of the CQI process. A new template is required for each improvement, with attention being paid to the recommendations section of the template to ensure changes are both working well and benefitting the organisations clients, staff and volunteers. If further changes are required reassess changes and implement as in stages 5-7.

8. Standardise the improvement

The improvements and changes to your organization or delivery of service have worked!
Once the desired outcome is achieved we need to standardize the procedure. This may mean changes to current policy or new policy for your organisation.    The board of management for your organisation can use the recommendations provided to them from the CQI Team, knowing the quality improvement steps have been followed and implementations tested and trialled.
Information and resources regarding policy for specific areas and help for changes can be found free and accessible from many places. You may also like to explore the following websites for more info:

Our Community
Dept of Sport and Recreation
Learning Centre Link
Volunteering WA
Volunteer SW
Volunteering Australia
Philanthropy Australia

And remember…
At this point in time it is also important to revisit our ‘matrix’ of self-assessment to investigate the organisation’s level of achievement to date. Questions we may ask ourselves during this reassessment include:

  • Are we meeting best practice standards
  • Or do we see ourselves as within the ‘building’ phase

After completing the matrix for the second time, your organisation should have a clearer understanding of the issues which need addressing or could be enhanced within your organisation to improve best practice standards for your agency. Revisiting the matrix at this stage will also allow for reviewing the 9 step Quality Improvement Plan to ensure changes are making the intended benefits.

9. Establish a future plan

After the reassessment using the ‘matrix’ continue using the Quality Improvement Cycle. Develop a new plan, involving all your programs and agency areas and begin the 9 steps to Quality Improvement again.

As you can see this process is continual for providing best practice technique and providing the best possible services, programs and policy for your organisation through self assessed and tested means.
Incorporating CQI as a policy within your organisation will ensure the long term commitment of your organisation to improving your service and practices, whilst providing a mechanism for improvement in any areas assessed using the process.

In the next section of this resource toolkit please find templates for each of the nine steps of the continual quality improvement.