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 student nurses aware of the usage of the Surgical Safety Checklist inside
the operating room?
b. Are the student nurses utilizing the Surgical Safety Checklist?

2. Randomly select five (or more) records (or other data sources, depending on the
question) to review. Determine a question that will be asked:
a. Student nurses of Saint Louis University- School of Nursing
Questions:
a. Are you aware of the Surgical Safety Checklist?
b. Are you implementing the Surgical Safety Checklist?
c. Are student nurses responsible for the implementation of the Surgical Safety
Checklist?
b. Clinical Instructors having their duties inside the operating room
a. Did you orient the usage of the Surgical Safety Checklist to your students during
your OR duties?
b. Are you letting your students implement/use the Surgical Safety Checklist?
c. Are your students aware of the Surgical Safety Checklist?
d. Are your students confident enough to execute the Surgical Safety Checklist
without your supervision?

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:

YES NO
CASE 1
a. Are you aware of the Surgical Safety Checklist? /
b. Are you implementing the Surgical Safety Checklist? /
c. Are student nurses responsible for the implementation of the /
Surgical Safety Checklist?
CASE 2
a. Did you orient the usage of the Surgical Safety Checklist to your /
students during your OR duties?
b. Are you letting your students implement/use the Surgical Safety /
Checklist?
c. Are your students aware of the Surgical Safety Checklist? /
d. Are your students confident enough to execute the Surgical /
Safety Checklist without your supervision?

4. If data is not readily available from medical records, what sources did you use to
collect your data and what are the steps did you take to collect this data?
a. Questionnaires will be used to assess if the students nurses are
knowledgeable of the Surgical Safety Checklist.
b. We will be laminating a small copy of the Surgical Safety Checklist by the
World Health Organization in order to implement the use of it.
 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

BAUTISTA, Elizabeth Adviser

BALLESTEROS, Rhedge Member

NERONA, Edri Member

TURAS, Vicente Member

DE GUZMAN, Jeremy Member

DIMACJE, Chaya Member

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
5 11/27/17 3:00pm Computer Shop
6 11/29/17 3:00pm SLU Silang Building S503
7 12/03/17 4:00pm Student Dorm
 School of Nursing
Saint Louis University
WORKSHEET C:
Team Meeting Notes

Team Meeting Notes

Team Members: 11
Team Start Date: 8/19
Team Goal: Finish all worksheets and search various RRLs and pass all requirements within the
semester in order to graduate on time!!!!!!!!!!!!!!!!!

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

We were able to identify and To plan a Every member

8/19/17
discuss a problem which is on strategy to promote should search for an
and 9/22/17
spill management i.e. awareness on spill RRL regarding the
9/22/17
chemotherapy drugs management. RRLs management of
needed. chemotherapy drugs
We were able to identify a
To plan a Every member
more specific topic which is
strategy to promote should search for an
9/27and30/ awareness of watchers of patients
in Safe Handling of RRL regarding the 9/30/17
17 in the Guidelines in Safe
Hazardous new topic and finish
Handling of Hazardous
Chemotherapy worksheets A to C
Chemotherapy Drugs
Drugs via posters
A new topic was identified
because of unavailability of the To plan a Every member
topic. Another group had the strategy to assess should search for
topic and was already approved patients satisfaction RRLs about the new
by DH 4. regarding the topic and have a
performances of group discussion on 11/28/17
11/27/17
Our group had identified student nurses how to implement
another topic, which was during their duties. the topic.
satisfaction of patients with
regards to the student nurses
performances and care during
their duties.

We went to DH4 to have our To plan a strategy to Every member has a

new topic be approved or assess the designated task.
11/29/17 rechecked however; he told us knowledge of Each member is
that the topic was taken. nursing students paired up and was
about the sign in and assigned with the
We had identified a new topic sign out in the different worksheets 11/30/17
 and that is the Knowledge and operating room. to work on
Attitude of Nursing Students
regarding Surgical Safety
Checklist Implementation

We met up and finished the

worksheets that each pair had Finish it all and let it All members should
made to ensure accuracy of be validated by the pass the assigned
12/03/17 information. DH4 and CI. worksheets. 12/04/17

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