EPoSSI Tool Refines QI Project Planning

Quality improvement (QI) efforts are a cornerstone in evolving and elevating patient care. Hospital teams are continuously planning and carrying out QI projects with the goal of improving processes related to improving patient outcomes.

The ACS has numerous quality programs, and as part of the verification process, QI projects are to be initiated annually.

To aid in planning these projects, the ACS along with the THIS Institute, have created the Early Planning of Small-Scale Surgical Improvement Projects (EPoSSI) Tool. The term “small-scale” can be ambiguous, and for the purposes of this tool, the term refers to local QI efforts, as opposed to national projects.

The tool helps provide structure for the project, align team members, and avoid poor planning. This is the first tool to specifically focus on the early planning phase of a project. While working through the nine domains of EPoSSI, the tool offers suggestions to guide decision-making. The domains span key areas of planning: choosing the team, choosing the interventions, planning end-of-project decision-making, and other areas in between.

For each domain, there are columns titled “Must Do” and “Considered Helpful.” (See Figure below.) The first domain, “Choose improvement team,” has two action items in the “Must Do” column:

Select team members and assign roles and responsibilities
Ensure sufficient time availability

The “Considered Helpful” column also has two action items:

Keep team size small and nimble
Choose at least one person with QI experience

Each action item is intentionally succinct, which makes them easier to follow and execute.

There also is a column describing items team members should “Try NOT to” do. For example, in the first domain, the “Try NOT to” column lists: Include members with minimal engagement.

“I’ve used the Quality Framework from the ACS for my QI projects. Does EPoSSI replace that framework?”

The ACS has a Quality Framework Toolkit, which is a set of free tools and resources for planning, conducting, and documenting a QI project. The toolkit includes a framework, notetaking tool, project charter, data plan, and communication plan.

The Quality Framework comprises eight components designed to help ensure the QI project is comprehensive and effective. This framework can be used in conjunction with EPoSSI, or it can be used on its own. If using the Quality Framework and EPoSSI together, start with EPoSSI, and then work through components four through eight of the Quality Framework. The first three components of the Quality Framework focus on planning, just like the EPoSSI Tool.

“We’ve completed our QI project. Now what?”

After completing a QI project, users are encouraged to submit their project for consideration to be included in the ACS Quality Improvement Case Study Repository. The repository is a collection of projects implemented by participants of the ACS Quality Programs. Showcasing your project and allowing others to learn from your experiences can inspire ideas for QI, as well as generate positive change across organizations.

Projects in the repository come from all quality programs the ACS offers, and many are applicable to numerous programs. All types of hospitals are represented in the Case Study Repository, including community, Department of Defense, rural, academic, and international. Data within the projects can be sourced from registries offered by the ACS or internally at the hospital. There also are projects from collaboratives, which represent many hospitals coming together. The Case Study Repository is always expanding and is a valuable resource to periodically review for updates.

If you are interested in participating in this initiative, email qualityresources@facs.org.