| Criteria | Exceptional | Good | Minimal | Basic | Weak |
| Identification of the Problem | 20 | 18 | 16 | 14 | 12 |
| | All components of the criterion are addressed in a comprehensive and thorough manner. | While all components of the criterion are addressed well, one component needed a more thorough discussion | While all components are addressed adequately, 2 components require a more thorough discussion. | Although all components are present, the content is superficial or not well developed | Did not address one or more components or was off topic. |
| 1. Identify the organization for whom the QIP is being prepared (hospital, physician office, etc) |
| 2. Use data to support the determination of the problem, such as rate of foot exam, or rate of flu vaccine as related to the organization (e.g rate of flu vaccination among nurcing home residents) Discuss the impact/potential impact of the problem |
| 3. Does this problem has any financial impact on reimbursement (e.g Medicare non-reimbursement of care related to infections acquired in the hospital), and pay for performance program (i.e. the organization will have financial penalty if teh rate is above acceptable threshold of Pay for Performance Program. |
| Application of PDSA Methodology | 15 | 13 | 11 | 9 | 7 |
| 1. Address the three discovery questions: | All components of the criterion are addressed in a comprehensive and thorough manner. | While all components of the criterion are addressed well, one component needed a more thorough discussion | While all components are addressed adequately, 2 components require a more thorough discussion. | Although all components are present, the content is superficial or not well developed | Did not address one or more components or was off topic. |
| a. What is the team trying to accomplish? |
| b. How will the team know that a change has been effective? |
| c. What changes can the team make that will result in improvement? |
| Use of the PDSA quality improvement | 30 | 23 | 21 | 19 | 17 |
| methodology, formulate a quality improvement process to address the problem identified . b. Select three evidence-based interventions that will be implemented to address patient falls with injuries and include any budgetary considerations that would be needed based on the interventions you selected. 2. Do: Strategies used to implement the selected evidence-based intervention. | All components of the criterion are addressed in a comprehensive and thorough manner. | While all components of the criterion are addressed well, one component needed a more thorough discussion | While all components are addressed adequately, 2 components require a more thorough discussion. | Although all components are present, the content is superficial or not well developed | Did not address one or more components or was off topic. |
| 1. Plan: a. Analyze the problem; evaluate the current literature to determine factors that are associated and contribute to the problem |
| Present two interventions that will be implemented to address the problem. Discuss any resource and budgetary considerations that would be needed for the interventions |
| 2. Do: Strategies used to implement the selected evidence-based intervention. Survey of patients, change in process, alerts and reminder for flu vaccination |
| 3. Study: Criteria the team will use to determine if the evidence-based interventions have been successful. a. Include information that will be analyzed to determine the success of the intervention. Types of data that will be collected and how the data will be analyzed. And the measures such as 20% change in follow-up calls from the current rate, 100% of foot exam for patients with diabetes |
| Act: Discuss the proposed action based on the results of the study. What the action will be if the results show and improvement and if otherwise. Will the intervention be spread to other units or modify and retest
the team’s prediction of success with the
new actions. |
| Team Process | 15 | 13 | 11 | 9 | 7 |
| | All components of the criterion are addressed in a comprehensive and thorough manner. | While all components of the criterion are addressed well, one component needed a more thorough discussion | While all components are addressed adequately, 2 components require a more thorough discussion. | Although all components are present, the content is superficial or not well developed | Did not address one or more components or was off topic. |
| Discuss the commuication strategies used by your team to manage team dynamics and for making decisions |
| What types of teamwork tools were used? (Brainstorming, flowchart etc) |
| Were the teamwork tools used beneficial? What would the team do differently ? |
| Scholarly writing | 10 | 8 | 6 | 4 | 2 |
| | The paper is exemplary and meets all 3 components of the criterion. | While the paper is
well done and
addressed all 3
components of the
criterion, one
component had
limitations. | While the paper is good and addressed all 4 criterion components of the criterion, two components had limitations. | Although the paper is acceptable and addressed all 3 components, all the components had limitations. | The paper did not contain one or more of the required components. |
| Paper is well written, organized within the paper limitation. |
| Grammar, spelling, punctuation are correct. |
| Conforms to APA standards for headings, citations and reference page |
| Member contribution | 10 | 8 | 6 | 4 | 0 |
| | Member met all the three criteria and contributes to writing more than one section and also review of the QIP | Member participated in the team meeting and contributes to writing at least a section and the review of the QIP | Member participated in the team meeting and contributes to writing one section of the QIP | Member participated in team meetings but did not contribute to writing the QIP | Member did not meet any of the criteria, participated is very few of the team meetings but did not contibutes to writing the QIP |
| Member participated in team meeting and deliberations |
| Member wrote at least a section of the QIP |
| Member reviewed the QIP |