I know that writing Quality Studies can be challenging. What do we study? How do we study? How do I get it into the format I need to meet accreditation?

I’ve had to write many a study and have helped others as well. I’ve seen people wanting to pull their hair out to get them right.

First, don’t struggle to determine a topic. Look to your incident reports, satisfaction surveys,  staff and physician complaints. Note the trends. You solve these problems all the time! All you have to do is put the process in writing.

Here’s how to do it: (In 10 easy steps, and in accreditation format):


1. Purpose: Define your problem and why it’s significant.

Example: We start cases late on Thursdays, and it is affecting patient satisfaction, which could impact volume.

2. Goal: Set a measurable goal of where you would like to be.

Give yourself a little wiggle room.

Example: Our goal is to start cases on time 95% of the time.

3. Data Description: State what data you will collect to define your problem.

Example: We will measure current scheduled times vs. late times for Thursday cases.

4. Data Collection: State the specifics of what you will or have collected.

Example: We will  measure January-March Thursday scheduled vs. actual start times.

5. Data Analysis: State your findings.

Make sure you quantify your result to measure against your goal.

Example: Room 1 started late 20% of the time and Room 2 started late 15% of the time. 

6. Comparison: Compare your goal to your findings.

Example: Our goal is to start cases on time 95% of the time. Our results show we are starting cases 82.5% of the time.

7. Corrective action:  Show your work.  Here is where you say how you think you will fix it.

Example: We fired our Thursday doctors. 

8. Re-Measurement: See if your corrective actions worked.

Example: We re-measured our scheduled vs. actual start times in May, and we are starting late 2% of the time.

9. Additional corrective action: You only need this step if you didn’t meet your goal.

10: Communicate Findings: Share what you did and the result to everyone who needs to know.  Especially your Governing Body.

When you first write the study, you won’t be able to fill in all the steps. Talk about the plans for the steps instead. As an example, if you have decided upon what actions you will take to try to improve the problem, but haven’t implemented the actions, you won’t know 6-9. However, you can tell your Governing Board about the study, with the results to be communicated at a later meeting.

Some Additional Hints:

  • Don’t be afraid to use graphs and charts to support your data collection.
  • If you are not meeting your goal and feel you are not going to, part of your additional corrective action may be to re-set your goal to a more achievable number.
  • Get collaboration in coming up with your corrective action plan.  Your staff may have some great solutions,  and will will help with buy-in.

Hopefully, if you find writing studies challenging, these steps will make the process a bit easier.  Once I broke  the process down to this level, the light bulb finally went on for me.

Feel free to comment below,  or e mail  me at leslie@almss.com if you could use some assistance with your studies,  or have some tips that work for you.

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