1. 1
Performance Improvement
Plan of Action Template
This template is used in conjunction with the “FOCUS” methodology for each of these identified performance gaps.
This methodology includes:
 Find a Process to Improve (Prioritized issues).
 Organize a Team – Form a team to work on process improvement related to the process or deficient
practice.
 Clarify the Process – The team will begin collecting information on the specific process or deficiency
through the identification of existing processes and procedures, mapping current processes and reviewing
and/or collecting baseline data.
 Understand the Variation – Comparison of facility processes to best practice to determine where variation
occurs.
 Select the Variation to Improve – Prioritize identified variation for improvement and intervention selection.
Follow the Model for Improvement and PDSA Improvement Cycle and begin with small tests of changes.
This material was adapted from the TMF Health Quality Institute, the Medicare Quality Improvement Organization for Texas, under contract with the Centers for Medicare & Medicaid Services
(CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 9SOW-TX-PS-11-13

2. 2

3. 3
Plan of Action Template
Area of focus for
Improvement
(per findings of the
RCA )
Action Plan Steps
Anticipated
completion
date
Measurement strategy
Methodology(chart audit, observational etc.)
Sample size ( how many)
Goal
Frequency(how often)
Duration( for how long)
Dates for progress charting(if applicable)
Person Responsible
Area of focus for
Improvement
(per findings of the
RCA )
Action Plan Steps
Anticipated
completion
date
Measurement strategy
Methodology(chart audit, observational etc.)
Sample size ( how many)
Goal
Frequency(how often)
Duration( for how long)
Dates for progress charting(if applicable)
Person Responsible

4. 4
Area of focus for
Improvement
(per findings of the
RCA )
Action Plan Steps
Anticipated
completion
date
Measurement strategy
Methodology (chart audit, observational etc.)
Sample size ( how many)
Goal
Frequency(how often)
Duration( for how long)
Dates for progress charting(if applicable)
Person Responsible
Area of focus for
Improvement
(per findings of the
RCA )
Action Plan Steps
Anticipated
completion
date
Measurement strategy
Methodology(chart audit, observational etc.)
Sample size ( how many)
Goal
Frequency(how often)
Duration( for how long)
Dates for progress charting(if applicable)
Person Responsible