GOV-PLN-002: Quality Improvement Plan

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Plan / template · GOV-PLN-002 · Version 1.1 · Approved by the ASF Expert Committee

Supports: 2A.3

At a glance

Cover every service and department, not only the main ones.
For each area, name the responsible person, the indicators and the target.
Review the indicators each month and report to the governing body each quarter.
Start an improvement project for each indicator that is off target.
Update the plan each year from the findings.
Stop and get help straight away if: a service or department has no named owner or indicators in the plan.

1. Purpose

To set out how the facility measures and improves quality in every part of the service, with responsibilities and indicators [E-006, EC].

2. Scope

Applies to	Every service, department and support function at the facility
Locations	The whole facility
When	Written yearly; reviewed monthly through indicators
Does not apply to	Individual improvement projects, which are recorded under the plan but run separately

3. Definitions

Term	Meaning
Indicator	A measure that shows whether quality is improving, with a target
Improvement project	A planned change to fix a gap, with an owner, a timeline and a measure

4. Background

Criterion 2A.3 requires a formal quality improvement plan covering every part of the facility, with responsibilities and indicators. A plan that covers only the clinical services does not meet it.

5. Responsibilities

Role	Responsibility	Competence
Chief executive	Approves the plan and reports it to the governing body	Executive leadership
Quality lead	Maintains the plan, the indicators and the project log	Quality improvement methods
Service heads	Own the indicators for their area and start projects where targets are missed	Management training

6. Materials and equipment

Item	Requirement	Condition
Indicator dashboard	Monthly data for each indicator	Updated monthly
Project log	Owner, start date, measure, status	Updated monthly

7. Safety

Indicators must not reward unsafe shortcuts. Check results against incidents and complaints.

8. Before you start

List every service and department on the plan.
Check each service has a named owner.

9. Procedure

Step 1. List every service and function.

Use the service declaration (GOV-FRM-001 section list) as the starting point.
Add support functions: facilities, IT, HR, finance, catering, laundry, transport.

Key point: If a function is not on the list, it will not be measured.

Step 2. Name an owner and indicators for each area.

Name one owner for each area.
Choose two to four indicators for each area, covering safety, effectiveness and experience where relevant.
Set a target and a data source for each indicator.

Key point: A number without an owner and a target does not drive change.

Step 3. Collect and review the data.

Collect data each month from the source named.
Review the dashboard monthly with each service head.
Mark each indicator as on target, watch, or off target.

Key point: Monthly review is what makes the plan work between audits.

Step 4. Start improvement projects.

For each off-target indicator, the owner starts a project within 30 days.
Each project has a measure, a timeline and a named lead.
Close the project when the target is met for three months.

Key point: A project is the response to a gap. Without it, the gap stays.

Step 5. Report to the governing body.

Send a quarterly report with the dashboard, projects and risks.
Record the discussion on GOV-FRM-001.

Key point: The governing body needs to see the trend, not only the latest number.

Step 6. Update yearly.

Review every indicator and target yearly.
Add new services and remove retired ones.
Record the version and approval.

Key point: A plan that does not change with the service becomes out of date.

10. Decision points

If an indicator is off target for two months, the project is escalated to the chief executive.

11. Special situations

Situation	Action
Service added or closed	Add or remove its owner and indicators within one month.

12. Escalation

Serious safety signals go to the chief executive at once, not at the quarterly report.

13. Monitoring

Measure	Target	Frequency	Owner	If not met
Services with a named owner and indicators	100%	Yearly, checked quarterly	Quality lead	Name owner within 14 days
Indicators reported monthly	100%	Monthly	Quality lead	Service head reports within 7 days
Off-target indicators with a project	100%	Monthly	Quality lead	Project started within 30 days

14. Records

Record	Kept in	Retention
Quality improvement plan (approved)	Quality file	the period set by the facility’s records policy years
Indicator dashboard	Quality file	the period set by the facility’s records policy years
Project log	Quality file	the period set by the facility’s records policy years

15. Training

Service heads are trained in indicators and improvement methods (EC).
Staff in each area are briefed on the indicators that concern them.

16. Related documents

ID	Title	Use
GOV-POL-003	Policy Development, Approval, Review and Application	Application checks feed the plan
INC-SOP-001	Root Cause Analysis of Serious Incidents	Projects from incidents
QUA-SOP-001	Safety Culture Survey	Survey results feed the plan
GOV-PLN-001	Strategic Plan	The QI plan supports the strategic goals

17. Evidence

Reference	Note
E-006	ASF Policy Framework v1.2. Adapted.
E-009	ASF Expert Committee consensus. Indicator targets are set by the facility.

18. Change history

Version	Date	What changed	Approval
1.0	the date of approval	First version	Approved by the ASF Expert Committee
1.1	the date of approval	Internal quality review: corrected cross-references, status wording and document control	Approved by the ASF Expert Committee

E-learning for this document

Documentation Fundamentals (A-03)
Document Control and the Records System (T-02)
Document Control Fundamentals (A-06)

References

Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)
Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)

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