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How to Guide 8 – Continuous Quality Improvement

This guide outlines some of the options for developing and implementing a Continuous Quality Improvement Plan. The main topics covered are:

  • PDCA Model Overview
  • PDCA Step-by-step
  • Building a CQI Plan for the organisation

Continuous Quality Improvement

Continuous Quality Improvement (CQI) is both a philosophy and a method of management that ensures specified standards of quality are met and are being continuously improved. A CQI Plan is a detailed program of improvement resulting from activities that may include but not be limited to internal reviews, internal or external assessments, service user feedback, complaints and other service delivery initiatives.[1]

A CQI Plan is your organisation’s roadmap for improving services, processes, capacity and outcomes. It guides your organisation and its clients, partners, key stakeholders and the Board  through the process of monitoring and using data to improve outcomes as part of everyday practice. A CQI Plan allows you to track progress towards planned quality improvements and document what has and has not worked in achieving them.

The PDCA Model Overview

The most common model used in Quality Management is the PDCA Model: plan→ do→ check→ act cycle. The main steps are:

Plan – identify the result or outcome to be achieved or improved and define what you will do to achieve this

Do – implement the Plan, taking small, controlled steps

Check – evaluate the results and document data on the steps taken and results. Has there been an improvement? If so, why, if not, why not?

Act – take action to standardise or embed the improvements into everyday operations.

PDCA Step-by-step


  • Identify an organisational area you would like to advance and the outcomes you would like to achieve.
  • Identify exactly how this area is working now and what the issue is. Expressed this as a measure if possible. For example, if you wish to reduce the amount of time new applicants are on the waitlist (say, current average is one month).
  • Set the goal for the improvement using the SMART goal setting method. Goals should be specific, measurable, achievable, realistic and timely.
  • Seek input from clients and stakeholders about the goal and then identify a measure for the improvement. For the example of current average wait time you may express the goal as directional (e.g., reduce the wait time to less than one month) or be more specific and state a minimum target (e.g., reduce the wait time by at least seven days).
  • You may also distinguish outputs from outcome In the waitlist example, the output could be defined as ‘reduced wait time for new applicants receiving a service’ and the outcome could be defined as ‘strengthening early intervention by reducing response times for people at risk of homelessness in the X area’.
  • After establishing a clear and measurable goal, design an improvement strategy to achieve it. It may be helpful to invite input from your clients and other stakeholders or create a reference group for an improvement project that includes clients and partner agencies.
  • Document all the steps that make up the improvement strategy with time frames and responsibilities and obtain approval in line with your organisation’s instrument of delegations. Make sure you allocate enough time and resources for the strategy to work.
  • Brief all the staff and other people who have a role or will be affected by the planned strategy.


  • Take the actions in your improvement Plan.
  • Document the completion of each step in the strategy and continue taking regular measures.
  • In the waitlist example, you need to be confident that all staff (and any volunteers) are accurately recording the dates each new applicant seeks and obtains a service, so that your average measures over time accurately measure any effect of the strategy.
  • Keep the stakeholders, and those who will be impacted by the Plan, informed of progress.
  • Document the decisions that were made and the outcomes that resulted from the implementation phase.
  • Give the strategy enough time to work.


  • Evaluate whether the strategy is delivering the intended outcomes.
  • If not, use the data from the first attempt to fine-tune or change the strategy until the desired result is achieved.
  • Measure and document the improvements, evaluation methods and results. Small or modest improvements and incremental steps may deliver the results you seek in the long term.


  • Once an improvement strategy has achieved the intended outcome, document a process for standardising the new approach. For example, this may be a new procedure for managing a waitlist, or a new software program for the whole organisation.
  • This step and its implementation should also be planned, whether it is a simple change that requires an email to all staff and an updated procedure, or an widespread improvement involving adding software to all computers, a training strategy and a roll-out schedule.
  • Keep everyone who will be affected by the change informed of the implementation. Large-scale changes and reforms can also have glitches, so keep measuring and fine-tuning the strategy, as needed, until the change is embedded in everyday operations.

Alternative methods

The PDCA Model is a straightforward and systematic method of quality improvement. There are tools available that complement the model, and other quality improvement models and software programs that can also be applied. Choose the method for CQI that is right for your organisation. You may find it useful to review The Smartsheet Company’s overview of CQI methods and tools at:


Building a CQI Plan for the organisation

The previous section looked at the approach for a single quality improvement initiative using the PDCA quality improvement model. In this section, we broaden the CQI perspective to look at some strategies for developing a whole, organisation-wide CQI Plan.

The key steps in building a CQI Plan for an organisation are:

  • Establish a working group
  • Start with your principles
  • Identify draft strategic priorities
  • Develop a draft CQI governance model
  • Consult and finalise
  • Develop project plans for individual improvements
  • Update and monitor
Establish a working group

You may find it helpful to establish a working group to develop your organisation’s CQI Plan. This is a great opportunity to include client representation, a cross-section of staff at different levels in the organisation and Board representation, since quality is everybody’s business.

Start with your principles

The foundation of the CQI approach is a set of principles for quality management and improvement. The eight principles underlying the ASES are:  

  1. Customer-focus
  2. Outcomes focus
  3. Clear direction with accountability
  4. Continuous learning and innovation
  5. Valuing people and diversity
  6. Collaborative work practices
  7. Evidence-based decision-making
  8. Environmental, social and ethical responsibility

Develop your organisation’s CQI principles by considering:

  • The ASES principles
  • Your organisation’s vision, mission and values statements
  • The overall method for improvement that you would like to adopt.
Identify draft strategic priorities

Although you may wish to improve many areas in your organisation it is important to be realistic about what is achievable. The CQI approach is based on embedding small, incremental steps that build to large-scale, positive change over time.

For each of the eight ASES Standards start with some ‘broad brushstrokes’ of the key areas for improvement over a three-year period.


  • The goals in your strategic Plan that require the most concerted improvement action
  • The projects in your Operational (Business Plan) and Risk Management Plan that require the most concerted improvement action
  • Any CQI recommendations in your ASES External Assessment Report that you haven’t yet actioned
  • Themes that are emerging from client, staff and stakeholder feedback, and the incident/accident (or similar) registers.

It can be helpful to use a 3-year matrix (sample below) to guide your development of strategic improvements. Although you don’t need to have improvement action against every Standard, starting off with a table listing all the Standards helps to visualise the ASES framework and to decide the greatest priorities for the next three years.

Three-year strategic improvement matrix sample for one Standard

Time frame → Year 1 Year 2 Year 3
ASES Standard ↓  
1 Planning:

Strategic planning
Business planning

Develop a draft CQI governance model

A CQI governance model sets out the roles and responsibilities, the monitoring and reporting and the overall resourcing of CQI within the organisation.

Consider the following questions when developing your governance model.

  • Who is responsible for the CQI Plan? (e.g., CEO, Service or Operations Manager)
  • Who will mentor CQI in the organisation? (e.g., A Board member with a focus on quality)
  • How will the CQI program be resourced? (e.g., Program budget and staffing for CQI activities)
  • How will the CQI Plan be approved and monitored? (e.g., CEO or the Board)
  • How often will the CQI Plan be reviewed and reported on? (e.g., Quarterly, monthly)
  • What will the process be for reviewing and sharing findings and outcomes? And what will the time frames be? (e.g., CQI teams meet face-to-face or via Skype. Monthly/quarterly meetings/ reports)
  • How will clients and/or stakeholders be involved? (e.g., Participate in working groups. Consultation at the beginning or at various points in CQI projects)
  • How will the final results be shared with all stakeholders? (e.g., newsletters, emails, staff meetings)
Consult and finalise

Once your organisation has identified draft priorities for improvement you can compile a  document for consultation with stakeholders. This describes why the draft priorities were chosen, and how they align with the state priorities for the NSW Specialist Homelessness Program and your organisation’s strategic directions.

The document should also confirm that there are no initiatives planned by other organisations (e.g., DCJ or Homelessness NSW) that address the issues identified.

After consultation and feedback the draft can be revised and submitted for approval using your organisation’s decision-making procedure and instrument of delegations.

Develop project plans for the individual improvement projects in the CQI Plan

Using the PDCA Model apply the steps to each individual improvement project and also identify any specific project governance and consultation arrangements that apply to it.

An individual improvement plan typically includes the following information.

  • Project title
  • Project leader
  • Working group members
  • Current situation – expressed as a measure
  • Why is this a problem?
  • The SMART goal expressed as a measure (directional or minimum target)
  • The golas expressed as outputs and outcomes
  • How will clients or stakeholders be consulted or involved in the project
  • What strategies will be used to address the problem? What time frame and responsibilities?
  • Which data will be used to measure success?
  • How often will the measure be taken?
  • Which data sources will be used?
  • How often will the working group meet?
  • What is the final measure of success?
  • How will the new approach be standardised in the organisation?
Update and monitor the CQI Plan

Regular monitoring and updating of your organisational CQI Plan will help to keep quality improvement alive in your organisation.

Consider an annual review of the CQI Plan each year in conjunction with developing your Operational (or Business) Plan, to make sure there is alignment between the two.

Celebrate successes with your CQI Plan, no matter how small. Sharing concrete results helps to keep staff motivated and engaged with the quality improvement process.

[1] Based on the South Australia. Dept. for Communities and Social Inclusion (now the Department of Human Services), Australian Service Excellence Standards: A road map to an excellent organisation, Third Edition, version 7, 2019, p. 82.




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