Organizational PDCA Kaiser Permanente

Organizational PDCA Kaiser Permanente

This presentation explains what continuous quality improvement (CQI) is and explains a Plan-Do-Check-Act (PDCA) process to address quality issues within the Kaiser Permanente Health Care Organization.


Quality Issue

Deficiencies in mental health services

Ensure that its quality assurance systems accurately track, measure, and monitor the accessibility and availability of providers.

Sufficiently monitor the capacity and availability of its providers network to ensure that appointments are offered within the regulatory timeframes.

Ensure that effective action is taken to improve care where deficiencies are identified.

Provide accurate and understandable mental health education materials, including information regarding the availability and optimal use of mental health care services provided by the plan.

As stated in as issue by the California Department of Managed Health Care, in 2013 Kaiser was fined $4 million due to their negligence in delivering mental health care in a timely manner. Although, somewhat resolved they still face issues with providing care in a timely manner and providing patients education on their covered services for mental health care (DMHC, 2013).


Department of Managed Health Care. (2013). DMHC Fines Kaiser $4 Million for Deficiencies that Limit Access to Mental Health Services. Retrieved from,2013.aspx


Continuous Quality Improvement (CQI)

Sometimes referred to as Performance and Quality Improvement, is a process of creating an environment in which management and workers strive to create constantly improving quality.

Continuous Quality Improvement (CQI) is a quality management process that encourages all health care team members to continuously ask the questions, “How are we going?” and “Can we do it better?” (HealthIT, 2008).


HealthIT. (2008). Continuous Quality Improvement (CQI) Strategies to Optimize your Practice. Retrieved from


Key Elements of CQI


Driven by good management … not crisis

Driven by input from all levels of staff and stakeholders


Continuous review of progress

Internal and external benefits of CQI include:

Improved accountability

Improved staff morale

Refined service delivery processes

Flexibility to meet service need changes

Enhances information management, client tracking, and documentation

Means to determine and track program integrity and effectiveness

Lends itself to design of new programs and program components

Allows creative/innovative solutions


Department of Children and Family Services. (2018). Continuous Quality Improvement. Retrieved from


Goals of CQI

Lead quality processes

Ensure high quality of services

Meet all standards and regulations

Meet all annual goals and objectives

The goals of CQI help to improve overall quality and ensure goals and objectives are constantly met. CQI is done constantly because there are always improvements that need to be made.


Plan-Do-Check-Act (PDCA)

PDCA’s conception began in 1939 after Walter Stewart introduced the idea that continuous evaluation management practices is key to the development of a successful organization. The Pan Do Check Act is an iterative four step problem solving model to promote continuous improvement. These four steps are completed in small cycles that ultimately yield exponential improvements (American College of Medical Quality, 2010). This presentation will utilize the PDCA cycle to address the issue of deficiencies in mental health services at Kaiser Permanente Health Care Organizations.

During the Plan stage areas in need of QI are identified. This part of the cycle involves developing indicators and monitors, thresholds and benchmarks, and the methodology for the study intervention.

The Do part of the cycle entails implementation and documenting problems and unexpected observations.

The Check portion involves collecting data from the Do part of the cycle and then producing information from those data.

The Act part involves determining whether intervention produced improved outcomes as reflected in the information.


American College of Medical Quality. (2010). Medical quality management: Theory and practice. Sudbury, MA: Jones and Bartlett.







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