Performance Improvement and Corrective Action Plans
Date: July 20, 2018
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Does your facility practice continuous Performance Improvement (PI) assessments, and create and implement Corrective Action Plans based on the data gathered from those assessments? If not, you should be. Putting together a Performance Improvement Team that looks at your facilities systems, policies, procedures, and client care practices is critical in developing a solid foundation for ongoing operations. Also, you know what they say in our industry; if it isn’t written down, it didn’t happen. That being said, it is equally as important to document PI Team meetings, the agenda in that meeting, and what areas were identified as needing a Corrective Action Plan. In fact, nationally accrediting agencies like The Joint Commission (TJC) require it!

Into Action Consulting, Inc. visits and assesses facility operations all day, every day. I am positive that every one of you have experienced the chaos that comes when a facility gets in bad habits. Our industry is a volatile one, and even when a facility is running smoothly, it still takes a lot emotionally and physically to keep up. Let us help you develop and implement an effective Performance Improvement Plan. We are experts at this and many other facets of the addiction treatment and mental health facility field.

I am including some text from our Performance Improvement policy, and a sample of a Corrective Action Plan that we use when consulting with an organization. As always, we appreciate your feedback and questions! Also, please sign up for our monthly newsletter and connect with us on Facebook and LinkedIn.


M. Craig Jewett
(714) 232-0649 cell
(714) 603-7415 office

Performance Improvement Program

The plan identifies Important Functions of the organization and Dimensions of Performance for or its basic framework. Additionally, this plan addresses the Monitoring and Evaluation model embraced by The Joint Commission (TJC) while maintaining compliance with state regulatory requirements. The PI plan is an eleven (11) step model that addresses the following:


  1. Assigns responsibility for monitoring and evaluating activities
  2. Delineates the scope of care provided by (your facility)
  3. Identifies the Important Aspects of Care
  4. Identifies indicators and clinical criteria for monitoring the Important Aspects of Care.
  5. Establishes thresholds for the indicators that may trigger further evaluation of care.
  6. Monitors the Important Aspects of Care by collecting and organizing the data for each indicator.
  7. Further evaluates care when thresholds are not reached in order to identify either opportunities to improve care or problems (corrective action).
  8. Takes action to improve care or correct identified problems.
  9. Assesses and re-evaluates the effectiveness of actions and document improvement to the organization and delivery of care.
  10. Communicates the results of the monitoring and evaluation process to relevant individuals, departments, internal committees, and Board of Directors.
  11. Evaluates feedback from clients, families, staff and other stakeholders.
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