5 Reporting


5 Reporting

5 Reporting

So you have gone through the continuous improvement cycle – now let’s look at the tools and reports that will help your team engage in it, and help you to govern it.

1. Continuous improvement form

You need a quick and easy means for people to capture and report on issue that they come across.  Check the downloadable ‘Continuous Improvement Form’.

2. Continuous improvement tracking form

A continuous improvement tracking form, such as the one here (downloadable) is useful in making sure the open loops on issues and opportunities for improvements are closed.  This form could also integrate with your Visual Management Board (described in a later section).

The A3 problem analysis process should inform this.

You might like to establish a regular QI forum in which these ideas are sorted through and developed further.

3. Improvement Project Report

Let me take you through the Improvement Project Report (feel free to adapt this so it better suits your needs and work context – be sure to share you report template if you have changed it).

Purpose – The outcome of the project.  This could be written in terms of a problem to fix or an outcome to achieve.

KPIs – Identify indicators of success and how these will be measured and captured (we’ll touch on data and KPIs again in a later section).

Target – What is your target for the next month? Make sure it is easy to get this data because you will need to report against it at the end of each month (Actual).

People – Who are the stakeholders that are affected by this. How are they affected? What do they think?

Communication and engagement strategy – You are already familiar with this as a result of the change project you have been doing.  A stakeholder communication and engagement plan can be a quick and dirty – its intention is to make sure you engage the right people asap – get them on board and know sooner rather than later whether they will help or hinder your attempts to improve things. Think about this from their perspective – what of their problems could you be fixing through this project? Can they contribute in any way?

Strategy – What strategy will you take to achieve this outcome (this is the broad level strategy – like “Introduce <new> model of care”, or “Start Nurse led Clinic”, etc?)

A3 – You are already familiar with the A3.  If the problem is complicated, use this approach to unpack the problem.  Do this with others so you get a more complete picture.  Spend most of your time on understanding the problem and researching solutions and how it is done  elsewhere.  Summarise your deliberations into this A3 form.  Send it around to everyone who needs to know about it, including your boss.  This shoudl be attached to the Improvement Project Report.

Action plan – Simply identify the specific actions that need to be taken to achieve the outcome using the Action Plan template. Provide a summary action plan on the A3 for reporting purposes.

Reporting progress, help needed and next steps – At the end of each month, tick off the actions that were taken, measure the indicators, ask people what they think and provide a few dot points on the progress.  It is OK to say things didn’t go according to plan so long as you are clear and honest about why that is so (Did you do the work? Were the actions the wrong actions?  Were the people the wrong people? Was there resistance?)

Identify anything you need help with to achieve your outcomes – it might be a decision, a resource, a meeting or conversation, executive endorsement.  List the next steps for the coming month.

The Team – The team is the Project Team (see the section on Project Team). List the members in this section.  A more detailed discussion on the Project Team is provided next.

4. Monthly operational report

This monthly operational report can be completed by individuals, and aggregated up into the Team report each month. For a team, it will guide the Monthly Operational meeting and then be shared with the lead of their larger team (e.g. DoN).

Purpose – It is important that the team agree on their team’s purpose and roles, and what they are being accountable for – and that these are listed.  This may not change – but they can depending on the tensions (or opportunities) that emerge.

Tensions – are simply conditions that do not match ideal.  They can be risks (a Riskman may have been completed if it occurred).  They can be opportunities that emerge as a result of new money, or a new initiative.  The tension in this case means that action has not yet been taken to realise this opportunity.

Or a tension can be raised by any individual (either in the meeting or via the improvement form) that identifies a situation that is not ideal or getting in the way of them achieving their ideal/accountabilities.

Response:  This is literally what was decided to do about the tension. Was it resolved in the meeting – refer to where they can find out more (e.g. might be a policy change; or the person who raised it has resolved it); was a project created to resolve it (would expect to see a Project team A3 and an Improvement project report next month); was it delegated/referred and if so to who?  It might appear in the ‘Help needed’ column if it is not clear how to resolve it or there is no authority or resources in this team to do so.  A team’s autonomy and ingenuity can be measured on the number of tensions it is able to resolve internally.  These tensions can also drive cross organisational collaborations through the projects.

KPIs – Focusing only on the critical KPIs that really tell us about the health and performance of the team and achievement of their purpose.  The team decides which KPIs to report on, informed by the ones passed down to them.  They can raise a tension if a KPI does not reflect the purpose or accountabilities of their team.  Accountabilities could relate to: maintaining  a positive operating position (revenue/costs); improvement and engagement (tensions resolved/tensions raised); customer experience (customer touch points; positive feedback; customer tensions resolved/customer tensions); quality of care (Patient goals achieved/set; Compliant audits/audits)

Achievements – provide an opportunity to promote the performance of the team. If a single individual is responsible, acknowledge them.

Help needed – Where the Team’s ability to achieve its purpose and accountability is exceeded, they can call for help in any form and it is up to their lead to source it.

Next steps – These are the mission critical next steps for the team for the coming months (not the ordinary work that needs to be done).  These need to be allocated to a role, and included as an accountability for that role.

Individual reporting:

Individuals will have their own version of this report, and they make it available to the team each month.  Any gaps or tensions in their performance or that are blocking their ability to perform their accountabilities should be picked up in this report.  They too can ask for help from any where and should get it.  If it becomes apparent that they are unable to meet their accountabilities, the lead may have a one on one conversation with them to decide how they can be supported to do so with their current roles, or consider re-allocating the roles to someone else who has the requisite skill set and capacity.

5. Quarterly operational report (90 Day report)

The Quarterly Operational Report is very similar to the monthly report.

Accountabilities – would include strategic priorities for the coming quarter that may have come from the executive retreat/strategic plan/team meetings.

KPIs, targets and progress – as for the monthly operational report

Mission critical goals/projects – A small number (3) Mission critical goals or projects will be identified for the quarter that will significantly move the organisation/team toward its purpose and/or accountabilities.  These are either significant tensions or opportunities that have emerged, or they may be contributing to a strategic priority of the organisation.

Team lead – A lead will be identified to lead the project – they are expected to prepare a project report and possibly an A3 if the project is a tension that is not already well understood.

Progress – Each quarter the lead will provide a report on progress and the project will either be refined or removed as the mission critical goal or project.

A database of projects will be maintained so that there is a record.


What reporting requirements do you already have in place?

Are these clearly integrated with your continuous improvement cycle and governance process?

Do they encourage individuals and teams to raise and address tensions, and redesign the actual process and structures if they need to?

Do you have reports that do not seem to add any value at all? Can you redesign them so that they are more useful – of stop doing them all together?

How might you use these reports in your own workplace? Provide a comment below.

A3 Problem solving template
Action plan template
Improvement form
Improvement project report
Improvement tracking form
Monthly operational report
Quarterly Operational report


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