CQI System Proposal

Grant Overview

Closing the Loop: Building an Audit-Ready CQI Documentation System

Project Overview

Nursing programs collect a lot of outcomes data - course results, standardized testing trends, student feedback, and faculty evaluation notes. The challenge is that this information can end up scattered or documented differently across courses and committees. When that happens, it is harder to show a clear "story" of improvement for accreditation - what we found, what we decided, what we changed, and whether the change actually helped (Accrediting Bureau of Health Education Schools [ABHES], 2026; Commission on Collegiate Nursing Education [CCNE], 2024).

This project is designed to make that process simple and consistent by implementing a Closing-the-Loop CQI documentation system. We will use the Plan-Do-Study-Act (PDSA) approach to test small improvements, review the results, and adjust based on evidence (Institute for Healthcare Improvement [IHI], n.d.). To support faculty, we will create shared tools that make documentation easier and more consistent, including a short CQI action plan template, an evidence tracker, and a standard decision-log meeting minutes template (ABHES, 2026; CCNE, 2024).

We will roll this out in phases. First, we will finalize the tools and set clear expectations for what CQI evidence each course or committee submits each term. Next, we will provide brief faculty training and coaching so everyone feels comfortable using the tools and running a basic PDSA cycle (IHI, n.d.). Then, we will build a shared evidence repository organized by accreditation standards/categories, so documentation is easy to locate during a self-study or site visit (ABHES, 2026; CCNE, 2024). Finally, we will review CQI completion rates and documentation quality each term and improve the process over time (IHI, n.d.).

By the end of the project, we expect to see more consistent CQI documentation, stronger faculty confidence with data-informed decision-making, and a more organized "audit-ready" evidence system that clearly demonstrates continuous improvement over time (ABHES, 2026; CCNE, 2024).

Goals & Objectives Alignment Table

Project goals mapped to objectives and measurable outcomes

Goals

Objectives

Outcomes

1 Standardize Closing-the-Loop CQI documentation across courses and committees.

Objectives

1.1 Finalize CQI mini action plan, evidence tracker, and decision-log minutes template.
1.2 Define minimum CQI artifact submission expectations per term for each course/committee.

Outcomes

1: ≥ 90% of courses/committees submit at least one CQI artifact per term.
2: ≥ 80% of artifacts include complete "finding, decision, action, and reassessment" documentation.

1 Standardize Closing-the-Loop CQI documentation across courses and committees.

1.1 Finalize CQI mini action plan, evidence tracker, and decision-log minutes template.
1.2 Define minimum CQI artifact submission expectations per term for each course/committee.

1: ≥ 90% of courses/committees submit at least one CQI artifact per term.
2: ≥ 80% of artifacts include complete "finding, decision, action, and reassessment" documentation.

2 Build faculty capacity to apply PDSA and document data-informed improvements.

Objectives

2.1 Deliver one faculty workshop on CQI expectations and documenting "closing the loop."
2.2 Provide coaching/office hours during the first implementation cycle.

Outcomes

1: ≥ 85% faculty attend training.
2: Pre/post survey shows improved confidence using PDSA and documenting CQI (increase by ≥ 1 point on a 5-point scale).

2 Build faculty capacity to apply PDSA and document data-informed improvements.

2.1 Deliver one faculty workshop on CQI expectations and documenting "closing the loop."
2.2 Provide coaching/office hours during the first implementation cycle.

1: ≥ 85% faculty attend training.
2: Pre/post survey shows improved confidence using PDSA and documenting CQI (increase by ≥ 1 point on a 5-point scale).

3 Create an audit-ready evidence repository aligned to accreditation standards/categories.

Objectives

3.1 Build a shared repository organized by standard/category for self-study and site visit readiness.
3.2 Hold CQI work sessions to review outcomes, upload artifacts, and confirm reassessment steps.

Outcomes

1: Repository contains ≥ 90% of required evidence categories by end of project period.
2: Internal readiness audit shows fewer missing items than baseline (target: 50% reduction).

3 Create an audit-ready evidence repository aligned to accreditation standards/categories.

3.1 Build a shared repository organized by standard/category for self-study and site visit readiness.
3.2 Hold CQI work sessions to review outcomes, upload artifacts, and confirm reassessment steps.

1: Repository contains ≥ 90% of required evidence categories by end of project period.
2: Internal readiness audit shows fewer missing items than baseline (target: 50% reduction).

References

Accrediting Bureau of Health Education Schools. (2026). Accreditation manual (19th ed., effective January 1, 2026).
Commission on Collegiate Nursing Education. (2024). Standards for accreditation of baccalaureate and graduate nursing programs. American Association of Colleges of Nursing.
Institute for Healthcare Improvement. (n.d.). Model for improvement. Institute for Healthcare Improvement.