Step Five: Evaluate Your Progress


In this final step of the toolkit, we will close the loop of continuous quality improvement by re-evaluating the status of your emergency department and circling back to amend or continue the path to a safer emergency department, defined by your original project plan. By re-evaluating your department after your action plan has been implemented, you can gain knowledge regarding the validity of your timeline and whether the action items are sufficient to meet the outcomes as planned. You may find that outcomes have been met and it is time to define new outcomes and action items as you move on to implement more positive changes.

Conducting a Re-evaluation Documentation of Progress Toolkit Resources Summary



Evaluation of your department for improvement after safety interventions is a critical part of any quality improvement process in that it validates that you are on the right path. While we invest hours of time and critical thinking in our original plan, we must always be prepared to alter our plan should we discover that the road to completion was not as we expected. How many of us can recall a project that went completely as planned? By re-evaluating and adjusting our project plan, we keep the workplace violence initiative relevant to the goals we would like to see achieved and allow ourselves to have a greater impact on change. To effectively adjust our project plan, we need to take periodic "snapshots" of where we are in our workplace violence initiative. It will help us define what is working, improving, not working and what we need to do better.

Timing is key to the re-evaluation of your department. At the outset of your project plan, determine what a reasonable time frame would be for re-evaluation with the assessment tools used in Step Two (Emergency Department Assessment Tool, Staff Assessment Survey). You may find that there are designated re-evaluation time frames necessitated by accreditation standards. You may find that there are elements of your project plan, certain outcomes or action items, that require a focused re-evaluation to gauge progress. The assessment tools that have been provided in this ENA toolkit are designed to allow a focused assessment of areas that are specifically impacted by your project plan (such as the environment or staff perceptions). You may have had occurrences since the beginning of the workplace violence initiative that have exposed new priorities in terms of safety.

Here are some tips for conducting your re-evaluation:

  • Use the same tools for re-evaluation as for your initial assessment so you are comparing similar data; if you introduce new assessment tools be sure to use the first data collection as a baseline in which to compare other data collected during re-evaluation.
  • As part of the re-evaluation, get feedback from your workplace violence team; what do they feel has worked, has the team dynamic been effective and what are the barriers they have encountered. All of these observations may have an impact on how you define your project plan going forward.
  • Don't forget to use the occurrence reports as a source of re-evaluation information; when reviewing reports, use those that have been documented since the last assessment took place so there is no overlap.
  • Document all assessments and summarize changes that are apparent based on the results.


Documentation of your re-evaluation findings is a critical step because this information can be shared with a variety of audiences that are key to the success of your workplace violence initiative. Share the summary information you collect with these groups:

  • Workplace Violence Team: This is the group that likely has the most time and initiative invested in the process of developing a plan to mitigate workplace violence. The documentation of the re-evaluation will help this group define the direction they will take with the original plan they devised and look towards ongoing and future goals.
  • Administration: Because this is a continuous quality improvement effort, the documentation of interim evaluation of progress is important to show evidence of the quality improvement effort to institutional accrediting and licensing authorities. If there is a Quality Assurance or Continuous Quality Improvement committee within your institution, consult with them to find the best way for you to report your findings so that they are useful to administration. Additionally, management within the insitution will need to see evidence that the workplace violence project is a productive use of resources. Documentation of findings and connecting the re-evaluation to the project plans as you have developed them will demonstrate to management that this is a valuable project and a wise use of time, skill and money.
  • Staff: A common pitfall when working through a project is to report results to supervising personnel or adminstrators that approve the project and forgetting to demonstrate and communicate progress to those that the outcomes will affect the most. Sharing your findings with the emergency department staff, that is, documenting progress through a re-evaluation and demonstrating that you are will to take information acquired through this process and make adjustments to achieve a bigger safety impact, will go far in gaining the trust from the staff members in the emergency department, both for the project and the changes implemented and in the leaders of the project.

The following is a list of toolkit resources and references used in Step Two: Analyze your Emergency Department's Present Status:

In completing this step, we emphasized the importance of using similar tools for both evaluation and re-evaluation so you are comparing similar data and can begin to draw some conclusions about the progress that has been made. You should have all the elements necessary to measure and document the progress you have made towards achieving the outcomes you have stated in Step Two of this process. More importantly, completion of this step represents the achievement of one cycle of this quality improvement inititative. From understanding the issue, assessing the current situation, defining where you want to be (outcomes) and how to get there (action plan), this final step evaluates the impact of the choices you have made so far and gives you the ability to make adjustments in your plan. From this point, the cycle continues until you re-evaluate again and measure progress and either complete parts of your plan and start to work towards new targets or readjust and work through existing choices.

We learned that it is important to share information with key people when the re-evaluation step is completed in the form of a summary of progress. The format of this summary should follow that of other quality improvement projects in your institution so that progress can be clearly demonstrated to accrediting or licensing organizations, administration and management.

Conclusion and Acknowledgements