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Applying Quality Improvement Techniques to Analyze Problems and Find
Solutions
The Open Forum
Leslie M. BeitschSeptember 17, 2009
Organize participation for performance improvement
• Big QI• Little qi• Leadership support and role
– What is leadership’s vision, commitment, expectation?
• Build the process strategically– Incorporate QI into broader initiatives (MAPP,
HP2010)– Involve others
To Carry Out a Quality Improvement Process, “Plan-Do-Check-Act”
Source: Turning Point Performance Management Collaborative, From Silos to Systems: Using Performance Management to Improve the Public’s Health , March 2003.
Plan
DoCheck
Act
Plan Plan changes aimed at improvement, matched to root causes
Do Carry out changes; try first on small scale
Check See if you get the desired results
Act Make changes based on what you learned; spread success
See Problem Solving, p. 12
To Carry Out a Quality Improvement Process, “Plan-Do-Check-Act”
Plan
DoCheck
Act
Regularly monitor and report progress.
• Regular reports necessary to chart progress
• Benchmark against self and others– Same industry, other industries
• Reports do not have to be computerized (although it helps!), expensive, color…
Some QI Tools to Help Teams Analyze Performance
Affinity Diagram
• It was created in the 1960s by Japanese anthropologist Jiro Kawakita.
• Tool for assimilating and understanding large amounts of information
• Draw out common themes from a large amount of information
• Discover all the hidden linkages
Affinity DiagramHow To Do It:
– Develop a clear purpose, problem, concern or issue statement to focus the group
– Materials needed: • sticky notes or 3x5 cards• marking pens,• large work surface
– Wall– table– floor.
.
Affinity Diagram
How To Do It:
– Process Steps:• Individual silent brainstorming • Record each idea with a marking pen on a
separate sticky note or card.• Need a complete statements – no one word
ideas
Exercise
Affinity Diagram
How To Do It:– Posting Step
• Each participant reads and randomly posts their ideas on the wall – one at a time
• Other participants can ask for clarification when an idea is read – no debate – just clarification
• Do not place the notes in any order - do not try to determine categories or headings in advance – use the whole wall
• After all ideas are posted – begin Silent Consensus
Affinity DiagramHow To Do It:• Silent Consensus:
• The entire team gathers around the posted notes• No talking during this step (remember the name…)• Look for ideas that seem to be related in some way• Move the Post-Its and place them side by side • Repeat until all notes are grouped• Okay to have “loners” that don’t seem to fit a group -
outliers• It’s all right to move a note someone else has already
moved.• If a note seems to belong in two groups, make a
second note
Affinity Diagrams• How To Complete It: Clarification Step:
– Participants can discuss the “results” of the chart– Any surprising patterns?– Any reasons for moving controversial notes.– A few more changes may be made – When ideas are grouped, select a heading for each group
• Look for a note in each grouping that captures the meaning of the group. If not create one
– Place it at the top of the group• highlight headers notes in a bright color.
– Combine groups into “super groups” if appropriate– Want 6 – 10 headers– Take the time to do this step – it is the foundation for the
other tools
Affinity Diagram Example
Issues Affecting the High Staff Turnover of Sunshine County Health Department
Issue Statement
LowSalary
LowSalary
Limited Professional Development
Limited Professional Development
LowMorale
LowMorale
Work Environment
Work Environment LeadershipLeadership Public Health
Misunderstood
Public HealthMisunderstood
Header Cards:
Cause and Effect Diagram
High StaffTurnover
Low SalaryPoor Morale
BudgetConstraints
LimitedProfessional Development
Training Availability
WorkUndervalued
WorkEnvironment
Poor Facilities
Lack ofCounty support
CareerAdvancement
Bad Neighborhoods
Outdated Equipment
HR System Restrictive
– Methods & Procedures– Motivation– Materials & Equipment– People – Information &
Feedback– Environment– Policy
Common root causesof performance problems
5 Whys
Five Why’s
Our influenza clinic was poorly attended
• Why? Residents had many opportunities• Why? There was a lot of competition• Why? Pharmacies are in on the action• Why? It brings customers in• Why? They can ‘multi-task’ in one stop
Other Explanations
Our influenza clinic was poorly attended
• Why? Residents had many opportunities
• Why? We didn’t advertise it well• Why? Inclement weather was a factor• Why? Our price wasn’t competitive• Why? The location wasn’t convenient
Five Why’s: Expand Scope Downward
My off white carpeting must be replaced
• Why? The carpeting has been stained• Why? My elder cat vomits periodically• Why? She is upset about something• Why? Her environment was
compromised• Why? I introduced a kitten last year
Five Why’s
I had to replace my car motor
• Why? The motor seized while in transit• Why? There was insufficient oil• Why? I have not maintained my car• Why? I didn’t make time for my service• Why? I did not make my car a priority
Ask “why” 5 times
People
Methods
Equipment Environment
Primary Cause1st Why
2nd Why
3rd Why
Primary Cause
Problem Statement
4th Why
5th Why
Cause and Effect Analysis (Fishbone)Cause and Effect Analysis (Fishbone)Cause and Effect Analysis (Fishbone)Cause and Effect Analysis (Fishbone)
Fishbone Fishbone DiagramDiagram
Our influenza clinic was poorly attended.
PeopleEnvironment
Equipment Methods
Primary Cause
They can multi-task in one stop
It brings customers in
Pharmacies are in on the action
Primary Cause
Problem Statement
Lots of competition
Residents had many opportunities
Staff unsure about how to post advertisements
No cross-training completed
We didn’t advertise it well
Missed deadlines at local paper for advertising
Turnover in staff person responsible for advertising
Primary Cause
Previous vendor was not delivering vaccine timely
Using new vendor
Vaccine costs more
Our price wasn’t competitive
Vendor had too many commitments and little vaccine to fulfill orders
Ask “why” 5 times
Flow Charting
“If you can't describe what you are doing as a process, you don't know what you're doing.”
W. Edwards Deming
Simple Flowchart Helps Understand
a Complex Process
FLOW CHARTPROCESS
AUDITPROCESS
IMPROVECAPABILITY
SORTPRODUCT
PLOTHISTOGRAM
ESTIMATEPROCESS
CAPABILITY
ANALYZEDATA
COLLECTDATA
CORRECTPROBLEMS PROBLEMS?
CAPABLE?
INCONTROL?
YES
NO
NO
Flow Charting• Flow charting is often the first step we take in
understanding a process • Organized combination of shapes, lines, and text• Flow charts provide a visual illustration, a picture of
the steps the process undergoes to complete it's assigned task
• From this graphic picture we can see a process and the elements comprising it
• Shows how interactions occur• Makes the invisible (less obvious) visible (more
obvious)
MappingMapQuest
• Takes directions and coverts them into a picture
• Shows various routes to a destination
• Shows communities you pass through to reach a destination
• Shows connecting roads• Shows faster and slower
routes• Provides alternative routes
Flow Chart• Takes procedures and
converts them into a visual• Shows the routes inputs
travel to become outputs• Shows handoffs• Shows connecting
processes• Highlights areas for
improvement• Triggers ideas to improve a
process
Flow Chart Benefits
• Creates a common vision• Establishes the “AS IS” baseline – Current State• Baseline to measure improvements• Identifies wasteful steps – activities/waits• Uncovers variations (usually unintended)• Shows where improvements could be made• Show potential impacts of improvements• Training tool
Flow Chart People Benefits
People involved in constructing a flow chart begin to: – Better understand the process– Understand the process in the same terms– Realize how the process and all the people
involved, including them, fit into the overall process or business
– Identify areas for improving the process– Become enthusiastic supporters to quality and
process improvement– Become process owners
Types of Flow Charts
• As Is – current state - baseline– Our task today!
• Could Be – improved state – transition
• Should Be – optimal state
Flow Charting Construction• Clearly define the process boundaries to be studied• Define the first and last steps – start and end points• Get the right people in the room• Decide on the level of detail
– Complete the big picture first – macro view– Fill in the details – micro view
• Gather information of how the process flows: • Experience• Observation• Conversation• Interviews• Research
• Clearly define each step in the process– Be accurate and honest
Flow Charting Steps• Use the simplest symbols possible – Post-Its • Make sure every loop has an escape • There is usually only one output arrow out of a process
box. Otherwise, it may require a decision diamond.• Trial process flow – walk though it in real time • Circulate the flowchart to other people involved in the
process to get their comments • Make changes if necessary
• Identify time lags and non-value-adding steps.
Flow Chart Construction• There is no one right way to develop a flowchart, but the
following guidelines provide a general structure:• Start with a simple one-line description or title of the
process being flowcharted , e.g., "How to..." • Using a top-down hierarchy, start with an oval symbol
named Start. • Connect each successive action step in the logical
sequence of events. • Reference detailed information through annotations or
connectors. • Follow the process through to completion, denoted by an
oval symbol named End
Flow Chart Symbols
Document
Wait/Delay
Storage
Data Base
Transport
Input
Output
Flow Lines
A Connector
Forms
CommentCollector
Input/OutputData
ManualOperation
Preparation
ManualInput
Display
Unfamiliar/Research
Constructing a Flow Chart
• Asking questions is the key to flow charting a process.
• For this process:– Who is the customer(s)?– Who is the supplier(s) ?– What is the first thing that happens? – What is the next thing that happens?– Where does the input(s) to the process come from? – How does the input(s) get to the process? – Where does the output(s) of this operation go? – Is their anything else that must be done at this point?
Exercise
Quality Improvement• Analyze the “As Is” flow chart• Look for Critical Processes• Look for Handoffs• Analyze with a Cause and Effect Diagram• Develop potential solutions• Develop the “Should Be” state• Communicate all changes• Track implementation progress• Document results• Present results
How Improvements Are Made
Focus on Critical Processes– Important sets of procedures or patterns of
tasks that determine success (i.e. customer satisfaction) for an organization or an individuals job.
What are the attributes of critical processes?
• They are few in number - usually 5 - 10• The critical processes of a flow chart should
capture 75-80% of the activities which determine the success of that process
• Critical processes describe what must occur on an on-going basis to achieve customer satisfaction.
• They can be mapped or diagrammed in a step-by-step format.
• They can be measured.• They can be improved
Improvement Opportunities
What to look for on a Flow Chart:– Duplication of effort– Unnecessary Activities/Steps/Tasks– Delays/Waits– Transports– Storage– Illogical Sequencing of Activities – Unclear Lines of Responsibility – Opportunities for Error – Supplier Error Opportunities– Disconnects
Improvement Opportunities
• Use a Cause and Effect Diagram to investigate areas identified on the “As Is” flow chart as areas that could be improved
• Can complete a micro level flow chart on specific process steps as required
• Fix the low hanging fruit first – quick success
• Involve customer/suppliers before any changes are made
Caution!!! In most processes:
– Few people have seen the total process and fully understand it!
– Those that designed the process now work elsewhere
– Work is being done that adds no value to customers
– Work the customer needs isn’t being done
– Rework is built into the process
– Inefficiencies are built into the process
– Workarounds have been developed that make the process appear to be working better than it really is
Advantages of Flow Charts
• Overview of the System
• Documents a system/process
• Shows Interrelationships
• Communication Tool
• Defines Roles
• Shows barriers/bottlenecks/problems
• Planning Tool for improvements
WIC Appointment
Child has WIC appt.
Show?
□ Due□ Overdue for shots?
Check report for immunization status
Due or overdue for shots?
Give parent immunization notice; answer or refer questions to DP&C nurse
Check report for C&TC eligibility & last exam
Check report for immunization status
Active on C&TC?
No
NoactionYes
No
No
No
Yes
Yes
Yes
Mail parent immunization notice
Encourage regular well child exams
Provide C&TC info/assist, encourage compliance w/exam schedule, code activity in Catch3
Memory Jogger II & Problem Solving Memory Jogger (Goal QPC) www.goalqpc.com
American Society for Quality (www.asq.org)