CHOOSING THE RIGHT TOOL SESLHD CGU CPI Training September 2014.

SESLHD CGU CPI Training September 2014

CHOOSING THE RIGHT TOOL


TALLY SHEETS

• Can be used to collect evidence when diagnosing the problem

• Can also be used in the intervention stage to monitor progress

• Data for Tally Sheets can be collected retrospectively, concurrently or prospectively


DESIGNING AND USING A TALLY SHEET

• Decide on area and category of performance or problem to be solved

• Design a simple form or collecting method

• Agree on time period for collection

• Trial tool

• Train people on how to use tool

• Collect data

• Analyse data


SAMPLE TALLY SHEETProject: Admission delays Name ( if applicable Shift: All

Location:

Date

Reason: 10/3 11/3 12/3 13/3 14/3 15/3 16/3

Lab delay II IIII II III III

No available beds I IIII III II I II I

Incomplete patient info I IIII I I II III IIII I

II

Total 4 12 4 6 6 4 6


FLOW CHARTS

• Pictures of process

• Maps a sequence of events in a process.

• Can be applied to anything from mopping the floor to servicing a product

• Useful to clarify procedures

• Helps detect areas of inefficiency

• One of the first tools used in the diagnostic phase


TYPES OF FLOW CHARTS

High level flow chart (macro)

• a diagram that describes the overall process

Low level flow chart (mini and micro)

• a diagram that provides more detail to the major steps of the high level flow chart.


Preparefor pregnancy

Suspect Pregnancy

Confirm Pregnancy

Antenatal care

Labour/Delivery

Postnatal care

Spontaneous labour

Failure to progress

Augmentation

Vaginal birth

Foetal/Maternal

complications

Plannedvaginal birth

Planned LSCS

LSCS

Mat/foetal

compli-cations

InducedLabour

Conception

Labour/ Delivery

Failureto

progress

Brent James IHC


BRAIN STORMING• Method to get ideas from groups

• Silent

• Sticky notes

• Display the problem

• Write one idea, cause concept on each sticky note providing a clear expression of issues (5-7 words)

• Stick on flat surface


AFFINITY DIAGRAMS• Useful tool for gathering and organising ideas, opinions

or issues identified by the team• Adds structure to a large or complicated issue by

breaking it down into categories• Allows for the team to reach agreement on an issue or

situation • The diagram is usually created after brain-storming

• Silently group similar groups together

• Remove duplicates

• Add in main headings• Identifies the theme for each group of ideas and

provided a title


AFFINITY DIAGRAM

CategoryCategory Category Category Category

Sub-categories are grouped and then a main category heading assigned


CAUSE AND EFFECT DIAGRAMS

• Informal, qualitative data

• It is a graphical display of an organised list of possible causes, solutions, or factors, focused on one topic or objective

• Used to quickly organise and categorise ideas generated in brain storming session

• Helps you to see relationships between causes

• Causes can be prioritised through multi voting

• Also known as a Fishbone or Ishikawa diagram

http://images.google.com/imgres?imgurl=http://bp1.blogger.com/_5NhPekd5TdE/Rhk1zLtqDAI/AAAAAAAAALE/jEgzHnqztAk/s400/fishbone.jpg&imgrefurl=http://learnsigma.com/cause-effect-diagrams/&usg=__3shvihwp2NrkGZf1Wvzb-hgncTc=&h=196&w=218&sz=6&hl=en&start=306&tbnid=wYFKderSLzNPFM:&tbnh=96&tbnw=107&prev=/images?q%3Dcause%2Band%2Beffect%2Bdiagrams%26gbv%3D2%26ndsp%3D20%26hl%3Den%26rlz%3D1T4WZPA_enAU314AU314%26sa%3DN%26start%3D300


CAUSE AND EFFECT DIAGRAM

Theme 1 Theme 2 Theme 3

Theme 4Theme 5 Theme 6

Effect


ISHIKAWA DIAGRAM SHOWING CAUSES OF POOR PAIN ASSESSMENT

Poor Pain Assessment

Not part of routine education

Education

Not know how to use pain scores

Too complex to understand

Culture

Traditionally not done

Considered unimportant

Not formally documented/ scored

Documentation

Shortage of time

Cumbersome

Time constraints

Inadequate reminders

Not asked for by doctors

Forgetfulness

Dr Hema Rajappa, RACP CPI – 2012

Inadequate reminders


Children not on pathway

ACT

Out of Area

Moved interstate

Moved overseas

Live rural NSW

Feel it would be too difficult

Travel issues

Assistance

Money

Chaotic family

Parental issues

Foster family

Moved and forget to tell

NeurosurgicalEmergencies

Medically unstable

Seizures

Medical issues

New therapists

Locums

New doctors

Saw local paediatrician

Team issues

Lack of understanding

Dr Lydia Garside, RACP CPI - 2012


Lack of Paeds Experience in ED (med/nursing)

Lack of senior supervision AH(ED/Paeds)

Inexper Paeds Reg/RMO

Health care providers Workplace GPs

Avoidable inpatient admissions

ParentsPatient FlowHospital culture

Parental Anxiety and pushiness

Lack of Ambulatory Care

Lack of paediatric outpatient appointments

Lack of knowledge about referral pathways

Lack of access to GPs in hours and afterhours

GPs create expectation of admission if sent from their rooms. This undermines parents confidence to be d/c from ED

Unrealistic expectations of the ability of ED to “fix” their child

Pressure from ED to move patients (Bed Block)

“4 hour rule”

Traditional or standard treatment is as an inpatient

ED staff create expectation of inpatient admission during workup

Lack of community nursing

Parents unconfident and unskilled at caring for sick child at home

Cause and Effect Diagram

Dr John Cass-Verco, RACP CPI – 2012


CAUSES OF DID NOT ATTEND IN OPD

SYSTEM STAFF

DidNot attendin OPD

Appointment Not clearly written

Illegible hand writing

Appointment Not Re-scheduled

Wrong disciplineClinic not blocked

Patient not informed of new appointment

Doctors not available

On leave

On conference

Communication

No care giver

Financial difficulty

Long waiting time

Feel well

Sufficient medication

Tight work schedule

No time

Time off not approvedby company

High out-patientcharges

UnemployedInstructions not clear

Language barrier Instructions not given

Change hospital

Seek 2nd opinionUnsatisfied service

ServiceNo phone number

Contact

Wrong phone number

Message not delivered

Sufficient medication

Physically not around

Too farPatient’s ability

Cancelled on same day

Forgot/overlooked

Data

Not Updated Wrong entry

Appointment

Patient has two appointments

Not updated(downtime)

Appointment datetoo far ahead

Downtime

Slowing down process

Long waitingtime

New staff

Not familiar With system

Wrong appointment

No orientation

Phone constantly engaged

Program

No mandatory fields

Contact number not obtained

PATIENT

Transport

Appointment

Inaccessibility


MULTI VOTING

An informal, non scientific way to determine priorities from a list of alternatives using team consensus.


THE AIM OF MULTI VOTING IS TO:

Reduce a list of many issues to a more manageable few

Ensure all team members have equal input into decision making

Not meant to provide a detailed analysis of the alternatives.


HOW TO MULTI VOTERound One:

1) Count the number of post-it notes and halve to determine the number of votes (e.g. if 42 post-it notes each person gets 21 votes)

2) Voting is completed in silence by individuals

3) After voting is completed, remove any post-it notes with 0, 1 and 2

Round Two (Weighted Voting):

1) Count the remaining post-it notes and halve to determine the numberof votes

2) Participants vote using weighted voting. The number of votes can be allocated on the single most important issue or between a number of issues


Option 2

MULTI-VOTING AN EXAMPLE

Option 1

Option 9

Option 3

Option 4 Option 5Option 6

Option 7Option 8

Round One


MULTI-VOTING AN EXAMPLE

Option 1 Option 3

Option 5Option 6

Option 8

Round Two


PARETO PRINCIPLE• Also known as the 80/20 rule.

• Means that in anything, a few (20 percent) are vital and many (80 percent) are useful.

• States that, for many events roughly 80% of the effects come from 20% of the causes

• Examples:

• 20% of the people own 80% of the world’s wealth• 80% of your time is spent on 20% of staff• 80% of the time you walk on 20% of your carpet

• suggests that teams need to focus 80% of their energies on the 20% that matters


PARETO CHART

• A graphical display of the relative weights or frequencies of competing choices or options

• A bar chart sorted from greatest to smallest, that summarises the relative frequencies of choices or options within a class (nominal data)

• Often includes a cumulative total line

• Can be constructed using many data collection methods such as brainstorming, multivoting, tally sheets and clinical indicator data sets.


39 13 5 4 3 358.2 19.4 7.5 6.0 4.5 4.5

58.2 77.6 85.1 91.0 95.5 100.0

0

10

20

30

40

50

60

70

0

20

40

60

80

100

Defect

CountPercentCum %

Per

cent

Cou

ntCauses of discharge delay from emergency


Sta

ff p

rob

lem

s

Pa

ren

tal i

ssu

es

Ou

t of a

rea

Me

dic

al i

ssu

es

Tra

vel i

ssu

es

0

20

40

60

80

100

120

140

160

180

200

Reasons patients not followed up after brain injury

Below Cutoff

Above Cutoff

Cumulative Total

Cut Off

Causes

Fre

qu

ency

Pareto chart


La

ck o

f am

bu

lato

ry c

are

un

it

Ine

xpe

rien

ced

ED

sta

ff

La

ck o

f se

nio

r su

pe

rvis

io...

Pa

ren

tal a

nxi

ety

4 h

ou

r ru

le

Ine

xpe

rince

d P

ae

ds

reg

Tra

diti

on

al m

od

el o

f ca

re

La

ck o

f acc

ess

to G

P

0

10

20

30

40

50

60

70

Pareto ChartCauses of Avoidable Admissions

Below Cutoff

Above Cutoff

Cumulative Total

Cut OffCauses

Fre

qu

en

cy


MULTIPLE PDSA CYCLE RAMPS

Detai

l Des

ign

A P

S D

AP

SD

A P

S D

D S

P A

A P

S D

AP

SD

A P

S D

D S

P A

A P

S D

AP

SD

A P

S D

D S

P A

A P

S D

AP

SD

A P

S D

D S

P A

Triage Diagnostic Testing

Fast TrackPatients

Capacity/Demand


MEASUREMENT

Measurement helps the team to understand the impact of the changes trialled.

To provide evidence that the intervention has resulted in an improvement

To justify permanent implementation of the changes

Critical part of testing and implementing change.


MEASUREMENT DURING PDSA CYCLESCollect useful data, not perfect data. The purpose of the data is learning, not evaluation.

Provide information and training for those collecting the data

Use a pencil and paper if an information system is not available

Use sampling as part of the plan to collect the data

Use qualitative and quantitative data

Record what went wrong during the data collection

Use what was learnt during the Interventions phase to inform an ongoing data collection plan


MEASUREMENT DURING PDSA CYCLES

Achieving success in a PDSA cycle does not guarantee sustained improvement.

The successful interventions then need to be formally implemented.

Implementing a change means making it a permanent part of normal business.

Only implement a change you know will result in an improvement


PROCESS AND OUTCOME MEASURES

Process Measures: Number of completed falls risk assessment, management plans, medication reviews, allied health referrals

Outcomes Measures: Number of falls, severity of injuries from falls, cost of injuries, LOS


MEASURING IMPACT

Plot data over time

Focus on measures that are directly related to your aim

Collect the data on the measure and plot the data as a run chart or annotated run chart.

The minimum standard to monitor progress is an annotated run chart.

This plots the performance of the system over time an included a note about key events during the period


EXAMPLE RUN CHART (ANNOTATED)

Jan Feb Mar Apr May Jun July Aug Sept Oct Nov Dec

0

2

4

6

8

10

12

14

Goal

Number of Patients Acquiring a Pressure Injury: 2013

Nu

mb

er

of

Pa

-ti

en

ts

Introduce policy on risk assessment.

Introduce pressure relieving mattresses


PERCENTAGES

Numerator / denominator

Can be plotted on a graph


RATES

Allow comparison of apples with apples

Often used to compare performance between wards and hospitals

Examples include number of falls / 1000 bed days



USING GRAPHS

• Graphs and Charts:

• Help visualize changes in a process over time

• Compares performance before and after an intervention.

• Types of Graphs:

• Bar Graphs• Pie Charts• Run Charts

http://images.google.com/imgres?imgurl=http://www.blueclaw-db.com/download/barchart.gif&imgrefurl=http://www.blueclaw-db.com/download/barchart_access_form.htm&usg=__vZ5KDLddUfl-oo_YwNn6Zdh0Tvg=&h=336&w=369&sz=5&hl=en&start=1&tbnid=d6QaFOhtAaeFeM:&tbnh=111&tbnw=122&prev=/images?q%3Dgraphs%2Band%2Bcharts%26gbv%3D2%26hl%3Den%26rlz%3D1T4WZPA_enAU314AU314

http://images.google.com/imgres?imgurl=http://www.theblog.ca/wp-content/uploads/2006/12/waterusagegraph.jpg&imgrefurl=http://www.theblog.ca/ez-components&usg=__M7Ruqza8TsUOjehVmjv-0dmK6w8=&h=249&w=399&sz=19&hl=en&start=20&tbnid=2bp2ycN8kFT9WM:&tbnh=77&tbnw=124&prev=/images?q%3Dgraphs%2Band%2Bcharts%26gbv%3D2%26hl%3Den%26rlz%3D1T4WZPA_enAU314AU314

http://images.google.com/imgres?imgurl=http://www.jpowered.com/php-scripts/area-graph/images/area-graph-401x402.gif&imgrefurl=http://www.jpowered.com/php-scripts/area-graph/&usg=__dXr5p3enORF7cntEICTxf8gzMOs=&h=402&w=401&sz=11&hl=en&start=53&tbnid=duok6vNxAdChoM:&tbnh=124&tbnw=124&prev=/images?q%3Dgraphs%2Band%2Bcharts%26gbv%3D2%26ndsp%3D20%26hl%3Den%26rlz%3D1T4WZPA_enAU314AU314%26sa%3DN%26start%3D40


WHY USE GRAPHS?

• Graphs /demonstrates the message

• Managers do no read all information contained within a report.

• Managers analyse figures and graphs to obtain information.

• The old saying” a picture is worth a thousand words”.

• Be accurate and clear


EXAMPLE BAR GRAPH


EXAMPLE PIE GRAPH


RUN CHARTS

A run chart is data such as counts, mean values and proportions that have been collected and plotted in time order

Annotated run chart records interventions

A run chart can assist in understanding variation and are used to examine data for trends or other patterns that occur over time


RUN CHART


ANNOTATED RUN CHART

WHAT IS VARIATION?

Everything varies - no two things are alike

Recognising this is a start but not enough: must understand it’s effect on outcomes and then manage it as appropriate


DIFFERENT TYPES OF VARIATION

Common Cause Variation

Stable in time and therefore relatively predictable

For example the traffic lights which hold us up today will probably hold us up in the next week


DIFFERENT TYPES OF VARIATION

Special Cause Variation

Irregular in time and therefore unpredictable

For example a police convoy escorting a wide load


CONTROLLED VARIATION

stable, consistent pattern of variation

“chance”/constant causes

0

10

20

30

40

50

60

70

80

F M A M J J A S O N D J F M A M J J A S O N D

Upper process

limit

Mean

Lower process

limit


UNCONTROLLED VARIATION

pattern changes over time

“assignable”/special causes

0

20

40

60

80

100

F M A M J J A S O N D J F M A M J J A S O N D


Date post:	18-Jan-2016
Category:	Documents
Upload:	pamela-ilene-shepherd
View:	237 times
Download:	4 times

CHOOSING THE RIGHT TOOL SESLHD CGU CPI Training September 2014.

Documents