East Central Regional Hospital

PERFORMANCE

IMPROVEMENT

REFRESHERLL Quality Management DepartmentRevised 11/03

This is a Typical Organizational

Direction !

?

?

This is the Preferred Organizational

Direction !

Our Mission

To provide quality mental health/developmental disabilities care and

treatment to our consumers

East Central Regional Hospital

Our Vision

To use resources, creativity, and innovation to become a

CENTER OF EXCELLENCE.

East Central Regional Hospital

Performance Improvementis a continuous effort of assessment,

evaluation and adaptation by an organization to improve the outcome of services, processes and functions.

Performance Improvement is every employee’s

concern!

No matter what your job, you play an important role in

helping provide quality patient care.Performance Improvement is on-

going!

Being committed to quality doesn’t mean reaching a goal, then quitting.

Even when something is working well, there is room for improvement.

BrainstormingAffinity Diagram

Cause and Effect Diagram (“Fishbone”)Flow Chart

ChecksheetsLine Graph

Pareto Chart Histograms

Performance Improvement Tools

HOW DO WE KNOW WHICH TOOLS TO USE?

Tools for generating ideas, setting priorities, providing direction,

understanding root causes, and helping to understand processes:

BrainstormingAffinity Diagram

Cause and Effect Diagram (“Fishbone”)Flow Chart

,

Performance Improvement Tools

(These are Qualitative Tools which focus on data describing consumers, occurrences & conditions)

Creativity Large Number of Ideas All team members involved Sense of ownership in decisions Input to other Tools

BrainstormingWhat is Brainstorming ?

A tool used by teams for creative exploration of options in

an environment free of criticism.

Benefits of Brainstorming

Brainstorming Ground Rules Active participation by everyone No discussion Build on others’ ideas Display ideas as presented Set a time limit Clarify and combine

What Is An Affinity Diagram?

A tool that gathers lots of “language data”, like ideas and opinions and then sorts and groups the related ideas.

Display Ideas

Sort Ideas into Related Groups

Drawing Finished Affinity

Superheader

Header

Idea

Idea

Idea

Header

Idea

Idea

Idea

Header

Idea

Idea

Idea

LL- QM DEPT.

What Is A Cause and Effect Diagram ?

(“Fishbone Diagram”)A tool that helps identify, sort, and display possible causes of a problem in a process.

Benefits of Using a Cause and Effect Diagram: Encourages group participation Uses an orderly, easy-to-read format Increases knowledge of what is happening in the process

Methods

Effect

People

Environment

Equipment

Methods

Late for Work

People

Environment

Equipment

Cause & Effect Diagram

EXAMPLE: Why are employees late for work?

Out of gas

Son misplaced books

Forgot to set clock

caught by train

Dog needed walking

car wouldn’t start

Tried a new route

Raining hard

LL QM Dept.

What Is A Flow Chart?

A diagram that uses graphic symbols to show the nature and flow of steps in a process.

Benefits of Using a Flow Chart: Promote process understanding Provide a tool for training Identify problem areas and improvement opportunities

Symbols Used in Flowcharts

Start/End

Process Step

Decision No

Yes

ConnectorMeasurement M

An example of a Flow Chart

D ec ide to eatlunc h

D id I br inglunc h?

G et lunc h fromrefr igerator

G o to Central

Kitc hen?

G et m oney. G o to Kitc hen

Eat lunc h

S elec t food anddrink

P ay for lunc h

G o to lounge D is c ard tras h G o to off ic e

Eat lunc h

T ake tray totray line

G o offc am pus ?

G et w allet andc ar keys

G et in to c arD ec ide w here

to eat D rive to lunc h O rder lunc h P ay for lunc h

Eat lunc h D is c ard tras h G et in to c ar D rive to w ork G o to off ic eP ut w allet and

keys aw ay

Res um e w ork

G o to off ic eP ut w allet and

keys aw ay

F orget lunc h,go to m eeting

ins teads top

S top

Yes

Yes

Yes

N o

N o

N o

L unch

Statistical Tools used for measuring performance, collecting and displaying data, and monitoring performance over

time:

Check Sheets Line Graph Pareto Chart Histograms

Performance Improvement Tools(These are Quantitative Tools and focus on specific measurement units)

CHECKSHEETS

Record data for further analysis, provide a historical analysis and introduce data collection methods.

TIME

(Minutes)

Time of Day8 109 11 12 1 32

0

10

5

15

20

25

Turn-around time

1-5 min

6-10 min

11-15 min

16-20 min

Dwl 11/03

What Is A Line Graph?

A line graph that shows results of a process over time.

Why Use Line Graphs? Analyze and check the data for patterns Monitor process performance Communicate process performance

Number of Restrictive Procedures Used Per Shift

0

2

4

6

8

10

Month

# P

rocedure

s U

sed

DayEveningNight

(The chart above is an example only, not an actual representation of restrictive procedures used)

What Is A Pareto Chart?

A graph using a set of bars to show how often a problem occurs.

Why use a Pareto Chart? Breaks big problems into smaller pieces Identifies most significant factors Shows where to focus efforts and improvement opportunities Allows better use of limited resources

05

1015202530354045

Number of Patients

Reason

Reasons Patients are Readmitted within 30 Days

Stopped takingmedicationsMajor life change

No Where to Stay

Commission of Crime

Other

(The chart above is an example only, not an actual representation of reasons for re-admissions)

What Is A Histogram?

A bar chart that shows the distribution of data.It’s like a “snapshot” of the process.

When are Histograms used? To summarize large data sets in a picture form Compare measurements to expectations Communicate information to the team Assist in decision making

05

1015202530354045

Number of Patients

Wait Times

Time Required to be Scheduled for Podiatry Appointment

2 Weeks or less2-4 WeeksMore than 4 Weeks

(The chart above is an example only, not an actual representation of appointment wait times)

What Is Data Collection?

Data Collectionis

obtaining useful information.

The issue is not: How do we collect data?It is: How do we obtain useful data?

Why Collect Data?

To establish a factual basis for making decisions

“I think the problem is……….”becomes

“The data indicate the problem is…..”

FOCUS-PDCAFOCUS-PDCAPerformance Improvement ModelPerformance Improvement Model

DOCHECK

PLAN

Improvement Data Collection

Improvement Data Collection Data Analysis

Data for process improvement

Find a process to improve

Organize a team that knows the process

Clarify current knowledge of the process

Understand causes of process variation

Select the process improvement

ACT To hold gain To continue improvement

Examples of Quality in a Hospital Setting JCAHO 1992

Find A Process to Improve

ThinK: High Volume? High Risk?Problem Prone? Externally mandated?Who will benefit from the process improvement? How does it fit the mission?

Organize a Team that knows the process

ThinK: Does the team include members who do the work & know the process ?

Clarify Current Knowledge of the Process ThinK: What are the things that contribute to the process not working the way we expect it will? Is this the actual flow of the process or the perceived flow?

?

?

?Perceived Actual

Understand Causes of Process Variation

ThinK: Can we use the data collected to determine specific, measurable andcontrollable variations?

Select the Process Improvement

ThinK: What changes can be made to improve the process?

Can we test the changes in a pilot project?

Plan the improvement and continued data collection.

ThinK: How do we make the changes that were selected as possible solutions and what are our goals and targets and how can we reach them?

Do the improvement, data collection and analysis

ThinK: As we begin the process improvement are we getting the results/outcomes we expected? Are there any surprises?

Check and study the results

ThinK: If there were surprises or unexpected outcomes, can we do anything about them? Has the process improvement been successful, or will it be necessary to modify the change?

Act to hold the gain and continue to improve the process.

ThinK: How will the improvement be implemented beyond the pilot, if one was used, and can the team find another potential improvement within the process? Are we prepared to return to “Plan” orearlier steps in the FOCUS-PDCA if needed?

FOCUS-PDCAFOCUS-PDCAPerformance Improvement ModelPerformance Improvement Model

DOCHECK

PLAN

Improvement Data Collection

Improvement Data Collection Data Analysis

Data for process improvement

Find a process to improve

Organize a team that knows the process

Clarify current knowledge of the process

Understand causes of process variation

Select the process improvement

ACT

To hold gain To continue improvement

Examples of Quality in a Hospital Setting JCAHO 1992

If necessary, you can start the FOCUS-PDCA again!

East Central Regional Hospital

Working together to improve Services, Safety and Quality of Care for all our consumers!