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MHVI 2-Day Quality Improvement Training

September 9, 2015

Welcome Back!Questions/Feedback from Day 1

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Today’s Agenda

• Plan-Do-Study-Act (PDSA) Cycle o Stage One, Steps 3, 4, and 5o Plan Stage Work Sessiono Stage Two, Overviewo Stage Three, Overviewo Stage Four, Overviewo QI Project Examples and Tips

• Next Steps

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PDSA RecapPLAN• Step 1: Getting

Started• Step 2: Assemble

the team• Step 3: Examine the

Current Approach• Step 4: Identify

Potential Solutions• Step 5: Develop an

Improvement Theory

DO• Step 6: Test the

Theory

ACT• Step 8:

Standardize the Improvement or Develop a New Theory

• Step 9: Establish Future Plans

STUDY• Step 7: Study the

Results

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Step 3: Examine the Current Approach(Continued)

• Examine the current approach or process flow

• Obtain existing baseline data, or create and execute a data collection plan to understand the current approach

• Obtain input from families• Analyze and display baseline data• Determine root cause(s) of

problem• Revise aim statement based on

baseline data as neededGuidebook, 2nd Edition, pages 30 & 36

• Problem Solving– When confronted with a

problem, most people like to tackle the obvious symptom and fix it.

– This often results in more problems

– Using a systematic approach to analyze the problem and find the root cause is more effective and efficient

– Tools can help to identify problems that aren’t apparent on the surface (root cause)

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Step 3: Examine the Current Approach

Guidebook, 2nd Edition, pages 30 & 36

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QI Tackles Root Cause• Root cause analysis is the process of identifying the

underlying factors that lead to a problem• Asks ‘why?’ a problem occurs, looking beyond the

obvious symptoms• Forces us to avoid jumping to a solution before we

really understand the problem

“We can’t solve problems by using the same kind of thinking we used when we created them.” - Einstein

For example…

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A Tool for Root Cause Analysis:Fishbone Diagrams

Fishbone Diagrams: Purpose

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• To identify and examine underlying or root causes of a problem

• To identify a target for your improvement that is likely to lead to change

• To explore possible causes of a problem

Guidebook, 2nd Edition, page 62

Memory Jogger, page 23

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Fishbone Diagrams: Construction

Step 1

• Write the problem statement in a box on the far right side of your paper, dry erase board, etc.

Step 2

• Draw an arrow (backbone) leading to that box

Step 3

• Draw smaller arrows (bones) leading to the backbone, and label these arrows with your major causes

Step 4

• For each cause, brainstorm minor causes related to each major cause and note them on the diagram by placing lines on each of the major bones.

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Example Fishbone Diagram

Interpret Your Fishbone Diagram• What causes came up again and again?• What causes came as a surprise?• What causes are within the group’s control or

influence?• What causes seem particularly important to

the team?• Do you know enough about these possible

causes to identify a root cause to address?

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Example: Families are not receiving the number of home visits that they should.

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Some Hints and Tips• Find the right problem or effect statement

– The problem statement should reflect an outcome of a process that you control or influence

– Be specific– Reach consensus

• Find causes that make sense and that you can impact– Ask “why?” to achieve a deep understanding– Know when to stop

Work Session: Developing a Fishbone Diagram

• As a team, develop a fishbone diagram for your QI project:– Listen for step-by-step guidance from the trainers– Use chart paper and sticky notes to create your

diagram

• Peer sharing: Be prepared to share your fishbone diagram with others.

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Potential Major Cause Categories

• People• Motivation/Incentives• Policy• Methods/Procedures• Environment• Information/Feedback• Data

17Memory Jogger, page 25

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Step Four: Identify Potential Solutions • Identify all potential

solutions to the problem based on the root cause(s)

• Review model or best practices to identify potential improvements

• Pick the best solution (the one most likely to accomplish your aim statement)Guidebook, 2nd Edition, pages 31 & 36

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Step Four: Process

Using the root cause, brainstorm all possible solutions

Search for similar

practices

Narrow to those you

have control or influence

over

Revisit your aim

statement

Pick the one most likely

to accomplish

your aim

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Brainstorming: Purpose

• To establish a common method for a team to creatively and efficiently generate a high volume of ideas on any topic by creating a process that is free of criticism and judgment.

Guidebook, 2nd Edition, page 58

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Brainstorming: When to Use

• To generate ideas about an opportunity for improvement

• To identify customers and/or stakeholders

• To identify potential solutions to the problem

Brainstorming: Structured ApproachStep 1 •Establish ground rules and define the issue or problem

Step 2 •Give participants 5-10 minutes to silently write down their ideas

Step 3 •Ask each participant to review their list and put a star next to their 3 clearest ideas

Step 4 •Have participants form pairs and share their 3 clearest ideas with each other and identify 4 ideas they want to be sure are shared with the whole team

Step 5 •Each pair shares their ideas (facilitator records or groups share cards with ideas captured)

Step 6 •Participants share any important ideas that are not already captured and ask clarifying questions

Step 7 •Collaborate to organize ideas into categories or identify themes

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A few Hints and Tips

• Useful for generating ideas and encouraging open thinking

• Fosters creativity

• Promotes building on the ideas of others

A Tool to Organize Ideas: Affinity Diagram

Group 1 Group 2 Group 3 Group 4

Idea

Idea

Idea

Idea

Idea

Idea

Idea

Idea

Idea

Idea

Idea

Idea

Idea

Idea

Idea

Idea

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• Creatively generate a large number of ideas

• Organize them into natural groupings

• Understand possible solutions to a problem

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Affinity Diagrams: Purpose

• To generate consensus

• When you need your team to think creatively

• To breakdown communication barriers

• To allow breakthroughs to emerge naturally

• To overcome “team paralysis”

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Affinity Diagrams: Step by StepStep 1 •Phrase the issue under discussion (in this case the root cause) as a full sentence

Step 2 •Brainstorm at least 20 solutions to the root cause of the problem•A “typical” Affinity has 40-60 items, but 100 or more are not unusual

Step 3 •Sort ideas (solutions) into 5 to 10 related groupings•Ideas (solutions) in each grouping should have an underlying theme that ties them together

Step 4 •For each grouping, create summary/header cards using consensus•Strive to capture the essence of all the ideas in each grouping

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Example Affinity Diagram

Identifying Potential Solutions: Hints and Tips

• Review Best/Model Practices related to the problem identified

• Look to your model developer and other programs for suggestions

• Narrow potential solutions to those within the team’s control or influence

• Further refine aim statement if needed• Pick the best solution – the one most likely to

accomplish team’s Aim Statement

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Work Session: Developing an Affinity Diagram

• Brainstorm potential solutions to the root cause of the problem your team identified– Take 5 minutes and brainstorm individually– Share your ideas with your team

• Write all unique ideas on cards (should have at least 20 cards)

• Group ideas that fit together (have a common theme that holds them together)

• Develop a descriptive title for each grouping that captures the common theme

Once your Affinity Diagram is Constructed…

• As a team, discuss the following questions:– What do you notice about the diagram? What

sticks out to you?– What does the diagram tell you about potential

solutions that could be tested? – What might you add to the diagram? Is anything

missing?– What solution will best address the root cause of

the problem identified in step 3?

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Lunch

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Step 5: Develop an Improvement Theory • Develop a theory for

improvement– What does the team predict

will happen if we use our solution?

– How will the team know if our prediction was correct?

– Use an “If/Then” approach

• Develop a strategy to test the theory– What will be tested? How?

When?– Who needs to know about the

test?Guidebook, 2nd Edition, pages 31 & 36

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If/Then Statements

• Use an “If/Then” approach to describe your theoryo “If we do______________, then we predict

______________________.”

• For example…o If we call families two days prior and the day of

their home visit, then more families will receive an adequate number of home visits.

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If/Then Statements• Develop If/Then statement(s) based on the

solutions you identified in Step 4• Your statement(s) should specify what will be

tested and how • Consider when the test will occur and who needs

to know about the test• You may need to develop more than one If/Then

statement• Adjust your aim statement accordingly, if needed• Record your If/Then statement(s) on your QI Team

Charter

Example Improvement Theory• Problem Statement: Families are not receiving

the number of home visits that they should• Aim Statement: By May 14th, 2013, the Sunny

County PAT program will increase the percent of families that receive the number of visits they should rom 72% to 80%.

• Improvement Theory (If/Then Statement): If the home visitor calls the family one business day prior to their visit, then Sunny County PAT’s intended service dosage will increase by 5%.

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Work Session: Developing an Improvement Theory

• As a team:o Develop an improvement theory (If/Then

Statement) for your QI project based on the solution you identified in Step 4.

• Record your improvement theory on your QI Team Charter and on a piece of chart paper

• Peer sharing: Be prepared to share your improvement theory with the larger group when we all come back together.

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Stages Two, Three, and FourSteps 6, 7, 8, and 9

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Stage Two: DOStep 6: Test the Theory

• Carry out the test• Collect, chart, and

display data to determine effectiveness of the test

• Document problems, unexpected observations, and side effects

Guidebook, 2nd Edition, pages 32 & 37

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Do Stage: How to• Take your improvement theory (If/Then

Statement) and plan for your test:o Prepare materials needed for your test

• Information/guidance documents, data collection documents, etc.

o Determine when your test will occur (start and end date)

• Creating a calendar/timeline can be very helpful hereo Determine who needs to know about your testoMeet with the people who will help you carryout

your test to share materials, timeline, data collection process, and answer questions

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Test!

• Test your improvement theory!

• Be sure to:– Implement your test for

long enough– Collect, track, and chart

data throughout your test

– Document problems and unexpected observations and side effects

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Never underestimate the value of an educated guess!

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Project Planning Work Session

• Revisit, add to, and update Team Charter• Review data sources and outline any

additional data needs and relevant plans• Create a project workplan for the remainder

of the team’s work

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Handout: Project Planning

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Stage Three: STUDYStep 7: Study the Results

• Primary focus is to determine if your test was successful.

• Do this by comparing the results of your test against:o Baseline datao Aim Statement

Guidebook, 2nd Edition, pages 32 & 38

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STUDY Stage: How To• Determine if your test was successful by:

o Compare results against baseline data and the measure of success (% or #) stated in your aim statement

o Answer the following questions:• Did the test work? • Did the results match the team’s If/Then

Theory?• Did the team notice any trends? • Was there an improvement?• Does more testing need to be done? • Were there any unintended side effects?

• Describe and document what you learned

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Stage Four: ACTStep 8: Standardize the Improvement or Develop a

New Theory• If your change was an

improvement you will want to consider the following:o Do you need to test the change

under different conditions (i.e. different time of the year, for longer, etc.)?

o Will your change improve performance in the future?

• If the likelihood of continued success is promising, make plans to standardize the improvemento Consider whether procedures or

guidance may need revision.Guidebook, 2nd Edition, pages 33, 34, & 39

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The ACT Stage: Step 8

• If your change was not an improvement you will want to consider the following:o Are better or different data needed?o Did we attack the wrong cause?o Did we pick the wrong solution?oWhat other approach might work better?

• Record your thoughts and begin the PDSA cycle again starting with PLAN to define a new or additional change

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Stage Four: ACTStep 9: Establish Future Plans

• Take steps to maintain your gains and accomplishments

• Make plans for additional improvements

• Spend time celebrating your success!

• Share your accomplishments with partners and stakeholders

• Begin your next PDSA cycleGuidebook, 2nd Edition, pages 34 & 39

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The ACT StageSteps 8 and 9: How to

• Standardize your improvement or develop a new improvement theory.

• Celebrate your success (even if your project did not yield the results you were hoping for) & recognize your team!

• Share your accomplishments with the interested parties you have kept informed throughout the project.

• Put processes in place to maintain your gains and accomplishments.

• Determine the next improvement project the team would like to conduct.

• Begin your next PDSA cycle!

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Example QI Project• Problem Statement: Families are not receiving the number of

home visits that they should.• Aim Statement: By May 14th, 2013, The Guidance Center will

increase by 5% the number of families that receive the number of visits they should.

• If/Then Statement: If the home visitor calls the family one business day prior to their visit, then the Guidance Center’s intended service dosage will increase by 5%.

• Study: After 3 months of testing the Improvement Theory, 96% of families received their expected number of visits (as compared to 60% of families receiving their expected number of visits prior to the test).

• Act: The program standardized the new calling procedure with all home visitors. Data collection continued to monitor the process. 55

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QI Project Tips• Think Big but Start Small• Process Mapping – Document what is, not

what you want it to be• Do not assume you know the solution• Take time to think about the Aim Statement –

Really think about it• Keep moving forward, test & learn• Keep others informed about the project – you

will need their input

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Fitting the Pieces Together• As your project takes shape,

be sure that you align the pieces:o The aim statement should

align with your if/then theoryo The if/then theory should

align with your testo The test should align with

your strategy for studying your results

o The strategy for studying your results should align with your aim statement

Next Steps• Provider Site CQI Teams (LIAs):

– Use knowledge and tools gained at this training and apply to LIA-specific CQI projects or HV CoIIN work

• LIA-specific – 2 CQI projects must be started per fiscal year and project documentation (team charters, tools, and story boards) submitted to MPHI on a quarterly basis

• HV CoIIN – documentation guidance from the CoIIN staff should be followed

– Schedule and conduct regular, internal CQI project meetings throughout the quarter

– Reach out to MPHI staff for TA when needed (available on an ongoing basis

– Attend quarterly CQI Learning Community webinars• NFP – October 20, 2015 from 8:30 am to 10 am• HFA/EHS – October 21, 2015 from 10 am to 11:30 am

– Participate in one CQI Learning Collaborative per year• Last meeting for FY15 – September 24, 2015; 10 am to 3 pm; Henry Center,

Lansing, MI• Initial meeting for FY16 – November 12, 2015; 9:30 am to 3:30 pm; location

TBD

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Next Steps• Local Leadership Group (LLG)

– Use knowledge and tools gained at this training and apply to current FY15 Learning Collaborative project/upcoming FY16 Learning Collaborative project

– Schedule and conduct regular, internal CQI project meetings throughout the quarter

– Submit required project documentation to MPHI for review and feedback according to predetermined dates

– Reach out to MPHI staff for TA when needed (available on an ongoing basis)

– Participate in one CQI Learning Collaborative per year• Last meeting for FY15 – September 21, 2015; 10 am to 3 pm; Lansing

Center, Lansing, MI• Initial meeting for FY16 – December 14, 2015; 10 am to 3 pm;

Lansing Center, Lansing, MI59

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Day 2 Wrap-Up• Closing Comments• MPHI Staff Contact Information• Evaluations• Adjourn

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Thank You!Best wishes on your quality journey!