SESLHD CGU CPI Training September 2014
CHOOSING THE RIGHT TOOL
SESLHD CGU CPI Training September 2014
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
SESLHD CGU CPI Training September 2014
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
SESLHD CGU CPI Training September 2014
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
SESLHD CGU CPI Training September 2014
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
SESLHD CGU CPI Training September 2014
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.
SESLHD CGU CPI Training September 2014
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
SESLHD CGU CPI Training September 2014
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
SESLHD CGU CPI Training September 2014
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
SESLHD CGU CPI Training September 2014
AFFINITY DIAGRAM
CategoryCategory Category Category Category
Sub-categories are grouped and then a main category heading assigned
SESLHD CGU CPI Training September 2014
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
SESLHD CGU CPI Training September 2014
CAUSE AND EFFECT DIAGRAM
Theme 1 Theme 2 Theme 3
Theme 4Theme 5 Theme 6
Effect
SESLHD CGU CPI Training September 2014
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
SESLHD CGU CPI Training September 2014
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
SESLHD CGU CPI Training September 2014
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
SESLHD CGU CPI Training September 2014
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
SESLHD CGU CPI Training September 2014
MULTI VOTING
An informal, non scientific way to determine priorities from a list of alternatives using team consensus.
SESLHD CGU CPI Training September 2014
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.
SESLHD CGU CPI Training September 2014
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
SESLHD CGU CPI Training September 2014
Option 2
MULTI-VOTING AN EXAMPLE
Option 1
Option 9
Option 3
Option 4 Option 5Option 6
Option 7Option 8
Round One
SESLHD CGU CPI Training September 2014
MULTI-VOTING AN EXAMPLE
Option 1 Option 3
Option 5Option 6
Option 8
Round Two
SESLHD CGU CPI Training September 2014
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
SESLHD CGU CPI Training September 2014
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.
SESLHD CGU CPI Training September 2014
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
SESLHD CGU CPI Training September 2014
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
SESLHD CGU CPI Training September 2014
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
SESLHD CGU CPI Training September 2014
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
SESLHD CGU CPI Training September 2014
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.
SESLHD CGU CPI Training September 2014
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
SESLHD CGU CPI Training September 2014
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
SESLHD CGU CPI Training September 2014
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
SESLHD CGU CPI Training September 2014
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
SESLHD CGU CPI Training September 2014
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
SESLHD CGU CPI Training September 2014
PERCENTAGES
Numerator / denominator
Can be plotted on a graph
SESLHD CGU CPI Training September 2014
RATES
Allow comparison of apples with apples
Often used to compare performance between wards and hospitals
Examples include number of falls / 1000 bed days
SESLHD CGU CPI Training September 2014
SESLHD CGU CPI Training September 2014
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
SESLHD CGU CPI Training September 2014
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
SESLHD CGU CPI Training September 2014
EXAMPLE BAR GRAPH
SESLHD CGU CPI Training September 2014
EXAMPLE PIE GRAPH
SESLHD CGU CPI Training September 2014
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
SESLHD CGU CPI Training September 2014
RUN CHART
SESLHD CGU CPI Training September 2014
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
SESLHD CGU CPI Training September 2014
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
SESLHD CGU CPI Training September 2014
DIFFERENT TYPES OF VARIATION
Special Cause Variation
Irregular in time and therefore unpredictable
For example a police convoy escorting a wide load
SESLHD CGU CPI Training September 2014
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
SESLHD CGU CPI Training September 2014
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
SESLHD CGU CPI Training September 2014