quality improvement tools-5

8/14/2019 Quality Improvement Tools-5

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Quality Improvement

Tools

Prepared by:Dr. Alber Paules


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Introduction

In order to improve a process capability to deliver

desired performance results, a systematic and fact-

based approach that enables you to implement

permanent solutions to root causes of problemsshould be used.

This approach necessities the use of the quality

improvement tools.


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Introduction

Quality improvement (QI) tools can be classified into

the following categories:

1. Process-analysis tools as flowchart.

2. Cause-analysis tools as fishbone diagram.

3. Idea-creating tools as brainstorming, affinity

grouping, and multivoting.

4. Data collection and analysis tools as histogram,Pareto chart, scatter diagram, run chart and

control chart.


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Introduction

These tools may be used at any stage of the QI

process according to the needed purpose. However,

each of these tools is typically used during certain

stage (stages) of the QI project. Whether you are following the DMAIC or the

FOCUS-PDCA methodologies, these tools have their

benefits during the sequential project stages.


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5

CQI Process Stages

Tools

Describe

process and

identify

sources of

variation

Conduct in-

depth analysis

to clarifyknowledge

and present

results

Identify

solutions,

weighalternatives

and make

choices

Designimprovements

Measure

effectiveness of

improvements

and monitor

stability of newly-

designed

processes

Flowchart X X

Cause-effect diagram X

Pareto diagram X X

Histogram X X

Scatter diagram X

Run and Control charts X

X


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Process-analysis Tools

They include the flowchart. Process flowchart is one of the most powerful

improvement tools as it is used to define, describe,

and communicate clinical (e.g., patient assessment),

administrative (e.g., patients registration at OPD),and operational (e.g., patient transfer within the

hospital) processes.

It is a pictorial representation of how a process works.

It outlines the sequence and relationship of the pieces

of the process.

Flowcharts tend to use simple and easily recognizable

symbols.


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Flowchart

The basic flowchart symbols include:

A semi-circle for the beginning or end of the

process

A rectangle for a step in the process (activities) A diamond for the decision points

An arrow to show the direction of moving from

one step to another

Check the attached flowchart.
http://localhost/var/www/apps/conversion/tmp/scratch_5/Sample%20Flowchart.pdfhttp://localhost/var/www/apps/conversion/tmp/scratch_5/Sample%20Flowchart.pdf


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Flowchart Uses of the flowchart:

1. When improving a process; here, it describes activities within

processes leading to better understanding of the process

being examined. Frequently, members are familiar with only

a few steps of the process and are not aware of what might

be occurring on either side of their activity segment.

2. When designing/planning a new process; here, a flowchart is

created to describe the steps of such process.

3. It identifies problems (it can detect bottlenecks, unnecessary

steps, and redundancies).

4. For clinical processes, flowcharts are used for depicting the

clinical practice guidelines (CPGs).

5. The flowchart can be used as an educational tool for the new-

comers.


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Flowchart

To construct a flowchart:1. Define the process to be diagrammed.

2. Define the basic stages of the process (draw a high-level

flowchart); then further define the process by breaking

each stage down into specific steps.

3. Gather information of how the process flows using

experience, observation/interviewing, and brainstorming

(during process development or planning).

4. Arrange the steps in proper sequence.

5. Compare final actual flow with best possible flow.

Discrepancies are sites of problems (e.g., delays,

redundanciesetc).


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Cause-analysis Tools

They include the fishbone diagram.

Fishbone diagramis also called the cause-and-effect

diagram and the Ishikawa diagram.

A cause-and-effect diagram is a visual display of thesuggested causal relationship between a problem

and all the possible causes.


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Fishbone DiagramProcedure of constructing fishbone diagram:

1. Start with the effect or the problem on the far right side of thediagram and draw a box around it. Draw a horizontal arrow to

the left of the problem

2. Determine the major categories of the causes of the problem

(e.g.) Manpower, Methods, Materials, Machines andMeasurements (5 Ms).

3. Link the major categories to the outcome with diagonal lines

angled from the horizontal line (these are the fishbones).

4. Brainstorm to identify possible main causes and link each oneto the major categories using horizontal lines touching the

appropriate diagonal line.

5. Develop the causes by asking Why?until you have reached a

useful level of detailthat is, when the cause is specific

enough to be able to identify a specific corrective action.
http://localhost/var/www/apps/conversion/tmp/scratch_5/CE%20diagram.pdfhttp://localhost/var/www/apps/conversion/tmp/scratch_5/CE%20diagram.pdfhttp://localhost/var/www/apps/conversion/tmp/scratch_5/CE%20diagram.pdfhttp://localhost/var/www/apps/conversion/tmp/scratch_5/CE%20diagram.pdf


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Fishbone Diagram

Uses Of fishbone Diagram: To identify and organize

causes of an identified problem following the

development of a process flowchart.

A brainstorming session is usually conducted during thedevelopment of the fishbone diagram.


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Idea-Creating Tools

They include:

1. Brainstorming

2. Affinity diagram3. Multivoting


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Brainstorming

Brainstorming is a quick, powerful, and energizing

technique to generate a large number of ideas from

a group (an improvement team) in a short period of

time. Conducting a brainstorming session:

i. The rules of the brainstorming session are reviewed

with group members, the question or purpose is clearly

noted and written on a flipchart. The team members

are allowed a few minutes to consider the issue and

then responses are invited and recorded/listed on the

flipchart. Discussion, judgment, and criticism are all

suspended during this step.


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Brainstorming

ii. It is important to record every idea in the speakers ownwords.

iii. All team members should take turn to present a single idea

until all ideas have been introduced and no new ideas occur

for several minutes. No limits should be placed on the

number of ideas considered by the group during

brainstorming.

iv. Team members can build on other ideas in order to

generate new ideas; this is facilitated by keeping all ideas

visible. Additionally, team members are encouraged to be

creative and to produce extraordinary ideas.

v. The group reviews the list to clarify the meaning of all items

or vague terms or statements and to eliminate duplications

and non-relevant ideas.


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Brainstorming

Uses of Brainstorming:

1. Brainstorm possible causes for a problem.

2. Brainstorm potential solutions to a problem.


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Affinity Grouping

Affinity grouping is usually used after the

brainstorming session in order to distribute/sort the

generated ideas into related groups.

There should be no more than 10 groups.

Following grouping, each group should have a short

title which describes it. Items can be moved from

one group to another if a consensus emerges duringthe discussion. Titles may stimulate the generation

of more ideas generation.


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Affinity Grouping

Advantages of the affinity grouping:

1. The grouping of ideas allows the team

members to have a more comprehensive

overview of the whole generated list.

2. This grouping of ideas may elicit team

members to generate more ideas into

different groups.


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Multivoting

This technique is usually used after the brainstorming andthe affinity grouping to narrow a list of ideas to a final

selection upon which there is consensus.

Steps:

1. Tag each idea with a number.

2. Allow each member of the team to vote for 1/3 of

the items.

3. Tally the votes and reduce the list by eliminatingitems receiving the fewest votes. The chosen 1/3

items can be ranked based on the votes received.

4. Repeat the process with the remaining items, if

necessary.


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Data Collection and Analysis

Tools

They include:

1. Histogram

2. Pareto chart3. Scatter diagram

4. Run and Control charts


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Histogram

One tool which is commonly used torepresent the frequency distribution of a set

of data.

The histogram is a special type of bar chartused to display the variation in continuous

data like time, age, weight, or temperature.


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Histogram

In the histogram, the bars are arranged on the X-axisto represent the adjacent data intervals of one

continuous variable. The Y-axis shows the

number/frequency of observations of the all the

intervals.

The histogram consists of a series of bars, each having

at its base one class interval of the continuous scale;

the class interval can represent one value in afrequency distribution or a group of values in a

frequency distribution. In this type of graph, there are

no spaces between the bars, since the data points

represented are continuous.


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Histogram

The number of class intervals typically ranges from6to 12.

In order to construct a histogram, first you have to

calculate the range of the data set (MAX Value

MIN Value), then divide the result by the number of

classes you are planning to have in the histogram.

The result should be rounded to the nearest

integer; this integer will represent the width of eachclass interval.


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Histogram

Uses of Histogram:

1. When the distribution of the data needs to be

emphasized.

2. After implementing improvements, a post-improvement histogram can be used to confirm

the effectiveness of the improvement efforts

when compared to the pre-improvement

histogram.


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Pareto Chart

A Pareto chart is a specialized form of a bar graph

that shows the relative frequency of the

contributing causes of a problem in a descending

order (bars are arranged from the longest first onthe left and moving successively toward the

shortest, each bar represents one contributing

cause to the problem).

Therefore, the chart visually shows which causesare more significant.


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Pareto Chart

This chart is based on the Pareto principle (which

was applied by Juran on the quality causes): 80% of

the troubles (problems) come from 20% of the

causes. Juran observed that the vital fewcauses account

for most of the defects; while other, the useful

many, account for a much smaller proportion of

the defects.

He noted that concentrating on the high-volume

causes should have the largest potential for

reducing process variation.


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Pareto Chart

Uses of Pareto chart

1. To identify the major causes of the problem and

to focus on them (i.e.) focus attention on the

vital few instead of all the problems.2. To evaluate the effectiveness of the

improvement using pre- and post-improvement

Pareto charts.


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Scatter Diagram

Hypotheses suggested by cause-and-effect analysisor by the frequency distribution in the histogram

have to be tested statistically by some form of

correlational modeling. Scatter diagram is the

appropriate tool to be used in this case; this diagramhelps identifying if there is correlation/association

between 2 variables.

Conducting correlational analyses immediately afterdeveloping the cause-and-effect analysis is crucial for

the QI team, since it helps the team to check out

their hypotheses early before eliciting work in

unfruitful areas.


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Scatter Diagram

The outcomes of the scatter diagram analysisare either:

i. Positive relationship

ii. Negative relationshipiii. No relationship.


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Scatter Diagram

Assume that a cause-and-effect analysis suggeststhat one possible cause for the patients

dissatisfaction at the Outpatient Clinics is the

prolonged waiting time before being examined. The

QI team can plot a scatter diagram to examine thevalidity of this relationship by correlating between

the patients satisfaction scores and their waiting

times. The team conducts 100 surveys over a one

month period.


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Scatter Diagram

If negative relationship exists (i.e., whenever the waitingtime increases, the patients satisfaction score

decreases), then the team has to address the waiting

time problem and solve it; but if the relationship does

not exist, then the team should try to focus their effortson other hypotheses (e.g.) may be the main cause of

patients dissatisfaction is the short time spent with the

physician which makes them feel that they do not receive

adequate attention or care. Time spent with the physician can be plotted against

the satisfaction scores and examined for the type of

correlation that exists between them.


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Run and Control Charts

Run and Control charts were first introduced by

W.A. Shewhart in 1920swith the intent of eliminating

abnormal variation by distinguishing variations due to

special (assignable) causes from common causes. Control charts provide us with more sensitive tools to

identify special causes, when compared to the run

charts.

Additionally, different data types have appropriate

specific control charts. Thus, control chart are more

commonly used in spite of being more complex to

develop.


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A The centerline in the run chart is the median;

while in the control chart, it is the mean. The

control chart is characterized by the presence of the

upper and lower control limits.

The control limits provide the basis for:

i. Additional tests to identify special causesii. Determining the capability of the process.


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A post-improvement control chart will assist the QI

team to monitor the stability of the newly designed

process and to address the causes of instability and

eliminate them. Additionally, if a pre-improvement control chart

exists (e.g., developed after quality planning), this

chart would help the QI team identify the

effectiveness of the improvement interventions by

shifting the process mean to the desired direction.


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Common-cause variation:

Variation that results from regular, natural, or

ordinary causes

It produces processes that are stable or incontrol.

One can make predications, within statistical limits,

about a process that has only common cause variation

(this is referred to as processcapability).

The presence of a common cause variation within a

process does not necessarily mean that the

performance of this process is acceptable. It only

means that the process is stable and predictable.


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Special-cause variation Variation that results from irregular or unnatural that are

not inherent in the process.

When present, a process may be described as unstable or

outof control.

The future performance of a process that exhibits special

causes will be unpredictable. This is why improvement

strategies should not be applied to processes exhibiting

special cause variation. Because they are unstable andunpredictable, attempts to improve them will only lead to

wasted time, effort and money.

The response to special causes should be to investigate the

origin of them, and then take steps to eliminate.


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Uses of run and control charts

i. Monitoring process variation over time.

ii. Distinguishes special from commonvariation.

iii. Helps in improving process performance.

iv. Determining capability of the process(with the control chart).

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