understanding and utilizing basic qi tools leslie m. beitsch charlotte, nc december 5, 2012
TRANSCRIPT
UNDERSTANDING AND UTILIZING BASIC QI TOOLS Leslie M. Beitsch
Charlotte, NC
December 5, 2012
Definition of Quality Improvement In Public Health
“Quality improvement in public health is the use of a deliberate and defined improvement process, such as Plan-Do-Check-Act, which is focused on activities that are responsive to community needs and improving population health.
It refers to a continuous and ongoing effort to achieve measurable improvements in the efficiency, effectiveness, performance, accountability, outcomes, and other indicators of quality in services or processes which achieve equity and improve the health of the community.”
Defining Quality Improvement in Public Health; Journal of Public Health Management & Practice: January/February 2010 - Volume 16 - Issue 1 - p 5–7, Riley, William J. PhD; Moran, John W. PhD, MBA, CQIA, CQM, CMC; Corso, Liza C. MPA; Beitsch, Leslie M. MD, JD; Bialek, Ronald MPP; Cofsky, Abbey -
Topic Big ‘QI’ – organization-wide Little ‘qi’ – program/unit
Improvement
Quality Improvement Planning
Evaluation of Quality
Processes
Quality Improvement Goals
Individual ‘qi’
Contrasting Big “QI”, Little “qi”, and Individual “qi”
System focus
Tied to the Strategic Plan
Responsiveness to a community need
Cut across all programsand activities
Strategic Plan
Specific project focus
Program/unit level
Performance of a processover time
Delivery of a service
Individual program/unit level plans
Daily work level focus
Tied to yearly individualperformance
Performance of daily work
Daily work
Individual performance plans
MACRO
MESO
MICRO
INDIVIDUAL
Turning Point
Baldrige
QFD
Lean/SS
Daily Management
P
DC
A
P
DC
AP
DC
A
S
DC
A
Big ‘QI’Little ‘qi’
Individual ‘qi’
QI Teams
Rapid Cycle Advance Tools of
QI
Basic Tools of QI
Continuous Quality Improvement System in Public Health
MAPP
Organization QI = Culture
General Approach On How To Use The Basic Tools Of Quality Improvement
Issue ToConsider
Flow ChartExisting Process
Brainstorm& ConsolidateData
Cause & EffectDiagram – Greatest Concern
Use 5 Whys ToDrill Down ToRoot Causes
Gather DataOn Pain Points
Translate DataInto Information
• Pie Charts• Pareto Charts• Histograms• Scatter Plots, etc.
Flow ChartNew Process
Monitor New Process & Hold
The Gains
• Run Charts• Control Charts
Data ManagementStrategy
“As Is” State to “Should Be” State
“As Is” StateBrainstormingForce and Effect
Analyze Information andDevelop Solutions
Solution andEffect Diagram
Source: The Public Health Quality Improvement Handbook, R. Bialek, G. Duffy, J. Moran, Editors, Quality Press, © 2009, p.160
“AIM”
They Are Not the Same
Quality Assurance• Reactive• Works on problems after they
occur• Regulatory usually by State or
Federal Law• Led by management• Periodic look-back• Responds to a mandate or
crisis or fixed schedule• Meets a standard (Pass/Fail)
Quality Improvement• Proactive • Works on processes • Seeks to improve (culture
shift)• Led by staff• Continuous• Proactively selects a process
to improve• Exceeds expectations
What Is Quality?• Today the most progressive view of quality is
that it is defined entirely by the customer or end user and is based upon that person's evaluation of his or her entire customer experience.
• The customer experience is the aggregate of all the Touch Points that customers have with the organization’s product and services, and is by definition a combination of these.
Continuous Improvement
Plan
DoCheck/Study
Act The continuous improvement phase of a process is how youmake a change in direction.The change usually is because the process output is deterioratingor customer needs have changed
Plan
1. Identify and Prioritize Opportunities
2. Develop AIMStatement
3. Describe the CurrentProcess
4. Collect Data on Current Process
5. Identify All PossibleCauses
6. Identify PotentialImprovements
7. Develop Improvement Theory
8. Develop Action Plan
1. Implement theImprovement
Do
2. Collect and DocumentThe data
3. Document Problems,Observations, and Lessons
Learned
Check/Study
1. Reflect on the Analysis
Act
2. Document Problems,Observation, and Lessons learned
Adopt
Adapt
Abandon
Standardize
Do
Plan
ABCs of the PDCA Cycle, G. Gorenflo and J. Moran, http://www.phf.org/pmqi/resources.htm
Maintenance and Standardization
Standardize
DoCheck/Study
Act The Maintenance and Standardization phase of a process is how we hold the gains. If our process is producingthe desired results we standardizewhat we are doing.
Integrated CycleThe SDCA and PDCA cycles areseparate but rather integrated.Once we have made a successfulchange we standardize and holdthe gain.When the process is not performingcorrectly we go from SDCA to PDCAand once we have the process performing correctly we standardize again.This switching back and forth betweenSDCA and PDCA provides us with the opportunity to keep our processcustomer focused.
P
DC
A
P
DC
A
P
DC
A
Knowledge & Experience
Pro
ject
Diff
icul
ty
PDCA should be repeatedly implemented in spirals of increasing knowledge of the system that converge on the ultimate goal, each cycle closer than the previous.
Hold the Gains
Rapid Cycle*
Rapid Cycle PDCA
Rapid Cycle PDCA, G. Duffy, J. Moran, and W. Riley Published: Texas Quality August 2009 Newsletter
The Basic Tools of QI• Flow Chart• Cause and Effect Diagrams• Pareto Chart• Check Sheet• Histogram• Scatter Diagram• Control Chart
People Centric
Data Centric
Enter Building
Enter Building
Greeter
Patient Flow
Possibly not
Yes
Clerical
Screener
Okay to
vaccinate?
Triage
RN
Okay to
vaccinate?
Need medic
al attenti
on?
NoExit Leave Building
EMT
Is patient able
to leave
on own?
No
Yes
No
Yes
Yes
EMT transports patient to medical facility
Swim Lanes
Spaghetti Diagram: Health Department Administrative Office Flow
Prep printed documents for mailing
Stuff Envelopes
With Pamphlets,
etc
Generic Computer
Work Station
Management
4 Supervisors
Prin
ters
Envelope Storage
different types and sizes of envelopes
Inserts for Letters
Retruned items from mail area –
incorrect labeling
Type up form for Fed Ex
Mailing
Labeling for Fed Ex
1 2 3 4 5
6 7 8
9
10
Mail Sort for location
Take Mail to Post Office
Pick-up
11 12
1st Floor
Document Wasted MovementMiles walked per day
40 Feet
20 F
eet
10 F
eet
40 Feet
Cause and Effect Diagram
PoorHIV Testing
ClientTest Location
Don’t see benefit
Counseling
Not Client Centered
Inconvenient
Staff
Not Respectful
Fearful
Not Offered Poor Experience
Too Public
Don’t Want Test
• 80% of process defects arise from 20% of the process issues.
• 80% of delays in schedule arise from 20% of the possible causes of the delays. • 80% of client complaints arise from 20% of your services.
Location Checklist
Frequency Polygon & Histogram – Grouped Data
10
20
30
40
50
Abs
olut
e F
requ
ency
0.41 0.494 0.497 0.500 0.503 0.506 0.509
60
Obese Children
Age in Years
BM
I –
kg/m
²
2 6 10 14 18
12
16
20
24
28
32
Scatter Plot
Run Chart
Time
Mea
sure
men
t
Median Line
x
x
x
xx
x
x
x
5 10 15 20
0.0
2.5
5.0
7.5
10.0
12.5
15.0
Mov
ing
Ra
nge
Obse rvation
MR Chart
LCL = 0.0
CL = 4.0
UCL = 13.2
0
5
10
15
20
25
Wa
it T
ime
(M
inute
s) X Chart
LCL = 1.6
CL = 12.4
UCL = 23.2
Jones County WIC Lobby Wait TimeXMR Chart
Control Chart
Flow Charting
“If you can't describe what you are doing as a process, you don't know what you're doing.”
W. Edwards Deming
Process/Activities:
Begins With:
Ends With:
Inputs:
Suppliers:
Outputs:
Customers:
Constraints:
Immunization High Level S I P O C+CM Collection Form
Measures
Patient Enters Clinic
Too much confusing signageChange mind after counselingCostSit and Wait/ Language barrier
Patient Leaves Clinic
• Fill out Form - Pay• Stand in line - Leave• Register• Sit & Wait• Counseling• Sit & Wait• Immunization
Wait time# PatientsCust Sat. Scores
• Referrals• Schools• WIC• Home Visits
• Pharma Cos• Schools• MD Offices• Dept. Nurses
• Vaccine Record• Immunized Pt.• Protected Community
• Community• Patient• Family• Schools• Dept. nurses
Flow Charting• Flow charting is the first step we take in understanding a
process
• Organized combination of shapes, lines, and text
• Flow charts provide a visual illustration, a picture of the steps the process undergoes to complete it's assigned task
• From this graphic picture we can see a process and the elements comprising it
• Shows how interactions occur
• Makes the invisible visible
Flow Chart Benefits• Creates a common vision
• Establishes the “AS IS” baseline – Current State– It will take multiple passes to get to the “As Is” State
• Baseline to measure improvements
• Identifies wasteful steps – activities/waits
• Uncovers variations - realize everyone is not doing it the same way – there will be disagreements
• Shows where improvements could be made and potential impacts
• Training tool – for new employees
Flow Chart People BenefitsPeople involved in constructing a flow chart begin
to:
– Better understand the process
– Understand the process in the same terms
– Realize how the process and all the people involved, including them, fit into the overall process or business
– Identify areas for improving the process
Olmsted County , MN – Performance Appraisal Process
Flow Charting Construction
• Clearly define the process boundaries to be studied
• Define the first and last steps – start and end points
• Get the right people in the room
• Decide on the level of detail– Complete the big picture first – macro view– Fill in the details – micro view
• Gather information of how the process flows: • Experience• Observation• Conversation• Interviews• Research
• Clearly define each step in the process– Be accurate and honest
Flow Charting Steps• Use the simplest symbols possible – Post-Its
• Make sure every loop has an escape
• There is usually only one output arrow out of a process box. Otherwise, it may require a decision diamond.
• Trial process flow – walk through people involved in the process to get their comments
• Make changes if necessary
• Identify time lags and non-value-adding steps.
Hands Are Dirty
Hands Are Clean
Macro to Micro
Flow Charting Moments• Aha!
• Surprise
• Bafflement
• Duh!
• Embarrassment
Flow Chart Symbols
Activity:Operation/Inspection
Decision
Start/EndBookends
Document
Wait/Delay
Storage
Data Base
Transport
Input
Output
Flow Lines
A Connector
Forms
CommentCollector
Input/OutputData
ManualOperation
Preparation
ManualInput
Display
Unfamiliar/Research
Constructing a Flow Chart• Asking questions is the key to flow charting a
process.
• Such as for this process:– Who is the customer(s)?– Who is the supplier(s) ?– What is the first thing that happens? – What is the next thing that happens?– Where does the input(s) to the process come from? – How does the input(s) get to the process? – Where does the output(s) of this operation go? – Is their anything else that must be done at this
point? – What is the baseline measurement of this process?
Analyzing A Flow Chart
Examine each:– Activity symbol – value/cost? – Decision point – necessary/redundant?– Choke Points – bottlenecks?– Rework loop – time/cost?– Handoff – is it seamless?– Document or data point – useful?– Wait or delay symbol – why?/reduce/eliminate– Transport Symbol – time/cost/location?– Data Input Symbol – right format/timely?– Document/Form Symbol – needed/cost/value?
Flow Charting Basics
Flow
DataVoice of the Process - VOP
Customer - VOC• Internal• External
Flow Charting Exercise
Flow Charting Exercise
Alarm Goes OffStart You are sound asleep and your alarm just went off at 6 AM this morning
Open your door andleave End
You open your door and leave forthis workshop
Your assignment: Flow chart all the activities you have to do to get to the point where you open the door and leave for this workshop.
* Identify two steps that are not needed and should be eliminated.
* Identify two steps that should be added that would add value to the process.
Only once on any flow chart
Alarm Goes off
Put on CoatShower
Dress
Eat & ReadPaper
Multi Tasking
Get Up
Open Door & Leave
Cause and Effect Diagrams
Moving from Treating Symptoms
To
Treating Causes
Problem Solving – What we usually see is the tip of iceberg – “The Symptom”
The Symptom
The Root Causes
Invisible
Hidden
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 efficient and effective
• Symptom – sign or indication
• Cause – whatever makes something happen
Cause and Effect Diagrams - Construction
• Write the issue as a problem statement on the right hand side of the page and draw a box around it with an arrow running to it.
• This issue is now the effect
Effect
Cause and Effect Diagrams - Construction
• Generate ideas as to what are the main causes of the effect
• Label these as the main branch headers
• Organizes group knowledge about causes of a problem and displays the information graphically
Effect
HeaderHeader
HeaderHeader
Cause and Effect Diagrams - Construction
• Typical Main Header are:– 4 M’s – Manpower, Materials, Methods, Machinery
– People– Policies– Materials– Equipment– Life style– Environment– Etc.
Cause and Effect Diagrams - Construction
• For each main cause category brainstorm ideas as to what are the related sub-causes that might effect our issue
• Use the 5 Why techniques when
a cause is identified
• Keep repeating the question until no other causes can be identified
• List the sub-cause using arrows
Effect
HeaderHeader
HeaderHeader
why
why
why
why
Selecting Items to Investigate• When the Cause and Effect Diagram is finished it is time
to decide what few areas should be focused on to develop solutions to solve the effect.
• Some are obvious – low hanging fruit » Caution - It could be rotten
• Some require some research using the other QI tools such as:– Pareto Diagrams– Run Charts– Surveys– Histograms– Etc.
Obese Children
Life Style
PoliciesEnvironment
TV ViewingNo Time For Food Prep
No Outdoor PlayUnsafe
Juices
Bottle Pacifier
Less Fruits and Veg.
Less Income Maternal
Choices
Less Vigorous Exercise
Curriculum
No Sidewalks
Unhealthy Food Choices
Few Community Recreational Areas or Programs
Built Environment For Strollers Not Toddling
Less Indoor Mobility
TV Pacifier
UnsafeHousing
Sodas/Snacks
Decreased Breast Feeding
Early Feeding Practices
Genetics
Syndromes
Genes
Pre NatalPractices
Excess Maternal Weight Gain
Over Weight Newborn
Over WeightPre School At School
At Home
Problem (Effect)
5 Why’s Technique
Why?
Why?
Why?
Why?
Why?
http://www.phf.org/resourcestools/Pages/Solve_The_Real_Problem_Using_RCA.aspx
Con
trol
Influ
ence
How To Prioritize
• Sort
• Vote
• Vote with data
• By Branch
• Branch with the most causes
• Must Confirm With Data
Cause and Effect Exercise
Why Are Employees Late For Work?
• It is a question that management has wrestled with for a long time.
• Every time we think we have heard all the excuses someone invents another creative one.
Investigating The Reasons
• Why Are Employee Late For Work?
• Use a Cause and Effect diagram to understand the causes.
• Use the 5 Why Technique to get to Root Cause.
Why EmployeesAre Late For Work?
Cause and Effect Diagram
Why EmployeesAre Late For Work?
Work IssuesTransportationFamily
ProcedureCulture
Lack of SupervisionSick Child
Late for Bus
Car problems
Poor Morale
No valuefor promptness
Wardrobe problems
Alarm not set
Unclear policy at work
Daycare closed
Pet Care
WeatherUnclear expectations
Dislikesco-workers
Uncooperative child
Health problems
Lots of parties
Cause and Effect Diagram
Flat Tire
UncontrollableFactors
Car Crash
Weather
Labor Strike
No Public Transportation
Traffic
Power outage
Boss is always late
Accepted Norm
64
Static and Dynamic Data AnalysisFour Generations
• Static Analysis– First Generation: Tables of Data,
Comparison of Summary Measures• Dynamic Analysis
– Second Generation: Trend Line– Third Generation: Run Chart– Fourth Generation: Control Chart
65
Run Chart
• A running record of process behavior over time.
• Easily understood by all,• Can be used on any type of process
and any type of data.• Requires no statistical calculations, can
detect some special causes.
66Run Charts
Determining a Run
• A run is one or more consecutive data points on the same side of the median.
• Do not count a point if it is on the centerline. (Put a box around it and ignore)
• “Useful Observations”– Subtract any observation that falls on median.
• Draw circle around each run, and count the number of runs.
67 Run Chart2 Tests to Identify Special Cause
• Test 1 – Long run: – If 7 or more in run( When
less than 20 “useful observations”) When 20 or more “useful observations” , then 8 or more data points needed for a run.
• Test 2 – Trend:– An unusually long series of
consecutive increase or decrease.
Total Data Points on Chart
Number Ascending or Descending
5-8 5 or more
9-20 6 or more
21 to 100 7 or more
Determining a Trend
68
Two Types of Variation
• Common Cause – Inherent in every process– Reflects a stable process because
variation is predictable– Is random variation
• Special Cause – A noticeable shift or trend in data over time– Process is unstable or unpredictable– Process is out of statistical control– Not present in every process
Jun-0
8Aug
Oct
DecFeb
AprJu
nAug
Oct
DecFeb
Apr0
200
400
600
800
1000
1200
Port Gamble S'Klallam TribeRun Chart: Number of Clinic Visits Per Month
June 2008 - May 2010
Number of Clinic Visits
Xbar (Median)
Month
Nu
mb
er o
f C
lin
ic V
isit
s
Median = 637 visits per month
Start ofIntervention
1st Staff Training 2nd Staff
Training
69
69
Jun-0
8Aug
Oct
DecFeb
AprJu
nAug
Oct
DecFeb
Apr0
200
400
600
800
1000
1200
Port Gamble S'Klallam TribeRun Chart: Number of Clinic Visits Per Month
June 2008 - May 2010Runs Above or Below Median
Number of Clinic Visits
Xbar (Median)
Month
Nu
mb
er o
f C
lin
ic V
isit
s
Median = 637 visits per month
Median = 637 visits per month
70
Interpretation
• How do you interpret the run chart?• What do you recommend?
71