Applying Quality Improvement Techniques to Analyze Problems and Find

Solutions

The Open Forum

Leslie M. BeitschSeptember 17, 2009

Organize participation for performance improvement

• Big QI• Little qi• Leadership support and role

– What is leadership’s vision, commitment, expectation?

• Build the process strategically– Incorporate QI into broader initiatives (MAPP,

HP2010)– Involve others

To Carry Out a Quality Improvement Process, “Plan-Do-Check-Act”

Source: Turning Point Performance Management Collaborative, From Silos to Systems: Using Performance Management to Improve the Public’s Health , March 2003.

Plan

DoCheck

Act

Plan Plan changes aimed at improvement, matched to root causes

Do Carry out changes; try first on small scale

Check See if you get the desired results

Act Make changes based on what you learned; spread success

See Problem Solving, p. 12

To Carry Out a Quality Improvement Process, “Plan-Do-Check-Act”

Plan

DoCheck

Act

Regularly monitor and report progress.

• Regular reports necessary to chart progress

• Benchmark against self and others– Same industry, other industries

• Reports do not have to be computerized (although it helps!), expensive, color…

Some QI Tools to Help Teams Analyze Performance

Affinity Diagram

• It was created in the 1960s by Japanese anthropologist Jiro Kawakita.

• Tool for assimilating and understanding large amounts of information

• Draw out common themes from a large amount of information

• Discover all the hidden linkages

Affinity DiagramHow To Do It:

– Develop a clear purpose, problem, concern or issue statement to focus the group

– Materials needed: • sticky notes or 3x5 cards• marking pens,• large work surface

– Wall– table– floor.

.

Affinity Diagram

How To Do It:

– Process Steps:• Individual silent brainstorming • Record each idea with a marking pen on a

separate sticky note or card.• Need a complete statements – no one word

ideas

Exercise

Affinity Diagram

How To Do It:– Posting Step

• Each participant reads and randomly posts their ideas on the wall – one at a time

• Other participants can ask for clarification when an idea is read – no debate – just clarification

• Do not place the notes in any order - do not try to determine categories or headings in advance – use the whole wall

• After all ideas are posted – begin Silent Consensus

Affinity DiagramHow To Do It:• Silent Consensus:

• The entire team gathers around the posted notes• No talking during this step (remember the name…)• Look for ideas that seem to be related in some way• Move the Post-Its and place them side by side • Repeat until all notes are grouped• Okay to have “loners” that don’t seem to fit a group -

outliers• It’s all right to move a note someone else has already

moved.• If a note seems to belong in two groups, make a

second note

Affinity Diagrams• How To Complete It: Clarification Step:

– Participants can discuss the “results” of the chart– Any surprising patterns?– Any reasons for moving controversial notes.– A few more changes may be made – When ideas are grouped, select a heading for each group

• Look for a note in each grouping that captures the meaning of the group. If not create one

– Place it at the top of the group• highlight headers notes in a bright color.

– Combine groups into “super groups” if appropriate– Want 6 – 10 headers– Take the time to do this step – it is the foundation for the

other tools

Affinity Diagram Example

Issues Affecting the High Staff Turnover of Sunshine County Health Department

Issue Statement

LowSalary

LowSalary

Limited Professional Development

Limited Professional Development

LowMorale

LowMorale

Work Environment

Work Environment LeadershipLeadership Public Health

Misunderstood

Public HealthMisunderstood

Header Cards:

Cause and Effect Diagram

High StaffTurnover

Low SalaryPoor Morale

BudgetConstraints

LimitedProfessional Development

Training Availability

WorkUndervalued

WorkEnvironment

Poor Facilities

Lack ofCounty support

CareerAdvancement

Bad Neighborhoods

Outdated Equipment

HR System Restrictive

– Methods & Procedures– Motivation– Materials & Equipment– People – Information &

Feedback– Environment– Policy

Common root causesof performance problems

5 Whys

Five Why’s

Our influenza clinic was poorly attended

• Why? Residents had many opportunities• Why? There was a lot of competition• Why? Pharmacies are in on the action• Why? It brings customers in• Why? They can ‘multi-task’ in one stop

Other Explanations

Our influenza clinic was poorly attended

• Why? Residents had many opportunities

• Why? We didn’t advertise it well• Why? Inclement weather was a factor• Why? Our price wasn’t competitive• Why? The location wasn’t convenient

Five Why’s: Expand Scope Downward

My off white carpeting must be replaced

• Why? The carpeting has been stained• Why? My elder cat vomits periodically• Why? She is upset about something• Why? Her environment was

compromised• Why? I introduced a kitten last year

Five Why’s

I had to replace my car motor

• Why? The motor seized while in transit• Why? There was insufficient oil• Why? I have not maintained my car• Why? I didn’t make time for my service• Why? I did not make my car a priority

Ask “why” 5 times

People

Methods

Equipment Environment

Primary Cause1st Why

2nd Why

3rd Why

Primary Cause

Problem Statement

4th Why

5th Why

Cause and Effect Analysis (Fishbone)Cause and Effect Analysis (Fishbone)Cause and Effect Analysis (Fishbone)Cause and Effect Analysis (Fishbone)

Fishbone Fishbone DiagramDiagram

Our influenza clinic was poorly attended.

PeopleEnvironment

Equipment Methods

Primary Cause

They can multi-task in one stop

It brings customers in

Pharmacies are in on the action

Primary Cause

Problem Statement

Lots of competition

Residents had many opportunities

Staff unsure about how to post advertisements

No cross-training completed

We didn’t advertise it well

Missed deadlines at local paper for advertising

Turnover in staff person responsible for advertising

Primary Cause

Previous vendor was not delivering vaccine timely

Using new vendor

Vaccine costs more

Our price wasn’t competitive

Vendor had too many commitments and little vaccine to fulfill orders

Ask “why” 5 times

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

Simple Flowchart Helps Understand

a Complex Process

FLOW CHARTPROCESS

AUDITPROCESS

IMPROVECAPABILITY

SORTPRODUCT

PLOTHISTOGRAM

ESTIMATEPROCESS

CAPABILITY

ANALYZEDATA

COLLECTDATA

CORRECTPROBLEMS PROBLEMS?

CAPABLE?

INCONTROL?

YES

NO

NO

Flow Charting• Flow charting is often 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 (less obvious) visible (more

obvious)

MappingMapQuest

• Takes directions and coverts them into a picture

• Shows various routes to a destination

• Shows communities you pass through to reach a destination

• Shows connecting roads• Shows faster and slower

routes• Provides alternative routes

Flow Chart• Takes procedures and

converts them into a visual• Shows the routes inputs

travel to become outputs• Shows handoffs• Shows connecting

processes• Highlights areas for

improvement• Triggers ideas to improve a

process

Flow Chart Benefits

• Creates a common vision• Establishes the “AS IS” baseline – Current State• Baseline to measure improvements• Identifies wasteful steps – activities/waits• Uncovers variations (usually unintended)• Shows where improvements could be made• Show potential impacts of improvements• Training tool

Flow Chart People Benefits

People 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– Become enthusiastic supporters to quality and

process improvement– Become process owners

Types of Flow Charts

• As Is – current state - baseline– Our task today!

• Could Be – improved state – transition

• Should Be – optimal state

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 though it in real time • Circulate the flowchart to other people involved in the

process to get their comments • Make changes if necessary

• Identify time lags and non-value-adding steps.

Flow Chart Construction• There is no one right way to develop a flowchart, but the

following guidelines provide a general structure:• Start with a simple one-line description or title of the

process being flowcharted , e.g., "How to..." • Using a top-down hierarchy, start with an oval symbol

named Start. • Connect each successive action step in the logical

sequence of events. • Reference detailed information through annotations or

connectors. • Follow the process through to completion, denoted by an

oval symbol named End

Flow Chart Symbols

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. 

• 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?

Exercise

Quality Improvement• Analyze the “As Is” flow chart• Look for Critical Processes• Look for Handoffs• Analyze with a Cause and Effect Diagram• Develop potential solutions• Develop the “Should Be” state• Communicate all changes• Track implementation progress• Document results• Present results

How Improvements Are Made

Focus on Critical Processes– Important sets of procedures or patterns of

tasks that determine success (i.e. customer satisfaction) for an organization or an individuals job.

What are the attributes of critical processes?

• They are few in number - usually 5 - 10• The critical processes of a flow chart should

capture 75-80% of the activities which determine the success of that process

• Critical processes describe what must occur on an on-going basis to achieve customer satisfaction.

• They can be mapped or diagrammed in a step-by-step format.

• They can be measured.• They can be improved

Improvement Opportunities

What to look for on a Flow Chart:– Duplication of effort– Unnecessary Activities/Steps/Tasks– Delays/Waits– Transports– Storage– Illogical Sequencing of Activities – Unclear Lines of Responsibility – Opportunities for Error – Supplier Error Opportunities– Disconnects

Improvement Opportunities

• Use a Cause and Effect Diagram to investigate areas identified on the “As Is” flow chart as areas that could be improved

• Can complete a micro level flow chart on specific process steps as required

• Fix the low hanging fruit first – quick success

• Involve customer/suppliers before any changes are made

Caution!!! In most processes:

– Few people have seen the total process and fully understand it!

– Those that designed the process now work elsewhere

– Work is being done that adds no value to customers

– Work the customer needs isn’t being done

– Rework is built into the process

– Inefficiencies are built into the process

– Workarounds have been developed that make the process appear to be working better than it really is

Advantages of Flow Charts

• Overview of the System

• Documents a system/process

• Shows Interrelationships

• Communication Tool

• Defines Roles

• Shows barriers/bottlenecks/problems

• Planning Tool for improvements

WIC Appointment

Child has WIC appt.

Show?

□ Due□ Overdue for shots?

Check report for immunization status

Due or overdue for shots?

Give parent immunization notice; answer or refer questions to DP&C nurse

Check report for C&TC eligibility & last exam

Check report for immunization status

Active on C&TC?

No

NoactionYes

No

No

No

Yes

Yes

Yes

Mail parent immunization notice

Encourage regular well child exams

Provide C&TC info/assist, encourage compliance w/exam schedule, code activity in Catch3

Memory Jogger II & Problem Solving Memory Jogger (Goal QPC) www.goalqpc.com

American Society for Quality (www.asq.org)