Planning Project-Breast Cancer Screening-PPP
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Transcript of Planning Project-Breast Cancer Screening-PPP
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Diploma In Total QualityManagement For Health Care
Reform
Quality Planning Project Prepared By
Dr. Ashraf A. Monem
MD,MRCP,PHD,CPHQAUC Instructor
2012
Breast Cancer Screening
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Breast Cancer
Screening
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Two tests are commonly used by healthcare providers to screen for breastcancer
Mammogram
Clinical breast exam (CBE)
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Mammogram
A mammogram is an x-ray of the breast.This test may find tumors that are toosmall to feel. A mammogram may also find
ductal carcinoma in situ, abnormalcells inthe lining of a breast duct, which maybecome invasive cancerin some women.The ability of a mammogram to find breast
cancermay depend on the size of thetumor, the density of the breast tissue, andthe skill of the radiologist.
http://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=45775&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=45944&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=304766&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=46634&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=45674&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=44636&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=46476&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=46441&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=45741&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=444971&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=444971&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=46683&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=46551&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=46551&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=46683&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=444971&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=444971&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=45741&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=46441&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=46476&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=44636&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=45674&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=46634&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=304766&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=45944&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=45944&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=45944&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=45775&version=Patient&language=English -
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Clinical breast exam. (CBE)
A clinical breast exam is an exam ofthe breast by a doctor or other healthprofessional. The doctor will carefully
feel the breasts and under the armsfor lumps or anything else that seemsunusual.
If a lump or other change is found bymammogram or clinical breast exam,follow-up tests may be needed.
http://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=304715&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=304715&version=Patient&language=English -
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General idea about the project
Samannod General Hospital decided tointroduce the service of mammogramfor early detection of breast cancer
among females as a result ofcontinuously increasing incidence ofbreast cancer.
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Steps of Quality planning project
Measure
Establish Project
Identify Customers
Discover Customer Needs
Develop Product
Develop Process
Develop Process Controls/Transfer to Operations
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Step 1:Establish Project
Mission statement
Goals
Team structure
Tree diagram
Planning net work
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Mission statement
To introduce a mammogram service as ascreening test for females above the age of40 and high risk females with a positive
family history of breast cancer wishing toinvestigate herself.
This service will start within two months aftercoordination between radiology and general
surgery department, and it will be provided ata reasonable cost that females can afford.
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Goals
1. To provide a screening test with high sensitivity andspecificity for early detection of breast cancer.
2. To provide this service at a reasonable cost femalescan afford 20% lower than market price.
3. To provide the service within reasonable time 15-20min. from reaching the hospital.
4. To provide a full detailed report about the findings ofthe test within 10 days after finishing examination.
5. To provide the service to at least 50 females/week.6. To increase the hospital revenues by about 1.000.000
within two years of operation.
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Team structure
It is a cross-functional team formed of ChiefExecutive officer (CEO) ,the quality director and
a representatives from the following departments:-
Radiology department
Surgery department
Reception
Finance
Purchasing department
Supplier company
Biomedical engineering department
Volunteers from Patients
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Tree Diagram
In tree diagram each step is furtherdefined by key activities and tasks tobe done.
The primary goals are subdivided tosecondary project goals or activitiesand activities are subdivided to the
major tasks that are most related to thefirst level goals.
C t fl di
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Design formammography
unit
Identifycustomers
Discover
customerneeds
Developproduct
Developprocess
Create flow diagram
List customers&prioritize
Survey / interview keycustomers
Plan more datacollection
Complete needsanalysis
Select sample
Design / test questions
Send questionnaires /arrangeinterviews
List single dimension needs
Translate
Determine unit of measure &sensor
Develop features &goals
Optimize features &goals
Set & publish finalproduct design
Determine methods
Develop high level features & goals
Develop detailed features & goals
Determine methods
Optimize
Publish final product features &product features goals
Review productgoals
Identify operatingconditions
Collect info. onalternative process
Ensure complete understanding ofproject goals by all team members
User understanding of theprocess
How the process will be used
Environment of use
Design the process anatomy
Review the current processanatomy
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Select generalprocess design
Process flow diagram
Testing of process the design
Identify processfeatures &goals
Select initial process features &goals
Set &publish final processfeatures&goals
Developprocesscontrol /
transfer tooperation
Choose controlsubjects
Identify objective of the process
Select control subject
Establishmeasurement
Develop unit of measure
Develop sensor
Establish
standards ofperformance
Set targets
Develop control methods
Set checking criteria
Measure actualperformance
Chart indicators
Develop detailed workinstructionsCompare to thestandards
Check results
Select appropriate action
Take action onthe difference
Analyze process
Make contingency plan
Troubleshoot
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Planning Network
It is a highly useful tool for taking acomplex or long term project anddividing it into specific tasks .
Some tasks are performed sequentiallywhile other tasks on different paths donot depend on each other and can beperformed simultaneously.
It is often developed based on a treediagram
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The project will start by 1st of December, and end by 22nd March
CRITICAL PATH: The path with the largest total elapse time labeled by green colors.Lost time for any of these tasks would put the entire project behind schedule
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Step 2:Identify Customers
High level flow diagram
Detailed flow diagram
Internal Customers list External customers list
Prioritization matrix
Vital few customers
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High level flow diagram
It is a graphic representation of thesequence of steps in a given processto produce some outputs.
It is used to determine who thecustomers are and as a basis forimproving the process that is being
planned.
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Registration
Arrangement for appointment with thesurgeon and radiologist
Writing thereportTaking history
Clinical examination
Performing the mammogram
Delivery of thereport
Taking history
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Detailed flow diagram
It is a more detailed diagram that showthe sequence of steps needed toaccomplish each activity within each
block of the high level flow diagram. It identifies the process inputs, all
internal and external customers, keycustomer interfaces, the processoutputs and the overall boundaries ofthe project.
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Start
Female calls the hospital to arrange for an
appointment
Female registers her data Registration log
Radiology clerk arrange for appointment with the surgeon and
radiologist
Female attends to the
hospital on registereddate
NoYes
Arrange for another
appointmentPatient meets the surgeon
The surgeon takes full historyPt. medical file
The surgeon examines her breasts and
axaillae
The surgeon refers her to the
radiologist
Referral report
The radiologist makes the mammogram
The radiologist writes the report
The radiology secretary asks female to come
to have the report within maximum 10 days
Mammo. report
End
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List of internal customers
1. Surgeon
2. Radiologist
3. Technicians
4. Nursing5. Reception
6. Administrative staff
7. Financial staff
8. Care coordinator
9. Supplier of medical equipments
10. Medical record staff
11. Medical engineering personnel
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List of external customers
1. Females above 40 years
2. Females with positive family history.
3. Relatives.
4. Health insurance organizations.5. Media.
6. MOH.
7. Pathologists.
8. Radiotherapist.
9. Chemotherapist.
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Impact (Prioritization) Matrix
It organizes data into sets of items to
be compared. The diagram
graphically shows relationships and/or evaluates the strengths of
relationships between the items in
each set.
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Impact matrix of internal customersOptions Criteria
Internalcustomers
Directrelation to
performance of the test
Quality ofthe testresults
Directrelation
with patientsatisfaction
Reputation Total score
Surgeon 5 5 9 5 24
Radiologist 9 9 9 9 36
Technicians 9 5 5 3 22
Nursingstaff
3 3 3 3 12
Reception 0 0 0 3 3
Administrative staff
0 0 0 3 3
Financialstaff
0 0 0 3 3
Supplier 0 9 5 3 17
Medicalrecord staff
0 0 3 3 6
Carecoordinator
0 0 5 3 8
Medicalengineeringpersonnel
0 5 3 3 11
Legend: Major impact : 9
Moderateimpact : 5
Minor impact : 3
No impact : 0
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Impact matrix of external customers
Legend: Major impact :
9 Moderate
impact : 5 Minor impact :
3 No impact : 0
Options Criteria
Externalcustome
rs
Impacton
market
share
Reputation
Total
revenue
Ability toshut me
down
Competit
ion rank
Total score
Patients 9 9 9 3 9 39
Relatives 9 9 5 3 3 29
Healthinsuranc
eorganiza
tions
9 5 5 3 3 25
Media 0 9 9 3 3 24
MOH 5 3 3 9 3 23
Pathologists
0 0 0 3 3 6
Radiotherapist
0 0 0 3 3 6
Chemotherapist
0 0 0 3 3 6
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Pareto analysis
Pareto Analysis is a useful approach
to sorting out customer priorities.
The Pareto principle states thatcustomers can be divided into two
categories:-
1. Vital few2. Useful many
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Pareto analysis of internal customers
So the vital Few internalcustomers are:-
Radiologists Surgeon Technician
Item Frequency Cumulativefrequency
Radiologist 25 25%
Surgeon 17 42%
Technician 15 57%
Supplier 12 69%
Nurses 8 77%
Medicalengineeringpersonnel
8 85%
Coordinator 6 91%
Medical record
staff4 95%
Administrativestaff
2 97%
Financial staff 2 99%
Reception 1 100%
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Pareto analysis of external customers
So the vital Few external
customers are:-
Patients Relatives
Health insurance organizations
Item
Frequency Cumulative
frequencyPatients 25 25%
Relatives 18 43%
Healthinsurance
organizations
16 59%
Media 15 74%
MOH 15 89%
Radiotherapist 4 92%
Chemotherapist 4 96%
Pathologists 4 100%
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Step 3:Discover Customers
Needs
Data collection
Customer need spread sheet
Needs analysis spread sheet Establishing of measures &sensors
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Data collection )Survey)
Is a special type of data collection
Data is provided by individuals andsummarized statistically to representthe view of relevant population
Data collected often concern softerissues like opinions and satisfaction.
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Survey for external customer
How would you like to register?
a) by phone b) by mail c) at the hospital it self
Would you like to be examined bya) by female doctor b) by male doctor c) No difference
How would you like to receive the report?a)By mail b) By E-Mail C) By hand
How would you like to learn self examinationa) By professional health staff b) CD
Time of providing the servicea) 9 p.m:1a.m b)10 p.m :2 a.m c) 11 p.m:3 a.m
Are you satisfied with the provided service?
a) satisfied b) not satisfied c) neutral
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Survey for internal customer
What is the relevant time would you like to
stay atwork?
a) 6 hrs b) 8 hrs c) 5 hrs in the morning & 5 hrs at
night
Is the physical environment is comfortable forwork?
a) Yes b) No
Would you like to attend training course?
a) Yes b) No The frequency of training course
a) Every 3 months b) Every 6 months c) Annually
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Customer Needs Spread Sheet
It a simple matrix spread sheet ,used tocorrelates customers and their needs.
It should include the vital few internaland external customers.
Correlate the relationship betweencustomers on the left hand column of
the spreadsheet and the needs listedon the top row.
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Customer needs spreadsheet
Customer needs
CustomersWritten
clear report
Confidentiality ofmedical
information
Protectedrecords
Radiationsafety
practices
Safemammogram
unit
Sufficientstaff
555555Patients
355553Relatives
513553Health insurance
organizations
555553Radiologists
535533Surgeon
001553Technician
231924302820Total
Customer needs spreadsheet ( cont )
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Customer needs spreadsheet ( cont. )
Customer needs
Customers Qualitycontrol
program
Timeavailability of
service
Qualifieddoctors
Trainedtechnicians
High qualityequipment
Trainedemployees
Measuresto ensurefollow upon time
3555555Patients
0553335Relatives
3313533
Health
insuranceorganizations
5155515Radiologists
5153315Surgeon
5005511Technician
21152124261424Total
Legend :
5 = strong relation
3 = moderate relation
1 = weak relation0 = no relation
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Needs Analysis spreadsheet
It usually looks like a blend of severaltree diagrams, showing all primarycustomer needs broken down into a
single dimension that can be measuredand addressed by individual initiatives.
Each primary need could be brokendown into secondary need(s) and eachsecondary need could be broken downinto tertiary need(s).
Needs analysis spreadsheet
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Needs analysis spreadsheet
Tertiary needsSecondary needsPrimary needs
Unit away from outpatient clinics &inwards
Unit away from areas of crowd ness
Radiation safetypractices
Availability & accessibility ofinternational radiology precautions
Unit complies with all laws ®ulations pertaining to radiological
& mammography services
Written policies for safety & forfacing disasters
Process for regular monitoring ofradiology staff
Staff radiation exposure monitored
Insulated mammogram unit
Safe mammogram unitRegular maintenance of the unit
Device capable to detect early &small lesions
Recent devices of high technology
High quality equipmentOf trusted brand name
Training program for techniciansWell trained technicians-with
identified training needs & Issuing atraining planTrained technicians
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Needs analysis spreadsheet ( cont. )
Tertiary needsSecondary needsPrimary needs
Records protected against fires &floods
Safe storage of recordsProtected records
Computerized filling system to
facilitate retrieval of data
Previous & subsequent records
are kept
Measures to ensure
follow up on time
A pre-prepared report format
Report includes description ofdetected abnormalities with clearassessment categories for cases ,recommendations for subsequent
follow up studies and suggestssurgeon consultation in high
probability category of breastcancer
Written clear report
Computerized report formsReports delivered in not more than
10 daysRapid results
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Establish Units of Measurement &Sensors
Measurement unitis a defined amount ofsome quality feature that permit evaluationof that feature in numbers, like hours of
time to provide the service. Sensoris a method or instrument of
measurement that carries out theevaluation and states the findings innumbers in terms of the unit of measure,like clock for telling time
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Measures & Sensors
SensorsMeasuresNeeds
Distance measuring scaleDistance between unit &nearest clinic or inward
Unit away from outpatientclinics & inwards
Check listY / NAvailability & accessibility of
international radiologyprecautions
Written policy& procedures
for disastersY / N
Policies for safety & for facing
disasters
Report of health appraisal ofradiology staff
Y / NProcess for regular
monitoring of radiology staff
Check listUnit is lead insulated acc. To
international precautionsInsulated mammogram unit
Maintenance registerY / NRegular maintenance of the
unit
Mammography filmsCapability to detect lesions of
. sizeDevice capable to detect early
& small lesions
Purchasing contractOf .. Or .. nameOf trusted brand name
Training registerY / NTraining program for
technicians
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Measures & Sensors ( cont. )
SensorsMeasuresNeeds
Evaluation form/Check listY/NRecords protected against
fires & floods
Computer programsY / NComputerized filling systemto facilitate retrieval of data
Computerized report
Y/NsA pre-prepared report format
Computerized reportY / NComputerized report forms
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Step 4:Develop Product
Affinity diagram
High level service /product features&goals spreadsheet
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Affinity diagram
Based on the data collected from theprevious step, the team can prioritize andgroup together those needs which relate to
similar functionality. This tool save time and ensure efficient
utilization of scarce resources.
It clusters related needs then prioritize these
sets of needs to ensure that the mostimportant needs receive the most attention.
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Affinity diagram
ReportsRecordsTraining needsHigh quality
needsSafety needs
A pre-preparedreport format
Recordsprotected against
fires & floods
Training programfor technicians
Device capable todetect early &small lesions
Unit away fromoutpatient clinics
& inwards
Computerized report
forms
Computerizedfilling system to
facilitate retrievalof data
Of trusted brand
name
Availability &accessibility of
internationalradiology
precautions
Regularmaintenance of
the unit
Written policiesfor safety & forfacing disasters
Process for
regularmonitoring ofradiology staff
Insulatedmammogram unit
Regularmaintenance of
the unit
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High level service /product features &
goals spreadsheet
High level product features mean thatfeatures are stated in broad terms, thatencompass other more detailed
features. Appropriate features should consider :-
An entirely new functionality
Replacing old features with new ones
Eliminating the unnecessary.
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The product goal should be SMARTand follow the concept of optimizationwhich include:-
Meeting the customer needs
Meeting the Supplier needs
Meet competition
Minimize the combined costs
High level service features & goals spreadsheet
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High level service features & goals spreadsheet
Service features
Customer needs
Device
capable todetectearly &small
lesions
Regularmaintenance of the
unit
Insulatedmammogr
am unit
Staffradiationexposuremonitored
Plan forfacing
disasters
Written policiesfor safety
Compliance withlaws & regulationspertaining toradiology&
mammography
Unit awayfromoutpatientclinics &inwards
05555555Radiation safety
55555530High quality Service
00000000Well trainedtechnicians
00005330Protected records
30000000Written clear report
00000000On time follow upensured
00000010Rapid results
Devicecapable to
detect lesionof .. size
Preventivemaintenance
of the unitonce monthly
Walls &floors of theunit are lead
insulated
Filmbadgefor each
technician
100% of stafftrained on
Plan forfacing
disasters
Safety policiesupdated on a six
monthly basis
Compliance with latestupdated laws &
regulations
At least 100m distance
between unit& inwardsand clinics
Service featuregoals
81010101513125Total
High level service features & goals spreadsheet (cont.)
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g g p ( )
Service features
Customer needs Rapiddelivery ofthe report
Previous &subsequentrecords are
kept
Clearassessmentcategoriesfor cases
Detailedreport
Recordsprotectedagainstfires &
floods
Experiencedtechnicians
Trainingprogram fortechnicians
Oftrustedbrandname
00000305Radiation safety
53531535High quality service
10130550Well trainedtechnicians
05115000Protected records
03551153Written clear report
33535010On time follow upensured
50000111Rapid results
Reportdelivered notlater than 10
days fromrequest andwithin 5 days
in case ofpositive report
Records are
kept for 5years fromdate of
procedure
Casescategorized as
(negative,Bgfindings,
probably Bg
findings ,suspiciousabnormality ,
highlysuggestive ofMg , known
biopsy provenMg)
Reportincludes
descriptionof detected
abnormalities &recommend
ations forsubsequent
follow upstudies
Records are
kept in fire &waterresistantcabinets
Certified licensed
technicians withminimum 2 years
experience
Monthly training
of all techniciansincluding on jobtraining sessions
Of .. Or. name
Service feature goals
1414171512151514Total
Legend :5 = strong relation
3 = moderate relation1 = weak relation0 = no relation
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Step 5:Develop Process
Process anatomy
Process flow diagram
Process features & goals spreadsheet
P t
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Process anatomy
It is a coherent structure which bindsor holds the process together.
It guides the flow of the work from start
to finish.
Shows in schematic form where thevarious sub-processes reside, how
they are linked together, and where theinputs enter and the outputs go.
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Process anatomy may be :-
Autonomous
Assembly tree
Procession (assembly line)
P t
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Process anatomy
Item Process Processanatomy
Macro process Mammogram unit Assembly tree
Sub process Registration Assembly tree
Clinical
examination
Procession
Performing the
mammogram
Procession
Report Procession
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HIGH LEVEL FLOW DIAGRAM(PROCESSANATOMY)
Registration
Clinical examination
Performing
mammogram
Report Delivering the report Writing the report
Arrangement forappointment
Billing
Preparing the patient
Positioning
History takingLocal examination
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Process anatomy
Mammogram unit
Registration Clinicalexamination
Performing
mammogram
Report
Arrangement forappointment
Billing History Localexamination
Preparing the
patient
positioning
Writing Delivering
P f t & l
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Process features & goalsspreadsheet
More or less it resembles the productfeatures &goal spreadsheet.
The process features can be
categorized under procedures,methods, equipments and supplies,materials, people, training andknowledge and other resources.
The process goals are like other goalsshould be SMART
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Step 6:Develop process controls
Feedback loop
Process control spreadsheet
Feedback loop
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Feedback loop
Feedback loop is the tool formonitoring the actual performance of aprocess and keeping it performing as it
was designed
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Step 6Step 6
Compare to
standard
Measureactual
performance
EstablishedControl s tandard
Identifyproblem Diagnosecause Remedycause
ok
Not ok
Trouble shoot
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Process control spreadsheet
This tool will enable the team to identify:-
1. The control subject.
2. The target goal
3. Criteria for taking action4. Who takes action
5. What action they take
6. Where they do it
7. When they do it
8. How they do it
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Every 3 months
for 3 days
Training
unit
Prepare for
trainingsessions
Head of
radiologydepartment
defective testsMore than 2%
Zero level
of defectivetest
Calculate theradiation
emission every
month
Mammogram unit
Proper Dose&time ofexposure
Radiologist&
technician
If the radiationexceed the safety
limits
100% safeProcedure
Whendiscovered
In thesecretary
office
Checkcoping&printingservices
Chiefexecutive
officer
Patientcomplaining from
delaying report
Within 10days
After each
patient
At
mammogram unit
Cleaning the
equipmentafter every
patient
NursePatient
complaining fromdermatological
infection
100%
Disinfectedequipments
Checkappointment
every day
Trainingunit
Trainsecretaries
Head ofradiology
department
More than 2%error
100%accuratereports
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