22670 Haggerty Road, Suite 100, Farmington Hills, MI 48335 ~ www.mpro.org

Quality Improvement Tools and Techniques: 2007

An MPRO Self-Instructional Module

Patricia L. Baker, RN, MS

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Tools for the Continuous Quality Improvement Journey

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Objectives

• Identify common quality improvement (QI) tools used to focus on important problems

• List tools for identifying problem causes

• Recognize tools for defining solutions

• Review tools used to develop QI plans

• Plan to display QI data

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Reference: Langley, G.J.; Nolan, K.M.; Nolan, T.W.; Norman, C.L.; and Provost, L.P. (1996).The Improvement Guide, San Francisco, CA: Jossey-Bass Publishers

MODEL forIMPROVEMENT

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Continuous Quality Improvement

PPAA

SSDD

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Tools to Identify the QI Focus

• Define the problem areas

• Compare the current state with the desired state

• Check alignment with organizational mission and goals

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Tools to Identify Focus

• Brainstorming

• Idea writing

• Impact analysis

• Pareto Diagram

• Problem statement

• Selection grid

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Brainstorming

• A focused creativity technique designed to collect multiple ideas about an issue

• Benefits Encourages creative thinking Generates a large number of ideas Gets all team members involved Eliminates fear of criticism Increases the number of options

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Brainstorming Rules

• No criticisms or compliments• No discussion• No questions• Speed is important• Think broadly• Develop wild, outrageous ideas• Build on ideas of others• Listen• Do not interrupt• Quantity is important

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Brainstorming Steps

1. Clarify the brainstorming objective

2. Write the objective at the top of the flip chart

3. Review brainstorming rules

4. Determine process: free flow or take turns

5. Record each idea on the flip chart

6. Continue until all ideas are exhausted

7. Clarify each idea after all ideas are listed

8. Group like ideas together

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Idea Writing

• Individual brainstorming on paper

• Benefits Idea notes may be written before the team

meeting Protects anonymity Idea notes shared at the meeting Includes those who cannot attend

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Impact Analysis

• Survey technique to discover the impact or effect of a situation or problem

• Benefits Confirms the problem or project is worthwhile Indicates the severity of the problem Often uncovers new information Allows for sharing of thoughts, opinions, and

ideas

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Pareto Diagram

• Bar chart that demonstrates the distribution of issues that cause most of the problems

• Benefits Applies the 80/20 rule Focuses on the 20% of the work that cause

80% of the problems Gives the biggest return for your efforts Helps explain problem to others

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Pareto Diagram

Reasons women do not get mammograms May, 2003

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8 7

3

0

5

10

15

Fear No insurance Forgot Test not ordered

Total

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Problem Statement

• Defines and summarizes the issue or problem• Benefits

Spells out the impact of the current state Defines the opportunities of the desired state Explains the expected impact of correcting the

situation Delivers a consistent message

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Define Goals

• What are we trying to accomplish?

• SMART Goals Specific Measurable Attainable Realistic Timely

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Tools to Understand the Cause

• Clarify the process Flow chart the process

• Determine cause Fishbone or Cause and Effect Diagram Impact analysis Data Pareto Diagram

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Flowchart the Process

• A diagram of the sequence of steps in a work effort• Benefits

Clarifies current knowledge of process Demonstrates the work flow Examines parts of a process and their relationship

to each other Identifies the sources of variation for each step

from start to finish Points out unnecessary complexity, inefficiency, and

redundancy Develops a common understanding

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Flowchart Steps

• Involve those most knowledgeable about the process

• Define the boundaries (beginning and end)

• List the work activities, decisions, and documents

• Place the activities, decisions, and documents in the order that they occur

• Connect the activities with arrows

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Diabetic Patient Registers

A1C due?

Nurse/MA reviews the diabetic flowsheet

Nurse/MA obtains blood sample and documents results

Patient escorted to exam room

NO

YES

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Patient Leaves Office

Physician/PA/NP reviews documentation

Patient checks out at receptionist

Diabetic Foot ExamNeeded

YES

Nurse/MA conducts foot examand documents on foot exam form

NO

Physician/PA/NP enters exam room

Physician/PA/NP examines patient and completes documentation

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Fishbone or Cause & Effect Diagram

• Explores and displays the identified causes and relationships leading to a specific outcome

• Benefits Involves multiple team members Allows grouping of information Displays related causes Gives ideas for goals Points out data needs Provides ideas for solutions Presents big picture of the problem Easy to understand

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Fishbone or Cause & Effect Steps

1. Agree on the problem statement or outcome

2. Identify major cause categories

3. Brainstorm reasons for each of the major causes

4. Clarify the diagram

5. Post for others to review

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Fishbone or Cause & Effect Diagram

Employees Materials Equipment

Environment Methods

Outcome

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Examine Solutions

• Tools to generate solutions Brainstorming Impact analysis Pareto Diagram Flowchart Fishbone Collaboration with others Literature

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Select a Change Option

• What change can we make that will result in improvement?

• Tools Decision matrix Selection grid Multi-voting Cost-benefit analysis Force Field Analysis

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Decision Matrix

Easy to Do

HighPay Off

Hard to Do

LowPay Off

A. B.

C. D.

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Selection Grid

Criteria

OptionsWorthwhile Cost

Admin

Support

Criteria

#4

Criteria

#5

A

4 yes

2 no

3 yes

3 no

3 yes

3 no

B

3 yes

3 no

5 yes

1 no

4 yes

2 no

C

5 yes

1 no

2 yes

4 no

3 yes

3 no

D

2 yes

4 no

yes

4 no

3 yes

3 no

Z 6 yes

4 yes

2 no

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Multi-voting

• A group decision-making technique designed to reduce a large list of ideas to a manageable number.

• Benefits Eliminates peer pressure Equal participation Allows for consensus Gains “buy-in” among the team

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Multi-voting Steps

1. List ideas or options on flip chart or chalk board2. Each team member votes for their top three

choices3. Clarify among the team and eliminate choices

with one or zero votes4. Each team member selects top two choices

from the remaining list5. Repeat the process until the top one or two

ideas have been selected

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Cost-benefit Analysis

• Determine the financial impact by comparing the costs and benefits

• Benefits Evaluates the cost of a change Supports decision-making Provides supporting documentation for QI

team’s recommendation

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Force Field Analysis

• Identify and discuss forces that support or interfere with a change

• Benefits Identifies obstacles Lists supporting elements Suggests action steps

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Force Field Analysis

Driving Forces Restraining Forces

DesiredState

CurrentState

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Determine Measures

• How will we know that a change is an improvement?

• What are the data needs?

• Consider: Data collection methods Data analysis plan Accountable persons

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Check List

• A method to systematically record data from observations or historical sources

• Benefits Easy-to-use form Minimal data collector training Efficient and fast data collection Detects patterns and trends

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Check List

Steps• Decide on data to collect• Clarify definitions• Decide on time period for collection• Select sample size• Decide who will collect data• Design and test the check list• Distribute form and collect the data• Tally and evaluate

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Develop Action Plan

• Brainstorm

• Force Field Analysis

• Political action plan

• Presentation

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Action Plan

Action Plan Project Name: _________________________________ Project Lead: ________________ Date: ________________ Goal (s) What are we trying to accomplish?

Steps What needs to be done?

Accountability Who will do it?

Deadline When will it be done?

Monitoring How is it going? What progress has been made?

1.

2.

3.

4.

5.

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Political Action Plan

• A communication strategy designed to inform and gain support

• Benefits Share information Build support Receive feedback Build consensus Eliminate “surprises”

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Presentation

• A communication technique to share information and obtain feedback

• Benefits Deliver a consistent message Gain understanding Elicit support Teach and share Receive ideas

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Presentation Strategies

• Be prepared

• The three “tells”

• Use visual aids Storyboard Slides Diagrams, charts, and graphs

• Practice

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Continuous Quality Improvement

PPAA

SSDD

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Continuous Quality Improvement

PPAA

SSDD

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Pie Chart

• A picture depicting parts of the whole

• Benefits Easily understood Draws interest Good visual

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Bar Chart: Aspirin at Arrival for AMI Patients

80.5 80.0

95.2

0.0

20.0

40.0

60.0

80.0

100.0

Michigan National Benchmark

Perc

ent (

%)

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Run Chart

Number of Foot Exams performed per M onth

0

10

20

30

40

JULY AUG SEP OCT NOV DEC

Total Foot Exams

New flow sheet

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Continuous Quality Improvement

PPAA

SSDD

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May your QI journey be fun, interesting, and successful!

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QI References

• Brassard M, Ritter D. The Memory Jogger II. GOAL/QPC, Methuen, MA, 1994.

• Brassard M, Joiner BL. The Team Memory Jogger. GOAL/QPC and Joiner Associates Inc, Methuen, MA, 1995.

• Langley GJ, Nolan KM, Nolan TW, Norman CL, and Provost LP. The Improvement Guide. Jossey-Bass Publishers, San Francisco, 1996.

• Scholtes PR. The Team Handbook. Joiner Associates, Inc. Madison, WI. 1988.

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Creativity References

• DeBono E. Serious Creativity. New York: Harper Collins, 1993.

• Higgens JM, 101 Creative Problem Solving Techniques, Winter Park, FL: New Management Publishing Company, 1994.

• Plsek PE, Creativity, Innovation, and Quality. Milwaukee, WI: ASQC Quality Press, 1997.

• Van Oech R, A Whack on the Side of the Head. New York: Warner Books, 1983.

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Continuing Education (CE) Contact Hours

• Answer the post test questions • Minimum passing score = 76%

• Minimum correct answers = 19/25

• Complete the evaluation

• Print your certificate

Thank You for Reading This SIM

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Additional Information

Patricia L. Baker RN, MS

Director, Staff Development

248-465-7324

pbaker@mpro.org

Carol J. Grubba, RN, MSN, BC

Project Manager, Continuing Education

248-465-7337

cgrubba@mpro.org

This material was prepared by MPRO, the Medicare Quality Improvement Organization for Michigan, under contract with the Centers for Medicare & Medicaid Services, an agency of the U.S. Department of Health and Human Services.

22670 Haggerty Road, Suite 100, Farmington Hills, MI 48335 ~ www.mpro.org 53

7SOW-MI-CE-05-05