Quality Improvement (QI)

Understanding the Cause and Effect Diagram

Gregg M. Reed, MPHQI Council

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Quality Improvement in Accreditation

“Quality improvement is the foundationof [Public Health Accreditation Board] PHAB’s accreditation program, to the extent that a health department attains accreditation status only if it embodies a culture of quality improvement.”

American Public Health AssociationQuality Improvement in Public Health: It Works! (2012)

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Summary Definition of Quality Improvement

• Continuous/ongoing process• Measureable change • Monitor factors/disproportions impacting quality• Achieve equity/uniform processes within a

system to improve health

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Agenda• Review Quality Improvement Tools– 10 minutes

• Group Work on Cause and Effect Diagram and 5 Whys– 30 minutes

• Review Group Work– 10 minutes

• Discussion and Next Steps– 10 minutes

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Cyclical Continuous Improvement

PLAN

DO

CHECK/STUDY

ACT

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Stating the Problem“A problem well stated is a problem half solved”Charles Kettering, an American inventor

An AIM Statement or Problem Statement

If you can’t describe what you are doing as a process, you don’t know what you’re doing. – W. Edwards Deming

A Flow Chart

Describing the Problem Process

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General ApproachIssue to

Consider:Delay in Travel

Reimbursement Brainstorm & Consolidate Data (Affinity Diagram)

Flow Chart Existing Process

(Examine Process to see

where problem might be -

Identified Delay)

Cause & Effect Diagram – Greatest Concern

Drill down to root causes (Five Whys)

Gather DataTranslate Data

into Information

Analyze Information and

develop solutions

(Solution and Effect Diagram)

Flow Chart New Process

Monitor new process and Hold

the Gains

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What is a Flow Chart

• A diagram that represents the sequence of operations in a process.

• Used to identify the actual flow/sequence of events in a process– Helps to determine:• What is going on?• Are there delays?• What are the next steps?• How can we improve this process?

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Gather Reciepts

No

Travel Reimbursement(Out-of-State)

Do you have the required original receipts?

Return from travel

Yes

1Do you fill out the travel

voucher?

Yes

No

Yes

No

1

Contact Accounting on how to proceed

Employee review travel voucher and sign

Employee receives check by inside mail

Submit original voucher and original receipts to accounting

Give to division director and/or section cheif for signatures

Audited and determined acceptable?

Employee emailed

No

Accounting stamps with date received

Entered into Peoplesoft

Returned to Employee Unpaid

Can you get the required original receipts?

Give proper information and documentation to

support person.22

Make copies and date stamp

Complete Travel Voucher and paper clip original reciepts

2

Payment ProcessedNo Yes

Direct Deposit set up for Employee?

Yes

Accounting picks up check from state treasury office

Employee account credited

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March Flow Chart Findings

• Bottlenecks• Hand-offs• Redundancy• Rework loops• Wait or delays

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What is an Affinity Diagram?

• A tool for assimilating and understanding large amounts of information.– Group large amounts of (team/partner generated)

information into themes for further analysis.

• Used to categorize and identify ideas.– Helpful after describing the process (flow chart).– Provides direction and impact

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Lack of Training and Unclear

ProcessLack of

Organization

Accounting Expectations vs.

Reality

Unnecessary Steps for Traveling

IndividualWorkload and

AvailabilityTravel Voucher

Problems OtherNot knowing policies and procedures (new/updated)

Employee organizing/saving receipts needed

Accounting thinks people know the process, but they don't.

Not knowing reimbursment rates

Availability of individuals needed for signatures

Travel voucher is not intuitive

Incorrect deposit information in PeopleSoft (Old accounts are saved)

Lack of written procedures/policies

Lack of traveler organization (some receipts in luggage/purse/pocket)

Lack of assistance from accounting

Which rates to use on travel days

Individual gets backed up due to workload when returning.

Form not filled out properly

Lack of training how to fill out during orientation

Have multiple receipts in different areas - have to take time to gather

Did something accounting doesn't like (ie; booking flight with Expedia)

Knowing if you quality for breakfast, lunch, dinner

Availability of division directors/section chiefs to sign

Did not complete form properly

No set individual to do the process. Everyone has to be trained.

Who does the training on completing the form

Unclear expectations from accounting

Knowing or locating per diem rates

Only one person in accounting who audits out of state travel

Form returned due to problem or lack of information/ documentation

Employee not familiar with policies/procedures, too much time to find answers

Unnecessary questions from accounting

Traveler has to find GSA rates to complete form and then rechecked by accounting

People needed to answer questions out of the office or unavailable

Incorrect or outdated form, then employee has to redo

Lack of trainingUnknown processing time from accounting

Signer Out or Messy Desk

Unsure of processIndividual workload or time

Lack of training

Support staff have to take time to ask traveler for clarification

Forget due to lack of out-of-state travel

Time available to complete the process

Not knowing which receipts neededWhat receipts are neededOffsite people have to mail original receipts

Lack of knowledge on which receipts are requiredWrong type of receipt (hotel must have amount charged and zero balance)

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Accounting Procedures Human ErrorDelay in Supervisor

Approval Staff Time Limitation Lack of Knowledge Technology Limitations

Accounting timelinesMissing receipts/No original receipts

Priority level with supervisors (to get signatures)

Administrative support has conflicting priorities

Separation of incurred costs (personal vs. required receipts)

Potential for People Soft to be down or unable to enter into the system

Questions on receiptsInclusive of all cost categories

Individual questions asked to the supervisor

Staff are out of the office- illness/AL

Knowledge of allowable and reimbursable expenses

Employee doesn't have direct deposit

Errors found after review

Sharing ground transportation and needing separation

Division Director or Section Chief not available for signature

Staff are not in the office (field staff, etc.)

Protocol for defined standards for reimbursement

Clarification is needed

challenge of management review and signature in a timely manner

Difficult for employee to track where in the process the form is at

Knowledge of reimbursement process- who does what

Accounting too busy

Completing travel reimbursement is not a priority to individual

Don't how to fill out the form correctly

Employee too busy to fill out form or forget to fill it out

Don't know perineum amounts

Knowledge of the funding source/categories

Lack of standardization of how the form is completed

Not familiar with the travel policy

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What is a Cause and Effect Diagram

• Uses of this Diagram• Organize the themes and factors generated in an Affinity

Diagram• Identify and categorize issues about the causes of

problems • Display the information graphically

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Cause and EffectStep 1

DELAY IN TRAVELREIMBURSEMENT

Write the problem statement on the right side of the page; this is known as the effect.

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Step 2Generate ideas about the main causes of the effectand write them to the left of the effect; these are the main cause headers. For example: “A” = Lack of Training and Unclear Process

DELAY IN TRAVELREIMBURSEMENT

C

BA = LACK OF TRAINING AND UNCLEAR PROCESS

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Step 3

DELAY IN TRAVELREIMBURSEMENT

C

BA = LACK OF TRAINING AND UNCLEAR PROCESS

Draw arrows from each main cause header to the backbone.

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Step 4Under each main cause header, list ideas that support it as the sub-cause; Draw arrows from each sub-cause tothe main branch header arrow. For example: 1= Employee Organizing/saving receipts needed

DELAY IN TRAVELREIMBURSEMENT

C

B

2

1

3

2

1

2

3

A = LACK OF TRAINING AND UNCLEAR PROCESS

1 = Not Knowing Policies and Procedures

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5 WHYS Analysis

Process will identify the root causes of the effect.Begin with a sub-cause selected by your group.

Not Knowing Policies and Procedures_____ WHY?___________________________________ WHY?___________________________________ WHY?___________________________________ WHY?___________________________________ WHY?

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Group Work (Divide Room into Half)

1. (Optional) Compile additional Main Cause Headers and sub-causes, if needed

2. Complete an applicable Cause and Effect Diagram3. Hang the diagram on the wall using provided supplies4. Complete 5-WHYS analysis on sub-causes of each Main

Cause Header5. Choose a group spokesperson to present

Please conclude by 1:40pm (30 minutes)

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Discussion

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Next QI Tool Learning Session

• Solution and Effect Diagrams–June 17th•11 am to 12 pm•Capital: AV Rooms 210 & 212

• Contact Susan Mormann or Kelly Nagel with questions