Solving Problems, Elevating Quality in Public Health

QI Coach’s Handbook

QI Coach CoordinatorsContact Information:

Sue Hancock 317-234-1648 shancock@isdh.in.gov

Sarah Strawbridge 317-233-7371 sstrawbridge@isdh.in.gov

Module 1

QI Basics

Why QI?The goals are to benefit:

Employees involved in work processes, making the work easier.

Our organization, through more efficient or effective work activities.

The customers of our work, who must use what we produce.

Kelly, 1992

Where did QI come from?• Grandfather of QI: W. Edwards Deming

– Statistician and professor by trade, consulted with American companies during WW II on production issues.

– Post world-war II: Worked with Japanese companies to rebuild. They embraced his techniques.

– Believed that the goal of business should not be just to make profits, but to stay in business so they could provide jobs.

W Edwards Deming

Has been called a “curmudgeon” for his critical workshop tactics.

In reality, he sympathized with the plight of workers.

A short story…Deming’s 14 Points

QI Assumptions• Workers want to perform well on the job, take

pride in their work. • Workers’ performance more often related to

faulty systems than employee error. – Jurran’s Principle: “85%-15% Rule”

• Management/leadership generally makes decisions about systems.

• Data is needed to make good system decisions.

What do we get from QI?Improves our job satisfaction – we know our

product or service is quality, a source of pride.

Reinforces the belief that we can solve problems, make a difference in our jobs

We have a greater investment, ownership for our work.

We have less tolerance for problems and poor quality.

QI BasicsImproving quality is a systematic process:

• PLAN: Define the problem, collectdata, select a possible solution.• DO: Implement solution on a smallscale.• CHECK: Collect data, determine if the solution worked. If not, go back toPlan and select another solution.• ACT: When a solution works, spread to all aspects of the operation.

Five-Step Problem Solving ModelQuality improvement can also be described as a

systematic problem-solving model: 1. Identify the problem – clearly state what needs

improvement.2. Analyze the problem – Determine what causes

problem to occur.3. Evaluate alternatives – Identify and select actions

to reduce or eliminate the problem.4. Test/implement a solution – Implement these

actions on a trial basis to determine effectiveness.5. Standardize – Ensure that useful actions are

preserved.

Module 2

Working Together as a Team

Working Together as a Team• Team Roles:

– Team members share their expertise to plan and implement project work.

– The Leader orchestrates team activities, maintains records, serves as communication link with rest of the organization.

– The Coach understands the tools and concepts of improvement, including approaches that help a team function well together.

– The Sponsor reviews and supports team efforts, interfaces with other parts of the organization.

Effective Team Members…• Participate fully in team meetings• Share knowledge and experience, listen

closely to that of other team members• Are open to new ideas• Carry out assignments between meetings• Assist leader with managing the meetings,

e.g. documentation, discussions.• Communicate effectively with colleagues

about project work.

An Effective Leader…• Organizes the team’s work and activities• Focuses on a data-based methods to solve the

problem• Serves as contact point for communication

between the team, sponsor, others in organization

• Keeps official team records, e.g. meeting minutes, agendas, data related to project.

• Assists with carrying out work between meetings• Implements project-driven changes within his or

her authority• Helps team resolve its problems

An Effective Coach…• Attends meetings but not is a leader or

member; an outsider who maintains a neutral position.

• Assists team in structuring or breaking down tasks and plans into assignments

• Works with team leader to plan meetings• Assists leader with team building• Teaches data collection, analysis techniques;

helps team graphically display data• Helps team prepare for presentation of

project to management, others

An Effective Sponsor…• Maintains overall responsibility, authority and

accountability for project• Approves “bubble-up projects,” assures

compatibility with organizational priorities• Sometimes initiates project, begins charter,

selects leader, coach and members• Approves resources for project• Interfaces with rest of the organization to assure

appropriate stakeholder involvement• Feeds data and lessons learned into a system for

future improvements, e.g. policy changes

Reality CheckIs everybody clear about the roles?Does everyone have a role?Are the leader, coach, sponsor roles filled?

If not, what is the plan?

Next Step: What’s our problem?

Module 3

Identifying the Problem

QI Toolkit: Identifying Problems

Brainstorming – generating a list of potential problems

Interviews or surveys - customer feedback, recommendations

List reduction - narrowing the list to a few items, by combining into groups

Problem selection matrix

Collect a large number of ideas from a group of people. Many ideas, quickly as possible.

One-at-a-time (everyone speaks)Open door (call out ideas)Write-it-down (confidentiality)Guidelines:

Be creativeBuild on ideas of othersNo critique allowed

QI Toolkit - Brainstorming

Interviews:Purpose: Collect data from direct

conversation.

Surveys: Purpose: Collect data from a large number of people.

QI Toolkit – Interviews, Surveys

Purpose: Reduce a large list of items to a manageable size.Useful in conjunction with brainstorming.Group votes for the most important items on

list (can cast as many votes as they want).Items with the most votes are circled.If further narrowing is required, process conducted again, limiting number of votes people can cast.

QI Toolkit – List Reduction

QI Toolkit: Selection MatrixProblem Selection Matrix

CriteriaProblems

Within our control or influence

Potential for cost savings

Number of customers affected

Significance of Problem

Total

Too many defects

3 3 3 3 12

Absenteeism high

1 2 2 3 8

Equipment breakdowns

1 3 3 2 9

Water cooler too far away

3 1 1 1 6

3 = High 2 = medium 1 = low

What’s Our Problem?

A little history…When did we notice the problem?Was there anything else going on when we

noticed it?Have other solutions been tried in the past?If so, what happened?

What’s Our Problem?Zooming in on the current state:What exactly is happening?When is it happening?Where is it happening?Who is involved?

What’s Our Problem?Zooming in on the future (or desired) state:What should be happening?When should it happen?Where should it happen?Who should make it happen?

Current State

• What is the current state?

• Why is this important?

• What is it costing us time/dollars/staff/etc?

• What is the impact on our customer/clients?

• What is the impact on our division/agency?

Future State:

• What are the important aspects of the future state?

• What is driving us to this future state?

• What might be the consequences of not moving to the future state?

• What might change?

• What is the proposed timeline?

Pathway

Consequences

Driving Forces:

Benefits

Current and Future State

QI Toolkit - Force Field Analysis

Figure 1 Force Field Analysis Diagram

+ Driving forces Restraining forces -

Use time effectively. Help plan other activities. Value all members equally. Publish agenda.

Changing priorities. Overcommitted schedules. Low team morale.

Lack of meeting notice.

Ideal state: To start meetings on time

Issue: Meetings starting late

Where is the process breaking down?

RFFlow Professional Flowcharting, http://www.rff.com/flowchart_samples.htm

QI Toolkit – Flowchart

Draft a Problem Statement

A good problem statement should be: Specific. Describes the problem, not the symptom. Relates the current situation to what is

desired. Does not include causes or solutions

Expressing Need for Improvement in Measurable Terms

Two-Step Process:Gathering information (data) about the

problem.Tool utilized: Checksheet

Organizing data so that it is meaningful and clarifies the problem.Tools utilized: Line graphs, Pareto charts,

Histograms, Bar and Pie charts.

Purpose: Collect data in an organized manner.Telephone Interruptions

Excerpted from Nancy R. Tague’s The Quality Toolbox, Second Edition, ASQ Quality Press, 2004, pages 141-142.

QI Toolkit: Checksheet

ReasonMon Tues Wed Thur Fri Total

Wrong # lllll ll l lllll lllll ll 20Info Requestll ll ll ll llll 10Boss lllll ll lllll ll l ll 19Total 12 6 10 8 13 49

Day

Purpose: Display the output of a process over time.

QI Toolkit: Line Graph

Purpose: Arrange data so that the most significant element in a set of elements is easily identifiable.

Diagram courtesy of Six Sigma http://www.isixsigma.com/offsite.asp?A=Fr&Url=http://www.skymark.com/resources/tools/pareto_charts.htm

QI Toolkit: Pareto Chart

Purpose: Determine how data are distributed.

QI Toolkit: Histogram

Purpose: Arrange data for quick and easy comparison.

QI Toolkit: Bar Chart

16.0 16.7

5.1

11.1

0

4

8

12

16

20

Diabetes Asthma

Comorbidities

per

cen

tage

Arthritis

No Arthritis

Purpose: Display the volume or quantity of one item in relation to others.

QI Toolkit: Pie Chart

Check Problem StatementDid data validate the original problem

statement?If not, revise and collect more data.If it did, refine the problem statement so that

it is: Specific. Describes the problem, not the symptom. Relates the current situation to what is

desired. Does not include causes or solutions

Establish Interim Target, DateTargets should be:

Intermediate and long termQuantitatively expressedAggressiveChanged as the situation changes

Example: This project aims to reduce the number of days it takes to process a payment voucher from 10 working days to 2 by December 31, 2010.

Module 4

Analyze the Problem

Identify the Root Cause(s)If the cause is removed, the problem should

be at least partially removed.A symptom is not a cause; a symptom is

evidence the problem exists.Several root causes may contribute to the

problem; it is important to examine all.QI Tools for establishing root cause(s):

Brainstorming, Flowcharts, Cause and Effect Diagrams, 5 Why’s.

Purpose: Identify a set of related causes that lead to an effect or problem.

QI Toolkit: Cause and Effect Diagram

QI Toolkit: 5 Why’sProblem: Patient falls in the hospital.

5 Why’s Response

Why does the patient fall? Not wearing skid-proof slippers.

Why does the patient not wear slippers?

Not issued by nurse.

Why were slippers not issued? No slippers in supply closet on patient’s floor.

Why were there no slippers in the closet on patient’s floor?

Staff did not re-order.

Why didn’t staff re-order? Busy with needs of other patients.

Verify Cause by Collecting DataQI Toolkit - Data collection and analysis:

Checksheet Root Cause Evaluation MatrixHistogramBar ChartPareto Chart

Root Cause Evaluation MatrixProblem: Suzie has been late to school 8 times in past 3 months.

Potential Root Cause Analysis Verified?

Doesn’t get up when called.

Occurred twice in past 3 months, not on days late to class.

No

Can’t find clothes. Has not occurred in past 3 months. No

Homework not complete.

Has occurred 10 times in past 3 months, always on days when late.

Yes

Guidelines for Data CollectionEstablish the purpose for collecting data –

helps you target your efforts, collect only what is needed.

Determine if indicators are reliable – What is the source of data? Are measuring practices consistent and accurate?

Track all data needed – collect enough to conduct a thorough analysis.

Record data carefully – Use a checksheet that is logical and makes collection easy.

Select Root Cause(s) Most Responsible Example: Investigating

delay associated with processing credit card applications, data could be grouped into the following categories:No signatureNo AddressCannot readCurrent customerOther

Module 5

Evaluate Alternate Solutions

Developing AlternativesQI Toolkit: Brainstorming, interviews,

survey, research (have others solved this problem?)

Guidelines:Be creative, identify as many potential

solutions as possible.Don’t be limited by the current practice (i.e.

“That’s the way we’ve always done it.Refrain from judging team members’

suggestions.

Evaluating AlternativesEffective? (Tried before? With what results?

Will it solve the problem? Achieve improvement target?)

Feasible? (Is it doable? Practical?)Timely? (How long will it take? Long term or

short term? Can we afford to wait?)Customer-oriented? (Will it improve

service quality? Satisfy customer identified requirements?)

Efficient? (Is it cost effective?)

Select Solutions to ImplementPlanning for implementation:People: Whose support is needed?Materials: What is needed? Who will

purchase?Methods: How will implementers be

trained? How will solutions be measured?Machinery/Equipment: Where will it come

from? How will it be funded? How will it be purchased? How will implementers be trained to use it?

Purpose: Document the hindering and supporting factors that influence a planned activity.

QI Toolkit – Barriers and Aids

PROVIDE ISDH PROGRAM STAFF TRAINING ON QI SKILLS

AIDSTraining materials available

Program staff want to learn QI

BARRIERS

Employee work schedules not compatible with dates

Program time is consumed with grant requirements.

Purpose: Document the hindering and supporting factors that influence a planned activity.

QI Toolkit – Barriers and Aids

PROVIDE ISDH PROGRAM STAFF TRAINING ON QI SKILLS

AIDSTraining materials available

Coordinate training dates to align with work schedules

Program staff want to learn QI

Develop efficiencies to clear out time for accreditation preparation

BARRIERS

Employee work schedules are not compatible with dates

Program time is consumed with grant requirements.

Elements of PlanningThe objective is clearly stated.Activities are each defined.Responsibility is assigned.Dues dates are established.Implementation Plan Matrix:

What How Who When Complete?

Task 1

Task 2

Task 3

Module 6

Test-Implement Plan

Test the PlanImplement on a trial or “pilot” basis.

Get all necessary approvals.Help solutions succeed by:

Communicating the planMonitoring implementationSupporting each otherAdjusting if necessary

Show measurable improvementsQI Toolkit: Line Graphs, Pareto Charts, Pie Charts, Bar Charts, Histograms , Checksheets.

Test the PlanIf measurable improvements are not evident,

return to problem-solving statement.Common reasons why this happens:

Poor problem statementAnalysis insufficient or inaccurateVerification of root causes is inadequate

Module 7

Standardize Improvements

Steps to StandardizationMake solutions permanent:

Make periodic checksClarify work activities (make a flowchart of new

process)Develop procedures and follow themAssign responsibility

Spread improvements to total process(beyond pilot)

Determine if solution is applicable to other areasGuard against “spotlight” effect—improvements

related to process being under investigation.

ReferencesKelley, MR. (1992).Everyone’s Problem Solving

Handbook. Productivity Press, Portland, OR.Walton M. (1986). The DEMING Management

Method. The Berkley Publishing Group, New York, NY.

Scholtes PR, Joiner BL, Streibel BJ. (2003). The Team Handbook, Third Ed. Oriel Inc, Madison, WI.

Healthcare Technical Assistance Program. (2007). Indiana Public Health System Quality Improvement Program. Purdue University, West Lafayette, IN.

Moran J, Duffy G. (2009). Public Health Foundation, Washintgon, DC.