Improvement Science In Action: Introduction

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Institute for Healthcare Improvement Faculty

Michael Posencheg, MD

Rebecca Steinfield, MA

Day 1ASeptember 9 2015

Improvement Science

In Action: Introduction

These presenters have nothing to disclose.

Objectives

At the end of this session, participants will be able to:

• Describe the context for quality improvement in health care

• Identify the elements of Deming’s System of Profound Knowledge

• Apply the lens of profound knowledge to your improvement project

• Define the system you want to improve

• Review, revise, and refine your improvement project aims

• Develop a family of measures for an improvement project, including outcome, process, and balancing measures

• Develop change ideas from change concepts

• Identify opportunities to use the core improvement tools in your improvement project

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IHI’s Mission:To improve health and health care worldwide

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IHI Faculty

Rebecca Steinfield

Rebecca Steinfield, MA, has been with IHI since

1996. She currently serves as Director of IHI’s

Improvement Advisor Professional Development

Program, teaches IHI courses on improvement

methods, and mentors “improvers-in-training.”

Rebecca sits on IHI’s Improvement Capability

Focus Area and Research and Evaluation teams.

Past IHI work includes serving as an Improvement

Advisor on IHI’s programming for reducing

unnecessary rehospitalizations and primary care

transformation in academic settings. She is also

mother to two teenagers: Jacob, 18, and Susie, 15.

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IHI Faculty

Michael PosenchegMichael Posencheg, MD, is an attending neonatologist

at the Children’s Hospital of Philadelphia and the

Hospital of the University of Pennsylvania where he is

the Medical Director of the Intensive Care Nursery and

Newborn Nursery. He has completed the Improvement

Advisor (IA) program at the IHI (Wave 23) and the

Graduate IA program (Wave 30). As part of his duties

as Medical Director, he coordinates quality improvement

projects for his unit and has published on some of those

results. He is on the QI faculty and steering committee

for the University of Pennsylvania Health System. He is

also father of twin teenage daughters, Hannah and

Hayden, 16, and a son, Dylan, 11.

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Housekeeping

• In this room all 3 days

• Restrooms

• Coffee Breaks and Lunch

• Parking Lot – questions, feed forward

• Turn off your cells & e-mail please

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Time to say hello at your table!

Develop a Group Resume

8

Background

All our work is a process that involves teams of one sort or another.

Can you think of any activity in the healthcare field, for example, that

can be completed by only one person with no direct or indirect

involvement of other individuals? It is very difficult to come up with a

healthcare related activity that does not involve more than one person.

Successful improvement work requires teams. No one individual is

smart enough to know all facets of an issue, a problem or how to make

the process be more efficient and effective.

Each member of a team has a unique array of talents, skills, and

experiences to offer the group. When working in teams, however, it is

important to understand what each person brings to the group. By

getting to know your fellow team members early in this program, you

will be better able to leverage each of your individual talents, skills, and

experiences as you proceed through the workshop.

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Purpose of this Exercise

The purpose of this exercise is to provide you with an opportunity to

familiarize yourselves with the other participants at your table and gain an

understanding of the many talents, skills, and experiences each of you

can bring to the group.

Activity Duration

Your team will have ~15 minutes to create your team resume. You will

then be given 2 minutes to present it to the rest of the class.

Guidance

Organize your resume to “sell” your team. Be creative, clever and

imagine that you are making a pitch to have your table hired as a

consulting team.


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Group Resume Directions

Select a team recorder who will present the group resume to the entire class

Use a flipchart page to prepare your summary

Your team resume should include, but is not limited to, the following:

Team Name (This should be something that uniquely identifies your team)

Each team member/s name

Educational background (schools attended, number of years of formal education,

number of degrees, etc.)

Professional Skills (public speaking, writing skills, organization, listening, persuasion,

planning, building, creativity, artistic, analytical, etc.)

Work experiences (years in healthcare, years at your current institution, etc.)

Major Accomplishments in your particular field

Publications and Awards

Volunteer and Community activities

Hobbies, hidden talents, travel, family

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11

Improvement Science In Action

(ISIA)

Improvement Science helps health

care organisations and individuals

develop the skills and resources

needed to carry out and sustain

successful improvement projects.

Program AIM

12

The ISIA is designed to help you…

• Plan and execute improvement projects using systems

principles.

• Apply a set of project measures to assess improvement.

• Understand and shape the organisational factors that drive

project progress.

• Implement and spread improvements.

• Utilise the Model for Improvement to develop, test, and

sustain reliable improvements.

• Make appropriate management decisions based on an

understanding of the variation that lies in your data.

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ISIA is grounded in the

Science of Improvement

W. Edwards Deming

1900-1993API’s Model for Improvement

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How Will We Do This?

1. Projects

• Focused on Goals of MonashHealth

• Solution is currently unknown

• Scoped for success within ~6 months

2. Improvement Theory, Methods and Tools

• System of Profound Knowledge and the Model for Improvement

• Variety of Team and Analytic Tools

• Measurement: designing measures, planning data collection,

understanding variation

3.Collaboration• Assignments and Conference calls

• Building a learning community (all teach, all learn!)

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Expectations of Participation

• A project – essential for successful learning!

• Attend all 3 days of the face-to-face workshop

• Participate in all 3 follow-up Conference Calls.

• Develop a Charter and a Driver Diagram for your project.

• Commitment to work on your project (test changes!) immediately following the workshop.

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Your Project…Should support our organization’s quality improvement

strategy and objectives.

Can be completed in 3-9 months.

Should have baseline data defining the need to work on

this topic and the potential measures have been identified.

Should be one in which the team has a reasonable

level of control over the factors that drive the process

or system of interest.

Has an assigned sponsor who will serve as your advocate

and support the team’s work.

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Not Good Candidates for a Project

• Developing a measurement or data collection system.

• Fix a transient problem or an emergency.

• A one-time or infrequent training or educational

workshop.

• Any project where you cannot answer the question

“How will you know a change is an improvement?”

• Huge (“solving world hunger”) projects with short

timeframes.

• Politically charged issues.

• Improving employee compensation.

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Role of your Project Charter

• Challenges you to think through the problem and

potential improvements

• Helps you outline the scope and boundaries for your

project (when does it start and when does it end)

• Focuses the timeline for your project

• Provides a document that can foster communication

and education

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Key Components of a Charter

Overview (Aim)

Problem Statement

Project Scope

Expected Outcomes

Measures

Ideas for Change

Sponsor(s)

Program Structure

• Prework

• Workshop: September 9-11, 2015─ Face-to-face session

─ Learn and apply the fundamentals of Improvement Science

─ Refine your charter and plan your project

• Continuing Learning Conference Calls─ October 6, 3:00 PM – 4:00 PM ET: Tests of Change

─ November 3, 3:00 PM – 4:00 PM ET: Data Collection & Analysis

─ December 1, 3:00PM – 3:00 PM ET: Holding the Gains

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ISIA provides a 5 month learning path

(August – December 2015)

PreworkWorkshop

9/29-10/1

Webex 1

10/14

Webex 2

11/2

Supports:

• Listserve

• Assignments

AP-1 AP-2Webex 3

11/30AP-3

Project

PlanningReliability

Sustaining

Gains

August

Workshop

Sept

(3 days)

Webex #3

Dec

Webex #1

Oct

• Faculty consults

• Webex calls

• Coaching calls

Webex #2

Nov

PDSA Measurement Holding

the Gains

ISIA Workshop Agenda by Day

Day 1 Day 2 Day 3

AM• Welcome & Introductions

• How do you improve?

• Profound Knowledge

• Model for Improvement Overview

• Aims

• Measurement

• Change Concepts & Ideas

LUNCH

PM• Tool Time!

• Divergent-Convergent Thinking

• Affinity Diagrams

• Force Field Analysis

• Pareto Diagram

• Scatter Plots

• Cause & Effect Diagram

• Flowcharting

• Close Day 1

• Adjourn (5:00)

AM• Morning reflection

• Assessing your Measurement Skills

& Knowledge

• Why are you measuring?

• Milestones in the Quality

Measurement Journey

• Selecting measures

• Building Operational Definitions

• Data collection strategies and

methods

LUNCH

PM• Understanding Variation

Conceptually

• Understanding Variation Statistically

• Run Chart construction and

interpretation

• Linking measurement to

improvement strategies

• Defining the system/Driver diagrams

• Adjourn (5:00)

AM• Morning reflection

• More on Driver Diagrams

• Setting Priorities with DDs

• Hanging Measures on the DD

• PDSA cycle and testing

LUNCH

PM• Teams and culture

• Learning from failed PDSAs

• Increasing the pace

• Planning your first/next PDSA

• Experiencing PDSAs Part II

• Implementing and Spreading

• Next steps

• Adjourn (2:30)

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Consultations

• We have a few slots for individual consultations in the

evenings and at lunch (see sign-up sheets).

• If we don’t have space for everyone, we will arrange for

follow-up phone calls.

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24

The Roadmap:

The Model for Improvement (MFI)

A P

DS

Plan

DoStudy

Act

AIM: What are we trying to accomplish?

MEASURES: How will we know if a

change is an improvement?

CHANGE: What changes can we make

that will result in improvement?

Your project

and charter will

serve as the

focal points for

improvement.

The MFI will

provide the

roadmap!

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. So …

Let’s start by taking a closer look at…

…improvement!

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How Do YOU improve?

How Do YOU improve?

• Build Skills?

• Increase Knowledge?

• Hard work?

• Build Relationships?

• Attention to detail?

• Write More Policies?

• Design a Study?

• Work more hours?

• Pay Attention?

• More Resources?

• Hire More Staff?

• Power & Control?

• Collect Data?

• Hope & Luck?

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The Primary Drivers of

Organizational Improvement

Will

IdeasExecution

QI

Having the Will (desire) to change the current state

to one that is better

Developing Ideas

that will contribute

to making

processes and

outcome better

Having the capacity

and capability to

apply CQI theories,

tools and

techniques that

enable the

Execution of the

ideas

Key Components* Self-Assessment

Will (to change)

Ideas

Execution

Low Medium High

Low Medium High

Low Medium High

*All three components MUST be viewed together. Focusing on one or even two of the components will

guarantee sub optimized performance. Systems thinking lies at the heart of QI!

How prepared are you?(your work group, department, team or facility?)

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The Tennis Ball Exercise

Time to see how good you are at improving!

Team Aim

Teams of 5-9 people at a table

attempt to pass/touch a tennis ball

in a specified sequence in the

shortest time possible.

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Guidance

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• People represent steps in patient process.

• The same person starts passing the ball and must end with the ball.

• Each person must pass/toss the ball and remember who they passed it to.

• If you drop the ball the test is over and you must start again.

• Designate a Timekeeper to:Document each test (what was your theory for

accomplishing the Aim?) The time it takes to complete a test

• Each test should follow the same sequence shown on the next slide.

• Do tests to improve the team’s time.34

More Guidance

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6 people

7 people

8 people

9 people

1

2

3

4

5

6

1

1

2

3

4

6

7

5

1

1

5

3

4

7

8

2

6

1

1

2

3

5

7

9

6

4

8

1

5 people

1

1

2

3

4

5

The sequence for different sized tables

Courtesy of

Break out Exercise

Courtesy of

Ready to run your first test?

Get set…

GO!

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Break out ExerciseRevisit the Team Aim:

To reduce the time taken for every person

to touch the ball!

Courtesy of

• Come up with change ideas and try them out.

• You can run as many tests as you wish.

• Just make sure your timekeeper records:

The time it takes to complete the task

Each new idea you came up with

Rules:

• The initial sequence as provided must be adhered to

• You may only test one change idea at a time

6 people

7 people

8 people

9 people

1

2

3

4

5

6

1

1

2

3

4

6

7

5

1

1

5

3

4

7

8

2

6

1

1

2

3

5

7

9

6

4

8

1

5 people

1

1

2

3

4

5

The sequence for different sized tables

Courtesy of

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How did you do?

Did your times constantly go

down with every test?

How many different ideas did

you come up with?

Break out Exercise

Did you try these ideas?

The Tower

The Tower

The Waterfall

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Langley et. al

PDSA Learning CyclePDSA




Day 1BSeptember 9

2015

Setting the Context for Quality Improvement

These presenters have

nothing to disclose.

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• What do you think is the definition of

quality?

• Use the sticky notes on your table.

• Fill in the following statement:

Quality is ___________________.

• Place your note(s) on the designated

flipchart.

What is Quality?

Quality is…a combination of value and outcome in the eyes of the consumer

a product or service delivered with 100% satisfaction the first time, every time

a product or service that provides an expected value

a product that lasts, for the best price

a satisfied customer

a very good product or service - one you would want again

above standard results or outcomes

an excellent product or service delivered by professional, friendly, knowledgeable people in a

timely manner at the appropriate time

an unending struggle for excellence

accurate results to health care consumers

anticipation and fulfillment of needs

A vision which provides growth and satisfaction for the customer or consumer of our service

attentive and excellent patient care

attention to detail, timeliness, competence

being the best, best of the best!

being present for every experience

best result possible in a given category

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“Quality is meeting and

exceeding the customer’s

needs and expectations and

then continuing to improve.”W. Edwards Deming

What is Quality?

QualityBetter

Old Way

(Quality Assurance)

QualityBetter Worse

New Way

(Quality Improvement)

Action taken

on all

occurrences

Reject

defectives

Defining Quality:

Old Way, New Way

Source: Robert Lloyd, Ph.D.

Requirement,

Specification or

Threshold

No

action

taken

here

Worse

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Institute for Healthcare Improvement, 2004

Quality Models & Approaches

Across the Years

Human Factors (Ancient Greece, early 1900s)

International Organization for Standardization (ISO) (1926)

Toyota Production System (1950s)

Six Sigma (Motorola, 1980s)

Baldrige Criteria (1987)

European Foundation for Quality Management

(EFQM) (1988)

Model for Improvement (1996)


Where do I begin

to untangle all

this stuff?

Models or Approaches to QI

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49

Theoretical

Concepts

(ideas & hypotheses)

Interpretation

of the Results

(asking why?)

Information

for Decision

Making

Data

Analysis and

Output

Select &

Define

Indicators

Data

Collection (plans & methods)

Deductive Phase

(general to specific)

Inductive Phase

(specific to general)

Source: R. Lloyd Quality Health Care, 2004, p. 153.

Theory

and

Prediction

The Scientific Method provides the

foundation for all improvement

Source: Moen, R. and Norman, C. “Circling Back: Clearing up Myths about the Deming

Cycle and Seeing How it Keeps Evolving,” Quality Progress November, 2010:22-28.

Understanding the Timeline is Critical

See the Appendix for additional details on the

Evolution of Quality Management

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Adding Six Sigma & Lean to the Timeline

Bill Smith (1986)

Motorola

Six SigmaMikel Harry (1988)

Motorola- MAIC

Forrest Breyfogle 111

(1992)- Integration

Michael George

(1991)- Integration

F.Taylor-The Principles of

Scientific Management

(1911)

Toyoda Family

Kiichiro Toyoda

Sakichi Tooda

Taiichi Ohno 1950-1980

Toyota Production System

Reference: Wortman 2001

Womack & Jones

Scoville & Little

Comparing Lean and

Quality Improvement

(2014)

Evolution of Quality Management in Healthcare

B.C. – Hippocrates (3rd century B.C.). Medicine was and is taught and learned as a craft.

1973 – Avedis Donabedian proposed measuring the quality of healthcare by observing :

structure, processes, and outcomes.

1970s – Quality Assurance (QA) of hospital care using structural standards

1980s – QA by government and insurers. The regulatory route relied on punishment and blame.

1986 – Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) announced

its Agenda for Change and stated that the “philosophical context” for the Agenda of

change is set by the theories of Continual Quality Improvement (QI).

1986 – National Demonstration Project (NDP) on Quality Improvement in Healthcare. A

demonstration project to explore the application of modern quality improvement methods

to healthcare.

1990 – NDP report: Berwick, D, Godfrey, J and Roessner, J. Curing Health Care. Jossey-Bass,

1990.

1991 – Don Berwick founded the Institute for Healthcare Improvement (IHI) committed to

redesigning health care delivery systems in order to ensure the best health care

outcomes at the lowest costs.

1993 – IHI adopts API Model for Improvement as its foundation for Improvement.

Source: Ron Moen, Associates in Process in Improvement

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The choice of a quality system, approach

or model should be driven by the

objectives of the organization, its culture

and its products or services!

The decision should NOT be driven by

how popular a particular approach is or

even if it has been used successfully in

other settings.

In short…

57

Walter

Shewhart

(1891 – 1967)

Joseph

Juran

(1904 - 2008)

W. Edwards

Deming

(1900 - 1993)

Three Quality Pioneers

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“These statistics will enable us to ascertain what diseases and ages press most heavily on the resources of particular hospitals."

“They will show subscribers how their money is being spent, what amount of good is really being done with it, or whether the money is doing mischief rather than good."

“To understand God's thoughts we must study statistics, for these are the measure of His purpose.”

Florence Nightingale

(1820-1910)

Women in Quality Improvement

Two Types of Knowledge

SOI

Knowledge

Subject Matter

Knowledge

Science of Improvement (SOI) Knowledge: The interplay of the

theories of systems, variation, knowledge, and psychology.

Subject Matter Knowledge:Knowledge basic to the things we do in life. Professional knowledge. Knowledge of work processes.

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Knowledge for Improvement

SOI

Knowledge

Subject Matter

Knowledge

Improvement: Learn to combine subject matter knowledge and SOI knowledge in creative ways to

develop effective changes for improvement.

Improvement

61

Joseph Juran

The Quality

Trilogy

W. Edwards

Deming

System of Profound

Knowledge

Two Key Approaches

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Juran Trilogy

The Lens of Profound

Knowledge63

Appreciation

of a system

Understanding Variation

Theoryof Knowledge

Human

BehaviorQI

“The system of profound knowledge provides a lens. It provides a new map of theory by which to understand and optimize our organizations.” (Deming, Out of the Crisis)

It provides an opportunity for dialogue and learning!

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64

Juran’s

Quality

Trilogy

Quality

Planning

Quality

Improvement

Quality

Control

Appreciation of a System

Theory of Knowledge

Human

Behavior

UnderstandingVariation

Deming’s System of

Profound Knowledge

The Quality Improvement Journey(blending Juran’s and Deming’s approaches)

Source: Robert Lloyd, Ph.D.

1939

The Deming Wheel

1. Design the product (with appropriate tests).

2. Make it; test it in the production line and in the laboratory.

3. Sell the product.

4. Test the product in service, through market research. Find out

what user think about it and why the nonusers have not bought it.

1950

Development of the

Shewhart Cycle

1986

Source: Moen, R. and Norman, C. “Circling Back” Quality Progress,

November 2010: 22-28.

Walter A.

Shewhart

(1891 – 1967)

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Deming’s

Sketch of the

Shewhart

Cycle for

Learning and

Improvement,

1985

The PDSA Cycle for Learning and Improvement

Plan• Objective

• Questions &

predictions

• Plan to carry out:

Who?When?

How? Where?

Do• Carry out plan

• Document

problems

• Begin data

analysis

Act• Ready to

implement?

• Try something

else?

• Next cycle

Study• Complete data

analysis

• Compare to

predictions

• Summarize

What will

happen if we

try something

different?

Let’s try it!Did it

work?

What’s

next?

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69You actually do PDSAs every day

70

• Is applicable to all types of

organizations.

• Provides a framework for the

application of improvement

methods guided by theory.

• Emphasizes and encourages the

iterative learning process of

deductive and inductive reasoning.

• Allows project plans to adapt as

learning occurs.

API added three basic questions to supplement the PDSA Cycle. The PDSA Cycle is used to develop, test, and implement changes.

API = Associates in Process Improvement

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Langley, J. et al. The Improvement Guide. Jossey-Bass Publishers, 2009.

The IHI Approach

When you

combine

the 3

questions

with the…

…the Model

for

Improvement.

PDSA cycle,

you get…

Finally, remember that you do PDSAs

throughout the Sequence of Improvement

Sustaining

improvements and

Spreading changes to

other locations

Developing

a change

Implementing a

change

Testing a

changeTheory

and

Prediction

Test under a

variety of

conditions

Make part of

routine

operations

Start Small

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Day 1CSeptember 2015

The Science of Improvement

and Profound Knowledge



75

Is life this simple?

X Y

(If only it was this simple!)

Patient

encounter

with

physician

A healthy

and

satisfied

patient

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The Messiness of Life!

76

“Some problems are so

complex that you have to be

highly intelligent and well

informed just to be undecided

about them.”--Laurence J. Peter

A good reference on this topic is “Wicked Problems and Social Complexity “

by Jeff Conklin, Ph.D., Chapter 1 in Dialogue Mapping: Defragmenting Projects through Shared Understanding. For more

information see the CogNexus Institute website at http://cognexus.org, 2004.

Life looks more like this…

X3

X2

X1

X5

X4

Y

There are numerous direct effects between the independent

variables (the Xs) and the dependent variable (Y).

Time 1 Time 3Time 2

Patient

Assessment Score

(could be health

outcomes,

functional status or

satisfaction)

Ind

ep

en

de

nt

Va

ria

ble

s

Current

health

status

Age

Gender

Communication

Coordination of care

http://cognexus.org/

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78

In this case, there are numerous direct and indirect effects between the

independent variables and the dependent variable. For example, X1 and X4

both have direct effects on Y plus there is an indirect effect due to the interaction

of X1 and X4 conjointly on Y.

Y

Actually life looks like this…

X3

X2

X1

X5

X4

Time 1 Time 3Time 2R3

R2

R1

R5

R4

RY

R = residuals or error terms

representing the effects of

variables not included in the

model.Coordination of

care

Age

Gender

Communication

Patient Assessment

Score (could be health

outcomes, functional

status or satisfaction)

Current

health

status

79

Walter

Shewhart

(1891 – 1967) Joseph Juran

(1904 - 2008)W. Edwards

Deming

(1900 - 1993)

The Quality Pioneers

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80

"Both pure and applied science have

gradually pushed further and further the

requirements for accuracy and precision.

However, applied science, is even

more exacting than pure science in

certain matters of accuracy and

precision."

Dr. Walter Shewhart

81

Y

The messiness of liferequires applied science.

X3

X2

X1

X5

X4

Time 1

Time 3

Time 2

R3

R2

R1

R5

R4

RY

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82

And, you

need to find

joy in the

messiness

of life!

I REALLY

do enjoy

the

messiness

of life!

Don’t you?

83

OK, enough of

this messy

talk.

Let’s start

untangling

this stuff!

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Knowledge for Improvement

SOI

Knowledge

Subject Matter

Knowledge

Improvement: Learn to combine subject matter knowledge and Science of Improvement (SOI) knowledge in creative ways to develop effective

changes for improvement.

Improvement

“Dr. Edwards Deming made an

important contribution to the science

of improvement by recognizing the

elements of knowledge that

underpin improvements over a wide

spectrum of applications.

He gave this body of knowledge the

foreboding name “a System of

Profound Knowledge.” “Profound”

denotes the deep insight that this

knowledge provided into how to

make changes that will result in

improvement in a variety of settings.

“System” denotes the emphasis on

the interaction of the components

rather than on the components

themselves.”

The Improvement Guide, page xxiv.

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W. E. Deming, The New Economics for

Industry, Government, Education. MIT, 1993

"One need not be eminent in any part of profound

knowledge in order to understand it and to apply it. The various segments of the

system of profound knowledge cannot be

separated. They interact with each other. For example

knowledge about psychology is incomplete without

knowledge of variation."

Profound - having intellectual depth and insight (Webster)

Appreciation of a System

Theory of Knowledge

Psychology

(Human

Behavior)

UnderstandingVariation

Milestones for the Development of Profound Knowledge

Variation

Systems

Psychology

Knowledge

1900 1920 1940 1950 1960 1970 1980 1990 2000

ShewhartControlChart 1924

Design ofExperimentsSir RonaldFisher, 1925

SamplingmethodsDeveloped,H. F. Dodge

Use of statisticalmethods tosupport the wareffort 1941 - 1945

Enumerative vs AnalyticStudies in Statistics, Deming

Shewhart’s 1931 and 1939Books on Quality Control*

Principles of SystemsJay Forrester, 1968

General Systems TheoryLugwig vonBertalanffy, 1949

5th DisciplinePeter Senge1990

Theory of ConstraintsE. Goldratt, 1990

The Goal1984

F. Taylor, Frank & Lillian Gilbreth, Scientific Management

B - f(p,e)Kurt Lewin1920

AnthropologyExpertsapply theoryto business

OrganizationDevelopmentD. McGregor

Tavistockinstitute 1951Eric TristSoclotechnicalSystem

Open SystemsFred Emery

Maslow – Hierarchy of Needs1962

Participatory ManagementMary Parker Follett, 1925

Human Side of EnterpriseD. McGregor, 1960

Motivation TheoryHerzberg,1968

Hawthorne ExperimentsPlant, EltonMayo, 1927

Mind & The World Order, C.I. Lewis1929*

Double LoopLearning in OrganizationsChris Argyris,1977

Lectures atThe USDA,1938, organizedBy Deming*

John DeweyRealism ofPragmatism, 1905

How We ThinkDewey, 1933

Motivation TheoryKohn1993

Motivation TheoryHerzberg,2003

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42

88

Appreciation

of a system


Theoryof Knowledge

Human

Behavior

The Lens of

Profound Knowledge

QI

“The system of profound knowledge provides a lens. It provides a new map of theory by which to understand and optimize our organizations.” (Deming, Out of the Crisis)

It provides an opportunity for dialogue and learning!

89

Appreciation for a System• Interdependence, dynamism of the parts

• The world is not deterministic

• Direct, indirect and interactive variables

• The system must have an aim

• The whole is greater than sum of the parts

Understanding Variation• Variation is to be expected!

• Common or special causes of variation

• Data for judgment or improvement?

• Ranking, tampering & performance management

• Potential sampling errors

Theory of Knowledge

• What theories drive

the system?• Can we predict?

• Learning from theory and

experience

• Operational definitions

(what does a concept

mean?)

• PDSAs for learning and

improvement

Human Behavior• Interaction between people

• Intrinsic versus extrinsic

motivation

• Beliefs, values & assumptions

• What is the Will to change?

What insights might be obtained by looking

through the Lens of Profound Knowledge?

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43

• Now that you understand the components of PK, we

would like you to apply the Lens of Profound Knowledge

to your project.

• You can work alone or with others.

• Use the PK Worksheet to record your responses.

Remember that there are no right or wrong responses.

• Engage in a dialogue on PK (i.e., the theories and

assumptions surrounding your project and the degree to

which it is “messy.”

• Spend about 10 minutes working on this exercise.

Exercise

Profound Knowledge

91

Profound Knowledge Worksheet

Appreciation for a System

•

•

•

•

• Human Behaviour

•

•

•

Theory of Knowledge

•

•

•

•


•

•

•

•

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44


Michael Posencheg, M.D.


Day 1D1September 9,

2015

The Model for Improvement



Now, let’s take a

another look at …

…the Model for Improvement!

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45

Langley, et al, The Improvement Guide, 2009

A Model for Learning and Change

When you

combine

the 3

questions

with the…

…the Model

for

Improvement.

PDSA cycle,

you get…



Let’s start

with the three

questions

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96

Developing the team’s

Aim Statement

Question #1:

What are We Trying to Accomplish?

97

Constructing an Aim Statement

• The System: the system to be improved

(scope, boundaries, patient population,

processes to address, providers, beginning &

end, etc.)

• Specific numerical goals for outcomes

─Ambitious but achievable

• Includes timeframe (How good by when?)

• Provides guidance on sponsor, resources,

strategies, barriers, interim & process goals

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98

• Involve senior leaders• Obtain sponsorship (geared to the project’s

complexity)

• Provide frequent and brief updates(practice the 2 minute elevator speech)

• Focus on issues that are important to your organization• Connect the team Aim Statement to the Strategic

Plan

• Build on the work of others (steal shamelessly!)

Constructing an Aim Statement

VOC VOP

Ideally you’d like the Voice of the Process (VOP) to

EXCEED the expectations of those you serve. At a

minimum, however, you want the VOC and the VOP

to at least be balanced.

And…don’t forget the

Voice of the Customer (VOC!)

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Identify

Customer

Expectations

Measure

Organizational

Performance

Manage

Unsolicited

Feedback

Pre-Service

Point-of-Service

Post-Service

Design Customer-Friendly

Systems

Identify Opportunities for

Further Improvement

Solicit

Point-

of -Service

Feedback

Consider when you listen to the VOC

Source: Lloyd, R. Quality Healthcare: A Guide to Developing and Using Indicators. Jones and Bartlett Publishers, Sudbury, MA, 2004.

Surveys X X X

Focus Groups X X

Observation X

Personal Interviews X X X

Unsolicited Feedback X X

High-Tech Tools X

Mystery Shopper X

Tool/Approach Pre POS Post

VOC Measurement should combine

Qualitative and Quantitative Data

Source: Lloyd, R. Quality Healthcare: A Guide to Developing and Using Indicators. Jones and Bartlett Publishers, Sudbury, MA, 2004.

9/21/2015

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Qualitative Quantitative

You should also strive to strike a balance between

qualitative and quantitative data. But, most of the

time healthcare focuses more on the quantitative

side of the ledger.

Balancing the Types of Data

103

Quantitative & Qualitative Data

“Wallander knew that interpreting statistics was

like pulling rabbits out of a hat. You could

always present a statistic as fact even if it was

an illusion.”From Henning Mankell, A Troubled Man, Vintage Books, 2009:457.

“Statistics are human beings with the tears

wiped off.”Victor Sidel in Paul Brodeur's Outrageous Misconduct:

The Asbestos Industry on Trial, Pantheon, 1985.

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104

Qualitative & Quantitative Data

“Trying to take satisfaction in life from the numbers you

ring up is ultimately no more successful than making

survival your goal. Meaning cannot be measured.”

“Measurement is a profoundly useful device, but it cannot tell us

what makes life worth living. The challenge Is to use measurement

every day, knowing all the while that we cannot measure that which

is of essential value.”

“Using measurement as a device is not the same as believing that

measurement captures the essential value of anything. You cannot

measure the good that you do.”

105

“Meaning cannot be measured.”

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106

How will you include the VOC

in your project?

107

Aim

Statement

Exercise:

You Make

the Call!

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108

Aim Statement Checklist

The System (scope & boundaries)

Numerical goals (How good?)

Timeframe (By when?)

Guidance (constraints in the system,

the VOC or other special considerations)

109

In the pilot units, we will reduce the incidence of falls (with

and without injury) by 50% within 3 months and to zero

within 1 year.

We will ensure that our work contributes to a sustainable QI

infrastructure to support future projects and we will gather

input on falls assessment and prevention practices from

patients and their caregivers.

• System: falls with and without injury in pilot units

• Goal: Reduce falls by 50% then to zero

• Timeframe: 3 months and 1 year

• Guidance: Build QI infrastructure and input from the VOC

Example of an Aim Statement

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©Copyright 2013 Institute for Healthcare Improvement/R. Lloyd

Aim Statement System of

interest?

How

good?

By

when?

Conclusion?

Good? Bad? Ugly?

1. We aim to reduce harm, improve safety and customer service for all

of our patients.

2. By December 2015 we will reduce the incidence of pressure ulcers

in the critical care unit by 50%. We hope to make patients and family

members involved in this project.

3. Our outpatient testing and therapy patient satisfaction scores are in

the bottom 10% of the national comparative database we use. As

directed by senior management, we need to get the score above the

50th percentile by the end of the year.

4. We will reduce all types of hospital acquired infections.

5. According to the consultant we hired to evaluate the flow of patients

in our outpatient clinic, we need to decrease wait times and improve

productivity. The board agrees, so we will work on these issues this

year.

6. Our most recent data reveal that on the average we only reconcile

the medications for 35% of our discharged inpatients. We intend to

increase this average to 50% by 31 Dec 2015 and to 75% by 31 March

2016. We will need to assess the impact of moving the pharmacy

department to a new location schedule for October 2015.

You Make the Call!

©2015 Institute for Healthcare Improvement and R. Lloyd.

Reproduction of this exercise without written permission from Dr.

Lloyd is prohibited.

111

Exercise: Aim Statement

• If you are already on an improvement team and have an Aim Statement then review your Aim for clarity, performance expectations, and completion date.

• If you aren’t on an improvement team yet create an Aim Statement for a team you plan to start.

• Spend about 10 minutes working on this exercise, then compare your Aim Statement with your neighbors.

• Use the Aim Statement Worksheet to create or revisit your an Aim Statement.

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112

Aim Statement Worksheet

Team name: ___________________________________

How good? ____________________________________

By when? _____________________________________

Who is the customer? ___________________________

Aim Statement: (What’s the problem? Why is it important? What are we going to do about it?)

“I have no data yet. It is a capital

mistake to theorise before one has

data. Insensibly one begins to

twist facts to suit theories, instead

of theories to suit facts.”

Source: Doyle, Sir Arthur Conan (1999-03-01).

The Adventures of Sherlock Holmes (p. 3).

(Courtesy of Dr. Imran Aurangzeb, FCCP, Sutter Health)

Question #2: How Do We Know that a

Change is an Improvement?

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114

“You can’t fatten a cow by weighing it”- Palestinian Proverb

Improvement is

NOT just about

measurement!

However, without measurement you will

never be able to know the answer to

question #2 in the MFI.

The Role of Measurement

Measurement is Central to the Team’s

Ability to Improve

• The purpose of measurement in QI work is for learning not judgment!

• All measures have limitations, but the limitations do not negate

their value for learning.

• You need a balanced set of measures reported daily, weekly or

monthly to determine if the process has improved, stayed the same

or become worse.

• These measures should be linked to the team’s Aim.

• Measures should be used to guide improvement and test changes.

• Measures should be integrated into the team’s daily routine.

• Data should be plotted over time on annotate graphs.

• Focus on the Vital Few!

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Even with this

thing, I have no

idea where we’re

headed!So, the question

is…do you have a

plan to guide your

quality measurement

journey?116

117

AIM (How good? By when?)

Concept

Measure

Operational Definitions

Data Collection Plan

Data Collection

Analysis ACTION

The Milestones in the Quality

Measurement Journey

Source: R. Lloyd. Quality Health Care: A Guide to Developing and Using Indicators. Jones and Bartlett Publishers, 2004.

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Types of Variation

Common Cause Variation• Is inherent in the design of the

process

• Is due to regular, natural or ordinary causes

• Affects all the outcomes of a process

• Results in a “stable” process that is predictable

• Also known as random or unassignable variation

Special Cause Variation

• Is due to irregular or unnatural

causes that are not inherent in the

design of the process

• Affect some, but not necessarily all aspects of the process

• Results in an “unstable” process

that is not predictable

• Also known as non-random or

assignable variation

118

If you do not understand variation

Deming’s Cycle of Fear will occur

Source: William Scherkenbach. The Deming Route to Quality and Productivity. Ceep Press,

Washington, DC, 1990, page 71.

Kill the

MessengerIncreased

Fear

Filtered

Information

Micro-

management

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Annotated Time Series(the minimum standard for QI projects)

Line Graph

Control Chart

Run Chart

121

AIM (How good? By when?)

Concept

Measure

Operational Definitions

Data Collection Plan

Data Collection

Analysis ACTION

The Quality Measurement Journey

Source: R. Lloyd. Quality Health Care: A Guide to Developing and Using Indicators. Jones and Bartlett Publishers, 2004.

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Question #3: What Changes Can We Make that

will Result in Improvement?

“Nobody really looks forward to change, except a wet baby!”

122

OK, I’m ready for a

change now…any

time would be fine!

On the Nature of Change

The Model for Improvement (MFI) provides an

approach to help increase the odds that the

changes we make will result in lasting

improvement.

123

“All improvement will require change,

but not all change will result in

improvement!”G. Langley, et al The Improvement Guide. Jossey-Bass Publishers,

San Francisco, 1996: xxi.

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Why don’t we change?

US standard rail gauge is 4’8.5” - Why?

Because English standard rail gauge is 4’8.5” -

Why?

Because pre-rail trams used that gauge - Why?

Because the same tools were used for building

railroads and wagons -Why?

Because the wheel spacing was designed to fit

the width of ruts in old English roads - Why?

Because the width of the ruts was

carved into the dirt by Roman

war chariots

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Change requires Creative Thinking

Creativity implies having thoughts that

are outside the normal pattern.

What can you do to have “new” thoughts

and ideas?

How do we “provoke” new thinking?

“I’ll be happy to give you creative thinking.

What are the guidelines?”

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62

Lateral Thinking of Edward de Bono

Provocation occurs

New thought

Logical in hindsight

(after that fact everyone is a genius)

IH: 16-2

Normal thought

Provocation introduces instability and allows

us to move to a new stable state.

“Provocation has

everything to do

with experiments

in the mind.”

Dr. Edward de Bono

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Case Study:

Organizations Learning from Patients

The Old Way

Ryhov Hospital in Jönköping, Sweden had traditional

hemodialysis and peritoneal dialysis center.

But in 2005, a patient, Christian, asked about doing it

himself.

The New Way

Christian taught a 73-yr-old woman how to do it…

…and they started to teach others how to do it.

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64

The New Way

Now they aim to have 75% of patients to be on

self-dialysis

They currently have 60% of patients

Lessons to Date (the VOC)

From Christian (patient):

– “I have a new definition of health.”

– “I want to live a full life. I have more energy and am

complete.”

– “I learned and I taught the person next to me, and

next to her. The oldest patient on self-dialysis is 83

years old.”

– “Of course the care is safer in my hands.”

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65

Lessons to Date (the VOP)

From Anette (nurse leader at Ryhov Hospital):

– Surprised at design differences between patients,

family, and staff

– Managing at 1/2 – 1/3 less cost per patient

– Evidence of better outcomes, lower costs, far fewer

complications and infections

– “We brought in the county’s employment office which

helped the patients make or update the CVs, and

trained them for a new career.”

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66

2015 Update

Now calculated costs at 50% of the costs in

other hemo-dialysis units

Complications dramatically reduced and

subsequent expensive care avoided

Measuring success by “number of patients

working”

Provocation: Random Entry

1. Choose one project at the table

2. Each table will be given a random word

3. Spend three minutes sharing ideas and associations related to the word

4. Spend three minutes thinking about connections between the word and related associations and the project

5. Be prepared to share one or two interesting ideas…

141

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Using Change Concepts

Change Concept: a general notion or approach to change that has been found to be useful in developing specific ideas for changes that lead to improvement.

Critical and creative thinking can lead to change concepts.

ConceptThoughtProcess

ConceptAn opportunity to create a new connection

Specific

Idea A

Specific

Idea B

143

Change Concepts

The Improvement Guide

contains an Appendix

(Appendix A: A Resource

Guide to Change

Concepts) that describes in

detail how 72 change

concepts can be used to

create ideas for testing.

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Complete List of Change Concepts

Eliminate Waste1. Eliminate things that are not used2. Eliminate multiple entry3. Reduce or eliminate overkill4. Reduce controls on the system5. Recycle or reuse6. Use substitution7. Reduce classifications8. Remove intermediaries9. Match the amount to the need10. Use Sampling 11. Change targets or set points

Improve Work Flow12. Synchronize13. Schedule into multiple processes14. Minimize handoffs15. Move steps in the process close

together16. Find and remove bottlenecks17. Us automation18. Smooth workflow19. Do tasks in parallel20. Consider people as in the same system21. Use multiple processing units22. Adjust to peak demand

Optimize Inventory23 Match inventory to predicted demand24 Use pull systems25 Reduce choice of features26 Reduce multiple brands of the same

item

Change the Work Environment

27. Give people access to information

28. Use Proper Measurements

29. Take Care of basics

30. Reduce de-motivating aspects of pay system

31. Conduct training

32. Implement cross-training

33. Invest more resources in improvement

34. Focus on core process and purpose

35. Share risks

36. Emphasize natural and logical consequences

37. Develop alliances/cooperative relationships

Enhance the Producer/customer

relationship

38. Listen to customers

39. Coach customer to use product/service

40. Focus on the outcome to a customer

41. Use a coordinator

42. Reach agreement on expectations

43. Outsource for “Free”

44. Optimize level of inspection

45. Work with suppliers

Manage Time

46. Reduce setup or startup time

47. Set up timing to use discounts

48. Optimize maintenance

49. Extend specialist’s time

50. Reduce wait time

Manage Variation51. Standardization (Create a Formal Process)

52. Stop tampering

53. Develop operation definitions

54. Improve predictions

55. Develop contingency plans

56. Sort product into grades

57. Desensitize

58. Exploit variation

Design Systems to avoid mistakes59. Use reminders

60. Use differentiation

61. Use constraints

62. Use affordances

Focus on the product or service63. Mass customize

64. Offer product/service anytime

65. Offer product/service anyplace

66. Emphasize intangibles

67. Influence or take advantage of fashion trends

68. Reduce the number of components

69. Disguise defects or problems

70. Differentiate product using quality dimensions

Reference: The Improvement Guide, Langley, Nolan, Nolan, Norman and Provost, p.295

Change Concepts vs. Ideas

Vague, strategic, Improve process to reduce

creative anxiety

Give patients and families

access to information

Use beepers for family and friends waiting

Specific, actionable, Make beepers available to

results families of all surgery patients for one day next week as first test of change

Taking a concept and getting specific. Getting to actionable ideas.

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IHI Improvement App

MFI Mobile App – Home Screen

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70

• Provocations

• Creative thinking

• Change concepts

• Watch out for the “yabuts”

What change can we make that will

result in improvement?

Exercise:

Developing Change Concepts & Ideas

• Develop several Change Concepts and Ideas to

Test for your project. Use the 72 Change Concepts

list in the Improvement Guide to stimulate

discussion (the list is in your Worksheet packet).

• Use the Developing Ideas for Change Worksheet

to record your ideas.

• Be sure to explore your theories and predictions

about each change concept with those at your table.

•

Exercise

Developing Change Concepts

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150Developing Ideas for Change

Worksheet

Discussion Questions:

• What specific change concepts and related ideas will achieve the Aim?

• What theories and predictions can you make about how these change concepts and ideas will cause improvement?

• Use Force Filed Analysis to evaluate the ideas

Work Area or Project: ____________________________

Change Concept Specific Ideas to Test

Theories and Predictions as to how or

why this idea will achieve the Aim

Now that you have some ideas

for change, how do you get

people to make the change?

Cass SunsteinRichard Thaler• Harvard Law School

• U Chicago Law School

• White House Office of

Information and

Regulatory Affairs

• Economist

• U Chicago Booth

School of Business

• Previously Cornell, MIT

Thaler, R. and C. Sunstein (2008). Nudge. New York, Penguin.

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QuestionWithout changing the menu, can you influence the foods

children select from a cafeteria line by rearranging the

placement of the food?

An example of a nudge

Nudges occur

every day!

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“A nudge is any aspect of the choice architecture that

alters peoples’ behavior in a particular way without

forbidding any options or significantly changing their

economic incentives.

To count as a mere nudge, the intervention must be

easy and cheap to avoid. Nudges are not mandates.

Putting the fruit at eye level counts as a nudge.

Banning junk food does not.”

Nudge, page 6.

A Nudge is based on the concept of

Libertarian Paternalism

“Libertarian aspect of our strategies lies in the

straightforward insistence that, in general. People

should be free to do what they like – and to opt out of

undesirable arrangements if they want to do so.”

“When we use the term libertarian to modify the word

paternalism, we simply mean liberty-preserving.

Libertarian paternalists want to make it easy for people

to go their own way; they do not want to burden those

who want to exercise their freedom.” Nudge, page 5.

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A Universal Impulse: Hit a Target!

Schiphol Airport, Amsterdam,

The Netherlands.

“Apparently insignificant

details can have major

impacts on people’s

behavior. A good rule of

thumb, therefore, is to

assume that everything

matters.”Nudge, page 3-4.

(NOTE: This nudge is claimed to

have reduced ‘spillage’ by 80%)

A Nudge with Architecture

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75

A Creative NudgeHow does a German senior center stop

Alzheimer’s patients from wandering off?

It builds a phony bus stop outside its

entrance.

The nursing home was continuously

relying on police to find wayward patients

who left the site in search of old homes

and families (that sometimes did not

exist).

“It sounds funny,” said Old Lions

Chairman Franz-Josef Goebel, “but (the

fake bus stop) helps. Our members are

84 years-old on average. Their short-term

memory hardly works at all, but the long-

term memory is still active. They know the

green and yellow bus sign and remember

that waiting there means they will go

home.”

The result is that errant patients now wait

for their trip home at the bus stop, before

quickly forgetting why they were there in

the first place.

Nursing home staff members then

approach them and invite them inside for

coffee.

As you plan and begin your project will

you be able to nudge people into a new

way of thinking?

If not, how do you plan to get new ideas

adopted?

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76



Now, let’s

review the

PDSA part of

the MFI and

tests of

change

161Quick Quiz

1.How many of you know what PDSA

stands for?

Well don’t be too quick to

assume that people know what

PDSA stand for!

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77

It is

important,

however,

to know

which

PDSA you

are

referring

to!

P

PDSA

D

A

S

Please

Do

Something

Anything!

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164Quick Quiz

1.How many of you know what PDSA

stands for?

2.How many of you have run 1 or more

PDSAs in the same day?

3.How many of you ran a PDSA last

week?

4.If you didn’t run one last week when did

you last run a PDSA?

The PDSA Cycle for Learning and Improvement

Plan• Objective

• Questions &

predictions

• Plan to carry out:

Who?When?

How? Where?

Do• Carry out plan

• Document

problems

• Begin data

analysis

Act• Ready to

implement?

• Try something

else?

• Next cycle

Study• Complete data

analysis

• Compare to

predictions

• Summarize

What will

happen if we

try something

different?

Let’s try it!Did it

work?

What’s

next?

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Repeated Use of the PDSA Cycle for

Testing

Hunches

Theories

Ideas

Changes That

Result in

Improvement

Very Small

Scale Test

Follow-up

Tests

Wide-Scale Tests of Change

Implementation of Change

What are we trying toaccomplish?

How will we know that achange is an improvement?

What change can we make thatwill result in improvement?

Model for Improvement

Sequential building of

knowledge under a wide range

of conditions

Spreading

AP D

S

A

P

D

S

AP

D S

A

P

D

S

APD

S

A

P

D

S

A P

DS

Sustaining the gains

The Sequence of Improvement

Sustaining improvements

and Spreading changes to

other locations

Developing

a change

Implementing

a change

Testing a

changeTheory

and

Prediction

Test under a

variety of

conditions

Make part of

routine

operations

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80

“It is the poetry of speculation that

makes a good scientist, provided the

rigor of information collecting is also

present.”

Edward De Bono, 1992, Serious Creativity, Harper Collins

(p. 65)

OK…hold that

thought. We will

dive into the PDSA

cycle in depth on

Day 3!

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81




Day 1ESeptember 9 2015

Tool Time!



IHI Functional Groupings of Tools

I. Viewing Systems & Processes

II. Gathering Information

III. Organizing Information

IV. Understanding Variation

V. Understanding Relationships

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173

Category Method or Tool Typical Use of Method or Tool

Viewing

Systems

and Processes

1. Flow Diagram Develop a picture of a process. Communicate and standardize processes.

2. Linkage of Processes (LOP)

Map

Develop a picture of a system composed of processes linked together.

Gathering

Information

3. Form for Collecting Data Plan and organize a data collection effort.

4. Surveys Obtain information from people.

5. Benchmarking Obtain information on performance and approaches from other organizations.

6. Creativity Methods Develop new ideas and fresh thinking.

Organizing

Information

7. Affinity Diagram Organize and summarize qualitative information.

8. Force Field Analysis Summarize forces supporting and hindering change.

9. Cause and Effect Diagram Collect and organize current knowledge about potential causes of problems or variation.

10. Matrix Diagram Arrange information to understand relationships and make decisions.

11.Tree Diagram Visualize the structure of a problem, plan, or any other opportunity of interest.

12. Quality Function

Deployment (QFD)

Communicate customer needs and requirements through the design and production

processes.

Understanding

Variation

13. Run Chart Study variation in data over time; understand the impact of changes on measures.

14. Control Chart Distinguish between special and common causes of variation.

15. Pareto Chart Focus on areas of improvement with greatest impact.

16. Frequency Plot Understand location, spread, shape, and patterns of data.

Understanding

Relationships

17. Scatterplot Analyze the associations or relationship between two variables; test for possible cause-

and-effect.

18. Two-Way Table Understand cause-and-effect for qualitative variables.

19. Planned Experimentation Design studies to evaluate cause-and-effect relationships and test changes.

Methods and Tools for Improvement

175

Tools we will focus on today

• Team Tools (for divergent and

convergent thinking)

• Force Field Analysis

• Pareto Diagram

• Scatter Plots

• Cause & Effect Diagram

• Flowcharting

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176

Few ideas or None Few Ideas

Affinity Diagram

Nominal Group

Technique

Brainstorming Structured

Discussion

Rank ordering

Multi-voting

Many Ideas

• Teams start with a few ideas for improvement or none.

• They need to engage in divergent thinking to open up their

brains and generate ideas.

• Once a team generates many ideas, however, they need to

engage in convergent thinking to reduce the many to the vital

few that they can test.

Team Tools

Divergent and Convergent Thinking

Divergent and Convergent Thinking

177

Divergent Thinking

Open-ended

Generative

Creative

Associative

A ‘brain dump’

Free wheeling

Convergent Thinking

Decisive

Organized

Evaluative

Planned

Focused

Structured

Teams need to

figure out how

to harness the

bet of both

types of

thinking!

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Divergent Thinking Tools(Idea Generating)

178

A form of structured brainstorming:

Nominal Group Technique (NGT)

1. Define THE SUBJECT of the brainstorming and ensure that it is written so all

group members can understand it.

2. Each member of the team is given a pile of sticky notes.

3. Each person writes their ideas on sticky notes - one idea per sticky note.

4. Usually about 5-10 minutes is sufficient to get their ideas down on the sticky

notes.

5. Each team member in turn reads one sticky note and they are placed on the flip

chart

6. No ideas are criticized. Ever!

7. Keep going around till all ideas are presented

• team members can write down new ideas throughout the process if new

ideas are generated

• Passing is permitted

8. When everyone is passing the idea generating part is over.

9. Review the written list for clarity and eliminate duplicate ideas.

10.Move on to Convergent Thinking Processes (affitizing, multi-voting, etc…)!

179

Exercise #1:

Nominal Group Technique

(abbreviated!)

• Use the NGT to generate ideas on ways to engage

patients and families in the care process.

• You will have 2 minutes to write down as many ideas as

you can on individual sticky notes (1 idea per sticky note).

• Select one person at your table to facilitate the next step.

• In turn, each person reads one idea and hands to the

facilitator who will place on the flip chart

• Continue until all ideas have been read and placed on the

flip chart

• Review each idea, clarify any idea that is unclear and

eliminate duplicate ideas.

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Affinity Diagram (Organizing Ideas)

180

Affinity Diagrams are used to organize ideas into categories that seem to form natural

groupings. The steps include:

1. Generate at least 20 ideas using brainstorming or NGT.

2. Each idea should be on a separate sticky note.

3. Place the ideas randomly on the wall, a window or flipchart pages.

4. Without talking (and believe me this is THE hardest thing for team members to do) start

sorting the ideas into related groups that have an “affinity” for each other.

5. This is usually done by having the team stand around all the notes and read them.

6. The facilitator invites someone to start putting ideas together that seem to more or less

have something in common.

7. Others will quickly join in this process. But remember it is done silently!

8. There will be times when a person will take a note from one grouping and place it in

another. This is acceptable.

9. New groupings may emerge, groups might be split up and there may be a few that don’t

fit with any others.

10. If you have a group of 20 ideas, it is typical to end up with about 4-5 groupings.

11. Finally create a label or header for each grouping.

Example of an

Affinity Diagram

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24 items were

listed here that the

respondent was

asked to group

into ‘logical’

categories.

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The Affinity

Diagram I

created

ended up

with 5

categories

AIM: To reduce inpatient physical violence at Tower

Hamlets Centre for Mental Health by 30% by Dec 2015

Social therapists, nurses, Drs, pharmacist, OT, psychologists, police, patients, carers

Courtesy of

Generate the ideas

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88

The Generated Ideas

pre-ward round activities to identify needs and anxieties

Daily reviews and

no WR

Respecting each others

opinions

Openness and fairness

Respect and dignity

More accessible

Provide an opportunity for

patients to express their needs

Patients feel they have more ownership

over choice of activities, WR

A mechanism by which patients are

able to express unhappiness

Advocate in ward

rounds

Courtesy of

Organizing Ideas(Which ideas have an “affinity” with others?)


Daily reviews and

no WR

Openness and fairness

Respect and dignity

More accessible


patients to express their needsA mechanism by which patients are


Advocate in ward

roundsRespecting each others

opinions

Patients feel they have more ownership

over choice of activities, WR

Courtesy of

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Staff attitudePatient choice and

empowermentWard Round

A mechanism by which patients are


Patients feel they have more

ownership over choice of activities,

WR


patients to express their needs


Daily reviews and no

weekly WR

Advocate in ward rounds

Respecting each others

opinions

Openness and

fairness

More accessible

Respect and dignity

Ideas arranged into categories with headings

Courtesy of

Exercise #2:

Affinity Diagram

189

• Now that you have generated a set of ideas, it is time to

use the Affinity Diagram to determine if there are clusters

of ideas that hang together (i.e., have an “affinity” to each

other).

• You will have 5 minutes to apply the Affinity Diagram

process to the ideas on your flipchart related to patient

and family engagement.

• Once you have identified groups of ideas that seem to

hang together or have a common theme, give a name or

title to each cluster.

• How many affinity groups did you end up with?

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Convergent Thinking Tools(Reaching Consensus on Ideas)

190

• Once you have generated a lot of ideas (e.g., more than

20-30) the team needs to come to some consensus on

which of these will form the vital few that can be tested.

• This Is when the Convergent Thinking tools are used.

• The sequence is that you use:

• Multivoting to reduce the list to less than 10 ideas.

• Rank order to put the 10 or less ideas in order of

preference or priority.

• Structured discussion to make sure all team members

get to voice their opinions on the final ideas selected.

Convergent Thinking Tools

191

Multivoting (MV)

(used with >10 ideas)

Rank Ordering (RO)

(used with <10 ideas)

Structured Discussion (SD)

(used with the final 1-3

ideas)

• This is a data reduction

procedure.

• Clarifying and eliminate duplicate

ideas.

• Decide on how many final ideas

you want to take to rank ordering

(this is usually 10 or less).

• Give the participants sticky dots.

The number of dots will depend

on (1) the number of people on

the team and (2) the total number

of ideas under consideration.

• Usually 5-8 dots works well.

• Each sticky dot is = 1 vote.

• You can place all your

dotes(votes) on 1 idea or spread

them around.

• Participants should place a dot on

an idea that they think has merit.

• The 5-10 ideas with the most dots

(votes) are the ones you can take

to a Rank Ordering exercise.

• If you still have a lot of ideas that

get only a few votes (say 15-20)

you can do another round of MV

to reduce the initial set of ideas.

• When you have a set of ideas

that are 10 or less, you can use

RO to decide which ideas are

the vital few.

• Assign a letter to each idea (not

numbers).

• Tape several flipchart pages

together and lay out a RO table.

• The rows are the letters

assigned to each of the ideas.

• The columns are the initials of

the team members.

• The far right column is the “total”

column.

• Each person reviews the list of

ideas and assigns a number

(e.g., 1-5 if you have 5 ideas) to

each idea.

• The idea they favor the most

receives the highest number of

votes (i.e., 5 in this example).

• Total the numbers assigned to

each idea.

• The idea with the highest total

number of votes is the first

choice, next highest the 2nd

choice and so on.

• Once you have settled on the

vital few ideas either through MV

and/or RO it is a good idea to

engage in a round of SD.

• Take the top 1-3 ideas (any more

makes this process too long).

• Decide on how long each person

gets to speak (usually no more

than 1-2 minutes).

• Assign someone to be

timekeeper and another to be

recorder.

• Each team member gets the

allotted time to say whatever they

want about the top ideas (pro or

con).

• The recorder notes key points on

the flipchart.

• This is not a debate so each

person presents their views

without rebuttal or debate from

the rest of the team.

• When everyone has had a

chance to present their views the

notes are reviewed and

questions or additional thoughts

are discussed and resolved.

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192

Step #1: Multi-Voting, Rank Ordering &

Structured Discussion Matrix

Idea Multi-

Vote

Individual Rank

Ordering

Total

RO

Score

Final

Ranking

SD comments

BL JB DV KJ FF

A

B

C

D

E

F

G

H

I

j

193

Step #2: Multi-Voting

Idea Multi-

Vote

Individual Rank

Ordering

Total

RO

Score

Final

Ranking

SD comments

BL JB DV KJ FF

A

B

C

D

E

F

G

H

I

J

Each person gets 5 dots (votes).

They can place them all on one idea or spread them around.

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194

Idea Multi-

Vote

Individual Rank

Ordering

Total

RO

Score

Final

Ranking

SD comments

BL JB DV KJ FF

A

B

C

D

E

F

G

H

I

J

With 10 ideas you would pick 40-50% of the ideas that got the most votes and

then rank order these ideas. In this case we took the top 5 ideas.

Step #2: Multi-Voting

195

Idea Multi-

Vote

Individual Rank

Ordering

Total

RO

Score

Final

Ranking

SD comments

BL JB DV KJ FF

A

B 1 3 4 2 3 13 4

C 5 1 3 3 2 14 3

D

E

F 3 2 1 3 1 10 5

G

H 2 5 2 5 4 18 2

I

J 4 4 5 4 5 22 1

Silently, everyone ranks the 5 ideas with 5 being their 1st choice, 4 their 2nd choice and so

on. Total the numbers for each idea. The idea with the highest score is the #1 choice.

Step #3: Rank Ordering

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196

Idea Multi-

Vote

Individual Rank

Ordering

Total

RO

Score

Final

Ranking

SD comments

BL JB DV KJ FF

A

B 1 3 4 2 3 13 4

C 5 1 3 3 2 14 3

D

E

F 3 2 1 3 1 10 5

G

H 2 5 2 5 4 18 2

I

J 4 4 5 4 5 22 1

Finally, move to structured discussion. Each person gets 1-2 uninterrupted minutes to

offer their views on the ideas and the reasons why they favor or do not favor the idea.

Especially explore why some ideas got very different rankings (e.g., item C or B) .

Step #4: Structured Discussion

Once the team has reached consensus on the #1 idea you could use force Field Analysis to

explore the factors that are associated with this idea being successfully implemented.

Exercise #3:

Convergent Thinking

197

• The final step is to engage in convergent thinking and narrow the list of many

ideas on patient and family engagement down to a few that can be taken into

PDSA testing.

• Take 2 flipchart pages tape them together and lay out the table for MV, RO

and SD.

• Start with MV then proceed to RO the final set of ideas (10 or less). What

idea was selected as the top idea to start testing?

• The last thing to do is to have a SD on the final ranking of ideas. It is

especially useful at this point to review the individual rankings and see if

there are wide discrepancies amongst the team member votes.

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198

What is it?

Force Field Analysis is a QI tool designed to identify driving

(positive) and restraining (negative) forces that support or work

against the solution of an issue or problem.

Once forces are identified, steps can be taken to reinforce the

driving forces and reduce the restraining forces

What does the Force Field do?

Allows comparisons of the “positives” and “negatives” of a situation

Encourages people to agree about the relative priority of factors on

each side of an issue

Supports the honest and open reflection on the underlying root

causes of a problem and ways to break down barriers

Forces people to think together about all the aspects of making the

desired change a permanent one

Force Field Analysis

Kurt Lewin,

Social

Psychologist,

1890 -1947

199

1. Draw a letter “T” on a flipchart page

2. Write the name of the issue or project across the top of the page

3. Label the left column “Driving Forces” and the right column the

“Restraining Forces”

4. Use brainstorming or nominal group technique (NGT) to generate the

list of forces or factors that are driving the issue or project and those

that are restraining or the holding things back

5. Eliminate duplicate ideas and clarify any ideas that are vague or not

specific

6. If the team feels the need, they can use rank ordering to set priorities

for the driving and restraining forces

7. Generate a list of ideas about actions that can be taken to reduce the

restraining forces

How do I set up a Force Field Analysis?

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Force Field Analysis Worksheet

Issue or Project: ______________________________________

Driving Forces (+) Restraining Forces (-)

Actions to reduce the Restraining Forces:

•

•

•

Courtesy of

CPA = Care Programme Approach which is a statutory framework in England for coordinating care

for people with severe mental illness.

MHCOP = Mental Health Care of Older People Team which combines both a Community Mental

Health Team (CMHT) and a Dementia Care Team (DCT).

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Exercise #4:

Force Field Analysis

202

• Issue: A patient or family member must be on

every QI team.

• Select a recorder to facilitate the conversation and

capture the ideas.

• Draw a Force Field Analysis table on the flipchart.

• Analyze the nominated project in terms of Driving

and Restraining Forces.

• For each of the Restraining Forces propose possible

actions that can be taken to reduce the restraining

forces.

Vilfredo Federico Damaso Pareto (1848-1923) was an Italian engineer,

sociologist, economist, political scientist and philosopher. He made several

important contributions to economics, particularly in the study of income

distribution and in the analysis of individuals' economic choices. He also

contributed to the fields of sociology and mathematics.

He introduced the concept of Pareto efficiency and helped develop the field of

microeconomics. He also was the first to discover that income follows a

distribution (now referred to as a Pareto distribution), which is technically called

a ‘power law probability distribution.’ The Pareto principle was named after him

and built on observations of Pareto’s that 80% of the land in Italy was owned by

20% of the people. The Pareto Diagram is a modification of the Lorenz curve

(1905).

Meet Vilfredo Pareto

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204

What is it?

A graphical display of the most important factors

contributing to a problem

What can the Pareto chart do?

Allows identification of the elements contributing most

to a problem (most common source of complaints,

most common incidents of harm, aspects of care of

most concern to service users..)

Identifies:

• Absolute Frequency

• Relative contribution to the total problem

• Which area(s) to focus on for greatest impact

Pareto Diagram

Vilfredo Pareto,

Economist and

political

scientist, 1848 -

1923

Pareto Diagram of Causes

TYPE OF ACCIDENT

Cars

Falls

Pedestrian

Drowning

Fire

Motorcycle

Poisoning

Chocking

Guns

Bicycles

Electrocution

0

5000

10000

15000

20000

25000

30000

CAUSES OF WRECKS

Intoxication

Weather

Poor Visibility

Mechanical

Distractions

Medication

Road Maintenance

Road Design

0

10

20

30

40

50

Method of Determining Causes:District Captain Using Investigator’s

Observations and the HighwayPatrol Procedures.

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wr o n g t im e wr o n g d o s e m e d o m it t e d wr o n g p a t ie n t wr o n g m e d

Type of Medicat ion Er ror

Perc

ent

0

1 0

2 0

3 0

4 0

5 0

6 0

7 0

8 0

9 0

1 0 0

3 7 3

1 0 7

3 22 0 1 3

Pareto Diagram

Reasons why a

Medication Administration Error Occurred

Most frequently

occurring reason for

a med error

This line indicates the cumulative percentage

100%

50%

0%

80%

25%

Cu

mu

lati

ve p

erc

en

tag

e

Source: R. Lloyd, Quality Health Care: A Guide to Developing and Using Indicators. Jones and Bartlett Publishers, 2004:309.

Pareto Diagram: incidents at ELFT

Courtesy of

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99

Unplanned Extubations - 7/11 to 2/12

13

10

7

4 4

34.2%

60.5%

78.9%

89.5%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

0

5

10

15

20

25

30

35

Tape loose or during retaping With patient care or procedure Suspected dislodgement Self Suspected plug

Even

ts

Causes of Unplanned Extubations

Tape loose

or during

retaping

With

procedure or

patient care

Suspected

dislodgement

Self / patient

motion

Suspected

plug

Updated Causes – 2/12 to 7/13

13

5

3 32

1 1 1

44.8%

62.1%

72.4%

82.8%

89.7%93.1%

96.6%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

0

5

10

15

20

25

Nu

mb

er

of

Even

ts

Causes of Unplanned Extubations

Still our

main

problem

A new

issue

9/21/2015

100

0

50

100

150

200

250

300

Ivory Ward ColumbiaWard

CazaubonWard

LeadenhallWard

Larch Lodge IntermediateCare Service

SallySherman

Ward

FothergillWard

ExtendedPrimary Care

Team -Central

ExtendedPrimary CareTeam - North

East

Falls by Service MHCOP and CHN 2014 - 2015

Services with the highest number of falls

between April 2014 – May 2015

Courtesy of

Vertical or Horizontal Pareto Charts?

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101

Pareto Example:

ADEs by Medication Type and Location

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

A B C D

Medication Surgical Medicine ICU

Dig 228 143 200

Hep 203 324 284

MorS 165 103 144

PotC 83 53 73

Insulin 160 100 140

War 194 121 170

Lov 45 28 39

Amp/P 27 17 23

Con 22 14 19

Cycl 19 12 17

Albt 14 9 13

MorS 12 8 11

Cef/T 12 8 11

Ben/P 11 7 10

Roc 10 7 9

Other 364 228 319

Pareto of Total ADEs

#

Medications Associated with Harmful Adverse Druge Event (ADE)

Total Counts

4228.90

21.52%

19.18%

13.49%

11.46%

10.45%

9.45%

4.95%

2.65%

1.59% 1.30% 1.13%

0.84% 0.71% 0.66% 0.61%

Percent

5%

10%

15%

20%

Other Hep Dig War MorS Insulin PotC Lov Amp/P Con Cycl Albt Cef/T Ben/P Roc

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Use of Stratification with Pareto

#

Medications Associated with Harmful Adverse Druge Event (ADE)

Total Counts

4228.90

Surgical

1569.60

Medicine

1179.50

ICU

1479.80

910.00

21.52% 811.20

19.18%

570.50

13.49% 484.75

11.46% 441.85

10.45% 399.65

9.45%

209.15

4.95%

112.20

2.65% 67.20

1.59% 55.00

1.30% 47.80

1.13% 35.60

0.84%

30.00

0.71%

28.00

0.66% 26.00

0.61%

364.00

23.19%

203.00

12.93%

228.00

14.53% 194.00

12.36% 177.00

11.28% 160.00

10.19%

83.00

5.29% 45.00

2.87% 27.00

1.72% 22.00

1.40% 19.00

1.21% 14.00

0.89%

12.00

0.76%

11.20

0.71% 10.40

0.66%

227.50

19.29%

324.00

27.47%

143.00

12.12% 121.00

10.26% 110.50

9.37% 100.00

8.48%

53.00

4.49% 28.00

2.37% 16.75

1.42%

13.75

1.17% 12.00

1.02% 9.00

0.76%

7.50

0.64%

7.00

0.59%

6.50

0.55%

318.50

21.52% 284.20

19.21%

199.50

13.48% 169.75

11.47% 154.35

10.43% 139.65

9.44%

73.15

4.94%

39.20

2.65% 23.45

1.58% 19.25

1.30% 16.80

1.14% 12.60

0.85%

10.50

0.71%

9.80

0.66% 9.10

0.61%

Count Percent

5%

10%

15%

20%

25%

200

400

600

800

1000

5%

10%

15%

20%

25%

50100150200250300350400

5%

10%

15%

20%

25%

30%

50

100

150

200

250

300

350

5%

10%

15%

20%

25%

50

100

150

200

250

300

350

Other Hep Dig War MorS Insulin PotC Lov Amp/P Con Cycl Albt Cef/T Ben/P Roc

Total ADEs

ICU ADEs

Medicine ADEs

Surgical ADEs

A Scatter Plot is a graphic display of two

variables, one on the Y axis (the dependent

variable) and the other on the X axis (the

independent variable).

The resulting plot allows the researcher to test

the strength of the relationship between the

two variables.

More advanced applications of the Scatter Plot

include the use of correlation coefficients and

regression lines.

Scatter Plots:

Moving Beyond One Variable

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103

X YIs there a relationship between these

two variables?

If so, what influences what?

As X increases do you think Y will also increase?

As X increases do you think Y will decrease?

Or, do you think that there is no relationship between X and Y?

Its all about relationships!

Theories on Relationships (X Y) +/-/None?

Variables (X & Y) Pos Neg None StrengthWeak-------Strong

Time on the job (tenure) and income

Nurse satisfaction and patient satisfaction

Volume of lab tests and turnaround time

Seniority on the job and errors made

Number of cars in the parking lot and the number of meals served in the cafeteria

Number of falls and the number of RN vacancies

Number medications delivered late to the ward and the number of requests for refills phoned into the pharmacy

The number of days to hire a new FTE and the number of open positions

Days of sick leave and case load

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What Does a Scatter Plot Look Like?

Figure 7.9 A strong positive relationship between the two variables

# of RN Vacancies

# of RN Vacancies

Figure 7.10 A weak positive relationship between the two variables

# o

f F

all

s

Low

High

Low High

# o

f F

all

s

Low

High

Low High

Figure 7.11 A strong negative relationship between the two variables

# of RN Vacancies

Figure 7.12 A weak negative relationship between the two variables

# o

f F

all

s

Low

High

Low High

# of RN Vacancies

# o

f F

all

s

Low High

Low

High

Source: R. Lloyd. Quality Health Care: A Guide to Developing and Using Indicators.

Jones and Bartlett Publishers, 2044; caste Study #6, 244-256.

What Does a Scatter Plot Look Like?

Figure 7.9 A strong positive relationship between the two variables

# of RN Vacancies

# of RN Vacancies

Figure 7.10 A weak positive relationship between the two variables

# o

f F

all

s

Low

High

Low High

# o

f F

all

s

Low

High

Low High

Figure 7.11 A strong negative relationship between the two variables

# of RN Vacancies

Figure 7.12 A weak negative relationship between the two variables

# o

f F

all

s

Low

High

Low High

# of RN Vacancies

# o

f F

all

s

Low High

Low

High



Strong +r

Weak +r

Strong -r

Weak -r

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No Relationship Between X & Y

Variable Y

Variable

X

No correlation (r = ~0)



222

Note to Self:

Not all relationships are linear

Stopping Distance by Speed

Fuel Used by SpeedReading Score by

Hours of Sleep

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You are asked to report the results

at an upcoming management

meeting.

The raw data are shown at the left.

What would you tell the group

about the relationship of case load

(volume) and sick days of the

staff?

Are there differences between

departments or are they all

performing the same?

How could you present this data in

the meeting?

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

31

32

A B C

Case Load (X) Days Sick (Y) Dept.

64 17 A

31 2 B

35 0 B

45 2 C

43 0 C

43 1 B

45 1 C

48 0 A

63 6 A

41 1 A

55 2 A

60 3 B

32 0 C

41 0 B

53 3 B

40 0 A

38 0 A

62 8 A

43 0 B

40 0 C

44 1 B

36 1 C

37 0 B

48 2 B

45 0 C

47 1 C

50 4 A

54 3 C

37 2 B

40 1 B

41 0 B

Case Load versus

Days Sick Leave Used

by Staff

Scatter sick days to case load

Scattergram

30 35 40 45 50 55 60 65

Case Load (X)

0

2

4

6

8

10

12

14

16

Days S

ick (

Y)

Scatter sick days to case load

Scattergram

30 35 40 45 50 55 60 65

Case Load (X)

0

2

4

6

8

10

12

14

16

Days S

ick (

Y)

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107

Case Load Vs Sick Days Total

30 35 40 45 50 55 60 65Case Load (X)

0

2

4

6

8

10

12

14

16

Days S

ick (

Y)

Case Load Vs Sick Days Dept A

40 45 50 55 60 65Case Load (X)

0

2

4

6

8

10

12

14

16

Days S

ick (

Y)

Case Load Vs Sick Days Dept B

30 35 40 45 50 55 60 65Case Load (X)

0

2

4

6

8

10

12

14

16

Days S

ick (

Y)

Case Load Vs Sick Days Dept C

35 40 45 50 55 60Case Load (X)

0

2

4

6

8

10

12

14

16

Days S

ick (

Y)

Total Dept. A

Dept. CDept. B

Is there a difference between

departments?

A Final Thought on Scatterplots

Scatterplots do not prove anything!

They help you:

Understand relationships

Understand the direction and strength of the relationships

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108

The Cause & Effect Diagram(a.k.a. the Ishikawa Diagram or Fishbone Diagram )

The Effect

or

Outcome

Environment Methods

Materials Equipment

People

The Causes

A search for

causes and cures

not symptoms!

Cause & Effect Diagram(Why would I use it and what does it do?)

• It is used to identify, explore and graphically display the variables that

“cause” a particular problem or condition to occur.

• The “effect” is the problem or undesirable outcome, issue or event being

studied.

• The branches (i.e., the fishbones) lead to functions or categories of

causes that can be broken down further when conducting a root cause

analysis (RCA).

• Brainstorming or nominal group technique can be used to help the team

generate the causes of the problem.

• The team discussion related to building the cause & effect diagrams is

the most important outcome of process. This is a tool to be used by the

team not an individual.

• Forces people to think explicitly about the specifics of the process as

well as their theories as to why something happened.

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Cause & Effect Diagram(How do I construct it?)

1. Write and effect or outcome in a box on the right side of the page or

flipchart.

2. Draw a horizontal line to the left of the effect.

3. Decide on the categories of causes that are most appropriate for the

effect.

4. Draw diagonal lines (i.e., the spines of the fishbone) above and below

the horizontal line and label each line with a category name.

5. Generate a list of causes for each category using brainstorming or

nominal group technique. Post-it notes are very useful in this step.

6. Organize the various causes on each diagonal line (i.e., the fishbone)

by drawing branches (new bones) off each diagonal. If the problem is

quite complex you may have branches off these bones as well.

7. Develop each main branch of the diagram and is related sub-branches

by asking “why” until the team agrees that a sufficient amount of detail

has been identified.

Basic C & E

Diagram format

Detailed C & E

Diagram format

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Cause & Effect Diagram Categories(How do I organize the causes?

There are several ways to organize the categories.

The traditional category labels for the main bones of the diagram

are:

• People (the individuals involved such as physicians, nurses,

patients, family members, support staff)

• Methods (how work is done including procedures and policies)

• Materials (inputs to the process such as tubing, needles,

cleaning agents, medications, forms, supplies, etc.)

• Equipment (machines)

• Environment (physical

environment as well as

social environment, weather

conditions and human

interactions)

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Delay in transfer

from ED to

Inpatient Unit

Reducing MRSA Colonization

234

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112

Cause & Effect Diagram Categories(How do I organize the causes?

Another approach is to use functions or steps in a process as the

main category labels and then within each function use the People,

Methods, Materials, Equipment and Environment as the sub-headings.

Consider a medication error and the role that ordering the medication

plays.

Ordering Medication

Medication

Error

EnvironmentMaterials

Equipment

PeopleMethods

Source: Kaoru Ishikawa, 1982

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Interpreting a Cause & Effect Diagram243

• Focus on theories not symptoms or facts!

• Develop questions not answers!

• Look for biases and areas of shallow knowledge!

• Minimize anecdotes, personal opinions and biases!

• Clarify the complexity of the problem!

• Develop and organize theories as to why this happened!

• Develop a flowchart of the process next!

A C & E Diagram does not PROVE that the

identified variables cause the effect that has

been observed!

The diagram merely provides a convenient ways

to organize potential relationships and causes

for further dialogue and analysis.

244

Flowcharting

Flowcharting

Types of Flowcharts

• High Level Block Diagram

• Top down

• Detailed

• Supplier-Customer

• Swim-lane (matrix or

functional deployment)

• Cost Added-Value Added

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245

Flowcharting Part I

Flowcharting Exercise246

Make 3 Flowcharts


• Top down

• Detailed

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247

Top Down

Flowchart

Current

Process

Source: East London Foundation Trust

248

Detailed

FlowchartSource: East London Foundation Trust

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249

Flowcharting

Types of Flowcharts


• Top down

• Detailed

• Supplier-Customer

• Swim-lane (matrix or

functional deployment)

• Cost Added-Value Added

250

Flowcharting Part II

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251

A final point about

tools…

be sure to think

about how you can

link the tools?

Example of Linking the Tools:

Where will you go for coronary by-pass graph (CABG) surgery?

Study the next 3 slides to see how you should be thinking

about linking the tools to gain even more knowledge.

What summary points can you make about these data

and the different ways to present it?

Medical

Group

Percent

Mortality

Average

CABG Cost

A 3.48% $17,000

B 3.48% $13,000

C 3.48% $14,500

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Comparison of Averages and HistogramsGroup A: % Monthly CABG Mortality (Ave 3.48%)

Percent Mortality

# M

onth

s F

alli

ng i

n T

his

Cate

gory

0

1

2

3

4

5

6

7

Group B: % Monthly CABG Mortality (Ave 3.48%)

Percent Mortality

# M

onth

s F

alli

ng i

n T

his

Cate

gory

0

1

2

3

4

5

6

7

Group C: % Monthly CABG Mortality (Ave 3.48%)

Percent Mortality

# M

onth

s F

alli

ng i

n T

his

Cate

gory

0

1

2

3

4

5

6

7

Based on these

histograms and

the average

percent mortality

(3.48% for each

medical group)

which one would

you select to

perform the

procedure?

Average = 3.48%

Average = 3.48%

Average = 3.48%

Group A

Group C

Group B

Comparison of Averages, Histograms and Run ChartsGroup A: % Monthly CABG Mortality (Ave 3.48%)

Percent Mortality

# M

onth

s F

alli

ng i

n T

his

Cate

gory

0

1

2

3

4

5

6

7 Group A: Percent CABG Mortality

Sequential Months

Perc

ent

1 2 3 4 5 6 7 8 9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

31

1

2

3

4

5

6

Mean

Group B: % Monthly CABG Mortality (Ave 3.48%)

Percent Mortality

# M

onth

s F

alli

ng i

n T

his

Cate

gory

0

1

2

3

4

5

6

7 Group B: Percent CABG Mortality

Sequential Months

Perc

ent

1 2 3 4 5 6 7 8 9 10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

2

3

4

5

6 UCL

Mean

Group C % Monthly CABG Mortality (Ave 3.48%)

Percent Mortality

# M

onth

s F

alli

ng i

n T

his

Cate

gory

0

1

2

3

4

5

6

7 Group C: Percent CABG Mortality

Sequential Months

Perc

ent

1 2 3 4 5 6 7 8 9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

31

0

1

2

3

4

5

6

7

Mean

Group A

Group C

Group B

Average cost = $17,000



Average = 3.48%

Average = 3.48%

Average = 3.48%

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255

Good Luck in Filling and Using your Toolbox!

256

Measures

PDSA

Fitting the pieces together!

Documents

Improvement Science In Action: Introduction