NQC Game Guide

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F l o r e n t i n e -

N e w Y o r k ” 2 0 0 5 ,

D e t a i l o f f u s e d - g l a s s i n s t a l l a t i o n b y K e v i n H u a n g - C r u z ,

H I V - p o s i t i v e a r t i s t

The Game GuideInteractive Exercises for Trainers to Teach Quality

Improvement in HIV Care

New York State Department of Health AIDS Institute

Health Resources and Services Administration HIV/AIDS Bureau



e ame u eInteractive Exercises for Trainers to TeachQuality Improvement in HIV Care

Developed by theNew York Department of HealthAIDS Institute

For Health Resources and Services Administration

HIV/AIDS Bureau

August 2006

T is pu ication was supported y grant num er 1

28 HA0 132 rom t e HIV AIDS Bureau, Hea t

esources and Services Administration. Its contentsre solely the responsibility of the authors and do not

ecessarily represent the off icial views of the Health

esources and Services Administration.





NYSDOH AI August 2006QC Game Guide

3

New York State Department of HealthAIDS Institute

Gut rie Bir ea , M.D., M.P.H.

Director

Hum erto Cruz, M.S.

Executive Deputy Director

Barbara Devore, M. P. A.

Executive Deputy Director

Bruce D. Agins, M.D., M.P.H.

Me ica Director

Office of the Medical DirectorHIV Quality of Care Program

ruce . g ns, . ., . . .

Me ica Director

C emens M. Stein öc , M.B.A.

Director o Qua ity Initiatives

Fran in Lau er, P .D.

Director for Performance Measurement

Kevin F. Garrett, L. M. S. W.

NQC Senior Manager

Meera Vo ra, M. P. H.

NQC Manager

JoAnn Perou, M. A.

Project Administrator

Barbara Boushon, R. N., B. S. N.

I Consu tant

Barbara Rosa, R. N. - C., M. S.

I Consu tant

Kat een C anon, M. D., F. A. C. P.

I Consu tant

Nancy S owers, D. S. W.

I Consultant

Nanette Brey Magnani, E . D.

I Consultant

ne ia Crespo, M. D.

I Consultant

u ia Hi a go, Sc. D., M. S. W., M. P. H.

I Consultant

Virginia Crowe, M. S.

I Consultant

oger Chaufournier, M. H. S.

I Consu tant

onna Yutzy

I Consu tant



NYSDOH AI NQC Game Guide August 2006

4

Table of Contents




5

Chapter I: Introduction 6

Chapter II: Game Content Matrix 12

Chapter III: Games to Teach Skills in Measurement 14

Re Bea Game 1

W ite Bea Game 20

eck of Cards Game . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Paper Puppets Game . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29

Who’s Here? Game . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Chapter IV: Game to Teach System Skills . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Peanut Butter and Jelly Game 43Butterfly Effect Game 46

Win as Muc as You Can Game 9

Chapter V: Games to Teach Skills in Developing Changes 54

in Insi e t e Box Game

Su o u Game 60

Egg S ip Game 64

Reversa s Game 68

Chapter VI: Games to Teach Skills in Testing and Making Changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Peg Game. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Tennis Ba ll Game . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .83

The Zin Obelisk Game . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88

Paper Airplane Game 4

Selling Spread Game 7

Mo e Kitc en Utensi Game 100

Chapter VII: Games to Teach Cooperation Skills 104

Many Questions Game 10

Scavenger Hunt Game 110

Hea iner Game 114




6

Introduction




7

Why a Game Guide?

In the work the New York State Department of Health,

AIDS Institute has done since 1998 to teach providers and

support staff about quality improvement, we have had the

most success when the teaching has been interactive and when it has been fun. Our experience is consistent with

a u t e arning t eory, w ic remin s us t at a u ts e arn y

oing, not y mere y istening.

In our teac ing over t e years we ave use a num er o

games t at o a goo jo o com ining an s-on earning

an a goo time. Some o t ese are c assics in t e qua ity

improvement e , some come rom ot er iscip ines an

some we have made up ourse lves to bring home an impor-

tant point. e purpose of this guide is to make these games

more broadly available by describing how they work and by

clarif ying the lessons they help to teach. We hope that you

will use this guide as you work to involve more and more

people in your program in the important, and ongoing, job

of improving the quality of your services.

How this Guide is Organized

We have organized this guide around five “critical concepts”

for quality improvement, that is, five ideas that the people

who work in your program will need to understand and be

omfortable applying in your quality improvement work.

ese ve concepts come rom a series o artic es t at

appeare in t e Anna s o Interna Me icine in 1998. e

series was e ite y Dona M. Berwic , M.D. an omas

W. No an, P .D., an we ave inc u e t e source in orma-

tion in t e Resources section at t e en o t is gui e.

n t e next page, we rie y escri e eac concept. e

games we have chosen will each highlight an important

element of the concept, one that we think will be important

to your program and its quality improvement work. We tell

you what these are when we describe each game. Remember,

though, there is a lot more to each concept than what we

are able to include in this guide. We urge you to explore

them further.




hanges that have a good chance of being successful for a

specific issue faced by your program. e games in this

section are designed to help the people in your program

nderstand what this information is and become comfort-able with putting it to use.

Testing an Ma ing C anges. Having an i ea is one

t ing, ma ing it wor in your setting is anot er. A i eas

or c ange ave to e tai ore to t t e speci c circum-

stances o t e organization in w ic t ey wi e ma e.

e on y way you can o t is tai oring is y testing t e

ange out, an a apting it ase on w at your test s ows

you. Many games in this section are designed to teach a

method called the plan-do-study-act (PDSA) cycle for doing

this testing and adaptation, and to help the people in your

program become comfortable using it. Other games in this

section teach participants how to help people be more open

to change.

ooperation. Hea t care is not a so o activity, it epen s

on peop e wor ing toget er to s are in ormation an i eas.

Because ea t care epen s on teams, qua ity improve-

ment oes a so. Ma ing improvements requires coopera-

tion among peop e across iscip ines an epartments. e

games in t is section require peop e to wor toget er to so ve

puzz es , e ping t em to un erstan t e va ue o coopera-

tion and to become more comfortable working with their

olleagues. e Game Content Matrix (page 13) gives

more information on how the games apply to each of

these concepts.

Descriptions of the Concepts

Data and Measurement. One of the key principles of

quality improvement is that “you can’t improve what you

can’t measure.” As clear as that sounds, the task of measur-

ing performance can quickly get very complicated. Yourprogram will need to decide what to measure, how to mea-

sure it, an ow to react to t e measurement once you ave

it. e games in t is section are esigne to e p t e peop e

in your program un erstan t e importance o , an ecome

com orta e wit , ma ing ecisions ase on ata.

Systems. No sing e process in ea t care stan s a one.

Eac process is part o a arger system, an c anges in one

process will most likely affect another process in that system.

Ultimately our goal is to improve the system of HIV care.

e games in this section are designed to help the people

in your program understand the relationship between pro-

cesses and systems and become more comfortable with how

systems work.

Deve oping C anges. “W at c anges can we ma e t at

wi resu t in an improvement?” is one o t e t ree questions

o e Improvement Mo e see t e Resources section or

more in ormation on t is mo e . Sometimes goo i eas

or c ange are o vious, sometimes t ey are not. ere is

a w o e o y o in ormation, some rom c inica researc

an some rom operations researc , a out ow to eve op




9

SE THIS GAME:

“ink Inside the Box” Game

Su o u Game

Egg Ship Game

eversa s Game

TO TEACH T HIS CONCEPT:

How to rea out o “stuc ” t in ing

Involving both customers and teams in problem-solving

What “change concepts ” are and how they work

How to build on the creativity of others

DEVELOPING CHANGES GAMES


ocusing on maximizing in ivi ua per ormance wi a ect t e organization as a w o e

Ma ing c ange can e power u , ut not a ways in ways you mig t pre ict

Each system is perfectly designed to achieve the results it gets

One part of a system affects the others

Workers can only do so much; sometimes managers must change the system in order

to get mprovement

SYSTEMS GAMES

USE THIS GAME:

ed Bead Game

aper Puppets Game

Peanut Butter and Jelly Game

Butter y E ect Game

Win as Muc as You Can Game


Ways o e ective y co ecting an isp aying simp e ata

Why processes matter and how to measure a process’s performance

W at “tampering” is, an w y it can e arm u

ampling works; you don’t have to measure every item

ata rom a process can e p you un erstan t e type o variation you see in a process – an

gui e you in ow to improve it

DATA AND MEASUREMENT GAMES

USE THIS GAME:

e Bea Game

White Bead Game

ec o Car s Game

aper Puppets Game

W o’s Here? Game




10

What We Tell You

Each game description contains:

• e “learning objectives” for the game, that is, what

points it is designed to teach.

• Recommendations for a target audience.• Where it comes from: who developed it and where you

can rea more a out it, i you want.

• W at you’ nee to p ay t e game:

- room set-up.

- genera an speci c too s.

- t e time it wi ta e.

• Bac groun in ormation you s ou give t e p ayers

e ore t e game starts.

• Instruct ions for playing the game.

• Tips on handling potential pitfall s.

• Key points to discuss when the game is over, to help

make sure that the game’s learning objectives are met.

What You Can Tell Us

lease let us know how you have used this guide, whether

you have found it helpful and suggestions you may have on

how it might be improved. Your comments can be sent to:

[email protected] or visit us at our website atNationalQualityCenter.org.

An i you ave come up wit games o your own t at

you are wi ing to s are, p ease et us now so t at we can

inc u e t em in uture a itions o t is gui e !




11


It’s important to ce e rate success!

e best teams use the skills of everyone on the team

Teams can get better results than individuals

COOPERATION GAMES

USE THIS GAME:

any Questions Game

Scavenger Hunt Game

Hea iner Hunt Game

USE THIS GAME:

eg Game

ennis Ba Game

in Obelisk Game

aper Airp ane Game

Selling Spread Game

Mo e Kitc en Utensi Game


eve oping an expan ing on pi ot tests

Working as a team to solve a diffi cult problem by developing and testing hypotheses

eci ing w ic c anges to ma e in a process

e PDSA Cyc e an ow it wor s

eople vary in how they adopt changes

Un erstan ing resistance to c ange

TESTING AND MAKING CHANGES GAMES




12

Game Content Matrix




13

Red Bead

White Bead

Deck of Cards

aper Puppets

Who’s Here?”

eanut Butter & Jelly

Butterfly Effect”

Win As Much As You Can

“ink Inside the Box”

Sudoku

Egg Ship

eversals

eg

Tennis Ball

Zin Obelisk

Paper Airplane

Selling Spread”

Paper Hat

Many Questions

cavenger unt

Headliner

●

■

■

■

▲

▲

■

●

▲

▲

■

■

▲

■

●

●

●

■

▲

G A M E S

KEY: ■ = STRONG LINK = SOME LINK ▲ = WEAK LINK BLANK= NO LINK

Being able to measure:

• progress towar s aims

• nee s an st atus o

patients an ot er

consumers of care

• local process charac-

teristics t at may e

re ate to aims

KEY CONCEPTS: DATA &MEASUREMENT

SYSTEMS DEVELOPINGCHANGES

TESTING &MAKING CHANGES

OOPERATION

eing able to understand the

processes o t e system an

t eir interactions

Being able to have “good

i eas o r c ange:”

• rom t e c inica

v i ence

• from operations

esearch

• rom creativity an

nnovat on

eing able to:

test c anges in action:

DSA cyc e

create support struc-

ures for change (train-

ng, documentation,

t an a r i za tion e yon

e testing perio

a ress resistance to

hange

Being able to:

• un erstan t at sys tem

er ormance is c osey

ie to interaction an

nterdependence

• foster this interdepen-

ence

• support teamwor an

o a or at ion

Sources : Berwick and Nolan, “Physicians as Leaders in Improving Health Care,” Annal s of Internal Medicine, 2/15/98 Langl ey et. al. The Improvement Guide. Jossey-Bass , 1996




14

Games to Teach Skills

in Measurement




15

Red Bead Game

ntro uction

e Game

e rie an Discussion Faci itator, participants, au ience

Facilitator, participants

aci itator

HOW LONG?

10 m nutes

25 minutes

30 m nutes

WHO?SESSION AT-A-GLANCE

Why Use This Game

• To teach that variation is to be expected any time you

measure something.

• To teach that there are different causes of this variation.

• To show how different management and improvementstrategies are needed, depending on the cause of the

var at on you are see ng.

• o e p co eagues un erstan t at t e structure o

a system etermines ow in ivi ua s per orm wit in

t at system.

Target Audience

Senior leaders, managers, quality improvement (QI) team

members, and all others who will be acting on the results

of data collection (patients and consumers may find it

interesting as well).

Type of Game

emonstration with volunteers participating (requires 6-9

audience members to participate).

Key Concepts

• Even wit i entica met o s an too s, t ere wi e

variation in resu ts. ese variations in resu ts may ave

itt e or not ing to o wit any one wor er’s s i or

wi ingness to wor ar .

• Any process as a ui t-in capa i ity t at is etermine y

t e way it is set up, not y a particu ar wor er’s actions.

• Rea improvements to a process come rom a ressing

the underlying way the process is set up.

• Management’s job is to work “on” the process, to change

the process design so the process works better.

Source, History and Resources forMore Information

e “Para e o t e Re Bea s” was eve ope y W. E -

war s Deming, a pivota gure in t e e o QI. He use it

as a teac ing too in un re s o seminars e gave t roug -

out t e wor unti is eat in 1993. Mary Wa ton’s oo ,

“ e Deming Management Met o ” Putnam, 1986 contains

a ive y escription o Dr. Deming’s con ucting t e game. A

se u we site or a itiona in ormation a out Dr. Deming

is http://deming.eng.clemson.edu/pub/den/files/




16

Materials

For t is game, you wi nee :

• A score s eet an a grap ormat on w ic to p ot t e

resu ts see e ow or examp es . ese s ou eit er

e projecte wit a transparency or rom a computer

or written arge enoug so everyone in t e room can

rea t em

• A “red bead kit.” is is a box with a mixture of red

beads and beads of one other color (usually 1000 red

beads and 4000 alternate color beads) and a paddle with

50 holes to pull beads out of the box

- Red bead kits can be purchased at www.redbead.com

- A simple variat ion on the kit can be made with glassmarbles of two colors (keeping the 1:4 ratio) and

a pa e rom t e game Bogg e. W i e t e sma

num er o o es in t is pa e may ma e t e resu ts

ess statistica y soun , t e ey earning points sti are

c ear y communicate

Preparation

To prepare for this session:

• Familiarize yourself with the session’s structure

and content:

- Read through the game instructions and key

teaching points in their entirety.

- Practice the game itself.

- Practice presenting the key teaching points.

• Prepare t e room:

- Arrange c airs in a semi-circ e or rows epen ing on

ow many wi e in your au ience .

- Set up a ta e in t e ront o t e room.

- Set up t e equipment e.g., ip c art, over ea

projector, or LCD projector you wi use to project

t e c art o game resu ts. est t e equipment to

make sure it works.

Playing the Red Bead Game

We come an Intro uctions

o egin t e game, we come participants an t an t em

or t eir participation. I necessary, as in ivi ua s to intro-

uce t emse ves to t e group.

Learning O jectives

Tell participants that by the end of the session they will:

• Understand that variation is to be expected any time

you measure something and that there are different

causes of this variation.

• Recognize that different management and improvement

strategies are needed, depending on the cause of thevar at on you are see ng.

• Appreciate t at t e structure o a system etermines

ow in ivi ua s per orm wit in t e system.

• Begin to see ow to app y t ese concepts to t eir

HIV program.

Agen a

rovi e a rie escription o t e session’s primary

omponents:

1. Background to the Red Bead Game.

2. e game itself.

3. Debrief and discussion on what the game shows, and

how its lessons can be applied to HIV care.

4. Feedback and close.




17

ttachment 1

Red Bead Game- Data Results Chart (5 workers)

NAME DAY 1 DAY 2 DAY 3 DAY 4 TOTAL PER WORKER

TOTAL PER DAY

AVERAGE PER DAY




18

Background to the Game

Faci itator’s note

In t e Re Bea Game, wor ers pro uce ea s in a awe

process t at resu ts in many e ects: re ea s. e man-

ager – p aye y you – tries severa “goo ” management

interventions esigne to improve in ivi ua ’s per ormance.

By oing t is s e e assumes t at t e e ect s resu t rom

individual actions rather than a logical consequence of the

way the process is designed. rough their f rustrat ion with

the manager, the game participants and audience come to

understand the importance of addressing the “common

causes” of variation – the design of the system.

Key points to explain to your audience:

• Many organizations wor ing in qua ity ave ong

iscussions a out exact y w ic qua ity in icators t ey

wi use, w at t ey wi measure. As qua ity expert Pau

P se says, owever, “w i e eci ing w at to measure

an ow to measure it are important c a enges, an

equa y important c a enge ies in etermining t e ap-

propriate reaction to t e measurement once we ave it.”

e Red Bead Game illustrates why this challenge is so

critical to quality improvement.

• All measurements show variation (if you see no variation,

someone is probably “cooking” the data!). e time of

your commute to work will vary every day, for example.

Sometimes, this variation may be a result of an unusual,

or “specia ” cause: a a acci ent, per aps, or an ice

storm. Most o t e time, owever, t e variation resu ts

rom “common” causes t at are ui t into t e process:

t e num er o peop e on t e roa , t e way t e tra c

ig ts are time , w et er you get out t e oor a ew

minutes ear ier or ater t an usua . You wi ave more

impact on improving t e per ormance o a process i you

work on reducing the common cause variation.

• e Red Bead Game is a way of explaining why it is

important to understand this difference.

The Game Itself

ese instructions are ase on ac groun materia or

t e Re Bea Game prepare y t e Institute or Hea t care

mprovement.

1. Organize t e company.

• Recruit your wor orce rom t e au ience.

- 4-6 workers.

- 1-2 quality inspectors.

- A quality data analyst, who records the results.

• Write each worker’s name on the data results chart that

is on the flip chart or projected in the front of the room.

2. Hold your first staff training session.• Welcome your workers.

• Exp ain t at t e purpose o t e company is to ma e

w ite or ue, or w atever your ominant co or is

ea s . You ave one researc ; t at is w at t e

customer wants.

• Demonstrate t e pro uction process yourse . Ma e it

comp icate , an stress t at it must e o owe exact y.

ne possi i ity:

- Stir the beads in the box with your right hand

three times, clockwise, while holding the paddle in

your left hand.

- Transfer the paddle to your right hand. Insert it into

he far side of the box, long side down. Move the

paddle towards you while shaking it so a bead falls

nto each hole. Smooth off the excess beads with

your e t an .

- Present t e pa e to t e inspector.

• Exp ain t at t e inspector now counts t e re ea s,

ecause t ey are e ects. e inspector reports t e count

o r e ea s to t e qua ity ata ana yst, w o recor s t e

num er o e ects on t e ata resu ts c art .

• Encourage your emp oyees to wor ar , o a goo jo ,

and not make red beads! You are relying on them not to

make mistakes ! is company has been your life-long

dream, and you are counting on their hard work to make

it a success!




19

3. Begin t e pro uction process.

• Eac wor er “ma es” one pa e’s wort o ea s an

t eir e ects are counte y t e inspector an recor e

y t e qua ity ata ana yst.

• Praise wor ers w o ma e ew re ea s. Be creative:

use every positive-rein orcement management tec nique

you know (for example, offer to make them employee

of the month).

• Criticize workers who make many red beads. Begin

by being sympathetic (“everything OK at home?”) and

move to criticism and threats to demote or fire them as

“days” of work go on.• After two days, inform your workers that the company

may go out o usiness i t ey on’t stop pro ucing so

many e ective re ea s.

• Continue wor ing or a tota o our ays, eeping up

your management interventions. At t e en o our ays

in orm t e wor ers t at t e company as o e , t an

t em an sen t em ome.

Debrief and Discussion

• Begin by asking the participants how it felt to work for

the Bead Company. Ask whether your management

interventions were helpful, whether they were surprised

at the results, and what they would have done to improve

the Bead Company’s production process.

- Most o t e time, participants answer t at t ey e t

rustrate an stupi . ey are not surprise y t e

resu ts ecause o t e set num er o re ea s in

t e ox, an to improve t e resu ts t ey wou ave

remove t e re ea s at t e start.

• Point to t e ata resu ts c art. Note t e variation in

per ormance. As w y it is occurring.

• Remind your audience of your presentation on special

cause and common cause variation. Ask them what they

see in the Red Bead Game results (answer: common

cause variation).

• As your au ience i t ey can recognize “re ea ” situa-

tions in t eir own HIV programs. I t ey nee prompt-

ing, as a out responses to t eir qua ity ata. W at

appens i a num er – t e num er o visits, or examp e

goes up or own in a given mont . Do t ey react just to

t at num er treating it as i it is t e resu t o a specia

cause) or look at the pattern over several months?

en probe further:

- Are they workers or managers in these situations?

- What is the result of reacting to data in this way?

- What changes would they like to make to how

data are used in their program?- How can they make these changes ? What

suggestions o ot ers ave to e p?

Feedback and Close

• As your au ience or ee ac on w et er t i s session

met its o jectives. a e notes o t eir response on a ip

c art, an eep it or your use in t e uture.

• Schedule an informal follow-up session with any

audience member who wants clarification or more

information on the game or the concepts you discussed.

• ank your audience, especial ly those who participated

in the game.




20

Intro uction

e Game

ebrief and Discussion

SESSION AT-A-GLANCE

Facilitator, participants, audience

aci itator, participants

aci itator

WHO? HOW LONG?

5 minutes

10 m nutes

10 minutes

White Bead GameWhy Use This Game

• To teach the concept of sampling, that you can get a

good estimate of performance by looking at a sub-set of

results rather than at your entire population.

Target Audience

Senior ea ers, managers, QI team mem ers, an a ot ers

w o wi esign ata co ection strategies.

Type of Game

A competition among teams.

Key Concepts:• Sampling is a good strategy for data collection: it is pos-

sible to determine how large a subset of existing data we

need in order to answer the question we have about these

data, with a prescribed amount of error.

Source, History and Resources for MoreInformation

e concepts behind this game are taking from the publica-

tion “ ampling Techniques, developed by Wai Cho Yee for

the New York City Health and Hospitals Corporation in1995. Yee based his work on two sources:

• P se , Pau E., “Tutoria : P anning or Data Co ection

Part III: Samp e Size ,” Qua ity Management in Hea t

are, 3:1, Fa 1994, pages 78-92.

• Ba ie, Ear , “ e Practice o Socia Researc ,” Sixt

E ition, Be mont, CA: Wa swort Pu is ing

Company, 1992.

• Coc ran, Wi iam G., “ amp ing Tec niques, Jo n

Wiley, 1977.




21

Materials


• A “re ea it.” is is a ox wit a mixture o re

ea s an ea s o one ot er co or usua y 1000 re

ea s an 4000 a ternate co or ea s an a pa e wit

50 o es to pu ea s out o t e ox

- Re ea its can e purc ase at:

www.redbead.com

• If you don’t have a red bead kit, you can use any

container with two types of objects in it: a box of both

large and small paper clips, for example, or with two

types of rubber bands. You will need to count how

many of each type are in the box • A pad of paper and pens for each team to record

its resu ts

• A ip c art an mar ers to recor t e ey points

o t e iscussion

Preparation

o prepare or t is session:


and content:


teachingpoints in their entirety.

- Practice the game itself.


• Prepare the room:

- Arrange c airs aroun a ta e. e participants wi

wor in 4 sma teams ut t ey wi use t e same ox

o ea s or paperc ips, or ru er an s s o t ey nee

to e c ose to eac ot er.

- Give eac team a pa o paper an pen.

- Set up t e ip c art so you can recor t e ey points

o t e iscussion a ter t e game.

Playing the White Bead Game





Learning O jectives


• Understand how useful it can be to take a sample of

data rather than to count every item (for example, every

patient, every visit, every screening).

• Begin to see how to apply this concept to the use of data

in their HIV program.

Agen a

rovi e a rie escription o t e session’s primary ‘

omponents:

1. Bac groun to t e W ite Bea Game.

2. e game itse .

3. De rie an iscussion on w at t e game s ows, an

ow its essons can e app ie to HIV care.



Facilitator’s note

Managing data is time-consuming and can be expensive.

rograms can have several hundred patients or clients and

on ucting a review o every c art to etermine, or ex-

amp e, ow many receive re erra s to a entist is a aunting

tas . e e o statistics comes to t e rescue y provi ing

a way to se ect a samp e o c arts t at wi sti give you a

va i picture o your enta visit re erra rate, or any ot er

measure you are oo ing at.

is game is designed to help you show your colleagues just

how useful sampling can be. Sometimes, people who have

not worked with statistics don’t quite trust that counting a

small number of charts (carefully selected, of course) can be




22

as accurate as oo ing at every sing e one. is game

intro uces t e concept o samp ing, to e p peop e ecome

more com orta e wit it .

Se ecting your actua samp e is more i cu t, as t ere are

ru es you must o ow an ecisions you must ma e on ow

precise you want the estimate provided by the sample to

be. e National Quality Center can provide additional

resources on sample selection, or take a look at the sources

mentioned earlier in this game description.

Remember that sampling gives you a result within a predict-able margin of error, and the value of using sampling is that

t e margin o error is pre icta e. In t e W ite Bea Game,

one team ases its estimate o t e num er o w ite ea s

y se ecting a samp e o 20, w i e anot er se ects a samp e

o 100. ere is a ways a c ance t at t e samp e o 20 may

provi e a more accurate estimate o t e num er o w ite

ea s t an t e samp e o 100. I t is appens, a s s eam C

an eam D to try severa more times. You wi see t at t e

sample of 100 (which has a margin of error of plus or minus

8%) provides a more consistent estimate than the smaller

sample size, whose margin of error is much larger.


• Sampling provides a way to measure, with a prescribed

amount of error, the performance of our program

wit out aving to count every sing e item or review

every sing e c art.

The Game Itself

• Divi e your group into our teams. e teams wi wor

sequentia y, an eac team wi ave ve minutes to

etermine t e num er o w ite ea s in t e ox o t e

re ea it. Eac team o ows a i erent approac :

- eam A tries to count every ea in t e ox.

- eam B creates an estimate wit out oing any counting.

- Team C pulls 20 beads at random from the box and

stimates the total number of white beads based on

his sample. Team C could repeat this process if

eeded (see Facilitator’s Note).

- Team D randomly selects 100 beads from the box and

stimates the total number of white beads based onhis sample. e number 100 is chosen as it should

ive a resu t t at, wit a 95% con ence eve , is

wit in t e true percentage o w ite ea s p us or

inus 8% or a ox containing 4000 w ite an 1000

e ea s . eam D cou repeat t is process i neces-

ary see Faci itator’s Note .

- Note t at t ese samp es must e ran om y c osen.

Be sure to mix t e ea s in t e ox t oroug y e ore

electing Team C’s or Team D’s samples.

• Ask each team to report its result.

• Report the actual percentage and number of white beads

(80%, or 4000) and see which team came the closest.




23


• Discuss t e resu ts. W ic met o o t e part icipants

pre er, an w y?

• I you are ami iar wit statistica samp ing, rie y

exp ain ow t e eam D’s samp e size was etermine .

• Discuss current ata co ection in your HIV program:

- Do we samp e anyt ing? I so, w at?

- What other data do we collect that we could sample,

rather than counting every item? (Anything involving

chart review is a likely candidate.)

- How can we create a sampling plan?

Feedback and Close




• Sc e u e an in orma o ow-up session wit any au i-

ence mem er w o wants c ari cation or more in orma-

tion on t e game or t e concepts you iscusse .

• ank your audience and congratulate them on

their hard work.




24

SESSION AT-A-GLANCE

Intro uction

e Game

e rie an Discussion Faci itator, participants, au ience

acilitator, participants

aci itator

WHO? HOW LONG?

1 m nutes

0 minutes

20 m nutes

Deck of Cards GameWhy Use This Game

• To show the problems that can result from making the

wrong kind of changes in a process.

• To demonstrate a “stable” process.

• To show how to how to make a stable process better.

Target Audience

Managers an ea ers o organizations. is game is geare

towar s peop e w o wi e ea ers o improvement e orts

an to t ose w o requent y review per ormance ata, suc

as QI committee mem ers.

Type of Game

A demonstration with everyone part icipating.

Key Concepts

• e first thing to do to improve a process is to make it

more sta e an pre icta e.

• It is easy to overcompensate an over a just as you try

to improve a process, an y oing t is you ma e t e

process e ss sta e an pre icta e.

• Some management approac es can resu t in extreme y

unsta e processes!

Source, History and Resources for Moren orma on

is game was developed by Kristin J. Arnold, president of

uality Process Consultants, Inc. in Fairfax, VA. Arnold

based this game on W. Edwards Deming’s funnel experi-ment, and published her description of the game in the

cto er, 2001 issue o Qua ity Progress page 112 .

Materials

or t is game, you wi nee :

• A room wit enoug empty oor space t at our groups

o 2-8 peope can wor wit out running into eac ot er

• Four sets of 12 playing cards each

• ree tape measures

• Four “targets” that will stick to the floor (sticky colored

dots work well)

• Twelve colored dots of a different color for Team B

• One “rule card” for each team

• A flip chart and markers to record the key points

o t e iscussion




5

Preparation


• Fami iarize yourse wit t e session’s structure

an content.

- Rea t roug t e game instruct ions an ey teac ing

points in t eir entirety.

- Practice t e game itse .


• Prepare the room.

- If necessary, move out chairs and other furniture so

there is ample playing space for 4 teams in the room.

- Place one colored dot on the floor for each of the

4 teams; this will be the target for each team.Make sure the targets are away from the walls and

eac ot er; it’s important to eep eac group’s

wor separate !

- Prepare t e “ru e car s” samp es are given

in Attac ment 1 :

• eam A: rop every car over t e target.

• eam B: A ter eac rop, measure t e istance z rom

t e target to t e spot w ere t e car an e . S et t e

next drop position over the point -z from the last tar-

geted position, which is the last spot you aimed at (same

distance, but opposite direction). Use a colored dot to

mark the last targeted position.

• Team C: After each drop, measure the distance (z)

from the target to the spot where the card landed. Set

the next drop position over the point -z from the

origina target.

• eam D: Set t e next rop position rig t over t e spot

w ere t e ast car an e .

Playing the Deck of Cards Game





Learning O jectives


• Understand how making the wrong changes in a process

can hinder the process.

• Understand how making these types of changes can be

demoralizing to the staff who work in the process.

• Begin to see how to apply these concepts to theirHIV program.

Agen a

rovi e a rie escription o t e session’s

pr mary components:

1. Bac groun to t e Dec o Car s Game.

2. e game itse .






eming developed his funnel experiment, on which Arnold

ase t is game, to i ustrate t e concept e ca e “tamper-

ing.” Forma y, tampering is ta ing action on a process

assuming t at t e cause o a pro em is a one-time, unusua ,

specia cause, rat er t an un erstan ing t at t e cause is

somet ing in erent in t e structure o t e process see our

escription o e Re Bea Game or more in ormation on

t ese two types o causes . A more genera escription o

tampering is “making changes or adjustments in a process

when such changes are not warranted” (Paul Plsek).




26

Deming points out t at t e unwarrante c anges invo ve

in tampering ma e processes wor ess we ecause t ey

intro uce new components every time t e process is run.

W en you measure t e resu ts, t ey en up a over t e

p ace. Any process t at pro uces unpre icta e resu ts is

muc ar er to manage we .

Tampering and its results can be diffi cult concepts to convey.

e Deck of Cards Game provides a clear picture of what

tampering looks like and will help the participants see why

it is so harmful. e game can then start a discussion of

examples of tampering the participants have experienced,especially in their HIV programs.

Key points to exp ain to your au ience:

• In eci ing ow to improve a process, we nee to e

aware t at some c anges can ma e t e process worse

rat er t an etter.

• Most o t e time, w en somet ing goes wrong in a

process our instinct is to react to w at we t in is t e

immediate cause. We “tweak” the process and hope

it works out.

• A better approach is to study the process to see if the

results it produces are basically stable and predictable.

If so, it will be better to work on the process as a whole.

The Game Itself

ese instructions are ta en rom Kristin Arno ’s Qua ity

rogress artic e cite a ove.

• Divi e t e participants into our teams. e eac team

to gat er aroun one o t e target ots on t e oor.

• e eac team t e o jective is to pro uce as many pro -

ucts as c ose to t e target as possi e, w i e o owing a

particular rule. Hold up the four rule cards for all to see.

• Explain that each team produces a product by standing

up and dropping one playing card from shoulder height.

e playing card should be held perpendicular to the

target on the floor, NOT parallel to the floor.

• Review the rules for each team and distribute the rulecards. Give each team its stack of playing cards. Teams

B, C an D a so eac get a tape measure, an team B

gets a page o co ore ots.

• Ma e sure eac team un erstan s its ru e, an a ow

eac team to wor co a orative y to pro uce 12

pro ucts. eams A an D wi nis quic y, teams B

an C ta e onger.




27


Review t e istri ution o car s wit t e entire group.

• As t e team to s are t e ru e it o owe an t e resu ts

an to specu ate a out w at appene to t e process:

- eam A: e car s wi pro a y c uster aroun t e

target. e istri ution is sta e an s ows minima

variation rom t e target. Even i you ave a a pro-

cess, your result will be predictable and manageable.

is is a stable process and the best choice.

- Team B: e distribution of cards fans out and is

unstable but symmetrical around the target. e team

knows where the standard is, but adjusts it based on

the last piece produced.- Team C: e distribution explodes in opposite direc-

tions ecause t e team overcompensates or its errors.

is is ow most processes ecome over-a juste rom

w ere t e operation was uring t e ast process run.

- eam D: e car s wi ten to ri t ecause t e is-

tri ution is unsta e an moves away rom t e target

in one irection. is is t e in o process ri t t at

can occur w en a process uses t e ast piece pro uce

as the standard for the next piece, instead of using a

universal product standard.

• Have each team come up with an example of rules B, C

and D in their HIV program. Examples of C and D are

most common.

- One c inic, or examp e, saw a ew wee s o ow

visits an starte sc e u ing ots more patients. e

in ic quic y ecame overcrow e an so t e sta

ca e ac t e num er o sc e u e visits, ea ing

o comp aints a out ac o access. is wou e an

xamp e o actions i e t ose ta en y team C.

- Team D’s experience shows what happens when, for

xample, you don’t have a consistent training program

or new employees. If one employee trains another,

nd so on, the message will change over time as

will your performance results.Ask the part icipants,

what has been the result to their program of theseypes of changes?

• I time permits, start a secon roun w ere t e teams

can ma e process improvements. Have eac team i en-

ti y one improvement to ma e, test it an t en compare.

For examp e, one process improvement mig t e to rop

t e car para e to t e oor. I ru e A i s use , a most

every car wi sett e on top o t e target.

• Discuss ow organizations can ta e a sta e process an

try to make it better.

Feedback and Close

• Ask your audience for feedback on whether this session

met its objectives. Take notes of their response on a flip

chart, and keep it for your use in the future.

• Sc e u e an in orma o ow-up session wit any

au ience mem er w o wants c ari cation or more

in ormation on t e game or t e concepts you iscusse .

• an your au ience an congratu ate t em on

t eir ar wor .




28

O jective: to pro uce as many pro ucts as c ose to t e target as possi e w i e o owing a particu ar ru e.

EAM A’s RULE

Drop every car over t e target.

TEAM B’s RULE

• After your first drop, measure the distance from the target to the spot where the card landed. For example, your card

may have landed 3” to the right of the target.

• Set the next drop point over the point the same distance from the target, but in the opposite direction (e.g., 3” to

the left of the target).

• Mark this point with a blue dot.• Drop again. is time, measure your distance from your current target (i.e., the blue dot).

• Set your new target t at istance, ut in t e opposite irection, rom t e ue ot.

• Mar t is new target wit anot er ue ot.

• Continue.

EAM C’s RULE

• A ter your rst rop, measure t e istance rom t e target to t e spot w ere t e car an e .

• Your new drop point is this distance from the origina l target, but in the opposite direction (e.g., if the card landed

3” to the right of the target, your new drop point is 3” to the left of the target).

• Drop again. Measure the distance from the target to the second spot where the card landed (e.g., now the card is

6” below the target).

• Your new drop point is this distance from the original target, but in the opposite direction (e.g., 6” above the target).

EAM D’s RULE

Set t e next rop posit ion rig t over t e spot w ere t e ast car an e .

ttachment 1

Sample Rule Cards




9

SESSION AT-A-GLANCE

ntro uction

e Game

Debrief and Discussion Facilitator, participants, audience

Faci itator, participants

aci itator

WHO? HOW LONG?

10 m nutes

2 m nutes

15 minutes

Paper Puppets GameWhy Use This Game

• To explain what a process is, a series of steps that turns

a set of “inputs” into an “output.”

• To show how to measure the different parts of a process.

• To introduce some of the tools used in analyzing dataabout a process.

Target Audience

C inica an a ministrative sta an anyone w o wi e

invo ve wit measuring an eva uating your program’s

qua ity o care.

Type of Game

Demonstration with volunteers participating (requires 6 au-

dience members to participate plus volunteer timekeepers).

Key Concepts

• A wor ta es p ace in processes a process is a series

o steps t at pro uces an output .

• e qua ity o a process can e measure at many

points in t e process.

• Simp e too s can e p you ana yze ata.


is game is taken from a more complex version developed

by Janelle Heineke of Boston University. Heineke uses her

version as a first class for her students in her OperationsManagement course. See: Heineke, Janelle, “Enhancing

Learning Using C assroom Games an Exercises,” Qua ity

Management Journa , 1997,4:4, 32-42.

Materials


• Colored paper, at least 25 sheets

• White paper, a few sheets

• Blue or black marker

• Red marker

• Scissors

• Ruler

• A flip chart and felt-tipped marker for displaying

grap s an c arts

• 5 tas time s eets Attac ment 1

• 5 t roug put time s eets Attac ment 2

• 1 qua ity contro orm Attac ment 3




30

Preparation



an content:






- Set up a long table at the front of the room with

five chairs along one long side (one for each “

workstation”).

- Seats for the rest of the audience should be set upauditorium style or in a semi-circle.

- P ace t e stac s o co ore an w ite paper at t e

rst wor station, t e scissors at t e secon , t e ue

mar er at t e ourt , an t e re mar er at t e t .

A so p ace a partia y comp ete unit at eac wor -

station to s ow eac wor er exact y w at is or er

output s ou oo i e.

- A a sixt c air at t e s ort en or t e

Quality Inspector.

- Prepare a sample puppet to use as a model

and demonstration.

Playing the Paper Puppets Game





Learning O jectives


• Understand what a process is and how the design of the

process affects quality.

• Have experience using tools for measuring a process.

• Have experience analyzing data about a process.

Agenda


omponents:

1. Bac groun to t e Paper Puppets Game.

2. e game itse .



4. Fee ac an c ose.




31



“Processes, not peop e” is one o t e rst concepts taug t

a out qua ity improvement. Most peop e in ea t care

wi e ami iar wit t is i ea, an most peop e e ieve it.

e purpose o t is game is to give peop e a c ance to see

just ow t e structure o a process can a ect qua ity, an to

give them experience with measuring and analyzing the

process’s function.

is version of the game focuses on two data analysis tools:

pareto diagrams and run charts. Pareto diagrams allow

you to analyze causes by category, and run charts show thevariation in data over time. By looking at causes by category

you can ma e a ata- riven ecision a out w ic part o a

process to a ress, an y oo ing at variation over time you

can egin to eve op ypot eses a out w y a process may

not e wor ing we . For examp e, you mig t oo at ap-

pointment no-s ow rates y age or sex o t e c ients, an see

t at women in t eir twenties are most i e y to miss t eir ap-

pointments. ese women are i e y to ave young c i ren,

so perhaps your program could consider offering support in

this area. Other exercises exist to teach these tools more

intensely; the purpose of this game is to illustrate how they

might be useful.


• Improvement comes from addressing the

processes o wor .

• One step in a process a ects anot er; eac step

can’t e viewe in iso ation.

• Deve oping an trac ing goo process measures is criti-

ca to eing a e to improve t e process.

• Simp e too s can e p ana yze w at t ese

measures s ow you.

The Game Itself

• e participants t at t eir jo is to pro uce a “comp ex

toy pro uct” an t at t eir pay wi e ase on t e

num er o pro ucts t at t ey comp ete.

• Instruct wor ers in t e 5 tas s o t e pro uction process:

- e tas 1 wor er o s t e ottom o a piece

o 8 1 ⁄2 x 11 paper to a ign wit t e rig t si e to

efine a square.

- Task 2 is designed to be the bottleneck task. e

worker must cut off the excess paper with a scissors,

old the second diagonal of the square, then fold

each corner in to the center of the square to form

a smaller square.

- e worker at task 3 again folds each corner of square

nwar towar t e center to orm a sti sma er square.

- e tas 4 wor er ips t e sma square over an

raws a pair o eyes, one eye on eac o 2 neig oring

quares, wit t e ac mar er.

- as 5 requires t e wor er to ip t e square over

ga in an raw in t e tongue wit t e re mar er.

- e puppet is ma e y ipping t e square once again

nd inserting a finger under each of the four

squares on this side and folding each side of the

square together.




32

• A ter t e tas s ave een exp aine to t e wor ers, give

t em a ew s eets o t e w ite paper to practice t eir

tas s e ore t e actua simu ation.

• As or vo unteers rom t e au ience to act as timers.

Five tas timers measure, in secon s, ow ong it ta es

eac wor er to o is or er tas rom t e time a wor er

picks up a unit until he or she is finished with that unit).

One throughput timer measures the time it takes to

complete a single unit. Note: this can be diffi cult as

bottlenecks can make it hard to keep track of an indi-

vidual unit. Use alternating colors of paper so the timer

can keep the different units straight.• Ask for one more volunteer to be the quality inspector

w o reviews an accepts or rejects eac nis e puppet.

Keep t e criteria t e inspector s ou use

purpose u y vague.

• Let t e system o pro uction pro uce 20 items.


• Review resu ts. As t e participants, w at i t ey

o serve? Most common responses are:

- as 2 was t e ongest tas .

- as 4 or sometimes 5 was t e s ortest tas .

- e wor er at tas 2 was never i e.

- e wor ers at tas s 3, 4, an 5 were i e

most of the time.

- e workers at tasks 3, 4, and 5 slowed down after a

ew units had been produced.

- e worker at task 1 ran out of space to send

units to task 2.

- e worker at task 2 exhibited signs of frustration:ushing, rushing, making comments about

eing overwor e .

- Wor -in-process WIP inventory on y ui t up at tas 2.

- Wor ers i n’t communicate muc wit eac ot er.

- e qua ity inspector i n’t communicate ac to t e

t er wor ers. e qua ity inspector rejecte or i n’t

eject many units.

• As or t eir conc usions a out t is process.

Most will answer:

- e bottleneck at step 2 limits the process’s capability.

- e workers didn’t communicate because they were

ot told to; workers often will not do something un-

less they are told it is OK.

- Some may give suggestions on how to improve the

process: providing square paper to start, for example,

r a temp ate or t e eyes an tongue or or t e o s

ee e in t e paper.




33

• Intro uce t e quantitative ana ysis.

- As one group o participants to oo at t e qua ity in-

spector’s ata an i enti y categories o e ects. Have

t em raw a ar grap , wit t e types o e ects on

t e orizonta axis an t e num er o puppets s ow-

ing suc e ects on t e vertica axis, wit t e ig est

number in the left hand bar and the rest in descend-

ing order (see Attachment 4 for an example). is is

a rough Pareto diagram, designed to show the relative

influence of different causes to an overall result (in

this case, poor quality puppets). e diagram helps

identify which part of the process should be looked atin order to provide puppets of higher quality.

- A itiona groups o participants can raw run

c arts – ine grap s – ase on t e tas t ime s eets

an t roug put time s eets. e orizonta axis is

num ere or eac unit, rom 1-20. e vertica axis

is a e e wit “num er o secon s” an t e time eac

unit too is recor e , wit t e points or eac unit

connecte wit a ine see Attac ment 5 . As a out

the conclusions they can draw from the charts. Why

does the throughput time increase? Which task takes

the longest and increases the most? How does this

relate to their initial response to the process?

• Ask about processes in their HIV programs:

- Which work well? Which seem to have bottlenecks?

- Which do we measure now? Which should we

measure? How?

- I we measure process per ormance, ow wi we

organize ourse ves to act on t e resu ts?

Feedback and Close







• ank your audience and congratulate them on their

hard work and success.




34

UNIT

1

2

TIME IN SECONDSUNIT

3

4

5

6

7

8

9

10

11

12

13

14

1

16

17

18

19

0

Average

as :

Recor t e time rom start o wor on unit to en o wor on unit.

ttachment 1

Task Time Sheet




35

Recor t e time rom start o wor on a unit at as 1 to t e comp etion o wor on t at unit at as 5 to en o wor on unit.

UNIT

1

TIME IN SECONDSUNIT

3

5

8

10

11

12

1314

15

16

17

18

19

20

Average

ttachment 2

Throughput Time Sheet




36

UNIT

1

ACCEPT OR REJECT?

3

5

8

10

11

12

13

14

15

16

17

18

19

20

Acceptance Rate

OMMENTS

ttachment 3

Quality Control Form




37

ttachment 4

Sample Pareto Diagram and Sample Run Chart

Pareto Diagram: Reasons or Rejects

50

00

250

200

50

0

50

1 5 9 1 3 5 7 19 21

Run Chart: Throughput Time

S E C O N D S

UNIT NUMBER

2

0

8

6

2

0

DOESN’T NOT A MESSY EYES

REASON

N U M B E R




38

Who’s Here? Game

SESSION AT-A-GLANCE

ntroduction

e Game

De rie an Discussion aci itator, au ience

acilitator, audience

acilitator

WHO? HOW LONG?

10 minutes

30 minutes

0 m nutes

Why Use This Game

• To give teams experience in designing indicators and

data collection methods.

• To show different ways of graphically displaying data.

• To start a discussion about data stratification, meanand range.

Target Audience

Senior sta , team mem ers, an anyone e se w o wi e

invo ve in co ecting an ana yzing ata. is game wor s

est i it is part o an intro uction to ata isp ay too s.

Type of Game


Key Concepts

• Data should give you the answers to useful questions.

• Disp aying t ese ata grap ica y ma e t em easier

to un erstan .

• A goo ata too wi a so te you a out t e istr i ution

o t e ata you ave co ecte .


e source for this game is “e Big Book of Six Sigma Train-

ing Games ,” by Chris Chen and Hadley Roth, New York:

McGraw-Hill, 2005 (pages 91-94).

Materials


• F ip c art an i erent coore mar ing pens

or eac team

• One instruction s eet or eac team see Attac ment 1

Preparation



and content:

- Read through the game instructions and key teaching

points in their entirety.


- Practice presenting t e ey teac ing points.


- Arrange c airs aroun a ta e or ta es , set up to ma e

t easy or t e participants to wor in sma groups.

- Set up an a it iona ip c art in t e ront o t e room

o you can capture ey points o t e iscussion

after the game.




39

Playing the Who’s Here? Game





Learning O jectives


• Understand the relationship between collecting data

and answering useful questions.

• Have experience creating data display tools.

• Have experience analyzing data displayed in

graphs and charts.

Agen a

Provi e a rie escription o t e session’s primary

components:

1. Bac groun to t e W o’s Here? Game.

2. e game itse .






e purpose of this game is to give participants experience

in creating and using data displays. Unlike data display

exercises t at give you a ata set an as you to grap it, t is

game requires eac participating team to, rst, create t e

“ in icator” t ey wi use t at is, a question t ey wi as o

t eir e ow participants an t en isp ay t e resu ts grap i-

ca y. is game i ustrates t e ata co ection an ana ysis

process, rat er t an t e mec anics o a particu ar too .

You may need to give the participants a quick refresher in

creating and using pie charts, histograms, line graphs, etc.,

although most people in health care settings have some fa-

miliarity with these. e authors of the game point out that

some teams may nee e p to structure a question t at wi

give t em ata t at can t en e put into a grap .

e iscussion at t e en o t e game can ea to concrete

p ans to ma e ata more avai a e in t e c inic or program.

Most programs have data reporting requirements and some

ollect additional data that interests the management or

staff. Consider making a plan to graph and distribute

dental referral rates, for example, if your program is not

already doing so.


• Discuss t e purpose o co ecting ata. Remin t em

t at ran om y co ecting ots o num ers is use ess. You

want ata t at ea to in ormation, t at give you answers

to your questions. Any goo ata co ection activity

s ou egin wit t e questions you want to answer.

• Review t e asic ata isp ay too s:

- Line grap s, s owing ata c ange over time.

- Histograms (frequency distributions) or bar charts that

how how many units have a particular characteristic

- Pie charts, that show the percentage of each contribu-

ion to the whole.

- Scatter diagrams, that show the relationship of one

variable to another.

• Review the concept of stratification: will we want to

now i t e answer to our question varies ue to a spe-

ci c e ement: ay o t e wee , season o t e year,

age or sex o t e participant, etc.? a a out ow

teams s ou consi er ow to esign t eir ata co ec-

tion strategy so t ese questions can e answere , i t ey

are mportant.




40

The Game Itself

• Ask participants to divide up into groups of 3 to 6 with

the people most like themselves with no more than 6

groups total. If asked what you mean by “most like

themselves,” provide no more information.

• Give each group a copy of the instructions (Attachment 1).• Each group gathers around its flip chart and gives itself a

name, writing it on t e ip c art.

• Eac team composes a question it wi as eac o

t e ot er participants to etermine ow t e groups

ave een orme .

• A ter a teams ave compose questions, instruct t e

participants to gat er ata rom a t e participants,

inc u ing t eir own team. eam mem ers s ou

record each person’s name and his/her answer.

• Each team then creates a graphical display of

their information.

• Teams then quickly present their findings and show

their charts/graphs.

• e facilitator selects the winning team.


• Review results.

• Ask the teams to describe their work: how did each

team decide on its questions?

• Look at the graphs and analyze the data more deeply:

• What do they show about the make-up of thegroup of participants?

- Can you strati y t e ata in a use u way?

- W at a out t e mean o t e ata an t e range?

W at conc usions can you raw a out t e nature o

e participants in t is game?

- How use u are t ese grap ics? How cou

t ey e improve ?

• Discuss t e app ication o w at t ey ave earne to

their own HIV program.

- Do the data they have access to provide answers to

seful questions? Why or why not?

- Do they get any data results in graphical format?

• If so, are these graphs useful?

• If not, what would they like to see? How could they go

about getting such graphs?

Feedback and Close





ence member who wants clarification or more informa-

tion on the game or the concepts you discussed.






41

ttachment 1

Who’s Here? Team Instructions Sheet

• Wor on y wit in your group.

• Deve op a sing e question t at wi e as e o eac mem er o eac team, inc u ing your own. e purpose o t is question is

to e p your team etermine ow t e ot er teams orme t emse ves.

- e question must as or in ormation t at can e isp aye grap ica y – in a ine grap , ar c art, istogram, pie c art or

ot er grap or c art.

- Use only your visual observation, the team names, and your existing knowledge of the people in the room in developing your

question.

- Do not ask a question that is too personal to be discussed in public.

- Do not use the team names in your question.

• e purpose of your graphical presentation is to characterize how people decided to form groups “most like themselves.”

Sample questions:

• How ta are you in inc es?

• How many mi es o you rive to wor eac ay?

• W at epartment o you wor or?




42

Games to Teach System Skills




43

Peanut Butter and Jelly GameWhy Use This Game

• To teach that systems only work as well as

they are designed.

• To teach the importance of error-proofing design.

• To show the importance of clearly documentingyour process.

Target Audience

Senior sta , team mem ers, an anyone e se w o wi

e invo ve in creating a new process or a tering an

ex st ng process.

Type of Game


Key Concepts

• Each system is perfectly designed to achieve the

resu ts it gets.

• C ear instructions to one person may not e c ear

instructions to anot er.

• Steps ear y in a process may ave an un oreseen impact

ater in t at process or system.

Source, History and Resources forMore Information

nformation about this game comes from Qualis Health,

the QIO for Washington State, and its Performance

mprovement Support Center.

Materials


• Ingre ients or a peanut utter an je y san wic

rea , peanut utter, je y, ni e

• A pa o paper an pens or eac team

• F ip c art an mar ers to recor t e ey points

of the discussion

Preparation



and content:

- Rea t roug t e game instructions an ey teac ing





- Arrange c airs aroun a ta e or ta es, set up to ma e

t easy or t e participants to wor in sma groups.

- Set up a small desk or table in the front of the room

nd place the sandwich ingredients on the table.

- Set up the flip chart so you can capture key points of

he discussion after the game.

SESSION AT-A-GLANCE

ntroduction

e Game

Debrief and Discussion acilitator, audience

Faci itator, au ience

acilitator

WHO? HOW LONG?

10 minutes

25 minutes

10 minutes




44

Playing the Peanut Butter and JellyGame





Learning Objectives


• Understand that systems and processes only work as well

as they are designed.

• Understand what is involved in error-proofing a design.

• Appreciate the importance of clear documentation ofprocess steps.

Agen a


components:

1. Bac groun to t e Peanut Butter an Je y Game.

2. e game itse .






“A system is e ne as a co ection o inter epen ent e e-

ments t at interact to ac ieve a common purpose.” It is t e

interaction o systems t at ma es t em tric y to manage

– somet ing t at a ects one part o a system may ave an

n oreseen impact ater on anot er part o t e system. In

thinking about making improvement, we have to under-

stand that each system is perfectly set up to achieve the

esults it gets. If we want to change the results, we need

to change the system. For example, the number of women

getting gynecology consults will not improve unless you do

something to change the link between the processes in yourprogram and those in the gynecology service.

e purpose o t is game is to teac t e in etween esign

an resu ts, an to stress t at ecisions t at ma e sense

w en ta en in iso ation i e ow to put peanut utter an

je y on rea can ave an unexpecte impact on t e resu t.

As you p ay your ro e, stic strict y to t e instruct ions as

given, an “p ay up” t e resu t. Participants wi quic y

grasp the relationship between clear documentation of the

process and the resulting sandwich, but may need help from

you to make the link to thinking about health care systems.


• Explain the definition of “process” and “system.” A pro-

cess is a series of steps that turns an input into an output.

A system is a group o processes wit a common aim. A

patient visit is a process. reating HIV is a system.

• Mention t at improving one process in a system may

ave an un oreseen impact on anot er process in a

system. Most peop e wi un erstan t is easi y; i you

ave time, iscuss some examp es o t is t at you or

participants ave encountere .

• Explain that this game will help illustrate some of the

issues involved in improving processes and systems.




45

The Game Itself

• Divi e t e participants into sma groups. Aim or

3 or 4 groups.

• e eac group to prepare, write own an su mit t e

process or ma ing a peanut utter an je y san wic .

• Reconvene as a arge group. You, as aci itator, emon-

strate eac set o instructions or ma ing t e san -

wich. Follow these instructions exactly as written – for

example, if the instructions don’t tell you to take the

peanut butter out of the jar, don’t take it out of the jar.

• Ask the group: do we adopt, adapt or abandon this

process? Discuss why.

• If time permits, try one round of adaptationof the instructions.


• Review resu ts.

• As t e group to escri e w at appene :

- Aim or comments t at t e instructions assume

peop e wou now to o certain t ings, even i

they were not stated.

- Ask if this situation ever occurs in their organization,

and discuss.

• Ask for feedback on your role as a sandwich-maker:

- Did you follow directions ?

- Did your result reflect what the instructions

contained? (Aim to get participants to see that the

resu ts per ect y matc e t e instructions.

- W at t ere ore nee e to e c ange , to ac ieve t e

expecte resu t? e un er ying way o oing wor

– t e core instructions or ma ing t e san wic .


t eir own HIV program:

- W at is t e in etween t e current esign o t eir

HIV care system and the results it achieves?

- What about existing process instructions? Are they

clear and well understood?

- Have t ey ma e improvements t at ave a un ore-

een consequences? How ave t ey an e t ese?

W at mig t t ey o i erent y? is can e a p ace

o ring up t e concept o PDSA: testing c anges on

sma sca e can revea t ese pro ems ear y.

Feedback and Close




• Schedule an informal follow-up session with any audi-ence member who wants clarification or more informa-


• an your au ience an congratu ate t em on t eir

ar wor an success.

• Provi e san wic es to t ose w o want t em.




46

Butterfly Effect GameWhy Use This Game

• To show how a change in one part of a system can

“ripple through” other parts of the system.

Target Audience



ex st ng process.

Type of Game

A emonstration wit everyone part icipating.

Key Concepts• Systems are complex and their parts are interrelated.

• Changes in one part of a system affect other parts

of the system.

• It’s important to make changes carefully so these unex-

pecte consequences can e accounte or.


In ormation a out t is game comes rom Qua is Hea t , t e

QIO or Was ington State, an its Per ormance Improve-

ment Support Center; the Ohio QIO provided information

about this game to Qualis Health.

Materials

• Flip chart and markers to record the key points

of the discussion

Preparation



an content:






- Arrange chairs in a circle around the outside of the

oom. You will need a large open space for people

to walk around in.

SESSION AT-A-GLANCE

Intro uction

e Game

ebrief and Discussion acilitator, audience


Faci itator

WHO? HOW LONG?

10 m nutes

10 m nutes

10 minutes




47

Playing the Butterfly Effect Game





Learning O jectives

e participants t at y t e en o t e session t ey wi :

• Understand that systems are complex.

• Appreciate how the parts of a system are interrelated.

• Understand the importance of pilot-testing planned

changes in a process or system.

Agenda

Provide a brief description of the session’s primary

components:

1. Bac groun to t e Butter y E ect Game.

2. e game itse .



4. Fee ac an c ose.



“A system is e ne as a co ection o inter epen ent e e-

ments t at interact to ac ieve a common purpose.” It is t e

interaction o systems t at ma es t em tric y to manage

– somet ing t at a ects one part o a system may ave an

n oreseen impact ater on anot er part o t e system.

n many cases, people can understand this concept intuitive-

ly. Sometimes, however, it helps to demonstrate the concept

in an unmistakable way. at is what this game is designed

to do. One simple change – the facilitator taking one or

two steps – causes the whole design of people in the room to

hange. Making change can be powerful, but not always in

easily predictable ways.


• Exp ain t e e nition o “process” an “system.” A pro-

cess is a series o steps t at turns an input into an output.

A system is a group o processes wit a common aim. A

patient visit is a process. reating HIV is a system.

• Mention t at ma ing c anges in one part o a system

may have an unforeseen impact on another part of the

system. Explain that this game will help illustrate this

characteri stic of systems in a visual way.




48

The Game Itself

• As a participants to stan in t e center o t e room.

• e eac participant to se ect two ot er peop e in

t e room, ut eep t e names o t ese two peop e

to t emse ves.

• e participants t at t ey must now stay equi istant

etween t e two peop e t ey ave c osen.

• As facilitator, move slowly through the room. Many

of the participants will have chosen you as one of their

people, and will need to move as you do. As they move,

others will need to move, and the configuration of the

room will keep changing.

- e facilitator can also move in stops and starts toclarify the effect.

• Keep it up unti peop e isso ve in aug ter or

express rustration.


• Reconvene as a arge group an review resu ts.

• As t e group to escri e w at appene :

- You can jump-start the discussion by asking one

person to identify their two chosen people, and to tell

how and why they moved around (this works best if

you can identify one of the people who chose you).

• Ask whether the movement of people in the room

was a system (try to get participants to see that it

was a system .


t eir own HIV program.

- W at are t e ey components o t eir HIV

care system

- W ic parts o t e system a ect ot er parts o t e

system? is cou e a very ric iscussion. Press

participants to t in a out t is care u y an to

share their conclusions.

- W at as appene w en c anges ave een ma e in

eir system? Di t ey “ripp e t roug ” t e sys-

em? W en an w y? O ten, ocusing on one part

t e care process improving PPD testing rates, or

xamp e can pu attention rom anot er part – ot er

ypes o re erra s, per aps. Has t is appene in

your program?

- Could this “rippling” have been prevented? What

ight they do differently? (is can be a place to

ring up the concept of PDSA: testing changes on

a small scale can reveal these problems early.)

Feedback and Close












49

SESSION AT-A-GLANCE

ntroduction

e Game



acilitator

WHO? HOW LONG?

10 minutes

2 m nutes

15 minutes

Win as Much as You Can GameWhy Use This Game

• To give teams experience in designing indicators and

ata collection methods.

• To show different ways of graphically displaying data.

• To start a discussion about data stratification, meanand range.

Target Audience

enior sta , team mem ers, an anyone e se w o wi e

nvove in co ecting an ana yzing ata. is game wor s

est i it is part o an intro uction to ata isp ay too s.

Type of Game


Key Concepts

• Data should give you the answers to useful questions.

• Disp aying t ese ata grap ica y ma e t em easier to

n erstan .

• A goo ata too wi a so te you a out t e istri ution

t e ata you ave co ecte .


e source for this game is “e Big Book of Six Sigma Train-

ing Games ,” by Chris Chen and Hadley Roth, New York:

McGraw-Hill, 2005 (pages 91-94).

Materials


• F ip c art an i erent coore mar ing pens or

eac team

• One instruction s eet or eac team see Attac ment 1




50

Preparation



an content:






- Arrange chairs around a table or tables, set up to make

it easy for the participants to work in small groups.

- Set up an additional flip chart in the front of the room

so you can capture key points of the discussion afterthe game.

Playing the Win as Much As You CanGame



or t eir participation. I necessary, as in ivi ua s to

intro uce t emse ves to t e group.

Learning Objectives


• Understand the relationship between collecting data

and answering useful questions.

• Have experience creating data display tools.

• Have experience analyzing data displayed in graphsand charts.

Agen a


omponents:

1. Bac groun to t e Win as Muc as You Can Game.

2. e game itse .







51



e purpose o t is game is to give participants experience

in creating an using ata isp ays. Un i e ata isp ay

exercises t at give you a ata set an as you to grap it, t is

game requires eac participating team to, rst, create t e

“ in icator” t ey wi use t at is, a question t ey wi as o

their fellow participants) and then display the results graphi-

cally. is game illustrates the data collection and analysis

process, rather than the mechanics of a particular tool.

You may need to give the participants a quick refresher in

creating and using pie charts, histograms, line graphs, etc.,although most people in health care settings have some

ami iarity wit t ese. e aut ors o t e game point out

t at some teams may nee e p to structure a question t at

wi give t em ata t at can t en e put into a grap .

e iscussion at t e en o t e game can ea to concrete

p ans to ma e ata more avai a e in t e c inic or program.

Most programs ave ata reporting requirements an some

collect additional data that interests the management or

staff. Consider making a plan to graph and distribute

dental referral rates, for example, if your program is not

already doing so.


• Discuss t e purpose o co ecting ata. Remin t em

t at ran om y co ecting ots o num ers is use ess. You

want ata t at ea to in ormation, t at give you answers

to your questions. Any goo ata co ection activity

s ou egin wit t e questions you want to answer.

• Review the basic data display tools:

- Line graphs, showing data change over time.

- Histograms (frequency distributions) or bar

charts that show how many units have a particular

haracteristic.

- Pie charts, that show the percentage of eachcontribution to the whole.

- Scatter iagrams, t at s ow t e re ations ip o

one varia e to anot er.

• Review t e concept o strati cation: wi we want

to now i t e answer to our question varies ue to a

speci c e ement: ay o t e wee , season o t e year, age

or sex o t e participant, etc.? a a out ow teams

s ou consi er ow to esign t eir ata co ection

strategy so these questions can be answered, if they

are important.




52

PAYOFF SCHEDULE

4 X’s

3 X’s

1 Y

2 X’s

2 Y’s

1 X

3 Y’s

4 Y’s

Lose $1.00 each

Win $1.00 each

Lose $3.00

Win $2.00 each

Lose $2.00 eac

Win $3.00

Lose $1.00 eac

Win $1.00 eac

ROUND

1

3

YOUR CHOICECIRCLE)

GROUP’S CHOICE PAYOFF ALANCE

5

X Y

X Y

X Y

X Y

X Y

X Y

X Y

X Y

X Y

Con er wit your partner in eac roun an ma e a joint ecision an mar t e scorecar accor ing y. A ter eac roun , trac t e

group’s c oices an t e payo .

ttachment 1

Win As Much As You Can Tally Sheet

Instructions: For 6 consecutive roun s you an your partner wi c oose eit er an X or a Y, an eac o t e ot er partners ips in

your group wi ma e t e same c oice. e payo or eac roun epen s on t e pattern o c oices ma e y your group.




53

The Game Itself

• As participants to ivi e up into groups o 3 to 6 wit

t e peop e most i e t emse ves wit no more t an 6

groups tota . I as e w at you mean y “most i e

t emse ves,” provi e no more in ormation.

• Give eac group a copy o t e instructions Attac ment 1.

• Eac group gat ers aroun it s ip c art an gives it se

a name, writing it on the flip chart.

• Each team composes a question it will ask each of the

other participants to determine how the groups have

been formed.

• After all teams have composed questions, instruct the

participants to gather data from all the participants,including their own team. Team members should record

eac person’s name an is er answer.

• Eac team t en creates a grap ica isp ay o

t eir in ormation.

• eams t en quic y present t eir n ings an s ow t eir

c arts grap s.

• e aci itator se ects t e winning team.


• Review resu ts.

• As t e teams to escri e t eir wor : ow i eac

team eci e on its questions?

• Loo at t e grap s an ana yze t e ata more eep y:

- W at o t ey s ow a out t e ma e-up o t e group

participants?

- Can you stratify the data in a useful way?

- What about the mean of the data and the range?

What conclusions can you draw about the nature

of the participants in this game?

- How useful are these graphics? How could

they be improved?• Discuss the application of what they have learned to


- Do t e ata t ey ave access to provi e answers

to use u questions? W y or w y not?

- Do t ey get any ata resu ts in grap ica ormat?

• I so, a re t ese grap s use u ?

• I not, w at wou t ey i e to see? How cou t ey go

a out gett ing suc grap s?

Feedback and Close• Ask your audience for feedback on whether this session



• Schedule an informal follow-up session with any audi-




ar wor an success.




54

Games to Teach Skills in

Developing Changes




55

Think Inside the Box Game

SESSION AT-A-GLANCE

Intro uction

e Game



Faci itator

WHO? HOW LONG?

10 m nutes

2 m nutes

15 minutes

Why Use This Game

• To teach the importance of going beyond the most

obvious result.

• To show that thinking creatively can be hard, but

it can be done.• To teach that teams working together can develop more

creative soutions t an in ivi ua s a one.

Target Audience



ex st ng process.

Type of Game A competition among teams.

Key Concepts

• It is easy to get stuc in our t in ing a out any pro em

wit w ic we are con ronte . at’s ecause our min s

are programme to t in in a ogica , inear as ion.

• Getting “unstuc ” in our t in ing is not easy, ut we

can earn to e etter at it.

• Wor ing in teams is one way to e p get unstuc .


nformation about this game comes from Qualis Health,

the QIO for Washington State, and its Performance

mprovement Support Center. For more information aboutreative thinking and quality improvement, see Plsek, Paul

E., Creativity, Innovation an Qua ity, Mi wau ee, ASQ

ress, 1997.

Materials


• A pa o paper an pens or eac team it e ps to ave

pens of different colors for each team)

• Flip chart and markers to demonstrate the game and to

record the key points of the discussion




56

Preparation

To prepare for this session:• Familiarize yourself with the session’s structure

an content:






- Arrange c airs aroun a ta e or ta es , set up to ma e


- Distribute a pad of paper and pen(s) for each team

that will participate.

- Set up the flip chart so you can give the instructions

and capture key points of the discussion after

the game.

Playing the Think Inside the Box Game





Learning O jectives


• Understand that developing innovative solutions

can be diffi cult.

• Understand what is involved in getting better

at being innovative.

• Appreciate the importance of teamwork inpromot ng creat v ty.

Agen a


omponents:

1. Bac groun to t e in Insi e t e Box Game.

2. e game itse .







57



Most peop e, most o t e time, practice w at creativity

expert E war e Bono ca s “vertica t in ing” – se-

quentia , ana ytic reasoning ase on esta is e pat-

terns o t oug t. is a i ity to ui on w at we a rea y

now ma es umans a e to an e situations o amazing

complexity, but because we are always building on these

established patterns of thought, vertical thinking is not very

good for designing innovative solutions to problems.

For example, most HIV clinics have problems with

no-show rates. Almost every clinic that works on thisproblem decides to address it by making reminder calls: our

min s are set in t is vertica pattern t at peop e on’t s ow

or appointments ecause t ey orget, an t is o ten mas s

our a i ity to a ress t i s pro em more e ective y.

o e etter innovators we nee to expan our a i ity to

practice e Bono’s “ atera t in ing” – w ere we can ta e

an image rom one setting an pair it wit an image rom a

completely different setting to create a new tool (Paul Plsek

points out that the Ziploc storage bag resulted from lateral

thinking. It combines two entirely different concepts – food

storage and fastening of clothes – into one new creative idea

that was a leap forward in the keeping of leftovers).

is game helps to introduce the concepts of vertical and

atera t in ing, y presenting a puzz e t at oo s simp e on

t e sur ace ut quic y gets muc more i cu t. Partici-

pants wor on t e puzz e in teams, e ping eac ot er to

t in more “ atera y” an na y agree on t e so ution.

e game a so gives teams a c ance to practice goo team

e aviors, as usua y one or two mem ers get t e so ution

more quic y an t en must exp ain it c ear y to t e ot er

team members – and that’s not always easy!


• Intro uce t e concepts o vertica t in ing – t e ogica

way we usua y approac pro ems, an atera t in ing

– w at we o w en we are eing creative.

• Exp ain t at t is game wi e p i ustrate t e i cu ty

we o ten ave wit atera t in ing an wi e p us

begin to understand how to do it better (i.e., by working

collaboratively).

The Game Itself

• Divide the participants into teams. Aim for 3 or 4 teams.• Tell each team to copy you as you:

- Draw a square on t e ip c art.

- Divi e it into 4 qua rants.

- Divi e eac qua rant into 4 qua rants.

• e eac team to wor toget er to count t e num er o

squares t at resu t.

• Eac team wi quic y come to “16” as t e answer most

i e y one in ivi ua wi s out it out . Remin t em

to work as a team to develop the answer. Tell them to

think seriously, count carefully and make sure everyone

on the team understands the answer.

• Watch the teams. Note which one arrives at the right

answer (which is 30 – see Attachment 1) first. Observe

how the teams work together.

• When all teams have the answer or appear too frustrated

to continue, ca t ime. As t e team t at arrive at t e

answer rst to wor as a team to present t e so ution to

t e rest o t e group.




58

1 ox t at is 4x4

4 oxes t at are 3x3

9 oxes t at are 2x2

16 oxes t at are 1x1

ota = 30

ttachment 1

How on Earth are there 30 Squares?




59


• Review resu ts.

• As t e team t at is presenting to escri e t eir

team process:

- How i t ey come to t eir soution?

- How a out ringing ot ers on t e team a ong?

A your own o servations.

• Ask other teams to describe their experiences and the

ease or diffi culty they had with the problem.

• Discuss the application of what they have learned to

their own HIV program.

- What problems keep coming up again and again in

the program?- What solutions have they tried? Have any of these

tru y een innovative?

- How cou t ey eve op more creative so utions?

• You may want to suggest some answers ere. P se ’s

oo inc u es ots o too s to strengt en groups’ creative

t in ing capa i ities. See t e Reversa s Game, e ow,

or one suggestion. But even somet ing as simp e as

enc mar ing rom anot er in ustry can e p promote

lateral thinking.

Feedback and Close














61

- Ma e copies o t e Su o u Puzz e or eac partici-

pant. Distri ute at east one pen to eac ta e.

- Prepare t e “c ange concept” note you wi s ip to one

participant in eam 3 part way t roug t e game see

game instructions, e ow, or t e text o t e note .


the discussion after the game.

Playing the Sudoku Game

Welcome and Introductions To begin the game, welcome participants and thank them



Learning O jectives


• Un erstan w at a c ange concept is.

• Un erstan ow c ange concepts can e use

for improvement.

• Appreciate senior leadership’s role in providing change

concepts to improvement teams.

Agenda

Provide a brief description of the session’s primary

components:

1. Bac groun to t e Su o u Game.

2. e game itse .



4. Fee ac an c ose.



e t ir question o e Improvement Mo e is “w at

ange can we ma e t at wi resu t in improvement?” e

e o operat ions researc as provi e muc in ormation

on ow to answer t is question or wor processes: mini-

mizing an o s, or examp e, wi a most a ways improve

work flow. “Minimizing handoffs” is therefore a change

oncept, what Langley and his colleagues call “a general

notion or approach that has been found to be useful in

developing specific ideas for change that result in improve-

ment.” As more improvement work takes place in health

are, clinical change concepts are being developed. Usingpatient registries, for example, has become recognized as a

ange concept or c ronic i ness care. “Set an ocument

se -management goa s co a orative y wit patients” is a

ange concept or HIV care.

n organizations committe to improvement, senior ea ers

ecognize t eir ro e in i ent i ying an provi ing c ange

oncepts t at are t en use y t eir improvement teams.

e purpose of this game is to help senior leaders understand

what change concepts are, and then to initiate a discussion

among leaders about their role in using change concepts.


• Introduce the idea of change concepts. Use the defini-

tion and examples above. It can also be helpful to think

up c ange concepts t at wou app y to recreationa

activities or o ies: “ eep your eye on t e a ” is a

c ange concept t at app ies to most sports, or examp e.

• Exp ain t at t is game wi e p i ustrate ow c ange

concepts are est use in improvement e orts.




62

The Game Itself

1. Divi e t e participants into t ree teams; ave eac

team sit at a ta e.

2. Exp ain t e purpose o t e game: to wor as a team to

t e gri wit num ers 1-9 so t at eac coumn, row,

an 3 x 3 square as t e num ers 1 - 9 wit no repeats

in any co umn, row, or 3 x 3 square. Su o u is not a

mathamatical game.

3. Distribute a copy of the Sudoku Puzzle (Attachment 1)

to each participant.

4. Tell the teams that the group will reconvene in 15 min-

utes to see how far each has gotten.

5. Immediately go to Team 1. Speak only to them, makesure the other teams cannot hear. Tell them you are giv-

ing t em a c ange concept or t e puzz e. at c ange

concept is: “ a egin wit t e one 3 x 3 square wit t e

most num ers a rea y e in an it in comp ete y;

t en pic t e one co umn wit t e most num ers

e in an comp ete it; an t en; c pic a row t e one

row wit t e most num ers e in. Repeat square,

co umn, an row.”

6. Team 2 receives no assistance.

7. Hand a note to one team member of Team 3. Try and

select the quietest member. e note should read: “Read

the following sentence aloud to your team: ‘I think there

is a change concept about this puzzle. It has something

to do with starting with the 3 x 3 squares, but I can’t

remember the details.’”

8. A ter anot er 15 minutes, ca time.


• Review resu ts.

- As t e teams to report in t e o owing or er:

eam 2, eam 1 an eam 3.

• Press eams 1 an 3 to escri e exact y ow t ey

receive t e c ange concept an ow it a ecte

t eir wor .

• Discuss the application of this experience to the use of

change concepts. Elicit that leadership’s taking a strong

role in providing the change concept at the beginning of

the puzzle was essentia l to the team’s success. Team 3’s

experience should be similar to relying on a team mem-

ber to come up with the change concept: it comes alonglater in the process, and may not be correct or complete.

It can e more rustrating t an e p u .



- W at c ange concepts ave t ey use , an ow

ave t ey wor e ?

- W at c ange concepts mig t app y to HIV care?

- W at improvement e orts are ta ing p ace now in

heir own programs for which they would like to

provide change concepts?

Feedback and Close


met its objectives. Take notes of their responses on a flip






ar wor an success.




63

ttachment 1

Sudoku: The Game

Sudoku: The Solution

5 3 769 8

6

1 56

68 3

31

4 1 91 7 9

52

5 3 76

9 8

6

1 56

68 3

31

4 1 91 7 9

52

6 8 13 49 2

1 3 2 5 75

1 3

2 67

51

4

4972

5

3 4 5

17

35

2 6

76 3

4




64

Egg Ship GameWhy Use This Game

• To help teams to get used to working together.

• To give teams practice in problem-solving.

• To focus teams on the importance of meeting

customer needs.

Target Audience

eam mem ers an ot ers w o wi e eve oping an

running PDSA cyc es, or wor ing on any sort o comp ex

team pro ect.

Type of Game


Key Concepts

• Keeping focused on customer needs helps teams solve

problems more smoothly.

• eams get etter at wor ing toget er over time.


is game comes rom “101 More Training Games ,” y Gary

Kroe nert, McGraw-Hi Boo Company Austra ia, Sy ney,

copyright 1999 (pp. 28-29). Mr. Kroehnert includes

permission to reproduce his games for educational purposes

or training activities.

Materials

or this game, you will need:

• For each team participat ing:

- One raw egg (hard-boiled may be substituted to help

with the clean-up if any break)- A roll of sticky tape

- A an u o rin ing straws

- Mar ing pens

- One copy o t e Brie ng S eet Attac ment 1

• A ip c art an mar ers to recor t e ey points

o t e iscussion

• A sma a er or step-stoo or t e 10- oot test ig t

Preparation



and content:






- Remove ta es; teams wi nee space to wor .

- Have t e equipment rea y to istri ute to teams.

- Set up t e ip c art so you can give t e instructions

n capture ey points o t e iscussion a ter

the game.

SESSION AT-A-GLANCE

Intro uction

e Game



Faci itator

WHO? HOW LONG?

10 m nutes

60 minutes

15 minutes




65

Playing the Egg Ship Game


o egin t e game, we come participants an t an t em or

t eir participation. I necessary, as in ivi ua s to intro uce

themselves to the group.

Learning Objectives


• Know their teammates better.

• Know how they and their teammates work together to

solve a problem.

• Have experience co a orating to a ress customer nee s.

Agen a


components:

1. Bac groun to t e Egg S ip Game.

2. e game itse .






One o t e rst t ings peop e earn a out qua ity improve-

ment is t at it ’s suppose to ocus on t e nee s o t e

customer. W en QI teams reac ecision points – aving

to eci e etween two options, or examp e – remem er-

ing t at t ey nee to meet or excee customers’ nee s e ps

make decisions and keep team’s work on target. In health

care it is especially important to remember to work to

improve care from the patient’s or client’s perspective, not to

make things “easier” for providers.

is game illustrates the value of having a clearly statedcustomer need – even though, in this case, it’s a need that

can e i cu t to meet! e game is un an ig t earte

ut contains important essons. a e t e time at t e en to

wor t roug t e iscussion questions.


• I t e participants ave not een expose to t e concepts

o customers an customer nee s, spen some time

discussing these with them. Some in health care can

be uncomfortable with the commercial connotation of

“customer” – stress that for us, customer is designed as

the person who receives and uses the service or product

you produce.

• Acknowledge that this is a diffi cult task and encourage

participants to help each other and to be creative.

• Ma e sure everyone un erstan s t e goa : to create

a spacecra t suita e or t e success u transportation

o raw eggs.




66

The Game Itself

• Divi e t e participants into teams o 5-7 peop e eac .

• e t e groups t at t ey represent companies t at

pro uce spacecra t. ese companies wi e competing

or a ucrative contract to construct a particu ar type

o cra t.

• Eac group t en starts t e tas o esigning, construct-

ing and evaluating a spacecraft suitable for the transpor-

tation of raw eggs. Give each team 45 minutes

to design and construct their Egg Ships using the

materials supplied.

• At the end of this time, begin the two-part evaluation.

Each evaluation consists of a test flight, one from 4 feetand the other from 10 feet. Should the eggs break

uring eit er test ig t, t e company wi e sue

or amages.

• Con uct t e rst part o t e eva uation y o ing t e

Egg S ips 4 eet a ove groun eve an ropping t em

to t e oor. e egg must not rea .

• Egg S ips t at survive t e 4 oot test move on to t e

secon part. Ho eac Egg S ip 10 eet a ove t e oor

(use the ladder or step-stool) and drop it. Again, the egg

must not break.


• Review resu ts. I enti y t e teams t at success u y

comp ete ot parts o t e eva uation.

• As t e teams a out ow t ey i t eir wor ?

• How i t ey approac t e tas ? Di t ey rea

own t e wor ? W o i w at?

• How a out ringing ot ers on t e team a ong? A

your own observations.

• Did any group ask the customer for more specific details,

such as the required color, placement of a company logo,

etc? Why or why not?

• Did any group get the customer involved in the process?

Why or why not?• Discuss the potential application of what they have

earne to t eir own HIV program.

- How o we invo ve customers in our pro em-so ving?

- Does our use o teamwor e p or in er our

pro em-so ving?

- W at mig t we o i erent y to improve?

Feedback and Close








ar wor an success.




67

Your team represents a company t at esigns, ui s an ies custom- ui t spacecra t. You wi e competing or a ucrative con-

tract to esign an construct Egg S ips or t e next eca e.

For t is exercise you wi ave 45 minutes to esign your Egg S ip. On comp etion o t e esign an construction your Egg S ip

wi e eva uate an put t roug two separate test ig ts. S ou t e egg rea uring eit er test ig t t e company wi e sue

or amages.

e first test flight will be from the height of 4 feet. e Egg Ship must be held 4 feet above ground level and dropped to the floor.

e egg must not break during this flight.

e second test flight will be a 10-foot flight. e Egg Ship will be located 10 feet above ground level and dropped to the floor.

Again, the egg must not break.

A o t e raw materia pun e nite y inten e wi e istri ute y your customer.

Goo uc !

ttachment 1

Egg Ship Briefing Sheet




68

Reversals Game

SESSION AT-A-GLANCE

Intro uction

e Game

ebrief and Discussion Facilitator, audience

aci itator, au ience

Faci itator

WHO? HOW LONG?

5 minutes

1 m nutes

36 minutes

Why Use This Game

• To teach groups a tool they can use to help them

generate innovative ideas about how to solve a problem.

• To help groups understand how to “un-stick”

their thinking.

Target Audience

eam mem ers an ot ers w o wi e invo ve in creat ing

a new process or a tering an existing process.

Type of Game

A demonstration with everyone part icipating. e game

works best with a group of no more than 8-10 people.

Key Concepts

• It is easy to get stuck in our thinking about any problem

with which we are confronted. at’s because our minds

are programme to t in in a ogica , inear as ion.

• Getting “unstuc ” in our t in ing is not easy, ut we

can earn to e etter at it.

• Speci c too s exist to e p us get unstuc .


is game is derived from exercises described by Paul E.

lsek in “Incorporating the Tools of Creativity into Quality

Management ,” Quality Progress, March, 1998, pp. 21-28,and in his book, Creativity, Innovation and Quality, Mil-

wau ee, ASQ Press, 1997.

Materials



o t e iscussion

PreparationTo prepare for this session:


and content:






- Arrange c airs in a circ e or U-s ape.

- Set up t e ip c art so you can:

• Recor t e resu ts o t e game.

• Capture key points of the discussion after the game.




69

Playing the Reversals Game





Learning O jectives


• Realize that they need consciously to break out of their

established way of thinking about problems.

• Know how to use a tool to help do this.

• Have experience applying this tool to HIV care.

Agenda


components:

1. Bac groun to t e Reversa s Game.

2. e game itse .



4. Fee ac an c ose.

Background to the GameFacilitator’s note

As we discussed in our introduction to the “ink Inside the

Box” Game, most people, most of the time, practice what

creativity expert Edward de Bono calls “vertical thinking”

– sequentia , ana ytic reasoning ase on esta is e pat-

terns o t oug t. is a i ity to ui on w at we a rea y

now ma es umans a e to an e situations o amazing

comp exity; ecause we are a ways ui ing on t ese esta -

is e patterns o t oug t, owever, vertica t in ing is not

very goo or esigning innovative so utions to pro ems.

Innovat ion requires more s i wit atera t in ing, a tec -

nique that can be learned. (See the Facilitator’s note for the

“ink Inside the Box” Game for more information).

A num er o too s ave een eve ope to e p peop e prac-

tice an ecome etter at atera t in ing. Many o t ese

are esigne to e p us escape rom t e way we a ways t in

o t ings y orcing our t oug t patterns to go in a i erent

irection. One common y-use too is ca a “reversa :” you

take an issue, and then ask what would it look like if the op-

posite of that situation existed? What would it look like our

patients were responsible for improving our health? What

would it look like if we wanted to raise costs and decrease

lient satisfaction? When presented with questions like this,

people laugh and come up with silly answers. Often, thesesilly answers contain a germ of an idea that can lead to a

tru y innovative approac to an existing pro em.

is game teac es t e reversa s too y app ying it to a

genera situation. is activity est serves as an intro uc-

tion to a an s-on app ication o t e too to your own HIV

program. Use t e game to get peop e warme up, re axe

an com orta e wit t e too . In t e e rie ng session

(instead of discussing what happened during the game), use

the tool and the group to develop possible solutions to your

own program, perhaps to work on that intractable problem

that you can’t seem to fix.

As the facilitator, you should introduce the concepts (see

below) and explain the reversals tool. Get the participants

to rainstorm rapi y or a ew minutes a out w at t is

“a sur ” situation wou oo i e. Ma e t is iscussion as

ree-w ee ing as you can: si y i eas are i e y to e t e ones

wit t e most potentia . Capture t e i eas on t e ip c art

as t ey come up. A ter 5 or 10 minutes, review t e ist wit

t e group an start w at P se ca s “ arvest ing” – seeing in

t e si y i eas core concepts t at mig t actua y e a apte

and put to use. e harvesting will be more diffi cult in the

abstract game and easier with the real-life situation.




0


• Intro uce, i you ave not a rea y, t e concepts o

vertica t in ing – t e ogica way we usua y approac

pro ems, an atera t in ing – w at we o w en we

are eing creative.

• Exp ain t at t is game emonstrates a too t at can e p

promote lateral thinking. Describe the tool.

• Tell participants that “anything goes” at the beginning,

and encourage absurd suggestions. en reassure them

that you’ll get serious after a bit and work to use the sug-

gestions to develop solutions to try.

The Game Itself

• e t e group t at you are going to wor on t e

pro em o c oose one rom t e o owing ist , or ma e

up your own :

- G o a warming

- C i oo o esity

- e unappea ing qua ity o oca ta e-out pizza.

• Present the reversal: what would it look like if:

- Our goal was to melt more of the polar ice cap,

more quickly?

- We wanted to get children to eat more junk

food and exercise less?

- We wanted to get local pizza shops to increase thereasiness of their products?

• Encourage rainstorming – no criticism – an outra-

geous i eas. Capture t em on t e ip c art.

• A ter a ew minutes, stop an review t e ist. e t e

group it’s time to return to rea ity. Go t roug t e

i eas an ea a iscussion a out w ic mig t actua y

e use u , or contain a use u concept? How cou t is

concept e expan e into an i ea t at as promise or

fixing the problem?






2

Games to Teach Skills in

Testing and Making Changes






4

Preparation



an content:



- Practice t e game itse see Attac ment 6 or t e

answer key.)



- Arrange chairs around a table or tables. A U-shaped

table works well.

- Set up a small desk, table or podium in the frontof the room.

- Set up t e equipment e.g., ip c art an over ea

projector or LCD projector you wi use to intro uce

t e game an recor t e resu ts. est t e equipment

to ma e sure it wor s.

- Prepare t e ip c art or an over ea transparency

wit t e “ eam Resu ts Summary” Attac ment 3.

Playing the Peg Game





Learning O jectives


• Know how to develop theories of change and how to

design tests of these theories.

• Understand how to use the results of these tests to design

new tests that reflect what they have learned.

• Appreciate the roles that ongoing data collection anddocumentation play in carrying out PDSA cycles.

• Begin to see ow to app y t ese concepts to t eir

HIV program.

Agen a


omponents:

1. Bac groun to t e Peg Game.

2. e Game Itself.



4. Feedback and Close.




75



As teams wor to ma e improvements in t eir HIV pro-

grams, t ey s ou e t in ing “we t in t is c ange wi

ma e t ings etter ecause it wi ....” I t ey o t is, teams

t en wi ave a way to assess w et er t e c ange was suc-

cess u . in ing a out w y a c ange mig t wor invo ves

developing a theory, and teams often find it hard to be dis-

ciplined enough to develop and test these theories. e Peg

Game encourages teams to be systematic about designing

and trying out solutions; the teams that do this well find the

solution more quickly.

e challenge in running this game is to make sure your

teams eve op a ypot esis e ore eac cyc e. Participants

may get excite a out trying to n t e soution an miss

t e rea point o t e game un ess you eep remin ing t em

an e p t em to see it .


• Descri e t e components o a PDSA cyc e. Use an

project) Attachment 5 to help you. Stress the impor-

tance of thoughtful planning before each test and careful

assessment of the result. Random doesn’t work.

• Review what is meant by “plan,” “do,” “study,” and “act.”

Use (and project) Attachment 4 to help you. Reinforce

that the purpose of the game is to teach how to run a

PDSA cycle.

• A t at mu tip e PDSA cyc es resu t in etter un er-

stan ing an etter resu ts. In icate t at t e game wi

i ustrate t is point as we .

The Game Itself

is escription is a apte rom t e manua or t e

nstitute or Hea t care Improvement’s Brea t roug

eries Co ege.

1. Give eac person a game oar Attac ment 1 an

mar ers. Eac person comp etes t e game.

a. Eac participant covers eac num er on t e game

oard with a marker, leaving one number blank. e

participant can then remove markers from the game

oard by “jumping” one marker over another and

hen into the blank spot: the marker that is jumped

ver then can be removed (people who have played

heckers will understand this immediately). e goals to set up your movements so that you end with only

ne mar er remaining on t e oar . Eac participant

ontinues or as ong as e or s e can, an notes ow

any mar ers remain on t e oar .

2. a y every o y’s resu ts. I ent i y t e est per ormers

an ave t em ecome ea ers o teams o 3-4 peop e

epen ing on t e size o your group .

3. e ea er teac es is or er team t e “ est” approac

and then team repeats as a group.

4. Tally results. Reconvene as the large group and discuss

what we have learned. In most cases, this “shared learn-

ing” will not result in better performance. Discuss why.

Ask: how many cycles have we run? (e answer is none.

Up to this point, the team hasn’t carried out any of the

parts of a PDSA cycle.) Also, no record has been kept of

t e way t e resu t was ac ieve . As teams t en to try

severa PDSA cyc es an see ow t ese go.

5. Eac team t en comp etes a u PDSA cyc e. Distri -

ute Attac ment 2 an ma e sure eac team recor s its

t eories, p ans an resu ts.

a e P an s ou inc u e t e t eory an pre iction,

e approac an a p an or recor ing w at was one

(you may provide a hint to the groups that they should

ecord each move in order, recording the space moved

rom and to, e.g., 6-1, 4-3).




6

I Some t eories: eep pegs unc e up, eep pegs

away rom corners, eave one si e empty, eep mi e

empty unti t e en .

II Some p ans: wor ac war s, wor in epen ent y.

Do invo ves comp eting t e game one time, o owing

t e p an. Eac team s ou recor its resu ts an any

problems or other observations.

c) In the Study phase each team should review what hap-

pened, adjust theories, adjust plans for the next cycle.

d) Act means to carry out the next cycle.

6. Each team completes a second cycle (you can suggest

that a good strategy might be for each member of theteam to run an independent test of the “same theory”

an t en see w o gets a goo resu t .

7. Comp ete a itiona cyc es as time permits.

8. Recor eac team’s est resu t on t e ip c art or over-

ea : “Summary o Peg Game” Attac ment 3


econvene as a arge group. Review resu ts.

• As t e team wit t e est resu ts to escri e t eir

t eory an p an to t e ot ers.

• I necessary, wa t roug t e answer ey Attac ment 6 .

• As participants ow t e PDSA approac i ere rom

t eir initia approac to t e pro em. Discuss ow

whether using PDSA was an improvement.

• Ask participants about improvements they have tried to

make in their HIV programs:

- Did they use a PDSA approach? Did they begin

y testing their change on a small scale – with one

provider’s patients, for example – and for a short(one or two sessions) period of time?

- I so, i it wor ? How mig t t ey ave one

PDSA even etter?

- I not, o t ey t in using PDSA cyc es wou ave

a e t is e ort more success u ? W y or w y not?

• As participants w ere mig t t ey use PDSA in t eir

current wor .

Feedback and Close








ar wor an success.








9

ttachment 3

Team Results Summary

NUMBER OF CYCLESEAM

1

3

5

BEST RESULT

8




0

ttachment 4

PDSA for the Peg Game

STEP 4: ACTDoes our approach leave 1 peg?

What new idea s should we test on the

next cycle?

STEP 1: PLANbjective: Test another

pproach to removing pegs.

Pre ictions: Wi we eave ewer pegs?

Plan: Who, What, Record moves.

:ompare data to predictions.

ummarize what was learned.

Update the team’s theory (approach).

:arry out the plan.

Record Moves.

Notes problems or changes to plan.

ACT PLAN

TUDY DO




81

ttachment 5

To Be Considered a PDSA Cycle

TO BE CONSIDERED A PDSA CYCLE:

e test or o servation was p anne inc u ing a p an or co ecting ata .

e plan was attempted.

Time was set aside to analyze the data and study the results.

Action was rationally based on what was learned.




2

1. Leave # 6 an .

2. Comp ete t e sequence o jumps in t is or er:

1 » 6

10 » 3

13 » 6

3 » 10

2 » 9

15 » 6

11 » 13

14 » 12

» 13

12 » 5

7 » 2

2 » 9

13 » 6

ttachment 6

Peg Game Answer Key




3

SESSION AT-A-GLANCE

ntroduction

e Game



acilitator

WHO? HOW LONG?

10 minutes

0 m nutes

15 minutes

Tennis Ball GameWhy Use This Game

• To teach how to approach improving a process.

• To teach how to build on knowledge gained from

one test in designing a second test.

• To teach how multiple testing cycles lead tomprovement.

• o teac t e concept o “ rea t roug ” improvement.

Target Audience


running PDSA cyc es.

Type of Game


Key Concepts

• Processes can be improved by changes in the steps

t at constitute t em.

• e resu ts o one test o a c ange can e p a team

i enti y a itiona c anges to ma e.

• More tests ea to more now e ge a out a process,

an to etter improvements.

• Setting “stretc goa s” can pus teams to ma e

su stantia improvements.


is game is used at the Institute for Healthcare Improve-

ment’s Breakthrough Series College and has been used by a

number of improvement collaboratives. Additional informa-tion about this game comes from Qualis Health, the QIO

or Was ington State, an its Per ormance Improvement

upport Center.

Materials


• A tennis a or ean ag or eac team

• A way of timing how long it takes each team to complete

its process: a stopwatch or a clock with a second hand

• A flip chart and markers to record the results of

the discussion

Preparation



an content:








4


Participants wi wor in teams o 6-7 peop e. Set

up t e room wit enoug ta es an c a irs to accom-

o ate groups o t at size. A ternative y, set c airs

p au itorium sty e an p an to ave t e teams wor

tan ing up t ey wi ave to move t e c airs out

of the way for this, as they will need to work standing

n circles).

Set up the flip chart in the front of the room.

Playing the Tennis Ball Game




ntro uce t emse ves to t e group.

Learning O jectives


• Know how to design changes to a process.

• Know how to test these changes and build on them to

esign subsequent changes.

• Appreciate how having a clear, ambitious goal can

energize a team to make improvements.

genda


omponents:

1. Bac groun to t e ennis Ba Game.

. e game itse .



. Fee ac an c ose.



is game is a simp er intro uction to t e concept o PDSA

t an t e Peg Game. It may wor etter wit improvement

teams or as a “just in time” teac ing tec nique. As t is

game is very p ysica , it is a so use u rig t a ter unc or

ot er times w en participants’ energy is agging.

is game illustrates the “accelerating improvement” com-

ponent of PDSA, as shown in the diagram in Attachment I.

e idea is that hunches and ideas, when tested, lead to

new knowledge that leads to improved processes. Each

testing cycle adds more knowledge, and many cycles leadto real improvements.

I your au ience is not ami iar wit t e i ea o improving

qua ity y improving processes, t is game can e p intro-

uce t at concept. Wa t roug t e steps o a stan ar

patient c ient visit. Discuss w at can comp icate eac step

an ow eac comp ication can a ect t e qua ity o care or

service you provi e.

Step 9 in the game instructions is optional. Using it will

allow you to introduce the concepts of benchmarking and

breakthrough improvement. Pointing out the excellent

results achieved by others is an example of benchmarking

– comparing your performance to the “best in class.” If

they can achieve these results, why can’t we? By presenting

t e “stretc goa ” o t e imaginary etter per ormance,

you may energize participants to e more aggressive in

improving t eir own per ormance. In turn, t ey may

ac ieve start ing resu ts!




85


• Descri e t e components o a PDSA cyc e. e at-

tac ments to t e Peg Game, a so in t is gui e, can e

adapted to help in explaining PDSA.

• Stress the idea that many PDSA cycles will accelerate the

rate of improvement. Use the diagram in Attachment

1 to illustrate this concept. One key point to stress is

that each PDSA cycle creates new knowledge about the

process, so focusing on running many cycles – carefully,

but expediently – will increase what you are able to learn

a out your process an t e improvements you p an.

The Game Itself

1. I t ey aven’t a rea y, as participants to orm groups o

6-7 peop e. One person ecomes t e qua ity o cer, t e

ot ers wi represent steps in t e patient visit process.

2. e peop e representing t e steps in t e patient visit

process stan in a circ e or sit aroun a circu ar ta e.

e qua ity o cer stan s outsi e t e circ e ut is a e

to see the process.

3. Begin the design of the patient visit process. One person

in the process passes the tennis ball to the person across

from him/her in the circle (remembering to whom you

threw it). en the receiver passes it to another person,

remembering who each time. e last person passes it tothe person that started.

4. Instruct t e qua ity o cer to ma e sure:

- no one rops t e a .

- t e sequence o steps i.e., peop e is t e same on

eac patient visit.

- t e a starts an en s wit t e same person.

5. e qua ity o cer recor s t e time rom t e start to t e

en o t e process.

. Practice once to establish the order of the steps.

7. Carry out the process once. e team must start over

if execution is done incorrectly or someone “drops the

ball”. e quality offi cer times the process and records

the time.




6

8. Comp ete a PDSA cyc e to test some i eas to improve t e

visit time o t e process.

• P an: Deci e w at c ange to ma e. W y o you

pre ict t is c ange wi resu t in a s orter visit time?

W o wi ma e t e c ange, w en an ow?

• Do: Execute t e P an – run t e process one time wit

the changes in place. Check for compliance with

quality criteria (see #4, above). Record visit time data.

• Study: Document what you learned from this test. Be

prepared to share your data with other teams.

• Act: Make a decision about the changes. What ideas

do you have for the next PDSA cycle?9. e facilitator can at this point ask each team for its fast-

est time. Sig eep y, an say t at you ear t at teams

in a neig oring c inic, city or state can an e a patient

visit muc more quic y. Urge your teams to pus to

matc t eir competitors.

10. Run at east one more PDSA cyc e. I you ave time,

run severa .



• As participants w at t ey experience . Di t eir

times get etter? How a out rom t e secon to t ir

cyc es ? Di t e secon roun o improvements ui

on t e rst?

• I you use t e optiona Step 9, exp ain w y you i so.

Explain benchmarking and breakthrough improvement.

Ask about the impact your comment had on their team’s

work and its result.

• e NQC website at NationalQualityCenter.org has

nformation about improvements other programs

have made in their HIV care, if you want to try someenchmarking yourself.

• As participants a out improvements t ey ave trie to

ma e in t eir HIV programs:

- Di t ey use a PDSA approac ?

- I so, i it wor ? How mig t t ey ave use

PDSA even etter?

- I not, o t ey t in using PDSA cyc es wou ave

a e t is e ort more success u ? W y or w y not?

• Ask participants where might they use PDSA in their

current work.

Feedback and Close


met its objectives. Take notes of their responses on a flip



au ience mem er w o wants c ari cation or more

in ormation on t e game or t e concepts you iscusse .


ar wor an success.






8

The Zin Obelisk Game

SESSION AT-A-GLANCE

Introduction

e Game



Facilitator

WHO? OW LONG?

10 minutes

25 minutes

25 minutes

Why Use This Game

• To teach how to work as a team to develop hypotheses,

test solutions and solve problems.

• To show how to develop better knowledge as you go

through multiple cycles of hypothesis developmentand testing.

• o e p teams un erstan ea ers ip, cooperation an

con ict issues in team pro em so ving.

Target Audience


running PDSA cyc es, as we as organization ea ers w o

will be overseeing and coaching the work of these teams.

Type of Game


Key Concepts

• eams nee to e a e to s are in ormation an isten

to eac ot er to wor we .

• In trying to so ve a comp ex pro em, some structure is

e p u . e approac o eve oping an testing

a ypot esis t e scienti c met o can provi e

t is structure.

• Each team will have its own strengths, weaknesses and

conflicts. As teams work together more, they will learn

how to manage these issues better.


is game has been used by the New York State Department

of Health, AIDS Institute. It comes from: Francis, D., &

Young, D. “Improving Work Groups: A Practical Manual for Team Building .” San Diego, CA: University Associates,

1979, p. 147–151.

Materials


• A copy o t e Zin O e is Group Instruction S eet

Attac ment 1 or eac participant

• Blank paper and a pencil for each participant

• A set of Zin Obelisk Information Cards for each

group (thirty three cards per set – see Attachment 2

for the text of the cards)

• Flip chart and markers

• A copy of the Zin Obelisk Review Sheet (Attachment 3)

for the facilitator




9

Preparation



an content:






- Set up circles of chairs for each team that will partici-

pate (the game works best with 5-8 participants).


the discussion after the game.

Playing the Zin Obelisk Game





Learning Objectives


• Understand the strengths and weaknesses of their team

as it works to solve a diffi cult problem.

• See how to apply the scientific method – developing and

testing a hypothesis – to their problem-solving approach.

• Begin to develop strategies for better listening and

cooperation wit in t eir team.

• See ow to app y t ese concepts to t eir HIV program.

Agen a


components:

1. Bac groun to t e Zin O e is Game.

2. e game itself.






e Zin O e is i s a i cu t an in some ways a sur

puzz e. It uses ma e-up situations an ma e-up wor s,

putting everyone on t e team in t e same position o eing

n ami iar wit t e situat ion.

e game is structured so no one person has all the informa-

tion necessary to solve the puzzle. e members of the team

must listen to, and respect, each other – and since the puzzle

is diffi cult and the time to complete it is short, team

members tempers may fray.

Teams should realize that random stabs at an answer will

not e p t em; t ey nee a systematic approac . W i e or-

ma PDSA cyc es see e Peg Game or a u escription

on’t ma e sense, t e scienti c met o t at un er ies t e

DSA concept may in act e p teams sort t roug t e Zin

e is . Just as you earne in ig sc oo io ogy, t e sci-

ent i c met o invo ves eve oping a ypot esis a out w at

may appen, con ucting an experiment an seeing i t e

esult confirms your hypothesis. Most health care workers

are familiar with this concept and will be open to applying it

to problem-solving.


• Reassure them that this is a diffi cult exercise taking place

under time pressure.

• Suggest to t e participants t at t ey e systematic in

t eir approac , an stress t at i stening an co a ora-

tion are eys to success at so ving t e puzz e.

• Remin part icipants a out t e scient i c met o an

suggest t at t ey eep t is approac in min as t ey

wor t roug t e puzz e.






91

n t e ancient city o At antis, a so i , rectangu ar o e is , ca e a zin, was ui t in onor o t e go ess ina. e structure too

ess t an two wee s to comp ete.

e tas o your team is to etermine on w ic ay o t e wee t e o e is was comp ete . You ave twenty- ve minutes or t is

as . Do not c oose a orma ea er.

You will be given cards containing information related to the task. You may share this information orally, but you may not show

your cards to other participants.

ttachment 1

Game Instruction Sheet




2

Ma e a set o t irty-t ree car s y typing eac o t e o owing sentences on a 3”x5” in ex car :

1. e asic measurement o time in At antis is a ay.

2. An At antian ay is ivi e into sc i s an pon s.

3. e length of the zin is 50 feet.

4. e height of the zin is 100 feet.

5. e width of the zin is 10 feet

. e zin is built of stone blocks.

7. Each block is 1 cubic foot.

8. Day 1 in the Atlantian week is called Aguaday.. Day 2 in the Atlantian week is called Neptiminus.

10. Day 3 in t e At antian wee is ca e S ar ay.

11. Day 4 in t e At antian wee is ca e Merma i ay.

12. Day 5 in t e At antian wee i s ca e Day o rum.

13. ere are ve ays in an At antian wee .

14. e wor ing ay as 9 sc i s.

15. Eac wor er ta es rest perio s uring t e wor ing ay tota ing 16 pon s.

16. ere are 8 pon s in a sc i .

17. Workers each lay 150 blocks per schlib.

18. At any time when work is taking place there is a gang of 9 people on site.

19. One member of each gang has religious duties and does not lay blocks.

20. No works takes place on Daydoldrum.

21. What is a cubitt?

22. A cubitt is a cube, all sides of which measure 1 megalithic yard.

23. ere are 3 1⁄2 feet in a megalithic yard.

24. Does wor ta e p ace on Sun ay?

25. W at is a zin?

26. W ic way up oes t e zin stan ?

27. e zin is ma e up o green oc s.

28. Green as specia re igious signi cance on Mermai ay.

29. Eac gang inc u es two women.

30. Wor starts at ay rea on Aqua ay.

31. Only one gang is working on the construction of the zin.

32. ere are eight gold scales in a gold fin.

33. Each block costs 2 gold fins.

ttachment 2

Text for the Zin Obelisk Information Cards




3

e answer is Neptiminus.

Rationa e:

1. e imensions o t e zin in icate t at it contains 50,000 cu ic eet o stone oc s.

2. e oc s are 1 cu ic oot eac , t ere ore, 50,000 oc s are require .

3. Each worker works 7 schlibs in a day (2 schlibs are devoted to rest).

4. Each worker lays 150 blocks per schlib, therefore each worker lays 1050 blocks per day.

5. ere are 8 workers per day, therefore 8,400 blocks are laid per working day.

6. e 50,000th block, therefore, is laid on the sixth working day.

7. Since work does not take place on Daydoldrum, the sixth working day is Neptiminus.

Attachment 3

Answer and Rationale




4

SESSION AT-A-GLANCE

ntroduction

e Game



acilitator

WHO? HOW LONG?

10 minutes

45 minutes

15 minutes

Paper A rplane Game

Why Use This Game

• o s ow ow incrementa c ange can, w en rep icate

an expan e over time, ea to improvement.

• o teac t e importance o p anning cyc es o c ange

an ui ing on t e now e ge earne in t e

previous cyc es.

• o s ow ow to eve op etter now e ge as you go

through these multiple cycles.

Target Audience

Team members and others who will be developing and

running PDSA cycles. Also, leaders who will be

overseeing these teams, to help them understand the

concept o sma -cyc e tests o c ange.

Type of Game


Key Concepts

• Goo c anges s tart sma .

• Base your next c ange on w at you earne rom its

pre ecessor; in t is way, your now e ge – an t e

impact o your c ange – wi grow over time.

• Improvement comes rom repeating t ese cyc es over time.

Source, History and Resources for More

Informationnformation about this game comes from Qualis Health, the

IO for Washington State, and its Performance Improve-

ment Support Center.

Materials


• Four ta es, one a e e “p an,” one “ o,” one “stu y,”

an one “act”

• Space or peop e to try to y t eir airp anes

• Materia s to ma e paper airp anes: stac s o

construction paper, paper clips, tape, scissors, glue

• A yardstick or long tape measure for each team

• A small prize for the winning team




95

Preparation



an content:

- Rea t roug t e game instruct ions an ey

teac ing points in t eir entirety.

- Practice t e game itse inc u ing i erent

airplane-making strategies).



- Move chairs out of the way. People will be standing

and gathering around tables. Need to have space to

fly the airplanes and see how far they can fly.- Prepare a flip chart so you can record results of the

iscussion, i appropriate.

Playing the Paper Airplane Game




introduce themselves to the group.

Learning Objectives


• Know how begin an improvement effort with a small

test of change.

• Understand how to learn from this first test and use

t at now e ge to esign new tests t at ecome more

e ective over time.

• Appreciate t e roe o team wor in t is e ort.

• Begin to see ow to app y t ese concepts to

t eir HIV program.

Agen a


omponents:

1. Bac groun to t e Paper Airp ane Game.

2. e game itse .






As teams wor to ma e improvements in t eir HIV

programs, t ey nee to ecome com orta e wit t e i ea o

starting out wit a sma -sca e, pi ot test o c ange t at t ey

wi ui on, an en arge, over time.

eams o ten n it ar to start out wit somet ing sma ;

t ey want to jump in an ma e a c ange t ey t in wi

have more impact, right away. e purpose of this game is

to help teams see that the incremental approach of increas-

ingly complex PDSA cycles will, in fact, lead to a better

product at the end.

You will need severa l coaches to help you with this game,

to make sure that each team thoughtfully carries out each

part o t e PDSA cyc e. at is w y you ave our stations

aroun t e room – one at w ic teams “p an” t eir airp ane,

one at w ic t ey “ o” t e test ig t ma e sure you ave

p enty o airspace at t is station , one at w ic t ey “stu y”

t e resu t o t e ig t, an one at w ic t ey “act” to eter-

mine t e c anges t ey wi ma e to airp ane esign in t e

next roun . e coac es are t ere to ensure t at eac team

goes through all four steps.

Make sure you have time to run through several improve-

ment cycles: a minimum of three, or more if possible.






97

SESSION AT-A-GLANCE

ntro uction

e Game

De rie an Discussion aci itator, au ience


aci itator

WHO? HOW LONG?

10 m nutes

15 minutes

10 m nutes

Selling Spread GameWhy Use This Game

• To help people understand the way innovation works,

and that not everyone will adopt a change easily at the

same t me.

• To communicate the factors that may affect how quicklypeople will adopt a change.

Target Audience

Senior sta an QI team mem ers w o are rea y to ta e

c anges t ey ave eve ope to t e rest o t e organization,

to try to imp ement t em eyon t e pi ot site s . You

may a so invo ve t e peop e to w om t e c anges are eing

“spread.” e game works best with groups of 30-40 people.

Type of Game


Key Concepts

• Peop e accept c ange at i erent rates.

• Peop e’s wi ingness to a opt a c ange wi vary

epen ing on t e :

- Re at ive a vantage o t e propose c ange.

- C ange’s compati i ity wit t e current system.

- Simp icity o t e c ange an transition p an.

- “Testability” of the change.

- Ability to observe the change and its impact.


arah Fraser, a scholar on spreading good practices in

health care, uses this demonstration in her teaching. She

led the demonstration at a learning session sponsored bythe Institute for Healthcare Improvement, which made this

escription avai a e to us.

Materials


o t e iscussion

Preparation



and content:






- Participants wi nee room to move aroun , so

ma e sure c airs can easi y e move to t e si es o

e room.




8

Playing the Selling Spread Game





Learning O jectives


• Understand some of the challenges in implementing

a change.

• Have a sense of how to present a change so more people

may be willing to try it out.

Agenda

Provi e a rie escription o t e session’s primary c

omponents:

1. Bac groun to Se ing Sprea Game.

2. e game itse .



4. Fee ac an c ose.

Background to the GameFacilitator’s note

is game is a demonstration to illustrate the research of

Everett M. Rogers about how innovation gets transmitted

through a population. In very simple terms, Rogers says

t at peop e a apt to somet ing new at i erent rates. Some

peop e are true innovators – t ose w o are most venture-

some a out ta ing on a c ange. ey are o owe y ear y

a opters, t e ear y majority, t e ate majority an ast y t e

aggar s. e istri ution o t ese groups in a popu ation

roug y mimics t e e curve, wit most a ing into t e

ear y majority or ate majority categories.

As t e game is esigne to s ow, many actors a out a

ange a ect w ic category a person wi a into or

any given c ange. Rogers as i enti e ve attri utes o

a c ange t at may a ect ow a person ee s a out c ange.

Exp ain t ese rie y to your au ience, primari y to e p

your “se ers” esign e ective pitc es or t eir i eas. Rogers

introduces each attribute as follows:

1. Relative advantage of the proposed change: “the degree

to which an innovation is perceived as being better than

the idea it supersedes .”

2. Compatibility with the current system: “the degreeto which an innovation is perceived as consistent with

existing va ues, past experiences, an nee s o

potentia a opters.”

3. Simp icity o t e c ange an transition: “t e egree to

w ic an innovation is perceive as re ative y i cu t

[or simp e] to un erstan an use.”

4. ria a i ity esta i ity: “t e egree to w ic an innova-

tion may e experimente wit on a imite asis.”

5. Observability [ability to observe the change and its

impact]: “the degree to which the results of an innova-

tion are visible to others.”

esearch also shows that those in the “early adopter”

ategory are most able and helpful to influence the majority

to warm up to a change. As you do your improvement work,

t in a out w o mig t e an ear y a opter on w om you

an re y or e p.


• Peop e em race c ange at i erent rates.

• How t ey ee a out c ange may vary epen ing on t e

speci c innovation eing propose .

• Careful explanations around key attributes can help

people be more open to change.




9

The Game Itself

1. In a group o 30-40 peop e, as or two vo unteers to

come up wit an “se ” a goo i ea to t e au ience.

It s ou e an i ea t ey t in is goo , ut mig t

e a itt e toug to se to t is group. e i eas can

e on any su ject: some t at re ate to an HIV

program inc u e:

- Providing beepers or cell phones to all patients to

remind them of their appointments.

- Instal ling computers in waiting rooms so patients

can update their own medical records.

- Allowing patients access to their provider

“24/7” via email.- Allowing patients access to the program’s scheduling

system so t ey can sc e u e t eir own visits.

2. Instruct t e two peop e giving t e “pitc ” to use Rogers’

attri utes o t e c ange t at a ect t e rate o a option,

t at is, t e:

- Re at ive a vantage o t e propose c ange.

- Compati i ity wit current system structure, va ues,

practices .

- Simplicity of the change and transition.

- Testability of the change.

- Ability to observe the change and its impact.

3. One of these two goes first and pitches their idea in front

of the crowd in one minute.

4. e remaining people listening are asked to group in the

front of the room, and to sort themselves out according

to t eir own eve o ent usiasm an i e y “a option” o

t e propose i ea. ey sort t emse ves rom e t inno-

vators ear y a opters to rig t ate a opters istorians

a ong t e ront o t e room. Expect a roug y

e s ape curve .

5. Have peop e at eac en o t e istri ut ion exp ain w y

t ey i or i not “ uy” t e c ange. Peop e w o ar-

ranged themselves in the middle of the distribution can

be asked what it would take for them to adopt the idea.

. e secon “se er” t en gets up an pitc es is or er

i ea or one minute, an t e group up ront is as e

to sort itse again y a option o t e new i ea. Expect

positions to c ange.


econvene as a large group. Review results.

• Ask participants what they think happened. Key points

to elicit from the discussion include:

- Different changes are easier or harder to sell than

others, so we need to tailor our communication abouthe change accordingly.

- Not everyone wi a opt a c ange quic y e an

“ear y a opter.” Expect more o a e -s ape curve.

- Some peop e are more i e y to accept one type o

ange versus anot er. Some are innovators or ag-

ar s epen ing on t e i erent type o i eas or

anges propose . It’s important not to stereotype

peop e as a ways eing innovative or not.

• Ask participants how they might apply what they learned

from this game to their HIV programs.

- What does this way of thinking about change tell us

bout how to make change happen in our program?

- How can we better address Rogers’ attributes of

hange in what we do?

Feedback and Close


met its o jectives. a e notes o t eir responses on a ip










100

Model Kichen Utensil Game

SESSION AT-A-GLANCE

Introduction

e Game



Facilitator

WHO? HOW LONG?

5 minutes

30 m nutes

15 minutes

Why Use This Game

• To teach about people’s reactions to dealing with change.

• To helps groups develop strategies for making change

more palatable.

Target Audience

QI team mem ers w o wi e invo ve in testing c anges

wit t eir co eagues. You may a so inc u e t e peop e w o

wi e testing t e c anges, as a are i e y to ene t rom a

iscussion o w at it’s i e to ea wit c ange.

Type of Game


Key Concepts

• People don’t like to deal with change.

• Some strategies will make it more likely that the change

you propose wi e accepte .


is game is very oose y ase on “Paper Anima s ” rom

C en & Rot ’s “ e Big Boo o Six Sigma Training Games ,”

(McGraw-Hill, 2005, pp. 208-213. Another source for

information about change is John Kotter’s Leading Change,

(Harvard Business School Press, 1996).

Materials

• For each team:

- A large quantity of scrap paper: construct ion paper,

ewspaper, recycling paper. Use the same type of

paper for each team- A roll of tape

- A pair o scissors

- Coore pens

- Ot er supp ies t at mig t ma e t ings interesting:

o ore tape, g ue, string


o t e iscussion

• I you want, a prize or prizes or t e winning team s

PreparationTo prepare for this session:


and content:






- Set up ta es an c airs at w ic eac team wi wor

n istri ute t e supp ies to eac ta e.

- Set up t e ip c art at t e ront o t e room.




101

Playing the Model Kitchen UtensilsGame





Learning Objectives


• Understand how people may react to dealing

with change.

• Develop ideas about how to present changes so

people feel more willing to try them.

Agen a


components:

1. Bac groun to t e Mo e Kitc en Utensi Game.

2. e game itse .






e purpose o t is game is to expose t e participants to a

situation w ere t ey wi ave to ea wit an unexpecte

ange in “t e ru es o t e game.” W en t ey ave ni s e

t e game, you can t en ea a iscussion a out ow it was

to cope wit t is unexpecte c ange, an raw essons out

that the participants might apply as they begin to test the

hanges for improvement they have developed.

A commonly used saying about change is that “people don’t

object to change, they object to being changed.” is game

seeks to show how to keep your change effort from being one where people feel they are “being changed.” Some effective

strategies inc u e:

• c ear, consistent exp anations o w at t e c ange invo ves.

• c ear statement o t e purpose o t e c ange.

• use o t e PDSA cyc e: start sma !

• e ping peop e see ow an ear ier tria o t e c ange as

wor e – on’t just te t em a out it.

• airness in app ication o t e new ru es.

• an opportunity to participate in designing the change

(PDSA helps here, too).

• communicating that you understand that making

change is hard.

is game should be adaptable to many different scenarios.

You could have the teams construct paper hats, for example.

en & Rot suggest aving t e teams ma e paper anima s.

Bui ing anyt ing t at is somew at e a orate an t at e n s

itse to c anging criter ia in t e mi e o t e game can

serve as t e purpose o t e team exercise.


• Peop e em race c ange at i erent rates.

• How they feel about change may vary depending on the

specific innovation being proposed.

• Careful explanations around key attributes can help

people become more open to change.




102

The Game Itself

1. e participants s ou wor in groups o 6-8 peop e.

2. Exp ain t e ta s :

a. e teams s ou use t e materia s provi e to ui

a rep ica o any common itc en utensi .

. ey may use on y t e materia s provi e .

c. ere wi e a prize at t e en or t e team

with the utensil that:

I. looks the most like the utensil it is supposed to

be, in, for example, size, shape and color.

II. is the most elaborately shaped (round cutting

boards, for example, would not score high on

this criterion).d. Tell the teams they have 25 minutes to complete

t e tas .

e. e t e teams t ere wi e a vote among participants

at t e en to etermine t e winner.

3. e teams egin wor .

4. A ter 10 minutes, get t e participants’ attention. e

t em you “ orgot” a t ir criterion. e utensi s wi

a so e ju ge on ow unctiona t ey are, t at is,

whether they can in fact be used for the purpose they

are intended (will a bowl really hold liquids? Will the

spatula really flip a pancake?)

5. After 25 minutes, stop the teams. Have each team

present its utensil. Vote for the winner by show of hands

and present the prize to the winner.



• As or a report rom eac group in turn:

- How i t ey wor toget er as a group? Were

ecisions ma e we ? Were t ey a e to e creative?

- Were t ey p ease wit t eir pro uct? W y or w y not?

• en egin a genera iscussion o peop e’s reaction to

the change in instructions:

- What did they think?

- How did their team react?

- Did the new instruction make their final product

better or worse?

- What would they have done differently if they’d knowhat criterion from the beginning?

- I c anges ave to e ma e, ow can t ey e one

in a way t at’s easier to an e? see t e Faci itator’s

Note, a ove .

• As part icipants ow t ey mig t app y w at t ey earne

rom t is game to t eir HIV programs.

- How ave c anges een ma e in t e past? W at as

wor e , an w at asn’t?

- What should we do as we begin to test our changes?

How can we help our colleagues deal with the

changes we will make?

- Develop, if appropriate, a simple work plan to make

ure the suggestions get implemented.




103

Feedback and Close





au ience mem er w o wants c ari cation or more in or-

mation on t e game or t e concepts you iscusse .








105

Many Questions GameWhy Use This Game

• To teach the idea of team synergy, that each member of

a team brings valuable skills and experience to a task and

that together, a team can produce a better result than

any one individual.

Target Audience

Senior sta an team mem ers, especia y newcomers to QI

wor an teams t at are just orming.

Type of Game


Key Concepts

• Joint problem-solving and idea-generating methods

are valuable.

Source, History and Resources for Moren orma on

is game comes from “ 01 More Training Games ”, by Gary

Kroehnert, McGraw-Hill Book Company Australia, Sydney,

opyright 1999 (pp. 44-45). Mr. Kroehnert includes per-mission to reproduce his games for educational purposes or

tra n ng act v t es.

Many ot ers ave eve ope games simi ar to t is one. e

most amous may e t e we - nown Lost at Sea simu ation,

w ic can e purc ase rom t e pu is er Jossey-Bass or

arge on- ine oo se ers. Josep G. Van Matre an Donna

. S ovens y pu is e a version o t e Many Quest ions

game that uses a wide variety of music selections rather

than trivia questions (Quality Management Journal vol. 7,

no. 2, 2000).

Materials


• A ist o varie trivia questions see Attac ment 1, or

any ist o trivia questions on a wi e variety o topics

wi wor : ma e enoug copies o t is ist or

eac participant

• Pens or eac participant

• F ip c art an mar ers to emonstrate t e game an

to recor t e ey points o t e iscussion

SESSION AT-A-GLANCE

ntro uction

e Game

De rie an Discussion Faci itator, au ience


aci itator

WHO? OW LONG?

2 m nutes

15 minutes

m nutes




106

Preparation



an content.

- Rea t roug t e game instruct ions an ey

teac ing points in t eir entirety.



• Prepare the room

- Arrange chairs around a table or tables, set up to make


- Distribute paper and pens for each participant.

- Set up the flip chart so you can give the instructionsand capture key points of the discussion after

t e game.

Playing the Many Questions Game





Learning O jectives


• Understand the value of working in teams to solve

problems and develop solutions.

Agenda

rovide a brief description of the session’s primaryomponents:

1. Bac groun to t e Many Questions Game.

2. e game itse .

3. De rie an iscussion on w at t e game s ows,

an ow its essons can e app ie to HIV care.

4. Fee ac an c ose.






108

1. W at rig t oes t e 2n Amen ment to t e U. S. Constitution give?

2. W ic co or jersey is tra itiona y worn y t e overa ea er in a mu tistage icyc e roa race?

3. W ic major eague a p ayer current y o s t e recor or t e most consecutive games in w ic e a a it?

4. Who painted e Night Watch?

5. Who won the first round of Survivor?

. Who was prime minister of the U.K. in 1981?

7. How do you say the number “one” in Japanese?

8. W ic Gree p i osop er ive rom 470 – 399 B. C.?

. In w at city an state i Britney Spears rst we ing ta e p ace?

a. extra cre it: ow ong i t is marriage ast?

10. W at is nep roepsis?

ttachment 1

Question Sheet




109

1. e rig t to ear arms

2. Ye ow

3. oe agg o

4. Rembrandt

5. Richard Hatch

6. Margaret atcher

7. Ichi

8. Socrates

9. Las Vegas

. ess t an 55 ours

10. A ern

Attachment 2

Answer Sheet




110

SESSION AT-A-GLANCE

Intro uction

e Game



aci itator

WHO? HOW LONG?

10 m nutes

30 m nutes

15 minutes

Scavenger Hunt GameWhy Use This Game

• To introduce future teammates to each other.

• To help people understand their own team

working styles .

• To show how teams function most effectively.

Target Audience

Peop e w o are a out to join a project wor ing team.

Type of Game


Key Concepts• Having a clearly understood goal is critical to

team performance.

• Teams work best when tasks are divided

among members.

• Creativity can e p so ve pro ems.


is game comes rom “ ames Trainers P ay , y E war E.

Scanne an Jo n W. Newstrom “New Yor : McGraw-

Hill, 1980, p. 51). Sources for additional information about

teams include Joiner & Associates e Team Handbook and

Meredith R. Belbin’s Management Teams, Why they

Succeed or Fail.

Materials


• Scavenger hunt instructions and the list of items

for each team to hunt for (see Attachment 1

for an example)• A small prize for the winning team

Preparation



an content:

- ea t roug t e game instructions an ey teac ing


- ractice the game itself.

- ractice presenting the key teaching points.

• Prepare the room.

- hairs can be set up auditorium style or in a semi-

ircle, depending on how many people you have and

he size of your room.

- et up a sma es or po ium in t e ron o t e room.

- et up t e ip c art so you can capture ey points o

e iscussion a ter t e game.

• Ma e enoug copies o t e instruction s eet so eac

participant can ave one.




111

Playing the Scavenger Hunt Game





Learning O jectives

Tell participants that by the end of the session

they will:

• Know their future teammates better.

• Understand the importance to teams of having

a clear goal.

• Understand how teams work most effectively.

Agen a


components:

1. Bac groun to t e Scavenger Hunt.

2. e game itse .






eams t at wor we are i e sports teams. e est ones

ave mem ers wit i erent s i s an strengt s, an

oor inate t ese s i s an strengt s in pursuit o a common

goa . Groups o peop e just orming as teams wi ave

i cu ty coor inating t eir e orts. ey wi not yet now

the skills of their colleagues and may not trust that they can

ontribute to the task. is game gives a new team experi-

ence at working on a task, and through this experience will

help give the team confidence in their ability to succeed

at the upcoming quality improvement work in your

HIV program.

Your jo as aci itator is to o serve ow t e teams go a out

t e scavenger unt. Does everyone on t e team searc

or every item toget er? Does one person go o on is or

er own to try to a t e wor wit out consu ting ot ers?

ances are, t e most success u team wi e t e one t at

ivi es up t e ta s s, an you s ou e prepare to point

t is out an ea a iscussion a out e ective teamwor .

n creating the list of items each team has to find, aim for

some that will be easy and some that will be hard. Try to

include items that will involve collaboration to locate. En-

ourage teams to be creative (that’s where the fun comes in)

but clarify that you will be the judge of whether a “creative”

item meets the requirements of the hunt (hint: use this op-

t ion to rewar examp es o goo co a orat ion an team-

wor . e teams are i e y to get very competitive!






113

Instructions:

Wor as a team to n as many o t e items on t is ist as you can. A prize wi e given to t e team s t at can n t e most

tems.

ime Limit:

30 Minutes. You wi e given t e exact time you must return to t e main meeting room.

Ground Rules:

• You may not leave the building with the sole exception of going to the parking lot to get one or more items out of a team

ember’s car.

• You may not negatively influence or affect the work of any other team.

• Creativity and teamwork are encouraged.

e List:

• A “state” quarter rom one o t e origina 13 states.

• A copy o t e “Home” section rom to ay’s New Yor imes.

• A ox o ic- acs at east partia y u .

• A ro o toi et paper.

• A ec o car s.

• A p otograp o a pet.

• A tube of Colgate Total toothpaste.

• A copy of a medical or hospital-related professional journal (e.g., New England Journal of Medicine, Modern Healthcare, Joint

ommission Perspectives, nursing or social work journals).

• A pair of white socks.

• A set of jumper cables.

• Any memorabilia (hat, t-shirt, key chain, socks, etc.) from the New York Mets or New York Yankees.

• A jar or bottle of cream or lotion containing alpha-hydroxyl acids.

Goo Luc !!!

Attachment 1

Sample Scavenger List and Team Instructions




114

SESSION AT-A-GLANCE

Intro uction

e Game

e rie an Discussion Faci itator, au ience


aci itator

WHO? HOW LONG?

m nutes

30 minutes

As ong as t e party asts!

Headliner GameWhy Use This Game

• When you have several teams that have done good im-

provement work, and you want to celebrate what they’ve

done and let others know about it.

Target Audience

eams w o ave wor e on QI projects. Senior ea ers can

e on- an w en t e teams present t eir resu ts.

Type of Game

A emonstration wit everyone part icipating.

Key Concepts• Making improvement is hard work. Teams that do this

work should celebrate their success.

• It’s important to let others in the organization know

what teams have done.


In ormation a out t is game comes rom t e Institute or

Hea t care Improvement’s Brea t roug Series Co ege an

a so rom Qua is Hea t , t e QIO or Was ington State,

and its Performance Improvement Support Center.

Materials


• Flip chart and markers for teams to write down

their “headlines”

• Masking tape so the flip chart pages can be posted• Recognition certificates for all teams

• Festive re res ments e.g., spar ing ci er,

c oco ates, a ca e

Preparation



and content:


teaching points in their entirety.

- Put yourself in a festive frame of mind.



- Chairs can be set up auditorium style or in a

semi-circ e, epen ing on ow many peop e you

ave an t e size o your room.

- Set up a sma es or po ium in t e ront o t e

oom P ace t e recognition certi cates on it.

- Set up t e ip c art so you can easi y give eac

team a page to wor on.




115

Playing the Headliners Game



or t eir atten ance.

Learning O jectives

e part icipants t at y t e en o t e session

they will have:

• Celebrated their team’s work.

• Learned what others have done.

Agenda

Provide a brief description of the session’s primarycomponents:

1. Intro uction to t e session an t e Hea iners Game.

2. e game itse , wit presentation o t e resu ts.

3. Forma recognition o eac team’s wor .



Your quality improvement projects will make changes that

will improve the quality of care and services provided by

your organization. at’s your primary goal. But each

project has a secondary goal: to teach everyone in your

organization that change can happen and that teams can be

successful in their improvement work. You can only achieve

this second goal if you broadcast and brag about what QI

teams o. e teams wor ar an sometimes try ris y

t ings. ey nee a c ance to s ow pri e in t ei r wor

an get recognition rom t eir organization or w at t ey

ave accomp is e .

The Game Itself

• We come everyone to t e event.

• As t em, as a rst step, to wor in t eir teams to

create a newspaper ea ine.

- e ea ine s ou capture t e wor t at t e

team as one t is year:

• W at as it accomp is e ?

• How has working on the project inspired the team?

- Give them 10 minutes to write the headline.

- ey should be creative!

• Have each team post and present its headline (creativity

in this presentation is also encouraged).

• Formally recognize each team’s work; distribute certificates.


• As i t ere are any questions or t e teams; aci itate

t e iscussion, i any arise.

• As or i eas rom participants or uture qua ity

improvement wor .

• Serve refreshments, relax and celebrate!








118

Notes




119

Notes



08/2006 NQC Game Guide # 9568



Documents

NQC Game Guide