Quality Tools - By - Dr. Doaa Hussein - 4-3-2014

Dr . Doaa Hussein

Quality Management Consultant.

MBA,CPHQ ,TQMD, TOT, HRMD,APD TQM AUCians Group member

Outline

Using Quality Improvement tools throughout the Quality improvement process

Dr.Doaa Hussein QM consultant

Effective Outcome


Effective outcome

Unique

Well-crafted Items

Solve Problem Situations.


Effective outcome

provide care to individuals, families, and communities so they may attain, maintain, or recover optimal health and quality of life.


http://en.wikipedia.org/wiki/Quality_of_life_(healthcare)

Effective outcome

Solve problems Improve quality


Quality Improvement ProcessUsing tools to improve quality and increase effectiveness


Define preferred state, problems, and improvement opportunities.

Identify barriers and root causes.

Develop improvement

solutions, strategies, tactics,

and plans

Implement plans.

Monitor results.Standardize and

generalizeDr.Doaa Hussein QM consultant

How To Write A Problem Statement

Should be SMART:

specific

Measurable

Attainable

Realistic

Timeframe

And should not:

include any causes or solutions or blame anybody


How To Identify the Problem or opportunity for improvement ?


Flow Charts

A pictorial representation displaying the actual sequence of steps and their inter-relationships in a specific process


Flowchart

Identify :

Hand-off (Appropriate And Inappropriate),

Inefficiencies,

Redundancies,

Waiting Steps;


Flowchart

Decide whether to :

Correct Steps Within The Current Process,

Design A New Process

Do corrections first, then redesign in the future.


Flowchart

Questioning whether actual process meets current policy/procedure

Analyzing problems to determine causes

Redesigning the process as part of the action

Designing a new process


Start / End

Process Step

Decision

Connector

No

Yes

A

Symbols Used in Flowcharts


Linear Flowchart Example

Yes

A

Start

Collectinputs

Draft POD

Type rough

Submit to XO

OK ?

Retype POD

No

Typesmooth

Sign POD

Make copies

Distribute

End

AProducingthe “Plan of

the Day”


Levels of Flowcharts

Start

End

DraftPOD

TypePOD

DistributePOD

Start

Get roughdraft of POD

Is itapproved

?

Typesmooth

Getapproval

End

Turn oncomputer

Start wordproc. apply.

Isrough in

word proc.apply.

?

Typerough POD

Edit POD

Arethere any

corrections?

Makecorrections

Print POD

No

Yes

Yes

No

No

Yes

MACRO MINI MICRO


Interpreting a Flowchart

Step 1 - Examine each process step

Bottlenecks? Poorly defined steps? Ineffective sequence? Delays? Weak links?

Step 2 - Examine each decision symbol

Can this step be eliminated?

Step 3 - Examine each rework loop

Can it be shortened or eliminated?

Step 4 - Examine each activity symbol

Does the step add value for the end-user?Dr.Doaa Hussein QM consultant

Draw Flowchart ?

Getting to Work

From:

Waking Up to

Entering Building.

Level ?

Steps?

Decisions?

Interpretation? Dr.Doaa Hussein QM consultant

Brainstorming

Create as many ideas as possible in as short a time as possible

What is the scope of the problem?

Who are the Stakeholders?

What is the impact of this problem on

Patient Care?

What are the possible solutions ?


Brainstorming

Structured Brainstorming:

Everyone in the group gives an idea in rotation or passes until the next round.

UnstructuredBrainstorming:

Everyone in the group gives ideas as they come to mind.


Five Steps of Brainstorming

Establish a time limit for the entire session;

Define the subject and direction of the session;

Allow time for initial, individual thought;

Request ideas according to the predetermined structure;

keep circling the issue until all ideas are recorded

Clarify all ideas generated to assure accuracy and understanding.


What can be done to improve employee morale?


Affinity Diagram

Organize large volumes of ideas or issues into major categories


Affinity Diagram

"Affinity" means close relationship or

connection, or similarity of structure;

When developing an Affinity Diagram, it is most important to determine the primary issue and major related subgroups in order to grasp the appropriate relationships, links, or connections.


Affinity Diagram

Steps:

Define the primary issue, using neutral, broad language;

Brainstorm - use cards or adhesive notes which can be moved and sorted;

Display in random fashion all ideas for the team (on a wall or table);

Cont..


Behavior modifications may

take longer than time available

Display the Generated IdeasIssues in Implementing Continuous Process Improvement

Too many projects at once

Everybody needs to change but me

Data collection process needs

Need new data collection system

Developing product without developing

process

Too busy to learn

Don’t know what customer wants

Short-term planning mentality

Pressure for success

Lack of training at all levels

Lack of management

understanding of need for it

Competition versus

cooperation

Need to be creative

Some people will never change

What are the rewards for using tools

Lack of follow-up by

management

Unrealistic allotment

of time

Lack of trust in the process

Not using collected

data

Which comes first, composing the team or

stating the problem?

Want to solveproblem beforeclearly defined


Sort Ideas into Related Groups

Issues in Implementing Continuous Process Improvement



Lack of management understanding of

need for it

Competition versus

cooperation


Too busy to learn


Lack of follow-up by management



Need new data collection system

Unrealistic allotment of

time

Not using collected data

Want to solve problem before clearly defined


process

Don’t know what customer wants

Which comes first, composing the team or

stating the problem?



Need to be creative

Some people will never change


Everybody needs to change but me


Create Header Cards


(Header Cards)

Breaking through old way

“Dinosaur” thinking

Lack of planning

Organizational issues

Old management

culture

Lack of TQL knowledge


Finished Affinity Diagram


Breaking through old

way "Dinosaur” thinking

Lack of planning

Organizational issues

Old management

culture

Lack of TQL knowledge



Lack of management

understanding of need for it

Competition versus

cooperation


Too busy to learn


Lack of follow-up by management

Everybody needs to change

but me



Need to be creative

Some people will never

change




Need new data collection

system

Unrealistic allotment of

time

Not using collected

dataWant to solve

problem before clearly defined


process

Don’t know what customer

wants

Which comes first, composing the

team or stating the problem?


Affinity Diagram

Each team member participates in sorting the ideas into major groupings -- in silence and quickly, without discussion and without time for contemplation -- until team consensus is reached;

Discuss the major groupings and create a concise title for each grouping;

Draw the affinity diagram, based on major groupings, linking all ideas related to each grouping.


Use the list generated during the Brainstorming Exercise


Prioritization Matrix

Select one option from a group of alternatives

It promotes objective decision making.





Steps: Limit the list of options (of problems or

solutions) to no more than eight (8);

Select the criteria against which each option will be rated, stated in either positive or negative terms, but not both;

Determine the weight (relative value) of each criterion; perhaps some are more important to meet than others;

Cont..



Select a scoring method, e.g.:

Point system: From 5 = Very important to 0 = Unimportant

Yes/No system: Criteria Met? Y=Yes; N=No

Check mark: Box checked if criteria met

+ or - system: + = Important/criteria met

- = Unimportant/criteria not met



Determine the desired score, what number of criteria must be met.

Prepare the matrix with options down the left side and criteria/total score column across the top.


Cause–and Effect “Fish-Bone”“Ishikawa” Diagram

Gather all possible causes as an overview.

The ultimate goal being to uncover the root cause of a problem.


Basic Layout ofCause and Effect Diagrams

EFFECT

Manpower(People)

Methods(Procedures)

Materials(Policies)

Machines(Plant)

Environment


Cause-and-effect Diagram

Determine and define the major categories which describe the system or process under review, e.g.,

5ps: (or) 5ms:

People Manpower

Provisions Materials

Policies Machines

Procedures Methods

Place MeasurementsDr.Doaa Hussein QM consultant


Brainstorm to identify possible main causes of

the negative outcome

Link each to one of the major categories

Using horizontal lines (parallel to the main

outcome line) touching the appropriate

diagonal line; Dr.Doaa Hussein QM consultant


Identify any possible sub causes of main causes by using the "Five-Why" technique, linking these to the main cause lines;

Evaluate the draft diagram as a team to determine the accuracy of the placement of issues and lines;



It is very important to study the relative frequencies of the different causes before acting to change the process.


Steps at a Glance: Cause & Effect

UseDispersion

Analysisor Process

ClassificationFormat?

Define majorcause categories

Draw in the bonesof the fish

Brainstorm causesor use data from

Check Sheet

Agree on theproblem statement

Start

Define majorprocess steps

ProcessClassification

Reachedthe appropriate

levelof detail?

Interpretfishbone

Act to correctthe causes

Agreement onroot causes?

DispersionAnalysis

Yes

Yes

No

No


Cause & Effect ExampleBed Assignment Delay

Information provided courtesy of Rush-Presbyterian-St. Luke’s Medical Center

System incorrect

Machine (PCIS)Ttiming

Hospital procedures Communication

Patient waitsfor bed

Not entered

Not used

No trust Need more training

Functions not useful

Not usedpending discharge

Discharged patientdid not leave

Wait for resultsWait for lunch

Wait for ride

Call housekeepingtoo late

Wait for MD

Call housekeepingtoo early

Think it will takemore time

Patient arrivestoo early

Transfer too earlyfrom another hospital

Call housekeepingwhen clean

Nursing shortage

Unit clerk staffing

Unit clerk training

Resources

Unit clerk unawareof discharge or transfer

On break

Not toldShift change

Reservationunaware

Not entered

Unit switch bedAdmitting unawarebed is clean

Delayedentry

SandbagToo busy

InappropriateER admittance

Manytransfers

Specialty beds

Cardiac monitors

Double rooms

Physician didnot write order

Medicineadmit quota

Physician misuse –inpatient

MD procedures


Pareto

Identify the vital few and useful many

Pareto principle


Pareto ChartBar chart arranged in

descending order of height from left to right

Bars on left relatively more important than those on right

Separates the "vital few" from the "useful many" (Pareto Principle)

Budget Allocation

80

3827

14 115

0

20

40

60

80

100

Co

de

20

Co

de

10

Co

de

50

Co

de

30

Co

de

40

Co

de

60

Thousands


Steps at a Glance: Pareto

Select problemto study

Is dataavailable?

Choosecategories

No

CheckSheet

available?

Yes Review datafrom Check Sheet

Constructdata table

No

Plot percent line

Yes

Interpret resultsYes

Start

Use inproblem-solving

process

Select unit ofmeasure

Choose timeperiod

Record scale ony axis (vertical)

Indicatecumulative

percent?

Barnstorm possiblecategories

Construct verticalbars on x axis(horizontal)

No

Create Check SheetGather new data


LEGEND: COMPLAINTS RECORDED IN BEQ / BOQ, 1 FEB - 30 APR 95.

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LightingStorage

StereoTV

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Furn

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Type of Complaint

Nu

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Break point

Example #1 - Pareto Chart


Find Solution

Ensure support from formal and informal leaders

Make the Remedy part of day to day management.

Issue policies, procedures, or guidelines to facilitate the implementation process.


Find Solution

Implement on a Pilot basis

Collect Data to check Effectiveness and Efficiency of the solution.

Monitor the impact of the solution on performance over time


Get ready for a wider scale of Implementation.

Educate Staff and prepare them for the upcoming change

Get ready to replicate your experience in other areas or other projects

Find Solution


Monitoring the Impact

Collect data using data collection tools.

Analyze data, transform data into information

Present your data using line, Bar and Pie Charts

Study Common/Special Cause Variations

Use Control Charts


Force Field Analysis

Force field analysis is used by the team when a proposed solution to a problem will require significant change.

Driving Forces

Restraining Forces



And it is important to analyze the potential impact and chances of success.

If no change occurs, it is because the opposing forces are equal, or the restraining forces are too strong.




Steps:

List in two groups all the driving and restraining forces affecting a desired change;

Discuss the overall value of the proposed change;

Come to team consensus about priorities for effecting change;

Include in the planned solution, actions to diminish or eliminate the restraining forces. Dr.Doaa Hussein QM consultant

Gantt Chart

1 2 3 4 5 6 7 8 9 10

1-

2-

3-

Goal:………………………………….


GANTT CHART

Is a graphic display—a type of bar chart—of the individual parts of a quality improvement process as bars on a horizontal time scale.

Is a project-planning tool for developing schedules;


Action Planning


Action Planning

Once the team selects a solution, an action plan need to be developed.

The team leader is responsible of monitoring the implementation process using a mean of verification that a certain task has been done (target , KPI).


STORYBOARD


Storyboards are valuable displays: Promote the team’s commitment to quality and the positive

impact on the organization;

Communicate quality improvement progress and outcome to the entire organization;

Summarize the effort for leader, Quality Council, governing body approval;

Provide visual description of QI/PI activity for training.




Documents

Quality Tools - By - Dr. Doaa Hussein - 4-3-2014