Transcript Applying QI Techniques to Analyze Problems

Applying Quality
Improvement Techniques to
Analyze Problems and Find
Solutions
The Open Forum
Leslie M. Beitsch
September 17, 2009
Organize participation for
performance improvement
• Big QI
• Little qi
• Leadership support and role
– What is leadership’s vision, commitment,
expectation?
• Build the process strategically
– Incorporate QI into broader initiatives (MAPP,
HP2010)
– Involve others
To Carry Out a Quality Improvement
Process, “Plan-Do-Check-Act”
Source: Turning Point Performance Management Collaborative,
From Silos to Systems: Using Performance Management to Improve
the Public’s Health , March 2003.
Act
Plan
Check
Do
To Carry Out a Quality Improvement
Process, “Plan-Do-Check-Act”
Plan
Do
Plan changes aimed
at improvement,
matched to root
causes
Carry out changes; try
first on small scale
Check See if you get the
desired results
Act
Make changes based
on what you learned;
spread success
Act
Plan
Check
Do
See Problem Solving, p. 12
Regularly monitor and report
progress.
• Regular reports necessary to chart
progress
• Benchmark against self and others
– Same industry, other industries
• Reports do not have to be computerized
(although it helps!), expensive, color…
Some QI Tools to Help Teams
Analyze Performance
Affinity Diagram
• It was created in the 1960s by Japanese
anthropologist Jiro Kawakita.
• Tool for assimilating and understanding
large amounts of information
• Draw out common themes from a large
amount of information
• Discover all the hidden linkages
Affinity Diagram
How To Do It:
– Develop a clear purpose, problem, concern or issue
statement to focus the group
– Materials needed:
• sticky notes or 3x5 cards
• marking pens,
• large work surface
– Wall
– table
– floor.
.
Affinity Diagram
How To Do It:
– Process Steps:
• Individual silent brainstorming
• Record each idea with a marking pen on a
separate sticky note or card.
• Need a complete statements – no one word
ideas
Exercise
Affinity Diagram
How To Do It:
– Posting Step
• Each participant reads and randomly posts their
ideas on the wall – one at a time
• Other participants can ask for clarification when an
idea is read – no debate – just clarification
• Do not place the notes in any order - do not try to
determine categories or headings in advance –
use the whole wall
• After all ideas are posted – begin Silent
Consensus
Affinity Diagram
How To Do It:
• Silent Consensus:
• The entire team gathers around the posted notes
• No talking during this step (remember the name…)
• Look for ideas that seem to be related in some way
• Move the Post-Its and place them side by side
• Repeat until all notes are grouped
• Okay to have “loners” that don’t seem to fit a group
- outliers
• It’s all right to move a note someone else has
already moved.
• If a note seems to belong in two groups, make a
second note
Affinity Diagrams
• How To Complete It: Clarification Step:
–
–
–
–
–
–
–
–
–
Participants can discuss the “results” of the chart
Any surprising patterns?
Any reasons for moving controversial notes.
A few more changes may be made
When ideas are grouped, select a heading for each
group
• Look for a note in each grouping that captures the
meaning of the group. If not create one
Place it at the top of the group
• highlight headers notes in a bright color.
Combine groups into “super groups” if appropriate
Want 6 – 10 headers
Take the time to do this step – it is the foundation for
the other tools
Affinity Diagram Example
Issue Statement
Issues Affecting the High Staff Turnover
of Sunshine County Health Department
Header Cards:
Low
Salary
Work
Environment
Limited
Professional
Development
Leadership
Low
Morale
Public Health
Misunderstood
Cause and Effect Diagram
Poor Morale
Low Salary
Work
Undervalued
Budget
Constraints
Outdated
Equipment
Lack of
County support
Training
Availability
Career
Advancement
Limited
Professional
Development
HR System Restrictive
Poor Facilities
Bad
Neighborhoods
Work
Environment
High Staff
Turnover
Common root causes
of performance problems
–
–
–
–
–
Methods & Procedures
Motivation
Materials & Equipment
People
Information &
Feedback
– Environment
– Policy
5 Whys
Five Why’s
Our influenza clinic was poorly attended
• Why? Residents had many
opportunities
• Why? There was a lot of competition
• Why? Pharmacies are in on the action
• Why? It brings customers in
• Why? They can ‘multi-task’ in one stop
Other
Explanations
Our influenza clinic was poorly attended
• Why? Residents had many
opportunities
• Why? We didn’t advertise it well
• Why? Inclement weather was a factor
• Why? Our price wasn’t competitive
• Why? The location wasn’t convenient
Five Why’s: Expand
Scope Downward
My off white carpeting must be replaced
•
•
•
•
Why? The carpeting has been stained
Why? My elder cat vomits periodically
Why? She is upset about something
Why? Her environment was
compromised
• Why? I introduced a kitten last year
Five Why’s
I had to replace my car motor
•
•
•
•
•
Why?
Why?
Why?
Why?
Why?
The motor seized while in transit
There was insufficient oil
I have not maintained my car
I didn’t make time for my service
I did not make my car a priority
Cause and Effect Analysis (Fishbone)
5th Why
4th Why
3rd Why
2nd Why
Methods
Ask “why” 5 times
1st Why
Primary Cause
Primary Cause
People
Problem Statement
Equipment
Environment
Fishbone
Diagram
Ask “why” 5
times
Residents had many opportunities
Environment
People
Lots of competition
We didn’t advertise it well
Missed deadlines at local paper for advertising
Pharmacies are in on the action
Turnover in staff person responsible for advertising
It brings customers in
They can multi-task in one stop
No cross-training completed
Primary Cause
Staff unsure about how to post advertisements
Primary Cause
Our influenza clinic was poorly attended.
Problem Statement
Primary Cause
Vendor had too many commitments and little vaccine to fulfill orders
Previous vendor was not delivering vaccine timely
Using new vendor
Vaccine costs more
Equipment
Methods
Our price wasn’t competitive
Flow Charting
“If you can't describe what
you are doing as a process,
you don't know what you're
doing.”
W. Edwards Deming
FLOW CHART
PROCESS
AUDIT
PROCESS
Simple Flowchart
Helps Understand
a Complex
Process
CORRECT
PROBLEMS
YES
PROBLEMS?
COLLECT
DATA
ANALY ZE
DATA
NO
IN
CONTROL?
PLOT
HISTOGRAM
ESTIMA TE
PROCESS
CAPABILITY
SORT
PRODUCT
NO
CAPABLE?
IMPROV E
CAPABILITY
Flow Charting
• Flow charting is often the first step we take in
understanding a process
• Organized combination of shapes, lines, and
text
• Flow charts provide a visual illustration, a
picture of the steps the process undergoes to
complete it's assigned task
• From this graphic picture we can see a
process and the elements comprising it
• Shows how interactions occur
• Makes the invisible (less obvious) visible
(more obvious)
Mapping
MapQuest
• Takes directions and coverts
them into a picture
• Shows various routes to a
destination
• Shows communities you
pass through to reach a
destination
• Shows connecting roads
• Shows faster and slower
routes
• Provides alternative routes
Flow Chart
• Takes procedures and
converts them into a visual
• Shows the routes inputs
travel to become outputs
• Shows handoffs
• Shows connecting
processes
• Highlights areas for
improvement
• Triggers ideas to improve a
process
Flow Chart Benefits
• Creates a common vision
• Establishes the “AS IS” baseline – Current
State
• Baseline to measure improvements
• Identifies wasteful steps – activities/waits
• Uncovers variations (usually unintended)
• Shows where improvements could be made
• Show potential impacts of improvements
• Training tool
Flow Chart People Benefits
People involved in constructing a flow
chart begin to:
– Better understand the process
– Understand the process in the same terms
– Realize how the process and all the people
involved, including them, fit into the overall
process or business
– Identify areas for improving the process
– Become enthusiastic supporters to quality and
process improvement
– Become process owners
Types of Flow Charts
• As Is – current state - baseline
– Our task today!
• Could Be – improved state –
transition
• Should Be – optimal state
Flow Charting Construction
•
•
•
•
Clearly define the process boundaries to be studied
Define the first and last steps – start and end points
Get the right people in the room
Decide on the level of detail
– Complete the big picture first – macro view
– Fill in the details – micro view
• Gather information of how the process flows:
• Experience
• Observation
• Conversation
• Interviews
• Research
• Clearly define each step in the process
– Be accurate and honest
Flow Charting Steps
• Use the simplest symbols possible – Post-Its
• Make sure every loop has an escape
• There is usually only one output arrow out of a
process box. Otherwise, it may require a decision
diamond.
• Trial process flow – walk though it in real time
• Circulate the flowchart to other people involved in the
process to get their comments
• Make changes if necessary
• Identify time lags and non-value-adding steps.
Flow Chart Construction
• There is no one right way to develop a
flowchart, but the following guidelines provide
a general structure:
• Start with a simple one-line description or
title of the process being flowcharted , e.g.,
"How to..."
• Using a top-down hierarchy, start with an oval
symbol named Start.
• Connect each successive action step in the
logical sequence of events.
• Reference detailed information through
annotations or connectors.
• Follow the process through to completion,
denoted by an oval symbol named End
Flow Lines
Flow Chart Symbols
Manual
Operation
PPAProcessctivr
Operation/Inspection
Data Base
Document
Forms
Connector
Comment
Collector
Wait/Delay
Storage
Input/
Output
Data
A
Transport
Input
Output
Display
Manual
Input
Preparation
Unfamiliar/
Research
Constructing a Flow Chart
• Asking questions is the key to flow charting a
process.
• For this process:
–
–
–
–
–
Who is the customer(s)?
Who is the supplier(s) ?
What is the first thing that happens?
What is the next thing that happens?
Where does the input(s) to the process come
from?
– How does the input(s) get to the process?
– Where does the output(s) of this operation go?
– Is their anything else that must be done at this
point?
Exercise
Quality Improvement
•
•
•
•
•
•
•
•
•
•
Analyze the “As Is” flow chart
Look for Critical Processes
Look for Handoffs
Analyze with a Cause and Effect Diagram
Develop potential solutions
Develop the “Should Be” state
Communicate all changes
Track implementation progress
Document results
Present results
How Improvements Are Made
Focus on Critical Processes
– Important sets of procedures or patterns of
tasks that determine success (i.e. customer
satisfaction) for an organization or an
individuals job.
What are the attributes of critical processes?
• They are few in number - usually 5 - 10
• The critical processes of a flow chart should
capture 75-80% of the activities which
determine the success of that process
• Critical processes describe what must occur
on an on-going basis to achieve customer
satisfaction.
• They can be mapped or diagrammed in a
step-by-step format.
• They can be measured.
• They can be improved
Improvement Opportunities
What to look for on a Flow Chart:
– Duplication of effort
– Unnecessary Activities/Steps/Tasks
– Delays/Waits
– Transports
– Storage
– Illogical Sequencing of Activities
– Unclear Lines of Responsibility
– Opportunities for Error
– Supplier Error Opportunities
– Disconnects
Improvement Opportunities
• Use a Cause and Effect Diagram to
investigate areas identified on the “As Is”
flow chart as areas that could be improved
• Can complete a micro level flow chart on
specific process steps as required
• Fix the low hanging fruit first – quick
success
• Involve customer/suppliers before any
changes are made
Caution!!!
In most processes:
– Few people have seen the total process and fully
understand it!
– Those that designed the process now work
elsewhere
– Work is being done that adds no value to
customers
– Work the customer needs isn’t being done
– Rework is built into the process
– Inefficiencies are built into the process
– Workarounds have been developed that make the
process appear to be working better than it really
is
Advantages of Flow Charts
•
•
•
•
•
•
•
Overview of the System
Documents a system/process
Shows Interrelationships
Communication Tool
Defines Roles
Shows barriers/bottlenecks/problems
Planning Tool for improvements
Child has WIC
appt.
□ Due
□
Overdue
for
shots?
Check report for
immunization
status
No
Show?
Yes
Mail parent
immunization
notice
No
Noaction
Yes
Check report for
immunization
status
Due or
overdue for
shots?
Yes
Give parent immunization
notice; answer or refer
questions to DP&C nurse
No
Check report for
C&TC eligibility &
last exam
Encourage
regular well
child exams
No
Yes
Active
on
C&TC?
Provide C&TC info/assist,
encourage compliance
w/exam schedule, code
activity in Catch3
WIC Appointment
Memory Jogger II &
Problem Solving Memory Jogger
(Goal QPC) www.goalqpc.com
American Society for Quality (www.asq.org)