Transcript Solving Problems, Elevating Quality in Public Health QI Coach’s Handbook QI Coach Coordinators  Contact Information:  Sue Hancock   317-234-1648 [email protected]  Sarah Strawbridge   317-233-7371 [email protected].

Solving Problems, Elevating Quality in Public Health
QI Coach’s Handbook
QI Coach Coordinators
 Contact Information:
 Sue Hancock


317-234-1648
[email protected]
 Sarah Strawbridge


317-233-7371
[email protected]
Module 1
QI Basics
Why QI?
 The goals are to benefit:
 Employees involved in work processes, making the work
easier.
 Our organization, through more efficient or effective
work activities.
 The customers of our work, who must use what we
produce.
Kelly, 1992
Where did QI come from?
• Grandfather of QI: W. Edwards Deming
– Statistician and professor by trade, consulted with
American companies during WW II on production
issues.
– Post world-war II: Worked with Japanese companies to
rebuild. They embraced his techniques.
– Believed that the goal of business should not be just to
make profits, but to stay in business so they could
provide jobs.
W Edwards Deming
 Has been called a “curmudgeon” for his critical
workshop tactics.
 In reality, he sympathized with the plight of workers.
 A short story…
 Deming’s 14 Points
QI Assumptions
• Workers want to perform well on the job, take pride in
their work.
• Workers’ performance more often related to faulty
systems than employee error.
– Jurran’s Principle: “85%-15% Rule”
• Management/leadership generally makes decisions
about systems.
• Data is needed to make good system decisions.
What do we get from QI?
 Improves our job satisfaction – we know our product
or service is quality, a source of pride.
 Reinforces the belief that we can solve problems, make
a difference in our jobs
 We have a greater investment, ownership for our work.
 We have less tolerance for problems and poor quality.
QI Basics
Improving quality is a systematic process:
• PLAN: Define the problem, collect
data, select a possible solution.
• DO: Implement solution on a small
scale.
• CHECK: Collect data, determine
if the solution worked. If not, go back to
Plan and select another solution.
• ACT: When a solution works, spread to all aspects
of the operation.
Five-Step Problem Solving Model
Quality improvement can also be described as a
systematic problem-solving model:
1. Identify the problem – clearly state what needs
improvement.
2. Analyze the problem – Determine what causes problem
to occur.
3. Evaluate alternatives – Identify and select actions to
reduce or eliminate the problem.
4. Test/implement a solution – Implement these actions
on a trial basis to determine effectiveness.
5. Standardize – Ensure that useful actions are preserved.
Module 2
Working Together as a Team
Working Together as a Team
• Team Roles:
– Team members share their expertise to plan and
implement project work.
– The Leader orchestrates team activities, maintains
records, serves as communication link with rest of the
organization.
– The Coach understands the tools and concepts of
improvement, including approaches that help a team
function well together.
– The Sponsor reviews and supports team efforts,
interfaces with other parts of the organization.
Effective Team Members…
• Participate fully in team meetings
• Share knowledge and experience, listen closely to that
•
•
•
•
of other team members
Are open to new ideas
Carry out assignments between meetings
Assist leader with managing the meetings, e.g.
documentation, discussions.
Communicate effectively with colleagues about project
work.
An Effective Leader…
• Organizes the team’s work and activities
• Focuses on a data-based methods to solve the problem
• Serves as contact point for communication between
•
•
•
•
the team, sponsor, others in organization
Keeps official team records, e.g. meeting minutes,
agendas, data related to project.
Assists with carrying out work between meetings
Implements project-driven changes within his or her
authority
Helps team resolve its problems
An Effective Coach…
• Attends meetings but not is a leader or member; an
•
•
•
•
•
outsider who maintains a neutral position.
Assists team in structuring or breaking down tasks and
plans into assignments
Works with team leader to plan meetings
Assists leader with team building
Teaches data collection, analysis techniques; helps
team graphically display data
Helps team prepare for presentation of project to
management, others
An Effective Sponsor…
• Maintains overall responsibility, authority and
•
•
•
•
•
accountability for project
Approves “bubble-up projects,” assures compatibility with
organizational priorities
Sometimes initiates project, begins charter, selects leader,
coach and members
Approves resources for project
Interfaces with rest of the organization to assure
appropriate stakeholder involvement
Feeds data and lessons learned into a system for future
improvements, e.g. policy changes
Reality Check
 Is everybody clear about the roles?
 Does everyone have a role?
 Are the leader, coach, sponsor roles filled?
If not, what is the plan?
 Next Step: What’s our problem?
Module 3
Identifying the Problem
QI Toolkit: Identifying Problems
 Brainstorming – generating a list of potential
problems
 Interviews or surveys - customer feedback,
recommendations
 List reduction - narrowing the list to a few items, by
combining into groups
 Problem selection matrix
QI Toolkit - Brainstorming
Collect a large number of ideas from a group of
people. Many ideas, quickly as possible.
 One-at-a-time (everyone speaks)
 Open door (call out ideas)
 Write-it-down (confidentiality)
Guidelines:
 Be creative
 Build on ideas of others
 No critique allowed
QI Toolkit – Interviews, Surveys
Interviews:
 Purpose: Collect data from direct conversation.
Surveys:
 Purpose: Collect data from
 a large number of people.
QI Toolkit – List Reduction
 Purpose: Reduce a large list of items to a
manageable size.
 Useful in conjunction with brainstorming.
 Group votes for the most important items on list (can
cast as many votes as they want).
 Items with the most votes are circled.
 If further narrowing is required,
process conducted again, limiting
number of votes people can cast.
QI Toolkit: Selection Matrix
Problem Selection Matrix
Criteria
Problems
Within our
control or
influence
Potential
for cost
savings
Number of
customers
affected
Significan
ce of
Problem
Total
Too many
defects
3
3
3
3
12
Absenteeism
high
1
2
2
3
8
Equipment
breakdowns
1
3
3
2
9
Water cooler
too far away
3
1
1
1
6
3 = High
2 = medium
1 = low
What’s Our Problem?
A little history…
 When did we notice the problem?
 Was there anything else going on when we noticed it?
 Have other solutions been tried in the past?
 If so, what happened?
What’s Our Problem?
Zooming in on the current state:
 What exactly is happening?
 When is it happening?
 Where is it happening?
 Who is involved?
What’s Our Problem?
Zooming in on the future (or desired) state:
 What should be happening?
 When should it happen?
 Where should it happen?
 Who should make it happen?
Current and Future State
Current State
• What is the current state?
Driving Forces:
Pathway
Future State:
• What are the important aspects of
the future state?
• Why is this important?
• What is driving us to this future state?
• What is it costing us
time/dollars/staff/etc?
• What is the impact on our
customer/clients?
• What is the impact on our
division/agency?
Consequences
Benefits
• What might be the consequences of
not moving to the future state?
• What might change?
• What is the proposed timeline?
QI Toolkit - Force Field Analysis
Figure 1 Force Field Analysis Diagram
Issue: Meetings starting late
Ideal state:
+ Driving forces
Use time effectively.
Help plan other
activities.
Value all members
equally.
Publish agenda.
To start meetings on time
Restraining forces -
Changing priorities.
Overcommitted
schedules.
Low team morale.
Lack of meeting
notice.
QI Toolkit – Flowchart
Where is the process
breaking down?
RFFlow Professional Flowcharting,
http://www.rff.com/flowchart_samples.htm
Draft a Problem Statement
 A good problem statement should be:
 Specific.
 Describes the problem, not the symptom.
 Relates the current situation to what is desired.
 Does not include causes or solutions
Expressing Need for Improvement in
Measurable Terms
Two-Step Process:
 Gathering information (data) about the problem.
 Tool utilized: Checksheet
 Organizing data so that it is meaningful and clarifies
the problem.
 Tools utilized: Line graphs, Pareto charts, Histograms,
Bar and Pie charts.
QI Toolkit: Checksheet
Purpose: Collect data in an organized manner.
Telephone Interruptions
Reason
Day
Mon
Tues
Wed
Thur
Fri
Wrong # lllll
ll
l
lllll
lllll ll
Info Request
ll
ll
ll
ll
llll
Boss
lllll
ll
lllll ll l
ll
Total
12
6
10
8
13
Total
20
10
19
49
Excerpted from Nancy R. Tague’s The Quality Toolbox,
Second Edition, ASQ Quality Press, 2004, pages 141-142.
QI Toolkit: Line Graph
Purpose: Display the output of a process over
time.
Retail Food Inspections
800
700
600
500
Inspections
400
Retail Follow-up
300
200
100
0
2002
2003
2004
2005
2006
2007
QI Toolkit: Pareto Chart
Purpose: Arrange data so that the most significant
element in a set of elements is easily identifiable.
Diagram courtesy of Six Sigma
http://www.isixsigma.com/offsite.asp?A=Fr&Url=http://www.skymark.com/resources/tools/pareto_
charts.htm
QI Toolkit: Histogram
Purpose: Determine how data are distributed.
QI Toolkit: Bar Chart
Purpose: Arrange data for quick and easy
comparison.
Arthritis
20
No Arthritis
16.7
16.0
percentage
16
11.1
12
8
5.1
4
0
Diabetes
Asthma
Comorbidities
QI Toolkit: Pie Chart
Purpose: Display the volume or quantity of one item in
relation to others.
Nurse time
Immunization 35%
Tb 30%
Comm. Disease 15%
School Nursing 5%
Phone Calls\Misc. 15%
Check Problem Statement
Did data validate the original problem statement?
 If not, revise and collect more data.
 If it did, refine the problem statement so that it is:




Specific.
Describes the problem, not the symptom.
Relates the current situation to what is desired.
Does not include causes or solutions
Establish Interim Target, Date
 Targets should be:
 Intermediate and long term
 Quantitatively expressed
 Aggressive
 Changed as the situation changes
 Example: This project aims to reduce the number of
days it takes to process a payment voucher from 10
working days to 2 by December 31, 2010.
Module 4
Analyze the Problem
Identify the Root Cause(s)
 If the cause is removed, the problem should be at least
partially removed.
 A symptom is not a cause; a symptom is evidence the
problem exists.
 Several root causes may contribute to the problem; it is
important to examine all.
 QI Tools for establishing root cause(s):
Brainstorming, Flowcharts, Cause and Effect
Diagrams, 5 Why’s.
QI Toolkit: Cause and Effect Diagram
Purpose: Identify a set of related causes that lead to
an effect or problem.
QI Toolkit: 5 Why’s
Problem: Patient falls in the hospital.
5 Why’s
Why does the patient fall?
Response
Not wearing skid-proof slippers.
Why does the patient not wear slippers? Not issued by nurse.
Why were slippers not issued?
No slippers in supply closet on patient’s
floor.
Why were there no slippers in the closet Staff did not re-order.
on patient’s floor?
Why didn’t staff re-order?
Busy with needs of other patients.
Verify Cause by Collecting Data
 QI Toolkit - Data collection and analysis:
 Checksheet
 Root Cause Evaluation Matrix
 Histogram
 Bar Chart
 Pareto Chart
Root Cause Evaluation Matrix
Problem: Suzie has been late to school 8 times in past 3 months.
Potential Root Cause
Analysis
Doesn’t get up when
called.
Occurred twice in past 3
months, not on days late
to class.
Can’t find clothes.
Has not occurred in past
3 months.
Homework not complete.
Has occurred 10 times in
past 3 months, always on
days when late.
Verified?
No
No
Yes
Guidelines for Data Collection
 Establish the purpose for collecting data – helps you
target your efforts, collect only what is needed.
 Determine if indicators are reliable – What is the
source of data? Are measuring practices consistent and
accurate?
 Track all data needed – collect enough to conduct a
thorough analysis.
 Record data carefully – Use a checksheet that is logical
and makes collection easy.
Select Root Cause(s) Most
Responsible
 Example: Investigating
delay associated with
processing credit card
applications, data could be
grouped into the following
categories:
 No signature
 No Address
 Cannot read
 Current customer
 Other
Module 5
Evaluate Alternate Solutions
Developing Alternatives
QI Toolkit: Brainstorming, interviews, survey,
research (have others solved this problem?)
Guidelines:
 Be creative, identify as many potential solutions as
possible.
 Don’t be limited by the current practice (i.e. “That’s
the way we’ve always done it.
 Refrain from judging team members’ suggestions.
Evaluating Alternatives
 Effective? (Tried before? With what results? Will it
solve the problem? Achieve improvement target?)
 Feasible? (Is it doable? Practical?)
 Timely? (How long will it take? Long term or short
term? Can we afford to wait?)
 Customer-oriented? (Will it improve service
quality? Satisfy customer identified requirements?)
 Efficient? (Is it cost effective?)
Select Solutions to Implement
Planning for implementation:
 People: Whose support is needed?
 Materials: What is needed? Who will purchase?
 Methods: How will implementers be trained? How
will solutions be measured?
 Machinery/Equipment: Where will it come from?
How will it be funded? How will it be purchased? How
will implementers be trained to use it?
QI Toolkit – Barriers and Aids
Purpose: Document the hindering and supporting factors
that influence a planned activity.
PROVIDE ISDH PROGRAM STAFF TRAINING ON QI SKILLS
AIDS
Training materials available
BARRIERS
Employee work schedules not
compatible with dates
Program staff want to learn QI
Program time is consumed with
grant requirements.
QI Toolkit – Barriers and Aids
Purpose: Document the hindering and supporting factors
that influence a planned activity.
PROVIDE ISDH PROGRAM STAFF TRAINING ON QI SKILLS
AIDS
Training materials available
Coordinate training dates to align with
work schedules
BARRIERS
Employee work schedules are not
compatible with dates
Program staff want to learn QI
Develop efficiencies to clear out time
for accreditation preparation
Program time is consumed with grant
requirements.
Elements of Planning
 The objective is clearly stated.
 Activities are each defined.
 Responsibility is assigned.
 Dues dates are established.
Implementation Plan Matrix:
What
Task 1
Task 2
Task 3
How
Who
When
Complete?
Module 6
Test-Implement Plan
Test the Plan
 Implement on a trial or “pilot” basis.
 Get all necessary approvals.
 Help solutions succeed by:
 Communicating the plan
 Monitoring implementation
 Supporting each other
 Adjusting if necessary
 Show measurable improvements
QI Toolkit: Line Graphs, Pareto Charts, Pie Charts,
Bar Charts, Histograms , Checksheets.
Test the Plan
 If measurable improvements are not evident, return to
problem-solving statement.
 Common reasons why this happens:
 Poor problem statement
 Analysis insufficient or inaccurate
 Verification of root causes is inadequate
Module 7
Standardize Improvements
Steps to Standardization
 Make solutions permanent:
 Make periodic checks
 Clarify work activities (make a flowchart of new process)
 Develop procedures and follow them
 Assign responsibility
 Spread improvements to total process(beyond pilot)
 Determine if solution is applicable to other areas
 Guard against “spotlight” effect—improvements
related to process being under investigation.
References
 Kelley, MR. (1992).Everyone’s Problem Solving Handbook.




Productivity Press, Portland, OR.
Walton M. (1986). The DEMING Management Method. The
Berkley Publishing Group, New York, NY.
Scholtes PR, Joiner BL, Streibel BJ. (2003). The Team
Handbook, Third Ed. Oriel Inc, Madison, WI.
Healthcare Technical Assistance Program. (2007). Indiana
Public Health System Quality Improvement Program.
Purdue University, West Lafayette, IN.
Moran J, Duffy G. (2009). Public Health Foundation,
Washintgon, DC.