1. Untangling Quality Improvement Tools
CAH/Small Rural Learning Community
Lynne Hall

2. Cause and Effect Diagrams
Histograms
Flow Charts
Run Charts
Check sheets
Scatter Diagrams
Cause and Effect Diagrams
Bar Charts
Force Field Analysis
Pareto Charts
Nominal Group Technique
Root Cause Analysis
Brainstorming

3. Objectives
Describe the quality control and the management and planning tools used in quality improvement
Explain how to use the various performance improvement tools to implement the quality management

4. What is Quality?
According to Merriam-Webster Online Dictionary, Quality is:
A degree of excellence : grade
A distinguishing attribute : characteristic <possesses many fine qualities>

5. Total Quality Management (TQM)
A management approach to achieve long- term success
Everyone in the organization participates in improving processes, services, patient care, and the culture where they work
TQM takes strong commitment from leaders in your organization

6. Quality Tools Key: Manage what you measure What process needs work?
Change process
Gather data
Act on data
Gather data
Act on data
We have all seen some sort of quality cycle (PDSA, DIMAIC, etc)
If you keep this cycle going, the process will change…but now what?
OR we know a process needs to be changed but we need leadership involvement

7. Quality Tools Key: Manage what you measure What process needs work?
Present data to leadership!!
Change process
Gather data
Act on data
Gather data
Act on data
PRESENT data. Let leadership know what’s going on and how it’s going….
This helps with leadership buy-in

8. Tools and Techniques
There are so many quality tools and techniques it’s hard to know where to begin. What do I use this one for? How can I show something to leadership that makes sense? What is the best way to use which technique to show the data? One the following slides, I will outline each tool and technique to untangle the quality tools and you will leave with a better understanding and knowledge of how best to present data and use it to your institutions advantage.

9. How do I decide which improvement area needs to be address first?
You can use:
Flow Chart
Check Sheet
Pareto Chart
Brainstorming
Nominal Group Technique
Root Cause Analysis

10. Brainstorming Process Define the topic
Ask each person for 5 ideas on the subject
Give them a couple of minutes to write them down
Ask for ideas and list them on a flipchart
Review / clarify / combine like ideas
Revisit and revise the list later in the meeting or at the next meeting

11. Brainstorming Methods
Have people use sticky notes and stick on a flipchart
Take turns around the room until everyone says pass
Have each team member write one idea on a sheet of paper and pass it to the next person can add to or build off other statements
This is your chance to think outside the box!!

12. Nominal Group Technique
Can enhance one or more dimensions of effectiveness of decision-making groups
NGT provides:
more unique ideas,
more balanced participation between group members,
increased feelings of accomplishment, and
greater satisfaction with idea quality and group efficiency
Sometimes this works well when you have one or two people

13. Nominal Group Technique
The nominal group technique is particularly useful:
When some group members are much more vocal than others.
When some group members think better in silence.
When there is concern about some members not participating.
When the group does not easily generate quantities of ideas.
Sometimes this works well when you have one or two people are very vocal and others don’t talk because of them

14. Nominal Group Technique
The nominal group technique is particularly useful:
When all or some group members are new to the team.
When the issue is controversial or there is heated conflict.
When there is a power-imbalance between facilitator and participants or participants: the structure of the NGT session can balance these out.
Sometimes this works well when you have one or two people

15. Flow Chart Identifies problems and opportunities
Helps define scope of process
Documents a process
Analyzes process for improvements

16. Flow Chart Get Bread Toasted? Not toasted Toasted Add Peanut Butter
Problem = I’m hungry
Identified gaps, I can analyze where improvements need to be made.
Add Jelly
Enjoy!

17. Check Sheet Used for data collection Measure/track:
Process
Problems
Causes
Other performance factors
Helps with pareto charts and other display tools (pie charts, run charts)

18. Check Sheet Application for Check Sheets:
Provides consistent data collection
Identifies and defines problems / opportunities
Sets priorities
Identifies root causes
Used for follow-up and verify results

19. Check Sheet Getting started: Determine the data to be gathered
Decide on the frequency
Design a checksheet
Train users
Mark appropriately (checks or hashmarks)
Compile results
Analyze and graph data

20. Making a PB & J Sandwich Data Analyst ___________
Check Sheet
Making a PB & J Sandwich Data Analyst ___________
Process Step
Date/Time start
Date/Time Stop

21. Pareto Chart A special type of bar chart
Helps focus team on components of the problem that has the biggest impact
Based on the Pareto Principle
80% of the effects we see are due to 20% of the causes
The data are easy to gather
They are easy to construct
Easy to interpret

22. Pareto Chart

23. Root Cause Analysis Interdisciplinary REVIEW of the process
surrounding an event (actual or near)
to develop prevention strategies
When – Unplanned Event (REACTIVE)
What – Tool for Review
Why - Review Process Steps
Who – Organizational Leadership AND Frontline Caregivers
How – Correct Process to Prevent Future Event
FOCUS on process NOT person
Appropriate use
Consistent use

24. Next: Describe the problem Check Sheet Pareto Chart Histogram
Pie chart
Stratification

25. Next:
Arrive at a statement that describes the problem in terms of what is specifically, where it occurs, when it happens, and its extent
Check Sheet
Pareto Chart
Histogram
Pie chart
Stratification

26. Stratification Utilizes the data to “slice and dice”
What are the differences
What are the similarities
Consider this application anytime you want to collect data

27. Stratification Factors Examples Who Department Individual
Customer Type
What
Type of Complaint
Defect Category
Reason
When
Month, quarter
Day of week
Time of Day
Where
Region
Unit

28. Histograms
Used with either continuous data or counts of attributes (discrete data)
Shows distribution of the data
Highs and lows
Allows you to see variation in the data
Helps answer questions:
Is the process centered on the customer requirement
Does the process miss the customer requirement
Is the process skewed with unexpected points

29. Histograms
EED: This is real data. 31 hospitals reporting.

30. Pie Chart A circular chart that illustrates a proportion of the data
Works particularly well when the slices represent 25 to 50% of the data

31. Pie Chart

32. What are all the possible Causes of the Problem?
Check Sheet
Cause & Effect Diagram
Brainstorming
Root Cause Analysis
Failure Mode Effect Analysis
Force Field Analysis
Hat

33. What are all the possible Causes of the Problem?
Check Sheet
Cause & Effect Diagram
Brainstorming
Root Cause Analysis
Failure Mode Effect Analysis
Force Field Analysis
Hat

34. Cause and Effect Diagram
Also know as Fishbone
Basically a structured Brainstorming
Establishes categories of potential causes
Gives focus to help begin process and data analysis
This IS NOT a way of identifying which idea is the “culprit”

35. Cause and Effect Diagram
Equipment
People
Nurses not rounding
Floor is wet
No handrails
Call lights not answered
Falls
Non-skid footwear
Education of family
Methods

36. Failure Modes and Effects Analysis
Helps anticipate problems so you can take steps to correct, reduce and eliminate (PREVENT problems or anticipated) risks
Identifies ways a change in a process, product or service that may cause unintended problems

37. Failure Modes and Effects Analysis
Brainstorm all the potential ways the change in the process could fail
List these failure modes
Identify the potential cause of these failures
Develop a rating scale
Rate each of the factors
Multiply the 3 numbers together to get the Risk Priority Number

38. Failure Modes and Effects Analysis
Multiply the 3 numbers together to get the Risk Priority Number
Start with the failures that have the highest RPN’s discuss for each failure ways to eliminate the causes, the chance of it reoccurring, ect
Assign responsibilities for each action identified

39. Force Field Analysis
Helps teams proactively build support and neutralize blocking factors to an impending change
Application
Determining solutions
Identifies and removes obstacles
Plans and implements a process change or solution

40. Force Field Analysis Clarify the change or solution to be analyze
Divide a flipchart page into two halves
Brainstorm forces for and against the change
Start with the driving forces and and identify ways to:
Reinforce the support
Make the support more visible in your plans
Link your solution to that support

41. Force Field Analysis 5. Categorize the restraining forces as follows:
Blocks – regulations, policies, laws
Constraints – resources, budget, time
Illusions – “That’s not what we have done before”
6. Identify steps to neutralize restraining forces
7. Determine which neutralizing actions are necessary and build into your plans

42. Force Field Analysis

43. Agree on basic cause(s) of the problem
Check Sheet
Pareto Chart
Scatter Diagram
Brainstorming
Nominal Group Technique

44. Agree on basic cause(s) of the problem
Check Sheet
Pareto Chart
Scatter Diagram
Brainstorming
Nominal Group Technique

45. Scatter Diagram
Allows you to test hypothesis about the causes of the problems
Uses paired data: Do these have an effect on one another?

46. Scatter Diagram

47. Scatter Diagram Positive correlation between the two data points
Example: Positive correlation between more falls at change of shift

48. Scatter Diagram Negative correlation between the two
Example: Less falls happen during shift change

49. Scatter Diagram Indicates a complex relationship
Example: More falls happen at change of shift on Tuesdays

50. Scatter Diagram No correlation at all between the two
Example: Falls don’t depend on shift change

51. Presenting Data to Leaders and Others
Run Charts
Pie Chart
Bar Graphs

52. Presenting Data to Leaders and Others
Run Charts
Pie Chart
Bar Graphs
Pareto Chart
Scatter diagram

53. Develop an effective and implementable solution and action plan
Run Charts
Pie Chart
Bar Graphs
Pareto chart
Scatter Diagram

54. Run Charts – watching performance over time
Purpose: to measure and track a key input, process, or output measure over time

55. Run Charts – watching performance over time
Run charts got their name because of the practice of counting “runs” or sequences of consecutive points of either side of the median
Too many or too few clusters are a signal that something special is happening within your process
Graphs of data show improvement over time
Tool for assessing the effectiveness of change

56. RUN CHARTS
Run charts have a variety of benefits:
Help improvement teams formulate aims by depicting how well (or poorly) a process is performing
Identifying problems, opportunities (trends, patterns, or output measure over time)
Determining potential root cause(s)
Follow-up and verification of results
Provides a quick look at a process

57. Monitoring Improvement… RUN CHARTS
Plot your data.
Find your mean or average
Identify runs
Look for Special Cause Variation
Note any changes made in the process

58. Monitoring Improvement… RUN CHARTS
Plot your data.
Find your mean or average
Identify runs
Look for Special Cause Variation
Note any changes made in the process
Implemented new fall process

59. Monitoring Improvement: Run Chart Rules
Common Cause Variation – the random variation associated with a process (No process is a straight line)
Special Cause Variation – a difference in the normal process variation
Six or more consecutive increasing or decreasing points
Nine or more consecutive points on the same side of the median
14 or more consecutive points alternating up and down around the median

60. Bar Graphs
Used for data that is not related to one another or is not continuous
Use for independent data

61. Bar Graphs

62. What is my improvement area?
Flow Charts
Check Sheet
Pareto Charts
Brainstorming
Nominal Group Technique
Root Cause Analysis
What is my improvement area?
Describe the Problem
Cause of the Problem
Check Sheet
Pareto Charts
Histogram
Pie Chart
Stratification
Check Sheet
Check Sheet
Check Sheet
Check Sheet
Check Sheet
Root Cause Analysis

63. References
quality- management/overview/overview.html
Melum, Mara Minerva and Sinioris, Marie Kuchuris; 1992; Total Quality Management
c-statistics/scatter-diagram.html