1. Indiana Quality Improvement
Solving Problems, Elevating Quality in Public Health
QI Coach’s Handbook

2. QI Coach Coordinators
Contact Information:
Sue Hancock
Sarah Strawbridge

3. Module 1
QI Basics

4. 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

5. 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.

6. 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
Read the Deming story (handout). Distribute 14 points.

7. 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.

8. 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.

9. 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.

10. 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.

11. Working Together as a Team
Module 2
Working Together as a Team

12. 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.

13. 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.

14. 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

15. 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

16. 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

17. 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?

18. Identifying the Problem
Module 3
Identifying the Problem

19. 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

20. 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

21. QI Toolkit – Interviews, Surveys
Purpose: Collect data from direct conversation.
Surveys:
Purpose: Collect data from
a large number of people.

22. 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.

23. QI Toolkit: Selection Matrix
Problem Selection Matrix
Criteria
Problems
Within our control or influence
Potential for cost savings
Number of customers affected
Significance of Problem
Total
Too many defects 3 12
Absenteeism high 1 2 8
Equipment breakdowns 9
Water cooler too far away 6
3 = High = medium = low

24. 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?
Facilitate discussion on these questions, and record answers on flip chart. These could all be on the same page.

25. 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?
Flow chart now?

26. 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?
The team could do a full-blown current and future state exercise here (on next slide).

27. Current and Future State
Current State
What is the current state?
Why is this important?
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?
Future State:
What are the important aspects of
the future state?
What is driving us to this future state?
What might be the consequences of
not moving to the future state?
What might change?
What is the proposed timeline?
Driving Forces:
Pathway
Consequences
Begin working on the current state
Benefits

28. QI Toolkit - Force Field Analysis

29. QI Toolkit – Flowchart Where is the process breaking down?
RFFlow Professional Flowcharting,

30. 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

31. 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.

32. QI Toolkit: Checksheet
Purpose: Collect data in an organized manner.
Telephone Interruptions
Excerpted from Nancy R. Tague’s The Quality Toolbox, Second Edition, ASQ Quality Press, 2004, pages

33. QI Toolkit: Line Graph
Purpose: Display the output of a process over time.

34. 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

35. QI Toolkit: Histogram
Purpose: Determine how data are distributed.

36. QI Toolkit: Bar Chart
Purpose: Arrange data for quick and easy comparison.

37. QI Toolkit: Pie Chart
Purpose: Display the volume or quantity of one item in relation to others.

38. 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

39. 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.

40. Module 4
Analyze the Problem

41. 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.

42. QI Toolkit: Cause and Effect Diagram
Purpose: Identify a set of related causes that lead to an effect or problem.

43. QI Toolkit: 5 Why’s Problem: Patient falls in the hospital. 5 Why’s
Response
Why does the patient fall?
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 on patient’s floor?
Staff did not re-order.
Why didn’t staff re-order?
Busy with needs of other patients.

44. Verify Cause by Collecting Data
QI Toolkit - Data collection and analysis:
Checksheet
Root Cause Evaluation Matrix
Histogram
Bar Chart
Pareto Chart

45. Root Cause Evaluation Matrix
Problem: Suzie has been late to school 8 times in past 3 months.
Potential Root Cause
Analysis
Verified?
Doesn’t get up when called.
Occurred twice in past 3 months, not on days late to class. No
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.
Yes

46. 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.

47. 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

48. Evaluate Alternate Solutions
Module 5
Evaluate Alternate Solutions

49. 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.

50. 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?)

51. 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?

52. 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
Program staff want to learn QI
BARRIERS
Employee work schedules not compatible with dates
Program time is consumed with grant requirements.

53. 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
Program staff want to learn QI
Develop efficiencies to clear out time for accreditation preparation
BARRIERS
Employee work schedules are not compatible with dates
Program time is consumed with grant requirements.

54. Elements of Planning The objective is clearly stated.
Activities are each defined.
Responsibility is assigned.
Dues dates are established.
Implementation Plan Matrix:
What
How
Who
When
Complete?
Task 1
Task 2
Task 3

55. Module 6
Test-Implement Plan

56. 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.

57. 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

58. Standardize Improvements
Module 7
Standardize Improvements

59. 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.

60. 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.