6Lao-Tse, 5th-century BC philosopher "If you tell me, I will listen. If you show me, I will see. But if you let me experience, I will learn.“Lao-Tse, 5th-century BC philosopher
7Why Quality Improvement? Foundation of new accreditation programResults of investment in public healthGetting better all the timeThe Public Health Accreditation Board’s voluntary accreditation program for state, local, tribal and territorial health departments is based on quality improvement.Particularly important in tough economic times to demonstrate to our public that their investment in the work we do is a good one. QI offers a platform to demonstrate our commitment to ensuring high quality servicesWe know we’re good at what we do, and QI tools will help us quantify – show in numerical terms – that we are getting better all the time
8Definition of Quality Improvement In Public Health “Quality improvement in public health is the use of a deliberate and defined improvement process, such as Plan- Do-Check-Act, which is focused on activities that are responsive to community needs and improving population health. It refers to a continuous and ongoing effort to achieve measurable improvements in the efficiency, effectiveness, performance, accountability, outcomes, and other indicators of quality in services or processes which achieve equity and improve the health of the community.”Defining Quality Improvement in Public Health; Journal of Public Health Management & Practice: January/February Volume 16 - Issue 1 - p 5–7, Riley, William J. PhD; Moran, John W. PhD, MBA, CQIA, CQM, CMC; Corso, Liza C. MPA; Beitsch, Leslie M. MD, JD; Bialek, Ronald MPP; Cofsky, Abbey -
9Continuous Improvement The continuous improvementphase of a process is how youmake a change in direction.The change usually is becausethe process output is deterioratingor customer needs have changed9
10Continuous Quality Improvement System in Public Health Turning Point BaldrigeQI TeamsLSSMAPPMICROBig ‘QI’MACROAPLittle ‘qi’CDBasic Tools of QIAPAPCDIndividual ‘qi’MESOCDINDIVIDUALASQFDRapidCycleCDAdvance Tools of QIDaily Management
15QA, QC, QI Plan Assure Strategic Preventive Control Tactical OperationalReal timeInspectAfter the fact
16They Are Not the Same Quality Assurance Quality Improvement Reactive Works on problems after they occurRegulatory usually by State or Federal LawLed by managementPeriodic look-backResponds to a mandate or crisis or fixed scheduleMeets a standard (Pass/Fail)Quality ImprovementProactiveWorks on processesSeeks to improve (culture shift)Led by staffContinuousProactively selects a process to improveExceeds expectations
17Contrasting Big “QI”, Little “qi”, and Individual “qi TopicBig ‘QI’ – organization-wideLittle ‘qi’ – program/unitIndividual ‘qi’ImprovementQuality ImprovementPlanningEvaluation of QualityProcessesGoalsSystem focusTied to the Strategic PlanResponsiveness to acommunity needCut across all programsand activitiesStrategic PlanSpecific project focusProgram/unit levelPerformance of a processover timeDelivery of a serviceIndividual program/unitlevel plansDaily work level focusTied to yearly individualperformancePerformance of dailyworkDaily workIndividual performanceplansContrasting Big “QI”, Little “qi”, and Individual “qi
20What Is Quality?Today the most progressive view of quality is that it is defined entirely by the customer or end user and is based upon that person's evaluation of his or her entire customer experience.The customer experience is the aggregate of all the Touch Points that customers have with the organization’s product and services, and is by definition a combination of these.
21Deming Cycle – PDCA or PDSA PDCA was made popular by Dr. Deming who is considered by many to be the father of modern quality control; however it was always referred to by him as the "Shewhart cycle."
22Continuous Improvement The continuous improvementphase of a process is how youmake a change in direction.The change usually is becausethe process output is deterioratingor customer needs have changed22
23The ABC’s of PDCA, G. Gorenflo and J. Moran Plan Check/StudyIdentify andPrioritize Opportunities7. Develop ImprovementTheory1. Reflect on the Analysis2. Develop AIMStatement8. Develop Action Plan2. Document Problems,Observation, andLessons learned3. Describe the CurrentProcessDoImplement theImprovement4. Collect Data onCurrent ProcessAct2. Collect and DocumentThe dataAdoptStandardize5. Identify All PossibleCausesAdaptDo3. Document Problems,Observations, and LessonsLearned6. Identify PotentialImprovementsAbandonPlan
24Maintenance and Standardization The Maintenance andStandardization phase of aprocess is how we hold thegains. If our process is producingthe desired results we standardizewhat we are doing.24
25Integrated Cycle The SDCA and PDCA cycles are separate but rather integrated.Once we have made a successfulchange we standardize and holdthe gain.When the process is not performingcorrectly we go from SDCA to PDCAand once we have the processperforming correctly we standardizeagain.This switching back and forth betweenSDCA and PDCA provides us withthe opportunity to keep our processcustomer focused.25
26PDCA should be repeatedly implemented in spirals of increasing knowledge of the system that converge on the ultimate goal, each cycle closer than the previous.APCDAPAPCDRapidCycle*Project DifficultyCDHold the GainsKnowledge & ExperienceRapid Cycle PDCA
27The Basic Tools of QI Flow Chart Cause and Effect Diagrams Pareto ChartCheck SheetHistogramScatter DiagramControl Chart
28Patient Flow Enter Building Greeter Possibly not Yes Clerical Screener Okay to vaccinate?TriageRNNeed medical attention?NoExitLeave BuildingEMTIs patient able to leave on own?EMT transports patient to medical facility
39AIM Problem Statements DiscreteCurrent StateTime BoundMeasureableBaselineImprovement TargetMeasures of the Target – know if we succeed
40AIM Outcome Influence Capacity Measurement Process Control Internal DiscreteMeasureableTime BoundInternalOperationalFocusExternalStrategic
41Some Tools To Help Create AIM Statements Current and Future State ModelAIM Work SheetForce Field DiagramForce and Effect Diagram
42What is the current state? Driving Forces: Future 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?Driving Forces: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?PathwayConsequencesBenefits
43(what will it improve and for whom?) AIM or Opportunity StatementAn opportunity exists to improve the________________________________________________________________________(name process, or area to work on)beginning with ___________________________________________________________(beginning boundary, starting point)and ending with __________________________________________________________.(ending boundary, finish point)This effort should improve______________________________________________________________________________________________________________________________________________(key characteristics of area the team is working on)for the ________________________________________________________________________________________________________________________________________.(customers, staff or those affected by the process under improvement)This process is important to work on now because_______________________________________________________________________(what will it improve and for whom?)
44Desired State Current State Force Field Diagram - Basic Positive ForcesNegative ForcesDesired StateCurrentState
46Force and EffectThe Force & Effect (F&E) Diagram is designed to identify barriers to agreement among team members concerning an AIM Statement.The F&E Diagram combines a Force Field and Cause & Effect Diagram.Instead of having one box on the cause and effect diagram we use a double headed effect.The first effect (far left) is the current state and the second effect (far right) is the desired future state. In between are branches of main causes that maintain the status quo. Too often we focus only on the causes of the current state without looking at what pushes us to change
48AIM Statement ExampleDetermine if our client education and teaching is effective for positive pregnancy testers in identifying the importance of seeking early prenatal care. Goal is to have % of our patients will receive prenatal care appointments in 2-3 weeks of positive pregnancy tests from the current level of 65% and 100% of clients will be using Prenatal vitamins which is currently at 70%.This project will take three months to analyze and develop solutions to trial. The trial period will last three months and then we will analyze the results, determine where we are in achieving our goal , and either standardize the solution or make adjustments or refinements if required.
49AIM Statement Example FOCUSING STATEMENT Currently we are using 5 different methods to collect mosquitoes within the county. Each of the 5 inspectors/collectors is using a method that best fits their schedule training, and motivation.This difference may be causing an extreme disparity among the collectors in regard to number of mosquitoes collected. These differences can translate into a lack of data in the respective area.The lack of data could lead to a use or misuse of control measures for mosquito control when there is an unidentified need.Lack of control may lead to mosquito borne disease outbreak and an unusually high number of nuisance complaints.The use or misuse of pesticides or other control measures costs the health department dollars. Also it could have a negative effect in regard to the public’s perception of use of pesticides. The chemicals we use are expensive and if a true measure of mosquito populations could be gained, overuse would be minimized.
50AIM Statement Example AIM STATEMENT In the coming mosquito seasons, our division needs to focus on ensuring that all the traps are set up in a manner to collect the maximum number of mosquitoes per trap site.The motivation behind this need is that some states and the EPA are moving to reduce the amounts of pesticide applied. These new laws require applicators to show with set evidence and numbers the need to apply pesticides.When these guidelines or codes go into effect, there will be harsh penalties for violations.Furthermore failure to move forward will possibly place the XYZ Health Department in violation. This is in addition to wasted money for over use of pesticides. The implementation of the program can be completed in the next (20XX) mosquito season.
51COMPONENTS OF ISSUE STATEMENT AIM Statement ExampleCOMPONENTS OF ISSUE STATEMENTThe environmental division has the ability to complete the project with employees already in place. We have complete control over the element.The project can be completed if the players allow the changes to be made if they put them into practice.Influence must be used by management to ensure that all collectors are properly executing the project. There should not be any out side influences in effect.The only element out of our control is the laziness of the collector in ensuring that the trap is set and operating properly.We need to focus on 1. Knowledge of collector 2. Use of the same water in trap 3. Ensuring batteries last duration of trap cycle 4. Moving to a 1 night trap event 5. Keep the collector motivated 6. Who is your collection substitute?
52Components of the Issue Statement Outside OurControl &InfluenceInvolve &InfluenceElementControlImplementFor each element check which column(s) applyFrom this select the area(s) of focus, develop a ranking of the elements to focus on,and write the problem statement for the Quality Improvement project to be started.
53Reduce Inconsistency Mosquito Trapping Outside OurControl &InfluenceInvolve &InfluenceElementControlImplementEducation Within Within Within InSame water Within Within Need influence InBatteries Out Within Need influence In1 night trapping Within Out Need influence InMotivation Out Out Need influence OutsideFor each element check which column(s) applyFrom this select the area(s) of focus, develop a ranking of the elements to focus on,and write the problem statement for the Quality Improvement project to be started.
56Who are recognized as top customer centric organizations?
57Who are recognized as top customer centric organizations? Marriott – extra mile for the customerSouthwest Airlines – letter of apologyPublix Market – 10 by 10 ruleNordstromOthers?
58Who are recognized as bottom of the barrel customer centric organizations?
59Dell Software Support Banks Cable Companies Credit Card Companies Who are recognized as bottom of the barrel customer centric organizations?Dell Software SupportBanksCable CompaniesCredit Card CompaniesCell phone CompaniesOthers?
60Understaffed call centers Hang Up on Customer Other reasons? Who are recognized as bottom of the barrel customer centric organizations?Why?Misplaced paper workUnhelpful clerksShort tempered clerksMisleading adsSurprise feesUnderstaffed call centersHang Up on CustomerOther reasons?
61BoseShopping at our store should be enjoyable, exciting and designed for you.
62L.L. Bean – Customer Delight Unexpected service and attentionMore than the customer expectedMore than satisfying the customerDeliver the unexpectedDeliver it with enthusiasm and sinceritySurprise the customerCreate a memory
63Next Door To L.L. Bean is J. L. Coombs - The Oldest Shoe Company in the United States“If You Do NotLike MyShoes the Hellwith you!”
64Customer Touch PointsWhen your customer (internal/external) comes in touch with your process what do they:See? (Initial reaction?)Feel?Sense?Hear?Experience?
65Understanding Your Customer Need to obtain the Voice of Your Customer:WantsNeedsSatisfiersDis-satisfiersFuture needs and wants
66Levels of Customer Satisfaction SatisfiedWowsWantsNeed not metNeed is metExpectedDissatisfiedThe Kano Model66
67Voices VOP – Voice of the Process (VOP) VOC – Voice of the Customer (VOC)VOG – Voice of the Organization (VOO)Voice of the Future (VOF)Need to balance them
68Who is Your Customer for Your Issue? What are their/your wants and needs?What will satisfy them?What will satisfy You??How can we align our needs??Communication is the key
69How To Obtain Customer Data Survey and ask themWhere to do the surveyWhat to ask?Best time to do itHow often to do it?
71“If you can't describe what you are doing as a process, you don't know what you're doing.” W. Edwards Deming
72W Edwards Deming ( )"Draw a flowchart for whatever you are doing. Until you do, you do not fully understand what you are doing. You just have a job.“"The first step in any organization is to draw a flow diagram to show how each component depends on others. Then everyone may understand what their job is. If people do not see the process, they cannot improve it."
73SIPOC+CMWhat it is:SIPOC is a data collection form that is used before we start to construct a flow chart since it helps us to gather relevant information about the process.Assists in gathering information about Suppliers, Inputs, Process, Outputs, and Customer of the process.SIPOC is high level view of the “As Is” state of a process under investigation.The C stands for constraints (barriers) facing the system and the M for the measures to be used.
74SIPOC+CM When to use it: When first starting to investigate a process and a team needs to understand the basics that make up the process.When a team needs a way to get the collective knowledge of the team members about a process recorded in an easy to view format.When we need to make a concise communication to others about a process and the parameters that it encompasses.
75SIPOC+CMHow to use it:On a piece of flip chart paper draw the SIPOC+CM diagram with seven blocks indicating the components of SIPOC+ CM.Clearly identify the process under study and define the process boundaries (start and end points) so that everyone involved understands the limits of the analysis.On the SIPOC+CM form identify the data available for each of the following major categories:Suppliers – who or what (internal or external) provides the raw materials, information, or technology to the processInputs – what are the material or information specifications that are needed by the processProcess – a highly level flow chart of the key 5 to 7 core activities that comprise the process. This is a 30,000 foot view of the process. The detail steps will be developed in the flow chart.Outputs – what the process produces as products, services, or technologyCustomers – who are the main users of the process’s output+ C –constraints facing the system or process+ M – measures being used or to be usedReview the form for completeness with relevant stakeholders, sponsors, and other interested parties.
76High Level S I P O C+CM Collection Form Constraints:Ends With:Begins With:Process/Activities:MeasuresOutputs:Inputs:Suppliers:Customers:76
78Flow ChartingFlow charting is the first step we take in understanding a processOrganized combination of shapes, lines, and textFlow 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 itShows how interactions occurMakes the invisible visible78
79Flow Chart Benefits Creates a common vision Establishes the “AS IS” baseline – Current StateBaseline to measure improvementsIdentifies wasteful steps – activities/waitsUncovers variationsShows where improvements could be made and potential impactsTraining toolCurrent state accuracy is important since it will be the point from which all improvements will be measured.Show all the problems – don’t try to cover them up79
80Flow Chart People Benefits People involved in constructing a flow chart begin to:Better understand the processUnderstand the process in the same termsRealize how the process and all the people involved, including them, fit into the overall process or businessIdentify areas for improving the processBecome enthusiastic supporters to quality and process improvement80
81Olmsted County , MN– Performance Appraisal Process
83Flow Charting Construction Clearly define the process boundaries to be studiedDefine the first and last steps – start and end pointsGet the right people in the roomDecide on the level of detailComplete the big picture first – macro viewFill in the details – micro viewGather information of how the process flows:ExperienceObservationConversationInterviewsResearchClearly define each step in the processBe accurate and honestFlowcharts don't work if they're not accurate or if the team is too far removed from the process itself.Team members should be true participants in the process and feel free to describe what really happens. A thorough flowchart should provide a clear view of how a process works.With a completed flowchart, you can:Identify time lags and non-value-adding steps.Identify responsibility for each step.Brainstorm for problems in the process.Determine major and minor inputs into the process with a cause & effect diagram.Choose the most likely trouble spots with the consensus builder.83
84Flow Charting Steps Use the simplest symbols possible – Post-Its Make sure every loop has an escapeThere is usually only one output arrow out of a process box. Otherwise, it may require a decision diamond.Trial process flow – walk through people involved in the process to get their commentsMake changes if necessaryIdentify time lags and non-value-adding steps.Flowcharts don't work if they're not accurate or if the team is too far removed from the process itself. Team members should be true participants in the process and feel free to describe what really happens. A thorough flowchart should provide a clear view of how a process works. With a completed flowchart, you can:Identify time lags and non-value-adding steps.Identify responsibility for each step.Brainstorm for problems in the process.Determine major and minor inputs into the process with a cause & effect diagram.Choose the most likely trouble spots with the consensus builder.84
86Flow Chart Construction Use a form of Post-It Notes – easier to rearrangeRealize everyone is not doing it the same way – there will be disagreementsIt will take multiple passes to get to the “As Is” State86
87Flow Chart Symbols Flow Lines Manual Operation Start/End Bookends A ConnectorData BaseCommentCollectorActivity:Operation/InspectionWait/DelayDecisionDisplayStorageInput/OutputDataTransportManualInputThese symbols are in Microsoft Power PointDocumentInputPreparationFormsOutputUnfamiliar/Research87
88Constructing 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?What is the baseline measurement of this process?The more questions everyone asks the better. 88
89Adding Time Lines Could Be Flow Chart Should Be Flow Chart As Is Flow ChartTimeTime
90Analyzing A Flow Chart Examine each: Activity symbol – value/cost? Decision point – necessary/redundant?Choke Points – bottlenecks?Rework loop – time/cost?Handoff – is it seamless?Document or data point – useful?Wait or delay symbol – why?/reduce/eliminateTransport Symbol – time/cost/location?Data Input Symbol – right format/timely?Document/Form Symbol – needed/cost/value?Unnecessary Tasks-usually paperwork or approvalDuplication-identical activities occurring at different places in the process flowDisconnects- process activities that are missing making the rest perform poorly90
91Voice of the Process - VOP Flow Charting BasicFlowCustomer - VOCInternalExternalDataVoice of the Process - VOP
92Flow Chart Summary Matrix PHF E-News, March 2, 2010,ActualProposedFlow Chart Step NumberType of StepDelta+/-∑∑P D P T W P D STouch Point (√)CostFTEs/Person Hrs.Supplies RequiredEquipment RequiredSpace RequiredTimeCost of QualityPartnerships NeededEtc.Value addedType of Step: P – process, D – decision, T – transport, W – wait, S – storageDelta = Proposed – Actual – the more negative the subtraction the better – more savings
95LSS5S is a visual method of setting the workplace in order. It is a system for workplace organization and standardization.The five steps that go into this technique:Seiri – sort – essential itemsSeiton – set in order – promote work flowSeison – shine – clean workplaceSeiketsu – standardize - consistencyshitsuke)- sustain – hold the gains
96Definition of 8 Types of Waste: DescriptionPublic Health ExampleOverproductionItems being produced in excess quantity and products being made before the customer needs themInsurance filing or immunization record opened before all required information is receivedWaitingPeriods of inactivity in a downstream process that occurs because an upstream activity does not produce or deliver on time.Paperwork waiting for management signature or reviewUnnecessaryMotionExtra steps taken by employees and equipment to accommodate inefficient process layouts.Immunology testing equipment stored in cabinets far from specialist work area.TransportationHandlingUnnecessary movement of materials or double handlingDepartment vehicles stored in central facility, requiring constant movement of vehicles to and from other high traffic locationsOver-processingSpending more time than necessary to produce the product or serviceCombining client survey instruments into one form rather than develop specific instruments for each programUnnecessary InventoryAny excess inventory that is not directly required for the current client’s orderOver estimating vaccination support materials requiring additional locked storage cages, inventory counting and reconciliationDefectsErrors produced during a service transaction or while developing a product.Ineffective scripts for initial intake applications. Unclear directions for filling out required formsDuplicationHaving to re-enter data or repeat details on forms.Poorly designed client intake computer screens or services checklists
98“Not everything that can be counted counts, and not everything that counts can be counted.” Albert Einstein
99"In God we trust, all others bring data.“ -W. Edwards Deming
100Why Measure?You can't manage what you don't measure. It is an old management adage that is accurate today.Unless you measure something you don't know if it is getting better or worse.You can't manage for improvement if you don't measure to see what is getting better and what isn't.
101Definitions . Measure: The verb means "to ascertain the measurements of“Measurement: The figure, extent, or amount obtained by measuring“Metric: "A standard of measurement“Benchmark: "A standard by which others may be measured or compared"
102Attributes of Measures Aligned to the strategy of the organizationAccuracy of Input - answers critical questionsTimeliness of inputQuality/use ability of outputAccuracy of outputReadily availableEnergizes user into actionManage what you measureGraphically displayed - show it in a simple usable format
103Ask how can we measure that when developing the AIM Statement? MeasurementMeasurement is critical to performance improvement and is the most difficult part of the processStart thinking of Measurement at the very beginning of the process.Ask how can we measure that when developing the AIM Statement?
104Develop an improvement theory. An improvement theory is a statement that articulates the effect that you expect the improvement to have on the problem.Writing an improvement theory crystallizes what you expect to achieve as a result of your intervention, and documents the connection between the improvement you plan to test and the measurable improvement objective.
105Test MethodologyTest method is a definitive procedure that produces a test result.A test can be considered as technical operation that consists of determination of one or more characteristics of a given product, process or service according to a specified procedure.The test result can be:qualitative (yes/no)quantitative (a measured value)personal observationoutput of a precision measuring instrument.
107The Public Health Quality Improvement Handbook, R. Bialek, G. Duffy, J The Public Health Quality Improvement Handbook, R. Bialek, G. Duffy, J. Moran, Quality Press, 2009, p. 147
108What is the purpose of sampling? To draw conclusions about populations from samples.To help us determine a population's characteristics by directly observing only a portion or sample of the population using statisticsWe obtain a sample rather than a complete enumeration (a census ) of the population for many reasons:EconomyTimelinessInaccessibility of some of the populationDestructiveness of the observation
109Target PopulationThe researcher must clearly define the target population.There are no strict rules to follow, and the researcher must rely on logic and judgment.The population is defined in keeping with the objectives of the study
110Problem DefinitionIn sampling, this includes defining the population from which our sample is drawn.A population can be defined as including all people or items with the characteristic one wishes to understand.Because there is very rarely enough time or money to gather information from everyone or everything in a population, the goal becomes finding a representative sample (or subset) of that population.
111Sampling FrameIt has the property that we can identify every single element and include any in our sampleThe sampling frame must be representative of the population
112Sampling Frame Problems 1. Missing elements: Some members of the population are not included in the frame.2. Foreign elements: The non-members of the population are included in the frame.3. Duplicate entries: A member of the population is surveyed more than once.4. Groups or clusters: The frame lists clusters instead of individuals.
113Sampling Methods Classified as either Probability or Non-Probability. Probability samples, each member of the population has a known non-zero probability of being selected.The advantage of probability sampling is that sampling error can be calculated. Sampling error is the degree to which a sample might differ from the population.Non-probability sampling, members are selected from the population in some nonrandom manner.In non-probability sampling, the degree to which the sample differs from the population remains unknown.
115Non-sampling errors are caused by the mistakes in data processing: Overcoverage: Inclusion of data from outside of the population.Undercoverage: Sampling frame does not include elements in the population.Measurement error: The respondent misunderstand the question.Processing error: Mistakes in data coding.Non-response
116RisksType I risk, or alpha risk is the "reasonable doubt." It is the chance of wrongly rejecting the null hypothesis when it is true. In acceptance sampling, it is the producer's risk, or risk of wrongly rejecting a lot that meets requirements.The Type II risk or beta risk is the chance of accepting the null hypothesis when it is false. The "consumer's risk" is the Type II risk for an acceptance sampling plan. It is the chance of passing a lot that does not meet the requirements.Type I risk – convict an innocent defendantType II risk – acquit a guilty defendant.
117Errors Statistical Decision Null Hypothesis is True Null Hypothesis is FalseReject theNull HypothesisType 1 ErrorCorrectConvict an InnocentPersonAccept theNull HypothesisCorrectType 2 ErrorAcquit a Guilty PersonNull Hypothesis – person is innocent
123Cause and Effect Diagrams Moving from Treating SymptomsToTreating Causes
124Problem Solving – What we usually see is the tip of iceberg – “The Symptom” The Root CausesInvisibleHidden124
125Problem SolvingWhen confronted with a problem most people like to tackle the obvious symptom and fix itThis often results in more problemsUsing a systematic approach to analysis the problem and find the root cause is more efficient and effectiveSymptom – sign or indicationCause – whatever makes something happen
126Cause and Effect Diagrams - Construction Write the issue as a problem statement on the right hand side of the page and draw a box around it with an arrow running to it. This issue is now the effectEffect
127Cause and Effect Diagrams - Construction Generate ideas as to what are the main causes of the effectLabel these as the main branch headersOrganizes group knowledge about causes of a problem and display the information graphicallyHeaderHeaderEffectHeaderHeader
128Cause and Effect Diagrams - Construction Typical Main Header are:4 M’s – Manpower, Materials, Methods, MachineryPeoplePoliciesMaterialsEquipmentLife styleEnvironmentEtc.
129Cause and Effect Diagrams - Construction For each main cause category brainstorm ideas as to what are the related sub-causes that might effect our issueUse the 5 Why techniques when a cause is identifiedKeep repeating the question until no other causes can be identifiedList the sub-cause using arrowsHeaderHeaderwhywhywhyEffectwhyHeaderHeader
130Selecting Items to Investigate When the Cause and Effect Diagram is finished it is time to decide what few areas should be focused on to develop solutions to solve the effect.Some are obvious – low hanging fruitSome require some research using the other QI tools such as:Pareto DiagramsRun ChartsSurveysHistogramsEtc.
131Pre Natal Practices Early Feeding Practices Life Style Environment Excess MaternalWeight GainDecreased BreastFeedingBottle PacifierTV ViewingNo Time ForFood PrepJuicesLess Fruits and Veg.Sodas/SnacksOver WeightNewbornNo Outdoor PlayLessIncomeUnsafeMaternal ChoicesObese ChildrenBuilt Environment ForStrollers Not ToddlingUnhealthy Food ChoicesGenesCurriculumFew Community RecreationalAreas or ProgramsSyndromesLess Indoor MobilityNo SidewalksTVPacifierUnsafeHousingOver WeightPre SchoolLess Vigorous ExerciseAt HomeAt SchoolEnvironmentPoliciesGenetics
135Root Cause Analysis Rating Form Impact on the ProblemPotentialRootCauseImprovedCustomerSatisfactionImprovedQualityReducedCostsOthersTotalScoreRankingImpact Scoring Scale: Low = 1, Medium = 3, High = 5
139Solution and Effect Diagram Similar to the Cause and Effect DiagramIdentifies changes and recommendationsEffect is now made into a positive statement:“What are the causes of Childhood Obesity”How to prevent Childhood Obesity”
140Solution and Effect Diagrams - Construction Place the Solution and Effect Diagram opposite the Cause and Effect DiagramWrite the issue as a positive statement on the left hand side of the page and draw a box around it with an arrow running to it. This issue is now the effectPositiveEffect
141Solution and Effect Diagrams - Construction Generate ideas as to what are the main Solutions of the effectLabel these as the main branch headersSolutionSolutionEffectSolutionSolution
142Solution and Effect Diagrams - Construction For each main Solution category brainstorm ideas as to what are the related sub-solutions that might effect our issueUse the 5 How techniques when a solution is identifiedKeep repeating the question until no other solutions can be identifiedList the sub-solutions using arrowsSolutionSolutionEffectSolutionSolution
143Solution and Effect Diagram CauseSolutionWhy?How?Why?How?Why?How?How?Why?EffectWhy?How?EffectSolutionSolutionCauseCauseC = Cause CategoryS = Solution Category
144Pre Natal Practices Early Feeding Practices Life Style Environment LessObese ChildrenMore MobilityCommunity RecreationalAreasLess TVSidewalksSafe HousingEnvironmentPolicesGenetics
1465 How’s of More Vigorous Exercise Less TV and Video GamesHow?More Community SponsoredRecreation ProgramsHow?More Family Recreational ActivitiesHow?Safe Play AreasHow?Additional ResourcesHow?146
147Selecting Items to Investigate When the Solution and Effect Diagram is finished it is time to decide what few areas should be focused on to develop solutions to solve the effect.
148Root Cause Analysis Solution Impact Analysis PotentialSolutionsCorrectiveActionTypeVerificationMethodCostToFixBenefitOfFixCostBenefitRatioSelected?Y/NCorrective Action Type: Immediate but Interim – II, Short-term Temporary - ST,Permanent – Short Term – PST, and Permanent – Long Term - PLT
149Solution and Effect Diagrams Cautions:Do not jump to quickly to Solution and EffectUse after a detailed analysis of “Cause”If you are still listing Causes – not enough detail on the Cause and Effect DiagramAsk if the proposed solution(s) will improve the effect or cause more problems
151Solution and Effect Diagram How To MakeEmployees OnTime For Work?
152What Can Go Wrong? - PDPC Ask the killer question Do not be surprised by the amount of problems a group can generate about a solution they have devisedPeople thrive on failureEveryone knows something will go wrong – it is not “If” but “When”Remember the National Lampoon’s Griswold vacation to Walley World?
153What Can Go Wrong?If we wanted this to fail, how could we accomplish that?What assumptions are we making that could turn out to be wrong?What has been our experience in similar situations in the past?Does this depend on actions, conditions or events?Are these controllable or uncontrollable?Decide how practical each countermeasure is by using criteria such as:Costtime requiredease of implementationeffectiveness
154Check How will we know if we are successful? What are the indicators of success?
155The ABC’s of PDCA, G. Gorenflo and J. Moran Plan Check/StudyIdentify andPrioritize Opportunities7. Develop ImprovementTheory1. Reflect on the Analysis2. Develop AIMStatement8. Develop Action Plan2. Document Problems,Observation, andLessons learned3. Describe the CurrentProcessDoImplement theImprovement4. Collect Data onCurrent ProcessAct2. Collect and DocumentThe dataAdoptStandardize5. Identify All PossibleCausesAdaptDo3. Document Problems,Observations, and LessonsLearned6. Identify PotentialImprovementsAbandonPlan
156Check/Study/ObserveThis phase involves analyzing the effect of an intervention.Compare the new data to the baseline data to determine whether an improvement was achieved.Whether the measures in the aim statement were met.
157Check/Study/Observe1. Reflect on the analysis, and consider any additional information that emerged as well. Compare the results of your test against the measurable objective2. Document lessons learned, knowledge gained, and any surprising results that emerged.Source: The ABCs of PDCA, Grace Gorenflo and John W. Moran,
158Check/Study/ObserveTools that can assist :Pareto chartsHistogramsRun chartsScatter plotsControl chartsRadar charts.
160Data Decision Maker 40% Data 60% Information Data by itself has no value – it just shows information.Information requires interpretation for it to have value.Decision makers add value through interpretationDecision Maker40% Data 60% Information
161Types of DataQuantitativeCan be discrete or continuousDiscrete Variables - counted or enumerated - # pills in a bottleContinuous – measured – length, width, weight, pressure, etc.
162Types of Data Qualitative Always discrete Attribute data Placed into two or more attribute categoriesYes/NoInfected/Not InfectedPass/FailPositive/NegativeGood/BadMale/FemaleRed/Yellow/GreenDead/Alive
164“Whenever there is fear, you will get wrong figures.” Data Management“Whenever there is fear, you will get wrong figures.”W. Edwards Deming
165Data Management Strategy CollectRaw DataCollectingTranslating – use data tablesConsolidateInterpretSummarizing – use descriptive statisticsCommunicateFraming - use charts/graphs
166Data Collection Questions Before collecting data we must answer the following questions:What is the purpose for collecting this data? What type of data is going to be collected?Where will the data be collected?Who will collect the data?When will they collect the data?How will they be trained to collect the data?What will we do with it after we collect the data?How will we summarize and present the data?
167Getting Good DataUnderstand the process being studied – walk itMake the collection simpleDefine where the data will be collected – collection pointsUse checksheets and checklists to helpMinimize the “other” category – by good classifications - too often the largest bar on a chartEstablish collection rules – sampling
168Getting Poor DataLack of training on what to doUnclear directionsAmbiguous terminology – need yearly data – fiscal or calendar year?Different units of measures – 9/23/99 – Mars spacecraft was a $125m lost because it missed entry by 100km – NASA used the metric system and Lockheed used the English units – inches versus metersMathematical errors – rounding, calculation, order of calculations, etc.
169There are three kinds of lies: Lies, Damned Lies, and Statistics
170Descriptive Statistics The majority of our data collection will be done through samplingPopulations versus SamplesPopulation parameters: μ and σSample statistics: Х and s
171Descriptive Statistics Measures of Central Tendency:Mean – arithmetic average of the items sampledMedian – middle value in the sampleMode – the one that most frequently occurs
172Descriptive Statistics These statistical measures help us to understand how the data is distributed:Symmetrical – normal – bell shapedSkewed – left or rightRectangularAlways plot the data and confirm the shape of the data
173Descriptive Statistics “A central theme of the statistical approach to data analysis is this:Variability always exists. No experiment can be repeated exactly.Variability can never be totally eliminated.”“Statistics An Introduction”, A Rickmers and H. Todd, Mc Graw-Hill, 1967, page v
174Descriptive Statistics – Variation Variation is everywhereIt is found in the output of any process of manufacturing, service, or administrativeBut variation is not all bad since it always displays a pattern or a distribution of itselfThese patterns or distributions can tell us a great deal about the process itself and the causes of problems found in the processHistograms help us identify and interpret these patterns
175Descriptive Statistics Measures of Variability: DispersionRange – Highest Value – Lowest ValueVariance – how much spread in our sample data - scatterStandard Deviation – dispersion of a random variable about its mean
176Descriptive Statistics The measures of central tendency and the measures of variability when compared to historical data can help us determine if:The center of the process has shiftedThe variability of the process has increasedCombination of both of the above
177Descriptive Statistics When constructing data tables and graphs:Do not throw any data awayKnow what type of data you are dealing with – qualitative or quantitativeKnow if the data is discrete or continuousLabel everything appropriatelyKeep it clear and simple
178TAPP/PDCA Integration* PlanTargetMonitorGapDoProcessActMonitorCheckPerformanceGap = Performance versus TargetAct only when Performance is below TargetSmall gaps – just fix itLarger gaps need a PDCA Cycle* Reference Article
179Check How will we know if we are successful? What are the indicators of success?Develop a few Indicators of project success
185HistoryThe first Gantt Chart was developed by Karol Adamiecki, who called it a HarmonogramBecause Adamiecki did not publish his chart until 1931, this famous chart bears Henry Gantt's name (1861–1919) designed his chart in 1910Wikipedia, the free encyclopedia
187Gantt Chart Henry L. Gantt – WWI Franklin Arsenal 1910Progress ChartWork planned and accomplished are shown in the same spaceEmphasizes work movement through timeDeals with plans and progressHelps identify and eliminate obstaclesThe Gantt Chart – William Clark, The Ronald Press Co, NY 1922187
188Gantt Charts A Gantt chart is a matrix diagram The vertical axis lists all the tasks to be performed for a projectEach row contains a single task identificationThe horizontal axis is headed by columns indicating estimated task duration in hours, days, weeks, months, etc., skill level needed to perform the task, and the name of the person assigned to the task, followed by one column for each period in the project's duration.188
191Use Of Gantt Charts Establish order of tasks: Sequential and ParallelIdentify resources requirementsTiming of resource needsIdentify the critical pathMonitor the project “On-Time” ScheduleAlerts where remedial action is required
192Traffic Light Gantt Chart Task: City of XYZ HD29-Feb7-Mar14-Mar21-Mar28-MarFinalize assessment analysisXGain consensus on prioritiesIdentify comm. with elected off.Plan PHF consultant visitSet agenda and travel scheduleCity HD/PHF PI meetingOn ScheduleWatchLate or at RiskUse Excel to build itHelps make projections on potential progresshighlights potential problemsVery Visual192
193Act Solution works: Solution does not work: Standardize Train Measure Continue to improveSolution does not work:RegroupNew teamNew AIM
194Communication PlanDecide who/what/where/when of the Communication PlanDescribe the end “game” – begin with the end in mindMake it flow – easy to understand and digestFront load – important points first – get their interestStress the benefits to the listener – WIIFMAsk for commitment – will you support the effort?If not – why?
196Documenting The Impact Of QI How many times have you reached the end of a quality improvement project only to be unsure of what has actually been accomplished?It is not unusual to get so caught up in the solving of the problem that we forget to accurately document what we did, when we did it, and what it accomplished.
197Documenting The Impact Of QI A quality improvement team moves quickly on its quest to gather data and solve problems but can easily delay recording what the interventions actually accomplished.It is difficult to recall or recreate history since people involved in the project usually have sketchy and conflicting memories of what was done, when it was done and the associated impact.
198Documenting The Impact Of QI Start as soon as you have developed the AIM statement.Develop a process by which you can document what quality improvements take place”What they were?When they where implemented?What change resulted?How much was the change?Other questions?
199Documenting The Impact Of QI It is easier to document in real time then to recreate history.Besides being a more accurate description of what has happened it also gives the quality improvement team a vehicle to start making predictions as to what
200Intervention and Impact Form AIM Statement Description: 184.108.40.206.220.127.116.11.Intervention NumberDateWhat Was The Change?How Did It Impact The AIM?How Did Your Thinking Change?How Did It Impact Your Procedures?How Did It Impact Your Customer?How Do You Know?Measures
201Documenting Unintended Consequences Unintended Consequences may happen.Being prepared for Unintended Consequences makes the process of dealing with them easier and quicker.
202Unintended Consequences Often “Unintended Consequences” arise from some of the interventions. Many could not be foreseen since they are a result of the interaction of the intervention with the process where it is being implemented.Unintended consequences happen frequently in quality improvement projects and these need to be tracked along with the interventions.Some of these unintended consequences may result in the quality improvement team developing a sub-AIM statement which will also have to be tracked and monitored.
203The following columns can be added to the Intervention and Impact Form when needed to track the impact of unintended consequences.9101112131415Unintended Consequence LetterUnintendedConsequenceDescriptionDate It HappenedImpact To Aim StatementNeed a Sub AIM Statement?Impact to CustomerModificationsMadeIntervention and Impact Form when needed to track the impact of unintended consequences.
205Stages Of Team Development Each stage has two components that compete with each other:Task FocusTeam BehaviorApplications and Tools for Creating and Sustaining Healthy Teams, Public Health Foundation, April 2011Tools_for_Creating_and_Sustaining_Healthy_Teams.aspx
206Stages Of Team Development Each stage has two components that compete with each other:Task FocusTeam BehaviorApplications and Tools for Creating and Sustaining Healthy Teams, Public Health Foundation, April 2011Tools_for_Creating_and_Sustaining_Healthy_Teams.aspx
207Top Ten Reasons Teams Fail AIM StatementTeam CharterTeam MembersProblem Solving ProcessRapid CycleTeam MaturityBase Line DataTrainingRoot Cause Analysis (RCA)Pilot Testing
208Train The Trainer Overview AssignmentsProject expectationsNext session
209Train The Trainer Overview Assignment for Teams: Topic LHD AssignedIntroduction to QIAIM statement (SMART)SIPOC-CMForce and Effect analysisFlowchart (Basic or Deployment)Flow Chart Summary FormCause and Effect (RCA) /5 whysForming, Storming, Norming,Performing, Adjourning
210Wrap Up Finish Post Test Next Steps? Planning Time Team Reports Adjourn