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Utah Association of Local Health Departments Quality Improvement Workshop September 21 st and 22 nd, 2011.

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Presentation on theme: "Utah Association of Local Health Departments Quality Improvement Workshop September 21 st and 22 nd, 2011."— Presentation transcript:

1 Utah Association of Local Health Departments Quality Improvement Workshop September 21 st and 22 nd, 2011

2 Workshop Overview Welcome Remarks Introductions Why are we here? Expectations Pre Test

3 … PHF Mission: We improve the public’s health by strengthening the quality and performance of public health practice Innovative Solutions. Measurable Results.

4 Contact Information Jack Moran T: – 0560 Grace Duffy T: cell

5 Introduction to QI

6 "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

7 Why Quality Improvement? Foundation of new accreditation program Results of investment in public health Getting better all the time

8 Definition 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 -

9 Continuous Improvement Plan Do Check/ Study Act The continuous improvement phase of a process is how you make a change in direction. The change usually is because the process output is deteriorating or customer needs have changed

10 MACRO MESO MICRO INDIVIDUAL Turning Point Baldrige QFD LSS Daily Management P DC A P DC A P DC A S DC A Big ‘QI’ Little ‘qi’ Individual ‘qi’ QI Teams Rapid Cycle Advance Tools of QI Basic Tools of QI Continuous Quality Improvement System in Public Health MAPP

11 General Approach On How To Use The Basic Tools Of Quality Improvement Issue To Consider Flow Chart Existing Process Brainstorm & Consolidate Data Cause & Effect Diagram – Greatest Concern Use 5 Whys To Drill Down To Root Causes Gather Data On Pain Points Translate Data Into Information Pie Charts Pareto Charts Histograms Scatter Plots, etc. Flow Chart New Process Monitor New Process & Hold The Gains Run Charts Control Charts Data Management Strategy “As Is” State to “Should Be” State “As Is” State Brainstorming Force and Effect Analyze Information and Develop Solutions Solution and Effect Diagram Source: The Public Health Quality Improvement Handbook, R. Bialek, G. Duffy, J. Moran, Editors, Quality Press, © 2009, p.160 “AIM”

12 Quick Check Of Your Enthusiasm Level & Mathematical Skills

13 Enthusiasm Level High Low High Mathematical Skills Low/Low High/Low High/High Low/High

14 Enthusiasm Level High Low High Mathematical Skills Low/Low High/Low High/High Low/High

15 Plan Strategic Preventive Assure Tactical Preventive Control Operational Real time Inspect Operational After the fact QA, QC, QI

16 They Are Not the Same Quality Assurance Reactive Works on problems after they occur Regulatory usually by State or Federal Law Led by management Periodic look-back Responds to a mandate or crisis or fixed schedule Meets a standard (Pass/Fail) Quality Improvement Proactive Works on processes Seeks to improve (culture shift) Led by staff Continuous Proactively selects a process to improve Exceeds expectations

17 TopicBig ‘QI’ – organization-wideLittle ‘qi’ – program/unit Improvement Quality Improvement Planning Evaluation of Quality Processes Quality Improvement Goals Individual ‘qi’ Contrasting Big “QI”, Little “qi”, and Individual “qi System focus Tied to the Strategic Plan Responsiveness to a community need Cut across all programs and activities Strategic Plan Specific project focus Program/unit level Performance of a process over time Delivery of a service Individual program/unit level plans Daily work level focus Tied to yearly individual performance Performance of daily work Daily work Individual performance plans

18 General Approach On How To Use The Basic Tools Of Quality Improvement Issue To Consider Flow Chart Existing Process Brainstorm & Consolidate Data Cause & Effect Diagram – Greatest Concern Use 5 Whys To Drill Down To Root Causes Gather Data On Pain Points Translate Data Into Information Pie Charts Pareto Charts Histograms Scatter Plots, etc. Flow Chart New Process Monitor New Process & Hold The Gains Run Charts Control Charts Data Management Strategy – Ch. 14 “As Is” State to “Should Be” State “As Is” State Brainstorming Force and Effect Analyze Information and Develop Solutions Solution and Effect Diagram Source: The Public Health Quality Improvement Handbook, R. Bialek, G. Duffy, J. Moran, Editors, Quality Press, © 2009, p.160 “AIM”

19 Large Issue, Cross Functional Problem, or Sensitive Situation Explore Brainstorming Affinity Diagram Sort & Prioritize Interrelationship DiGraph Prioritization Matrix Understand & Baseline Radar Chart SWOT Analysis Develop Actions & Tasks Tree Diagram Prioritize Actions & Tasks Control & Influence Plots Prioritization Matrix Know & Don’t Know Matrix Develop Project Plans Monitor PERT Gantt Chart SMART Chart Figure 4 PDPC Problem Prevention General Approach On How To Use The Advance Tools Of Quality Improvement Source: The Public Health Quality Improvement Handbook, R. Bialek, G. Duffy, J. Moran, Editors, Quality Press, © 2009, p.190

20 What 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. ouch Points 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.

21 Deming 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."

22 Continuous Improvement Plan Do Check/ Study Act The continuous improvement phase of a process is how you make a change in direction. The change usually is because the process output is deteriorating or customer needs have changed

23 Plan 1.Identify and Prioritize Opportunities 2. Develop AIM Statement 3. Describe the Current Process 4. Collect Data on Current Process 5. Identify All Possible Causes 6. Identify Potential Improvements 7. Develop Improvement Theory 8. Develop Action Plan 1.Implement the Improvement Do 2. Collect and Document The data 3. Document Problems, Observations, and Lessons Learned Check/ Study 1. Reflect on the Analysis Act 2. Document Problems, Observation, and Lessons learned Adopt Adapt Abandon Standardize Do Plan The ABC’s of PDCA, G. Gorenflo and J. Moran

24 Maintenance and Standardization Standardize Do Check/ Study Act The Maintenance and Standardization phase of a process is how we hold the gains. If our process is producing the desired results we standardize what we are doing.

25 Integrated Cycle The SDCA and PDCA cycles are separate but rather integrated. Once we have made a successful change we standardize and hold the gain. When the process is not performing correctly we go from SDCA to PDCA and once we have the process performing correctly we standardize again. This switching back and forth between SDCA and PDCA provides us with the opportunity to keep our process customer focused.

26 P DC A P DC A P DC A Knowledge & Experience Project Difficulty PDCA should be repeatedly implemented in spirals of increasing knowledge of the system that converge on the ultimate goal, each cycle closer than the previous. Hold the Gains Rapid Cycle* Rapid Cycle PDCA

27 The Basic Tools of QI Flow Chart Cause and Effect Diagrams Pareto Chart Check Sheet Histogram Scatter Diagram Control Chart

28 Enter Building Greeter Patient Flow Possibly not Yes Clerical Screener Okay to vaccina te? Triage RN Okay to vaccina te? Need medical attentio n? No ExitLeave Building EMT Is patient able to leave on own? No Yes No Yes EMT transports patient to medical facility

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30 Cause and Effect Diagram Poor HIV Testing Client Test Location Don’t see benefit Counseling Not Client Centered Inconvenient Staff Not Respectful Fearful Not Offered Poor Experience Too Public Don’t Want Test

31 NC Accreditation Collaborative

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33 Measured In Inches Tally Grouped Absolute Frequency Absolute Cumulative Frequency Relative Frequency Cumulative Relative Frequency I II IIII IIIII IIIII IIIII IIIII IIIII IIIII IIIII IIIII III IIIII IIIII IIIII IIIII I IIIII IIIII IIII IIIII IIII IIII I I Cell Mid-Point Cell Boundary Grouped Frequency Distribution Table

34 Frequency Polygon & Histogram – Grouped Data Absolute Frequency

35 Obese Children Age in Years BMI – kg/m² Scatter Plot

36

37 Run Chart Time Measurement Median Line x x x x x x x x

38 Control Chart

39 AIM Problem Statements Discrete Current State Time Bound Measureable Baseline Improvement Target Measures of the Target – know if we succeed

40 AIM Discrete Measureable Time Bound Control Influence External Internal Operational Strategic Outcome Process Measurement Focus Capacity

41 Some Tools To Help Create AIM Statements 1.Current and Future State Model 2.AIM Work Sheet 3.Force Field Diagram 4.Force and Effect Diagram

42 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? Pathway Consequences Driving Forces: Benefits

43 AIM or Opportunity Statement An 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?)

44 Positive ForcesNegative Forces Current State Force Field Diagram - Basic Desired State

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46 Force and Effect The 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

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48 AIM Statement Example Determine 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.

49 AIM 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.

50 AIM 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.

51 AIM Statement Example COMPONENTS OF ISSUE STATEMENT The 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?

52 Components of the Issue Statement ElementControlImplement Involve & Influence Outside Our Control & Influence For each element check which column(s) apply From 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.

53 Reduce Inconsistency Mosquito Trapping ElementControlImplement Involve & Influence Outside Our Control & Influence For each element check which column(s) apply From 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. Education Within Within Within In Same water Within Within Need influence In Batteries Out Within Need influence In 1 night trapping Within Out Need influence In Motivation Out Out Need influence Outside

54 LHD’s Work On Their Draft AIM Statements

55 Customer Centric Organizations

56 Who are recognized as top customer centric organizations?

57 Marriott – extra mile for the customer Southwest Airlines – letter of apology Publix Market – 10 by 10 rule Nordstrom Others?

58 Who are recognized as bottom of the barrel customer centric organizations?

59 Dell Software Support Banks Cable Companies Credit Card Companies Cell phone Companies Others?

60 Who are recognized as bottom of the barrel customer centric organizations? Why? Misplaced paper work Unhelpful clerks Short tempered clerks Misleading ads Surprise fees Understaffed call centers Hang Up on Customer Other reasons?

61 Bose Shopping at our store should be enjoyable, exciting and designed for you.

62 L.L. Bean – Customer Delight Unexpected service and attention More than the customer expected More than satisfying the customer Deliver the unexpected Deliver it with enthusiasm and sincerity Surprise the customer Create a memory

63 Next Door To L.L. Bean is J. L. Coombs - The Oldest Shoe Company in the United States “If You Do Not Like My Shoes the Hell with you!”

64 Customer Touch Points When your customer (internal/external) comes in touch with your process what do they: See? (Initial reaction?) Feel? Sense? Hear? Experience?

65 Understanding Your Customer Need to obtain the Voice of Your Customer: Wants Needs Satisfiers Dis-satisfiers Future needs and wants

66 Levels of Customer Satisfaction Satisfied Need is met Need not met Dissatisfied Expected Wants Wows The Kano Model

67 Voices 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

68 Who 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

69 How To Obtain Customer Data Survey and ask them Where to do the survey What to ask? Best time to do it How often to do it?

70 Flow Charting

71 “If you can't describe what you are doing as a process, you don't know what you're doing.” W. Edwards Deming

72 W 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."

73 SIPOC+CM What 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.

74 SIPOC+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.

75 SIPOC+CM How 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 process Inputs – what are the material or information specifications that are needed by the process Process – 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 technology Customers – who are the main users of the process’s output + C –constraints facing the system or process + M – measures being used or to be used Review the form for completeness with relevant stakeholders, sponsors, and other interested parties.

76 Process/Activities: Begins With: Ends With: Inputs: Suppliers: Outputs: Customers: Constraints: High Level S I P O C+CM Collection Form Measures

77 SIPOC+CM

78 Flow Charting Flow charting is 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 visible

79 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 Shows where improvements could be made and potential impacts Training tool

80 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

81 Olmsted County, MN – Performance Appraisal Process

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83 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

84 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 through people involved in the process to get their comments Make changes if necessary Identify time lags and non-value-adding steps.

85 Flow Charting Moments Aha! Surprise Bafflement Duh! Embarrassment Disappointment

86 Flow Chart Construction Use a form of Post-It Notes – easier to rearrange Realize everyone is not doing it the same way – there will be disagreements It will take multiple passes to get to the “As Is” State

87 Flow Chart Symbols Activity: Operation/Inspection Decision Start/End Bookends Document Wait/Delay Storage Data Base Transport Input Output Flow Lines A Connector Forms Comment Collector Input/ Output Data Manual Operation Preparation Manual Input Display Unfamiliar/ Research

88 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? What is the baseline measurement of this process?

89 Adding Time Lines As Is Flow Chart Could Be Flow ChartShould Be Flow Chart Time

90 Analyzing 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/eliminate Transport Symbol – time/cost/location? Data Input Symbol – right format/timely? Document/Form Symbol – needed/cost/value?

91 Flow Charting Basic Flow Data Voice of the Process - VOP Customer - VOC Internal External

92 Flow Chart Summary Matrix PHF E-News, March 2, 2010, ∑ Flow Chart Step Number Type of Step Type of Step: P – process, D – decision, T – transport, W – wait, S – storage Delta = Proposed – Actual – the more negative the subtraction the better – more savings 1.Touch Point (√) 2.Cost 3.FTEs/Person Hrs. 4.Supplies Required 5.Equipment Required 6.Space Required 7.Time 8.Cost of Quality 8.Partnerships Needed 9.Etc. 10.Value added Actual Delta +/- ∑ Proposed P D P T W P D S

93 Flow Charting Exercise

94 Lean Check List

95 LSS 5S 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 items Seiton – set in order – promote work flow Seison – shine – clean workplace Seiketsu – standardize - consistency shitsuke)- sustain – hold the gains

96 Definition of 8 Types of Waste: WasteDescriptionPublic Health Example OverproductionItems being produced in excess quantity and products being made before the customer needs them Insurance filing or immunization record opened before all required information is received WaitingPeriods 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 review Unnecessary Motion Extra steps taken by employees and equipment to accommodate inefficient process layouts. Immunology testing equipment stored in cabinets far from specialist work area. Transportation Handling Unnecessary movement of materials or double handling Department vehicles stored in central facility, requiring constant movement of vehicles to and from other high traffic locations Over-processingSpending more time than necessary to produce the product or service Combining client survey instruments into one form rather than develop specific instruments for each program Unnecessary Inventory Any excess inventory that is not directly required for the current client’s order Over estimating vaccination support materials requiring additional locked storage cages, inventory counting and reconciliation DefectsErrors produced during a service transaction or while developing a product. Ineffective scripts for initial intake applications. Unclear directions for filling out required forms DuplicationHaving to re-enter data or repeat details on forms. Poorly designed client intake computer screens or services checklists

97 Measurement Part 1

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

100 Why 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.

101 Definitions. 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"

102 Attributes of Measures Aligned to the strategy of the organization Accuracy of Input - answers critical questions Timeliness of input Quality/use ability of output Accuracy of output Readily available Energizes user into action Manage what you measure Graphically displayed - show it in a simple usable format

103 Measurement Measurement is critical to performance improvement and is the most difficult part of the process Start thinking of Measurement at the very beginning of the process. Ask how can we measure that when developing the AIM Statement?

104 Develop 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.

105 Test Methodology Test 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 observation output of a precision measuring instrument.

106 Sampling and Surveying Tips and Techniques

107 The Public Health Quality Improvement Handbook, R. Bialek, G. Duffy, J. Moran, Quality Press, 2009, p. 147

108 What 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 statistics We obtain a sample rather than a complete enumeration (a census ) of the population for many reasons: Economy Timeliness Inaccessibility of some of the population Destructiveness of the observation

109 Target Population The 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

110 Problem Definition In 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.

111 Sampling Frame It has the property that we can identify every single element and include any in our sample The sampling frame must be representative of the population

112 Sampling 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.

113 Sampling 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.

114 Types of Sampling Systematic Sampling Stratified Sampling Convenience Sampling Judgment Sampling Snowball Sampling

115 Non-Sampling Error Non-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

116 Risks Type 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 defendant Type II risk – acquit a guilty defendant.

117 Errors Null Hypothesis is True Null Hypothesis is False Statistical Decision Reject the Null Hypothesis Type 1 Error Accept the Null Hypothesis Type 2 Error Correct Null Hypothesis – person is innocent Convict an Innocent Person Acquit a Guilty Person

118 Sample Size Determinants Accuracy/Confidence – alpha/beta risk Precise – understand variation Difference trying to measure

119 Sample Size – Rules of Thumb 1. Trial and Error – n > 3 – 80% confidence 2.CLT – n > 30 3.Reliability – n = % confident 4.Shewhart - n >100 – 4 sets of 25 to determine process stability

120 How much data to collect? n = 30 (Good or Bad?) A complete cycle of the process? Time based – when it is done? Representative?

121 Sample Size

122 Cause and Effect Diagrams

123 Moving from Treating Symptoms To Treating Causes

124 Problem Solving – What we usually see is the tip of iceberg – “The Symptom” The Symptom The Root Causes Invisible Hidden

125 Problem Solving When confronted with a problem most people like to tackle the obvious symptom and fix it This often results in more problems Using a systematic approach to analysis the problem and find the root cause is more efficient and effective Symptom – sign or indication Cause – whatever makes something happen

126 Cause 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 effect Effect

127 Cause and Effect Diagrams - Construction Generate ideas as to what are the main causes of the effect Label these as the main branch headers Organizes group knowledge about causes of a problem and display the information graphically Effect Header

128 Cause and Effect Diagrams - Construction Typical Main Header are: 4 M’s – Manpower, Materials, Methods, Machinery People Policies Materials Equipment Life style Environment Etc.

129 Cause and Effect Diagrams - Construction For each main cause category brainstorm ideas as to what are the related sub-causes that might effect our issue Use the 5 Why techniques when a cause is identified Keep repeating the question until no other causes can be identified List the sub-cause using arrows Effect Header why

130 Selecting 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 fruit Some require some research using the other QI tools such as: Pareto Diagrams Run Charts Surveys Histograms Etc.

131 Obese Children Life Style PoliciesEnvironment TV Viewing No Time For Food Prep No Outdoor Play Unsafe Juices Bottle Pacifier Less Fruits and Veg. Less Income Maternal Choices Less Vigorous Exercise Curriculum No Sidewalks Unhealthy Food Choices Few Community Recreational Areas or Programs Built Environment For Strollers Not Toddling Less Indoor Mobility TV Pacifier Unsafe Housing Sodas/Snacks Decreased Breast Feeding Early Feeding Practices Genetics Syndromes Genes Pre Natal Practices Excess Maternal Weight Gain Over Weight Newborn Over Weight Pre School At School At Home

132 Problem (Effect) 5 Why’s Technique Why?

133

134

135 Root Cause Analysis Rating Form Potential Root Cause Improved Quality Reduced Costs Improved Customer Satisfaction OthersTotal Score Ranking Impact Scoring Scale: Low = 1, Medium = 3, High = 5 Impact on the Problem

136 Cause and Effect Exercise

137 Why Employees Are Late For Work? Cause and Effect Diagram

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139 Solution and Effect Diagram Similar to the Cause and Effect Diagram Identifies changes and recommendations Effect is now made into a positive statement: “What are the causes of Childhood Obesity” How to prevent Childhood Obesity”

140 Solution and Effect Diagrams - Construction Place the Solution and Effect Diagram opposite the Cause and Effect Diagram Write 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 effect Positive Effect

141 Solution and Effect Diagrams - Construction Generate ideas as to what are the main Solutions of the effect Label these as the main branch headers Effect Solution

142 Solution and Effect Diagrams - Construction For each main Solution category brainstorm ideas as to what are the related sub-solutions that might effect our issue Use the 5 How techniques when a solution is identified Keep repeating the question until no other solutions can be identified List the sub-solutions using arrows Effect Solution

143 Solution and Effect Diagram Effect Why? Cause Solution How? C = Cause Category S = Solution Category

144 Less Obese Children Life Style PolicesEnvironment Sidewalks Community Recreational Areas More Mobility Less TV Safe Housing Early Feeding Practices Genetics Pre Natal Practices

145 Solution (Effect) 5 How’s Technique How?

146 5 How’s of More Vigorous Exercise How? Less TV and Video Games More Community Sponsored Recreation Programs Safe Play Areas Additional Resources More Family Recreational Activities

147 Selecting 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.

148 Root Cause Analysis Solution Impact Analysis Potential Solutions Corrective Action Type Verification Method Cost To Fix Benefit Of Fix Cost Benefit Ratio Selected? Y/N Corrective Action Type: Immediate but Interim – II, Short-term Temporary - ST, Permanent – Short Term – PST, and Permanent – Long Term - PLT

149 Solution and Effect Diagrams Cautions: Do not jump to quickly to Solution and Effect Use after a detailed analysis of “Cause” If you are still listing Causes – not enough detail on the Cause and Effect Diagram Ask if the proposed solution(s) will improve the effect or cause more problems

150 Solution and Effect Diagram Exercise

151 How To Make Employees On Time For Work? Solution and Effect Diagram

152 What 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 devised People thrive on failure Everyone knows something will go wrong – it is not “If” but “When” Remember the National Lampoon’s Griswold vacation to Walley World?

153 What 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: Cost time required ease of implementation effectiveness

154 Check How will we know if we are successful? What are the indicators of success?

155 Plan 1.Identify and Prioritize Opportunities 2. Develop AIM Statement 3. Describe the Current Process 4. Collect Data on Current Process 5. Identify All Possible Causes 6. Identify Potential Improvements 7. Develop Improvement Theory 8. Develop Action Plan 1.Implement the Improvement Do 2. Collect and Document The data 3. Document Problems, Observations, and Lessons Learned Check/ Study 1. Reflect on the Analysis Act 2. Document Problems, Observation, and Lessons learned Adopt Adapt Abandon Standardize Do Plan The ABC’s of PDCA, G. Gorenflo and J. Moran

156 Check/Study/Observe This 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.

157 Check/Study/Observe 1. Reflect on the analysis, and consider any additional information that emerged as well. Compare the results of your test against the measurable objective 2. Document lessons learned, knowledge gained, and any surprising results that emerged. Source: The ABCs of PDCA, Grace Gorenflo and John W. Moran,

158 Check/Study/Observe Tools that can assist : Pareto charts Histograms Run charts Scatter plots Control charts Radar charts.

159 Measurement Part 2

160 Data Data by itself has no value – it just shows information. Information requires interpretation for it to have value. Decision makers add value through interpretation 40% Data60% Information Decision Maker

161 Types of Data Quantitative Can be discrete or continuous Discrete Variables - counted or enumerated - # pills in a bottle Continuous – measured – length, width, weight, pressure, etc.

162 Types of Data Qualitative Always discrete Attribute data Placed into two or more attribute categories Yes/No Infected/Not Infected Pass/Fail Positive/Negative Good/Bad Male/Female Red/Yellow/Green Dead/Alive

163

164 Data Management “Whenever there is fear, you will get wrong figures.” W. Edwards Deming

165 Data Management Strategy Collect Raw Data Interpret Communicate Consolidate Collecting Translating – use data tables Summarizing – use descriptive statistics Framing - use charts/graphs

166 Data 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?

167 Getting Good Data Understand the process being studied – walk it Make the collection simple Define where the data will be collected – collection points Use checksheets and checklists to help Minimize the “other” category – by good classifications - too often the largest bar on a chart Establish collection rules – sampling

168 Getting Poor Data Lack of training on what to do Unclear directions Ambiguous 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 meters Mathematical errors – rounding, calculation, order of calculations, etc.

169 Lies There are three kinds of lies: Lies, Damned Lies, and Statistics

170 Descriptive Statistics The majority of our data collection will be done through sampling Populations versus Samples Population parameters: μ and σ Sample statistics: Х and s

171 Descriptive Statistics Measures of Central Tendency: Mean – arithmetic average of the items sampled Median – middle value in the sample Mode – the one that most frequently occurs

172 Descriptive Statistics These statistical measures help us to understand how the data is distributed: Symmetrical – normal – bell shaped Skewed – left or right Rectangular Always plot the data and confirm the shape of the data

173 Descriptive 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

174 Descriptive Statistics – Variation Variation is everywhere It is found in the output of any process of manufacturing, service, or administrative But variation is not all bad since it always displays a pattern or a distribution of itself These patterns or distributions can tell us a great deal about the process itself and the causes of problems found in the process Histograms help us identify and interpret these patterns

175 Descriptive Statistics Measures of Variability: Dispersion Range – Highest Value – Lowest Value Variance – how much spread in our sample data - scatter Standard Deviation – dispersion of a random variable about its mean

176 Descriptive 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 shifted The variability of the process has increased Combination of both of the above

177 Descriptive Statistics When constructing data tables and graphs: Do not throw any data away Know what type of data you are dealing with – qualitative or quantitative Know if the data is discrete or continuous Label everything appropriately Keep it clear and simple

178 Target Performance Act Plan Do Check Process Gap TAPP/PDCA Integration* Gap = Performance versus Target Act only when Performance is below Target Small gaps – just fix it Larger gaps need a PDCA Cycle Monitor * Reference Article

179 Check How will we know if we are successful? What are the indicators of success? Develop a few Indicators of project success

180 Act Project Planning

181 Ongoing Activities New Activities Start Time LowHigh Resources committed to change Transitional Time Line

182 Ongoing Activities New Activities Start Time LowHigh Resources committed to change Transitional Time Line

183 Gantt Chart

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185 History The first Gantt Chart was developed by Karol Adamiecki, who called it a Harmonogram Because Adamiecki did not publish his chart until 1931, this famous chart bears Henry Gantt's name (1861–1919) designed his chart in 1910 Wikipedia, the free encyclopedia

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187 Gantt Chart Henry L. Gantt – WWI Franklin Arsenal 1910 Progress Chart Work planned and accomplished are shown in the same space Emphasizes work movement through time Deals with plans and progress Helps identify and eliminate obstacles

188 Gantt Charts A Gantt chart is a matrix diagram The vertical axis lists all the tasks to be performed for a project Each row contains a single task identification The horizontal axis is headed by columns indicating estimated task duration in hours, days, weeks, months, etc.

189

190

191 Use Of Gantt Charts Establish order of tasks: Sequential and Parallel Identify resources requirements Timing of resource needs Identify the critical path Monitor the project “On-Time” Schedule Alerts where remedial action is required

192 Traffic Light Gantt Chart Task: City of XYZ HD29-Feb7-Mar14-Mar21-Mar28-Mar Finalize assessment analysisX Gain consensus on prioritiesX Identify comm. with elected off.X Plan PHF consultant visitX Set agenda and travel scheduleX City HD/PHF PI meetingX On Schedule Watch Late or at Risk

193 Act Solution works: Standardize Train Measure Continue to improve Solution does not work: Regroup New team New AIM

194 Communication Plan Decide who/what/where/when of the Communication Plan Describe the end “game” – begin with the end in mind Make it flow – easy to understand and digest Front load – important points first – get their interest Stress the benefits to the listener – WIIFM Ask for commitment – will you support the effort? If not – why?

195 Documenting The Impact Of QI

196 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.

197 Documenting 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.

198 Documenting 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?

199 Documenting 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

200 Intervention Number Date What 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 Intervention and Impact Form AIM Statement Description:

201 Documenting Unintended Consequences Unintended Consequences may happen. Being prepared for Unintended Consequences makes the process of dealing with them easier and quicker.

202 Unintended 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.

203 The following columns can be added to the Intervention and Impact Form when needed to track the impact of unintended consequences Unintended Consequence Letter Unintended Consequence Description Date It Happened Impact To Aim Statement Need a Sub AIM Statement? Impact to Customer Modifications Made Intervention and Impact Form when needed to track the impact of unintended consequences.

204 Stages Of Team Development Adjourning

205 Stages Of Team Development Each stage has two components that compete with each other: Task Focus Team Behavior Applications and Tools for Creating and Sustaining Healthy TeamsApplications and Tools for Creating and Sustaining Healthy Teams, Public Health Foundation, April Tools_for_Creating_and_Sustaining_Healthy_Teams.aspx

206 Stages Of Team Development Each stage has two components that compete with each other: Task Focus Team Behavior Applications and Tools for Creating and Sustaining Healthy TeamsApplications and Tools for Creating and Sustaining Healthy Teams, Public Health Foundation, April Tools_for_Creating_and_Sustaining_Healthy_Teams.aspx

207 Top Ten Reasons Teams Fail 1.AIM Statement 2.Team Charter 3.Team Members 4.Problem Solving Process 5.Rapid Cycle 6.Team Maturity 7.Base Line Data 8.Training 9.Root Cause Analysis (RCA) 10.Pilot Testing

208 Train The Trainer Overview Assignments Project expectations Next session

209 Train The Trainer Overview Assignment for Teams: TopicLHD Assigned Introduction to QI AIM statement (SMART) SIPOC-CM Force and Effect analysis Flowchart (Basic or Deployment) Flow Chart Summary Form Cause and Effect (RCA) /5 whys Forming, Storming, Norming, Performing, Adjourning

210 Wrap Up Finish Post Test Next Steps? Planning Time Team Reports Adjourn


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