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East Central Regional Hospital PERFORMANCE IMPROVEMENT REFRESHER LL Quality Management Department Revised 11/03.

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Presentation on theme: "East Central Regional Hospital PERFORMANCE IMPROVEMENT REFRESHER LL Quality Management Department Revised 11/03."— Presentation transcript:

1 East Central Regional Hospital PERFORMANCE IMPROVEMENT REFRESHER LL Quality Management Department Revised 11/03

2 This is a Typical Organizational Direction ! ? ?

3 This is the Preferred Organizational Direction !

4 Our Mission To provide quality mental health/developmental disabilities care and treatment to our consumers East Central Regional Hospital

5 Our Vision To use resources, creativity, and innovation to become a CENTER OF EXCELLENCE. East Central Regional Hospital

6 Performance Improvement is a continuous effort of assessment, evaluation and adaptation by an organization to improve the outcome of services, processes and functions.

7 Performance Improvement is every employee’s concern! No matter what your job, you play an important role in helping provide quality patient care. Performance Improvement is on-going! Being committed to quality doesn’t mean reaching a goal, then quitting. Even when something is working well, there is room for improvement.

8 Brainstorming Affinity Diagram Cause and Effect Diagram (“Fishbone”) Flow Chart Checksheets Line Graph Pareto Chart Histograms Performance Improvement Tools

9 HOW DO WE KNOW WHICH TOOLS TO USE?

10 Tools for generating ideas, setting priorities, providing direction, understanding root causes, and helping to understand processes: Brainstorming Affinity Diagram Cause and Effect Diagram (“Fishbone”) Flow Chart, Performance Improvement Tools (These are Qualitative Tools which focus on data describing consumers, occurrences & conditions)

11 a Creativity a Large Number of Ideas a All team members involved a Sense of ownership in decisions a Input to other Tools Brainstorming What is Brainstorming ? A tool used by teams for creative exploration of options in an environment free of criticism. Benefits of Brainstorming Brainstorming Ground Rules a Active participation by everyone a No discussion a Build on others’ ideas a Display ideas as presented a Set a time limit a Clarify and combine

12 What Is An Affinity Diagram? A tool that gathers lots of “language data”, like ideas and opinions and then sorts and groups the related ideas. Display Ideas Sort Ideas into Related Groups Drawing Finished Affinity Superheader Header Idea Header Idea Header Idea LL- QM DEPT.

13 What Is A Cause and Effect Diagram ? (“Fishbone Diagram”) A tool that helps identify, sort, and display possible causes of a problem in a process. Benefits of Using a Cause and Effect Diagram: t Encourages group participation t Uses an orderly, easy-to-read format t Increases knowledge of what is happening in the process Methods Effect People Environment Equipment

14 Methods Late for Work People Environment Equipment Cause & Effect Diagram EXAMPLE: Why are employees late for work? Out of gas Son misplaced books Forgot to set clock caught by train Dog needed walking car wouldn’t start Tried a new route Raining hard LL QM Dept.

15 What Is A Flow Chart? A diagram that uses graphic symbols to show the nature and flow of steps in a process. Benefits of Using a Flow Chart: t Promote process understanding t Provide a tool for training t Identify problem areas and improvement opportunities Symbols Used in Flowcharts Start/End Process Step Decision No Yes Connector Measurement M

16 An example of a Flow Chart

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18 Statistical Tools used for measuring performance, collecting and displaying data, and monitoring performance over time: Check Sheets Line Graph Pareto Chart Histograms Performance Improvement Tools (These are Quantitative Tools and focus on specific measurement units)

19 CHECKSHEETS Record data for further analysis, provide a historical analysis and introduce data collection methods. TIME (Minutes) Time of Day Turn-around time 1-5 min 6-10 min min min Dwl 11/03

20 What Is A Line Graph? A line graph that shows results of a process over time. Why Use Line Graphs? t Analyze and check the data for patterns t Monitor process performance t Communicate process performance (The chart above is an example only, not an actual representation of restrictive procedures used)

21 What Is A Pareto Chart? A graph using a set of bars to show how often a problem occurs. Why use a Pareto Chart? t Breaks big problems into smaller pieces t Identifies most significant factors t Shows where to focus efforts and improvement opportunities t Allows better use of limited resources ( The chart above is an example only, not an actual representation of reasons for re-admissions)

22 What Is A Histogram? A bar chart that shows the distribution of data. It’s like a “snapshot” of the process. When are Histograms used? t To summarize large data sets in a picture form t Compare measurements to expectations t Communicate information to the team t Assist in decision making ( The chart above is an example only, not an actual representation of appointment wait times)

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24 What Is Data Collection? Data Collection is obtaining useful information. The issue is not: How do we collect data? It is: How do we obtain useful data? Why Collect Data? To establish a factual basis for making decisions “I think the problem is……….” becomes “The data indicate the problem is…..”

25 FOCUS-PDCA Performance Improvement Model DO CHECK PLAN E Improvement E Data Collection E Improvement E Data Collection E Data Analysis EData for process improvement Find a process to improve Organize a team that knows the process Clarify current knowledge of the process Understand causes of process variation Select the process improvement ACT E To hold gain E To continue improvement Examples of Quality in a Hospital Setting JCAHO 1992

26 F ind A Process to Improve ThinK: High Volume? High Risk? Problem Prone? Externally mandated? Who will benefit from the process improvement? How does it fit the mission?

27 O rganize a Team that knows the process ThinK: Does the team include members who do the work & know the process ?

28 C larify Current Knowledge of the Process ThinK: What are the things that contribute to the process not working the way we expect it will? Is this the actual flow of the process or the perceived flow? ? ? ? PerceivedActual

29 U nderstand Causes of Process Variation ThinK: Can we use the data collected to determine specific, measurable and controllable variations?

30 S elect the Process Improvement ThinK: What changes can be made to improve the process? Can we test the changes in a pilot project?

31 P lan the improvement and continued data collection. ThinK: How do we make the changes that were selected as possible solutions and what are our goals and targets and how can we reach them?

32 D o the improvement, data collection and analysis ThinK: As we begin the process improvement are we getting the results/outcomes we expected? Are there any surprises?

33 C heck and study the results ThinK: If there were surprises or unexpected outcomes, can we do anything about them? Has the process improvement been successful, or will it be necessary to modify the change?

34 Act to hold the gain and continue to improve the process. ThinK: How will the improvement be implemented beyond the pilot, if one was used, and can the team find another potential improvement within the process? Are we prepared to return to “Plan” or earlier steps in the FOCUS-PDCA if needed?

35 FOCUS-PDCA Performance Improvement Model DO CHECK PLAN E Improvement E Data Collection E Improvement E Data Collection E Data Analysis EData for process improvement Find a process to improve Organize a team that knows the process Clarify current knowledge of the process Understand causes of process variation Select the process improvement ACT E To hold gain E To continue improvement Examples of Quality in a Hospital Setting JCAHO 1992 If necessary, you can start the FOCUS-PDCA again!

36 East Central Regional Hospital Working together to improve Services, Safety and Quality of Care for all our consumers!


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