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

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

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

9. HOW DO WE KNOW WHICH TOOLS TO USE?

10. Cause and Effect Diagram (“Fishbone”)
Performance Improvement Tools
(These are Qualitative Tools which focus on data describing consumers, occurrences & conditions)
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 ,

11. Benefits of Brainstorming
What is Brainstorming ?
A tool used by teams for creative exploration of options in an environment free of criticism.
Benefits of Brainstorming
Creativity
Large Number of Ideas
All team members involved
Sense of ownership in decisions
Input to other Tools
Brainstorming Ground Rules
Active participation by everyone
No discussion
Build on others’ ideas
Display ideas as presented
Set a time limit
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
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:
Encourages group participation
Uses an orderly, easy-to-read format
Increases knowledge of what is happening in the process
Methods
Effect
People
Environment
Equipment

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

15. Benefits of Using a Flow Chart:
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:
Promote process understanding
Provide a tool for training
Identify problem areas and improvement opportunities
Symbols Used in Flowcharts
Start/End
Decision No
Process Step
Yes M
Connector
Measurement

16. An example of a Flow Chart

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

19. CHECKSHEETS Turn-around time
Record data for further analysis, provide a historical analysis and introduce data collection methods.
Turn-around time
1-5 min
6-10 min
11-15 min
16-20 min
TIME
(Minutes)
Time of Day 8 10 9 11 12 1 3 2 5 15 20 25
Dwl /03

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

21. A graph using a set of bars to show how often a problem occurs.
What Is A Pareto Chart?
A graph using a set of bars to show how often a problem occurs.
Why use a Pareto Chart?
Breaks big problems into smaller pieces
Identifies most significant factors
Shows where to focus efforts and improvement opportunities
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?
To summarize large data sets in a picture form
Compare measurements to expectations
Communicate information to the team
Assist in decision making
(The chart above is an example only, not an actual representation of appointment wait times)

24. What Is Data Collection?
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
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
To hold gain
To continue
improvement
PLAN
Improvement
Data Collection DO
CHECK
Improvement
Data Collection
Data Analysis
Data for process
improvement
Examples of Quality in a Hospital Setting JCAHO 1992

26. Find 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. Organize a Team that knows the process
ThinK: Does the team include members
who do the work & know the process ?

28. Clarify 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?
Perceived
Actual ? ? ?

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

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

31. Plan 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. Do 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. Check 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
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
To hold gain
To continue
improvement
If necessary, you can start the FOCUS-PDCA again!
PLAN
Improvement
Data Collection DO
CHECK
Improvement
Data Collection
Data Analysis
Data for process
improvement
Examples of Quality in a Hospital Setting JCAHO 1992

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