4East Central Regional Hospital Our MissionTo provide quality mental health/developmental disabilities care and treatment to our consumers
5To use resources, creativity, and innovation to become a East Central Regional HospitalOur VisionTo use resources, creativity, and innovation to become aCENTER OF EXCELLENCE.
6Performance Improvement is a continuous effort of assessment, evaluation and adaptation by an organization to improve the outcome of services, processes and functions.
7Performance Improvement is every employee’s concern! No matter what your job, you play an important role in helpingprovide 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.
8Cause and Effect Diagram (“Fishbone”) Performance Improvement ToolsBrainstormingAffinity DiagramCause and Effect Diagram (“Fishbone”)Flow ChartChecksheetsLine GraphPareto ChartHistograms
10Cause 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:BrainstormingAffinity DiagramCause and Effect Diagram (“Fishbone”)Flow Chart,
11Benefits of Brainstorming What is Brainstorming ?A tool used by teams for creative exploration of options in an environment free of criticism.Benefits of BrainstormingCreativityLarge Number of IdeasAll team members involvedSense of ownership in decisionsInput to other ToolsBrainstorming Ground RulesActive participation by everyoneNo discussionBuild on others’ ideasDisplay ideas as presentedSet a time limitClarify and combine
12What 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 IdeasSort Ideas into RelatedGroupsDrawing FinishedAffinitySuperheaderHeaderIdeaLL- QM DEPT.
13What 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 participationUses an orderly, easy-to-read formatIncreases knowledge of what is happening in the processMethodsEffectPeopleEnvironmentEquipment
14EXAMPLE: Why are employees late for work? Cause & Effect DiagramEXAMPLE: Why are employees late for work?MethodsEnvironmentcaught by trainTried a new routeRaining hardForgot to set clockLate for WorkDog needed walkingOut of gascar wouldn’t startSon misplaced booksPeopleEquipmentLL QM Dept.
15Benefits 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 understandingProvide a tool for trainingIdentify problem areas and improvement opportunitiesSymbols Used in FlowchartsStart/EndDecisionNoProcess StepYesMConnectorMeasurement
18Performance Improvement Tools (These are Quantitative Tools and focus on specificmeasurement units)Statistical Tools used for measuring performance, collecting and displaying data, and monitoring performance over time:Check SheetsLine GraphPareto ChartHistograms
19CHECKSHEETS Turn-around time Record data for further analysis, provide a historical analysis and introduce data collection methods.Turn-around time1-5 min6-10 min11-15 min16-20 minTIME(Minutes)Time of Day810911121325152025Dwl /03
20A 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 patternsMonitor process performanceCommunicate process performance(The chart above is an example only, not an actual representation of restrictive procedures used)
21A 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 piecesIdentifies most significant factorsShows where to focus efforts and improvement opportunitiesAllows better use of limited resources(The chart above is an example only, not an actual representation of reasons for re-admissions)
22What 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 formCompare measurements to expectationsCommunicate information to the teamAssist in decision making(The chart above is an example only, not an actual representation of appointment wait times)
24What 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…..”
25FOCUS-PDCA Performance Improvement Model Find a process to improveOrganize a team that knows the processClarify current knowledge of the processUnderstand causes of process variationSelect the process improvementACTTo hold gainTo continueimprovementPLANImprovementData CollectionDOCHECKImprovementData CollectionData AnalysisData for processimprovementExamples of Quality in a Hospital Setting JCAHO 1992
26Find 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?
27Organize a Team that knows the process ThinK: Does the team include memberswho do the work & know the process ?
28Clarify 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???
29Understand Causes of Process Variation ThinK: Can we use the data collectedto determine specific, measurable andcontrollable variations?
30Select the Process Improvement ThinK: What changes can be made to improve the process?Can we test the changes in a pilot project?
31Plan 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?
32Do 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?
33Check 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?
34Act 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 toreturn to “Plan” orearlier steps in theFOCUS-PDCA if needed?
35FOCUS-PDCA Performance Improvement Model Find a process to improveOrganize a team that knows the processClarify current knowledge of the processUnderstand causes of process variationSelect the process improvementACTTo hold gainTo continueimprovementIf necessary, you can start the FOCUS-PDCA again!PLANImprovementData CollectionDOCHECKImprovementData CollectionData AnalysisData for processimprovementExamples of Quality in a Hospital Setting JCAHO 1992
36East Central Regional Hospital Working together to improve Services, Safety andQuality of Care for all our consumers!