1. Quality Tools for Process Improvement

2. PDCA/PDSA

3. PDCA/PDSA PDCA PDSA Plan. Do. Check. Act Plan. Do. Study. Act
Cyclic approach
Managing a project
Problem solving process
Increasing your knowledge with each cycle
Recording results
Emphasizes understanding results not recording them

4. PDSA Cycle for Learning and Improvement
Objective, questions and predictions (why)
Plan to carry out the cycle (who, what, where, when)
Plan
Continuous Improvement
Carry out the plan
Document problems and unexpected observations
Begin analysis of the data
What changes are to be made?
Next cycle?
Act Do
Study
Complete the analysis of the data to predictions
Summarize what was learned

5. The Model for Improvement
What are we trying to accomplish?
How will we know that a change is an improvement?
What change can we make the will result in improvement?
When you combine these three questions with the PDSA cycle, you get the Model for Improvement. P A D S

6. Root Cause Analysis

7. Root Cause Analysis – 5 Why Process
The first “Why?”
This is the top reason behind the problem
Answer that question
The second “Why?”, third “Why?” and so on
This should follow the same idea
Continue until you have drilled down to the root of the problem or root cause of your issue
“Lean” Six Sigma- DMAIC- Define- Measure- Analyze- Improve- Control
This is the ANALYZE part--
Toyota called this tool “The 5 Why Process”. There can be more or less than 5 whys depending upon your situation. It just seems that “5” is the magic number.
Basically, it is a simple approach that leads to an actionable item.
Just keep peeling away the layers. Even if you feel you how reached your solution- ask one more why.
Let’s look at our first example.

8. Why is the French Toast Burnt?
The flame on the stove was too hot
Why was the flame too high?
Staff didn’t know how to work the stove
Why didn’t the staff know how to work the stove?
The staff was never instructed in use of stove
Why wasn’t the staff instructed in the use of the stove?
It is not in the job description training
Why is it not in the job description training?
French toast is a new item on the menu

9. Superstorm Sandy Example
Why were there not enough oxygen concentrators?
There were not enough working electrical outlets
Why were there not enough working electrical outlets?
Some outlets were cracked or did not work
Why were the outlets cracked or not working?
The staff did not check/test the outlets
Why didn’t the staff check the outlets?
It is not in the preparation checklist
Why is it not on the preparation checklist?
We never had a problem before
Here are some things that can be learned from the 5 Why process:
1- You cannot accept every step as necessary just because you have “always done it that way”
2- Find out what steps are missing- what didn’t you do that you should do now.
Look at the process with “fresh eyes”. Maybe something needs to change because other variables have changed. Is this a new problem??
3- Your team needs to understand that the dialogue might change. They may need to “defend” their position with facts and perhaps previous successes.
4- Look at the financial commitment- is it still cost effective to make the change being discussed?
5- Be ready for the conversation about both cost, staffing and efficiency.

10. Fishbone Diagram

11. Fishbone Diagram (Ishikawa Diagram)
Represents cause and effect
Effect forms the head of the fish
Potential causes form the skeleton
Structured way to represent contributors to problems
In a series of events where people are involved, mistakes happen.
Healthcare has many functional areas that are composed by a series of events, involving people, process, machines, environment and other variables. Undoubtedly, mistakes will happen.
What typically happens in response to mistakes is that blame is thrown around, this builds resistance, then communication fails which could lead to project failure.
The better approach is to identify the root causes of the mistake as a team with an open mind.

12. Fishbone Diagram continued
Environment
System
Facilities
This example uses “Cause and Effect”. The effect or the problem is at the head of the fish.
The 6 M’s cover the majority of areas where problems occur. Methods, Machinery, Mother Nature, Management, Materials, and Manpower.
You can use whatever titles work for your situation.
The cause explains why that area was affected as you will see in our next example.
Then yet a deeper answer to the question “why” will explain the “reason” for the problem.
Sometimes, you can work as the group and share perspectives.
With patience and a few questions you may see how it all unfolds through the eyes of others. s
Patients
Materials
Manpower

13. Fishbone Diagram Reasons to use a Fishbone Diagram:
Organizes causes/potential causes
Helps the team discuss the issues
Provides framework to organize issues
Visual presentation by areas
Living document
Limitations of the Fishbone Diagram:
Based on opinion
Lost energy spent on “potential” causes
Comes down to a democratic vote
Is it a true cause or potential cause? Has it happened or “could” it happen? Can you avoid a potential problem?
Allow the team to discuss the problem or the effect from all sides. Everyone should contribute to the conversation. Go around the table and give all participants a voice.
It is a great framework that can keep you organized as you continue to add information.
The visual gives each area the opportunity to be explored. And everyone gets to look at each other’s area. It provides transparency.
This document can grow with information. Keep an open mind-

14. Process Mapping

15. Process Mapping for Continuous Quality Improvement
Simple method
Highlights wasteful steps in your process
Maps out the actual processes
Not processes in procedures and manuals

16. Process Mapping Symbols
Oval shows input to start process or output at end of process
Box or rectangle shows task or activity performed in process
There is usually only one arrow out of an activity box. If there is more you may need a decision diamond.
Diamond shows places in process where yes/no question is asked or decision is required
Yes
Oval shows input to start process or output at end of process No

17. Process Mapping
Source: wikipedia/commons/9/91/Proposed_Patient_Appointment_Procedure.png.

18. Process Mapping continued
Now What?
Discuss “reality” with the leadership
Use recommendations to create a new map
Change one thing- not everything
Test the new process map
Gather key information to support the change
Saves time, supplies, staff time
Increased accuracy, consistency
Better definition of task= improved teamwork
Discuss updating policies and procedures

19. References
Knoth, J., Miller, J. (2014). Quality Tools for Process Improvement. Healthcare Quality Strategies. Inc.