3 PDCA/PDSA PDCA PDSA Plan. Do. Check. Act Plan. Do. Study. Act Cyclic approachManaging a projectProblem solving processIncreasing your knowledge with each cycleRecording resultsEmphasizes 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)PlanContinuous ImprovementCarry out the planDocument problems and unexpected observationsBegin analysis of the dataWhat changes are to be made?Next cycle?ActDoStudyComplete the analysis of the data to predictionsSummarize 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.PADS
7 Root Cause Analysis – 5 Why Process The first “Why?”This is the top reason behind the problemAnswer that questionThe second “Why?”, third “Why?” and so onThis should follow the same ideaContinue 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- ControlThis 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 hotWhy was the flame too high?Staff didn’t know how to work the stoveWhy didn’t the staff know how to work the stove?The staff was never instructed in use of stoveWhy wasn’t the staff instructed in the use of the stove?It is not in the job description trainingWhy 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 outletsWhy were there not enough working electrical outlets?Some outlets were cracked or did not workWhy were the outlets cracked or not working?The staff did not check/test the outletsWhy didn’t the staff check the outlets?It is not in the preparation checklistWhy is it not on the preparation checklist?We never had a problem beforeHere 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.
11 Fishbone Diagram (Ishikawa Diagram) Represents cause and effectEffect forms the head of the fishPotential causes form the skeletonStructured way to represent contributors to problemsIn 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 EnvironmentSystemFacilitiesThis 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.sPatientsMaterialsManpower
13 Fishbone Diagram Reasons to use a Fishbone Diagram: Organizes causes/potential causesHelps the team discuss the issuesProvides framework to organize issuesVisual presentation by areasLiving documentLimitations of the Fishbone Diagram:Based on opinionLost energy spent on “potential” causesComes down to a democratic voteIs 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-
15 Process Mapping for Continuous Quality Improvement Simple methodHighlights wasteful steps in your processMaps out the actual processesNot processes in procedures and manuals
16 Process Mapping Symbols Oval shows input to start process or output at end of processBox or rectangle shows task or activity performed in processThere 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 requiredYesOval shows input to start process or output at end of processNo
17 Process MappingSource: wikipedia/commons/9/91/Proposed_Patient_Appointment_Procedure.png.
18 Process Mapping continued Now What?Discuss “reality” with the leadershipUse recommendations to create a new mapChange one thing- not everythingTest the new process mapGather key information to support the changeSaves time, supplies, staff timeIncreased accuracy, consistencyBetter definition of task= improved teamworkDiscuss updating policies and procedures
19 ReferencesKnoth, J., Miller, J. (2014). Quality Tools for Process Improvement. Healthcare Quality Strategies. Inc.