1. Shawnee County Health Agency Leading the way to a healthier Shawnee County Basic QI Tools & Techniques

2. Shawnee County Health Agency Leading the way to a healthier Shawnee County Why QI? By continually working to improve all processes, we increase our learning and knowledge. QI is not about pass/fail or right/wrong. Rather it’s about testing a theory. You have a learning opportunity.

3. Shawnee County Health Agency Leading the way to a healthier Shawnee County Basic Tools of QI Data collection Check Sheet Survey Tool / Interviews Nat’l, State, Local stat’s Data Analysis Pie Charts Bar Graph Pareto Chart Line Graph Process Analysis Flow Charts – Process Mapping 5 Why’s Idea Creation Affinity Diagram Brainstorming Fishbone Diagram Effect/Cause Analysis 5 Why’s Fishbone Pareto Chart Brainstorming Interrelationship Diagraph Evaluation & Decision-Making SWOT Analysis Evidence-based Literature Stakeholder Analysis Force Field Analysis Nominal Group Technique PMI Logic Model Planning & Implementation PDCA/PDSA Bone Diagram Action Plans

4. Shawnee County Health Agency Leading the way to a healthier Shawnee County Stage 1 Step #1 - Getting Started Describe the Situation Writing about the Situation What’s the issue? Why is this a issue? For whom does the issue exist? Who has a stake in the issue? What do we know about the issue/people involved? What do existing research and experience tell us about the issue?

5. Shawnee County Health Agency Leading the way to a healthier Shawnee County Example #1

6. Shawnee County Health Agency Leading the way to a healthier Shawnee County Stage 1 Step #1 - Getting Started Describe the Situation An invading enemy sought to overthrow the kingdom. During the fierce battle the kingdom’s well trained warriors mounted their warhorses to fight the enemy. All in the kingdom were confident they would be victorious as the enemy forces were outnumbered. Ultimately, not all warriors got “deployed” and in the end - THE KINGDOM WAS LOST.

7. Shawnee County Health Agency Leading the way to a healthier Shawnee County Stage 1 Step #2 - Assemble the Team No one person understands the entire system. One cannot change one part of a process without influencing other parts in some ways.

8. Shawnee County Health Agency Leading the way to a healthier Shawnee County Stage 1 Focus on defining the problem(s) / improvement needed Define the issues(s) before attempting to fix something What’s important? What’s broken / Needs improvement? Where is the “Mother Lode?” (high volume, high profile, problem-prone)

9. Shawnee County Health Agency Leading the way to a healthier Shawnee County Stage 1 Define the Issue “The kingdom was lost.” “Reduce the likelihood the kingdom can be taken again” What’s important? What’s broken? Needs improvement? Not enough warriors were “deployed”

10. Shawnee County Health Agency Leading the way to a healthier Shawnee County Stage 1 Define the Issue “The kingdom was lost.” “Reduce the likelihood the kingdom can be taken again” What’s important? What’s broken? Needs improvement? Not enough warriors were “deployed” Where’s the “Mother Lode?” (high volume, high profile, problem prone)

11. Shawnee County Health Agency Leading the way to a healthier Shawnee County Stage 1 Step #3 - Examine Current Process/Approach May need to interview staff, external partners Make a process flow chart Check for efficiency, duplicative steps, missed steps, steps needed

12. Shawnee County Health Agency Leading the way to a healthier Shawnee County Stage 1 Step #3 - Examine Current Process/Approach “For want of a nail the shoe was lost For want of a shoe the horse was lost For want of a horse the warrior was lost For want of a warrior the battle was lost For want of a battle the kingdom was lost All for the want of a nail.”

13. Shawnee County Health Agency Leading the way to a healthier Shawnee County Leverage the 5-Whys Basically, the five-why analysis is a fundamental approach of thinking, based on the logical linkage of elements into a root cause analysis. It is a tool that works with ideas/concepts With each specific answer, repeat the question up to five times and you will typically end up with a rather solid root cause. For each answer, look at WHO is involved

14. Shawnee County Health Agency Leading the way to a healthier Shawnee County Leveraging the 5-Whys Lost the kingdom Lost the battle Not enough warriors Not enough horses Horses were not shod Not enough nails Root Cause Why?

15. Shawnee County Health Agency Leading the way to a healthier Shawnee County Leveraging the 5-Whys The therefore test has proven to be a very reliable method to check the logic of the five- why analysis. To do the therefore test, you read the key findings of the analysis in reverse and insert the word therefore between each step.

16. Shawnee County Health Agency Leading the way to a healthier Shawnee County Leveraging the 5-Whys Lost the kingdom Lost the battle Not enough warriors Not enough horses Horses were not shod Not enough nails Root Cause Why? Therefore Start Result Why? Therefore

17. Shawnee County Health Agency Leading the way to a healthier Shawnee County Stage 1 Define the Issue “The kingdom was lost.” “Reduce the likelihood the kingdom can be taken again.” What’s important? What’s broken? Needs improvement? Not enough warriors mounted on warhorses Where’s the “Mother Lode?” Not enough nails to shod all the warhorses

18. Shawnee County Health Agency Leading the way to a healthier Shawnee County Problem Statement Not enough nails to shod all the warhorses. Analyze the Problem Root cause - Brainstorming 6-3-5 Affinity Diagram  Fishbone Diagram – all possible causes

19. Shawnee County Health Agency Leading the way to a healthier Shawnee County Fishbone Diagram Not enough nails to shod all the warhorses Main Cause 2Main Cause 1 Minor Cause influence

20. Shawnee County Health Agency Leading the way to a healthier Shawnee County Stage 1 Step #4 - Potential Solutions Avoid making your first QI effort a large- scale project. Solving issues is usually easiest when you focus on decreasing/reducing the “negative” driving forces rather than increasing the “positive” driving forces.

21. Shawnee County Health Agency Leading the way to a healthier Shawnee County “Expand-Focus Sequence” Expand Focus Expand Focus Expand Focus POSSIBLE PROBLEMS PROBLEM DEFINED POSSIBLE CAUSES ROOT CAUSE IDENTIFIED POSSIBLE SOLUTIONS SOLUTION CHOSEN TO TEST

22. Shawnee County Health Agency Leading the way to a healthier Shawnee County Imposing a Change Before imposing a change, begin by asking three key questions: What are you trying to accomplish? How will you know that a change is an improvement? What changes can you make that will result in an improvement? Define changes you believe will achieve your goal Countermeasures

23. Shawnee County Health Agency Leading the way to a healthier Shawnee County Stage 1 Step #5 - Develop an Improvement Theory Make a prediction – How will you know that a change is improvement? (Measurement is essential!) Plan What Where Who How When – timeline

24. Shawnee County Health Agency Leading the way to a healthier Shawnee County Stage 2 Step #6 - Test the Theory Just Do It!!!! Carry out the plan During the process collect, chart, and display data to determine efficiency. Document problems, unexpected observations

25. Shawnee County Health Agency Leading the way to a healthier Shawnee County Stage 3 Step #7 - Study the Results Based on measurements What worked? What didn’t work?

26. Shawnee County Health Agency Leading the way to a healthier Shawnee County Stage 4 Step #8 - ACT Sustain if improvement Monitor Develop new theory If successful, plan another cycle to test it on a larger scale or under different conditions If unsuccessful, test a different theory

27. Shawnee County Health Agency Leading the way to a healthier Shawnee County Stage 4 Step #9 - Establish Future Plans Recognize, review, refocus your efforts What went right? Where can we apply what we’ve learned? What’s next?

28. Shawnee County Health Agency Leading the way to a healthier Shawnee County 9 Steps of Improvement Focus Improve Sustain Honor Plan – Do – Study – Act

29. Shawnee County Health Agency Leading the way to a healthier Shawnee County Describe Situation Assemble Team Develop aim statement Define problem(s) / improvement needed Examine Current Process Decide on potential solutions Collect supportive data -Surveys / Interviews -Nat’l, State, Local stat’s -What’s important? -What’s broken/needs improvement? -Where’s the Mother Lode? -Logic Model-Flow charts -Survey’s-Pareto chart -Line graph -Include qualitative information -Check sheets -Standardization-Flow charts -Documentation-Training Analyze the problem PDSA Cycles -Develop theory -Test improvement theory -Study Results -ACT -CELEBRATE! -Flow Charts -5 Why’s -Fishbone-Brainstorming -5 Why’s-Affinity Diagram -Pareto chart -SWOT Analysis-CIC Analysis -Stakeholder Analysis -Force Field Analysis -Bone Diagram CQI STAGE 4 STAGE 3 STAGE 2 STAGE 1

30. Shawnee County Health Agency Leading the way to a healthier Shawnee County Example #2 “QI Feud”

31. Shawnee County Health Agency Leading the way to a healthier Shawnee County Stage 1 Step #1 - Getting Started Describe the Situation During the last 5 months of the year there has been a increase in errors in paychecks

32. Shawnee County Health Agency Leading the way to a healthier Shawnee County

33. Shawnee County Health Agency Leading the way to a healthier Shawnee County Stage 1 Step #2 – Assemble the Team

34. Shawnee County Health Agency Leading the way to a healthier Shawnee County Define the Problem / Improvement Needed “Errors in paychecks.” “Reduce errors” What’s important? Where’s the “Mother Lode?” Printed checks What’s Broken? Needs Improvement?

35. Shawnee County Health Agency Leading the way to a healthier Shawnee County Stage 1 Step #3 – Examine Current Process/Approach Printed Checks

36. Shawnee County Health Agency Leading the way to a healthier Shawnee County Where’s the “Mother Lode”?

37. Shawnee County Health Agency Leading the way to a healthier Shawnee County Defining the Problem “Errors in paychecks.” “Reduce errors” What’s broken? What’s important? Where’s the “Mother Lode?” Printed checks Time codes

38. Shawnee County Health Agency Leading the way to a healthier Shawnee County Problem Statement During the first five months of the year, time code errors accounted for 47% of all incorrect printed paychecks, which was 2X higher than the next highest contributor (non-printed).

39. Shawnee County Health Agency Leading the way to a healthier Shawnee County All Possible Causes

40. Shawnee County Health Agency Leading the way to a healthier Shawnee County Next Steps Step #4 - Potential Solutions

41. Shawnee County Health Agency Leading the way to a healthier Shawnee County “Expand-Focus Sequence” Expand Focus Expand Focus Expand Focus POSSIBLE PROBLEMS PROBLEM DEFINED POSSIBLE CAUSES ROOT CAUSE IDENTIFIED POSSIBLE SOLUTIONS SOLUTION CHOSEN TO TEST

42. Shawnee County Health Agency Leading the way to a healthier Shawnee County Next Steps – Impose a Change Step #5 - Develop Improvement Theory Target – 50% reduction in time code errors by 6/1/09 Step #6 – Do Test the Theory Step #7 – Study The Results Step #8 – Act Step #9 – Honor CELEBRATE!!!

43. Shawnee County Health Agency Leading the way to a healthier Shawnee County Improvement

44. Shawnee County Health Agency Leading the way to a healthier Shawnee County Example #3

45. Shawnee County Health Agency Leading the way to a healthier Shawnee County Stage 1 Step #1 - Getting Started The Situation “It appears (staff observations)” WIC clients are not keeping scheduled appointments

46. Shawnee County Health Agency Leading the way to a healthier Shawnee County Collect supportive data

47. Shawnee County Health Agency Leading the way to a healthier Shawnee County Stage 1 Step #2 – Assemble the Team Nurses Dietitians Clerks

48. Shawnee County Health Agency Leading the way to a healthier Shawnee County Stage 1 Defining the Problem “WIC no-show rates.” “Reduce no-show rates.” What’s broken / Needs improvement? What’s important? FU Appts” Where’s the Mother Lode?

49. Shawnee County Health Agency Leading the way to a healthier Shawnee County Stage 1 Step #3 – Examine Current Process/Approach Scheduling FU Appointments

50. Shawnee County Health Agency Leading the way to a healthier Shawnee County Collect supportive data

51. Shawnee County Health Agency Leading the way to a healthier Shawnee County What’s Broken / Needs Improvement?

52. Shawnee County Health Agency Leading the way to a healthier Shawnee County Defining the Problem “WIC no show rates.” “Reduce no-show rates.” What’s broken / Needs improvement? What’s important? “Re-cert appts” Where’s the Mother Lode?

53. Shawnee County Health Agency Leading the way to a healthier Shawnee County Defining the Problem “WIC no show rates.” “Reduce no-show rates.” What’s broken? What’s important? “Re-certs” Where’s the Mother Lode? “?? – ”

54. Shawnee County Health Agency Leading the way to a healthier Shawnee County Stage 1 Step #3 – Examine Current Process/Approach Scheduling Re-cert Appointments

55. Shawnee County Health Agency Leading the way to a healthier Shawnee County Problem Statement During May 2008-July 2008. WIC Recertification (RC) appointments accounted for 33% of WIC “No-show” rates.

56. Shawnee County Health Agency Leading the way to a healthier Shawnee County Analyze All Possible Causes

57. Shawnee County Health Agency Leading the way to a healthier Shawnee County Defining the Problem “WIC no show rates.” “Reduce no-show rates.” What’s broken? What’s important? “Re-certs” Where’s the Mother Lode? “1) – Staff training ”

58. Shawnee County Health Agency Leading the way to a healthier Shawnee County Client Satisfaction Survey Please circle how well you think we are doing in the following areas: GREAT 5 (avg.67%) GOOD 4 OK 3 FAIR 2 POOR 1 Ease of getting services: Ability to get in to be seen85 (64%) 37 (28%) 11 (8%) 00 Hours office is open82 (62%) 41 (31%) 8 (6%) 1 (1%) 0 Convenience of office location83 (64%) 36 (28%) 9 (7%) 2 ( 2%) 0 Prompt return on calls60 ( 46%) 43 ( 33%) 17( 13%) 6 ( 5%) 4 (3%) Time in waiting room 56 (43%) 47 (35%) 19 (14%) 8 ( 6%) 1 (1%) Staff: (Nurse/Dietitian) Friendly and Helpful to you96 (72%) 27 (20%) 8 (6%) 2 (2%) 0 Takes enough time with you 89 (67%) 32 (24%) 8 (6%) 3 (2%) 0 Explains what you want to know 91 (69%) 29 (22%) 9 (7%) 2 (2%) 0

59. Shawnee County Health Agency Leading the way to a healthier Shawnee County Defining the Problem “WIC no show rates.” “Reduce no-show rates.” What’s broken? What’s important? “Re-certs” Where’s the Mother Lode? 1) – “Staff training ” 2) – “Prompt return of phone calls”

60. Shawnee County Health Agency Leading the way to a healthier Shawnee County Next Steps Step #4 – Potential Solutions Cross train staff Prompt return on phone calls Need to conduct a phone call tally

61. Shawnee County Health Agency Leading the way to a healthier Shawnee County Next Steps – Impose a Change Step #5 – Develop Improvement Theory Target – Step #6 – Do Test Theory Step #7 – Study The results Step #8 – Act Step #9 – Honor CELEBRATE!!!