1. QI & PDSA for Public Health Debra Tews, MA Michigan Dept. of Community Health PPHC Pre-Session Bay City, MI 10/26/2010 Plan DoStudy Act 1

2.  A brief overview of QI including PH definitions for Quality and QI  An intro to PDSA from Michigan’s Quality Improvement Guidebook  An intro to QI tools Today’s Focus 2

3. What is Quality in Public Health? “ Quality in public health is the degree to which policies, programs, services and research for the population increase desired health outcomes and conditions in which the population can be healthy.” Public Health Quality Forum 3

4. So How Can One Define Quality Improvement for Public Health? Use of a deliberate and defined improvement process, such as Plan-Do-Check [Study]-Act, which is focused on activities that are responsive to community needs and improving population health. It refers to a continuous and ongoing effort to achieve measurable improvements in the efficiency, effectiveness, performance, accountability, outcomes, and other indicators of quality in services or processes which achieve equity and improve the health of the community. Accreditation Coalition 2009 4

5. Why QI in Public Health? QI Can:  Reduce costs and redundancy  Eliminate waste  Streamline processes  Enhance ability to meet service demand  Increase customer satisfaction  Improve outcomes Tough Economic Times Require a Different Approach! 5

6. Is it QI or is it QA? Quality Improvement GOES BEYOND Quality Assurance! 6

7. Doing Both?  QUALITYASSURANCE relates to Monitoring & Compliance. It GUARANTEES quality. Standards met? Deficiencies corrected? QA is..... reactive!  QUALITY IMPROVEMENT relates to Learning & Improving. It RAISES quality. Quality can’t always be assured. Ongoing efforts to identify opportunities for improvement are needed. QI relies on measurement & data-driven decisions to improve outcomes. QI is..... proactive! 7

8. Principles of QI From the Public Health Memory Jogger Pocket Guide of QI Tools:  Develop a strong customer focus  Continually improve all processes  Involve employees  Mobilize both data and team knowledge to improve decision making 8

9. Three Key Questions !!! 1. What are we trying to accomplish? 2. How will we know that a change is an improvement? 3. What changes can we make that will result in improvement? 9

10. Change Vs. Improvement Edwards Deming: Of all changes observed, about 5% were improvements, the rest at best were illusions of progress! To move beyond illusions of progress, a QI method (PDSA) and QI tools are needed. Embracing Quality in Local Public Heath: Michigan’s QI Guidebook explains the PDSA method and suggests tools. 10

11. Snapshot: Plan-Do-Study-Act (PDSA) Plan DoStudy Act 11

12. Some Common Tools of QI  Process Mapping  Cause and Effect/Fishbone Diagrams  Five Whys  Run Charts  Pareto Charts  Check Sheets Understand Your Process & Make Sense of Your Data! 12

13. QI: Assembling the Pieces  Listen to LHD customers  Use data to make data- driven decisions  Continually improve processes in your LHD  Use recognized QI methods and tools  Work together; a team approach is best.  Ask the 3 Key Questions! 13

14. What Do Users Say?  “We now have staff eager to use the same tools/methods to evaluate performance and make improvements in other areas of our work” MLC-3 LHD  “The PH focus of the Guidebook helps with the application of QI methods; it becomes ‘real’ for participants... we can ‘look through our public health windows’” Allegan LHD  “For any PH agency interested in learning QI and how PH can apply these principles/methods, I would recommend they start with this Guidebook” Saginaw LHD  “The Guidebook has been a road map for our team as we navigate our way down this new path of improving our processes” MMDHD “I refer to the Guidebook often even though I know the steps” MI Mentor 14

15. There’s More...  “The Guidebook has been incredibly useful for QI work, serving as the primary textbook for teaching QI throughout the department” MI Mentor  “The Guidebook helps with capacity building... it would not be possible to spread QI methodologies easily without it” Muskegon LHD  “The Guidebook is used in our QI meetings as an effective discussion and clarification tool; it generates comfort levels” Allegan LHD “The Guidebook is the glue that holds the whole effort together” MI Consultant 15

16. QI Resources for Public Health www.accreditation.localhealth.net and www.phf.orgwww.accreditation.localhealth.netwww.phf.org 16

17. Another Resource for QI Tools  http://www.langfordlearning.com 17

18. Using QI Tools There are many tools that can help you meet the goal of improving your work processes and services 18

19. PDSA and Using QI Tools  Using tools as part of the PDSA cycle  Some tools will be useful in the planning stage  Others will help you to implement your QI project  And/or will help you study the impact of your process change 19

20. Useful QI Tools  Process Mapping  Check Sheets  Pareto Charts  Cause and Effect Diagrams  Fishbone Diagrams  The 5 Whys  Run Charts 20

21. PROCESS MAPPING Sometimes called Flow Charting… 21

22. QI Works on Existing Processes  A process is a series of steps or actions performed to achieve a specific purpose  It describes how things get done  Your work is made up of many processes 22

23. What is a Process Map?  A pictorial representation of the sequence of actions that describe a process 23

24. Why is Process Mapping Important?  It’s an opportunity to learn about the work being done  It involves documenting the obvious, as well as all that which goes without saying  Helps to discover inconsistencies  Most processes today are undocumented  Helps to control the “evolution” of a process 24

25. Process Maps are Used To  Document the way we do our work  Analyze and improve on processes 25

26. How Do We Prepare to Process Map? (1)  Assemble the QI Team  Agree on the process you want to document  Agree on the purpose of the process  Agree on beginning and ending points 26

27. How Do We Prepare to Process Map? (2)  Agree on the level of detail to be displayed  Begin by preparing an outline of steps  Identify and recruit other people that should be involved 27

28. What are the Symbols Used in Process Mapping?  Start and End of the Process:  A process Activity:  A process Decision:  A Break in the process: 28

29. Helpful Tips to Keep in Mind  Process Map what is, the actual process  Process Mapping is dynamic  Clearly define the boundaries of the process 29

30. Example: Process Map of Conference Approvals Process  Do a Process Map that documents the process used to obtain approval to attend conferences. 30

31. The Simplest Map 31

32. A More Detailed Map 32

33. Mapping the True Process 33

34. More Useful Tips  Other exercises can help you identify the process you want to map  There is no single right way to Process Map  Process Mapping is not an end in itself  Process Maps, once created, can be useful in a variety of settings 34

35. Summing Up Process Mapping  We Process Map to learn  We Process Map to document a baseline of performance  We Process Map to discover where data may be hiding 35

36. QI Scenario: Process Mapping Exercise  Highlighting Excellence Health Department  Improvement sought-Improved Customer Satisfaction with health department services  Improve performance connecting clients with services  Please take a moment to read the Scenario write-up that is in your handouts 36

37. 37

38. CHECK SHEETS Observing a Process 38

39. What is the Purpose of a Check Sheet?  To turn observational data into numerical data  From records  Newly collected  To find patterns using a systematic approach that reduces bias  Use check sheets when data can be observed or collected from your records 39

40. Check Sheets Step by Step (1)  Step 1  Decide what to observe  Define key elements  Establish shared understanding  Step 2  Identify where, when, & how long  Think about confounding factors o That you want to eliminate o That you want to study 40

41. Check Sheets Step by Step (2)  Step 3  Design your check sheet  Develop a protocol 41 Problem/Project Name:Name of Observer:Other: Location of Data Collection:Dates of Observation: Dates of Data CollectionTotal Event A B C Total Grand Total

42. Check Sheets Step by Step (3)  Step 4  Identify and train your observers  Practice & adjust  Step 5  Collect data  Review & adjust  Step 6  Summarize data across observations & observers  Study the results 42

43. Tips for Using Check Sheets  Make sure you’re getting clean data  Define, train, check, adjust, & repeat!  Consider and address potential sources of bias  Use “other” categories sparingly  Strike a balance  Fine vs. inclusive categories  Few vs. many categories 43

44. Check Sheet Exercise (1)  When customers report dissatisfaction with LHD services, staff track the primary reason for customer complaints  They believe dissatisfaction may be caused by several conditions that they can document  Use your handout to set up the check sheet for this situation 44

45. Check Sheet Exercise (2) 45 Problem: Client DissatisfactionName: A. MartinTime: 9-5 Location: Excellence Health Department’s Customer Service Department Dates: Week of 9/6, 9/13, 9/20, 9/27, 10/4, 10/11, 10/18 Date Total Reason9/69/139/209/2710/410/1110/18 Service not offered343234019 Service was difficult to access 10126300031 Long wait times002361012 Poor staff interaction22120018 Inaccurate information 231210110 Total17211312105280

46. PARETO CHARTS 80% of the problem 46

47. What is the Purpose of Pareto Charts? (1)  To identify the causes that are likely to have the greatest impact on the problem if addressed  “80% of the effects come from 20% of the causes”  To bring focus to a small number of potential causes 47

48. What is the Purpose of Pareto Charts? (2)  To guide the process of selecting improvements to test  Use when you have, or can collect, quantitative or numeric data on several potential causes 48

49. Pareto Charts: Step by Step (1)  Step 1  Identify potential causes of the problem you wish to study  Step 2  Develop a method for gathering your data o Historical data o Collection of new data 49

50. Pareto Charts: Step by Step (2)  Step 3  Collect your data  Each time the problem occurs, make note of the primary cause  Step 4  Order your results & calculate the percentage of incidents that fall into each category 50

51. Pareto Charts: Step by Step (2)  Step 5: Display your data on a graph…. 51

52. Pareto Charts: Step by Step (3)  Step 6  Make sense of your results by examining your data 52

53. Tips for Using Pareto Charts  You’ll only learn about causes that you investigate - be inclusive!  Check and double check your data  Results can be used in more than one way and they can be used differently at different points in time 53

54. Pareto Chart Exercise 54 Problem: Client DissatisfactionName: J. HeanyTime: 9-5 Location: Excellence Health Department’s Customer Service Department Dates: Week of 9/6, 9/13, 9/20, 9/27, 10/4, 10/11, 10/18 Date Total Reason9/69/139/209/2710/410/1110/18 Service not offered343234019 Service was difficult to access 10126300031 Long wait times002361012 Poor staff interaction 22120018 Inaccurate information 231210110 Total17211312105280

55. BREAK TIME (10 MINUTES) 55

56. CAUSE & EFFECT DIAGRAMS Moving from treating symptoms to treating causes 56

57. Seeing Beyond the Tip of the Iceberg 57 The Symptom The Cause

58. Problem Solving & Root Cause  When confronted with a problem most people like to tackle the obvious symptom and fix it  This often results in more problems  Using a systematic approach to analyze the problem and find the root cause is more efficient and effective  Tools can help to identify problems that aren’t apparent on the surface (root cause) 58

59. What is the Purpose of Fishbone Diagrams?  To identify underlying or root causes of a problem  To identify a target for your improvement that is likely to lead to change 59

60. Construction of a Fishbone Diagram (1)  Draw an arrow leading to a box that contains a statement of the problem 60 Effect/Problem

61. Construction of a Fishbone Diagram (3)  Draw smaller arrows (bones) leading to the center line, and label these arrows with either major causal categories or process categories 61 Cause 1 Effect/Problem Cause 2 Cause 3 Cause 4

62. Construction of a Fishbone Diagram (2)  Then for each cause identify deeper root causes 62 Cause 1 Effect/Problem Cause 2 Cause 3 Cause 4

63. Berrien County Fishbone Root causes for lack of BCHD general PH articles 63 Minimal articles Effect Causes People/Staff Media Relations Topics Process No long-term arrangements Secluded media team One writer, poor health Articles for events only Confusion/duplication No time to develop Sporadic writing

64. Another Fishbone Diagram 64 Obese Children Life Style PolicesEnvironment TV ViewingNo Time For Food Prep No Outdoor Play Unsafe Juices Bottle Pacifier Less Fruits and Veg. Less Income Maternal Choices Less Exercise @ School Curriculum No Sidewalks Unhealthy Food Choices Few Community Recreational Areas or Programs Built Environment For Strollers Not Toddling Less Indoor Mobility TV Pacifier Unsafe Housing Sodas/Snacks Decreased Breast Feeding Early Feeding Practices Genetics Syndromes Genes Pre Natal Practices Excess Maternal Weight Gain Over Weight Newborn Over Weight Pre School 64

65. Tips for Using Fishbone Diagrams  Find the right problem or effect statement  Find causes that make sense and that you can impact  Make use of your results 65

66. Fishbone Diagram Exercise  Create a Fishbone Diagram using the Pareto Chart you made in your last exercise  Listing effect(s), major causes, and data related causes (root) on the diagram  It is OK if data related causes show up in more than one major cause area 66

67. THE 5 WHY’S More Cause and Effect 67

68. What is the 5 Whys?  A question asking method used to explore the cause/effect relationships underlying a particular problem  The goal is to determine the ROOT CAUSE of a problem 68

69. An Example of the 5 Whys  My car will not start. (the problem)  Why? - The battery is dead. (first why)  Why? - The alternator is not functioning. (second why)  Why? - The alternator belt has broken. (third why)  Why? - The alternator belt was well beyond its useful service life and has never been replaced. (fourth why)  Why? - I have not been maintaining my car according to the recommended service schedule. (fifth why, root cause) 69

70. The 5 Whys and Hows  This technique is easy to use and apply  But it requires skill to use  The answers should be grounded in observation and data  Avoid deductive reasoning with this technique 70

71. Limitations of the 5 Whys  Does not always lead to root cause identification  Can lead to bad judgment calls when used in the absence of data  Process changes are then made that address the wrong root cause  This can make the situation worse 71

72. Use Data to Overcome Limitations 72

73. Summing Up Cause and Effect  Use Fishbone and 5 Whys to explore and graphically display in increasing detail all of the possible causes related to the problem  Use Fishbone and 5 Whys to find dominant causes rather than symptoms  Use Fishbone and 5 Whys to identify the root cause of the problem we seek to improve 73

74. 5 Whys Exercise  Perform 5 whys on the two causes that received the greatest number of responses as shown in the Pareto Chart (Service was difficult to assess and Service not offered). 74

75. RUN CHARTS Tracking Process Performance 75

76. What is the Purpose of Run Charts?  To study data measured over time  Run charts help to:  Study the performance of a process  Identify trends  Measure change in performance following a change in process  Use when you have, or can collect:  Quantitative data  Data measuring the performance of a process  Data collected over time 76

77. Run Charts: Step by Step (1)  Step 1  Decide what data you need  Determine the timeframe  Determine the number of data collection points  Step 2  Gather your data 77

78. Run Charts: Step by Step (2)  Step 3  Graph your data o On the Y-axis, set up a scale that corresponds with your measure o On the X-axis, set up a scale that corresponds with your measurement timeframe o Plot your data on the chart, placing one dot at each measurement point o Draw a line through your dots o Calculate the mean score and draw a line at the mean o Mark the timing of your process change on the line 78

79. Example Run Chart 79

80. Run Charts: Step by Step (3)  Step 4  Make sense of your results by examining your data o Does the mean reflect an appropriate level of service or outcome of your process? o Is there a trend that should be investigated? o Do you see a shift in your data? Are there 8 or more consecutive points on one side of the center line? o Do you see a trend in your data? Are there six consecutive jumps in the same direction (up or down)? o Do you see a pattern in your data? Does a pattern recur eight or more times in a row? 80

81. Tips for Using Run Charts  Every process will have some variation  Be sure to track data over a long enough period of time 81

82. Run Chart Exercise 82 MonthResponse rate in ‘08 Response rate in ‘09 January 21.8 February 2.31.9 March 2.22 April 2.53.5 May 2.63.8 June 2.23.9 July 2.14 August 1.94.1 September 1.94.3 October 24.5 November 2.14.5 December 2.24.5

83. Quality Improvement Resources  Michigan’s QI Guidebook  The Public Health Memory Jogger II  Quality Improvement Resources Handout 83

84. Working Session Bringing QI into your Programs 84

85. Working Session Exercise 1  Identify Two WIC Program or Health Division Areas where QI Processes would be Helpful 85

86. Working Session Exercise 2  Identify which Front Line, Middle Management and Administrative Staff need to be Involved in QI Problem Solving in the work processes you prioritized for improvement in Exercise 1 86

87. Working Session Exercise 3  Four Essential Elements to creating an internal environment supportive to QI:  Policy  Leadership  Core Values  Resources  Identify Three Key Means to Build Support for and Initiate QI Processes in Your Organization 87

88. Q & A Please feel free at this time to email any questions you may have about the training and/or exercises 88

89. BREAK – 10 minutes  Upcoming Events: February 23 – WIC Coordinator Webcast March 6 – Anthropometric Training, Flint March 7 – Lab Training, Flint March 21,22 – CPA Training, Grand Rapids 89

90. BREAK – 10 minutes  2012 WIC Training & Educational Conference  Make your Hotel Accommodations NOW…  events.mphi.org events.mphi.org 90