4Why QI? The goals are to benefit: Employees involved in work processes, making the work easier.Our organization, through more efficient or effective work activities.The customers of our work, who must use what we produce.Kelly, 1992
5Where did QI come from? Grandfather of QI: W. Edwards Deming Statistician and professor by trade, consulted with American companies during WW II on production issues.Post world-war II: Worked with Japanese companies to rebuild. They embraced his techniques.Believed that the goal of business should not be just to make profits, but to stay in business so they could provide jobs.
6W Edwards DemingHas been called a “curmudgeon” for his critical workshop tactics.In reality, he sympathized with the plight of workers.A short story…Deming’s 14 PointsRead the Deming story (handout). Distribute 14 points.
7QI AssumptionsWorkers want to perform well on the job, take pride in their work.Workers’ performance more often related to faulty systems than employee error.Jurran’s Principle: “85%-15% Rule”Management/leadership generally makes decisions about systems.Data is needed to make good system decisions.
8What do we get from QI?Improves our job satisfaction – we know our product or service is quality, a source of pride.Reinforces the belief that we can solve problems, make a difference in our jobsWe have a greater investment, ownership for our work.We have less tolerance for problems and poor quality.
9QI Basics Improving quality is a systematic process: PLAN: Define the problem, collectdata, select a possible solution.DO: Implement solution on a smallscale.CHECK: Collect data, determineif the solution worked. If not, go back toPlan and select another solution.ACT: When a solution works, spread to all aspectsof the operation.
10Five-Step Problem Solving Model Quality improvement can also be described as a systematic problem-solving model:1. Identify the problem – clearly state what needs improvement.2. Analyze the problem – Determine what causes problem to occur.3. Evaluate alternatives – Identify and select actions to reduce or eliminate the problem.4. Test/implement a solution – Implement these actions on a trial basis to determine effectiveness.5. Standardize – Ensure that useful actions are preserved.
11Working Together as a Team Module 2Working Together as a Team
12Working Together as a Team Team Roles:Team members share their expertise to plan and implement project work.The Leader orchestrates team activities, maintains records, serves as communication link with rest of the organization.The Coach understands the tools and concepts of improvement, including approaches that help a team function well together.The Sponsor reviews and supports team efforts, interfaces with other parts of the organization.
13Effective Team Members… Participate fully in team meetingsShare knowledge and experience, listen closely to that of other team membersAre open to new ideasCarry out assignments between meetingsAssist leader with managing the meetings, e.g. documentation, discussions.Communicate effectively with colleagues about project work.
14An Effective Leader… Organizes the team’s work and activities Focuses on a data-based methods to solve the problemServes as contact point for communication between the team, sponsor, others in organizationKeeps official team records, e.g. meeting minutes, agendas, data related to project.Assists with carrying out work between meetingsImplements project-driven changes within his or her authorityHelps team resolve its problems
15An Effective Coach…Attends meetings but not is a leader or member; an outsider who maintains a neutral position.Assists team in structuring or breaking down tasks and plans into assignmentsWorks with team leader to plan meetingsAssists leader with team buildingTeaches data collection, analysis techniques; helps team graphically display dataHelps team prepare for presentation of project to management, others
16An Effective Sponsor…Maintains overall responsibility, authority and accountability for projectApproves “bubble-up projects,” assures compatibility with organizational prioritiesSometimes initiates project, begins charter, selects leader, coach and membersApproves resources for projectInterfaces with rest of the organization to assure appropriate stakeholder involvementFeeds data and lessons learned into a system for future improvements, e.g. policy changes
17Reality Check Is everybody clear about the roles? Does everyone have a role?Are the leader, coach, sponsor roles filled?If not, what is the plan?Next Step: What’s our problem?
18Identifying the Problem Module 3Identifying the Problem
19QI Toolkit: Identifying Problems Brainstorming – generating a list of potential problemsInterviews or surveys - customer feedback, recommendationsList reduction - narrowing the list to a few items, by combining into groupsProblem selection matrix
20QI Toolkit - Brainstorming Collect a large number of ideas from a group of people. Many ideas, quickly as possible.One-at-a-time (everyone speaks)Open door (call out ideas)Write-it-down (confidentiality)Guidelines:Be creativeBuild on ideas of othersNo critique allowed
21QI Toolkit – Interviews, Surveys Purpose: Collect data from direct conversation.Surveys:Purpose: Collect data froma large number of people.
22QI Toolkit – List Reduction Purpose: Reduce a large list of items to a manageable size.Useful in conjunction with brainstorming.Group votes for the most important items on list (can cast as many votes as they want).Items with the most votes are circled.If further narrowing is required,process conducted again, limitingnumber of votes people can cast.
23QI Toolkit: Selection Matrix Problem Selection MatrixCriteriaProblemsWithin our control or influencePotential for cost savingsNumber of customers affectedSignificance of ProblemTotalToo many defects312Absenteeism high128Equipment breakdowns9Water cooler too far away63 = High = medium = low
24What’s Our Problem? A little history… When did we notice the problem? Was there anything else going on when we noticed it?Have other solutions been tried in the past?If so, what happened?Facilitate discussion on these questions, and record answers on flip chart. These could all be on the same page.
25What’s Our Problem? Zooming in on the current state: What exactly is happening?When is it happening?Where is it happening?Who is involved?Flow chart now?
26What’s Our Problem? Zooming in on the future (or desired) state: What should be happening?When should it happen?Where should it happen?Who should make it happen?The team could do a full-blown current and future state exercise here (on next slide).
27Current and Future State Current StateWhat is the current state?Why is this important?What is it costing us time/dollars/staff/etc?What is the impact on our customer/clients?What is the impact on our division/agency?Future State:What are the important aspects ofthe future state?What is driving us to this future state?What might be the consequences ofnot moving to the future state?What might change?What is the proposed timeline?Driving Forces:PathwayConsequencesBegin working on the current stateBenefits
29QI Toolkit – Flowchart Where is the process breaking down? RFFlow Professional Flowcharting,
30Draft a Problem Statement A good problem statement should be:Specific.Describes the problem, not the symptom.Relates the current situation to what is desired.Does not include causes or solutions
31Expressing Need for Improvement in Measurable Terms Two-Step Process:Gathering information (data) about the problem.Tool utilized: ChecksheetOrganizing data so that it is meaningful and clarifies the problem.Tools utilized: Line graphs, Pareto charts, Histograms, Bar and Pie charts.
32QI Toolkit: Checksheet Purpose: Collect data in an organized manner.Telephone InterruptionsExcerpted from Nancy R. Tague’s The Quality Toolbox, Second Edition, ASQ Quality Press, 2004, pages
33QI Toolkit: Line GraphPurpose: Display the output of a process over time.
34QI Toolkit: Pareto Chart Purpose: Arrange data so that the most significant element in a set of elements is easily identifiable.Diagram courtesy of Six Sigma
35QI Toolkit: HistogramPurpose: Determine how data are distributed.
36QI Toolkit: Bar ChartPurpose: Arrange data for quick and easy comparison.
37QI Toolkit: Pie ChartPurpose: Display the volume or quantity of one item in relation to others.
38Check Problem Statement Did data validate the original problem statement?If not, revise and collect more data.If it did, refine the problem statement so that it is:Specific.Describes the problem, not the symptom.Relates the current situation to what is desired.Does not include causes or solutions
39Establish Interim Target, Date Targets should be:Intermediate and long termQuantitatively expressedAggressiveChanged as the situation changesExample: This project aims to reduce the number of days it takes to process a payment voucher from 10 working days to 2 by December 31, 2010.
41Identify the Root Cause(s) If the cause is removed, the problem should be at least partially removed.A symptom is not a cause; a symptom is evidence the problem exists.Several root causes may contribute to the problem; it is important to examine all.QI Tools for establishing root cause(s): Brainstorming, Flowcharts, Cause and Effect Diagrams, 5 Why’s.
42QI Toolkit: Cause and Effect Diagram Purpose: Identify a set of related causes that lead to an effect or problem.
43QI Toolkit: 5 Why’s Problem: Patient falls in the hospital. 5 Why’s ResponseWhy does the patient fall?Not wearing skid-proof slippers.Why does the patient not wear slippers?Not issued by nurse.Why were slippers not issued?No slippers in supply closet on patient’s floor.Why were there no slippers in the closet on patient’s floor?Staff did not re-order.Why didn’t staff re-order?Busy with needs of other patients.
44Verify Cause by Collecting Data QI Toolkit - Data collection and analysis:ChecksheetRoot Cause Evaluation MatrixHistogramBar ChartPareto Chart
45Root Cause Evaluation Matrix Problem: Suzie has been late to school 8 times in past 3 months.Potential Root CauseAnalysisVerified?Doesn’t get up when called.Occurred twice in past 3 months, not on days late to class.NoCan’t find clothes.Has not occurred in past 3 months.Homework not complete.Has occurred 10 times in past 3 months, always on days when late.Yes
46Guidelines for Data Collection Establish the purpose for collecting data – helps you target your efforts, collect only what is needed.Determine if indicators are reliable – What is the source of data? Are measuring practices consistent and accurate?Track all data needed – collect enough to conduct a thorough analysis.Record data carefully – Use a checksheet that is logical and makes collection easy.
47Select Root Cause(s) Most Responsible Example: Investigating delay associated with processing credit card applications, data could be grouped into the following categories:No signatureNo AddressCannot readCurrent customerOther
49Developing Alternatives QI Toolkit: Brainstorming, interviews, survey, research (have others solved this problem?)Guidelines:Be creative, identify as many potential solutions as possible.Don’t be limited by the current practice (i.e. “That’s the way we’ve always done it.Refrain from judging team members’ suggestions.
50Evaluating Alternatives Effective? (Tried before? With what results? Will it solve the problem? Achieve improvement target?)Feasible? (Is it doable? Practical?)Timely? (How long will it take? Long term or short term? Can we afford to wait?)Customer-oriented? (Will it improve service quality? Satisfy customer identified requirements?)Efficient? (Is it cost effective?)
51Select Solutions to Implement Planning for implementation:People: Whose support is needed?Materials: What is needed? Who will purchase?Methods: How will implementers be trained? How will solutions be measured?Machinery/Equipment: Where will it come from? How will it be funded? How will it be purchased? How will implementers be trained to use it?
52QI Toolkit – Barriers and Aids Purpose: Document the hindering and supporting factors that influence a planned activity.PROVIDE ISDH PROGRAM STAFF TRAINING ON QI SKILLSAIDSTraining materials availableProgram staff want to learn QIBARRIERSEmployee work schedules not compatible with datesProgram time is consumed with grant requirements.
53QI Toolkit – Barriers and Aids Purpose: Document the hindering and supporting factors that influence a planned activity.PROVIDE ISDH PROGRAM STAFF TRAINING ON QI SKILLSAIDSTraining materials availableCoordinate training dates to align with work schedulesProgram staff want to learn QIDevelop efficiencies to clear out time for accreditation preparationBARRIERSEmployee work schedules are not compatible with datesProgram time is consumed with grant requirements.
54Elements of Planning The objective is clearly stated. Activities are each defined.Responsibility is assigned.Dues dates are established.Implementation Plan Matrix:WhatHowWhoWhenComplete?Task 1Task 2Task 3
56Test the Plan Implement on a trial or “pilot” basis. Get all necessary approvals.Help solutions succeed by:Communicating the planMonitoring implementationSupporting each otherAdjusting if necessaryShow measurable improvementsQI Toolkit: Line Graphs, Pareto Charts, Pie Charts, Bar Charts, Histograms , Checksheets.
57Test the PlanIf measurable improvements are not evident, return to problem-solving statement.Common reasons why this happens:Poor problem statementAnalysis insufficient or inaccurateVerification of root causes is inadequate
59Steps to Standardization Make solutions permanent:Make periodic checksClarify work activities (make a flowchart of new process)Develop procedures and follow themAssign responsibilitySpread improvements to total process(beyond pilot)Determine if solution is applicable to other areasGuard against “spotlight” effect—improvements related to process being under investigation.
60ReferencesKelley, MR. (1992).Everyone’s Problem Solving Handbook. Productivity Press, Portland, OR.Walton M. (1986). The DEMING Management Method. The Berkley Publishing Group, New York, NY.Scholtes PR, Joiner BL, Streibel BJ. (2003). The Team Handbook, Third Ed. Oriel Inc, Madison, WI.Healthcare Technical Assistance Program. (2007). Indiana Public Health System Quality Improvement Program. Purdue University, West Lafayette, IN.Moran J, Duffy G. (2009). Public Health Foundation, Washintgon, DC.