Quality Tools for Process Improvement

PDCA/PDSA

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

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

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

Root Cause Analysis

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.

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

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.

Fishbone Diagram

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.

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

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-

Process Mapping

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

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

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

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

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