1. Learning Collaborative #1 March 2017
National Immunization Partnership with the Academic Pediatric Association (NIPA) Wave 3
CDC Grant # 1H23IP000950

2. Agenda Attendance Diagnostic QI Tools HPV Vaccine Delivery
Process Flow Maps and Fishbone Diagrams
Past Participant Experiences
LC schedule
Baseline Chart Review Data Collection Reminder
Contact Information
Any questions?

3. Diagnostic QI Tools HPV Vaccine Delivery
National Immunization Partnership with the Academic Pediatric Association (NIPA)
Adapted from a presentation by
Lory D. Harte, PharmD, CPHQ
Children’s Mercy – Kansas City

4. Process Flow Maps and Fishbone Diagrams

5. Process Flow Maps
Depicting the current and future state of a process

6. Key Points for Process Maps
Observe the process
Understand the current state
Identify failure modes
Determine your future state
Making observations
Understanding the baseline
Distinguishing between QA vs QI
Identifying failure modes

7. Why Map a Process?

8. Identify Steps in the Process
Patient
comes
to clinic
meets
criteria
to receive
HPV
Vaccine is
ordered
prepared
Consent
signed
given
monitored
for
side
effects
discharged
Thinking of the points just highlighted (why map a process?) here is the process map for vaccines. It is high level.
Much easier and quicker to construct than writing all the words needed to describe each step. Are there steps that people don’t think about?
USE WORDS ON SLIDE/ POINT

9. How to Construct/Interpret a Process Map
Clearly define the starting point and ending point
Determine the steps in the process, then place them in sequence as they currently stand
Walk through the chart with your team to test the accuracy
Interpret
Analyze the flow of events relative to the ideal flow
Look for duplication of effort or unnecessary wait time
Consider how it could be simplified
Determine if there is variation in how different people follow the process

10. What is the process (flow map) for delivering immunizations in your continuity clinic?

11. Summer 2014 SPEND SOME TIME ON THIS/ USE POINTER
POINT OUT RESIDENT INVOLVEMENT

12. Summer 2014 SPEND SOME TIME ON THIS/ USE POINTER
POINT OUT RESIDENT INVOLVEMENT

13. Does the process map go deep enough to see these things?
What elevation are you assessing?

14. Failure Modes Identify variations Assess gaps
Determine inconsistencies
“Failure modes” means the ways, or modes, in which something might fail. 
Failures are any errors or defects, especially ones that affect the patient, and can be potential or actual.
why attacking Failure Modes is helpful?
Quality Improvement – identify a problem before it becomes a reality (Tackle the effects of a bad design)

15. Key Points
Understanding the “Current State” allows for proper planning for the “Future State”
Identifying “failure modes” will help in designing a “Future State” that can prevent them from occurring
Matt: Understanding the “Current State” allows for proper planning for the “Future State.” And identifying “non-value added steps” and “failure modes” will help in designing the most meaningful project

16. Fishbone and 5 Whys Analyze the problem and
the potential causes through the use of cause and effect tools

17. Key Points for Cause & Effect Tools
You can’t fix what you don’t know is a problem
1st seek to understand, then work to improve
Making observations
Understanding the baseline
Distinguishing between QA vs QI
Identifying failure modes

18. Fishbone Diagram
Kaoru Ishikawa , a Japanese statistician, pioneered quality management processes in the Kawasaki shipyards, and in the process became one of the founding fathers of modern management.
It was first used in the 1960s, and is simply a diagram that closely resembles the skeleton of a fish and groups ideas about the causes of a problem.
Also known as Ishikawa Diagrams, Cause &Effects Analysis, & Root Cause Analysis

19. Why use a Fishbone Diagram?
Uses an orderly, easy-to-read format
Helps determine root causes
Indicates possible causes of variation
Increases process knowledge
Identifies areas for data collection

20. Building a Fishbone
Start with a concise description of the “Effect” to which everyone agrees and place in the fish head
Can be stated in the form of a question: Why do we have low rates of HPV vaccination?
Can be phrased as a positive (objective or AIM) or negative (problem)

21. Building a Fishbone
Brainstorm the Primary Causes influencing the Effect and list them for each category
Secondary Causes may also be identified by continued brainstorming and asking “Why is this happening?” Add sub-factors under each segment and keep asking “Why” until you no longer obtain useful information

22. Building a Fishbone
Analyze for “Most Likely Causes” where items appear in more than one category
Identify “Most Probable Cause” by collecting data or surveying team members

23. Fishbone Diagram
Use the words on the slide and pointer

24. Fishbone Diagram
Use the words on the slide and pointer

25. Five Why’s Simply ask “Why” at least 5 times in a row.
Problem Statement: Eligible patients do not receive the HPV vaccine series?
1. Why? Because the patient is unaware it is available   Why? Because the provider does not discuss it    Why? Because the provider does not remember to discuss it    Why? Because the provider was not prompted to remember   
5. Why? Because the process did not work as designed   

26. Key Points
Using cause and effect tools helps to determine the factors that contribute to the problem.
These tools can also help you determine the most likely or most probable cause.
Interventions targeted at preventing the factors will lead to improvement in your outcome.

27. Past Participant Experiences

28. Past Participant Experiences
Who was involved in your team?
What helped you to get started? What were you looking to change?
Where did you notice your site’s greatest barriers? Successes?
When did you start to notice your implementation strategies becoming part of your site’s routine?
Why have you decided to continue with the project?

29. Next Learning Collaboratives: April 2017
Data Due:
May Monthly Chart Review Data is due April 5th!
If your site has IRB approval, Holly will send each site lead instructions, materials, and site-specific link to access REDCap.
April 2017 Learning Collaborative Schedule:
Tuesday 8am ET/ 7am CT/ 6am MT/ 5am PT
Tuesday Noon ET/ 11am CT/ 10am MT/ 9am PT
Friday Noon ET/ 11am CT/ 10am MT/ 9am PT

30. Baseline Chart Review Data Collection
If your site has IRB approval, each site lead will receive instructions and materials for completing Baseline Chart Review.
Deadline: June 2017

31. Contact Information
Please contact:
Holly Tyrrell, MSSW
Phone: 703/ x113 I Fax: 703/

32. Any questions?