1. Quality Improvement Tools for Intervention Determination
Presenters:
Kris Hartmann, MS
Healthcare Analyst, Performance Improvement Projects
Don Grostic, MS
Biostatistician, Performance Improvement Projects

2. Objectives of the Workshop
To share the latest knowledge on quality improvement tools.
To address identified opportunities for improvement from prior Florida PIP validations.
To support current efforts in determining interventions for ongoing PIPs.
To provide a systematic, step-by-step approach that can be used to select impactful interventions.
It’s important to be thoughtful about the quality improvement activities and interventions selected in this stage of the process but these initial activities and interventions may change throughout the course of the project. This is a normal occurrence with quality improvement.

3. “What changes can we make that will result in improvement?”
Summary of Objectives
To empower you, your team, and your organization to answer the question:
“What changes can we make that
will result in improvement?”
It’s important to be thoughtful about the quality improvement activities and interventions selected in this stage of the process but these initial activities and interventions may change throughout the course of the project. This is a normal occurrence with quality improvement.

4. Quality Improvement Tools
Team Building
Process Mapping
Failure Modes and Effects Analysis (FMEA)
Pareto Diagram
Failure Mode Priority Ranking
This slide summarizes the QI tools that we will review today. I will cover the first 2 tools (in orange) and Don will present the remaining 3 tools.

5. Building a PIP Team
Including the right people on the PIP team is critical to a successful improvement effort.
Teams may vary in size and composition.
Team composition should be driven by the PIP topic.

6. Building a PIP Team: Senior Management
A Sponsor from Senior Management:
Is critical to support the PIP team efforts.
Serves to link the PIP team with senior management and assure alignment with the organizational strategy.
Provides resources and assists with overcoming organizational barriers on behalf of the team.
Enables the PIP Team to make the changes necessary to improve the process.

7. Building a PIP Team: Clinical Support
A clinical leader:
Is critical to the PIP team efforts.
Provides insight into the clinical implications of potential interventions and can anticipate the impact of system changes.
Should come from the areas of the organization that are relevant to the PIP topic.
For example, if the PIP focuses on behavioral health, include clinical support from the behavioral health department.

8. Building a PIP Team: Analytical Support
Should be included from the beginning of the project.
Provides sound methodology upon which the project is based.
Ensures that outcomes are accurately measured.
Analytical Support can:
Provide data summaries to identify areas of needed improvement and support selection of the PIP topic.
Help to select and define appropriate measures.
Assist with the data collection plan and sampling methodology.

9. Building a PIP Team: Step-by-Step Approach
Steps to develop an effective team:
Review the PIP topic.
Consider the process being targeted for improvement.
Include team members who are knowledgeable about the different levels and steps of the process.
Include analytical support from the beginning of the project.

10. Building a PIP Team: Step by Step Approach
Identify an executive sponsor who takes responsibility for the success of the project.
Consider including partners from external organizations that are part of the process.
External partners include providers, hospitals, members, and professional organizations.

11. Process Mapping A process map is:
A quality improvement tool that illustrates how a current process is being administered.
A global view of all the steps in the current process to determine where improvement efforts are most needed.
Most effective if it is documented from the perspective of the person most affected by the overall process, typically the enrollee.
Why use process mapping?
It helps identify the actual flow of a process to help determine:
What’s going on?
Are there any delays, redundancies or unnecessary steps?
How can the process be improved?
Is there a need for standardization.
Can systems fit together?
Completing a process map enables examination of efficiency and impact, and it can serve as a training aid to better understand a process.
It can be used to build enthusiasm for process and quality improvement.
Your process map will go through many revisions as your team works through its quality improvement activities and tests interventions.
The team’s intentions and what you think will happen is not always what happens.

12. Building A Process Map: Step-by-Step Approach
Determine the beginning and ending points.
Involve the individuals responsible for the different steps of the process.
Determine 3–5 prominent phases that occur for the process to work.
List the activities for each phase of the process.
Obtain feedback from all team members before finalizing the process map.
By having a clear understanding of the starting and ending points of the process, and knowing who’s doing the work, you can ensure that you have all of the right people involved with creating the process map. This also allows for everyone involved in the process map to accurately depict their views and roles.
Questions for the team to ask when completing the process map:
Who are the right people to have involved?
What do we expect from the process map?
Who will use it?
How will they use it?
What level of detail is needed?
It will take more than one meeting and multiple versions of the process map to get to a final version. And- even though it may be considered final at one particular point, it still may be revised based on lessons learned along the way.

13. Here is a simplified process map using the Preventive Dental Visits PIP topic as an example.
There are four basic symbols to use when completing a process map.
The oval represents the starting and ending points of the process
Rectangles represent each step or activity within the process
Diamonds represent “yes and no” questions
Arrows are used to connect each step of the process in the direction that the process flows.

14. Questions on Team Building and Process Mapping
Questions and Answers
Questions on Team Building and Process Mapping
Are there are any questions or comments about team building or process mapping before we move onto the next QI tool?

15. Quality Improvement Tools
Team Building
Process Mapping
Failure Modes and Effects Analysis (FMEA)
Pareto Diagram
Failure Mode Priority Ranking
Presenter:
Don Grostic, MS
Biostatistician, Performance Improvement Projects
Now that we’ve built a solid team and mapped our process, the team will use the process map to identify opportunities for improvement. Don Grostic will address this next step as he introduces the FMEA – Failure Modes and Effects Analysis tool. He will also describe a method for priority ranking and using the Pareto diagram.

16. Failure Modes and Effects Analysis
A Failure Modes and Effects Analysis (FMEA) is:
A systematic, proactive method for evaluating a process.
A quality improvement tool that helps identify where and how a process is failing or might fail in the future.
Useful to pinpoint specific steps most likely to affect the overall process so interventions can have the desired impact on PIP outcomes.

17. Failure Modes and Effects Analysis
Failure Modes: What could go wrong? Any scenario that could go wrong (failing now or can go wrong in the future). Failure Causes: Why would the failure happen? Explanation of why the failure mode would occur; what is the root cause of the failure? Failure Effects: What is the consequence of the failure? What is the aftermath of the failure?
Based on the failure effects, the team can determine the priority ranking (high, medium, low) for developing an intervention for each identified failure.

18. Steps for Conducting FMEA
Determine up to three sub-processes from the process map that will have the most impact on improving the PIP outcomes.
Include all individuals responsible for the chosen sub-processes.
Brainstorm all failure modes that can occur for each sub-process.
A sub-process is a set of activities that have a clear purpose in the overall process.
Be sure to make informed decisions when selecting the sub-processes.
The sub-processes selected should be those that can influence the PIP outcomes and not those easiest to change.
The team conducting the FMEA should include those individuals who have roles and responsibilities for the sub-processes, as well as someone from data analytics. The team should agree on the selected sub-processes.

19. Steps for Conducting FMEA
Brainstorm failure causes and effects for each failure mode.
Evaluate the results and determine the priority ranking for each failure mode.
Obtain feedback from all individuals before finalizing the FMEA.
Just like with your process map, your FMEA most likely will be revised throughout the PIP based on lessons learned along they way.

20. Failure Modes and Effects Analysis Priority Ranking
Priority ranking allows for the highest ranked failure modes to take precedence when determining the interventions to be tested.
The highest priority failure modes are those that have the most leverage on affecting the PIP Outcomes.
The priority ranking should be based on MCO data and experience.
Another method to assigning priority ranking is using a Risk Priority Number (RPN). The RPN is a numeric assessment of risk assigned to a process or steps in a process as part of the FMEA. The RPN has three basic components:
Likelihood that the failure would occur.
Likelihood that the failure would not be detected.
The amount of harm or damage the failure mode may cause.
Assigning a risk priority number is an objective method for ranking failure modes as opposed to gathering subjective opinions from members on the team. This method will also help the team stay unified when ranking the failure modes.
By using a scale of 1-5, the team will assign each failure mode a numeric value that quantifies the likelihood of occurrence, likelihood of detection, and severity of impact (harm or damage). To get the RPN, the team will multiply the numeric values of the likelihood of occurrence, likelihood of detection, and severity of impact. For example…likelihood of occurrence=2; likelihood of detection=1; Amount of harm or damage=3 RPN= 6
The failure modes with the highest RPN should take precedence over lower ranked failure modes.

21. Pareto Diagram
A Pareto diagram is another method to identify specific areas in the overall process that warrant interventions.
When to use a Pareto chart:
Analyzing data about the frequency of problems or causes in a process.
There are many problems or causes and you must focus on the most significant.
Analyzing broad causes by looking at their specific components.
Communicating to others about your data.
The Pareto chart displays the relevance of data and will help you direct your efforts to the biggest opportunity for improvement.
The Pareto chart works best if you have at least 30 observations; however, you don’t need to have 30 observations to complete a Pareto chart. To start off, you can survey just one provider you’re working with to obtain information about the primary barriers.
The Pareto chart is a very useful tool to not only identify opportunities for improvement, but to drill down to understand the reasons or special causes on graphs showing counts, percentages and rates.

22. Pareto Diagram Example: Preventive Dental Visits
100%
90%
80%
70%
60%
50%
40%
30%
20%
10% 0%
Cumulative Percentage

23. Priority Ranking: Risk Priority Number (RPN)
The RPN is a numeric assessment of risk or impact of each sub-process.
The RPN has three basic components:
Likelihood that the failure would occur.
Likelihood that the failure would not be detected.
The amount of harm or damage the failure mode may cause.
Each Component is ranked on a scale of 1 to 5:
(Low Risk) (High Risk)
Assigning a risk priority number is an objective method for ranking failure modes as opposed to gathering subjective opinions from members on the team. This method will also help the team stay unified when ranking the failure modes.
By using a scale of 1-5, the team will assign each failure mode a numeric value that quantifies the likelihood of occurrence, likelihood of detection, and severity of impact (harm or damage). To get the RPN, the team will multiply the numeric values of the likelihood of occurrence, likelihood of detection, and severity of impact. For example…likelihood of occurrence=2; likelihood of detection=1; Amount of harm or damage=3 RPN= 6
The failure modes with the highest RPN should take precedence over lower ranked failure modes.

24. FMEA Example with RPN: Preventive Dental Visits
Sub-processes
Failure Modes
Failure Causes
Failure Effects
Likely to Occur
Likely to go Undetected
Amount of Damage
Priority Ranking Number
Scheduling the preventive dental visit appointment
Parent/caregiver and enrollee do not see the importance of preventive dental visits.
No educational materials available.
Parent/caregiver takes no action to obtain preventive dental visit for child. 3 5 45
Scheduling outreach not provided by dental office.
No process in place for dental provider to provide outreach for scheduling a preventive dental visit.
Parent/caregiver does not have the guidance to schedule an appointment. 4 2 32
Attending the preventive dental visit appointment
Parent/caregiver and enrollee do not have transportation to keep appointment.
No process to assess and assistance with transportation barriers for dental appointments.
Enrollee is unable to attend scheduled appointment. 75
Dental offices do not offer convenient hours.
Appointment is scheduled at a time that is difficult to attend.
100

25. Failure Mode Ranking Example: Preventive Dental Visits
Priority
(Highest to Lowest)
Priority Ranking Score
Failure Modes 1
100
Dental offices do not offer convenient hours. 2 75
Parent/caregiver and enrollee do not have transportation to keep appointment. 3 45
Parent/caregiver does not see the importance of preventive dental visits. 4 32
Scheduling outreach not provided by dental office.

26. Intervention Determination
The ranked failure modes should be used as a guide to determine the interventions to be tested.
The failure modes with the higher ranking need more attention.

27. Intervention Determination Example: Preventive Dental Visits
Failures
Potential Interventions
Consideration for Reliability
Dental offices do not offer convenient hours.
Partnering with dental offices to offer Saturday and/or evening preventive dental appointments.
Offering Saturdays and evening appointment times will decrease the difficulty working parents/caregivers may have in attending appointments with their children.  
Parent/caregiver and enrollee do not have transportation to keep appointment.
Hosting a mobile dental service van at various locations.
Bringing a mobile dental unit near the enrollee’s residence will reduce the structural transportation barrier that makes it difficult to access preventive dental services.
Parent/caregiver does not see the importance of preventive dental services.
Partnering with pediatrician offices to provide education to parents/caregivers on importance of preventive dental care, recommended frequency of visits.
Messages provided during pediatric well or sick visits will capitalize on the opportunity to provide face-to-face education and help parents/caregivers to understand how dental care fits into the overall health of children.

28. Discussion and Breakout Sessions
Questions and Answers
Discussion and Breakout Sessions