1. Performance Improvement Team Handbook
Developed by Southeast Georgia Health System
Quality Management Department

2. Introduction
Congratulations! You all have been selected as members in a new PI team. The most critical task for any new team is to establish its purpose, process and measures of team progress. Once these are established, they should be posted at each team meeting for reference.
Many teams enjoy terrific starts and then soon fizzle. The real challenge is to keep a team focused on its purpose.
We use the PDCA model for PI teams and we are introducing the Rapid Performance Improvement (RPI) Methodology.
Teams make improvements related to the six aims: safe, effective, patient centered, timely, efficient and equitable. As a result clinicians experience greater satisfaction at being able to better do their jobs and bring improved health to those who receive their care.

3. Teams Utilize the PDCA Methodology
P: Plan the improvement
D: Do the data collection needed, implement the modified or new process
C: Check the data for improvement
A: Act to sustain the improvement
Teams follow certain methodology: PDCA
P: Plan the improvement
D: Do the data collection needed, implement the modified or new process
C: Check the data for improvement
A: Act to sustain the improvement

4. The PDCA cycle for learning and improvement
Act
Plan
Objective
Questions and
predictions (why)
Plan to carry out the cycle
(who, what, where, when)
What changes
are to be made?
Next cycle?
Check Do
Complete the
analysis of the data
Compare data to
predictions
Summarize what
was learned
Carry out the plan
Document problems
and unexpected
observations
Begin analysis of
the data

5. Principles of PDCA Cycles
Use shorter cycles of changes to accelerate rate of improvement
small scale tests (“What can you test by next Tuesday”)
just collect enough information
Create flow of ideas, then emphasize implementation
increase the frequency of tests
increase the belief that the change will result in improvement and minimize resistance upon implementation
Adoption of existing knowledge (‘not more research but more application of existing knowledge’)
‘Steal shamelessly, Share senselessly’
Promote peer learning
Toyota: 80 improvements per employee; US hospital: 0.5 improvement per employee
electronic interchange of improvement learning (IHI-Extranet; Kaiser Permanente-Learning Link; VHA Improvement Exchange)

6. Tips for PDCA Cycles - formulate question and predict results
- test first in ‘safe zones’ (with team members, volunteers)
- ‘Just-do-it’ mentality
collect useful just enough data, not perfect data
think a couple of cycles ahead
scale down size of test (# of patients, clinics)
be innovative to make test feasible
Example: Improve decision support by using a standard based flowsheet
- adapt flowsheet with one pt
- revise flowsheet and test with Dr. 1 pts on Monday
- present flowsheet to all MDs
- revise and test for one week
- implement and monitor standards

7. Smaller Scale Tests: Scale Down Timeframe
Years
Quarters
Months
Weeks
Days
Hours
Minutes
Reduce your timeframe to plan Test Cycle!
When you’re in your meeting, listen for a time frame. Move down two levels to do a test. This formula helps people rethink the time frame.
If you hear quarters…Ask what test can we do by the end of next week?
If you hear weeks, what can do in the next hours. You won’t get the change all tested but gets people moving.

8. New Teams may utilize the Rapid Performance Improvement (RPI) Methodology
Rapid Performance Improvement (RPI) Methodology, a practical performance-based process improvement approach. The sequence of steps involved is:
Document the goals and problems to be addressed
Current performance is documented
Practices are compared to best practice and “gaps” are identified
Gaps are prioritized and a revised process is developed to achieve these objectives
The revised processes are deployed to the target groups and results are monitored
Performance and process adherence are assessed to determine the level of success. The resulting new practices become the target groups’ current performance and the cycle is repeated.
We are introducing a new methodology:Rapid Performance Improvement (RPI) Methodology, which is a practical performance-based process improvement approach. The sequence of steps involved is:
Document the goals and problems to be addressed
Document Current performance
Compare practices to best practice and identify“gaps”
Prioritize Gaps and develop a revised process to achieve these objectives
The revised processes are disseminated to the target groups and results are monitored
Assess performance and process adherence to determine the level of success. The resulting new practices become the target groups’ current performance and the cycle is repeated.

9. Rapid Performance Improvement (RPI) Methodology Tools
Gap Analysis:
Current Performance
Best Practice
Gaps Identified
Gap Prioritization:
Gap Identified Description
Severity Rating
Probability Rating
Detectability Rating
Hazard Score
priority number
Severity: = No Harm; 2 = Temporary Harm; 3 =Permanent Harm; 4 Death/major loss of function
Probability: = Remote; 2 = Uncommon; 3 = Occasional; 4 = Frequent
Detectability: 1 = Very Likely; 2 = Likely; 3 = Unlikely; 4 = Very Unlikely
Hazard Score: Risk Priority Number (RPN = Severity x Probability x Detectability)

10. Team Roles
All members except the facilitator are active team members even though they may have additional roles.

11. Team Roles Team Member Team Leader Recorder Timekeeper Facilitator
Members are chosen because they work in, have knowledge of that is the focus of the team. or receive benefit of the process that is the focus of the team. They share responsibility for the effectiveness of the team.
Contribute ideas
Make decisions
Plan future work
Support collaboration
Collect and analyze data
Team Leader
The leader is generally the person who is recognized as the owner of the process that is the focus of the team.
Works with the facilitator to develop a plan for the team
Coordinates and directs the work of the team
Manages the meeting process
Recorder
Recorder can be assigned or rotated to help the team maintain a record of its work.
Records on flipchart when needed
Takes minutes
Timekeeper
Timekeeper can be assigned or rotated to help the team manage time.
Helps the team determine how it wants to be informed about the time
Calls out the time remaining on agenda items or at designated intervals decided by the team.
Facilitator
Facilitator is a team advisor who monitors and helps team members keep their interactions positive and productive.
Works with the team in developing plans
Provides feedback to the team to keep them on track
Assists in interpretation of data
Assists in maintaining efficiency

12. Team Rules Keep an open mind Listen and understand what is said
Avoid side conversations
Respect other’s opinions
Avoid personal agendas
Come prepared to do what’s good for the health system
Complete assignments
Follow up on action items
No idea is a bad idea
Be creative
Take risks
No criticism allowed
Start on time
End on time
Participate!
Have fun!

13. Brainstorming Activity
Generate ideas
Use games and exercises to “warm up” your creative thinking
When ideas slow down, try another exercise to generate fresh ideas
Breaking into smaller groups may be helpful
Use a computer or flip chart to capture every comment/idea

14. Set SMART Goals Goals are
Specific
Measurable
Achievable
Realistic
Time-phased
Set goals: realistic, reasonable, challenging, attainable goals
Long-term
Intermediate-term
Short-term

15. Using Data Identify why we are collecting the data
JCAHO PI.1.1, DHR, CMS
What are we going to do with it?
Always define data
Ask yourself if the data is complete or do we need additional information
When using data, define targets and benchmarks. Identify those benchmarks on the graphic displays.
Remember: Data is not information until it has been interpreted!

16. Statistical Terms
Mean-sum of quantities/number of quantities (the average)
Median-middle value when all data points are arranged numerically; used a lot of times as the middle line in run charts because it requires no calculation
Mode-the most frequently occurring value
Standard deviation-measure of the spread of a distribution
Control limit-an expected limit of common-cause variation referred to as either an upper or lower limit. Limits are calculated from process data
Variation-the inevitable difference among individual outputs of a process. The sources of variation can be grouped into two major classes: Common Causes and Special Causes.

17. Performance Improvement Tools
Flowcharts are available in Powerpoint and QI Macros in Excel.
Oval represents the beginning or ending of a process
Rectangle represents an action step in the process.
Diamond represents a decision step.
Arrows represent the direction of the process flow.

18. Performance Improvement Tools
Tree Diagram
Run Chart
Histogram
Pareto Chart
Tools are available in QI Macros in Excel

19. Performance Improvement Tools
Failure Modes and Effects Analysis
Scatter Diagram and Probability Plot
Comparison Matrix
Relationship Diagram
Tools are available in QI Macros in Excel

20. Plans of Action Develop programs/methods/plans of action:
The requirements for achieving set goals.
Who will do which part.
How the different parts tie together.
Determine the phases of the action plan
Identify a representative that will be responsible for each phase.
Determine the beginning, middle, and end of each phase.
Determine benchmarks to measure strengths and areas of improvement

21. Good Luck and Have Fun!!!

22. References
Moen, Ronald, Thomas Nolan; “Process Improvement” Quality Progress, 1987, p62
Langley, Gerald, Kevin Nolan and Thomas Nolan; “The Foundation of Improvement,” Quality Progress, June 1994, p. 81
Langley, Gerald, Kevin Nolan, Thomas Nolan, Cliff Norman, and Lloyd Provost; “The Improvement Guide” San Francisco, CA; Jossey-Bass, 1996
Nolan, Kevin; “ASQs Accelerating Change Collaborative Series: A Challenge for Industry,” Quality Progress, Jan 1999, p55
2006 Hospital Accreditation Standards. Joint Comission on Accreditation of Healthcare Organizations
QI Macros Training Manual. Lifestar