1. 7 TOOLS OF QUALITY IMPROVEMENT
Dinesh John MD
Natalia Hernandez MD Joan Mitchell MD
VAMC, Syracuse, NY

3. 7 Tools of Quality Improvement
A fixed set of graphical techniques identified as being most helpful in troubleshooting issues related to quality
Suitable for troubleshooting most quality-related problems, and require little formal training in statistics

4. What Are These Tools? Ishikawa (fishbone) diagram Check sheet
Control chart
Histogram
Pareto chart
Scatter diagram
Flowchart/Flowmap

5. ISHIKAWA diagram
Popularized by Kaoru Ishikawa: pioneered quality management processes in Kawasaki Shipyards
A.K.A cause-and effect diagram, herringbone/fishbone diagram
Used to demonstrate cause of a specific event
Used mainly in product design and quality defect prevention, can also be used retrospectively

6. ISHIKAWA diagram Causes grouped into major categories: 6M’s
Manpower: Anyone involved with the process
Methods: How process is performed and requirements for doing it, i.e. policies, procedures, rules.
Machines: equipment, computers, tools, etc.
Materials: Raw materials, parts used to produce final product
Measurements: Data generated from process that are used to evaluate its quality
Environment (Milieu) conditions, such as location, time, temperature, and culture in which process operates

7. IHI.ORG

8. A Fishbone Diagram was famously used prior to the manufacture of the Mazda Miata, which went on to be the best-selling 2 seat roaster in HISTORY!!

9. Make a Fishbone Diagram about the reasons why you think the ER always seems overcrowded using the ‘6M’ approach. Be as detailed as you can, listing as many causes as possible under the six categories Note to instructor: There is a Fishbone template MS Word file in Sharepoint

10. CHECK SHEET A tally sheet to collect data on frequency of occurrence
Used when data can be observed and collected repeatedly by either the same person or the same location
Effective tool when collecting data on frequency and identifying patterns of events, problems, defects, and defect location, and for identifying defect causes.

11. Number of people in wait line at Registration Desk
This helps to determine staffing needs and size of waiting room

12. CONTROL CHART Pioneered by Walter Shewhart who worked at
Bell Labs in the 1920’s
Helped to improve the
reliability of the telephone
transmission system at Bell

13. CONTROL CHART
Chronological plot of measurements of important variables
Upper and lower reference thresholds called control limits (3 Std. Deviations from Mean) are plotted: define natural range of variation within which plotted points should fall
Any points falling outside of control limits may indicate that all data were not produced by the same process, either because of lack of standardization or a change in the process may have occurred
Such changes could represent either quality improvement or quality deterioration, depending on which control limit is crossed
Useful both for monitoring if processes get worse and for testing and verifying improvement ideas

14. Upper & lower control limits indicate threshold at which process output is considered statistically 'unlikely' ; drawn 3 std. errors from the centre line
i.e. mean of the variables
Sometimes ‘warning lines are drawn 2 std. errors from center line

15. In 2005, the Robert Wood Johnson Hospital won the Malcolm Baldrige National Quality Award. Currently their ER LOS is 38 minutes for a discharged patient and 90 minutes for an admitted patient. They offer a minute guarantee: see a nurse in 15 minutes and a doctor in 30. The quicker response time and LOS in their ER has brought increasing revenues each year, and another wing had to be added to the hospital to accommodate their ER admissions.

16. This is a hyperlink to an excellent video on how to make a statistical control chart on MS excel

17. HISTOGRAM Introduced by Karl Pearson, the father of mathematical
statistics
Etymology uncertain. Said to be derived from the Greek histos 'anything set upright' and gramma 'drawing, record, writing‘
It is also said that Karl Pearson, who introduced the term in 1895, derived the name from "historical diagram".

18. HISTOGRAM
Frequency distribution shows how often each different value in a data set occurs
A histogram is the most commonly used graph to show frequency distributions (next slide)
Looks like a bar chart, but used for continuous data(as opposed to categorical data)

19. HISTOGRAM Continuous data, so there are no spaces in between the bars
Data collected into categories of width 30 LB

20. Your preceptor will assign you a task involving data collection and using an MS Excel template to create a histogram

21. PARETO CHART Concept introduced by Vilfredo Pareto, mathematician
and economist
Built on observations of his such as that 80% of the land in Italy was owned by 20% of the population
The purpose is to highlight the most important among a (typically large) set of factors causing defects/delays

22. Lt. vertical axis: Frequency of occurrence
Rt. vertical axis: cumulative percentage of total number of occurrences,
GO AFTER THE 2 OR 3 MOST IMPORTANT FACTORS TO GET THE DESIRED RESULTS
CRITICAL FEW
TRIVIAL MANY

23. This is a hyperlink to a video on how to make a Pareto Chart on MS excel

24. SCATTER DIAGRAM When trying to identify potential
root causes of problems.
After brainstorming causes and effects using a fishbone diagram, to determine objectively whether a particular cause and effect are related
Pairs of data where a relationship is suspected are plotted on the X axis(independent variable) and Y axis(dependent variable)
First described by Sir Francis Galton, English Mathematician(cousin of Darwin)

25. TYPES OF RELATIONSHIPS BETWEEN THE VARIABLES
Pairs of data where a relationship is suspected are plotted on the X axis(independent variable) and Y axis(dependent variable)

26. There is a negative correlation between years of experience of MRI Techs and rate of repeat MRI scans(no surprise here!)
DEPENDENT VARIABLE
IINDEPENDENT VARIABLE

27. This is a link to a video on how to make a scatter plot in MS Excel

28. FLOW CHART/WORKFLOW DIAGRAM
Pioneered by Frank Gilbreth,
Inspiration for the movie
Cheaper by the Dozen
Diagram that represents a
process, showing steps as boxes
of various kinds, and their order by connecting them with arrows
Used in analyzing, designing, documenting or managing a process

29. START/STOP BOX
DECISION DIAMOND
PROCESS BOX
CONNECTING ARROWS DETERMINE ORDER OF PROCESS

30. Note: There will be a dedicated session on workflow mapping

32. THANK YOU