1. QI Tools to Diagnose HPV Vaccine Delivery Concerns in Your Practice
National Immunization Partnership with the Academic Pediatric Association (NIPA)

2. Process Flow Maps Apply the methods for depicting the
current and future state of a process
Mamta: The next item on this morning’s agenda is the use of Process Flow Maps.

3. Key Points for Process Maps
Observe the process
Understand the current state
Identify failure modes
Determine your future state
Mamta: As a part of the next hour, Matt and I are going to talk about the value of:
Making observations
Understanding the baseline
Distinguishing between QA vs QI
Identifying failure modes

4. Why Map a Process? Visualize the flow. Identify waste and barriers.
Outline different ideas about how the process works.
Replace pages of words with one good process map.
Relate this back to…why use a Map or GPS? Sure you know how to get from point A to point B but do you know the optimal route or were you aware of consturction? Mapping can help show you the best route or bring to light information that was not known.
BENEFITS
Identifies all of the stakeholders in the process(es)
Depicts impact of amount of tasks, exceptions, and coordination that a process requires
A Process Map can help you gain agreement about the sequence of steps.
Learn how steps rely upon each other
Process Maps promote understanding in a way that written procedures cannot.
Share process flows with other disciplines and/or across facilities
Sets baseline for developing future state processes

5. Why Map a Process?

6. What is Process Mapping?
A process map is a diagram that uses graphic symbols to depict the nature and flow of the steps in a process.
Process Maps are working documents and are a visual representation of:
A process map visually describes:
Major activities or tasks
Variables, and their settings, tolerances, and specifications
Customer expectations
Bottlenecks
Sub-processes (reworking steps)
Suppliers
y = f(x1,x2,….,xi)
(Y is a function of all inputs)

7. 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 lab orders. 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?

8. 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

9. Immunization Process Flow Diagram

10. Understanding the Current State
What is the status quo?
Does the map go deep enough to see the gaps and variations?
Keep asking yourself “Why?”

11. Does the process map go deep enough to see these things?
What elevation are you assessing?
Strategy/ plan of attack – establish the “control line” or fireline – line around the fire that keeps it from spreading.
Mamta: I know existing factors: pts arrive late, space is a limitation, nurses can call in, equipment can be down; I know these things that can happen everyday.
Matt: Exactly these are all factors that we can anticipate in order to manage expectations.
Mamta: Our goal is How do we keep todays fires from spreading to everyday fires?
Matt: Put out the fire today and then solve the bigger problem by creating the control line in the future.

12. 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)

13. 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

14. Fishbone and 5 Whys
Analyze the problem and the potential causes through the use of cause and affect tools

15. Key Points for Cause and Effect Tools
You can’t fix what you don’t know is a problem
First seek to understand, then work to improve
Mamta: As a part of the next hour, Matt and I are going to talk about the value of:
Making observations
Understanding the baseline
Distinguishing between QA vs QI
Identifying failure modes

16. 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

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

18. 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)

19. 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

20. 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

21. Fishbone Diagram

22. 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   

23. 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.
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

24. Questions? Thanks to: Lory D. Harte, PharmD, CPHQ
Quality Improvement Program Manager
Continuous Quality and Practice Improvement Education
Center for Clinical Effectiveness