Basic QI Tools  Techniques

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Why QI?. By continually working to improve all processes, we increase our learning and knowledge.QI is not about pass/fail or right/wrong. Rather it's about testing a theory. You have a learning opportunity.. Basic Tools of QI. Data collectionCheck SheetSurvey Tool / InterviewsNat'l, State, Local stat'sData AnalysisPie ChartsBar GraphPareto ChartLine GraphProcess AnalysisFlow Charts

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Basic QI Tools Techniques

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1. Basic QI Tools & Techniques

2. Why QI? By continually working to improve all processes, we increase our learning and knowledge. QI is not about pass/fail or right/wrong. Rather it’s about testing a theory. You have a learning opportunity. Consider any QI tool you use as a “trial”Consider any QI tool you use as a “trial”

3. Basic Tools of QI Data collection Check Sheet Survey Tool / Interviews Nat’l, State, Local stat’s Data Analysis Pie Charts Bar Graph Pareto Chart Line Graph Process Analysis Flow Charts – Process Mapping 5 Why’s Idea Creation Affinity Diagram Brainstorming Fishbone Diagram Check Sheet – every person has to be looking for & recording the SAME thing Survey / interviews – observations as they happen Pie Charts – are limited to one topic at a time and are used to show proportion or significance Bar Graphs – simple bar graphs show how several items differ from each other in a single characteristic Pareto Chart – tallest bars indicate the contributors to the issue; focus on issues that offer the greatest potential for improvement Line Graph/Run/Trend Graph – monitor performance over time to study patterns over a specified period of time. Flow / Process Analysis – defines the beginning and end essential to steps taken between; identifies all steps/decisions; use to streamline, identify if not working, or to help in designing a new process 5 Why’s – detect meaning of a particular situation Affinity Diagram – organize natural grouping Brainstorming – generate a high number of all possible factors that may impact the problem – group under headings that define the problem Fishbone – all possible causes Interrelationship diagraph – cause & effect relationship Bone Diagram – can be used as a planning tool and for reflection on the current and future state of a project Regardless of the specific QI tools used, there are several principles that underlie the application of QI tools: Know your stakeholders and what they need Focus on processes Use data for making decisions Understand variation in processes Use teamwork to improve work Make quality improvement continuous Demonstrate leadership commitmentCheck Sheet – every person has to be looking for & recording the SAME thing Survey / interviews – observations as they happen Pie Charts – are limited to one topic at a time and are used to show proportion or significance Bar Graphs – simple bar graphs show how several items differ from each other in a single characteristic Pareto Chart – tallest bars indicate the contributors to the issue; focus on issues that offer the greatest potential for improvement Line Graph/Run/Trend Graph – monitor performance over time to study patterns over a specified period of time. Flow / Process Analysis – defines the beginning and end essential to steps taken between; identifies all steps/decisions; use to streamline, identify if not working, or to help in designing a new process 5 Why’s – detect meaning of a particular situation Affinity Diagram – organize natural grouping Brainstorming – generate a high number of all possible factors that may impact the problem – group under headings that define the problem Fishbone – all possible causes Interrelationship diagraph – cause & effect relationship Bone Diagram – can be used as a planning tool and for reflection on the current and future state of a project Regardless of the specific QI tools used, there are several principles that underlie the application of QI tools: Know your stakeholders and what they need Focus on processes Use data for making decisions Understand variation in processes Use teamwork to improve work Make quality improvement continuous Demonstrate leadership commitment

4. Stage 1 Step #1 - Getting Started Describe the Situation Writing about the Situation What’s the issue? Why is this a issue? For whom does the issue exist? Who has a stake in the issue? What do we know about the issue/people involved? What do existing research and experience tell us about the issue? Begin to think about any data (numerical or descriptive) related to the current status of your “issue” Obtain baseline data or collect data to understand the current “issue” Start with what you know and decide what is missing Let data/information be your guide to identify “issues” Gather data / information about the importance of the issue to other stakeholders Identify personal and environmental factors and broader conditions (later will determine root causes) Data needs to serve us, not make our goals harder to achieve The data cycle starts with data collection and storage of data in such a way that it can be retrieved. Only then can we analyze, mine, and listen to the data so we can understand what it is telling us. Prioritize areas for action “Frame” the issue to be addressedBegin to think about any data (numerical or descriptive) related to the current status of your “issue” Obtain baseline data or collect data to understand the current “issue” Start with what you know and decide what is missing Let data/information be your guide to identify “issues” Gather data / information about the importance of the issue to other stakeholders Identify personal and environmental factors and broader conditions (later will determine root causes) Data needs to serve us, not make our goals harder to achieve The data cycle starts with data collection and storage of data in such a way that it can be retrieved. Only then can we analyze, mine, and listen to the data so we can understand what it is telling us. Prioritize areas for action “Frame” the issue to be addressed

5. Example #1

6. Stage 1 Step #1 - Getting Started Describe the Situation An invading enemy sought to overthrow the kingdom. During the fierce battle the kingdom’s well trained warriors mounted their warhorses to fight the enemy. All in the kingdom were confident they would be victorious as the enemy forces were outnumbered. Ultimately, not all warriors got “deployed” and in the end - THE KINGDOM WAS LOST.

7. Stage 1 Step #2 - Assemble the Team No one person understands the entire system. One cannot change one part of a process without influencing other parts in some ways. Start discussing the situation / opportunity for improvement. Discuss - who might we want to pull into “The Team”? Begin the process of broadly developing an initial aim statement to describe what you want to accomplish. As you process through your QI effort, the aim statement will most likely become more specific and be modified based on what you are learning. The aim statement will be fully developed during later stages of the QI cycle.Start discussing the situation / opportunity for improvement. Discuss - who might we want to pull into “The Team”? Begin the process of broadly developing an initial aim statement to describe what you want to accomplish. As you process through your QI effort, the aim statement will most likely become more specific and be modified based on what you are learning. The aim statement will be fully developed during later stages of the QI cycle.

8. Stage 1 Focus on defining the problem(s) / improvement needed Define the issues(s) before attempting to fix something What’s important? What’s broken / Needs improvement? Where is the “Mother Lode?” (high volume, high profile, problem-prone) Start with what you know Decide what is missing Start with what you know Decide what is missing

9. Stage 1 Define the Issue “The kingdom was lost.” If we stopped right here, what most likely would we try to do to improve?If we stopped right here, what most likely would we try to do to improve?

10. Stage 1 Define the Issue “The kingdom was lost.”

11. Stage 1 Step #3 - Examine Current Process/Approach May need to interview staff, external partners Make a process flow chart Check for efficiency, duplicative steps, missed steps, steps needed

12. Stage 1 Step #3 - Examine Current Process/Approach “For want of a nail the shoe was lost

13. Leverage the 5-Whys Basically, the five-why analysis is a fundamental approach of thinking, based on the logical linkage of elements into a root cause analysis. It is a tool that works with ideas/concepts With each specific answer, repeat the question up to five times and you will typically end up with a rather solid root cause. For each answer, look at WHO is involved Let’s check the logical linkage of elements in the poem using the 5-Why’s Who is part of the problem will be part of the resolutionLet’s check the logical linkage of elements in the poem using the 5-Why’s Who is part of the problem will be part of the resolution

14. Leveraging the 5-Whys Lost the kingdom You have two examples in your packets using the 5-Why’s technique Choose one of the two issues and work through asking “Why is this happening” 5 timesYou have two examples in your packets using the 5-Why’s technique Choose one of the two issues and work through asking “Why is this happening” 5 times

15. Leveraging the 5-Whys The therefore test has proven to be a very reliable method to check the logic of the five-why analysis. To do the therefore test, you read the key findings of the analysis in reverse and insert the word therefore between each step.

16. Leveraging the 5-Whys Lost the kingdom

17. Stage 1 Define the Issue “The kingdom was lost.” Do we need to add anyone to our team? Do we need to update the aim statement?Do we need to add anyone to our team? Do we need to update the aim statement?

18. Problem Statement Not enough nails to shod all the warhorses. Drilldown to determine the cause of “not enough” nailsDrilldown to determine the cause of “not enough” nails

19. Fishbone Diagram Focus on the content of the issue, not on the history Focuses on cause not symptoms The cause may be within or outside of the groupFocus on the content of the issue, not on the history Focuses on cause not symptoms The cause may be within or outside of the group

20. Stage 1 Step #4 - Potential Solutions Avoid making your first QI effort a large-scale project. Solving issues is usually easiest when you focus on decreasing/reducing the “negative” driving forces rather than increasing the “positive” driving forces. How do you decide to solve the problem? How important do group members perceive the issue to be? Is it feasible? Time, likelihood of improving? Are you the best people to solve the problem? Have you considered the negative impacts? Use best practices to help identify potential solutions It is highly recommended that planning needs to include a stakeholder analysis; both external and internal Narrow solutions to those within the team’s control or influence CIC Analysis What resources are needed? Is the solution a process improvement or a totally new process? Further refine your aim statement if applicable. SWOT Analysis Bone Diagram How do you decide to solve the problem? How important do group members perceive the issue to be? Is it feasible? Time, likelihood of improving? Are you the best people to solve the problem? Have you considered the negative impacts? Use best practices to help identify potential solutions It is highly recommended that planning needs to include a stakeholder analysis; both external and internal Narrow solutions to those within the team’s control or influence CIC Analysis What resources are needed? Is the solution a process improvement or a totally new process? Further refine your aim statement if applicable. SWOT Analysis Bone Diagram

21. “Expand-Focus Sequence”

22. Imposing a Change Before imposing a change, begin by asking three key questions: What are you trying to accomplish? How will you know that a change is an improvement? What changes can you make that will result in an improvement? Define changes you believe will achieve your goal Countermeasures What are you trying to accomplish? “If you do not know how to ask the right question you discover nothing.” – Deming Quantifiable Consider SMART goals: specific, measurable, attainable, realistic, timely How do you know that a change is an improvement? Measuring where you are – where you’re going. What changes can you make that will result in an improvement? What have others done? What theories/hunches do we have? Force Field Analysis Decide on top priority solution using NGT What are you trying to accomplish? “If you do not know how to ask the right question you discover nothing.” – Deming Quantifiable Consider SMART goals: specific, measurable, attainable, realistic, timely How do you know that a change is an improvement? Measuring where you are – where you’re going. What changes can you make that will result in an improvement? What have others done? What theories/hunches do we have? Force Field Analysis Decide on top priority solution using NGT

23. Stage 1 Step #5 - Develop an Improvement Theory Make a prediction – How will you know that a change is improvement? (Measurement is essential!) Plan What Where Who How When – timeline Can run several PDSA cycles at the same time Evaluation must be considered in Planning Plan changes aimed at improvement matched to root causes Define your measure of success Identify national and state standards Possible QI Tools: Fishbone Logic Models Flow ChartsCan run several PDSA cycles at the same time Evaluation must be considered in Planning Plan changes aimed at improvement matched to root causes Define your measure of success Identify national and state standards Possible QI Tools: Fishbone Logic Models Flow Charts

24. Stage 2 Step #6 - Test the Theory Just Do It!!!! Carry out the plan During the process collect, chart, and display data to determine efficiency. Document problems, unexpected observations “By testing changes on small scale, it’s okay to have failures . . It becomes a leaning exercise rather than an overall loss.” - Dr. John Biddy QI tools that may be useful in this stage - Check sheets Survey’s Pareto charts Line graphs “By testing changes on small scale, it’s okay to have failures . . It becomes a leaning exercise rather than an overall loss.” - Dr. John Biddy QI tools that may be useful in this stage - Check sheets Survey’s Pareto charts Line graphs

25. Stage 3 Step #7 - Study the Results Based on measurements What worked? What didn’t work? Did the test work? How do you know? Did the results match the theory/predictions? What does data show? Are there trends? Is there improvement? Desired effect? Lessons learned? QI tools that may be beneficial in this stage Pareto charts Line chartsDid the test work? How do you know? Did the results match the theory/predictions? What does data show? Are there trends? Is there improvement? Desired effect? Lessons learned? QI tools that may be beneficial in this stage Pareto charts Line charts

26. Stage 4 Step #8 - ACT Sustain if improvement Monitor Develop new theory If successful, plan another cycle to test it on a larger scale or under different conditions If unsuccessful, test a different theory Flow charts may be useful throughout the ACT stage. Do you need to test the improvement under other conditions? Continue to compare our results with best practices if applicable.Flow charts may be useful throughout the ACT stage. Do you need to test the improvement under other conditions? Continue to compare our results with best practices if applicable.

27. Stage 4 Step #9 - Establish Future Plans Recognize, review, refocus your efforts What went right? Where can we apply what we’ve learned? What’s next? CELEBRATE success!!!!!CELEBRATE success!!!!!

28. 9 Steps of Improvement Focus Improve Sustain Honor Continuous quality improvement requires observation, assessment of where there are gaps, trial and error in making the improvement complete.Continuous quality improvement requires observation, assessment of where there are gaps, trial and error in making the improvement complete.

30. Example #2 “QI Feud”

31. Stage 1 Step #1 - Getting Started Describe the Situation During the last 5 months of the year there has been a increase in errors in paychecks

32. Data analysis QI tools Bar charts Run charts Pareto chartsData analysis QI tools Bar charts Run charts Pareto charts

33. Stage 1 Step #2 – Assemble the Team Who would we want to include on our team? – Who would we want to include on our team? –

34. Define the Problem / Improvement Needed “Errors in paychecks.”

35. Stage 1 Step #3 – Examine Current Process/Approach Printed Checks

36. Where’s the “Mother Lode”? Cause analysis Pareto chart Brainstorming FishboneCause analysis Pareto chart Brainstorming Fishbone

37. Defining the Problem “Errors in paychecks.”

38. Problem Statement Revise your aim statement if applicableRevise your aim statement if applicable

40. Next Steps Step #4 - Potential Solutions

41. “Expand-Focus Sequence”

42. Next Steps – Impose a Change Step #5 - Develop Improvement Theory Target – 50% reduction in time code errors by 6/1/09 Step #6 – Do Test the Theory Step #7 – Study The Results Step #8 – Act Step #9 – Honor CELEBRATE!!!

44. Example #3

45. Stage 1 Step #1 - Getting Started The Situation “It appears (staff observations)” WIC clients are not keeping scheduled appointments

46. Collect supportive data

47. Stage 1 Step #2 – Assemble the Team Nurses Dietitians Clerks

48. Stage 1 Defining the Problem “WIC no-show rates.”

49. Stage 1 Step #3 – Examine Current Process/Approach Scheduling FU Appointments Staff was intervieweStaff was interviewe

50. Collect supportive data

51. What’s Broken / Needs Improvement?

52. Defining the Problem “WIC no show rates.”

53. Defining the Problem “WIC no show rates.” Staff decided to try a fishbone diagramStaff decided to try a fishbone diagram

54. Stage 1 Step #3 – Examine Current Process/Approach Scheduling Re-cert Appointments Staff was interviewed – decided to brainstorm about possible causes Recognized they needed consumer’s view – Scheduled a patient satisfaction surveyStaff was interviewed – decided to brainstorm about possible causes Recognized they needed consumer’s view – Scheduled a patient satisfaction survey

55. Problem Statement Need a problem statement to conduct a fishbone diagramNeed a problem statement to conduct a fishbone diagram

56. Analyze All Possible Causes Fishbone clearly identified staff training as one internal issueFishbone clearly identified staff training as one internal issue

57. Defining the Problem “WIC no show rates.”

58. Client Satisfaction Survey Consumer satisfaction survey conducted to further analyze the problem Consumer satisfaction survey identified two issues Prompt return on calls Time in waiting room Team decision to focus on a “quick win” – returning phone callsConsumer satisfaction survey conducted to further analyze the problem Consumer satisfaction survey identified two issues Prompt return on calls Time in waiting room Team decision to focus on a “quick win” – returning phone calls

59. Defining the Problem “WIC no show rates.”

60. Next Steps Step #4 – Potential Solutions Cross train staff Prompt return on phone calls Need to conduct a phone call tally Staff started with determining a phone call tally to identify Demand - # of phone calls in a day Types of phone calls Staff started with determining a phone call tally to identify Demand - # of phone calls in a day Types of phone calls

61. Next Steps – Impose a Change Step #5 – Develop Improvement Theory Target – Step #6 – Do Test Theory Step #7 – Study The results Step #8 – Act Step #9 – Honor CELEBRATE!!!

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