Academic Pediatric Association QUALITY IMPROVEMENT TRAINING: Module #4

1. Academic Pediatric AssociationQUALITY IMPROVEMENT TRAINING: Module #4 More QI Tools to Better Understand the System This work is supported by a grant from The Centers for Disease Control & Prevention.

2. National Partnership for Adolescent ImmunizationPI: Peter SzilagyiCoordinators: Christina Albertin, Nui Dhepyasuwan • Ed Marcuse • Cindy Rand • Jan Schriefer (QI expert) • Stanley Schaffer • Janet Serwint • William Stratbucker • Donna D'Alessandro • William Atkinson • Paul Darden • Sharon Humiston (moderator) • Keith Mann (QI expert) FACULTY & CONSULTANTS

3. This is part of the APA series on Quality Improvement. The examples focus on adolescent immunization, but the principles are widely applicable. The series includes: • Overview: The Model for Improvement and Deming’s System of Profound Knowledge • Improvement cycles and the psychology of change • Initiating a QI project • More tools to better understand the system • How will we know that a change is an improvement? An introduction to QI measurement • Changes we can make that will result in improvement

4. Module 4 Objectives After viewing this segment, you will be able to describe the development and purpose of each of the following tools for understanding the system: • Flowcharts • Cause and effect diagrams • The 5 whys technique

5. Flowcharts

6. Flowcharts • What:Draw a picture of your process as a team • High-level flowchart - shows the process in 6-12 steps, useful early to show major activity blocks • Detailed flowchart – shows dozens of steps; useful later to identify rework loops and process complexity • Purpose:Coming to agreement on what the process really is. This helps the team understand the process and develop ideas about how to improve it. • Who:All the groups involved (there will likely be as many versions of the process as there are people) http://www.ihi.org/knowledge/Pages/Tools/Flowchart.aspx http://tipqc.org/qi/jit/tools/flowcharts/

7. IHI’s Sample High-Level Flowchart: Ischemic Heart Disease Patient Flow http://www.ihi.org/knowledge/Pages/Tools/Flowchart.aspx

8. IHI’s Sample High-Level Flowchart: Ischemic Heart Disease Patient Flow http://www.ihi.org/knowledge/Pages/Tools/Flowchart.aspx

9. From American Society for Quality http://asq.org/learn-about-quality/process-analysis-tools/overview/flowchart.html

10. The same process as a detailed flowchart http://asq.org/learn-about-quality/process-analysis-tools/overview/flowchart.html

11. To see a sample (fictional) flowchart on “HPV Vaccination in a Pediatric Residency Clinic” https://www.dropbox.com/s/lmsr8arhjh88bqi/Teen%20Immunization_work_flow-SAMPLE.pdf

12. How to Make a Flowchart • Prepare: • Right people • Right level • Right boundaries - beginning and ending • Step-by-step: • Starting at the top, ask, “What’s next?” • Put each step under last, on a “sticky note” • Where you disagree, lay the options side-by-side; come back later, and discuss which is preferable.

13. Completing Your Flowchart • Use software to document • You may need to • Gather info • Revise the flowchart as more is understood about the actual process

14. QUESTION #1: Which 1 of the following is FALSE regarding flowcharts? •  A high-level flowchart shows a process in 6-12 steps and is useful early in the QI project for shining a light on the major blockages. • The main purpose for creating a flowchart is to come to agreement on what the process really is, which, in turn, helps the team understand the process and develop ideas about how to improve it. • As far as possible, the main clinic administrator should be the only one to have input into the creation of the flowchart so it reflects the way the process should go. • When flowcharts are formally produced (using software), decision points in the process are shown as diamonds.

15. QUESTION #1: Which 1 of the following is FALSE regarding flowcharts? •  A high-level flowchart shows a process in 6-12 steps and is useful early in the QI project for shining a light on the major blockages. • The main purpose for creating a flowchart is to come to agreement on what the process really is, which, in turn, helps the team understand the process and develop ideas about how to improve it. • As far as possible, the main clinic administrator should be the only one to have input into the creation of the flowchart so it reflects the way the process should go. As far as possible, all the groups involved in the process should have input into the creation of the flowchart. • When flowcharts are formally produced (using software), decision points in the process are shown as diamonds.

16. Cause and effect diagrams

17. Cause and Effect Diagrams(aka “Fishbone Diagram”) • What: A graphic display of a list • Purpose: Permits identification and organization of a list of factors thought to cause a problem or affect variation; can also be used as a Root Cause Analysis Tool • Who: All the people involved http://www.ihi.org/knowledge/Pages/Tools/CauseandEffectDiagram.aspx http://tipqc.org/qi/jit/tools/cause-and-effect-diagram/

18. Sample Cause & Effect Diagram Nursing Providers Motivation Motivation Training Training Schedulers Motivation Training Better handout for reluctant parents MD recommendation is not strong Computers slow No return appts set up Lack of automated reminder system Standing order instruction sheets Adolescent immunization record scattered

19. Typical Categories for Major Causes • Equipment, Methods, Materials, People, Environment/Measurements/Procedures • Who, What, When, Where • People, Provisions (Supplies), Procedures, Place, Patients/Families • Steps of Process

20. Sample Cause & Effect Diagram Process Type NO RECOMMEND VACCINE? • No info given • Registration unfriendly • (per survey) • Hurried! No time to answer “in depth” questions YES • No expectation for • vaccination • No parent for • consent • Conversation is social; • not educational • Some nurses are anti- • vaccine (per rumor) NO FAMILY ACCEPTS? • No good info sheet • Providers not trained to • answer succinctly YES • Delayed if busy • Med room is 30 steps • from most exam rooms

21. How to Make a Cause and Effect Diagram Fill in each of the following: • Large arrow pointing to the name of the problem or issue • The branches off the large arrow represent main categories of potential causes. • Smaller branches, representing sub-categories (can be a list of items)

22. The 5 whys technique

23. The ‘5 Whys’ • What: Repetitive questioning, looking for deeper levels of the problem’s root causes • Purpose: To overcome the tendency to be satisfied with superficial answers and get at root causes • Who: QI team http://www.ihi.org/knowledge/Pages/ImprovementStories/AskWhyFiveTimestoGettotheRootCause.aspx http://www.isixsigma.com/tools-templates/cause-effect/determine-root-cause-5-whys/

24. An example of the 5 Whys • Why does our clinic have such low rates of HPV vaccination for boys? Because the doctors forget to order it. • Why do the doctors forget to order it? Because some of our doctors only work part-time…Are they even aware that it’s a routine recommendation or why it’s important • Why would the part-time attendings be unaware…Because there hasn’t been any kind of in-service for the part-time attendings. • Why hasn’t there been an in-service for the part-time attendings? Because it would cost the office a lot to bring them all in for an extra hour and they’d want food, too. • Why would we have to bring them in? There’s an online learning module…

25. QUESTION #2. Which of the following is FALSE regarding the tools discussed in this module? • The ‘5 Whys’ is a simple tool, easy to complete without statistical analysis. • Equipment, Methods, Materials, Why, and Environment/Measurements/Procedures are major categories that are commonly used in Cause and Effect Diagrams. • Who, What, When, and Where are major categories commonly used in Cause and Effect Diagrams. • Use of Cause and Effect Diagrams helps identify and organize factors believed to cause a problem.

26. QUESTION #2. Which of the following is FALSE regarding the tools discussed in this module? • The ‘5 Whys’ is a simple tool, easy to complete without statistical analysis. • Equipment, Methods, Materials, Why People, and Environment/Measurements/Procedures are major categories that are commonly used in Cause and Effect Diagrams. • Who, What, When, and Where are major categories commonly used in Cause and Effect Diagrams. • Use of Cause and Effect Diagrams helps identify and organize factors believed to cause a problem.

27. By understanding a system, one may be able to • predict the consequences of a proposed change. • W.E.Deming This module highlights just a few tools to help understand the system. There are many more options. The more you QI projects you do, the more tools you will want in your tool bag. Garbage in, garbage out

28. Summary In this module, we discussed the development and purpose of a few tools for understanding the system: • Flowcharts are a graphic display of your process, used to help understand what the process really is • Cause and effect diagrams (or fishbone diagrams) are a graphic display of a list, used to identify and organize factors thought to cause a problem or affect variation. • The 5 whys technique is repetitive questioning, looking for deeper levels of the problem’s root causes.

29. The End of Module #4 IHI. Science of Improvement: How to Improve http://www.ihi.org/knowledge/Pages/HowtoImprove/ScienceofImprovementHowtoImprove.aspx