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Indiana Quality Improvement. Solving Problems, Elevating Quality in Public Health QI Coach’s Handbook. QI Coach Coordinators. Contact Information: Sue Hancock 317-234-1648 Sarah Strawbridge 317-233-7371 Module 1. QI Basics. Why QI?.

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Indiana quality improvement

Indiana Quality Improvement

Solving Problems, Elevating Quality in Public Health

QI Coach’s Handbook

Qi coach coordinators
QI Coach Coordinators

  • Contact Information:

    • Sue Hancock

      • 317-234-1648


    • Sarah Strawbridge

      • 317-233-7371


Module 1
Module 1

QI Basics

Why qi
Why QI?

  • The goals are to benefit:

    • Employees involved in work processes, making the work easier.

    • Our organization, through more efficient or effective work activities.

    • The customers of our work, who must use what we produce.

      Kelly, 1992

Where did qi come from
Where did QI come from?

  • Grandfather of QI: W. Edwards Deming

    • Statistician and professor by trade, consulted with American companies during WW II on production issues.

    • Post world-war II: Worked with Japanese companies to rebuild. They embraced his techniques.

    • Believed that the goal of business should not be just to make profits, but to stay in business so they could provide jobs.

W edwards deming
W Edwards Deming

  • Has been called a “curmudgeon” for his critical workshop tactics.

  • In reality, he sympathized with the plight of workers.

  • A short story…

  • Deming’s 14 Points

Qi assumptions
QI Assumptions

  • Workers want to perform well on the job, take pride in their work.

  • Workers’ performance more often related to faulty systems than employee error.

    • Jurran’s Principle: “85%-15% Rule”

  • Management/leadership generally makes decisions about systems.

  • Data is needed to make good system decisions.

What do we get from qi
What do we get from QI?

  • Improves our job satisfaction – we know our product or service is quality, a source of pride.

  • Reinforces the belief that we can solve problems, make a difference in our jobs

  • We have a greater investment, ownership for our work.

  • We have less tolerance for problems and poor quality.

Qi basics
QI Basics

Improving quality is a systematic process:

  • PLAN: Define the problem, collect

    data, select a possible solution.

  • DO: Implement solution on a small


  • CHECK: Collect data, determine

    if the solution worked. If not, go back to

    Plan and select another solution.

  • ACT: When a solution works, spread to all aspects

    of the operation.

Five step problem solving model
Five-Step Problem Solving Model

Quality improvement can also be described as a systematic problem-solving model:

1. Identify the problem – clearly state what needs improvement.

2. Analyze the problem – Determine what causes problem to occur.

3. Evaluate alternatives – Identify and select actions to reduce or eliminate the problem.

4. Test/implement a solution – Implement these actions on a trial basis to determine effectiveness.

5. Standardize – Ensure that useful actions are preserved.

Module 2
Module 2

Working Together as a Team

Working together as a team
Working Together as a Team

  • Team Roles:

    • Team members share their expertise to plan and implement project work.

    • The Leader orchestrates team activities, maintains records, serves as communication link with rest of the organization.

    • The Coach understands the tools and concepts of improvement, including approaches that help a team function well together.

    • The Sponsor reviews and supports team efforts, interfaces with other parts of the organization.

Effective team members
Effective Team Members…

  • Participate fully in team meetings

  • Share knowledge and experience, listen closely to that of other team members

  • Are open to new ideas

  • Carry out assignments between meetings

  • Assist leader with managing the meetings, e.g. documentation, discussions.

  • Communicate effectively with colleagues about project work.

An effective leader
An Effective Leader…

  • Organizes the team’s work and activities

  • Focuses on a data-based methods to solve the problem

  • Serves as contact point for communication between the team, sponsor, others in organization

  • Keeps official team records, e.g. meeting minutes, agendas, data related to project.

  • Assists with carrying out work between meetings

  • Implements project-driven changes within his or her authority

  • Helps team resolve its problems

An effective coach
An Effective Coach…

  • Attends meetings but not is a leader or member; an outsider who maintains a neutral position.

  • Assists team in structuring or breaking down tasks and plans into assignments

  • Works with team leader to plan meetings

  • Assists leader with team building

  • Teaches data collection, analysis techniques; helps team graphically display data

  • Helps team prepare for presentation of project to management, others

An effective sponsor
An Effective Sponsor…

  • Maintains overall responsibility, authority and accountability for project

  • Approves “bubble-up projects,” assures compatibility with organizational priorities

  • Sometimes initiates project, begins charter, selects leader, coach and members

  • Approves resources for project

  • Interfaces with rest of the organization to assure appropriate stakeholder involvement

  • Feeds data and lessons learned into a system for future improvements, e.g. policy changes

Reality check
Reality Check

  • Is everybody clear about the roles?

  • Does everyone have a role?

  • Are the leader, coach, sponsor roles filled?

    If not, what is the plan?

  • Next Step: What’s our problem?

Module 3
Module 3

Identifying the Problem

Qi toolkit identifying problems
QI Toolkit: Identifying Problems

  • Brainstorming – generating a list of potential problems

  • Interviews or surveys - customer feedback, recommendations

  • List reduction - narrowing the list to a few items, by combining into groups

  • Problem selection matrix

Qi toolkit brainstorming
QI Toolkit - Brainstorming

Collect a large number of ideas from a group of people. Many ideas, quickly as possible.

  • One-at-a-time (everyone speaks)

  • Open door (call out ideas)

  • Write-it-down (confidentiality)


    • Be creative

    • Build on ideas of others

    • No critique allowed

Qi toolkit interviews surveys
QI Toolkit – Interviews, Surveys


  • Purpose: Collect data from direct conversation.


  • Purpose: Collect data from

  • a large number of people.

Qi toolkit list reduction
QI Toolkit – List Reduction

  • Purpose: Reduce a large list of items to a manageable size.

    • Useful in conjunction with brainstorming.

    • Group votes for the most important items on list (can cast as many votes as they want).

    • Items with the most votes are circled.

    • If further narrowing is required,

      process conducted again, limiting

      number of votes people can cast.

What s our problem
What’s Our Problem?

A little history…

  • When did we notice the problem?

  • Was there anything else going on when we noticed it?

  • Have other solutions been tried in the past?

  • If so, what happened?

What s our problem1
What’s Our Problem?

Zooming in on the current state:

  • What exactly is happening?

  • When is it happening?

  • Where is it happening?

  • Who is involved?

What s our problem2
What’s Our Problem?

Zooming in on the future (or desired) state:

  • What should be happening?

  • When should it happen?

  • Where should it happen?

  • Who should make it happen?

Current and future state
Current and Future State

  • Future State:

  • What are the important aspects of

  • the future state?

  • What is driving us to this future state?

  • What might be the consequences of

  • not moving to the future state?

  • What might change?

  • What is the proposed timeline?

  • Current State

    • What is the current state?

    • Why is this important?

    • What is it costing us time/dollars/staff/etc?

    • What is the impact on our customer/clients?

    • What is the impact on our division/agency?

  • Driving Forces:


  • Consequences

  • Benefits

Qi toolkit flowchart
QI Toolkit – Flowchart

Where is the process

breaking down?

RFFlow Professional Flowcharting,

Draft a problem statement
Draft a Problem Statement

  • A good problem statement should be:

    • Specific.

    • Describes the problem, not the symptom.

    • Relates the current situation to what is desired.

    • Does not include causes or solutions

Expressing need for improvement in measurable terms
Expressing Need for Improvement in Measurable Terms

Two-Step Process:

  • Gathering information (data) about the problem.

    • Tool utilized: Checksheet

  • Organizing data so that it is meaningful and clarifies the problem.

    • Tools utilized: Line graphs, Pareto charts, Histograms, Bar and Pie charts.

Qi toolkit checksheet
QI Toolkit: Checksheet

Purpose: Collect data in an organized manner.

Telephone Interruptions

Excerpted from Nancy R. Tague’sThe Quality Toolbox, Second Edition, ASQ Quality Press, 2004, pages 141-142.

Qi toolkit line graph
QI Toolkit: Line Graph

Purpose: Display the output of a process over time.

Qi toolkit pareto chart
QI Toolkit: Pareto Chart

Purpose: Arrange data so that the most significant element in a set of elements is easily identifiable.

Diagram courtesy of Six Sigma

Qi toolkit histogram
QI Toolkit: Histogram

Purpose: Determine how data are distributed.

Qi toolkit bar chart
QI Toolkit: Bar Chart

Purpose: Arrange data for quick and easy comparison.

Qi toolkit pie chart
QI Toolkit: Pie Chart

Purpose: Display the volume or quantity of one item in relation to others.

Check problem statement
Check Problem Statement

Did data validate the original problem statement?

  • If not, revise and collect more data.

  • If it did, refine the problem statement so that it is:

    • Specific.

    • Describes the problem, not the symptom.

    • Relates the current situation to what is desired.

    • Does not include causes or solutions

Establish interim target date
Establish Interim Target, Date

  • Targets should be:

    • Intermediate and long term

    • Quantitatively expressed

    • Aggressive

    • Changed as the situation changes

  • Example: This project aims to reduce the number of days it takes to process a payment voucher from 10 working days to 2 by December 31, 2010.

Module 4
Module 4

Analyze the Problem

Identify the root cause s
Identify the Root Cause(s)

  • If the cause is removed, the problem should be at least partially removed.

  • A symptom is not a cause; a symptom is evidence the problem exists.

  • Several root causes may contribute to the problem; it is important to examine all.

  • QI Tools for establishing root cause(s): Brainstorming, Flowcharts, Cause and Effect Diagrams, 5 Why’s.

Qi toolkit cause and effect diagram
QI Toolkit: Cause and Effect Diagram

Purpose: Identify a set of related causes that lead to an effect or problem.

Verify cause by collecting data
Verify Cause by Collecting Data

  • QI Toolkit - Data collection and analysis:

    • Checksheet

    • Root Cause Evaluation Matrix

    • Histogram

    • Bar Chart

    • Pareto Chart

Guidelines for data collection
Guidelines for Data Collection

  • Establish the purpose for collecting data – helps you target your efforts, collect only what is needed.

  • Determine if indicators are reliable – What is the source of data? Are measuring practices consistent and accurate?

  • Track all data needed – collect enough to conduct a thorough analysis.

  • Record data carefully – Use a checksheet that is logical and makes collection easy.

Select root cause s most responsible
Select Root Cause(s) Most Responsible

  • Example: Investigating delay associated with processing credit card applications, data could be grouped into the following categories:

    • No signature

    • No Address

    • Cannot read

    • Current customer

    • Other

Module 5
Module 5

Evaluate Alternate Solutions

Developing alternatives
Developing Alternatives

QI Toolkit: Brainstorming, interviews, survey, research (have others solved this problem?)


  • Be creative, identify as many potential solutions as possible.

  • Don’t be limited by the current practice (i.e. “That’s the way we’ve always done it.

  • Refrain from judging team members’ suggestions.

Evaluating alternatives
Evaluating Alternatives

  • Effective? (Tried before? With what results? Will it solve the problem? Achieve improvement target?)

  • Feasible? (Is it doable? Practical?)

  • Timely? (How long will it take? Long term or short term? Can we afford to wait?)

  • Customer-oriented? (Will it improve service quality? Satisfy customer identified requirements?)

  • Efficient? (Is it cost effective?)

Select solutions to implement
Select Solutions to Implement

Planning for implementation:

  • People: Whose support is needed?

  • Materials: What is needed? Who will purchase?

  • Methods: How will implementers be trained? How will solutions be measured?

  • Machinery/Equipment: Where will it come from? How will it be funded? How will it be purchased? How will implementers be trained to use it?

Qi toolkit barriers and aids
QI Toolkit – Barriers and Aids

Purpose: Document the hindering and supporting factors that influence a planned activity.

Qi toolkit barriers and aids1
QI Toolkit – Barriers and Aids

Purpose: Document the hindering and supporting factors that influence a planned activity.

Elements of planning
Elements of Planning

  • The objective is clearly stated.

  • Activities are each defined.

  • Responsibility is assigned.

  • Dues dates are established.

    Implementation Plan Matrix:

Module 6
Module 6

Test-Implement Plan

Test the plan
Test the Plan

  • Implement on a trial or “pilot” basis.

    • Get all necessary approvals.

  • Help solutions succeed by:

    • Communicating the plan

    • Monitoring implementation

    • Supporting each other

    • Adjusting if necessary

  • Show measurable improvements

    QI Toolkit: Line Graphs, Pareto Charts, Pie Charts, Bar Charts, Histograms , Checksheets.

Test the plan1
Test the Plan

  • If measurable improvements are not evident, return to problem-solving statement.

  • Common reasons why this happens:

    • Poor problem statement

    • Analysis insufficient or inaccurate

    • Verification of root causes is inadequate

Module 7
Module 7

Standardize Improvements

Steps to standardization
Steps to Standardization

  • Make solutions permanent:

    • Make periodic checks

    • Clarify work activities (make a flowchart of new process)

    • Develop procedures and follow them

    • Assign responsibility

  • Spread improvements to total process(beyond pilot)

  • Determine if solution is applicable to other areas

  • Guard against “spotlight” effect—improvements related to process being under investigation.


  • Kelley, MR. (1992).Everyone’s Problem Solving Handbook. Productivity Press, Portland, OR.

  • Walton M. (1986). The DEMING Management Method. The Berkley Publishing Group, New York, NY.

  • Scholtes PR, Joiner BL, Streibel BJ. (2003). The Team Handbook, Third Ed. Oriel Inc, Madison, WI.

  • Healthcare Technical Assistance Program. (2007). Indiana Public Health System Quality Improvement Program. Purdue University, West Lafayette, IN.

  • Moran J, Duffy G. (2009). Public Health Foundation, Washintgon, DC.