Step 1 Identify a Project

Continuous Quality Improvement Projects Step 1 Identify a Project - Nominate projects. - Evaluate projects. - Select project. - Ask: Is it quality improvement? 1. What is a Quality Improvement Project? It is a problem scheduled for solution: - First, it is a problem – an observed deficiency that needs to be remedied. - Second, it is scheduled. The problem is specified and resources are identified to work on the problem. - Third, it requires a solution. A quality improvement project is not complete until the solution is in place and working with demonstrated effectiveness. Who identifies the project? The quality council. A department's management or a group of employees. 2. Nominate projects To nominate projects, you need to consider sources of information that can provide you with an understanding of the quality problems your organization is facing. These sources include: Customers – Managers/employees – Reviews/audits – Other quality improvement projects – Business plans 3. Evaluate projects Projects are evaluated in terms of potential impact on: -retaining customers - attracting new customers - reducing the costs of poor quality -enhancing employee satisfaction Data required evaluating possible projects: - The complaints and dissatisfaction most likely to drive away existing or new customers. - The most costly deficiencies.

1 - The deficiencies in internal processes that have the most adverse effect on employee. Using data is important: - To tell us which problems are the most important? - Only with data can we know the project has brought about any improvement. 4. Select a Project There are seven criteria for selecting a project: 1. Chronic, 2. Significance, 3. Size, 4. Measure of potential impact, 5. Urgency, 6. Risk, 7. Potential resistance to change. When the organization is new to quality improvement: There are two additional criteria to consider when selecting a project: 8. The project should be a sure winner, 9. The problem must be measurable. 5. Ask: Is it Quality Improvement? A quality improvement project is a structured approach to identifying and removing the root causes of performance problems. Step 2 Establish the Project There are three activities to establish the project: 1. Prepare a mission statement. 2. Select a team. 3. Verify the mission. Prepare A Mission Statement: A mission statement: is the written instruction to the team selected to tackle a quality improvement project. It describes: - The problem to be resolved. - The objective of the project, that is, what the team is to do about the problem. Criteria for Describing the Problem: - Specific, Observable, Measurable, Manageable. Describing the Objective: An effective mission indicates the objective of the project. Pitfalls to avoid in a Mission Statement: Imply a cause - Suggest a remedy - Assign blame

2 Select a Project Team: In any hospital the chain of commands is vertical. Goals, work standards, and controls are established at the top and then passed down to the departments where policy is translated into actual work. Quality improvement often requires teams composed of people who share the problem and represent various places in the work flow. Guidelines for Team Selection: There are four places to look:  Where the problem is observed or the pain is felt.  Where sources or causes of the problem might be found.  Among those with special knowledge, information or skill in uncovering the root cause of this particular problem.  In areas that can be helpful in implementing the remedy. - Once the quality council determines what parts of the organization will be represented. Each person should have:  Direct, detailed, personal knowledge of some part of the problem.  Time for team meetings and between meetings assignments. Finally, as a group, team members should be able to:  Understand the problem fully, that is, be able to describe accurately the major elements of the processes associated with the problem.  Work with their departments to implement the remedy. Verify the Mission: The final activity for establishing a project is to verify the mission.  Evaluate the problem description and the mission description to make sure they meet the criteria for an effective mission statement.  Verify that the problem exists. If the problem has not been measured, however, the team will need to take measurements before proceeding.  Identify any aspects of the project that need clarification.  Verify that team members represent the appropriate departments.  Obtain clarification and agreement from the quality council on any needed changes to the mission statement.

3 Step Three: Diagnose the Cause There are five activities to diagnose the cause: 1. Analyze symptoms. 2. Confirm or modify the mission. 3. Formulate theories. 4. Test theories. 5. Identify root causes. 1. Analyze Symptoms When we analyze symptoms we understand fully the nature and extent of the problem to be resolved. - To analyze symptoms: - Develop operational definitions. - Measure the symptoms. - Define boundaries. - Concentrate on the vital few. 1.1 Develop Operational Definitions: Often definitions are needed to ensure that all project team members have the same understanding of the mission statement. If you are in doubt about a definition, question other team members about their understanding. 1.2 Measure the Symptoms: All quality problems have symptoms that can be objectively measured to determine the scope of a problem. If you need to develop a measure, asking these questions may be helpful: - How do customers evaluate the symptoms? - Where is each symptom observed? - What documentation exists on the symptoms? - What method should be used to obtain the measure: Tabulations from data bases. Data in administrative records. Interviews. Physical counts of things: instruments, medications. - What is the appropriate unit of measure:

4 Time: years, months Costs of poor quality: dollars. Defects: number of defects as percentages of all occurrences. 1.3 Define Boundaries Defining the problem boundaries establishes the scope of the project – where the project begins and ends. To define boundaries, your team might ask, does the project address all aspects of a problem or just some of them? Defining boundaries should be based on three factors: - Evidence in the data - The size of the project - The beginning and end points 1.4 Concentrate on the vital few: Analyzing the symptoms of the problem often reveals many sources of difficulty. The team must concentrate only on those found to be largely responsible for the problem (Pareto). 2. Confirm or Modify the Mission Once the team has measured the symptoms. Reached agreement on the definitions for key terms. Completed a high-level flow diagram, and considered the results of a Pareto analysis, it should decide whether the mission requires modification or can be confirmed as it is written. 3. Formulate theories A theory is simply an unproven statement of the cause of a certain condition. The physician would consider a number of theories based on a range of symptoms. Jumping into conclusions before considering many theories and proving which is correct would be risky. It would be just as risky as diagnosing an illness before considering all the symptoms. Brainstorming is a quality tool that is very useful at this point, because it helps the team to consider a full range of theories about possible causes. 4. Test Theories To test theories a team must: - Decide which theories to test. - Plan for data collection

5 - Collect data - Analyze the results 4.1 Decide which theories to test: The cause effect diagram helps us to test the theories. Strategies to test theories: - one theory at a time - groups of theories - all theories at the same time 4.2 Plan for Data collection: - Design the test - Describe the data required - Decide where to collect the data - decide how to collect the data include: Research of existing records Direct observation Personal interviews Telephone interviews Mail surveys - Train data collectors At this point, some teams decide to try implementing a change in the process as a means for testing a theory. There are times when a well-designed experiment is the final stage in identifying the root cause, but such experiments should be undertaken only after theories have been carefully tested with data from the existing process. 4.3 Collect data Collect data to ensure that the specified procedures are being followed and that biases are not being introduced through the procedures being used. 4.4 Analyze the Results: The data are tabulated and the results are displayed. The team must answer three questions with respect to each test: 1. Which theories are supported by the results? This is highlighted from the cause and effect diagram.

6 2. Which theories are eliminated by the results? The team should remove these theories. Root causes should account for most of the problem. Any theories that account for only small parts of the problem should be eliminated. 3. What new theories are suggested by the results? Data analysis to the cause- effect diagram will suggest new theories that need to be tested. Quality Tool: Data Sheet Various diagnostic tools for data analysis are: Pareto diagram – Histogram – Scatter diagram. 5. Identify Root Cause The quality improvement tools help us to identify the root cause. A root cause is the source of the problem, when removed, will sharply reduce or eliminate the deficiency. There are two questions that will help you decide whether you have found the root cause: 1. Do the data suggest any other possible causes? Each data display (Pareto diagram – histogram – scatter diagram or other chart) should be examined by asking whether it suggests additional theories. 2. Is the proposed root cause controllable in some way? Some causes are beyond our ability to control like the weather. Other possible factors are too broad and general to be broken into components. For example. Lack of training as a cause needs further definition of the specific skill or knowledge that is missing. Step 4: Remedy the Cause 1. Evaluate alternatives. 2. Design Remedy. 3. Design controls. 4. Design for culture. 5. Prove effectiveness. 6. Implement. 1. Evaluate Alternatives Since not all solutions are equally good, the team must consider a range of possible solutions and agree on the most effective and appropriate remedy. Brainstorming is used to identify a number of possible alternatives. Then the team should evaluate each one in terms of its probable impact on the problem and the organization.

7 Evaluation Criteria:  Total cost - Impact on the problem - Benefit/cost relationship - Cultural impact/resistance to change - Implementation time - Uncertainty about effectiveness - Health, safety, and the environment. After evaluating the alternative remedies the team agrees on the most promising. Quality Tool: Remedy Selection Matrix The team can use the matrix in a number of ways:  Each team member can complete a matrix and then have some one average rating of all team members.  The team can discuss each criterion and reach consensus on rating for each proposed remedy. 2. Design the Remedy This is performed by four tasks:  Ensure that the remedy achieves project goals.  Determine the required resources: the required resources to implement the remedy are (people – money – time – materials).  Specify the procedures and other changes required: before implementing the remedy, the team must describe what procedures will be required to adopt the proposed remedy. Also the team must describe what changes need to be made to existing organizational policies, procedures, systems and work patterns.  Assess human resources requirements: We may need to train or retrain staff. The team must explore fully all training requirements, as well as the training resources. Tools to design a remedy: Flow diagram - Tree diagram - Planning matrix - Planning network. A flow diagram helps us to indicate how the remedy will operate. This helps the team to identify gaps in the design. 3. Design Controls When quality improvement reduces deficiency in existing goods, services or processes, the result is frequently referred to as breakthrough. To ensure breakthrough is maintained, the quality improvement team needs to develop effective quality control. To build feedback loop, the team will need:  Provide the means to measure the results of the improved process.

8  Establish the control standard for each measure.  Determine how the actual performance will be compared to the standard.  Design actions to be taken to regulate performance if it does not meet the standard. 3.2 Establish the Control Standards: Quality control standards are based on actual performance of the new process. They reflect both the typical level of performance and the amount of variation in the performance. These standards which describe the maximum natural variation of the process are usually called control limits. 3.3 Determine How Actual Performance Compares to the Standard: The Control chart is used to compare the actual performance to the established standard. 3.4 Designing Actions if Performance does not meet Standard: When performance does not meet the standard, you need to design a plan of action to bring the process back within its control limits. When planning control systems, it is usually helpful to complete quality control spread sheet. 4. Design for Culture Quality improvement means change – something many people resist because of the cultural changes a new approach may bring. To plan for resistance: - Identify all likely sources of resistance (barriers) and support (aids). - Rate the barriers and aids according to their perceived strengths. - Identify countermeasures needed to overcome barriers. 5. Prove effectiveness We must prove effectiveness of the remedy under the operating conditions. A pilot program is useful to examine the remedy under the operating conditions. A pilot test is on a limited scale; any short comings or deficiencies can be recognized and corrected before implementing the change in the organization wide. 6. Implement Implementation requires introducing change to the people who will make it work. Some of those people may have members of the project team and are familiar with the remedy while others need information and preparation. - Implementing a change in operations should always include:

9 1. A clear plan. 2. A description of the change. 3. An explanation indicating why the change is necessary. 4. Involvement of those affected in some aspects of the planning and preparation for the change. Change may also require: 1. Written procedures. 2. Training. 3. New equipment, materials and supplies. 4. Changes in staffing. 5. Changes in responsibilities for certain positions. Team members must work with one another and with those affected individuals to ensure that all planning is complete. Depending on the nature of the change, the team may also need to obtain support and/ or resources from the quality council or other senior managers before full-scale implementation. Step 5: Hold the Gains A project team needs to be certain that the gains continue and the problem does not recur. It consists of three activities: - Design effective quality controls. - Foolproof the remedy. - Audit the controls. 1. Foolproof the Remedy: To foolproof the remedy. The team makes it so reliable that the likelihood of mistakes or failure is minimal. To foolproof a remedy you: - Design systems to reduce the likelihood of errors. - Replace human sensing with technological sensing. - Keep feedback loops as short as possible. - Use active rather than passive checking. 1. Systems to reduce Likelihood of Error: Design work so that errors are either impossible or very unlikely. 2. Technological Sensing: Technology can provide better measures than human senses.

10 3. Keep Feedback loops as Short as Possible: There are two ways to keep feedback loops as short as possible: - Check each piece of work as soon as it is completed. This can prevent repetition of error. - Report the results of checking directly to the individuals doing the work. Providing the individuals with the means and authority to check their own work. 4. Active vs. Passive Checking: Actively doing something to check a result is far more accurate than merely expecting it. Audit the Controls: Effective audits answer two questions: - Are the intended results being achieved? This looks at the results. - Are the quality controls being followed? This looks at how the results are achieved. Satisfactory results without adequate controls may be a disaster waiting to happen. Using a control that does not produce the intended results is already a disaster. To ensure that its work continues to be effective, a team needs to include the following in its remedy: - Routine reporting of results. - Clear documentation. 1. Report Results: Be certain that the ongoing results of the improved process are routinely reported to a level of management prepared to monitor progress and respond if gains are not held. 2. Document Controls: Document all critical element of the control process. Develop a quality control system in terms of goals measurements, and feedback responsibilities. Step 6: Replicate results and Nominate New Projects These activities ensure that an effective remedy for one problem is applied to similar ones and that the organization continues to make improvements in the delivery of quality to customers. Replicate the Project Results:

11 When a new technique has been tried successfully and evaluated, its results are widely communicated. Similarly, if the root cause of a problem has been identified and remedied satisfactory, the lessons learned are applied to similar problems. Replication is the transfer of learning from one situation to another. This is the responsibility of the quality council or a group of individuals appointed by the council. 1. Opportunities for Replication: In Health Care Organizations, there are several kinds of opportunities to replicate project results: - In large hospitals, there are similar processes in several locations. For example a process of delivering babies. Once an improvement has been made at one hospital, similar improvements should be considered for all other hospitals. - The various clinical units tend to have variations of similar processes – preparing patients for discharge – process improvement in one clinical unit should be considered for replication in other units. - In most organizations, even different departments have certain activities in common; each must return telephone calls, improvement made in one department should be studied for replication elsewhere. 2. The Replication process: To replicate a quality improvement process, a team follows the six steps used for an original project. Nominate New Projects: Sources for project nomination are: - The team focuses on the vital few and excludes the useful many. The useful many should be reconsidered for another project. - As the team uncovers the root cause of a problem, other related but previously undocumented deficiencies may be uncovered.