Quality Improvement Tools Gina M. Berg, PhD, MBA
Wesley Leadership Institute Quality Improvement Academy Learning Objectives
At the end of this lesson, you should be able to: DESCRIBE • Improvement Model/PDSA • Flowchart (process analysis) • Brainstorming Benefit(s) • 5 Whys (root cause analysis) • Fishbone/Ishikawa diagram (root cause analysis) • Pareto chart (rank order by importance) • Control chart (performance over time) • LEAN • Six Sigma Definitions
Quality Care Quality Improvement (IOM, Crossing Quality Chasm, 2001) (Hastings Center, 2003)
Systematic, data-guided Safe activities designed to bring Timely about immediate improvements Effective in health care delivery in particular settings Equitable
Patient centered Form of experiential learning Efficient Developing QI Project
Why? Why? Why? Why? Why? IHI Model
1 What are we trying to accomplish?
How will we know 2 that a change is an improvement?
What changes can we 3 make that will result www.IHI.org Langley GL, Moen R, Nolan KM, Nolan TW, Norman CL, Provost LP. The in an improvement? Improvement Guide: A Practical Approach to Enhancing Organizational Performance (2nd edition). San Francisco: Jossey-Bass Publishers; 2009. PDSA Cycle
Plan small process change
Implement or discard
Execute on small scale
Test or measure Continuous Quality Improvement
Repeated Use of the Cycle Changes That Result in A P Improvement S D
A P S D Hunches Theories Ideas Hit the mark Flow Chart
Picture of the separate steps of a process in sequential order (http://asq.org/)
Document a process Develop understanding Study for improvement Communicate to others Planning a project
Complex Sepsis Flow Chart Brainstorming
Spontaneous group discussion to produce ideas for problem solving
Amass information
Stimulate creative thinking
Develop new ideas Fishbone Diagram: Purpose
Cause and Effect Diagram
Identifies causes of problems
Sorts ideas into categories Methods Machines (equipment) Manpower (people) Materials Measurement Environment
Example: Fishbone Diagram Example: Fishbone Diagram Why? Why? Why? Five Whys? Why? Why?
Iterative interrogative technique used to explore the cause-and-effect relationships underlying a particular problem
Five iterations to reach underlying cause
Six-Sigma tool Machines
Examples: Fishbone Diagrams Pareto Charts: Definition & Purpose
Visual depiction of significance and cumulative accountability Data driven Analysis of frequency of causes Prioritization/focuses attention on most significant
Communication about cause significance with others
http://asq.org
Example: Pareto Chart Example: Pareto Chart Pareto Principle (80/20 Rule)
80/20 Rule
Law of the vital few
Principle of factor sparsity
For many events, roughly 80% of the effects come from 20% of the causes (unequal distribution)
Most things in life are not distributed evenly Throughput Example
Question Example What are we trying to Improve efficiency of office visits accomplish? Improve patient satisfaction 1 How will we know that a Decreased elapsed time from change is an improvement? patient check-in to patient check- 2 out What changes can we make that will result in an improvement? 3
www.IHI.org Langley GL, Moen R, Nolan KM, Nolan TW, Norman CL, Provost LP. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance (2nd edition). San Francisco: Jossey-Bass Publishers; 2009. Throughput Flow Chart
T0 Scheduled appointment ET7 = T1 to T7 time ET8 = T0 to T7 ET0
T1 T2 T3 T4 First Patient Nurse Patient Contact ET1 “Arrived” ET2 ET3 “Ready”
ET4
T5 T6 T7 Provider Provider Done Patient ET5 Start Or Nurse Needed ET6 Discharged Throughput Fishbone Diagram
Delay to First Contact Nurse Delay Patient Late UA needed Long Line Room not ready Computer Issue With another patient Other Other Delays in Supplies missing Didn’t check out Throughput Review records Went to lab Outside records missing Went to referral Other Other
Delay to Physician Delay to Checkout Throughput Data Collection
Check In Delays N= 87 Nurse Delays N= 87 Patient arrived late 13 15% Room not ready 46 53% Long line 17 20% UA needed prior 25 29% Computer issue 26 30% With another patient 13 15% Other 31 36% Other 28 32%
Physician Delays N= 87 Check Out Delays N= 87 Med student saw patient first 19 22% Patient didn’t stop at front desk 24 28% Needed to review records 9 10% Patient went to lab 22 25% Outside records missing 12 14% Patient went for referral 17 20% Supplies missing 29 33% Other 4 5% Throughput Pareto Chart Throughput Pareto Chart Throughput Example
Question Example What are we trying to Improve efficiency of office visits accomplish? Improve patient satisfaction 1 How will we know that a Decreased elapsed time from change is an improvement? patient check-in to patient check- 2 out What changes can we make • Back office supports front desk that will result in an • Standardize exam rooms improvement? • Preview records day before 3
www.IHI.org Langley GL, Moen R, Nolan KM, Nolan TW, Norman CL, Provost LP. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance (2nd edition). San Francisco: Jossey-Bass Publishers; 2009. Throughput Example
Repeated Use of the Cycle Changes That Result in A P Improvement S D
Preview patient records
A P Standardize exam rooms S D Back office supports front desk high volume Ideas Control Charts
Single quality characteristic measured or computed
Analysis indicates process In control: stable (variation only coming from sources common to the process) Out control: Identify sources of variation Predict future performance
Control Charts
Six Sigma
Problem -solving methodology Minimize mistakes (cost)
Sigma scale is universal measure
Sigma Percent Defective Per Million 1 69% 691,462 2 31% 308,538 3 6.7% 66,807 4 0.62% 6,210 5 0.023% 233 6 0.00034% 3.4 7 0.0000019% 0.19 LEAN
Maximize customer value while minimizing waste Seven Forms of Waste
Form of Waste Explanation Transport Movement product/materials Waiting Operator idleness Overproduction More than customer requires Defect Anything fails to meet specifications Inventory Financial resources, at-risk Motion Movement that does not add value Extra Processing Process that does not add value Problems are man-made, therefore may be solved by man. John F. Kennedy
The outcome depends upon the knowledge and persistence of the people involved. Important Dates
Session Day/Date Time Venue Topic 06 Thursday, 3/24 Noon - 1pm Cessna Building QI Toolkit #4: Control Charts 07 Thursday, 4/28 Noon - 1pm Cessna Expand QI Knowledge #1: Error & Risk 08 Thursday, 5/26 Noon - 1pm Cessna Building QI Toolkit #5: TeamSTEPPS 09 Thursday, 6/23 Noon - 1pm Cessna Expand QI Knowledge #2: Just Culture 10 Thursday, 7/28 Noon - 1pm Cessna Expand QI Knowledge #3: High Reliability Org 11 Thursday, 8/25 Noon - 1pm Cessna Expand QI Knowledge #4: Disparities 12 Thursday, 9/22 Noon - 1pm Cessna Quality Forum Present QI Project (IHI Prep) * WLI QIA typically meets 4th Thursday of month; please note12/3 is first Thursday due to holidays THANK YOU
EVERYDAY YOU SHOULD ASK YOURSELF HOW CAN I IMPROVE?
Wesley Leadership Institute Quality Improvement Academy