Quality Improvement Tools and Techniques: 2007 An MPRO Self-Instructional Module

1. Quality Improvement Tools and Techniques: 2007An MPRO Self-Instructional Module Patricia L. Baker, RN, MS Welcome to the MPRO self-instructional module for Quality Improvement Tools and Techniques. The goal of this module is to assist health care providers in understanding and using the tools, techniques and principles of quality improvement. Nurses completing this module are eligible to receive 1.6 continuing nursing education (CNE) contact hours. This educational activity is provided by MPRO, an approved provider of continuing nursing education by the Michigan Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation. See page 51 for details. The average time to complete this module is 100 minutes. Disclosures: In order to receive nursing contact hours for this education activity, you must pass a post test with a score of at least 76% and complete an evaluation form. The authors and the planning committee for this SIM declare there is no conflict of interest and there is no discussion of off-label use of products. This activity has no commercial support. The awarding of contact hours is based on an assessment of the educational merit of the self instructional module and does not constitute endorsement of the use of any specific modality in the care of clients. Welcome to the MPRO self-instructional module for Quality Improvement Tools and Techniques. The goal of this module is to assist health care providers in understanding and using the tools, techniques and principles of quality improvement. Nurses completing this module are eligible to receive 1.6 continuing nursing education (CNE) contact hours. This educational activity is provided by MPRO, an approved provider of continuing nursing education by the Michigan Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation. See page 51 for details. The average time to complete this module is 100 minutes. Disclosures: In order to receive nursing contact hours for this education activity, you must pass a post test with a score of at least 76% and complete an evaluation form. The authors and the planning committee for this SIM declare there is no conflict of interest and there is no discussion of off-label use of products. This activity has no commercial support. The awarding of contact hours is based on an assessment of the educational merit of the self instructional module and does not constitute endorsement of the use of any specific modality in the care of clients.

2. 2 Tools for the Continuous Quality Improvement Journey Like beginning on a vacation journey, quality improvement (QI) requires effective planning to be a successful event with good outcomes. When preparing for your vacation, you consider multiple factors like: Location Companions Cost Time Previous experience Desired outcome Likewise, your QI journey will require assessment and planning to be a successful experience. This module will take you through many tools and techniques that will help your QI journey to have the desired outcome. Like beginning on a vacation journey, quality improvement (QI) requires effective planning to be a successful event with good outcomes. When preparing for your vacation, you consider multiple factors like: Location Companions Cost Time Previous experience Desired outcome Likewise, your QI journey will require assessment and planning to be a successful experience. This module will take you through many tools and techniques that will help your QI journey to have the desired outcome.

3. 3 Objectives Identify common quality improvement (QI) tools used to focus on important problems List tools for identifying problem causes Recognize tools for defining solutions Review tools used to develop QI plans Plan to display QI data The objectives for this self-instructional module are listed here. In order to focus on organizational priorities and problems that will make a positive difference, it is necessary to target important issues. Similar to planning where to go on your next vacation, the tools and techniques in this learning module will help the QI Team in their journey to improve. Furthermore, tools are reviewed that assist the team in identifying and analyzing causes for problems or errors. Aids for examining and displaying data support the QI Team in planning, implementing, and evaluating the action steps in a successful journey to improve health care. These tools will be discussed using the plan, do, study, act methodology and the three questions of The Model for Improvement (Langley et at). The objectives for this self-instructional module are listed here. In order to focus on organizational priorities and problems that will make a positive difference, it is necessary to target important issues. Similar to planning where to go on your next vacation, the tools and techniques in this learning module will help the QI Team in their journey to improve. Furthermore, tools are reviewed that assist the team in identifying and analyzing causes for problems or errors. Aids for examining and displaying data support the QI Team in planning, implementing, and evaluating the action steps in a successful journey to improve health care. These tools will be discussed using the plan, do, study, act methodology and the three questions of The Model for Improvement (Langley et at).

4. 4 This is a picture of The Model for Improvement by Langley, et al. The model raises three questions which assist the QI Team in maintaining focus, and the plan, do, study, act or PDSA cycle. The three questions are: What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in an improvement? The premise of this model is to rapidly identify and implement quality improvement changes by implementing small PDSA cycles to learn and build knowledge. Quick, small-scale trials are emphasized while continuing to improve the change as you go. This model will be the organizing framework for examining quality improvement tools and techniques for each of the PDSA phases.This is a picture of The Model for Improvement by Langley, et al. The model raises three questions which assist the QI Team in maintaining focus, and the plan, do, study, act or PDSA cycle. The three questions are: What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in an improvement? The premise of this model is to rapidly identify and implement quality improvement changes by implementing small PDSA cycles to learn and build knowledge. Quick, small-scale trials are emphasized while continuing to improve the change as you go. This model will be the organizing framework for examining quality improvement tools and techniques for each of the PDSA phases.

5. 5 Continuous Quality Improvement The P is for Plan. When beginning a QI journey, planning is the most important, intense, and longest piece of the cycle. This learning module will review some helpful tools and techniques for planning. Subsequent planning phases are less intense because the QI Team is building on what was learned in previous PDSA tests of change. Planning for a successful QI project involves multiple steps. Like getting ready for a long trip, we must assess our options, examine possible solutions, and determine where the QI journey will travel. There are multiple steps in developing a comprehensive plan. The SIM will examine tools and techniques that will assist with the steps in the planning phase (pages 5 to 41). The P is for Plan. When beginning a QI journey, planning is the most important, intense, and longest piece of the cycle. This learning module will review some helpful tools and techniques for planning. Subsequent planning phases are less intense because the QI Team is building on what was learned in previous PDSA tests of change. Planning for a successful QI project involves multiple steps. Like getting ready for a long trip, we must assess our options, examine possible solutions, and determine where the QI journey will travel. There are multiple steps in developing a comprehensive plan. The SIM will examine tools and techniques that will assist with the steps in the planning phase (pages 5 to 41).

6. 6 Tools to Identify the QI Focus Define the problem areas Compare the current state with the desired state Check alignment with organizational mission and goals The first step in the QI journey is to determine where you are going. What is the focus of your quest for improvement? This is like asking “Where do you want to spend your vacation?” This may be determined by the organization’s leadership. Sometimes the organization’s mission and vision set the direction for the QI journey. The vision and mission identifies where the organization would like to be in three to five years as opposed to where it is now. Administration may determine the area of focus and assign the QI project. Areas for improvement are often determined by data and information that identify broad issues or problems. Then the specific area of focus needs to be determined and a QI Team developed to address the issue(s). Usually the area of focus is determined by cost, or problem areas, or processes that are used frequently or are high volume, data that reflects a problem compared to other similar organizations, or problem areas that seem like they could be remedied with a minimum of cost and energy. There may be several improvement efforts that stem from one broad goal or focus area. The first step in the QI journey is to determine where you are going. What is the focus of your quest for improvement? This is like asking “Where do you want to spend your vacation?” This may be determined by the organization’s leadership. Sometimes the organization’s mission and vision set the direction for the QI journey. The vision and mission identifies where the organization would like to be in three to five years as opposed to where it is now. Administration may determine the area of focus and assign the QI project. Areas for improvement are often determined by data and information that identify broad issues or problems. Then the specific area of focus needs to be determined and a QI Team developed to address the issue(s). Usually the area of focus is determined by cost, or problem areas, or processes that are used frequently or are high volume, data that reflects a problem compared to other similar organizations, or problem areas that seem like they could be remedied with a minimum of cost and energy. There may be several improvement efforts that stem from one broad goal or focus area.

7. 7 Tools to Identify Focus Brainstorming Idea writing Impact analysis Pareto Diagram Problem statement Selection grid Tools that may be helpful to identify the QI focus are listed here: Brainstorming Idea writing Pareto Diagram Impact analysis Selection grid Brainstorming and idea writing focus on using creativity to generate a large volume of ideas. The Pareto Diagram allows the team to see the major causes of a problem. A problem statement defines the issue or problem to be addressed by the QI Team. Selection grid is one method to prioritize and select one problem area for the focus of this QI project. This will be explained on page 30.Tools that may be helpful to identify the QI focus are listed here: Brainstorming Idea writing Pareto Diagram Impact analysis Selection grid Brainstorming and idea writing focus on using creativity to generate a large volume of ideas. The Pareto Diagram allows the team to see the major causes of a problem. A problem statement defines the issue or problem to be addressed by the QI Team. Selection grid is one method to prioritize and select one problem area for the focus of this QI project. This will be explained on page 30.

8. 8 Brainstorming A focused creativity technique designed to collect multiple ideas about an issue Benefits Encourages creative thinking Generates a large number of ideas Gets all team members involved Eliminates fear of criticism Increases the number of options Brainstorming is a technique designed to collect ideas through interaction among team members. It can be used during any phase of the improvement process. It is presented here to highlight the methods to identify a focus for quality improvement. The benefits of brainstorming are that it uses our creative side and generally is a fun group activity. This is a time to encourage your team to “think outside the box” and be focused on listing as many ideas as possible. It is also an opportunity to involve all of the team, even those who may tend to be less talkative during meetings. The leader may have everyone take turns going around the room until all ideas have been listed, or may choose to use a free flowing format, with people calling out ideas at random. By using the brainstorming rules listed on page nine, this technique eliminates fear of criticism and judgement of ideas, and also encourages people to think beyond the obvious. If the QI Team wishes to collect ideas from staff not represented, a large sheet of paper with the topic title and objective may be posted in a central location for a few days where other staff can write their ideas. Brainstorming is a technique designed to collect ideas through interaction among team members. It can be used during any phase of the improvement process. It is presented here to highlight the methods to identify a focus for quality improvement. The benefits of brainstorming are that it uses our creative side and generally is a fun group activity. This is a time to encourage your team to “think outside the box” and be focused on listing as many ideas as possible. It is also an opportunity to involve all of the team, even those who may tend to be less talkative during meetings. The leader may have everyone take turns going around the room until all ideas have been listed, or may choose to use a free flowing format, with people calling out ideas at random. By using the brainstorming rules listed on page nine, this technique eliminates fear of criticism and judgement of ideas, and also encourages people to think beyond the obvious. If the QI Team wishes to collect ideas from staff not represented, a large sheet of paper with the topic title and objective may be posted in a central location for a few days where other staff can write their ideas.

9. 9 Brainstorming Rules No criticisms or compliments No discussion No questions Speed is important Think broadly Develop wild, outrageous ideas Build on ideas of others Listen Do not interrupt Quantity is important Before reviewing the steps for conducting a brainstorming session, let’s review some rules for brainstorming. Before beginning a brainstorming session, share these rules with all participants. By eliminating criticism, judgement, compliments, and questions, participants are better able to contribute ideas that do not require explanation. It helps the spontaneous “free flow” of ideas that results in a long list of possibilities. Participants are encouraged to add-on to the ideas of others. That is, to use the ideas already listed to add a twist or a new spin, or as a map to a new idea. If you have multiple ideas, and are afraid that you may forget an idea before your next turn, jot down a key word on a piece of paper. However, it is important to listen to the rest of the ideas. Taking notes interferes with the mental freedom necessary for good brainstorming. If you cannot think of something to add, say “Pass”. By your next turn you may have heard something that will result in another creative idea. Remember, there are no “dumb” ideas. Quantity is more important than quality when brainstorming.Before reviewing the steps for conducting a brainstorming session, let’s review some rules for brainstorming. Before beginning a brainstorming session, share these rules with all participants. By eliminating criticism, judgement, compliments, and questions, participants are better able to contribute ideas that do not require explanation. It helps the spontaneous “free flow” of ideas that results in a long list of possibilities. Participants are encouraged to add-on to the ideas of others. That is, to use the ideas already listed to add a twist or a new spin, or as a map to a new idea. If you have multiple ideas, and are afraid that you may forget an idea before your next turn, jot down a key word on a piece of paper. However, it is important to listen to the rest of the ideas. Taking notes interferes with the mental freedom necessary for good brainstorming. If you cannot think of something to add, say “Pass”. By your next turn you may have heard something that will result in another creative idea. Remember, there are no “dumb” ideas. Quantity is more important than quality when brainstorming.

10. 10 Brainstorming Steps 1. Clarify the brainstorming objective 2. Write the objective at the top of the flip chart 3. Review brainstorming rules 4. Determine process: free flow or take turns 5. Record each idea on the flip chart 6. Continue until all ideas are exhausted 7. Clarify each idea after all ideas are listed 8. Group like ideas together Important steps for brainstorming include: Be specific about the objective and write it at the top of the flip chart to be a subtle reminder to the group about the focus. Clarify the objective or purpose of the brainstorming. For example, the team may ask: How can we make registering patients flow smoothly and quickly? And then brainstorm some answers. Or for the vacation analogy: Where do we want to spend two weeks this summer? When there is a large number of participants, it is helpful to have two recorders, and multiple sheets of paper for recording ideas. Additional steps are noted on the notes above. As a last step, clarifying the listed ideas will help the team to understand the intent and avoid misinterpretation. Grouping similar ideas will allow the team to make better choices from among the multiple ideas listed. The brainstorming leader guides the group and gains agreement in noting the clarified statements and groupings.Important steps for brainstorming include: Be specific about the objective and write it at the top of the flip chart to be a subtle reminder to the group about the focus. Clarify the objective or purpose of the brainstorming. For example, the team may ask: How can we make registering patients flow smoothly and quickly? And then brainstorm some answers. Or for the vacation analogy: Where do we want to spend two weeks this summer? When there is a large number of participants, it is helpful to have two recorders, and multiple sheets of paper for recording ideas. Additional steps are noted on the notes above. As a last step, clarifying the listed ideas will help the team to understand the intent and avoid misinterpretation. Grouping similar ideas will allow the team to make better choices from among the multiple ideas listed. The brainstorming leader guides the group and gains agreement in noting the clarified statements and groupings.

11. 11 Idea Writing Individual brainstorming on paper Benefits Idea notes may be written before the team meeting Protects anonymity Idea notes shared at the meeting Includes those who cannot attend For idea writing, team members note their thoughts on small pieces of paper. The idea notes may be written before or during the meeting. The papers are collected, and read randomly while someone notes the thought on a flip chart. The method should follow the rules of brainstorming. The identity of all participants is protected. This is sometimes a good initial method to gain participation of those who are very reluctant to speak-up. Once a team has worked together for a time, reticent members may be more open to sharing their thoughts publicly. For members who are unable to attend the meeting, their idea notes can be incorporated into those of the rest of the team. Following the listing of the idea notes, the team clarifies the meaning of each item as needed, and proceeds to group items together.For idea writing, team members note their thoughts on small pieces of paper. The idea notes may be written before or during the meeting. The papers are collected, and read randomly while someone notes the thought on a flip chart. The method should follow the rules of brainstorming. The identity of all participants is protected. This is sometimes a good initial method to gain participation of those who are very reluctant to speak-up. Once a team has worked together for a time, reticent members may be more open to sharing their thoughts publicly. For members who are unable to attend the meeting, their idea notes can be incorporated into those of the rest of the team. Following the listing of the idea notes, the team clarifies the meaning of each item as needed, and proceeds to group items together.

12. 12 Impact Analysis Survey technique to discover the impact or effect of a situation or problem Benefits Confirms the problem or project is worthwhile Indicates the severity of the problem Often uncovers new information Allows for sharing of thoughts, opinions, and ideas For this technique, the QI Team asks individuals their perception of the situation or problem. This may be a structured interview with specific focused questions or more generic. A more generic example would be to ask a friend – Where was your best vacation and why was it the best? A more structured example would be to ask detailed questions about travel time, which roads were taken, cost of hotels, etc. The impact analysis of a situation gives the team information about the problem, how bad the problem is, what the contributing factors are, or what makes it so intolerable, and other thoughts and opinions. Examples of what the survey questions might start with are: What do you think about x? Why do you think x is a problem? How does this x situation affect your work? How does it affect the work of others? How does the x situation affect our customers? When do issues with x most often occur? More open questions might be: Tell me your impression of x. Or, describe the things you know about x. A health care example might be “How do you think we can improve documentation on the patient record?” Often the team will uncover new ideas, information or even some ideas for solutions. Examples might include: high rate of errors, many problems with the process, costly, long duration, etc.For this technique, the QI Team asks individuals their perception of the situation or problem. This may be a structured interview with specific focused questions or more generic. A more generic example would be to ask a friend – Where was your best vacation and why was it the best? A more structured example would be to ask detailed questions about travel time, which roads were taken, cost of hotels, etc. The impact analysis of a situation gives the team information about the problem, how bad the problem is, what the contributing factors are, or what makes it so intolerable, and other thoughts and opinions. Examples of what the survey questions might start with are: What do you think about x? Why do you think x is a problem? How does this x situation affect your work? How does it affect the work of others? How does the x situation affect our customers? When do issues with x most often occur? More open questions might be: Tell me your impression of x. Or, describe the things you know about x. A health care example might be “How do you think we can improve documentation on the patient record?” Often the team will uncover new ideas, information or even some ideas for solutions. Examples might include: high rate of errors, many problems with the process, costly, long duration, etc.

13. 13 Pareto Diagram Bar chart that demonstrates the distribution of issues that cause most of the problems Benefits Applies the 80/20 rule Focuses on the 20% of the work that cause 80% of the problems Gives the biggest return for your efforts Helps explain problem to others Vilfredo Pareto is credited with defining the 80/20 rule, which says that 80% of the problems are caused by 20% of the possible issues or services. You could turn this around and say that 20% of the work causes 80% of the problems. Let’s return to our travel analogy. To prepare your automobile for a lengthy trip, you would check those things that are known to cause most automobile breakdowns: tires, gas, lack of warranty work, dying battery, etc. The top two are probably gas and tires, so your action plan is to check the tires and fill up with gas before you leave home. Using this 80/20 principle, QI teams can focus their efforts on the most frequent issues to solve the problem. This way you get the biggest return for your time and effort. To identify distinct categories of issues, ask: who, what, where, when, how, and why. By organizing information into distinct categories the team can learn which categories are responsible for most of the problems. Vilfredo Pareto is credited with defining the 80/20 rule, which says that 80% of the problems are caused by 20% of the possible issues or services. You could turn this around and say that 20% of the work causes 80% of the problems. Let’s return to our travel analogy. To prepare your automobile for a lengthy trip, you would check those things that are known to cause most automobile breakdowns: tires, gas, lack of warranty work, dying battery, etc. The top two are probably gas and tires, so your action plan is to check the tires and fill up with gas before you leave home. Using this 80/20 principle, QI teams can focus their efforts on the most frequent issues to solve the problem. This way you get the biggest return for your time and effort. To identify distinct categories of issues, ask: who, what, where, when, how, and why. By organizing information into distinct categories the team can learn which categories are responsible for most of the problems.

14. 14 Pareto Diagram In this Pareto Diagram, distinct category items are listed for why women do not get a mammogram. The different categories were tallied for 30 women. The categories are displayed in a bar graph with the most frequent at the left, and the other categories follow in descending order. The resulting picture tells the most frequent reasons and thus where to focus attention to improve mammography rates. Steps in creating the Pareto Diagram are: Create the distinct categories to be compared. Tally the frequency or responses for each category. Prepare the graph with categories on the horizontal or X axis, and the frequency on the vertical or Y axis. Place the categories in descending order from the left. Many charts also calculate a cumulative line to show where 80% of the problems are located. In this mammography example, the two categories “Fear” and “No insurance” account for 20 of the 30 responses or 66.6%. If we add “Forgot”, these three reasons account for 90% of the reasons. Often the team will decide to examine the largest category by gathering more data. So, they might decide to examine “Fear” in greater detail. They might ask women about fear of pain, fear of potential cancer, or fear of embarrassment, etc. in order to learn more about fear. In this Pareto Diagram, distinct category items are listed for why women do not get a mammogram. The different categories were tallied for 30 women. The categories are displayed in a bar graph with the most frequent at the left, and the other categories follow in descending order. The resulting picture tells the most frequent reasons and thus where to focus attention to improve mammography rates. Steps in creating the Pareto Diagram are: Create the distinct categories to be compared. Tally the frequency or responses for each category. Prepare the graph with categories on the horizontal or X axis, and the frequency on the vertical or Y axis. Place the categories in descending order from the left. Many charts also calculate a cumulative line to show where 80% of the problems are located. In this mammography example, the two categories “Fear” and “No insurance” account for 20 of the 30 responses or 66.6%. If we add “Forgot”, these three reasons account for 90% of the reasons. Often the team will decide to examine the largest category by gathering more data. So, they might decide to examine “Fear” in greater detail. They might ask women about fear of pain, fear of potential cancer, or fear of embarrassment, etc. in order to learn more about fear.

15. 15 Problem Statement Defines and summarizes the issue or problem Benefits Spells out the impact of the current state Defines the opportunities of the desired state Explains the expected impact of correcting the situation Delivers a consistent message When the focus of the problem area or issue has been determined using tools such as brainstorming, impact analysis, and the Pareto Diagram, it is best to write a problem statement. This statement is used to deliver a clear, concise and compelling argument for improving the current situation. The problem statement includes three main areas: Defines the current situation or process and the challenges or difficulties that result. Explains how the current situation or process is different than what is expected or desired. Relates the benefits of fixing the problem or issue, and why it is important to do it now. Most problem statements contain a summary of the methods used to examine and define the problem and to evaluate the benefits (brainstorming, Pareto, impact analysis, cost/benefit, etc.). It is advantageous to include numeric targets for the improvement such as: will decrease wait times by 30 minutes, or reduce the medication error rate by 25%. Additionally, listing the specific boundaries of the problem provides for common understanding of the exact process being addressed. When the focus of the problem area or issue has been determined using tools such as brainstorming, impact analysis, and the Pareto Diagram, it is best to write a problem statement. This statement is used to deliver a clear, concise and compelling argument for improving the current situation. The problem statement includes three main areas: Defines the current situation or process and the challenges or difficulties that result. Explains how the current situation or process is different than what is expected or desired. Relates the benefits of fixing the problem or issue, and why it is important to do it now. Most problem statements contain a summary of the methods used to examine and define the problem and to evaluate the benefits (brainstorming, Pareto, impact analysis, cost/benefit, etc.). It is advantageous to include numeric targets for the improvement such as: will decrease wait times by 30 minutes, or reduce the medication error rate by 25%. Additionally, listing the specific boundaries of the problem provides for common understanding of the exact process being addressed.

16. 16 Define Goals What are we trying to accomplish? SMART Goals Specific Measurable Attainable Realistic Timely Once the area of focus has been defined, the QI Team will define the specific goals for the improvement project. Here it is helpful to use the first of the three questions noted in The Model for Improvement by Langley et al. What are we trying to accomplish?” This question will keep the team focused throughout the improvement project. SMART Goals This acronym is very helpful in designing goals. When goals are specific they tell you exactly the expected outcome (We will be in Chicago for the weekend). Measurable goals use well defined criteria to measure progress (We will average 55 miles an hour driving time). Attainable means that it is reasonable and possible for us to do this (We have vacation time and we have a car that can travel 55 mph). For a goal to be realistic, it means that it can be done in the real world (We don’t expect to drive from Lansing to Chicago in two hours without a car). Timely refers to establishing a time line that is reasonable or “doable” (We will be in Chicago by 5 p.m.). Using concrete criteria in writing goals lets you know when you have arrived, and reached your goal. A health care example would be that we can increase documentation rates of diabetic foot exams by 50% in the next month, by having every diabetic patient remove their shoes and socks after entering the examination room.Once the area of focus has been defined, the QI Team will define the specific goals for the improvement project. Here it is helpful to use the first of the three questions noted in The Model for Improvement by Langley et al. What are we trying to accomplish?” This question will keep the team focused throughout the improvement project. SMART Goals This acronym is very helpful in designing goals. When goals are specific they tell you exactly the expected outcome (We will be in Chicago for the weekend). Measurable goals use well defined criteria to measure progress (We will average 55 miles an hour driving time). Attainable means that it is reasonable and possible for us to do this (We have vacation time and we have a car that can travel 55 mph). For a goal to be realistic, it means that it can be done in the real world (We don’t expect to drive from Lansing to Chicago in two hours without a car). Timely refers to establishing a time line that is reasonable or “doable” (We will be in Chicago by 5 p.m.). Using concrete criteria in writing goals lets you know when you have arrived, and reached your goal. A health care example would be that we can increase documentation rates of diabetic foot exams by 50% in the next month, by having every diabetic patient remove their shoes and socks after entering the examination room.

17. 17 Tools to Understand the Cause Clarify the process Flow chart the process Determine cause Fishbone or Cause and Effect Diagram Impact analysis Data Pareto Diagram Once the problem and the process boundaries have been determined, then the QI Team should examine the possible causes of the problem. The most common improvement tools used to understand the issues and identify opportunities for improvement with a process are listed here. A flow chart is a drawing of the steps in a process to understand how it is organized. Analysis of the process flow chart allows the team to identify areas that are redundant, repetitive, inefficient, overly complex, or even unnecessary. To further determine causes, the team may complete a fishbone or cause and effect diagram about the problem. Conducting an impact analysis (discussed earlier on page 12) with those involved in the work process, often provides revealing insights. Data may include information about time, satisfaction surveys, turn-around time, erroneous data, etc. The Pareto Diagram discussed earlier (pages 13 and 14) can also be helpful to further examine the top two or three causes identified in the first phase of planning. Once the problem and the process boundaries have been determined, then the QI Team should examine the possible causes of the problem. The most common improvement tools used to understand the issues and identify opportunities for improvement with a process are listed here. A flow chart is a drawing of the steps in a process to understand how it is organized. Analysis of the process flow chart allows the team to identify areas that are redundant, repetitive, inefficient, overly complex, or even unnecessary. To further determine causes, the team may complete a fishbone or cause and effect diagram about the problem. Conducting an impact analysis (discussed earlier on page 12) with those involved in the work process, often provides revealing insights. Data may include information about time, satisfaction surveys, turn-around time, erroneous data, etc. The Pareto Diagram discussed earlier (pages 13 and 14) can also be helpful to further examine the top two or three causes identified in the first phase of planning.

18. 18 Flowchart the Process A diagram of the sequence of steps in a work effort Benefits Clarifies current knowledge of process Demonstrates the work flow Examines parts of a process and their relationship to each other Identifies the sources of variation for each step from start to finish Points out unnecessary complexity, inefficiency, and redundancy Develops a common understanding A flow chart is a picture of the sequence of steps in a process (shows the logical series of steps and the path of a process). It also helps to explain the steps, actions, decisions, and outcomes in that process, and how they are related. Furthermore, it may describe the activities, decisions, documentation, flow of work, and how they all fit together. The process flow chart is used to understand the current work process, improve it, and to create a common understanding of how it should be done. It is helpful to compare the real process to the ideal process. The team can also see where there are redundancies, overlaps, missing points, potential sources of problems or trouble, areas of complexity, unnecessary steps, loops, inefficiencies, and misunderstandings. The team begins by determining the starting and ending points of the process to be examined. They focus on the actual process as it is, not on the ideal process. A flow chart is a picture of the sequence of steps in a process (shows the logical series of steps and the path of a process). It also helps to explain the steps, actions, decisions, and outcomes in that process, and how they are related. Furthermore, it may describe the activities, decisions, documentation, flow of work, and how they all fit together. The process flow chart is used to understand the current work process, improve it, and to create a common understanding of how it should be done. It is helpful to compare the real process to the ideal process. The team can also see where there are redundancies, overlaps, missing points, potential sources of problems or trouble, areas of complexity, unnecessary steps, loops, inefficiencies, and misunderstandings. The team begins by determining the starting and ending points of the process to be examined. They focus on the actual process as it is, not on the ideal process.

19. 19 Flowchart Steps Involve those most knowledgeable about the process Define the boundaries (beginning and end) List the work activities, decisions, and documents Place the activities, decisions, and documents in the order that they occur Connect the activities with arrows To construct a flow chart, the team writes down each step in the process and then arranges the steps in the order that they occur. To do this effectively, people who work with the process need to be involved. If not, important steps may be missed. This is especially true when there are multiple staff and different roles within the same process. A helpful tip when listing work activities is to initially record the steps on sticky notes. This way, the steps can be rearranged easily or missed steps added if needed. The team clarifies each step in the process as they define and document the flow. Decision points are noted with a yes or no answer. A yes answer follows one path and a no answer requires a different next step. Documents or forms used in the process are also noted in the flow chart. In addition, flow charting examines how the parts of the process relate to each other and assists the team to streamline the steps and identify sources of complexity, redundancy, and inefficiencies. To construct a flow chart, the team writes down each step in the process and then arranges the steps in the order that they occur. To do this effectively, people who work with the process need to be involved. If not, important steps may be missed. This is especially true when there are multiple staff and different roles within the same process. A helpful tip when listing work activities is to initially record the steps on sticky notes. This way, the steps can be rearranged easily or missed steps added if needed. The team clarifies each step in the process as they define and document the flow. Decision points are noted with a yes or no answer. A yes answer follows one path and a no answer requires a different next step. Documents or forms used in the process are also noted in the flow chart. In addition, flow charting examines how the parts of the process relate to each other and assists the team to streamline the steps and identify sources of complexity, redundancy, and inefficiencies.

20. 20 This flow chart example highlights the initial steps in a process for a diabetic patient entering the physician office system. In this standard work flow process, a diabetic patient is in for a follow-up visit. The nurse or medical assistant reviews the flow sheet to determine if a hemoglobin A1c test is due. If so, the lab work is obtained and documented in the chart. The patient is then escorted to an exam room. This flow chart example highlights the initial steps in a process for a diabetic patient entering the physician office system. In this standard work flow process, a diabetic patient is in for a follow-up visit. The nurse or medical assistant reviews the flow sheet to determine if a hemoglobin A1c test is due. If so, the lab work is obtained and documented in the chart. The patient is then escorted to an exam room.

21. 21 This is page two of the flowchart. Note that after the patient is in the room the decision is made about the need for a diabetic foot exam. Also note that the physician, physician assistant, or nurse practitioner review the documentation and then examine the patient. It is then up to the physician, PA or NP to determine if there is a need for these tests.This is page two of the flowchart. Note that after the patient is in the room the decision is made about the need for a diabetic foot exam. Also note that the physician, physician assistant, or nurse practitioner review the documentation and then examine the patient. It is then up to the physician, PA or NP to determine if there is a need for these tests.

22. 22 Fishbone or Cause & Effect Diagram Explores and displays the identified causes and relationships leading to a specific outcome Benefits Involves multiple team members Allows grouping of information Displays related causes Gives ideas for goals Points out data needs Provides ideas for solutions Presents big picture of the problem Easy to understand The purpose of the fishbone or cause and effect diagram is to explore and display the possible causes for a problem and to identify the relationship among those causes. It is often called a fishbone because it looks like the skeleton of a fish. It is also a useful tool to identify barriers and possible sources of variation within a process. The team first agrees on the outcome or problem that they are examining. An outcome may be determining why diabetic patients do not receive their preventive screening tests, or why nursing home patients fall out of bed, or why staff do not report medication errors, or why female patients do not obtain their mammogram, etc. The fishbone tool helps the QI team to focus on the content of the problem and to identify obvious and obscure causes.The purpose of the fishbone or cause and effect diagram is to explore and display the possible causes for a problem and to identify the relationship among those causes. It is often called a fishbone because it looks like the skeleton of a fish. It is also a useful tool to identify barriers and possible sources of variation within a process. The team first agrees on the outcome or problem that they are examining. An outcome may be determining why diabetic patients do not receive their preventive screening tests, or why nursing home patients fall out of bed, or why staff do not report medication errors, or why female patients do not obtain their mammogram, etc. The fishbone tool helps the QI team to focus on the content of the problem and to identify obvious and obscure causes.

23. 23 Fishbone or Cause & Effect Steps Agree on the problem statement or outcome Identify major cause categories Brainstorm reasons for each of the major causes Clarify the diagram Post for others to review A first step in using a fishbone or cause and effect diagram is to determine the problem statement such as: Why are home health personnel not completing OASIS information? or Why are heart attack patients not getting aspirin at discharge? After the problem statement is clarified, the team identifies major cause categories. There are some alliteration mnemonics of main causes that are frequently used with the fishbone tool: The “Ms” or Man (and woman) power, Materials, Machines, and Methods The “Ps” or People, Procedures, Place (environment), Products, and Process or Production The “Es” or Employees, Environment, Equipment, and Effort (work process) The team is also free to develop their own main categories. A first step in using a fishbone or cause and effect diagram is to determine the problem statement such as: Why are home health personnel not completing OASIS information? or Why are heart attack patients not getting aspirin at discharge? After the problem statement is clarified, the team identifies major cause categories. There are some alliteration mnemonics of main causes that are frequently used with the fishbone tool: The “Ms” or Man (and woman) power, Materials, Machines, and Methods The “Ps” or People, Procedures, Place (environment), Products, and Process or Production The “Es” or Employees, Environment, Equipment, and Effort (work process) The team is also free to develop their own main categories.

24. 24 Fishbone or Cause & Effect Diagram Employees Materials Equipment In this diagram of a fishbone or cause and effect diagram, the problem or outcome is listed in the box at the right. The problem or outcome and the major bones of the fish are defined by the team. As you can see, this diagram uses a combination of the three mnemonics for remembering major categories. Using the brainstorming technique discussed earlier (pages 8 to 10) the team lists the various causes that lead to the outcome. As you recall, the key to brainstorming is to quickly gain a lot of ideas. After the brainstorming is done the team can then go back and determine if the thoughts are listed under the correct category and to clarify ideas. Some teams choose to brainstorm about one of the main causes like “Employees” and then brainstorm about the next main cause. Others prefer to brainstorm about all contributing factors at the same time. Another helpful technique is to post this diagram in a staff area to gain input from those not at the meetings. Following the brainstorming, the team will organize the list by clarifying ideas and condensing the items listed. In this diagram of a fishbone or cause and effect diagram, the problem or outcome is listed in the box at the right. The problem or outcome and the major bones of the fish are defined by the team. As you can see, this diagram uses a combination of the three mnemonics for remembering major categories. Using the brainstorming technique discussed earlier (pages 8 to 10) the team lists the various causes that lead to the outcome. As you recall, the key to brainstorming is to quickly gain a lot of ideas. After the brainstorming is done the team can then go back and determine if the thoughts are listed under the correct category and to clarify ideas. Some teams choose to brainstorm about one of the main causes like “Employees” and then brainstorm about the next main cause. Others prefer to brainstorm about all contributing factors at the same time. Another helpful technique is to post this diagram in a staff area to gain input from those not at the meetings. Following the brainstorming, the team will organize the list by clarifying ideas and condensing the items listed.

25. 25 Examine Solutions Tools to generate solutions Brainstorming Impact analysis Pareto Diagram Flowchart Fishbone Collaboration with others Literature After the team has explored the problem or project in depth, it is time to travel to creativity land to generate a list of possible solutions. There are several books listed at the end of this presentation (pages 49 and 50) that may help teams to develop their imagination and creativity. To generate a list of possible ideas, the team may wish to review the work already accomplished and summarized. The results of these investigations may give the team ideas for improvement. Problem Statement (listed the desired state and the identified issues) Impact Analysis (defined the ideas or opinions of people involved in the work) Pareto (displayed the high volume problems) Flow Chart (showed the current process with possible problem areas) Fishbone (noted the probable causes of a problem) Furthermore, collaborating with others opens a new avenue for sharing successes and lessons learned in overcoming barriers at their organization. For example: Hospital A may compare policies and procedures for reporting medication errors with hospitals B and C; or Happy Home Health may meet with Sunny Days Home Care to learn more about personnel policies. At a state meeting of outpatient group practices, the nurse manager from Top Care Physicians Group may talk with the presenter from the Office of First Physicians and they continue to share ideas via e-mail for many months. The literature and web information can provide many ideas for improvement. The Joint Commission Journal on Quality and Safety and the Institute for Healthcare Improvement also offer many health care examples. After the team has explored the problem or project in depth, it is time to travel to creativity land to generate a list of possible solutions. There are several books listed at the end of this presentation (pages 49 and 50) that may help teams to develop their imagination and creativity. To generate a list of possible ideas, the team may wish to review the work already accomplished and summarized. The results of these investigations may give the team ideas for improvement. Problem Statement (listed the desired state and the identified issues) Impact Analysis (defined the ideas or opinions of people involved in the work) Pareto (displayed the high volume problems) Flow Chart (showed the current process with possible problem areas) Fishbone (noted the probable causes of a problem) Furthermore, collaborating with others opens a new avenue for sharing successes and lessons learned in overcoming barriers at their organization. For example: Hospital A may compare policies and procedures for reporting medication errors with hospitals B and C; or Happy Home Health may meet with Sunny Days Home Care to learn more about personnel policies. At a state meeting of outpatient group practices, the nurse manager from Top Care Physicians Group may talk with the presenter from the Office of First Physicians and they continue to share ideas via e-mail for many months. The literature and web information can provide many ideas for improvement. The Joint Commission Journal on Quality and Safety and the Institute for Healthcare Improvement also offer many health care examples.

26. 26 Select a Change Option What change can we make that will result in improvement? Tools Decision matrix Selection grid Multi-voting Cost-benefit analysis Force Field Analysis There are many possible roads to take to reach the desired state identified in the problem statement. Sometimes the choices are overwhelming. Two of the three questions of The Model for Improvement (Langley, et al) are very helpful in keeping the team focused. “What are we trying to accomplish” and “What change can we make that will result in improvement?” set the stage for this section. Many ideas may be creative, interesting, fun, and desirable, but may not result in the desired improvement. Listed here are several tools that will help the team select the best options for the situation in their organization. The next five pages will examine several of the decision-making tools and techniques which are listed here. These tools are useful throughout the QI project, whenever group decision-making needs to arise. In selecting a change option to improve the problem area or situation, the QI Team will also want to consider how to measure the change, so that we know whether or not the situation actually improved.There are many possible roads to take to reach the desired state identified in the problem statement. Sometimes the choices are overwhelming. Two of the three questions of The Model for Improvement (Langley, et al) are very helpful in keeping the team focused. “What are we trying to accomplish” and “What change can we make that will result in improvement?” set the stage for this section. Many ideas may be creative, interesting, fun, and desirable, but may not result in the desired improvement. Listed here are several tools that will help the team select the best options for the situation in their organization. The next five pages will examine several of the decision-making tools and techniques which are listed here. These tools are useful throughout the QI project, whenever group decision-making needs to arise. In selecting a change option to improve the problem area or situation, the QI Team will also want to consider how to measure the change, so that we know whether or not the situation actually improved.

27. 27 Decision Matrix This 2x2 decision matrix table is a simple diagram for making choices. Along the top “Easy to do” and “Hard to do” are the options. Along the vertical axis there are two more options of “High Pay-off” and “Low Pay-off”. The combination for quadrant “A” would be “High Pay-off” and “Easy to do”. These choices are what people call the “low-hanging fruit”. Quadrant C would have a low pay-off, but would be easy to do. The QI Team could select any two items to replace “Pay-off” and “Easy or hard to do”. For example, they could consider time: Short time and long time to implement. They could select cost as one of the dimensions: For example, Reasonable cost ($2,000 and under) and High cost (Over $2,000). This decision matrix often works well for simpler decisions. However, when there are multiple factors and multiple options to consider the team will need to explore more dimensions before making a decision. Then the Selection Grid may be helpful. This 2x2 decision matrix table is a simple diagram for making choices. Along the top “Easy to do” and “Hard to do” are the options. Along the vertical axis there are two more options of “High Pay-off” and “Low Pay-off”. The combination for quadrant “A” would be “High Pay-off” and “Easy to do”. These choices are what people call the “low-hanging fruit”. Quadrant C would have a low pay-off, but would be easy to do. The QI Team could select any two items to replace “Pay-off” and “Easy or hard to do”. For example, they could consider time: Short time and long time to implement. They could select cost as one of the dimensions: For example, Reasonable cost ($2,000 and under) and High cost (Over $2,000). This decision matrix often works well for simpler decisions. However, when there are multiple factors and multiple options to consider the team will need to explore more dimensions before making a decision. Then the Selection Grid may be helpful.

28. 28 Selection Grid The selection grid can be quite straightforward or more challenging, depending on the needs of the team and the complexity of the issues surrounding the improvement. Shown here is a simplified selection grid. The team decides what are the criteria for selecting the best options and lists them across the top of the chart. It is best to limit the criteria to five or six. The more criteria that are listed the more confusing and complex the grid becomes. The options are listed along the left axis. The team then decides how to apply the criteria. This page shows a simple yes or no answer to the listed criteria. The team may choose a more complex system of weighting each criteria, for example: stating that “cost” is weighted more heavily than the “worthwhile” category. Or, the team may apply a scale of 1 through 5 to rate how well the option meets the criteria. The end result is that the team has narrowed the choices and perhaps chosen the best option to implement for the first cycle of PDSA. The selection grid may not give a clear cut answer. Remember to save the other ideas, as they may be good ideas if the first option does not turn out to be the best when tried in the clinical situation. The selection grid can be quite straightforward or more challenging, depending on the needs of the team and the complexity of the issues surrounding the improvement. Shown here is a simplified selection grid. The team decides what are the criteria for selecting the best options and lists them across the top of the chart. It is best to limit the criteria to five or six. The more criteria that are listed the more confusing and complex the grid becomes. The options are listed along the left axis. The team then decides how to apply the criteria. This page shows a simple yes or no answer to the listed criteria. The team may choose a more complex system of weighting each criteria, for example: stating that “cost” is weighted more heavily than the “worthwhile” category. Or, the team may apply a scale of 1 through 5 to rate how well the option meets the criteria. The end result is that the team has narrowed the choices and perhaps chosen the best option to implement for the first cycle of PDSA. The selection grid may not give a clear cut answer. Remember to save the other ideas, as they may be good ideas if the first option does not turn out to be the best when tried in the clinical situation.

29. 29 Multi-voting A group decision-making technique designed to reduce a large list of ideas to a manageable number. Benefits Eliminates peer pressure Equal participation Allows for consensus Gains “buy-in” among the team Another decision-making tool is multi-voting. Multi-voting helps the team narrow down ideas or come to a consensus when many options exist. Before beginning the multi-voting process, your team should determine whether financial or environmental constraints exist. For example, your team may have been given a limitation of $1,000 to apply toward a quality improvement initiative. This financial constraint would automatically remove any options that cost more. Another decision-making tool is multi-voting. Multi-voting helps the team narrow down ideas or come to a consensus when many options exist. Before beginning the multi-voting process, your team should determine whether financial or environmental constraints exist. For example, your team may have been given a limitation of $1,000 to apply toward a quality improvement initiative. This financial constraint would automatically remove any options that cost more.

30. 30 Multi-voting Steps List ideas or options on flip chart or chalk board Each team member votes for their top three choices Clarify among the team and eliminate choices with one or zero votes Each team member selects top two choices from the remaining list Repeat the process until the top one or two ideas have been selected The steps for multi-voting are noted here. After giving each idea a letter or number, team members select ideas by voting for their top three ideas from the list. The team clarifies the list and eliminates the items receiving only one or zero votes. The team then votes again by selecting from the ideas that remain on the list. This process is repeated until the top one or two ideas have been selected. Another elimination method for multi-voting is to limit the second and subsequent votes to the top 50% of those items receiving votes.The steps for multi-voting are noted here. After giving each idea a letter or number, team members select ideas by voting for their top three ideas from the list. The team clarifies the list and eliminates the items receiving only one or zero votes. The team then votes again by selecting from the ideas that remain on the list. This process is repeated until the top one or two ideas have been selected. Another elimination method for multi-voting is to limit the second and subsequent votes to the top 50% of those items receiving votes.

31. 31 Cost-benefit Analysis Determine the financial impact by comparing the costs and benefits Benefits Evaluates the cost of a change Supports decision-making Provides supporting documentation for QI team’s recommendation The cost benefit analysis estimates the financial costs of a change and is very helpful to the team in determining change options. Furthermore, it provides needed information to gain administrative support for the improvement. To prepare a brief cost-benefit analysis, use the following steps: Define the period of time for the analysis (usually one year) Brainstorm a list of cost factors (materials, personnel, training time, etc.) Determine the dollar value of each cost factor Total the costs for the recommended solution Brainstorm the benefits of the solution (saves time, decreases number of personnel, improves wait time, etc.) Determine the costs for each of the listed benefits Total the benefit costs Present the results as the cost-benefit ratio or cost/benefit Hints: Estimate costs a bit higher than expected and savings or benefits a bit lower than expected. Leave out (or place as an addendum) any costs or benefits for which there are no dollar estimates. Sometimes a solution may provide many benefits that cannot be measured in dollars. Some examples may be: customer satisfaction, machine preference, safety, reputation, etc. The cost benefit analysis estimates the financial costs of a change and is very helpful to the team in determining change options. Furthermore, it provides needed information to gain administrative support for the improvement. To prepare a brief cost-benefit analysis, use the following steps: Define the period of time for the analysis (usually one year) Brainstorm a list of cost factors (materials, personnel, training time, etc.) Determine the dollar value of each cost factor Total the costs for the recommended solution Brainstorm the benefits of the solution (saves time, decreases number of personnel, improves wait time, etc.) Determine the costs for each of the listed benefits Total the benefit costs Present the results as the cost-benefit ratio or cost/benefit Hints: Estimate costs a bit higher than expected and savings or benefits a bit lower than expected. Leave out (or place as an addendum) any costs or benefits for which there are no dollar estimates. Sometimes a solution may provide many benefits that cannot be measured in dollars. Some examples may be: customer satisfaction, machine preference, safety, reputation, etc.

32. 32 Force Field Analysis Identify and discuss forces that support or interfere with a change Benefits Identifies obstacles Lists supporting elements Suggests action steps The force field analysis is an excellent tool to evaluate the forces or things that are influencing the change in a positive or negative manner. The forces that assist or support the change are the driving forces. The forces that oppose or obstruct the change are the restraining forces. The forces are dynamic and some are stronger forces than others. Preparing this diagram allows the team to evaluate the impact of the forces and to develop a plan to increase the strength of the driving forces and decrease the influence of the restraining forces. Think of this as your dream trip to the Super Bowl and the battle of football teams. Or, deciding whether to go on a cruise in February. What are the forces encouraging you to go on a cruise (all inclusive cost, great food, sun, entertainment included, etc.)? What are the restraining or negative forces (costly, tendency toward motion sickness, cannot swim, etc.)? For a health care example, consider the forces that encourage patient care aides to continue working in a nursing home versus those causing them to seek other employment. Consider the driving and restraining forces for administering influenza immunizations to patients while they are in the hospital. The force field analysis is an excellent tool to evaluate the forces or things that are influencing the change in a positive or negative manner. The forces that assist or support the change are the driving forces. The forces that oppose or obstruct the change are the restraining forces. The forces are dynamic and some are stronger forces than others. Preparing this diagram allows the team to evaluate the impact of the forces and to develop a plan to increase the strength of the driving forces and decrease the influence of the restraining forces. Think of this as your dream trip to the Super Bowl and the battle of football teams. Or, deciding whether to go on a cruise in February. What are the forces encouraging you to go on a cruise (all inclusive cost, great food, sun, entertainment included, etc.)? What are the restraining or negative forces (costly, tendency toward motion sickness, cannot swim, etc.)? For a health care example, consider the forces that encourage patient care aides to continue working in a nursing home versus those causing them to seek other employment. Consider the driving and restraining forces for administering influenza immunizations to patients while they are in the hospital.

33. 33 Force Field Analysis This is a diagram for a Force Field Analysis. Note the current state and the desired state from your problem statement (page 15). The driving forces are trying to move things toward the desired state and the restraining forces are trying to maintain the status quo or current state. These are the classic “for and against”, positive and negative, or “yin and yang”. The team brainstorms a list of the driving forces (pushing toward the goal, like a football team on the offensive driving to reach the goal post) and then the restraining forces (like the opponents defending the goal). Sometimes the lines on the diagram for the driving and restraining forces are manipulated in length to reflect the strength of a driving or restraining force. Most driving and restraining forces in a work process relate to people, procedures, products, place (environment) etc., like the items discussed in the fishbone diagram (pages 22 to 24). The team then discusses what can be done to increase the strength of the driving forces and decrease the influence of the restraining forces. The goal is to “accentuate the positive and eliminate the negative” as some may recall from this old song. The outcome of these discussions becomes a part of the QI action plan (pages 37 to 41).This is a diagram for a Force Field Analysis. Note the current state and the desired state from your problem statement (page 15). The driving forces are trying to move things toward the desired state and the restraining forces are trying to maintain the status quo or current state. These are the classic “for and against”, positive and negative, or “yin and yang”. The team brainstorms a list of the driving forces (pushing toward the goal, like a football team on the offensive driving to reach the goal post) and then the restraining forces (like the opponents defending the goal). Sometimes the lines on the diagram for the driving and restraining forces are manipulated in length to reflect the strength of a driving or restraining force. Most driving and restraining forces in a work process relate to people, procedures, products, place (environment) etc., like the items discussed in the fishbone diagram (pages 22 to 24). The team then discusses what can be done to increase the strength of the driving forces and decrease the influence of the restraining forces. The goal is to “accentuate the positive and eliminate the negative” as some may recall from this old song. The outcome of these discussions becomes a part of the QI action plan (pages 37 to 41).

34. 34 Determine Measures How will we know that a change is an improvement? What are the data needs? Consider: Data collection methods Data analysis plan Accountable persons The next step in the Plan portion of PDSA is to plan for data needs. “The Model for Improvement” authors give us a third and final question to evaluate this, “How will we know that a change is an improvement?” (Langley, et al) If we do not make observations about the change we will not be sure that the change we made was a good change. All we will know is, that it is different. Measurement means collecting and aggregating data to evaluate the level of performance. There are many kinds of data that can give the QI Team information, such as: Ongoing data like the gas gauge in your car – or a patient’s hemoglobin A1c or number of patients in surgery each day Quantitative data uses numbers in measurement like number of patient falls or the rate of surgical infections, or the percentage of heart attack patients receiving aspirin on admission to the hospital Qualitative data describes the characteristics or traits, and may be a value or an attribute. Qualitative data usually uses words rather than numbers. The QI Team may decide to use before and after measures like: time to complete a process, number of people involved in a process, number of forms completed accurately, scores on tests, quality indicator rates, etc. They also need to determine who will collect the data, what type of data collection form will they use, when the data collection will occur, etc. The next step in the Plan portion of PDSA is to plan for data needs. “The Model for Improvement” authors give us a third and final question to evaluate this, “How will we know that a change is an improvement?” (Langley, et al) If we do not make observations about the change we will not be sure that the change we made was a good change. All we will know is, that it is different. Measurement means collecting and aggregating data to evaluate the level of performance. There are many kinds of data that can give the QI Team information, such as: Ongoing data like the gas gauge in your car – or a patient’s hemoglobin A1c or number of patients in surgery each day Quantitative data uses numbers in measurement like number of patient falls or the rate of surgical infections, or the percentage of heart attack patients receiving aspirin on admission to the hospital Qualitative data describes the characteristics or traits, and may be a value or an attribute. Qualitative data usually uses words rather than numbers. The QI Team may decide to use before and after measures like: time to complete a process, number of people involved in a process, number of forms completed accurately, scores on tests, quality indicator rates, etc. They also need to determine who will collect the data, what type of data collection form will they use, when the data collection will occur, etc.

35. 35 Check List A method to systematically record data from observations or historical sources Benefits Easy-to-use form Minimal data collector training Efficient and fast data collection Detects patterns and trends The check list is a simple data collection tool for recording data from observations or historical sources so patterns and trends can be easily shown and detected. The check list is an efficient way to manually collect data for measuring your process improvement change. Some examples of check lists for health care are: number of meals served, daily census, number of patients using a wheelchair or stretcher, number of laboratory tests for hemoglobin A1c and for cholesterol, etc. The check list is a simple data collection tool for recording data from observations or historical sources so patterns and trends can be easily shown and detected. The check list is an efficient way to manually collect data for measuring your process improvement change. Some examples of check lists for health care are: number of meals served, daily census, number of patients using a wheelchair or stretcher, number of laboratory tests for hemoglobin A1c and for cholesterol, etc.

36. 36 Check List Steps Decide on data to collect Clarify definitions Decide on time period for collection Select sample size Decide who will collect data Design and test the check list Distribute form and collect the data Tally and evaluate The first step involves deciding what data to collect and for what period of time. A sample size is determined and someone is identified to collect the data. The tool is designed and tested. Once these steps are accomplished, the check list is ready for use. A check list is a helpful tool for gathering data for identifying the problem, for developing a Pareto Diagram, and for evaluating the test or change. For our vacation analogy: Do you recall the travel games of listing the number of stop signs, railroad signs, police cars, trucks or convertibles? This game was a diversion that used a check list.The first step involves deciding what data to collect and for what period of time. A sample size is determined and someone is identified to collect the data. The tool is designed and tested. Once these steps are accomplished, the check list is ready for use. A check list is a helpful tool for gathering data for identifying the problem, for developing a Pareto Diagram, and for evaluating the test or change. For our vacation analogy: Do you recall the travel games of listing the number of stop signs, railroad signs, police cars, trucks or convertibles? This game was a diversion that used a check list.

37. 37 Develop Action Plan Brainstorm Force Field Analysis Political action plan Presentation The final step in the planning phase is to develop a detailed plan for the change or test. The QI Team must develop this plan and several tools are helpful in this task. This module has already presented brainstorming (pages 8 to 10) which provides ideas on how we can make the change happen. Also, the Force Field Analysis tells which driving forces we need to strengthen and which restraining forces will require our attention (pages 32 and 33). A political action plan is a technique which will assist the team in dealing with issues and people that may have been listed in the Force Field Analysis. Presentation skills will help each team member to be able to share an accurate and concise story about the project. Pages 39 and 40 will discuss these strategies.The final step in the planning phase is to develop a detailed plan for the change or test. The QI Team must develop this plan and several tools are helpful in this task. This module has already presented brainstorming (pages 8 to 10) which provides ideas on how we can make the change happen. Also, the Force Field Analysis tells which driving forces we need to strengthen and which restraining forces will require our attention (pages 32 and 33). A political action plan is a technique which will assist the team in dealing with issues and people that may have been listed in the Force Field Analysis. Presentation skills will help each team member to be able to share an accurate and concise story about the project. Pages 39 and 40 will discuss these strategies.

38. 38 Action Plan This is a sample Action Plan. The team first identifies the work to be done. From this list of work, the QI Team develops an implementation action plan that notes who is responsible for what activities during the test or change. Each team member needs to be involved and take accountability. The action plan should provide clear directions and identify targets and deadlines. These will help the team to check the progress and outcomes of the improvement project. If the QI Team has discussed possible barriers that may arise, and met with key stakeholders identified in the political action plan, then they will be more prepared for those “surprises” that always happen. This will facilitate rapid response and solutions to those barriers in the implementation phase. This sample plan may be useful in your QI journey. It identifies the goals, steps to be taken, accountable person, deadline, and monitoring. The monitoring section is an evaluation of how a particular step is progressing. This allows the team to discuss and adjust for problems or issues. There are other examples in books such as The Team Memory Jogger and The Team Handbook (see reference list page 49). This is a sample Action Plan. The team first identifies the work to be done. From this list of work, the QI Team develops an implementation action plan that notes who is responsible for what activities during the test or change. Each team member needs to be involved and take accountability. The action plan should provide clear directions and identify targets and deadlines. These will help the team to check the progress and outcomes of the improvement project. If the QI Team has discussed possible barriers that may arise, and met with key stakeholders identified in the political action plan, then they will be more prepared for those “surprises” that always happen. This will facilitate rapid response and solutions to those barriers in the implementation phase. This sample plan may be useful in your QI journey. It identifies the goals, steps to be taken, accountable person, deadline, and monitoring. The monitoring section is an evaluation of how a particular step is progressing. This allows the team to discuss and adjust for problems or issues. There are other examples in books such as The Team Memory Jogger and The Team Handbook (see reference list page 49).

39. 39 Political Action Plan A communication strategy designed to inform and gain support Benefits Share information Build support Receive feedback Build consensus Eliminate “surprises” A political action plan will help the team to share the project goals and strategies with key stakeholders, in order to gain support, build consensus, and receive feedback about the project. Key stakeholders are people who have the influence and power to help make the project a success or to derail or veto it. Some of the key stakeholders may have been listed during the Force Field Analysis exercise (pages 32 and 33). The steps to define a political action plan are to: Brainstorm who should be informed. Who are the key stakeholders? List what the team needs from each person on the list Plan and prepare the information to be shared Assign accountability for communications Meet with the key stakeholders to gain input and support Evaluate results and adjust accordingly Provide regular follow-up with key stakeholders A political action plan will help the team to share the project goals and strategies with key stakeholders, in order to gain support, build consensus, and receive feedback about the project. Key stakeholders are people who have the influence and power to help make the project a success or to derail or veto it. Some of the key stakeholders may have been listed during the Force Field Analysis exercise (pages 32 and 33). The steps to define a political action plan are to: Brainstorm who should be informed. Who are the key stakeholders? List what the team needs from each person on the list Plan and prepare the information to be shared Assign accountability for communications Meet with the key stakeholders to gain input and support Evaluate results and adjust accordingly Provide regular follow-up with key stakeholders

40. 40 Presentation A communication technique to share information and obtain feedback Benefits Deliver a consistent message Gain understanding Elicit support Teach and share Receive ideas This is a simple explanation of a topic that generates multiple books in your local library, interest and support groups like “Toastmasters, Inc.”, and produces great fear in many hearts. Yet, all team members need to be able to share the goals and plans of the QI project, and later the results. There are two techniques that should help allay some fear about what to say. The first is planning which makes the second, presenting, much easier. Planning requires that you know the project, which is not hard if you have been an active team member. Based on this knowledge, write an outline of the project using the problem statement, goals, implementation plan, data collection, and results. Having lived through all this QI process you are the experts on this project. Another outline format would be to use the three questions of The Model for Improvement. Developing a content outline that tells “What the team is trying to accomplish”, What changes are being made that will result in improvement” and “How the team will know that the change was an improvement”, will provide all the components needed for an overview, or a detailed explanation of the project. Sometimes the team will prepare project information materials together, so that all members are sharing the same important points This is a simple explanation of a topic that generates multiple books in your local library, interest and support groups like “Toastmasters, Inc.”, and produces great fear in many hearts. Yet, all team members need to be able to share the goals and plans of the QI project, and later the results. There are two techniques that should help allay some fear about what to say. The first is planning which makes the second, presenting, much easier. Planning requires that you know the project, which is not hard if you have been an active team member. Based on this knowledge, write an outline of the project using the problem statement, goals, implementation plan, data collection, and results. Having lived through all this QI process you are the experts on this project. Another outline format would be to use the three questions of The Model for Improvement. Developing a content outline that tells “What the team is trying to accomplish”, What changes are being made that will result in improvement” and “How the team will know that the change was an improvement”, will provide all the components needed for an overview, or a detailed explanation of the project. Sometimes the team will prepare project information materials together, so that all members are sharing the same important points

41. 41 Presentation Strategies Be prepared The three “tells” Use visual aids Storyboard Slides Diagrams, charts, and graphs Practice Presenting information in front of others can indeed be terrifying, but here are two excellent techniques to ease your fears: The “Three Tells” and “Use Visual Aids”. The three tells are: 1.) Tell them what you are going to talk about, 2) Tell them, and 3) Tell them what you told them. Some add a fourth, which is: Tell them “Thank you” for listening. The first should be only one to three sentences. The second “Tell” is where you share information about the project. This could be done using the previously listed outlines or simply repeating what happened during the teams PDSA cycles. The third Tell is a summary, which also should be only a couple sentences. The second technique is to use visual aids. These aids help you to remember the QI story and what to say about it. A storyboard is a poster that tells the QI story. You can walk through the pieces of information on the storyboard explaining the pictures, charts, diagrams, and highlighted points. In a more formal presentation it is helpful to use your content outline to prepare some materials similar to a slide presentation. Preparing talking points helps you to recall the key pieces of information to share. Practice is a third point that increases confidence. First talk to a mirror, then your family and friends or co-workers. Soon you will be able to do a group presentation with confidence. The MPRO SIM on “Presentation Skills” offers many helpful ideas on preparing and sharing a presentation (www.mpro.org/continuing education).Presenting information in front of others can indeed be terrifying, but here are two excellent techniques to ease your fears: The “Three Tells” and “Use Visual Aids”. The three tells are: 1.) Tell them what you are going to talk about, 2) Tell them, and 3) Tell them what you told them. Some add a fourth, which is: Tell them “Thank you” for listening. The first should be only one to three sentences. The second “Tell” is where you share information about the project. This could be done using the previously listed outlines or simply repeating what happened during the teams PDSA cycles. The third Tell is a summary, which also should be only a couple sentences. The second technique is to use visual aids. These aids help you to remember the QI story and what to say about it. A storyboard is a poster that tells the QI story. You can walk through the pieces of information on the storyboard explaining the pictures, charts, diagrams, and highlighted points. In a more formal presentation it is helpful to use your content outline to prepare some materials similar to a slide presentation. Preparing talking points helps you to recall the key pieces of information to share. Practice is a third point that increases confidence. First talk to a mirror, then your family and friends or co-workers. Soon you will be able to do a group presentation with confidence. The MPRO SIM on “Presentation Skills” offers many helpful ideas on preparing and sharing a presentation (www.mpro.org/continuing education).

42. 42 Continuous Quality Improvement The D is for the Do phase of the PDSA quality improvement cycle. This is when the “rubber meets the road” and the project test or change begins. Here the team needs to follow the detailed action plan that they developed, and collect the data using the tested data collection forms. It is helpful to have some of the team members present at the test site during the pilot to assist the implementation staff with immediate issues, to make sure data collection is occurring, and to gather any observations about the progress of the change project. The D is for the Do phase of the PDSA quality improvement cycle. This is when the “rubber meets the road” and the project test or change begins. Here the team needs to follow the detailed action plan that they developed, and collect the data using the tested data collection forms. It is helpful to have some of the team members present at the test site during the pilot to assist the implementation staff with immediate issues, to make sure data collection is occurring, and to gather any observations about the progress of the change project.

43. 43 Continuous Quality Improvement The S is for Study. In this part of the PDSA cycle, the team will examine and evaluate the data to determine what was learned from the test or change. The team will consider what happened during the implementation: Evaluate any crisis or large problem Assess the positives and the negatives of the implementation plan Note any large barriers Take a look at the data: Did the collection form work well? Is there sufficient information? What does the data tell about the change? Did the change result in improvement?, etc. Analyzing and displaying the data gathered in the do phase is very important. This section of the module will briefly discuss how data may be displayed using a pie chart, bar chart, and a run chart. The S is for Study. In this part of the PDSA cycle, the team will examine and evaluate the data to determine what was learned from the test or change. The team will consider what happened during the implementation: Evaluate any crisis or large problem Assess the positives and the negatives of the implementation plan Note any large barriers Take a look at the data: Did the collection form work well? Is there sufficient information? What does the data tell about the change? Did the change result in improvement?, etc. Analyzing and displaying the data gathered in the do phase is very important. This section of the module will briefly discuss how data may be displayed using a pie chart, bar chart, and a run chart.

44. 44 Pie Chart A picture depicting parts of the whole Benefits Easily understood Draws interest Good visual A pie chart is just what it sounds like: a pie. Different size slices of the pie depict (or represent) the percentage for each category of the whole pie. In the picture above, imagine that we are reporting the number of patient falls. Red could be the 25% percent of falls due to slippery floors, orange could be the 25% of falls due to tripping, blue could be the 25% of falls due to not using walking aids (crutches, cane, walker, etc.), white could be the 12.5% of falls due to unknown causes, and grey the 12.5% of falls due to stairways. Usually the percentages are noted on the slice of the pie or with an arrow pointing to the slice. A pie chart is easily understood. A pie chart is just what it sounds like: a pie. Different size slices of the pie depict (or represent) the percentage for each category of the whole pie. In the picture above, imagine that we are reporting the number of patient falls. Red could be the 25% percent of falls due to slippery floors, orange could be the 25% of falls due to tripping, blue could be the 25% of falls due to not using walking aids (crutches, cane, walker, etc.), white could be the 12.5% of falls due to unknown causes, and grey the 12.5% of falls due to stairways. Usually the percentages are noted on the slice of the pie or with an arrow pointing to the slice. A pie chart is easily understood.

45. 45 Bar Chart: Aspirin at Arrival for AMI Patients A bar graph displays comparisons, with each bar representing the number or volume of the item listed in that category. The Pareto Diagram on page 14 is an example of a bar chart. This graph shows the percentage of patients with an AMI (acute myocardial infarction) who received aspirin within 24 hours of arrival at a hospital. The distinct groups of data are identified on the horizontal or X axis, and the percent is listed on the vertical or Y axis. The use of different colors makes the three groups stand out as unique. A bar graph displays comparisons, with each bar representing the number or volume of the item listed in that category. The Pareto Diagram on page 14 is an example of a bar chart. This graph shows the percentage of patients with an AMI (acute myocardial infarction) who received aspirin within 24 hours of arrival at a hospital. The distinct groups of data are identified on the horizontal or X axis, and the percent is listed on the vertical or Y axis. The use of different colors makes the three groups stand out as unique.

46. 46 Run Chart A run chart provides a picture of data over a period of time. Each point on the graph tells the measurement at a specific time, and these points are connected by lines. The visual effect of a graph allows the QI Team to readily identify a pattern or trend, thus is often called a line graph or a trend chart. The run chart can demonstrate the difference of a measure before and after a change is implemented. It is helpful to place a note on the chart when a specific intervention occurred. This is called an annotated chart. In this example, we can see that a new flow sheet was used in the physician office in September, and that the percent of foot exams increased after the new flow sheet was implemented. A travel example for a run chart would be to place each hour of driving time along the X axis (horizontal line) and report the number of miles traveled each hour. Note the time spent for lunch or for a tourist attraction to explain changes. A statistical process control (SPC) chart is a sophisticated run chart that shows statistically calculated specific measurement lines above and below the average. This type of chart is used to evaluate whether or not a process is demonstrating normal variation. All processes have some variation … things are not always the same, but are usually within a “normal” range. For example, your average body temperature is near 98.2º F. If you check your temperature six times a day it will vary a little from your average of 98.2º F. However, if you develop bacterial pneumonia, your temperature will likely be much higher, above the normal upper limit for your temperature. A QI Team would need someone with experience in SPC charts to calculate and prepare an SPC chart for their process.A run chart provides a picture of data over a period of time. Each point on the graph tells the measurement at a specific time, and these points are connected by lines. The visual effect of a graph allows the QI Team to readily identify a pattern or trend, thus is often called a line graph or a trend chart. The run chart can demonstrate the difference of a measure before and after a change is implemented. It is helpful to place a note on the chart when a specific intervention occurred. This is called an annotated chart. In this example, we can see that a new flow sheet was used in the physician office in September, and that the percent of foot exams increased after the new flow sheet was implemented. A travel example for a run chart would be to place each hour of driving time along the X axis (horizontal line) and report the number of miles traveled each hour. Note the time spent for lunch or for a tourist attraction to explain changes. A statistical process control (SPC) chart is a sophisticated run chart that shows statistically calculated specific measurement lines above and below the average. This type of chart is used to evaluate whether or not a process is demonstrating normal variation. All processes have some variation … things are not always the same, but are usually within a “normal” range. For example, your average body temperature is near 98.2º F. If you check your temperature six times a day it will vary a little from your average of 98.2º F. However, if you develop bacterial pneumonia, your temperature will likely be much higher, above the normal upper limit for your temperature. A QI Team would need someone with experience in SPC charts to calculate and prepare an SPC chart for their process.

47. 47 Continuous Quality Improvement The A is for Act. This is the final step in the PDSA cycle. Here the team decides the next steps for the project: to adopt, adapt (alter), or abandon the change. If the choice is to adopt the change and monitor the process, the team would continue to gather data and monitor the results in order to hold the gains and keep the process operating. The QI Team would pay attention to potential problems by looking for special variations in the process. If the choice is to adapt or alter the change, then the next PDSA cycle can be much quicker and more efficient, because the team already has baseline information and additional knowledge gained from the previous test. If the only option is to abandon this change and start fresh with a new PDSA cycle, the team has gained new knowledge with this test and has already listed several change options that were not tried yet. For more detailed information on the PDSA cycle, please visit the Quality Improvement with PDSA self-instructional module on the MPRO Web (www.mpro.org). The A is for Act. This is the final step in the PDSA cycle. Here the team decides the next steps for the project: to adopt, adapt (alter), or abandon the change. If the choice is to adopt the change and monitor the process, the team would continue to gather data and monitor the results in order to hold the gains and keep the process operating. The QI Team would pay attention to potential problems by looking for special variations in the process. If the choice is to adapt or alter the change, then the next PDSA cycle can be much quicker and more efficient, because the team already has baseline information and additional knowledge gained from the previous test. If the only option is to abandon this change and start fresh with a new PDSA cycle, the team has gained new knowledge with this test and has already listed several change options that were not tried yet. For more detailed information on the PDSA cycle, please visit the Quality Improvement with PDSA self-instructional module on the MPRO Web (www.mpro.org).

48. 48 May your QI journey be fun, interesting, and successful! We hope that this module has provided some helpful tools for you in your QI journey. This was a brief introduction to some of the many tools and techniques that can make traveling the QI road interesting and successful. There are several references listed on the next two pages that may be helpful and offer more detailed information. We hope that this module has provided some helpful tools for you in your QI journey. This was a brief introduction to some of the many tools and techniques that can make traveling the QI road interesting and successful. There are several references listed on the next two pages that may be helpful and offer more detailed information.

49. 49 QI References Brassard M, Ritter D. The Memory Jogger II. GOAL/QPC, Methuen, MA, 1994. Brassard M, Joiner BL. The Team Memory Jogger. GOAL/QPC and Joiner Associates Inc, Methuen, MA, 1995. Langley GJ, Nolan KM, Nolan TW, Norman CL, and Provost LP. The Improvement Guide. Jossey-Bass Publishers, San Francisco, 1996. Scholtes PR. The Team Handbook. Joiner Associates, Inc. Madison, WI. 1988. You may find these references helpful in your quality improvement work.You may find these references helpful in your quality improvement work.

50. 50 Creativity References DeBono E. Serious Creativity. New York: Harper Collins, 1993. Higgens JM, 101 Creative Problem Solving Techniques, Winter Park, FL: New Management Publishing Company, 1994. Plsek PE, Creativity, Innovation, and Quality. Milwaukee, WI: ASQC Quality Press, 1997. Van Oech R, A Whack on the Side of the Head. New York: Warner Books, 1983. You may find these references helpful in your quality improvement work.You may find these references helpful in your quality improvement work.

51. 51 Continuing Education (CE) Contact Hours Answer the post test questions Minimum passing score = 76% Minimum correct answers = 19/25 Complete the evaluation Print your certificate Thank You for Reading This SIM Now that you have completed reading the “Quality Improvement Tools and Techniques: 2007” SIM, you may proceed to take the Post Test. There are 25 questions in the post test. You must answer 19 of the questions correctly to achieve a passing grade. If you do not pass the test the first time, you have the option of reviewing the module and taking the post test again. After successfully passing the post test, and completing the evaluation, you will be able to print a certificate.   If you have difficulty with this SIM, please contact the MPRO helpdesk at (248) 465-7450. If you have any questions regarding the continuing education contact hours, please contact Carol Grubba at (248) 465-7337 or cgrubba@mpro.org Now that you have completed reading the “Quality Improvement Tools and Techniques: 2007” SIM, you may proceed to take the Post Test. There are 25 questions in the post test. You must answer 19 of the questions correctly to achieve a passing grade. If you do not pass the test the first time, you have the option of reviewing the module and taking the post test again. After successfully passing the post test, and completing the evaluation, you will be able to print a certificate.   If you have difficulty with this SIM, please contact the MPRO helpdesk at (248) 465-7450. If you have any questions regarding the continuing education contact hours, please contact Carol Grubba at (248) 465-7337 or cgrubba@mpro.org

52. 52 Additional Information Patricia L. Baker RN, MS Director, Staff Development 248-465-7324 pbaker@mpro.org Carol J. Grubba, RN, MSN, BC Project Manager, Continuing Education 248-465-7337 cgrubba@mpro.org For additional information about MPRO QI materials and services, please contact Patricia Baker or Carol Grubba. For additional information about MPRO QI materials and services, please contact Patricia Baker or Carol Grubba.

53. 53 7SOW-MI-CE-05-05