Indiana Quality Improvement

1. Indiana Quality Improvement Solving Problems, Elevating Quality in Public Health QI Coach’s Handbook

2. QI Coach Coordinators • Contact Information: • Sue Hancock • 317-234-1648 • shancock@isdh.in.gov • Sarah Strawbridge • 317-233-7371 • sstrawbridge@isdh.in.gov

3. Module 1 QI Basics

4. Why QI? • The goals are to benefit: • Employees involved in work processes, making the work easier. • Our organization, through more efficient or effective work activities. • The customers of our work, who must use what we produce. Kelly, 1992

5. Where did QI come from? • Grandfather of QI: W. Edwards Deming • Statistician and professor by trade, consulted with American companies during WW II on production issues. • Post world-war II: Worked with Japanese companies to rebuild. They embraced his techniques. • Believed that the goal of business should not be just to make profits, but to stay in business so they could provide jobs.

6. W Edwards Deming • Has been called a “curmudgeon” for his critical workshop tactics. • In reality, he sympathized with the plight of workers. • A short story… • Deming’s 14 Points

7. QI Assumptions • Workers want to perform well on the job, take pride in their work. • Workers’ performance more often related to faulty systems than employee error. • Jurran’s Principle: “85%-15% Rule” • Management/leadership generally makes decisions about systems. • Data is needed to make good system decisions.

8. What do we get from QI? • Improves our job satisfaction – we know our product or service is quality, a source of pride. • Reinforces the belief that we can solve problems, make a difference in our jobs • We have a greater investment, ownership for our work. • We have less tolerance for problems and poor quality.

9. QI Basics Improving quality is a systematic process: • PLAN: Define the problem, collect data, select a possible solution. • DO: Implement solution on a small scale. • CHECK: Collect data, determine if the solution worked. If not, go back to Plan and select another solution. • ACT: When a solution works, spread to all aspects of the operation.

10. Five-Step Problem Solving Model Quality improvement can also be described as a systematic problem-solving model: 1. Identify the problem – clearly state what needs improvement. 2. Analyze the problem – Determine what causes problem to occur. 3. Evaluate alternatives – Identify and select actions to reduce or eliminate the problem. 4. Test/implement a solution – Implement these actions on a trial basis to determine effectiveness. 5. Standardize – Ensure that useful actions are preserved.

11. Module 2 Working Together as a Team

12. Working Together as a Team • Team Roles: • Team members share their expertise to plan and implement project work. • The Leader orchestrates team activities, maintains records, serves as communication link with rest of the organization. • The Coach understands the tools and concepts of improvement, including approaches that help a team function well together. • The Sponsor reviews and supports team efforts, interfaces with other parts of the organization.

13. Effective Team Members… • Participate fully in team meetings • Share knowledge and experience, listen closely to that of other team members • Are open to new ideas • Carry out assignments between meetings • Assist leader with managing the meetings, e.g. documentation, discussions. • Communicate effectively with colleagues about project work.

14. An Effective Leader… • Organizes the team’s work and activities • Focuses on a data-based methods to solve the problem • Serves as contact point for communication between the team, sponsor, others in organization • Keeps official team records, e.g. meeting minutes, agendas, data related to project. • Assists with carrying out work between meetings • Implements project-driven changes within his or her authority • Helps team resolve its problems

15. An Effective Coach… • Attends meetings but not is a leader or member; an outsider who maintains a neutral position. • Assists team in structuring or breaking down tasks and plans into assignments • Works with team leader to plan meetings • Assists leader with team building • Teaches data collection, analysis techniques; helps team graphically display data • Helps team prepare for presentation of project to management, others

16. An Effective Sponsor… • Maintains overall responsibility, authority and accountability for project • Approves “bubble-up projects,” assures compatibility with organizational priorities • Sometimes initiates project, begins charter, selects leader, coach and members • Approves resources for project • Interfaces with rest of the organization to assure appropriate stakeholder involvement • Feeds data and lessons learned into a system for future improvements, e.g. policy changes

17. Reality Check • Is everybody clear about the roles? • Does everyone have a role? • Are the leader, coach, sponsor roles filled? If not, what is the plan? • Next Step: What’s our problem?

18. Module 3 Identifying the Problem

19. QI Toolkit: Identifying Problems • Brainstorming – generating a list of potential problems • Interviews or surveys - customer feedback, recommendations • List reduction - narrowing the list to a few items, by combining into groups • Problem selection matrix

20. QI Toolkit - Brainstorming Collect a large number of ideas from a group of people. Many ideas, quickly as possible. • One-at-a-time (everyone speaks) • Open door (call out ideas) • Write-it-down (confidentiality) Guidelines: • Be creative • Build on ideas of others • No critique allowed

21. QI Toolkit – Interviews, Surveys Interviews: • Purpose: Collect data from direct conversation. Surveys: • Purpose: Collect data from • a large number of people.

22. QI Toolkit – List Reduction • Purpose: Reduce a large list of items to a manageable size. • Useful in conjunction with brainstorming. • Group votes for the most important items on list (can cast as many votes as they want). • Items with the most votes are circled. • If further narrowing is required, process conducted again, limiting number of votes people can cast.

23. QI Toolkit: Selection Matrix

24. What’s Our Problem? A little history… • When did we notice the problem? • Was there anything else going on when we noticed it? • Have other solutions been tried in the past? • If so, what happened?

25. What’s Our Problem? Zooming in on the current state: • What exactly is happening? • When is it happening? • Where is it happening? • Who is involved?

26. What’s Our Problem? Zooming in on the future (or desired) state: • What should be happening? • When should it happen? • Where should it happen? • Who should make it happen?

27. Current and Future State • Future State: • What are the important aspects of • the future state? • What is driving us to this future state? • What might be the consequences of • not moving to the future state? • What might change? • What is the proposed timeline? • Current State • What is the current state? • Why is this important? • What is it costing us time/dollars/staff/etc? • What is the impact on our customer/clients? • What is the impact on our division/agency? • Driving Forces: Pathway • Consequences • Benefits

28. QI Toolkit - Force Field Analysis

29. QI Toolkit – Flowchart Where is the process breaking down? RFFlow Professional Flowcharting, http://www.rff.com/flowchart_samples.htm

30. Draft a Problem Statement • A good problem statement should be: • Specific. • Describes the problem, not the symptom. • Relates the current situation to what is desired. • Does not include causes or solutions

31. Expressing Need for Improvement in Measurable Terms Two-Step Process: • Gathering information (data) about the problem. • Tool utilized: Checksheet • Organizing data so that it is meaningful and clarifies the problem. • Tools utilized: Line graphs, Pareto charts, Histograms, Bar and Pie charts.

32. QI Toolkit: Checksheet Purpose: Collect data in an organized manner. Telephone Interruptions Excerpted from Nancy R. Tague’sThe Quality Toolbox, Second Edition, ASQ Quality Press, 2004, pages 141-142.

33. QI Toolkit: Line Graph Purpose: Display the output of a process over time.

34. QI Toolkit: Pareto Chart Purpose: Arrange data so that the most significant element in a set of elements is easily identifiable. Diagram courtesy of Six Sigma http://www.isixsigma.com/offsite.asp?A=Fr&Url=http://www.skymark.com/resources/tools/pareto_charts.htm

35. QI Toolkit: Histogram Purpose: Determine how data are distributed.

36. QI Toolkit: Bar Chart Purpose: Arrange data for quick and easy comparison.

37. QI Toolkit: Pie Chart Purpose: Display the volume or quantity of one item in relation to others.

38. Check Problem Statement Did data validate the original problem statement? • If not, revise and collect more data. • If it did, refine the problem statement so that it is: • Specific. • Describes the problem, not the symptom. • Relates the current situation to what is desired. • Does not include causes or solutions

39. Establish Interim Target, Date • Targets should be: • Intermediate and long term • Quantitatively expressed • Aggressive • Changed as the situation changes • Example: This project aims to reduce the number of days it takes to process a payment voucher from 10 working days to 2 by December 31, 2010.

40. Module 4 Analyze the Problem

41. Identify the Root Cause(s) • If the cause is removed, the problem should be at least partially removed. • A symptom is not a cause; a symptom is evidence the problem exists. • Several root causes may contribute to the problem; it is important to examine all. • QI Tools for establishing root cause(s): Brainstorming, Flowcharts, Cause and Effect Diagrams, 5 Why’s.

42. QI Toolkit: Cause and Effect Diagram Purpose: Identify a set of related causes that lead to an effect or problem.

43. QI Toolkit: 5 Why’s

44. Verify Cause by Collecting Data • QI Toolkit - Data collection and analysis: • Checksheet • Root Cause Evaluation Matrix • Histogram • Bar Chart • Pareto Chart

45. Root Cause Evaluation Matrix

46. Guidelines for Data Collection • Establish the purpose for collecting data – helps you target your efforts, collect only what is needed. • Determine if indicators are reliable – What is the source of data? Are measuring practices consistent and accurate? • Track all data needed – collect enough to conduct a thorough analysis. • Record data carefully – Use a checksheet that is logical and makes collection easy.

47. Select Root Cause(s) Most Responsible • Example: Investigating delay associated with processing credit card applications, data could be grouped into the following categories: • No signature • No Address • Cannot read • Current customer • Other

48. Module 5 Evaluate Alternate Solutions

49. Developing Alternatives QI Toolkit: Brainstorming, interviews, survey, research (have others solved this problem?) Guidelines: • Be creative, identify as many potential solutions as possible. • Don’t be limited by the current practice (i.e. “That’s the way we’ve always done it. • Refrain from judging team members’ suggestions.

50. Evaluating Alternatives • Effective? (Tried before? With what results? Will it solve the problem? Achieve improvement target?) • Feasible? (Is it doable? Practical?) • Timely? (How long will it take? Long term or short term? Can we afford to wait?) • Customer-oriented? (Will it improve service quality? Satisfy customer identified requirements?) • Efficient? (Is it cost effective?)