Basic QI Tools & Techniques

1. Basic QI Tools & Techniques

2. Why QI? • By continually working to improve all processes, we increase our learning and knowledge. • QI is not about pass/fail or right/wrong. Rather it’s about testing a theory. You have a learning opportunity.

3. Basic Tools of QI • Effect/Cause Analysis • 5 Why’s • Fishbone • Pareto Chart • Brainstorming • Interrelationship Diagraph • Evaluation & Decision-Making • SWOT Analysis • Evidence-based Literature • Stakeholder Analysis • Force Field Analysis • Nominal Group Technique • PMI • Logic Model • Planning & Implementation • PDCA/PDSA • Bone Diagram • Action Plans • Data collection • Check Sheet • Survey Tool / Interviews • Nat’l, State, Local stat’s • Data Analysis • Pie Charts • Bar Graph • Pareto Chart • Line Graph • Process Analysis • Flow Charts – Process Mapping • 5 Why’s • Idea Creation • Affinity Diagram • Brainstorming • Fishbone Diagram

4. Stage 1Step #1 - Getting StartedDescribe the Situation • Writing about the Situation • What’s the issue? • Why is this a issue? • For whom does the issue exist? • Who has a stake in the issue? • What do we know about the issue/people involved? • What do existing research and experience tell us about the issue?

5. Example #1

6. Stage 1Step #1 - Getting StartedDescribe the Situation • An invading enemy sought to overthrow the kingdom. During the fierce battle the kingdom’s well trained warriors mounted their warhorses to fight the enemy. All in the kingdom were confident they would be victorious as the enemy forces were outnumbered. Ultimately, not all warriors got “deployed” and in the end - • THE KINGDOM WAS LOST.

7. Stage 1Step #2 - Assemble the Team No one person understands the entire system. One cannot change one part of a process without influencing other parts in some ways.

8. Stage 1Focus on defining the problem(s) / improvement needed • Define the issues(s) before attempting to fix something • What’s important? • What’s broken / Needs improvement? • Where is the “Mother Lode?” (high volume, high profile, problem-prone)

9. Stage 1Define the Issue “The kingdom was lost.” What’s important? “Reduce the likelihood the kingdom can be taken again” What’s broken? Needs improvement? Not enough warriors were “deployed”

10. Stage 1Define the Issue “The kingdom was lost.” What’s important? “Reduce the likelihood the kingdom can be taken again” What’s broken? Needs improvement? Not enough warriors were “deployed” Where’s the “Mother Lode?” (high volume, high profile, problem prone)

11. Stage 1Step #3 - Examine Current Process/Approach May need to interview staff, external partners Make a process flow chart Check for efficiency, duplicative steps, missed steps, steps needed

12. Stage 1Step #3 - Examine Current Process/Approach “For want of a nail the shoe was lost For want of a shoe the horse was lost For want of a horse the warrior was lost For want of a warrior the battle was lost For want of a battle the kingdom was lost All for the want of a nail.”

13. Leverage the 5-Whys Basically, the five-why analysis is a fundamental approach of thinking, based on the logical linkage of elements into a root cause analysis. It is a tool that works with ideas/concepts With each specific answer, repeat the question up to five times and you will typically end up with a rather solid root cause. For each answer, look at WHO is involved

14. Leveraging the 5-Whys Lost the kingdom Lost the battle Why? Not enough warriors Why? Not enough horses Why? Horses were not shod Why? Not enough nails Why? Root Cause

15. Leveraging the 5-Whys The therefore test has proven to be a very reliable method to check the logic of the five-why analysis. To do the therefore test, you read the key findings of the analysis in reverse and insert the word therefore between each step.

16. Leveraging the 5-Whys Result Lost the kingdom Therefore Lost the battle Why? Therefore Not enough warriors Why? Therefore Not enough horses Why? Therefore Horses were not shod Why? Therefore Not enough nails Start Why? Root Cause

17. Stage 1Define the Issue “The kingdom was lost.” What’s important? “Reduce the likelihood the kingdom can be taken again.” What’s broken? Needs improvement? Not enough warriors mounted on warhorses Where’s the “Mother Lode?” Not enough nails to shod all the warhorses

18. Problem Statement • Not enough nails to shod all the warhorses. Analyze the Problem • Root cause - • Brainstorming 6-3-5 • Affinity Diagram • Fishbone Diagram – all possible causes

19. Fishbone Diagram Main Cause 2 Main Cause 1 Minor Cause Minor Cause Minor Cause Minor Cause influence influence Minor Cause Minor Cause Not enough nails to shod all the warhorses Minor Cause Minor Cause Minor Cause Minor Cause Minor Cause influence influence Minor Cause influence Minor Cause influence Main Cause 1 Main Cause 1 Main Cause 1

20. Stage 1Step #4 - Potential Solutions • Avoid making your first QI effort a large-scale project. • Solving issues is usually easiest when you focus on decreasing/reducing the “negative” driving forces rather than increasing the “positive” driving forces.

21. “Expand-Focus Sequence” POSSIBLE PROBLEMS Expand Focus PROBLEM DEFINED POSSIBLE CAUSES Expand Focus ROOT CAUSE IDENTIFIED POSSIBLE SOLUTIONS Expand Focus SOLUTION CHOSEN TO TEST

22. Imposing a Change • Before imposing a change, begin by asking three key questions: • What are you trying to accomplish? • How will you know that a change is an improvement? • What changes can you make that will result in an improvement? • Define changes you believe will achieve your goal • Countermeasures

23. Stage 1Step #5 - Develop an Improvement Theory • Make a prediction – How will you know that a change is improvement? (Measurement is essential!) • Plan • What • Where • Who • How • When – timeline

24. Stage 2Step #6 - Test the Theory • Just Do It!!!! • Carry out the plan • During the process collect, chart, and display data to determine efficiency. • Document problems, unexpected observations

25. Stage 3Step #7 - Study the Results • Based on measurements • What worked? • What didn’t work?

26. Stage 4Step #8 - ACT • Sustain if improvement • Monitor • Develop new theory • If successful, plan another cycle to test it on a larger scale or under different conditions • If unsuccessful, test a different theory

27. Stage 4Step #9 - Establish Future Plans • Recognize, review, refocus your efforts • What went right? • Where can we apply what we’ve learned? • What’s next?

28. 9 Steps of Improvement • Focus • Improve • Sustain • Honor Plan – Do – Study – Act

29. Describe Situation Collect supportive data -Surveys / Interviews -Nat’l, State, Local stat’s Assemble Team Develop aim statement -What’s important? -What’s broken/needs improvement? -Where’s the Mother Lode? Define problem(s) / improvement needed -Flow Charts -5 Why’s Examine Current Process -Fishbone -Brainstorming -5 Why’s -Affinity Diagram -Pareto chart Analyze the problem -SWOT Analysis -CIC Analysis -Stakeholder Analysis -Force Field Analysis -Bone Diagram Decide on potential solutions PDSA Cycles -Develop theory -Test improvement theory -Study Results -ACT -CELEBRATE! STAGE 1 CQI -Logic Model -Flow charts -Survey’s -Pareto chart -Line graph -Include qualitative information -Check sheets -Standardization -Flow charts -Documentation -Training STAGE 2 STAGE 3 STAGE 4

30. Example #2 “QI Feud”

31. Stage 1Step #1 - Getting StartedDescribe the Situation During the last 5 months of the year there has been a increase in errors in paychecks

33. Stage 1Step #2 – Assemble the Team

34. Define the Problem / Improvement Needed “Errors in paychecks.” What’s important? “Reduce errors” What’s Broken? Needs Improvement? Printed checks Where’s the “Mother Lode?”

35. Stage 1Step #3 – Examine Current Process/Approach • Printed Checks

36. Where’s the “Mother Lode”?

37. Defining the Problem “Errors in paychecks.” What’s important? “Reduce errors” What’s broken? Printed checks Where’s the “Mother Lode?” Time codes

38. Problem Statement During the first five months of the year, time code errors accounted for 47% of all incorrect printed paychecks, which was 2X higher than the next highest contributor (non-printed).

39. All Possible Causes

40. Next Steps • Step #4 - Potential Solutions

41. “Expand-Focus Sequence” POSSIBLE PROBLEMS Expand Focus PROBLEM DEFINED POSSIBLE CAUSES Expand Focus ROOT CAUSE IDENTIFIED POSSIBLE SOLUTIONS Expand Focus SOLUTION CHOSEN TO TEST

42. Next Steps – Impose a Change • Step #5 - Develop Improvement Theory • Target – 50% reduction in time code errors by 6/1/09 • Step #6 – Do • Test the Theory • Step #7 – Study • The Results • Step #8 – Act • Step #9 – Honor • CELEBRATE!!!

43. Improvement

44. Example #3

45. Stage 1 Step #1 - Getting StartedThe Situation “It appears (staff observations)” WIC clients are not keeping scheduled appointments

46. Collect supportive data

47. Stage 1Step #2 – Assemble the Team Nurses Dietitians Clerks

48. Stage 1Defining the Problem “WIC no-show rates.” What’s important? “Reduce no-show rates.” What’s broken / Needs improvement? FU Appts” Where’s the Mother Lode?

49. Stage 1Step #3 – Examine Current Process/Approach • Scheduling FU Appointments

50. Collect supportive data