Steps in QI Step 1: Identifying a problem, forming a team and writing an aim statement Step 2: Analyzing the problem and measuring quality of care Step 3: Developing and testing changes Step 4: Sustaining improvement

Step 2 Learning objectives You will learn Tools for understanding processes and systems of healthcare and how to use them How these tools can help identify possible solutions to reach your aim How to choose indicators for process and outcome How to use indicators to track progress and improvement I would be discussing about the aspects of understanding processes and systems of healthcare. How the systems underlying healthcare affect the delivery of care and how these tools lead to identification of possible solutions to reach your aim

“Business of Management” Quality Improvement “Business of Management” in Medicine I have been thinking about why I am here in the first place. If we reflect QI is not a new concept . It is ingrained in each and everyone of us . Simply put it is an attempt to do things in a better way than we already are doing. As doctors we just think as an individual doing our best to give the best to the patient but sometimes things are not that simple and when we get down the business of management in medicine that is what I would call a QI

This is a classic concept in QI This is a classic concept in QI . We are what we repeatedly do and expecting to get diffrenet results by doing the same processes simply defies logic. These tools will help us in analysisng problems by looking at a system centric rather than just a people centrric approach

Before we go on to discuss the actual tools it is important to understand that success of an organisation or healthcare delivery in our case depends on a cohesive system. A boat doesn’t sink on one end .. Sooner or later the entire system gets afftected

SEVEN QUALITY TOOLS Cause and Effect Diagrams Flow Charts Checksheets Histograms Pareto Charts Control Charts Scatter Diagrams The tools that we would be talking about are like putting in bold letters our subconcious behaviour. Man by nature is a perfectionaist. Each and every act that we do today is a learning ground for how to do it better next time. Whther it’s a surgery or a perticular treatment or even a recipe. We all learn and try to do it better… but when there are complex processes involved we need to organise it better Some of the commonly used tools are: Cause and Effect Diagrams Flow Charts Checksheets Histograms Pareto Charts Control Charts Scatter Diagrams

Step 2: Analyzing and measuring quality of care Cause & effect Why might a problem be happening? Get to the root cause of the quality issue (4P’s) People Places Procedures (practices) Policies anything else Lets talk about the cause and effect diagram . Also called the fish bone or the ishikawa chart. Think about why a problem might be happening ? It can be attributed to the issues of the people involved , or the place , policies or procedures. So it like sieving through the problems to categorise them and bring them in order.

Thank you So let’s breakdown each of the problem into bite sized problems which can be easier to address

1. Fishbone Get to the root cause of the quality issue(4P’s) v Policy People Major influence Minor influence Problem PPPP Making this interesting diagram of a fishbone with the problem at its head and the 4Ps as its major influences. Each of the minor influences can be charted under the respective subheading. This technique really puts things in perspective to identify what we can really address as intervention to bring about a change Major influence Minor influence Procedure Place

Establishing Skin to Skin Contact after delivery

When the “Why s” give you the “What” (..needs to be done?) Curiosity killed the cat? You could be a child again ! The next tool that we will discuss is the 5 why’s . This tool brings back the basic instincts of being a child again. If we keep asking the WHYS we will get to know what needs to be done When the “Why s” give you the “What” (..needs to be done?)

Tree Diagram-Graphic display of the 5 whys The idea of asking the why is really to look at the root cause of the problem and not superficial symptoms or the effects of the problem. Tree Diagram-Graphic display of the 5 whys

2. “Five whys” Mothers are not breastfeeding – Why? They feel uncomfortable taking their gown off – Why? The gown opens at back, so they have to take entire gown off to breast feed, so they feel exposed. Why they have this type gown? That is what store keeper orders. Why doesn’t the store keeper order better gowns appropriate for breast feeding? Because no one has requested him to do that This again is a simple demonstration of asking Whys to get to the root of the problem

80% of the problem is due to 20% of causes 3. Pareto charts 80% of the problem is due to 20% of causes The next tool I would be talking about is the Pareto principal which says that 80% of the problem is due to 20% of causes. The vital few Vs the trivial many.

Interestingly the origin of this concept came from an italian economist Wilfedo Pareto Who said that 80% of the land was owmen by 20 % of people or that 20% of pea pods in the garden contained 80% of the peas. This is essentially to that the impact of a few causes is much more than a lot of others put together PARETO CHARTS

When to Use a Pareto Chart? When there are numerous causes to a problem When you want to analyze the frequency of the causes behind a problem When you want to categorize the problems having a potential to contribute to improving the problem you are addressing

Example: Medication error v For example when looking at the causes of medication error it is the prscription error and handwriting error which contribute majorly compared to the rest together. Hence targetting these as interventions will give you more value for the inputs .

Example: Medication error v Example: Medication error 80% of problems due to 30% of causes

4. Process flow chart How to develop a process flow chart Decide the beginning and end points of the process to be flow charted Identify the steps of the process as these are practiced at present Link the steps with arrows showing direction Review the chart to see whether the steps are in their logical order to achieve the end point efficiently: Is the order wrong, are some steps unnecessary? The last tool that we will discuss today is the “Process Flow Map”. As is being discussed time and again, the success of a health care system lies in the processes involved at every step. Even for a small problem that you identified think of the steps involved from the beginnig to the end. As you go through these steps as they are presently happening the problem areas present themselves for you to work upon.

How to create a process Flow chart One flow line out of step Two flow lines out of steps that lead to different options One flow line out of cloud steps that are not clear Step Option Yes No Cloud step Technically, making a process flow map involves using some symbols including the start and stop , the essential steps , diamond which is a decision point or a cloud where things are not very clear. Start/stop

Key tips Analysis helps to find out the root cause of problems Try to find few barriers that account for most of the problem Help the teams think about how re-organization can help with fixing the problem Video on Pareto chart