/ 241 An Workshop Wonca Europe, September 2008, Istanbul Basic Tools of Quality Dr. Zekeriya Aktürk, Dr. Nezih Dağdeviren, Dr. Turan Set

/ 242 Workshop outline Presentation: quality tools –15 min Brainstorm: reasons for decline in FM –10 min Group work: pareto analysis –25 min Summary –10 min

/ 243 Basic Tools of Quality 1.Cause and effect diagram 2.Check sheet 3.Control chart 4.Flow chart 5.Histogram 6.Pareto chart 7.Scatter diagram

/ Cause and effect diagram A Cause-and-Effect Diagram is useful in examining the factors that have contributed to the problem. To develop the Cause-and-Effect Diagram, we have to go through four steps, namely: –identify the problem's characteristics –brainstorm the reasons why the problem is occurring using a Causal Table (also known as the Why-Because Technique) –group the causes by relationship using an Affinity Technique –create a Cause-and-Effect Diagram

/ 245 S1: Identify the problem's characteristics QuestionAnswer 1. What is this problem about? Delay in attending to users. 2. Who is affected by this problem? One-fourth (25%) of patients wait more than 90 minutes for care. 3. When does this problem occur? Waiting time increases beginning midmorning on Mondays and Fridays. 4. Where does it occur? In the health center, mainly at the registration desk, in the doctor's waiting room, and in the laboratory.

/ 246 Step 2: Brainstorm Next, the team participates in brainstorming sessions to analyze the causes of the waiting-time problem. After the team is finished with brainstorming, we have a list of possible causes for the problem.

/ 247 Immediate CauseRoot Cause Staff arrives late to work staff member has a second job staff must complete domestic chores before coming to work staff experiences unexpected delay in getting to work Too much paperwork disorganization of the files complicated storage methods complicated procedures Lack of user cooperation users don't respect turns users don't bring ID cards users don't keep appointments Limited space insufficient capacity for number of users Procedures take too long lack of automation of procedures outdated methods

/ 248 Step 3: Affinity Technique In preparation for describing the causes graphically, the team decides to group them by relationships, or affinities, into policy and user issues. Working with a group of between five and eight participants, we ask each participant to write down, individually, on four or five cards, their ideas about the common factors of the causes. After 10 minutes, the cards are put on the wall and the ideas reordered in groups. Each participant moves any cards to group them by affinity, until all the participants are in general agreement with the grouping of ideas. In our example, the causes may be grouped under the following headings: –policy –personnel –user –methods/procedures

/ 249 Step 4: Create the Cause-and-Effect Diagram

/ Pareto Analysis After analyzing the causes of long waiting times, we need to choose the most important causes to solve. One way to do this is by using a Pareto Analysis

/ 2411 Step 1: Frequency Analysis The first step of the Pareto Analysis is to gather data on the frequency of the causes. We can continue on the above example of waiting times. Let us interview a sample of 50 users and 20 staff members of the health center to determine which of the possible causes happen most frequently in the health center.

/ 2412 Possible Causes of Long Wait TimePercent of Total Policies require excess information on users1 Policies require complicated procedures1 Too much paperwork2 Not enough funding2 Inadequate schedules13 Inadequate policies2 Clinic personnel have too many chores at home2 Clinic personnel have other jobs2 Clinic personnel lack punctuality6 Clinic personnel have insufficient training2 Clinic personnel aren't motivated1 Clinic personnel are careless1 Clinic personnel don't follow the schedule16 Users forget ID cards1 Users don't keep appointments2 Users are uncooperative1 Delay in handing over lab results to doctors14 Outdated methods12 Lack of automation9 Procedures take too long11 Here are the results of the survey, in a table: Clinic personnel don't follow the schedule Delay in handing over lab results to doctors Inadequate schedules Outdated methods Procedures take too long 65%

/ 2413 The Pareto Principle states that a problem can be solved by focusing on solving the most frequently occurring causes. Usually, there are four to six causes that lead to 80% of the problems. These are called the "vital few" causes.

/ 2414 To identify the "vital few" causes, we rank the causes based on the frequencies we found in the survey, we have to calculate the cumulative percentage (each percentage added to the one before it) so we can build a pareto graph. We construct a chart with the cause, percentage, and cumulative percentage:

/ 2415 Cause%Cum. % Clinic personnel don't follow the schedule16% Delay in handing over lab results to doctors14%30% Inadequate schedules13%43% Outdated methods12%55% Procedures take too long11%66% Lack of automation9%75% Clinic personnel lack punctuality6%81%

/ 2416 Step 3: Pareto Graph Now we are ready to draw the pareto graph. We draw a horizontal axis (x) that represents the different causes, ordered from the most to least frequent. Next, we draw a vertical axis (y) with percentages from 0 to 100%. Now, we construct a bar graph based on the percentage of each cause. We construct a line graph of the cumulative percent. Finally, we draw a line from 80% on the y-axis to the line graph, and then drop the line down to the x-axis. This line separates the important causes from the trivial ones.

/ 2417

/ Check Sheet

/ Control chart (Shewhart chart)

/ Flow chart A flowchart is a schematic representation of an algorithm or a process

/ Histogram A histogram is a graphical display of tabulated frequencies. It shows what proportion of cases fall into each of several categories.

/ 2422 Histogram of age

/ Scatter Diagram

/