2. 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

3. 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

4. “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

5. 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

6. 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

7. 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

8. 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.

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

10. 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

11. Establishing Skin to Skin Contact after delivery

12. 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?)

13. 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

14. 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

15. 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.

16. 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

17. 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

18. Example: Medication errorv
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 .

19. Example: Medication errorv
Example: Medication error
80% of problems due to 30% of causes

20. 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.

21. 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

23. 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