1. Managing Change through Quality Control
Rosa West PhD, MBA, LMHC, LMFT
This product is supported by Florida Department of Children and Families
Substance Abuse and Mental Health Program Office funding.

2. Objectives
Review quality management processes and key control techniques.
Learn how to select appropriate Quality Control (QC) tools and strategies at various points of the change process.
Learn how to use QC tools to effectively manage short and long-term project goals.

3. Leading Successful Change
Requires:
Leadership
Staff Buy-In
Resources
Commitment

4. Change is Hard
Information or Data is invaluable to leading successful change

6. Good Data Provides… Enhanced services
Greater likelihood of finding a solution
Stronger support & clarity
Starting point!

7. So Why Measure?
We can use data to create change by measuring what matters!
You cannot manage what you cannot measure!

8. Types of Measures Outcome Measures
Tells whether changes made lead to improvement
Tells whether a specific process change has been accomplished and if it is having intended effect
Used to determine if changes to improve are part of the system is or isn’t causing problems in another part
Process Measures
Balancing Measures

9. Outcome Measures Reducing appointment times
Average length of time in days between the day a patient requests an appointment and the next available appointment
14 day avg. reduced to 3 day avg.

10. Process Measures Patient Continuity
Percentage of visits the patient makes to their own clinician vs. another provider

11. Continuity of Care Formula
Formula: Number of Patients of Provider X that were seen by Provider X, divided by the total number of Patients for Provider X that have been seen.
94 of Dr. Smith’s patients were seen in the clinic this month.
78 patients were seen by Dr. Smith.
16 of Dr. Smith’s patients were seen by another provider.
78 / 94 = .829
.829 X 100 =
82.9% Continuity

12. Balancing Measures
How would you rate the length of time waiting for today’s visit?

13. When Implementing Change…
It’s important to assess readiness in instituting change.

14. Ready…
Set…
Go!!!

15. Change Readiness Diagnostic: Risk Assessment
Rate each from 1 to 5 with
1 = very low, 2 = low, 3 = medium, 4 = high, 5 = very high
Totals points Watch Out!
points Keep a Close Eye on Things
points You/Your Organization are Very Likely to Successfully Implement the Change Program
Risk Factor 1: Adequacy of Risk Management Process
Risk Factor 2: Adequacy of Change Program Definition
Risk Factor 3: Effectiveness of Change Management Process
Risk Factor 4: Adequacy of Sponsorship and Resources
Risk Factor 5: Adequacy of Communication and Involvement
Risk Factor 6: Range of Linked /Consequential Actions Identified
Risk Factor 7: Coherence in the Sequencing of Linked Actions
Change Readiness Diagnostic: Risk Assessment

16. Change Readiness Diagnostic:
Risk Assessment
Rate of Return Factor 1: Extent and Timing of Benefits
Rate of Return Factor 2: Change Program Budgets Economy
Rate of Return Factor 3: Extent to which Project Time, Specifications and Costs are Managed
Rate of Return Factor 4: Degree of Focus on Business Results
Latent Opportunity Factor 1: Program Scope
Latent Opportunity Factor 2: Linking Change Drivers Through Actions to Performance
Latent Opportunity Factor 3: Appropriateness of Benchmark Targets
Latent Opportunity Factor 4: Quality of the Benchmarking Process

17. Mobilizing Commitment Stakeholder Analysis/Commitment Chart
Steps:
Plot where individuals currently are with regard to desired change
(O = current).
2. Plot where individuals need to be (X = desired) in order to successfully
accomplish desired change. Identify gaps between current and
desired.
3. Indicate how individuals are linked to each other. Draw lines to
indicate an influence link; use an arrow () to indicate who
influences whom.
4. Plan action steps for closing gaps. Can use Resistance Analysis tool.

18. Mobilizing Commitment Stakeholder Analysis/Commitment Chart
Grumpy
Grumpy
Snooty
Snooty
Grouchy
Grouchy
Slouchy
Slouchy

19. Include as member of Change Team
Mobilizing Commitment Resistance Analysis
Include as member of Change Team
Job Security
Ambiguous Roles
Grumpy
High
Snooty
Structure ?
Med ?
Grouchy
Slouchy

20. Motivating Change

21. Restraining Forces for Change Driving Forces for Change
Motivating Change
Force Field Analysis
Restraining Forces for Change
Current Situation
Driving Forces for Change

22. Motivating Change CHANGE Force Field Analysis
Strengthening or Adding Driving Forces
CHANGE
Removing or Reducing Straining Forces
Changing the Direction of Some of the Forces

23. Think of an Area in Your Department Which Would Benefit From Change…
What are the driving forces?
___________________________________
What are the restraining forces?
_______________________________

24. Root Cause Analysis

25. Why Do Root Cause Analysis?
“There is too much to do.”
“We don’t have time to think; we need results now.”
Reality - fix symptoms without regard to actual causes
Root Cause Analysis - structured and thorough review of problem designed to identify and verify what is causing the symptoms

26. Can you blame somebody else?
Root Cause Analysis
Yes
The Copier is Broken No
Don’t Mess With it!
Did you mess with it?
Yes No
Does anybody Know?
You Idiot!!! No
Will you catch hell?
Hide It!
Yes
Can you blame somebody else?
You’re Screwed! No
Yes
Never Happened!
Problem Solved

27. Key Definitions
Cause (causal factor): a condition or event that results in an effect
Direct Cause: cause that directly resulted in the occurrence
Contributing Cause: a cause that contributed to the occurrence, but by itself would not have caused the occurrence
Root Cause: cause that, if corrected, would prevent recurrence of this and similar occurrences

28. How Is Root Cause Analysis Done?
Individual/Team identifies all possible causes
The actual root causes are identified and verified
Corrective action(s) are identified to reduce or eliminate the problem

29. Root Cause Tools Cause and Effect Diagram (Fishbone) Five Whys
Force Field Analysis

30. Cause and Effect Diagrams

31. What Is It?
An analysis tool that provides a systematic way of looking at effects and their respective causes

32. Why Implement This?
Structured way of determining the root causes of a problem
Encourages group participation and utilizes group knowledge of the process
Easy-to-read format to show cause-and-effect relationships
Indicates possible causes of variation in a process

33. Why Implement This?
Increases knowledge of the process by helping everyone to learn more about the factors at work and how they relate
Identifies areas where data should be collected for further study

34. Intake Admission Process
Client Phones
Staff Collect Client info
Info Entered into Health Record
Client Provided w/Appt. Date/Time
Records Sent to Location of Client Appt.
Client Arrives
Client Checked-In/Completes Paperwork
Client Evaluated & Referred for Services

35. STEP 1:
Identify and clearly define the outcome or EFFECT to be analyzed.
Decide on the effect to be examined.
An effect may be positive (an objective) or negative (a problem), depending upon the issue that is being discussed.
>POSITIVE
Good customer service
Variety of services available
> NEGATIVE
Focusing on what caused the problem rather than what causes a desired outcome
Concentrating on what may go wrong

36. STEP 2: Draw the SPINE and create the EFFECT box.
Draw a horizontal arrow pointing to the right. This is the spine.
To the right of the arrow, write a brief description of the effect or outcome which results from the process.
Draw a box around the description of the effect.

37. Client No-Shows for Appt.
Spine
Client No-Shows
for Appt.
Effect Box

38. STEP 3:
Identify the main CAUSES contributing to the effect being studied.
Establish main causes, or categories, under which other possible causes will be listed.
3Ms and P – Methods, Materials, Machinery, and People
4Ps – Policies, Procedures, People, and Plant
Environment
Write the main categories of focus to the left of the effect box. Draw some above and below the spine.
Draw a box around each category label and use a diagonal line to form a branch from the box to the spine.

39. Methods People Client No-Shows For Appt. Machinery Materials
Main Causes
Machinery
Materials

40. STEP 4:
For each major branch, identify other specific factors which may be the CAUSES of the EFFECT.
Identify as many factors or causes as possible and attach them as sub-branches of the major branches.
Fill in detail for each cause.

41. Methods People Client No-Shows For Appt. Machinery Materials
Clients must
call for update
of next available
appt.
Staff neglect to close out appt.
when clients call to reschedule
Available appt.
times not updated
routinely
Poor staff
training
Client No-Shows
For Appt.
Information provided
to client is outdated
Unreliable
mail system
Lack of signage on-site
to direct client to correct
location of appt.
Ineffective
Health Record
System
Machinery
Materials

42. You can do this by asking a series of WHY questions.
STEP 5:
Identify more detailed levels of causes and continue organizing them under related causes or categories.
You can do this by asking a series of WHY questions.
FROM GIVEN EXAMPLE:
Q: Why are appointments not closed out when clients reschedule?
A: Because staff entering appointments do not know about reschedules
Q: Why don’t staff know?
A: Clients call the therapist to reschedule but support staff
handle scheduling.
Q: Why don’t the therapists reschedule the clients?
A: Because the therapists don’t have access to the
system and aren’t trained on it’s use.

43. Methods People Client No-Shows For Appt. Machinery Materials
Clients must
call for update
of next available
appt.
Staff neglect to close out appt.
when clients call to reschedule
Available appt.
times not updated
routinely
Poor Training
Inefficient Process
Poor staff
training
Client No-Shows
For Appt.
Information provided
to client is outdated
Inefficient Process
Unreliable
mail system
Lack of signage onsite
to direct client to correct
location of appt.
Ineffective
Health Record
System
Machinery
Materials

44. STEP 6: Analyze the diagram.
Look for causes that appear repeatedly. These may represent root causes.
Look for what you can measure in each cause, so you can quantify the effects of any changes you make.
Most importantly, identify and circle the causes that you can take action on.
A thick cluster of items in one area may indicate a need for further study.
A main category having only a few specific causes may indicate a need for further identification of causes.
If several major branches have only a few sub-branches, you may need to combine them under a single category.
Identify causes that warrant further investigation.
Determine the cause to focus on first.

45. Factors and/or categories of factors
Fishbone Diagram
(cause and effect)
People
Methods
Cause
Cause
Cause
Cause
Cause
Factors and/or categories of factors
Effect
Cause
Cause
Cause
Cause
Enter the names of the categories in the “Influence” boxes. You can copy, cut, and paste any of the arrows or figures as needed to meet the needs of your own diagram.
Machinery
Material

47. A Case Example….

48. Five Whys Describe the problem in specific terms
For each likely cause ask, “Why did this happen?”
Continue for a minimum of five times
Show logical relationships of each response to the one that preceded it
Stop when the team has enough information to identify the root cause

49. An Example… Why won’t the car start? *The engine won’t start.
Why won’t the engine turn over?
*The battery is dead.
Why is the battery dead?
*The alternator is not functioning.

50. An Example… Why is the alternator not functioning?
*The belt is broken.
Why is the alternator belt broken?
*Routine maintenance was not performed according to the manufacturer’s recommendations.

51. Decision-Making Tools

52. Affinity Diagram Random Ideas Affinity Diagram Theme 1 Theme 2 Theme 3
A group decision-making technique designed to sort a large number of ideas, process variables, concepts, and opinions into related groups.
Random Ideas Affinity Diagram
Theme Theme Theme 3

53. How to Conduct an Affinity Sort
Conduct a brainstorming session on the topic under investigation.
Clarify the list of ideas. Record them on small cards or post-it notes.
Randomly lay out cards on a table, flipchart, wall, etc.
Without speaking, sort the cards into "similar" groups based on your gut reaction. If you don't like the placement of a particular card, move it. Continue until consensus is reached.
Create header cards consisting of a concise 3-5 word description; the unifying concept for the group. Place header card at top of each group.
Discuss the groupings and try to understand how the groups relate to each other.

54. Affinity Diagrams (cont.)…
Human Resource
Issues
Lack of Standard
Process &
Measurement
Workplace Culture
High Turnover
No Standard
System
Lack of
Management
Support
Untrained Staff
No Measurement
for What is
and What is Not
Working
Staff Feel
Unappreciated
Staff Morale is
Low
Staff Aren’t
Compensated for
What They Do

55. Problem-Solving Strategies
Cost-Of-Poor-Quality Analysis
(COPQ)

56. Calculate Cost-Of-Poor-Quality (COPQ)
How much does it HURT?
Measure which determines:
Baseline in terms of where you are today
Pain caused by defects, poor quality
Types of Costs (5 categories):
Internal failure costs
Hard costs
Soft costs
Appraisals costs
(Prevention costs)

57. COPQ: Costs! Internal Failure Costs- Hard Costs-
Internal Costs - reworking, failure analysis, etc.
External Failure Costs -correspond to defects found after the customer/consumer/client receives the service
Hard Costs-
Warranty - cost to repair/replace under the terms of a contract
• Customer Returns - i.e., profit lost on the product, cost of product replacement
Customer Complaints - time spent analyzing complaints, examining the relevant issues and the resolution of the issues

58. COPQ: Costs! Soft Costs-
• Loss of Customer - customers will void contracts due to poor quality. Additionally, many potential customers are asking for data related to delivery, capability and/or quality. This data could cost.
Appraisal Costs- (costs related to conforming to requirements)
•Inspection and Testing - any incoming and in-process inspections
• Materials Utilized for Inspection and Testing - any resources consumed during the inspection/ test of product.

59. COPQ-Costs! Prevention Costs-
• Planning - the amount of money spent on the methods used to eliminate or minimize defects including the creation of procedures, work instructions, mistake proofing devices, etc.
• Process Control - inspections used to determine if the process is acting as planned.
• Supplier “Department” Appraisal - knowing that your supplier can meet your company’s requirements regarding quality, delivery, and customer service are also prevention costs.
• Training - time spent creating and presenting training programs related to quality. Remember, quality does not mean only “quality of the product or service.” Quality relates to all functions of an organization.

60. How Much Does the Issue Affect Profitability?
COPQ = internal costs + external costs
Let’s Try It!!!

61. Benchmarking

62. Benchmarking Four types:
"... benchmarking ...[is] ...'the process of identifying, understanding, and adapting outstanding practices and processes from organizations anywhere in the world to help your organization improve its performance.'" —American Productivity & Quality Center
Four types:
Internal (benchmark within an organization; i.e., between programs).
Competitive (benchmark performance or processes with competitors).
Functional (benchmark similar processes within an industry).
Generic (comparing operations between unrelated industries).

63. Benchmarking (cont.)… Basic Steps:
Know your operation. Accurately assess your strengths and weaknesses.
Know your industry leaders or competitors. Understand and compare yourself to the best practices in the industry and/or its leaders.
Incorporate the best. Learn from industry leaders and your competition. If they are strong in given areas, uncover why and how they got that way. Find best practices wherever they exist and do not hesitate to copy or modify and incorporate them in your own operation. Emulate their strengths.

64. Measuring the Effectiveness of Change
Measurement
Before you begin any process improvement project you need to collect baseline data. Keep this in mind “How will you know how far you gone if you don’t know where you were?” (click to the next slide)
Rosa West PhD, LMHC, LMFT

65. Measuring the Effectiveness of Change
Aims & Goal Setting
Reduce Waiting Times
Reduce No Shows
Increase Admissions
Increase Continuation
After you conduct your initial walk through want to make sure you identify your aim. The Aim that you choose to focus on should be selected based on the insights gained from your walkthrough or aligned with the priorities of your CEO and/or Executive sponsor. A quick review of the NIATx aims (click to the next slide)
Rosa West PhD, LMHC, LMFT

66. An Example: Reducing Waiting Times
Measuring the Effectiveness of Change
An Example: Reducing Waiting Times
Let’s consider an example. Although we may not actually see this standing in front of our desk, this is the vision; particularly this gentlemen staring at watch wondering when it’s his turn. I think this is a concern for many of us as we want to make sure we provide timely service (click to next slide)
Rosa West PhD, LMHC, LMFT

67. Measurement

68. Measuring the Effectiveness of Change
Key Principles…
What gets measured, gets done!
Change is virtually impossible when we do not measure our performance.
Rosa West PhD, LMHC, LMFT

69. Measuring the Effectiveness of Change
Key Principles…
It’s important to choose the most appropriate means of measuring the change.
Change is virtually impossible when we do not measure our performance.
Rosa West PhD, LMHC, LMFT

70. When Choosing Measures:
Relevance: does it have a significant, demonstrable relation to the goals/objectives?
Reliable: is the measure consistent? Will we get the same results after repeating the measure?
Availability: is the data necessary for measuring the change available at a reasonable cost?

71. Deciding What to Measure?
You must do proper problem exploration prior to measurement

72. If You have the Wrong Problem, You will get the Wrong Solution.
Problem exploration is the first stage in selecting the change and establishing measures.
However……
Exploration may be limited because you think.

73. If You Have the Wrong Problem, You Will Get the Wrong Solution.
Problem exploration is the first stage in selecting the change and establishing measures.
However……
You know what you want.

74. If You Have the Wrong Problem, You Will Get the Wrong Solution.
Problem exploration is the first stage in selecting the change and establishing measures.
However……
The problem is obvious (although perception is flawed).

75. If You Have the Wrong Problem, You Will Get the Wrong Solution.
Problem exploration is the first stage in selecting the change and establishing measures.
However……
The assumptions are known (although assumptions can be so ingrained you fail to notice them).

76. If You Have the Wrong Problem, You Will Get the Wrong Solution.
Problem exploration is the first stage in selecting the change and establishing measures.
However……
Complexity means this will be hard to solve.

77. Considerations in Selecting Measures
Measuring the Effectiveness of Change
Considerations in Selecting Measures
Re-evaluating existing measures (minimize influence of):
Fear
Ownership
What-Ifs
Estimates
Staff/Managers may be fearful of measuring performance. What will the data show? How will the findings effect us?
Rosa West PhD, LMHC, LMFT

78. Considerations in Selecting Measures
Measuring the Effectiveness of Change
Considerations in Selecting Measures
It’s important to measure processes and results
Measuring processes can provide information about the effectiveness of the process and measure the ultimate results of these process
Rosa West PhD, LMHC, LMFT

79. Considerations in Selecting Measures
Measuring the Effectiveness of Change
Considerations in Selecting Measures
Measures Should Foster Goal-Driven Teamwork
Rosa West PhD, LMHC, LMFT

80. Measuring Effectiveness of Change
Measuring the Effectiveness of Change
Measuring Effectiveness of Change
What change was most important?
What changes worked?
Before
What changes resulted in an improvement?
During
What didn’t work?
We need to make sure we measure the effectiveness of our change by asking ourselves multiple questions…
By collecting data before, during, and after your organization’s change cycle, you can measure the progress you have made towards achieving your goals and the impact of your change cycle. (click to next slide)
After
Rosa West PhD, LMHC, LMFT

81. Collecting Data Be mindful of potential variations
i.e., sampling today may not yield same sample as during holidays

82. Warning!!! Do not collect too much data
Do not focus on too many measures
Avoid analysis paralysis!

83. Tips for Success Identify the question you want answered.
Build measurement into daily workflow.
Post data where everyone can see it.
Create team ownership of the data.
Use data to drive decision-making.

84. Remember…..
“Failure is the opportunity to begin again more intelligently.” - Henry Ford

85. Celebrate Your Successes!!!

86. Questions/Comments?