1. Academic Pediatric Association QUALITY IMPROVEMENT TRAINING: Module #4
Welcome to the APA’s quality improvement training module #4:
More QI Tools to Better Understand the System
This work is part of APA’s National Partnership for Adolescent Immunization.
NPAI was Funded by a grant from The Centers for Disease Control & Prevention.
This work is supported by a grant from The Centers for Disease Control & Prevention.
More QI Tools to Better Understand the System

2. National Partnership for Adolescent Immunization PI: Peter Szilagyi Coordinators: Christina Albertin, Nui Dhepyasuwan
FACULTY & CONSULTANTS
Donna D'Alessandro
William Atkinson
Paul Darden
Sharon Humiston (moderator)
Keith Mann (QI expert)
Ed Marcuse
Cindy Rand
Jan Schriefer (QI expert)
Stanley Schaffer
Janet Serwint
William Stratbucker
My name is Dr. Sharon Humiston and I’ll be your moderator today.
I’m part of the National Partnership for Adolescent Immunization, the collaborative that created this podcast series.
The members of the NPAI team are shown here.

3. This is part of the APA series on Quality Improvement
This is part of the APA series on Quality Improvement. The examples focus on adolescent immunization, but the principles are widely applicable. The series includes:
Overview: The Model for Improvement and Deming’s System of Profound Knowledge
Improvement cycles and the psychology of change
Initiating a QI project
More tools to better understand the system
How will we know that a change is an improvement? An introduction to QI measurement
Changes we can make that will result in improvement
This is part of the APA series on Quality Improvement.
The examples focus on adolescent immunization, but the principles are widely applicable.
The topics for each module are shown on this slide.

4. Module 4 Objectives
After viewing this segment, you will be able to describe the development and purpose of each of the following tools for understanding the system:
Flowcharts
Cause and effect diagrams
The 5 whys technique
Module 4 Objectives are shown here.
After viewing this segment, you’ll be able to describe the development and purpose of each of the following tools for understanding the system:
Flowcharts
Cause and effect diagrams
The 5 whys technique

5. Flowcharts
Let’s start with Flowcharts

6. Flowcharts What: Draw a picture of your process as a team
High-level flowchart - shows the process in 6-12 steps, useful early to show major activity blocks
Detailed flowchart – shows dozens of steps; useful later to identify rework loops and process complexity
Purpose: Coming to agreement on what the process really is. This helps the team understand the process and develop ideas about how to improve it.
Who: All the groups involved (there will likely be as many versions of the process as there are people)
With a flowchart you draw a picture of your process as a team.
It can be a High-level flowchart, which shows the process in 6-12 steps. This is useful early on to show major activity blocks
A detailed flowchart shows dozens of steps; it’s useful later to identify rework loops and process complexity
The Purpose of creating a flowchart is that it makes the team come to agreement on what the process really is. This helps the team understand the process and develop ideas about how to improve it.
It has to be done with the input of many people. It’s best to include
all the groups involved (there will likely be as many versions of the process as there are people)

7. IHI’s Sample High-Level Flowchart: Ischemic Heart Disease Patient Flow
Here is the Institute for Healthcare Improvement’s Sample High-Level Flowchart.
The topic is Ischemic Heart Disease Patient Flow.

8. IHI’s Sample High-Level Flowchart: Ischemic Heart Disease Patient Flow
You see that the decision points are shown as diamond-shaped boxes.
Other than the decision points, there are only 7 steps shown.

9. From American Society for Quality
Here’s another example of a high-level flowchart, this time for order filling

10. The same process as a detailed flowchart
This is the same process as a detailed flowchart
For information on Commonly Used Symbols in Detailed Flowcharts
please see the ASQ website (the link is shown here)

11. To see a sample (fictional) flowchart on “HPV Vaccination in a Pediatric Residency Clinic”
To see a sample (fictional) flowchart on “HPV Vaccination in a Pediatric Residency Clinic”
Go to the dropbox link shown here

12. How to Make a Flowchart Prepare: Step-by-step: Right people
Right level
Right boundaries - beginning and ending
Step-by-step:
Starting at the top, ask, “What’s next?”
Put each step under last, on a “sticky note”
Where you disagree, lay the options side-by-side; come back later, and discuss which is preferable.
How Can you Make a Flowchart?
To prepare
Gather the right people – folks that have different perspectives and really know the process
Determine the right level – are you going for the 20,000 foot level or the details?
Determine the right boundaries – what do you want to consider the beginning and ending of the process. That seems easy until you really start thinking about it.
Next you’ll be thinking through the step-by-step process:
Starting at the top, ask, “What’s next?”
Put each step under or next to the last, using a “sticky note” makes it easy to rearrange the steps
Where you disagree, lay the options side-by-side; come back when you have finished the entire process, and discuss which is preferable. Agree on one standard way to do the work.

13. Completing Your Flowchart
Use software to document
You may need to
Gather info
Revise the flowchart as more is understood about the actual process
To complete Your Flowchart
--Use software to document the flow you’ve depicted with sticky notes
You may need to gather information in order to clarify the fuzzy areas
You also may need to revise the flowchart as more is understood about the actual process

14. QUESTION #1: Which 1 of the following is FALSE regarding flowcharts?
 A high-level flowchart shows a process in 6-12 steps and is useful early in the QI project for shining a light on the major blockages.
The main purpose for creating a flowchart is to come to agreement on what the process really is, which, in turn, helps the team understand the process and develop ideas about how to improve it.
As far as possible, the main clinic administrator should be the only one to have input into the creation of the flowchart so it reflects the way the process should go.
When flowcharts are formally produced (using software), decision points in the process are shown as diamonds.
To check on your understanding so far, please answer QUESTION #1:
Which 1 of the following is FALSE regarding flowcharts?
 A high-level flowchart shows a process in 6-12 steps and is useful early in the QI project for shining a light on the major blockages.
The main purpose for creating a flowchart is to come to agreement on what the process really is, which, in turn, helps the team understand the process and develop ideas about how to improve it.
As far as possible, the main clinic administrator should be the only one to have input into the creation of the flowchart so it reflects the way the process should go.
When flowcharts are formally produced (using software), decision points in the process are shown as diamonds.

15. QUESTION #1: Which 1 of the following is FALSE regarding flowcharts?
 A high-level flowchart shows a process in 6-12 steps and is useful early in the QI project for shining a light on the major blockages.
The main purpose for creating a flowchart is to come to agreement on what the process really is, which, in turn, helps the team understand the process and develop ideas about how to improve it.
As far as possible, the main clinic administrator should be the only one to have input into the creation of the flowchart so it reflects the way the process should go. As far as possible, all the groups involved in the process should have input into the creation of the flowchart.
When flowcharts are formally produced (using software), decision points in the process are shown as diamonds.
C. Is false.
In fact, As far as possible, all the groups involved in the process should have input into the creation of the flowchart.

16. Cause and effect diagrams
Let’s talk next about Cause and effect diagrams

17. Cause and Effect Diagrams (aka “Fishbone Diagram”)
What: A graphic display of a list
Purpose: Permits identification and organization of a list of factors thought to cause a problem or affect variation; can also be used as a Root Cause Analysis Tool
Who: All the people involved
A cause and effect diagram (or fishbone diagram) is a graphic display of a list, created by a QI team.
The branches off the large arrow represent main categories of potential causes usually Materials, Methods, Equipment, Environment, and People.
Smaller branches, representing sub-categories are then drawn off of each major branch.
The purpose of creating a cause and effect diagram is to identify and organize of a list of factors thought to cause a problem or to affect variation the process.
For this reason, it can also be used as a Root Cause Analysis Tool.
Again, all the groups involved in the process should help create the diagram.

18. Sample Cause & Effect Diagram
PEOPLE
MATERIALS
ENVIRON-MENT
Low rate of HPV immunization for yr old patients
METHODS
EQUIPMENT
Nursing
Providers
Motivation
Motivation
Training
Training
Schedulers
Motivation
Training
Better handout for reluctant parents
MD recommendation is not strong
Computers slow
No return
appts set up
Lack of automated reminder system
Standing order instruction sheets
Adolescent immunization record scattered

19. Typical Categories for Major Causes
Equipment, Methods, Materials, People, Environment/Measurements/Procedures
Who, What, When, Where
People, Provisions (Supplies), Procedures, Place, Patients/Families
Steps of Process
The main categories (or “Bones”) can be chosen to fit the process under study.
Typical categories of major causes used in cause-and-effect diagram are:
Equipment, Methods, Materials, People, and Environment/Measurements/Procedures
Who, What, When, Where
People, Provisions (Supplies if you are not into alliteration), Procedures, Place, Patients/Families Or
You can used the Steps of the Process. The process type cause and effect diagram looks a little different from the traditional one.

20. Sample Cause & Effect Diagram
Process Type
PATIENT ARRIVES
PATIENT CHECKS IN
OBTAIN WEIGHT AND VSs;
GO TO EXAM ROOM
PROVIDER DOES H&P
GIVE ORDER TO NURSE
NURSE GETS VACCINE
NURSE GIVES VACCINE; DOCUMENT
PATIENT
DISCHARGE NO
RECOMMEND VACCINE?
No info given
Registration unfriendly
(per survey)
Hurried! No time to answer “in depth” questions
YES
No expectation for
vaccination
No parent for
consent
Conversation is social;
not educational
Some nurses are anti-
vaccine (per rumor) NO
FAMILY
ACCEPTS?
No good info sheet
Providers not trained to
answer succinctly
YES
Delayed if busy
Med room is 30 steps
from most exam rooms

21. How to Make a Cause and Effect Diagram
Fill in each of the following:
Large arrow pointing to the name of the problem or issue
The branches off the large arrow represent main categories of potential causes.
Smaller branches, representing sub-categories (can be a list of items)
How to Make a Cause and Effect Diagram
Fill in each of the following
Large arrow pointing to the name of the problem or issue
The branches off the large arrow represent main categories of potential causes.
Smaller branches, representing sub-categories (which can be a list of items) are then drawn off of each major branch.
The hard part is coming up with the truth about the process, and not just taking things at face value, which brings us to our next tool.

22. The 5 whys technique
The 5 whys technique

23. The ‘5 Whys’
What: Repetitive questioning, looking for deeper levels of the problem’s root causes
Purpose: To overcome the tendency to be satisfied with superficial answers and get at root causes
Who: QI team
This is a form of repetitive questioning, looking for deeper levels of the problem’s root causes
The purpose of the technique is to overcome the tendency to be satisfied with superficial answers and get at root causes
Who should participate: By now you know that I think the perspectives of the whole QI team are going to be valuable.

24. An example of the 5 Whys
Why does our clinic have such low rates of HPV vaccination for boys? Because the doctors forget to order it.
Why do the doctors forget to order it? Because some of our doctors only work part-time…Are they even aware that it’s a routine recommendation or why it’s important
Why would the part-time attendings be unaware…Because there hasn’t been any kind of in-service for the part-time attendings.
Why hasn’t there been an in-service for the part-time attendings? Because it would cost the office a lot to bring them all in for an extra hour and they’d want food, too.
Why would we have to bring them in? There’s an online learning module…
Here’s an example of the 5 whys technique
Why does our clinic have such low rates of HPV vaccination for boys? Because the doctors forget to order it.
Why do the doctors forget to order it? Because some of our doctors only work part-time…Are they even aware that it’s a routine recommendation or why it’s important?
Why would the part-time attendings be unaware…Because there hasn’t been any kind of in-service for the part-time attendings.
Why hasn’t there been an in-service for the part-time attendings? Because it would cost the office a lot to bring them all in for an extra hour and they’d want food, too.
Why would we have to bring them in? There’s an online learning module…

25. QUESTION #2. Which of the following is FALSE regarding the tools discussed in this module?
The ‘5 Whys’ is a simple tool, easy to complete without statistical analysis.
Equipment, Methods, Materials, Why, and Environment/Measurements/Procedures are major categories that are commonly used in Cause and Effect Diagrams.
Who, What, When, and Where are major categories commonly used in Cause and Effect Diagrams.
Use of Cause and Effect Diagrams helps identify and organize factors believed to cause a problem.
Are you ready for QUESTION #2? Which of the following is FALSE regarding the tools discussed in this module
The ‘5 Whys’ is a simple tool, easy to complete without statistical analysis.
Equipment, Methods, Materials, Why, and Environment/Measurements/Procedures are major categories that are commonly used in Cause and Effect Diagrams.
Who, What, When, and Where are major categories commonly used in Cause and Effect Diagrams.
Use of Cause and Effect Diagrams helps identify and organize factors believed to cause a problem.

26. QUESTION #2. Which of the following is FALSE regarding the tools discussed in this module?
The ‘5 Whys’ is a simple tool, easy to complete without statistical analysis.
Equipment, Methods, Materials, Why People, and Environment/Measurements/Procedures are major categories that are commonly used in Cause and Effect Diagrams.
Who, What, When, and Where are major categories commonly used in Cause and Effect Diagrams.
Use of Cause and Effect Diagrams helps identify and organize factors believed to cause a problem.
Here is the answer

27. By understanding a system, one may be able to
predict the consequences of a proposed change.
W.E.Deming
This module highlights just a few tools to help understand the system. There are many more options.
The more you QI projects you do, the more tools you will want in your tool bag.
Garbage in, garbage out
By understanding a system, one may be able to
predict the consequences of a proposed change.
This module highlights just a few tools to help understand the system. There are many more options.
The more you QI projects you do, the more tools you’ll want in your tool bag.
And of course – the gorgeous tool is just garbage if it’s based on faulty information from people who don’t really understand the system.
Garbage in, garbage out

28. Summary
In this module, we discussed the development and purpose of a few tools for understanding the system:
Flowcharts are a graphic display of your process, used to help understand what the process really is
Cause and effect diagrams (or fishbone diagrams) are a graphic display of a list, used to identify and organize factors thought to cause a problem or affect variation.
The 5 whys technique is repetitive questioning, looking for deeper levels of the problem’s root causes.
Let’s sum up this module.
In this module, we discussed the development and purpose of a few tools for understanding the system:
Flowcharts are a graphic display of your process, used to help understand what the process really is
Cause and effect diagrams (or fishbone diagrams) are a graphic display of a list, used to identify and organize factors thought to cause a problem or affect variation.
The 5 whys technique is repetitive questioning, looking for deeper levels of the problem’s root causes.

29. The End of Module #4 IHI. Science of Improvement: How to Improve
That’s the end of module 4.
Thanks for watching this APA QI Module!
IHI. Science of Improvement: How to Improve