1. The Open Forum Leslie M. Beitsch September 17, 2009
Applying Quality Improvement Techniques to Analyze Problems and Find Solutions
The Open Forum
Leslie M. Beitsch
September 17, 2009

2. Organize participation for performance improvement
Big QI
Little qi
Leadership support and role
What is leadership’s vision, commitment, expectation?
Build the process strategically
Incorporate QI into broader initiatives (MAPP, HP2010)
Involve others

3. To Carry Out a Quality Improvement Process, “Plan-Do-Check-Act”
PDCA in Users’ Guide:
Plan: Plan changes aimed at improvement, matched to root causes; identify measures of improvement.
Do: Carry out changes; try first on a small scale.
Check: See if you get desired results.
Act: Make changes based on what you learned; spread success or try again.
*Also called Plan–Do–Study–Act (PDSA), Deming, or Shewhart cycles.
Source: Turning Point Performance Management Collaborative, From Silos to Systems: Using Performance Management to Improve the Public’s Health , March 2003.

4. To Carry Out a Quality Improvement Process, “Plan-Do-Check-Act”
Plan Plan changes aimed at improvement, matched to root causes
Do Carry out changes; try first on small scale
Check See if you get the desired results
Act Make changes based on what you learned; spread success
Plan Do
Check
Act
Focus on:
Plan Plan changes aimed at improvement, matched to root causes
PDCA in Users’ Guide:
Plan: Plan changes aimed at improvement, matched to root causes; identify measures of improvement.
Do: Carry out changes; try first on a small scale.
Check: See if you get desired results.
Act: Make changes based on what you learned; spread success or try again.
*Also called Plan–Do–Study–Act (PDSA), Deming, or Shewhart cycles.
See Problem Solving, p. 12

5. Regularly monitor and report progress.
Regular reports necessary to chart progress
Benchmark against self and others
Same industry, other industries
Reports do not have to be computerized (although it helps!), expensive, color…

6. Some QI Tools to Help Teams Analyze Performance
Involve people who carry out processes, see various parts of the system, or experience problems first hand
Use following techniques with NPHPSP work groups, staff, partners
First discuss qualitative techniques to identify potential causes of performance problems, then sort into categories

7. Affinity Diagram
It was created in the 1960s by Japanese anthropologist Jiro Kawakita.
Tool for assimilating and understanding large amounts of information
Draw out common themes from a large amount of information
Discover all the hidden linkages
When you work through the process of creating relationships and working backward from detailed information to broad themes, you get an insight you would not otherwise find.
When to Use an Affinity Diagram
When you are confronted with many facts or ideas in apparent chaos
When issues seem too large and complex to grasp
When group consensus is necessary
When you cannot see the forest for the trees, an affinity diagram may be exactly what you need to get back in focus

8. Affinity Diagram How To Do It:
Develop a clear purpose, problem, concern or issue statement to focus the group
Materials needed:
sticky notes or 3x5 cards
marking pens,
large work surface
Wall
table
floor. .

9. Affinity Diagram How To Do It: Process Steps:
Individual silent brainstorming
Record each idea with a marking pen on a separate sticky note or card.
Need a complete statements – no one word ideas
Allow plenty of time for randomly-arranged notes in a public place and allow grouping to happen over several days.
Most groups that use this technique are amazed at how powerful and valuable a tool it is.

10. Exercise
Why does Sunshine County Health Dept (insert your own health department name) have such high staff turnover????
I want 6 ideas from each participant

11. Affinity Diagram How To Do It: Posting Step
Each participant reads and randomly posts their ideas on the wall – one at a time
Other participants can ask for clarification when an idea is read – no debate – just clarification
Do not place the notes in any order - do not try to determine categories or headings in advance – use the whole wall
After all ideas are posted – begin Silent Consensus
Some people make their own private space -

12. Affinity Diagram How To Do It: Silent Consensus:
The entire team gathers around the posted notes
No talking during this step (remember the name…)
Look for ideas that seem to be related in some way
Move the Post-Its and place them side by side
Repeat until all notes are grouped
Okay to have “loners” that don’t seem to fit a group - outliers
It’s all right to move a note someone else has already moved.
If a note seems to belong in two groups, make a second note

13. Affinity Diagrams How To Complete It: Clarification Step:
Participants can discuss the “results” of the chart
Any surprising patterns?
Any reasons for moving controversial notes.
A few more changes may be made
When ideas are grouped, select a heading for each group
Look for a note in each grouping that captures the meaning of the group. If not create one
Place it at the top of the group
highlight headers notes in a bright color.
Combine groups into “super groups” if appropriate
Want 6 – 10 headers
Take the time to do this step – it is the foundation for the other tools

14. Affinity Diagram Example
Issue Statement
Issues Affecting the High Staff Turnover
of Sunshine County Health Department
Header Cards:
Limited
Professional
Development
Low
Salary
Low
Morale
Leadership
Public Health
Misunderstood
Work
Environment

15. Cause and Effect Diagram
Poor Morale
Low Salary
Budget
Constraints
Work
Undervalued
HR System Restrictive
Lack of
County support
Outdated
Equipment
High Staff
Turnover
Training
Availability
Poor Facilities
Career
Advancement
Bad
Neighborhoods
Work
Environment
Limited
Professional
Development

16. Common root causes of performance problems
Methods & Procedures
Motivation
Materials & Equipment
People
Information & Feedback
Environment
Policy
Methods & procedures
Motivation (incentives or consequences)
Materials/Equipment (including technology, resources)
People (including personnel, patients, partners, or providers) – adequate supply, match to innate talents, knowledge and skill
Information/feedback – incl. information not available when needed, no information on best practices available
Environment
Policy
Pitfalls to avoid:
Jumping to conclusions about what’s needed
Other examples - reasons people might not meet standards for:
Controlling healthcare costs – no data, no one assigned to examine, no expertise to analyze costs, no incentives to providers to change, no feedback to managers, etc.
Workforce standards – lack of priority, lack of information about available training, assignment of training costs to programs create disincentives for training staff

17. 5 Whys

18. Five Why’s Our influenza clinic was poorly attended
Why? Residents had many opportunities
Why? There was a lot of competition
Why? Pharmacies are in on the action
Why? It brings customers in
Why? They can ‘multi-task’ in one stop

19. Other Explanations Why? Residents had many opportunities
Our influenza clinic was poorly attended
Why? Residents had many opportunities
Why? We didn’t advertise it well
Why? Inclement weather was a factor
Why? Our price wasn’t competitive
Why? The location wasn’t convenient

20. Five Why’s: Expand Scope Downward
My off white carpeting must be replaced
Why? The carpeting has been stained
Why? My elder cat vomits periodically
Why? She is upset about something
Why? Her environment was compromised
Why? I introduced a kitten last year

21. Five Why’s I had to replace my car motor
Why? The motor seized while in transit
Why? There was insufficient oil
Why? I have not maintained my car
Why? I didn’t make time for my service
Why? I did not make my car a priority

22. Cause and Effect Analysis (Fishbone)
Ask “why” 5 times

23. Fishbone Diagram Ask “why” 5 times
The fishbone diagram is another quality tool that gets to the root causes and allows participants the opportunity to organize a large amount of information by showing links between events and their potential or actual causes. It’s also a means to generate ideas about why the problem is occurring and possible effects of that cause.
When developing the fishbone diagram, remember to focus the team on causes and not symptoms or solutions.

24. Flow Charting

25. “If you can't describe what you are doing as a process, you don't know what you're doing.”
W. Edwards Deming

26. Simple Flowchart Helps Understand a Complex Process

27. Flow Charting
Flow charting is often the first step we take in understanding a process
Organized combination of shapes, lines, and text
Flow charts provide a visual illustration, a picture of the steps the process undergoes to complete it's assigned task 
From this graphic picture we can see a process and the elements comprising it
Shows how interactions occur
Makes the invisible (less obvious) visible (more obvious)

28. Mapping MapQuest Flow Chart
Takes directions and coverts them into a picture
Shows various routes to a destination
Shows communities you pass through to reach a destination
Shows connecting roads
Shows faster and slower routes
Provides alternative routes
Flow Chart
Takes procedures and converts them into a visual
Shows the routes inputs travel to become outputs
Shows handoffs
Shows connecting processes
Highlights areas for improvement
Triggers ideas to improve a process

29. Flow Chart Benefits Creates a common vision
Establishes the “AS IS” baseline – Current State
Baseline to measure improvements
Identifies wasteful steps – activities/waits
Uncovers variations (usually unintended)
Shows where improvements could be made
Show potential impacts of improvements
Training tool
Current state accuracy is important since it will be the point from which all improvements will be measured.
Show all the problems – don’t try to cover them up

30. Flow Chart People Benefits
People involved in constructing a flow chart begin to:
Better understand the process
Understand the process in the same terms
Realize how the process and all the people involved, including them, fit into the overall process or business
Identify areas for improving the process
Become enthusiastic supporters to quality and process improvement
Become process owners

31. Could Be – improved state – transition
Types of Flow Charts
As Is – current state - baseline
Our task today!
Could Be – improved state – transition
Should Be – optimal state

32. Flow Charting Construction
Clearly define the process boundaries to be studied
Define the first and last steps – start and end points
Get the right people in the room
Decide on the level of detail
Complete the big picture first – macro view
Fill in the details – micro view
Gather information of how the process flows:
Experience
Observation
Conversation
Interviews
Research
Clearly define each step in the process
Be accurate and honest
Flowcharts don't work if they're not accurate or if the team is too far removed from the process itself.
Team members should be true participants in the process and feel free to describe what really happens. A thorough flowchart should provide a clear view of how a process works.
With a completed flowchart, you can:
Identify time lags and non-value-adding steps.
Identify responsibility for each step.
Brainstorm for problems in the process.
Determine major and minor inputs into the process with a cause & effect diagram.
Choose the most likely trouble spots with the consensus builder.

33. Flow Charting Steps Use the simplest symbols possible – Post-Its
Make sure every loop has an escape
There is usually only one output arrow out of a process box. Otherwise, it may require a decision diamond.
Trial process flow – walk though it in real time
Circulate the flowchart to other people involved in the process to get their comments
Make changes if necessary
Identify time lags and non-value-adding steps.
Flowcharts don't work if they're not accurate or if the team is too far removed from the process itself. Team members should be true participants in the process and feel free to describe what really happens. A thorough flowchart should provide a clear view of how a process works. With a completed flowchart, you can:
Identify time lags and non-value-adding steps.
Identify responsibility for each step.
Brainstorm for problems in the process.
Determine major and minor inputs into the process with a cause & effect diagram.
Choose the most likely trouble spots with the consensus builder.

34. Flow Chart Construction
There is no one right way to develop a flowchart, but the following guidelines provide a general structure:
Start with a simple one-line description or title of the process being flowcharted , e.g., "How to..."
Using a top-down hierarchy, start with an oval symbol named Start.
Connect each successive action step in the logical sequence of events.
Reference detailed information through annotations or connectors.
Follow the process through to completion, denoted by an oval symbol named End

35. PPAProcessctivrProcess
Flow Chart Symbols
Flow Lines
Manual
Operation
Start/End A
Connector
PPAProcessctivrProcess
Operation/Inspection
Data Base
Comment
Collector
Wait/Delay
Decision
Display
Storage
Input/
Output
Data
Transport
Manual
Input
Document
Input
These symbols are in Microsoft Power Point
Preparation
Forms
Output
Unfamiliar/
Research

36. Constructing a Flow Chart
Asking questions is the key to flow charting a process. 
For this process:
Who is the customer(s)?
Who is the supplier(s) ?
What is the first thing that happens?
What is the next thing that happens?
Where does the input(s) to the process come from?
How does the input(s) get to the process?
Where does the output(s) of this operation go?
Is their anything else that must be done at this point?
The more questions everyone asks the better. 

37. Exercise

38. Quality Improvement Analyze the “As Is” flow chart
Look for Critical Processes
Look for Handoffs
Analyze with a Cause and Effect Diagram
Develop potential solutions
Develop the “Should Be” state
Communicate all changes
Track implementation progress
Document results
Present results
Perform QI on the flow chart now that you have one…

39. How Improvements Are Made
Focus on Critical Processes
Important sets of procedures or patterns of tasks that determine success (i.e. customer satisfaction) for an organization or an individuals job.
At the executive level, some Critical Processes may be quite broad and comprehensive. It may be helpful to think in terms of "critical systems" which are a collection of critical processes that must occur simultaneously across the organization. One such critical system is the human resource system, which may consist of a number of critical processes such as hiring, training, development, recognition, and compensation

40. What are the attributes of critical processes?
They are few in number - usually
The critical processes of a flow chart should capture 75-80% of the activities which determine the success of that process
Critical processes describe what must occur on an on-going basis to achieve customer satisfaction.
They can be mapped or diagrammed in a step-by-step format.
They can be measured.
They can be improved

41. Improvement Opportunities
What to look for on a Flow Chart:
Duplication of effort
Unnecessary Activities/Steps/Tasks
Delays/Waits
Transports
Storage
Illogical Sequencing of Activities
Unclear Lines of Responsibility
Opportunities for Error
Supplier Error Opportunities
Disconnects

42. Improvement Opportunities
Use a Cause and Effect Diagram to investigate areas identified on the “As Is” flow chart as areas that could be improved
Can complete a micro level flow chart on specific process steps as required
Fix the low hanging fruit first – quick success
Involve customer/suppliers before any changes are made

43. Caution!!! In most processes:
Few people have seen the total process and fully understand it!
Those that designed the process now work elsewhere
Work is being done that adds no value to customers
Work the customer needs isn’t being done
Rework is built into the process
Inefficiencies are built into the process
Workarounds have been developed that make the process appear to be working better than it really is

44. Advantages of Flow Charts
Overview of the System
Documents a system/process
Shows Interrelationships
Communication Tool
Defines Roles
Shows barriers/bottlenecks/problems
Planning Tool for improvements

45. WIC Appointment Child has WIC appt. □ Due □ Overdue for shots?
Show?
□ Due
□ Overdue for shots?
Check report for immunization status
Due or overdue for shots?
Give parent immunization notice; answer or refer questions to DP&C nurse
Check report for C&TC eligibility & last exam
Active on C&TC? No
Noaction
Yes
Mail parent immunization notice
Encourage regular well child exams
Provide C&TC info/assist, encourage compliance w/exam schedule, code activity in Catch3
On the average it took 27 minutes for a customer call
When there are many flaws in the system the number of steps in the process is very large the probability of error at each step increases dramatically
WIC Appointment

46. Problem Solving Memory Jogger (Goal QPC) www.goalqpc.com
Memory Jogger II &
Problem Solving Memory Jogger (Goal QPC)
American Society for Quality (