1. NYS HIVQUAL Workshop: Quality Improvement Tools & Resources November 18 th, 2009 Meera Vohra & Susan Weigl NYSDOH AIDS Institute mxv10@health.state.ny.us,sweigl@yahoo.com

2. Learning Objectives: We will learn about.. Tools for understanding processes (e.g., flowcharts) Tools to organize ideas (e.g., cause-and-effect diagrams) Tools to analyze and display data (e.g., run charts) Resources and help that is available to support your HIV program’s Quality Improvement efforts.

3. Key Question What tools can help my HIV care program analyze information and make decisions? Key Question

4. Ice Breaker Tools Brainstorming Affinity Diagrams Prioritization Processes

5. Ice-Breaker Generate ideas by brainstorming. (5 minutes)brainstorming What things need to be considered in planning the perfect vacation? Write each idea on a separate sticky note and put these on a wall. Remember to: –Emphasize volume of ideas –Suspend judgment –Piggyback on other ideas –Assure fair and equal participation The team with the most answers in 5 min. wins!

6. Ice-Breaker Sort ideas by affinitizing. (15 minutes) 5 Volunteers will sort ideas into natural themes by asking: - What ideas are similar? - Is this idea connected to any of the others? Keep moving the Post-It notes around until consensus is reached. Sort the ideas in silence so that no one is influenced by anyone else's comments.

7. Ice-Breaker Create an affinity/header label (5 minutes) Volunteers will create a description for each related group of ideas. Write this theme/header on a colored post-it and place at the top of the group it describes. Utilize a prioritizing process to rank groups. Each person has red dots. Use red dots to vote on the most important ideas. Count the total dots for each affinity group and rank the top 3 ideas.

8. Brainstorming Purpose: To provide a freewheeling environment in which everyone is encouraged to participate. Use:  generate new ideas/insights  draw out experiences of each participant  when creative ideas have been suppressed by group Caution: ideas will need elaboration discussion impedes & limits flow of ideas

9. Brainstorming Tips:  Most important factors: - Getting the right people in the room - Getting the question right  Remember the rules: - Don’t discuss, debate or censor - Get every idea out on paper  Can be difficult for quiet people to participate

10. Affinity Analysis Purpose: Gather large amounts of information & organize it on basis of affinities (natural relationships) Use:  Sifting through large volumes of data  Encouraging new patterns of thinking Caution:  Minimize discussion during sorting  If less than 15 items of information have been identified you can skip the Affinity process

11. Affinity Analysis Tips:  Smaller teams of people are best. Maximum of 10, 5-6 is best  When you move your Post-Its, make sure the groupings are clear  Single Post-It “groups” are OK  You can divide large groupings into subgroups. Create sub-header cards if you do so

12. Creating and Affinity Diagram Step 1 – Generate ideas Step 2 – Display ideas Step 3 – Sort ideas into groups Step 4 – Create header cards Step 5 – Draw finished diagram IDEA SUPER HEADER HEADER IDEA

13. Understanding Processes Processes are the object of our quality effort Improving quality means improving processes

14. Types of Processes in Health Care Flowcharts Patient flow Information flow Material flowClinical practice

15. Commonly Used Flow Chart Symbols: Purpose: Graphic depiction of how a process works Use: 1) visualize and understand a process; 2) consider ways to simplify; 3) recognize unnecessary steps; 4) identify who will be involved in or effected by improvement process Caution: 1) flowchart must reflect real process; 2) people who know the process must be involved; 3) be sure the flowchart focuses on the identified problem Task or Step Terminator Decision Wait symbol Flow Charts

16. Flow Chart Example Patient arrives at front desk Client in system? Receptionist asks client to complete paperwork for new clients and return it to front desk NO Ask client to be seated in the Waiting room YES HR Counselor takes client into Counseling Room ETC. Front Desk Staff Asks Client for Name & Searches Database Client Arrives at Drop-In Center

17. Creating a Flow Chart 1.Agree on use and level of detail 2.Define starting and ending points 3.Document each step 4.Follow each branch to the end 5.Review the chart 6.Assign action items to fill in blanks and verify accuracy Flowcharts

18. Flow Chart Group Exercise: The Best Pizza in the World (20 Minutes) Decide on start and end point Brainstorm all the steps in the process Write a single step on a single post-it note Arrange the post-it notes in order on your flipchart

19. Flow Chart Exercise Debrief What are your take-aways from the exercise? When instructing others on creating process flowcharts, what one thing would you emphasize?

20. Flow Charts Tips for Success Get the right people in the room Drive out fear! Use Post-it™ notes Capture improvement ideas as you go Record the major steps in one meeting Carefully review the flowchart Flowcharts

21. Organizing “Theories of Cause” Process problems are caused by: Methods Materials Equipment Environment People Cause-and-Effect Diagrams

22. Cause-and-Effect Diagram Organizes and displays all causes and sub-causes that may influence a problem, outcome, or effect Helps push people to think beyond the obvious causes, (money, time) to find some causes that they can fix/improve Helps organize potential solutions and make clear who should be involved in solutions Encourages a balanced view Demonstrates complexity of the problem

23. CAUSE-AND-EFFECT DIAGRAM SAMPLE Low show rate for appointments ProceduresPeople Patients Patient unaware of appointment Computer System down for routine maintenance Skeleton Equipment Environment

24. Cause-and-Effect Diagram Example

25. 25

26. Cause-&-Effect Diagram-Practice (20 Minutes) Problem: Low Rate of Consumer Involvement in QI Please select a facilitator/recorder & report back to full group 1. Draw the diagram’s skeleton. 2. Write the problem (“effect”) in box on right-side. 3. Brainstorm potential causes. 4. Review and refine causes. (Ask “why does this happen?”3-5 xs) 5.Based upon causes determine major categories. (E.g.. Methods; Materials; Systems; Policies; Environment; People) 6. Check for logic, completeness and balance.

27. Have the Diagram, Now What? Need to test the theories On to your quality improvement work! & OUR BREAK Cause-and-Effect Diagrams

28. Analyzing and Displaying Data Run charts Histograms Pareto diagrams Analyzing & Displaying Data

29. Run Chart Purpose: What Are We Looking For? Variation Trends over time Performance against a goal Analyzing & Displaying Data

30. Run Chart Analyzing & Displaying Data

31. Creating a Run Chart Analyzing & Displaying Data 1.Horizontal axis = time 2.Vertical axis = performance 3.Plot and connect data points 4.If useful, add average, median, performance goal or improvement activities

32. Histograms Purpose Used to display the variation in continuous data like time, weight, size or temperature Helps teams recognize and analyze patterns in data that are not apparent simply by looking at a table of data, or by finding the average or median

33. Constructing a Histogram Horizontal axis = continuous variable (often time, size, weight, or age) Vertical axis = frequency Count how many fall into each category Analyze and develop explanations for the pattern Analyzing & Displaying Data

34. Analyzing a Histogram Analyzing & Displaying Data

35. What the Patterns Tell Us Bell-shaped: normal Double-peaked: two of something Skewed: why the long tail? Analyzing & Displaying Data Truncated: why the abrupt end? Plateau: ill-defined process

36. What’s our Pattern Here? Group Discussion (10 Minutes) Number of days for follow-up GYN appointment Source: Institute for Healthcare Improvement Analyzing & Displaying Data

37. Pareto Chart Purpose Compare the various factors that contribute to an overall effect. Indentify the “vital few” (factors that, warrant the most attention) from the “useful many” (factors that, while useful to know about, have relatively smaller effect). Based on the Pareto Principle which suggests that most effects are the result of relatively few causes, that is, approximately 80% of effects come from 20% of potential causes. Analyzing Data

39. Constructing a Pareto Diagram Gather data on the contributing factors Create histogram with the various factors, from largest to smallest Calculate the cumulative percentages Construct another vertical percentage graph Connect a line starting from the top of the tallest bar

40. Key Summary Points There are a wealth of tools available to support QI teamwork: Brainstorming is useful to generate new ideas Affinity Grouping helps organize large amounts of data and group ideas that are related Prioritizing processes narrow down the top ideas and gets everyone on the same page to focus efforts Flowcharts help you understand processes Cause-and-effect diagrams help you gather and display theories about causes of problems Run charts, histograms and Pareto diagrams help you understand the variation in your data Key Points

41. Links to Resources on Tools NQC Quality Academy On-line Training NationalQualityCenter.org/QualityAcademy Module 14 Useful QI Tools Module 21 Statistics 101 and Creating Graphs in Excel Institute for Healthcare Improvement www.ihi.org www.ihi.org Brainstorming & Affinity Grouping Cause and Effect Diagram Pareto Diagram Histogram Mind Tools www.MindTools.comwww.MindTools.com Problem Solving and QI Tools, Affinity Grouping Balanced Score Card Affinity Diagram http://www.balancedscorecard.org/Portals/0/PDF/affinity.pdf http://www.balancedscorecard.org/Portals/0/PDF/affinity.pdf

42. Other Resources on Tools Paul Plsek’s teaching manual for “Methods and Tools of Quality Improvement,” a course sponsored by the National Demonstration Project on Quality Improvement in Health Care. Berwick, Donald M. et. al., Curing Health Care: New Strategies for Quality Improvement, San Francisco: Jossey-Bass, 1990. See especially Resource B: A Primer on Quality Improvement Tools (pp. 177-219).

43. QI Resources

44. http://NationalQualityCenter.org

45. Quality Academy NationalQualityCenter.org/QualityAcademy NationalQualityCenter.org/QualityAcademy Free online training course 32 interactive tutorials beginner to advanced 8 available in Spanish Each 15-15 min. long Slides and facilitator notes available for download

46. Quality Improvement Publications: Getting Started

47. Quality Improvement Publications for Teaching

48. Publications: Consumer Involvement

49. Quality Improvement Publications

50. Quality Improvement Publications (new!)