1. MHVI 2-Day Quality Improvement Training September 9, 2015 1

2. Welcome Back! Questions/Feedback from Day 1 2

3. Today’s Agenda Plan-Do-Study-Act (PDSA) Cycle o Stage One, Steps 3, 4, and 5 o Plan Stage Work Session o Stage Two, Overview o Stage Three, Overview o Stage Four, Overview o QI Project Examples and Tips Next Steps 3

4. PDSA Recap 4 PLAN Step 1: Getting Started Step 2: Assemble the team Step 3: Examine the Current Approach Step 4: Identify Potential Solutions Step 5: Develop an Improvement Theory DO Step 6: Test the Theory ACT Step 8: Standardize the Improvement or Develop a New Theory Step 9: Establish Future Plans STUDY Step 7: Study the Results

5. Step 3: Examine the Current Approach (Continued) Examine the current approach or process flow Obtain existing baseline data, or create and execute a data collection plan to understand the current approach Obtain input from families Analyze and display baseline data Determine root cause(s) of problem Revise aim statement based on baseline data as needed 5 Guidebook, 2 nd Edition, pages 30 & 36

6. Problem Solving – When confronted with a problem, most people like to tackle the obvious symptom and fix it. – This often results in more problems – Using a systematic approach to analyze the problem and find the root cause is more effective and efficient – Tools can help to identify problems that aren’t apparent on the surface (root cause) 6 Step 3: Examine the Current Approach Guidebook, 2 nd Edition, pages 30 & 36

7. QI Tackles Root Cause Root cause analysis is the process of identifying the underlying factors that lead to a problem Asks ‘why?’ a problem occurs, looking beyond the obvious symptoms Forces us to avoid jumping to a solution before we really understand the problem 7 “We can’t solve problems by using the same kind of thinking we used when we created them.” - Einstein

8. For example… 8

9. A Tool for Root Cause Analysis: Fishbone Diagrams 9

10. Fishbone Diagrams: Purpose 10 To identify and examine underlying or root causes of a problem To identify a target for your improvement that is likely to lead to change To explore possible causes of a problem Guidebook, 2 nd Edition, page 62 Memory Jogger, page 23

11. Fishbone Diagrams: Construction Step 1 Write the problem statement in a box on the far right side of your paper, dry erase board, etc. Step 2 Draw an arrow (backbone) leading to that box Step 3 Draw smaller arrows (bones) leading to the backbone, and label these arrows with your major causes Step 4 For each cause, brainstorm minor causes related to each major cause and note them on the diagram by placing lines on each of the major bones. 11

12. 12 Example Fishbone Diagram

13. Interpret Your Fishbone Diagram What causes came up again and again? What causes came as a surprise? What causes are within the group’s control or influence? What causes seem particularly important to the team? Do you know enough about these possible causes to identify a root cause to address? 13

14. 14 Example: Families are not receiving the number of home visits that they should.

15. Some Hints and Tips Find the right problem or effect statement – The problem statement should reflect an outcome of a process that you control or influence – Be specific – Reach consensus Find causes that make sense and that you can impact – Ask “why?” to achieve a deep understanding – Know when to stop 15

16. Work Session: Developing a Fishbone Diagram As a team, develop a fishbone diagram for your QI project: – Listen for step-by-step guidance from the trainers – Use chart paper and sticky notes to create your diagram Peer sharing: Be prepared to share your fishbone diagram with others. 16

17. Potential Major Cause Categories People Motivation/Incentives Policy Methods/Procedures Environment Information/Feedback Data 17 Memory Jogger, page 25

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19. Step Four: Identify Potential Solutions Identify all potential solutions to the problem based on the root cause(s) Review model or best practices to identify potential improvements Pick the best solution (the one most likely to accomplish your aim statement) 19 Guidebook, 2 nd Edition, pages 31 & 36

20. Step Four: Process 20 Using the root cause, brainstorm all possible solutions Search for similar practices Narrow to those you have control or influence over Revisit your aim statement Pick the one most likely to accomplish your aim

21. Brainstorming: Purpose To establish a common method for a team to creatively and efficiently generate a high volume of ideas on any topic by creating a process that is free of criticism and judgment. 21 Guidebook, 2 nd Edition, page 58

22. Brainstorming: When to Use To generate ideas about an opportunity for improvement To identify customers and/or stakeholders To identify potential solutions to the problem 22

23. Brainstorming: Structured Approach Step 1 Establish ground rules and define the issue or problem Step 2 Give participants 5-10 minutes to silently write down their ideas Step 3 Ask each participant to review their list and put a star next to their 3 clearest ideas Step 4 Have participants form pairs and share their 3 clearest ideas with each other and identify 4 ideas they want to be sure are shared with the whole team Step 5 Each pair shares their ideas (facilitator records or groups share cards with ideas captured) Step 6 Participants share any important ideas that are not already captured and ask clarifying questions Step 7 Collaborate to organize ideas into categories or identify themes 23

24. A few Hints and Tips Useful for generating ideas and encouraging open thinking Fosters creativity Promotes building on the ideas of others 24

25. A Tool to Organize Ideas: Affinity Diagram Group 1Group 2Group 3Group 4 Idea 25 Creatively generate a large number of ideas Organize them into natural groupings Understand possible solutions to a problem

26. Affinity Diagrams: Purpose To generate consensus When you need your team to think creatively To breakdown communication barriers To allow breakthroughs to emerge naturally To overcome “team paralysis” 26

27. Affinity Diagrams: Step by Step 27 Step 1 Phrase the issue under discussion (in this case the root cause) as a full sentence Step 2 Brainstorm at least 20 solutions to the root cause of the problem A “typical” Affinity has 40-60 items, but 100 or more are not unusual Step 3 Sort ideas (solutions) into 5 to 10 related groupings Ideas (solutions) in each grouping should have an underlying theme that ties them together Step 4 For each grouping, create summary/header cards using consensus Strive to capture the essence of all the ideas in each grouping

28. 28 Example Affinity Diagram

29. Identifying Potential Solutions: Hints and Tips Review Best/Model Practices related to the problem identified Look to your model developer and other programs for suggestions Narrow potential solutions to those within the team’s control or influence Further refine aim statement if needed Pick the best solution – the one most likely to accomplish team’s Aim Statement 29

30. Work Session: Developing an Affinity Diagram Brainstorm potential solutions to the root cause of the problem your team identified – Take 5 minutes and brainstorm individually – Share your ideas with your team Write all unique ideas on cards (should have at least 20 cards) Group ideas that fit together (have a common theme that holds them together) Develop a descriptive title for each grouping that captures the common theme 30

31. Once your Affinity Diagram is Constructed… As a team, discuss the following questions: – What do you notice about the diagram? What sticks out to you? – What does the diagram tell you about potential solutions that could be tested? – What might you add to the diagram? Is anything missing? – What solution will best address the root cause of the problem identified in step 3? 31

32. Lunch 32

33. Step 5: Develop an Improvement Theory Develop a theory for improvement – What does the team predict will happen if we use our solution? – How will the team know if our prediction was correct? – Use an “If/Then” approach Develop a strategy to test the theory – What will be tested? How? When? – Who needs to know about the test? 33 Guidebook, 2 nd Edition, pages 31 & 36

34. If/Then Statements Use an “If/Then” approach to describe your theory o “If we do______________, then we predict ______________________.” For example… o If we call families two days prior and the day of their home visit, then more families will receive an adequate number of home visits. 34

35. If/Then Statements Develop If/Then statement(s) based on the solutions you identified in Step 4 Your statement(s) should specify what will be tested and how Consider when the test will occur and who needs to know about the test You may need to develop more than one If/Then statement Adjust your aim statement accordingly, if needed Record your If/Then statement(s) on your QI Team Charter 35

36. Example Improvement Theory Problem Statement: Families are not receiving the number of home visits that they should Aim Statement: By May 14 th, 2013, the Sunny County PAT program will increase the percent of families that receive the number of visits they should rom 72% to 80%. Improvement Theory (If/Then Statement): If the home visitor calls the family one business day prior to their visit, then Sunny County PAT’s intended service dosage will increase by 5%. 36

37. Work Session: Developing an Improvement Theory As a team: o Develop an improvement theory (If/Then Statement) for your QI project based on the solution you identified in Step 4. Record your improvement theory on your QI Team Charter and on a piece of chart paper Peer sharing: Be prepared to share your improvement theory with the larger group when we all come back together. 37

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40. Stages Two, Three, and Four Steps 6, 7, 8, and 9 40

41. Stage Two: DO Step 6: Test the Theory Carry out the test Collect, chart, and display data to determine effectiveness of the test Document problems, unexpected observations, and side effects 41 Guidebook, 2 nd Edition, pages 32 & 37

42. Do Stage: How to Take your improvement theory (If/Then Statement) and plan for your test: o Prepare materials needed for your test Information/guidance documents, data collection documents, etc. o Determine when your test will occur (start and end date) Creating a calendar/timeline can be very helpful here o Determine who needs to know about your test o Meet with the people who will help you carryout your test to share materials, timeline, data collection process, and answer questions 42

43. Test! Test your improvement theory! Be sure to: – Implement your test for long enough – Collect, track, and chart data throughout your test – Document problems and unexpected observations and side effects 43

44. Never underestimate the value of an educated guess! 44

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46. Project Planning Work Session Revisit, add to, and update Team Charter Review data sources and outline any additional data needs and relevant plans Create a project workplan for the remainder of the team’s work 46 Handout: Project Planning

47. Stage Three: STUDY Step 7: Study the Results Primary focus is to determine if your test was successful. Do this by comparing the results of your test against: o Baseline data o Aim Statement 47 Guidebook, 2 nd Edition, pages 32 & 38

48. STUDY Stage: How To Determine if your test was successful by: o Compare results against baseline data and the measure of success (% or #) stated in your aim statement o Answer the following questions: Did the test work? Did the results match the team’s If/Then Theory? Did the team notice any trends? Was there an improvement? Does more testing need to be done? Were there any unintended side effects? Describe and document what you learned 48

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50. Stage Four: ACT Step 8: Standardize the Improvement or Develop a New Theory If your change was an improvement you will want to consider the following: o Do you need to test the change under different conditions (i.e. different time of the year, for longer, etc.)? o Will your change improve performance in the future? If the likelihood of continued success is promising, make plans to standardize the improvement o Consider whether procedures or guidance may need revision. 50 Guidebook, 2 nd Edition, pages 33, 34, & 39

51. The ACT Stage: Step 8 If your change was not an improvement you will want to consider the following: o Are better or different data needed? o Did we attack the wrong cause? o Did we pick the wrong solution? o What other approach might work better? Record your thoughts and begin the PDSA cycle again starting with PLAN to define a new or additional change 51

52. Stage Four: ACT Step 9: Establish Future Plans Take steps to maintain your gains and accomplishments Make plans for additional improvements Spend time celebrating your success! Share your accomplishments with partners and stakeholders Begin your next PDSA cycle 52 Guidebook, 2 nd Edition, pages 34 & 39

53. The ACT Stage Steps 8 and 9: How to Standardize your improvement or develop a new improvement theory. Celebrate your success (even if your project did not yield the results you were hoping for) & recognize your team! Share your accomplishments with the interested parties you have kept informed throughout the project. Put processes in place to maintain your gains and accomplishments. Determine the next improvement project the team would like to conduct. Begin your next PDSA cycle! 53

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55. Example QI Project Problem Statement: Families are not receiving the number of home visits that they should. Aim Statement: By May 14 th, 2013, The Guidance Center will increase by 5% the number of families that receive the number of visits they should. If/Then Statement: If the home visitor calls the family one business day prior to their visit, then the Guidance Center’s intended service dosage will increase by 5%. Study: After 3 months of testing the Improvement Theory, 96% of families received their expected number of visits (as compared to 60% of families receiving their expected number of visits prior to the test). Act: The program standardized the new calling procedure with all home visitors. Data collection continued to monitor the process. 55

56. QI Project Tips Think Big but Start Small Process Mapping – Document what is, not what you want it to be Do not assume you know the solution Take time to think about the Aim Statement – Really think about it Keep moving forward, test & learn Keep others informed about the project – you will need their input 56

57. Fitting the Pieces Together As your project takes shape, be sure that you align the pieces: o The aim statement should align with your if/then theory o The if/then theory should align with your test o The test should align with your strategy for studying your results o The strategy for studying your results should align with your aim statement 57

58. Next Steps Provider Site CQI Teams (LIAs): – Use knowledge and tools gained at this training and apply to LIA-specific CQI projects or HV CoIIN work LIA-specific – 2 CQI projects must be started per fiscal year and project documentation (team charters, tools, and story boards) submitted to MPHI on a quarterly basis HV CoIIN – documentation guidance from the CoIIN staff should be followed – Schedule and conduct regular, internal CQI project meetings throughout the quarter – Reach out to MPHI staff for TA when needed (available on an ongoing basis – Attend quarterly CQI Learning Community webinars NFP – October 20, 2015 from 8:30 am to 10 am HFA/EHS – October 21, 2015 from 10 am to 11:30 am – Participate in one CQI Learning Collaborative per year Last meeting for FY15 – September 24, 2015; 10 am to 3 pm; Henry Center, Lansing, MI Initial meeting for FY16 – November 12, 2015; 9:30 am to 3:30 pm; location TBD 58

59. Next Steps Local Leadership Group (LLG) – Use knowledge and tools gained at this training and apply to current FY15 Learning Collaborative project/upcoming FY16 Learning Collaborative project – Schedule and conduct regular, internal CQI project meetings throughout the quarter – Submit required project documentation to MPHI for review and feedback according to predetermined dates – Reach out to MPHI staff for TA when needed (available on an ongoing basis) – Participate in one CQI Learning Collaborative per year Last meeting for FY15 – September 21, 2015; 10 am to 3 pm; Lansing Center, Lansing, MI Initial meeting for FY16 – December 14, 2015; 10 am to 3 pm; Lansing Center, Lansing, MI 59

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61. Day 2 Wrap-Up Closing Comments MPHI Staff Contact Information Evaluations Adjourn 61 Thank You! Best wishes on your quality journey!