1. QUALITY IMPROVEMENT QUALITY IMPROVEMENT WORKSHOP Grace Gorenflo, MPH, RN National Network of Public Health Institutes AND Utah Public Health QI Trainers

2. SESSION OVERVIEW QI Basics Plan  Aim Statement  Flow Chart  Root Cause Analysis  Data Collection  Problem Prioritization  Solution Identification and Refinement  Work Plan 2

3. FIST TO FIVE Indicates level of support and “pulse” of the room Focuses discussion on the critical issues Elicits feedback from less vocal participants Useful for making decisions and determining degree of consensus 3

4. I will do all I can to block this! I’d like to discuss some changes MEHI like it I love it and would help lead it I need some changes No additional discussionAdditional discussion required 4

5. GROUND RULES 1.Start and end on time 2.Actively participate 3.Be respectful of other opinions 4.Keep your phone volume on low and speak softly when you take or make a call. 5

6. BRAINSTORMING/AFFINITY DIAGRAM Platform for generating many creative ideas and giving everyone a “voice” Organizes ideas in natural groupings 6

7. BRAINSTORMING/AFFINITY DIAGRAM PROCEDURE 1.Silently brainstorm – one idea per sticky note 2.Put all sticky notes up on the wall 3.Read all sticky notes and clarify as needed 4.Silently organize the notes into different groupings 5.Stop when the groups are “good enough” 6.Label each group with a brief sentence or phrase 7

8. WHAT DO YOU HOPE TO ACCOMPLISH TODAY? 1.Silently brainstorm – one idea per sticky note 2.Put all sticky notes up on the wall 3.Read all sticky notes and clarify as needed 4.Silently organize the notes into different groupings 5.Stop when the groups are “good enough” 6.Label each group with a brief sentence or phrase 8

9. QI BASICS Overview 9

10. DEFINITION OF QI IN PUBLIC HEALTH A continuous and ongoing effort, using a deliberate and defined process, to achieve measurable improvements in the efficiency, effectiveness, performance, accountability, outcomes, and other indicators of quality in services or processes which achieve equity and improve the health of the community. 10

11. MYTHBUSTERS 11 QI is about weeding out the bad apples QI is about processes - series of steps or actions performed to achieve a specific purpose. It requires a culture of transparency and accountability, and an understanding that improvement is continuous

12. If I don’t achieve my goal, I’ve failed Achieving QI goals may entail lengthening the time that an improvement is implemented, modifying or changing the improvement strategy, or even modifying the goals to reflect what has been learned MYTHBUSTERS 12

13. All change = improvement All improvement = change MYTHBUSTERS 13

14. CONTINUOUS IMPROVEMENT 14 Act Do Check Plan

15. Develop an aim statement 15

16. Describe the current process 16

17. Identify the root cause 17

18. Collect data on the current process 18

19. Identify potential improvements 19

20. DEVELOP AN ACTION PLAN 20

21. JUST DO IT!  Implement the improvement  Collect and document the data  Capture observations – barriers, keys to success, surprises, unintended consequences 21

22. CHECK: WHAT DID YOU LEARN?  Analyze the results: was an improvement achieved?  Document lessons learned, knowledge gained, and unanticipated results 22

23. TAKE ACTION  Adopt – standardize then monitor  Adapt – modify and repeat the test  Abandon – start over 23

24. WHAT IS THE PROBLEM YOU ARE SEEKING TO ADDRESS? 24

25. HOW WILL YOU KNOW THAT YOU HAVE MADE AN IMPROVEMENT? 25

26. AIM STATEMENT 1.Written discrete, measurable, and time-bound description of the scope of an improvement effort 2.Provides focus and clarity for the QI Team 3.Speaks to WHAT will be achieved, not HOW it will be achieved 4.Revisit and modify as needed 26

27. AIM STATEMENT ELEMENTS  WHAT are we striving to accomplish?  WHEN will this occur (what is the timeline)?  HOW MUCH ? What is the specific, numeric improvement we wish to achieve?  FOR WHOM ? Who is the target population? 27

28. Increase immunization rates By December 31, 2015, increase the rate of age-appropriate immunizations among school-aged children attending Faith Tabernacle by 50% 28

29. AIM STATEMENT  WHAT are we striving to accomplish?  WHEN will this occur (what is the timeline)?  HOW MUCH ? What is the specific, numeric improvement we wish to achieve?  FOR WHOM ? Who is the target population? 29

30. WHAT CHANGES WILL RESULT IN AN IMPROVEMENT? 30

31. “If you can't describe what you are doing as a process, you don't know what you're doing.” W. Edwards Deming 31

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33. FLOW CHART First step to understanding a process Organized combination of shapes, lines, and text Illustrates the entire process and how all involved people fit into the process  Uncovers variations and wasteful steps  Adjunct for policies and procedures Training tool for new employees 33

34. SymbolNameFunction Start/endSignifies the beginning or the end point ArrowShows the order of activities and clarifies the relationship between shapes RectangleRepresents an activity, task or process DiamondIndicates a decision point 34

35. FLOW CHART PROCEDURE 1.Agree on process start point and end point. 2.Agree on the level of detail needed to understand the process and identify problem areas (e.g., high-level to understand general process flow or detailed to show every specific action and decision point). 3.As a group, brainstorm a list of all major activities and decisions and write one per sticky note. 4.Start the flow chart by labeling an elongated circle as "Start". 5.Arrange the steps in the order they are carried out. (Where a decision needs to be made, arrows will need to leave the decision diamond for each possible outcome.) 6.Show the end of the process using an elongated circle labeled "Finish". 7.Add arrows once the group has agreed on all of the activities 35

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37. FLOW CHART PROCEDURE 1.Agree on process start point and end point. 2.Agree on the level of detail needed to understand the process and identify problem areas (e.g., high-level to understand general process flow or detailed to show every specific action and decision point). 3.As a group, brainstorm a list of all major activities and decisions and write one per sticky note. 4.Start the flow chart by labeling an elongated circle as "Start". 5.Arrange the steps in the order they are carried out. (Where a decision needs to be made, arrows will need to leave the decision diamond for each possible outcome.) 6.Show the end of the process using an elongated circle labeled "Finish". 7.Add arrows once the group has agreed on all of the activities 37

38. REVIEW YOUR AIM STATEMENT Do you need to refine it? 38

39. FISHBONE DIAGRAM AKA “Cause-and-effect diagram, and “Ishikawa Diagram” Identifies possible causes for a problem Promotes brainstorming 39

40. FISHBONE DIAGRAM PROCEDURE 1. Agree on a problem statement (effect). 2. Brainstorm the major categories of causes of the problem. Some generic headings: Methods, Materials/equipment, People, Policies, Environment 3. Brainstorm all the possible causes in each category. Ask “Why does this happen?” and write it as a branch from the appropriate category/fish spine. Causes can be written in several places if they relate to several categories. 4. Analyze the results: what are causes that appear the most frequently? What causes seem to be at the root? What causes appear to be significant? 40

41. FISHBONE DIAGRAM 41 People Environment Policies/ Procedures Resources/ Materials

42. ANALYZE THE FISHBONE DIAGRAM 1.What are causes that appear the most frequently? 2.What causes seem to be at the root? 3.What causes appear to be significant? 42

43. REVIEW YOUR AIM STATEMENT Do you need to refine it? 43

44. “A LOT” IS NOT A NUMBER & “TOO LONG” IS NOT A TIME 44

45. CHECK SHEET Captures data observed and collected repeatedly by the same person or at the same location Collects data on the frequency or patterns of events, problems, defects, defect location, defect causes, etc. 45

46. CHECK SHEET PROCEDURE 1. Decide what event or problem will be observed. Develop operational definitions. 2. Decide when data will be collected and for how long. 3. Design the form so that data can be recorded simply by making check marks or similar symbols. 4. Label all spaces on the form. 5. Test the check sheet for a short trial period to be sure it collects the appropriate data and is easy to use. 6. Each time the targeted event or problem occurs, record data on the check sheet. 46

47. CHECK SHEET

48. CHECK SHEET TOTALS

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56. WHAT DATA DO YOU NEED TO COLLECT? 56

57. REVIEW YOUR AIM STATEMENT Do you need to refine it? 57

58. 58 2X2 PRIORITIZATION MATRIX: WHAT ARE THE PROBLEMS WE WILL SEEK TO ADDRESS ? Quickly portray the value of different options MUST HAVES IS THE “BANG WORTH THE BUCK”? LOW-HANGING FRUIT MUST NOTS Our level of control Impact High Low

59. IMPROVEMENT STRATEGIES AKA Solutions, Interventions 59

60. SOLUTION AND EFFECT DIAGRAM 60 People Environment Policies/ Procedures Resources/ Materials

61. 61 2X2 PRIORITIZATION MATRIX: WHAT ARE THE BEST SOLUTIONS TO TEST? Ensure that the quadrant definitions are consistent with what you are seeking to compare Who is your customer? For example, staff, management, supervisor, clients, community, etc. MUST HAVES IS THE “BANG WORTH THE BUCK”? LOW-HANGING FRUIT MUST NOTS Customer Satisfaction Affordability High Low

62. SOLUTION-PROOF Potential ProblemSolution 62

63. REVIEW YOUR AIM STATEMENT Do you need to refine it? 63

64. DEVELOPING A WORK PLAN 64

65. CRITICAL ITEMS Work plan components  Activity/Task  Lead  Resources needed  Due Date Work plan content  Data collection  Communication plan  QI Council  All who are affected 65

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67. Simple Gantt Chart Constructed in Excel 67

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69. EVALUATION 69