Useful Quality Improvement Tools

1. Useful Quality Improvement Tools The Quality Academy Tutorial 14

2. Learning Objectives: You Will Learn About… • Tools for understanding processes (e.g., flowcharts) • Tools to analyze and display data (e.g., run charts, histograms) • Tools to organize ideas (e.g., cause-and-effect diagrams) Learning Objectives

3. Tips for Viewing This Presentation Read along with the narrator Search for keywords in the presentation Skip to other slides in the presentation Review current slide Play, rewind and fast forward View full screen Tips for Viewing

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

5. A Picture is Worth a Thousand Words Tools for Understanding Processes

6. Understanding Processes • Processes are the object of our quality effort • Improving quality means improving processes Flowcharts

7. Types of Processes in Health Care Patient flow Information flow Material flow Clinical practice Flowcharts

8. Flowcharts to Understand Processes A flowchart is a picture of the steps of a process to: • Understand the process • Identify potential sources of problems • Outline the ideal process steps • Enable communications with others Flowcharts

9. Creating a Flowchart • Agree on use and level of detail • Define starting and ending points • Document each step • Follow each branch to the end • Review the chart • Assign action items to fill in blanks and verify accuracy Flowcharts

10. Most Commonly Used Flowchart Symbols Activity Connecting lines Terminator Decision A Page connector Wait symbol Flowcharts

11. Is This an Efficient Process? Staff asks name, searches data- base for file Patient in system? Patient arrives at front desk Staff asks patient to be seated Yes No Patient waits Staff asks patient to provide information Nurse takes patient to exam room Flowcharts

12. Non-Real Work “The additional steps we do because everything in the process is not perfect.” Flowcharts

13. 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

14. Be Aware… Drawing intricately detailed flowcharts can exhaust the quality improvement team’s time, energy and resources! Flowcharts

15. A) True B) False Creating a good flowchart is the most important thing a quality improvement team can do. This is where a quality improvement team should start its work, and it should continue to work on the flowchart until it is accurate, complete, comprehensive and detailed. Test Question Flowcharts

16. A) It is important to use information that is based on fact and not anecdote. B) It is best to involve those who are part of the process. C) You can either use flowcharts to identify potential problem steps or outline the ideal process flow. D) The beginning and end points in a flowchart are not critical. Which of the following statements is NOT correct? Test Question Flowcharts

17. Analyzing and Displaying Data • Run charts • Histograms • Pareto diagrams Analyzing & Displaying Data

18. Run Chart Analyzing & Displaying Data

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

20. What Are We Looking For? • Variation • Trends • Performance against a goal Analyzing & Displaying Data

21. Histograms Show Us… …the pattern of the distribution in a set of data: Number of days for follow-up GYN appointment Source: Institute for Healthcare Improvement Analyzing & Displaying Data

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

23. Which Patterns Matter? Analyzing & Displaying Data

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

25. What’s our Pattern Here? Number of days for follow-up GYN appointment Source: Institute for Healthcare Improvement Analyzing & Displaying Data

26. The Pareto Principle • “Whenever a number of individual factors contribute to some overall effect, relatively few of those items account for the bulk of the effect” • Identifying these “vital few” helps make our improvement work effective and efficient Analyzing Data

27. Analyzing Data

28. 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 Analyzing & Displaying Data

29. A) Run chart B) Histogram C) Both will work My QI team wants to see how often we meet our performance goal. Which data display tool should we use? Test Question Analyzing & Displaying Data

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

31. The Cause-and-Effect Diagram Organizes and displays theories about causal factors • Allows constructive use of anecdotes • Encourages a balanced view • Demonstrates complexity of the problem Cause-and-Effect Diagrams

32. Possible Causes of Delayed Test Results Source: Institute for Healthcare Improvement Cause-and-Effect Diagrams

33. Constructing a Cause-and-Effect Diagram • Write down the effect • Decide on major areas • Brainstorm possible causes • Ask “why?” 3 to 5 times • When ideas run low, ask for “just one more” • Check for logic, completeness and balance Cause-and-Effect Diagrams

34. Be Aware… Broad problem statements can lead to vague or unnecessarily complex cause-and-effect diagrams. Cause-and-Effect Diagrams

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

36. A) GYN follow-up appointments take a long time B) 65% of GYN follow-up appointments take two weeks or more C) Many GYN follow-up appointments happen within two days, why don't they all? D) GYN appointments don't take place on the weekends Choose the best "effect" statement: Test Question Test Question

37. Key Points • Flowcharts help you understand processes • Run charts, histograms and Pareto diagrams help you understand the variation in your data • Cause-and-effect diagrams help you gather and display theories about causes of problems Key Points

38. Resources • 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, helped inform this Tutorial. • 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). • Instructions for these and other tools are available on the website of the Institute for Healthcare Improvement, http://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/Tools/ Resources

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40. Related Tutorials • To learn more about the importance of processes, study Tutorial 12 • To learn more about run charts and variation, study Tutorial 7 • To learn more about bar charts and Pareto diagrams, study Tutorial 10 • To learn more about PDSA, study Tutorial 13 • To learn more about creating graphs, study Statistics 101 and Making Graphs in Microsoft Excel Related Tutorials

41. The Quality Academy For further information, contact: National Quality Center New York State Dept. of Health 90 Church Street, 13th floor New York, NY 10007-2919 Work: 212.417.4730 Fax: 212.417.4684 Email: Info@NationalQualityCenter.org Or visit us online at NationalQualityCenter.org In Closing