Shawnee County Health Agency Leading the way to a healthier Shawnee County Basic QI Tools & Techniques.
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Shawnee County Health AgencyLeading the way to a healthier Shawnee County
Basic QI Tools & Techniques
Shawnee County Health AgencyLeading the way to a healthier Shawnee County
Why QI? By continually working to improve all
processes, we increase our learning and knowledge.
QI is not about pass/fail or right/wrong. Rather it’s about testing a theory. You have a learning opportunity.
Shawnee County Health AgencyLeading the way to a healthier Shawnee County
Basic Tools of QI Data collection
Check Sheet Survey Tool / Interviews Nat’l, State, Local stat’s
Data Analysis Pie Charts Bar Graph Pareto Chart Line Graph
Process Analysis Flow Charts – Process Mapping 5 Why’s
Idea Creation Affinity Diagram Brainstorming Fishbone Diagram
Effect/Cause Analysis 5 Why’s Fishbone Pareto Chart Brainstorming Interrelationship Diagraph
Evaluation & Decision-Making SWOT Analysis Evidence-based Literature Stakeholder Analysis Force Field Analysis Nominal Group Technique PMI Logic Model
Planning & Implementation PDCA/PDSA Bone Diagram Action Plans
Shawnee County Health AgencyLeading the way to a healthier Shawnee County
Stage 1Step #1 - Getting StartedDescribe the Situation Writing about the Situation
What’s the issue? Why is this a issue? For whom does the issue exist? Who has a stake in the issue? What do we know about the issue/people involved? What do existing research and experience tell us about
the issue?
Shawnee County Health AgencyLeading the way to a healthier Shawnee County
Example #1
Shawnee County Health AgencyLeading the way to a healthier Shawnee County
Stage 1Step #1 - Getting StartedDescribe the Situation An invading enemy sought to overthrow the
kingdom. During the fierce battle the kingdom’s well trained warriors mounted their warhorses to fight the enemy. All in the kingdom were confident they would be victorious as the enemy forces were outnumbered. Ultimately, not all warriors got “deployed” and in the end -
THE KINGDOM WAS LOST.
Shawnee County Health AgencyLeading the way to a healthier Shawnee County
Stage 1Step #2 - Assemble the Team
No one person understands the entire system.
One cannot change one part of a process without influencing other parts in some ways.
Shawnee County Health AgencyLeading the way to a healthier Shawnee County
Stage 1Focus on defining the problem(s) / improvement needed Define the issues(s) before attempting to fix
something What’s important? What’s broken / Needs improvement? Where is the “Mother Lode?” (high volume,
high profile, problem-prone)
Shawnee County Health AgencyLeading the way to a healthier Shawnee County
Stage 1Define the Issue
“The kingdom was lost.”
“Reduce the likelihood the kingdom can be taken again”
What’s important?
What’s broken? Needs improvement?Not enough warriors were
“deployed”
Shawnee County Health AgencyLeading the way to a healthier Shawnee County
Stage 1Define the Issue
“The kingdom was lost.”
“Reduce the likelihood the kingdom can be taken again”
What’s important?
What’s broken? Needs improvement?Not enough warriors were
“deployed”Where’s the “Mother Lode?” (high volume, high profile,
problem prone)
Shawnee County Health AgencyLeading the way to a healthier Shawnee County
Stage 1Step #3 - Examine Current Process/Approach
May need to interview staff, external partners
Make a process flow chart Check for efficiency, duplicative steps,
missed steps, steps needed
Shawnee County Health AgencyLeading the way to a healthier Shawnee County
Stage 1Step #3 - Examine Current Process/Approach
“For want of a nail the shoe was lost
For want of a shoe the horse was lost
For want of a horse the warrior was lost
For want of a warrior the battle was lost
For want of a battle the kingdom was lost
All for the want of a nail.”
Shawnee County Health AgencyLeading the way to a healthier Shawnee County
Leverage the 5-Whys Basically, the five-why analysis is a
fundamental approach of thinking, based on the logical linkage of elements into a root cause analysis. It is a tool that works with ideas/concepts
With each specific answer, repeat the question up to five times and you will typically end up with a rather solid root cause.
For each answer, look at WHO is involved
Shawnee County Health AgencyLeading the way to a healthier Shawnee County
Leveraging the 5-WhysLost the kingdom
Lost the battle Not
enough warriors Not
enough horses
Horses were not
shodNot
enough nails
Root Cause
Why?
Why?
Why?
Why?
Why?
Shawnee County Health AgencyLeading the way to a healthier Shawnee County
Leveraging the 5-Whys The therefore test has proven to be a very
reliable method to check the logic of the five-why analysis.
To do the therefore test, you read the key findings of the analysis in reverse and insert the word therefore between each step.
Shawnee County Health AgencyLeading the way to a healthier Shawnee County
Leveraging the 5-Whys
Lost the kingdom
Lost the battle Not
enough warriors Not
enough horses Horses
were not shod
Not enough
nails
Root Cause
Why?
Therefore
Start
Result
Why?
Why?
Why?
Why?
Therefore
Therefore
Therefore
Therefore
Shawnee County Health AgencyLeading the way to a healthier Shawnee County
Stage 1Define the Issue
“The kingdom was lost.”
“Reduce the likelihood the kingdom can be taken again.”
What’s important?
What’s broken? Needs improvement?Not enough warriors
mounted on warhorses Where’s the “Mother Lode?”
Not enough nails to shod all the warhorses
Shawnee County Health AgencyLeading the way to a healthier Shawnee County
Problem Statement Not enough nails to shod all the
warhorses.
Analyze the ProblemRoot cause -
Brainstorming 6-3-5
Affinity Diagram
Fishbone Diagram – all possible causes
Shawnee County Health AgencyLeading the way to a healthier Shawnee County
Fishbone Diagram
Not enough nails to shod all the warhorses
Main Cause 2
Main Cause 1
Main Cause 1
Main Cause 1
Main Cause 1
Minor Cause
Minor Cause
Minor Cause
Minor Cause
Minor Cause
Minor Cause
Minor Cause
Minor Cause
Minor Cause
Minor Cause
Minor Cause
Minor Cause
Minor Cause
influence
influence
influence
influence
influence
influence
Shawnee County Health AgencyLeading the way to a healthier Shawnee County
Stage 1Step #4 - Potential Solutions Avoid making your first QI effort a large-
scale project. Solving issues is usually easiest when you
focus on decreasing/reducing the “negative” driving forces rather than increasing the “positive” driving forces.
Shawnee County Health AgencyLeading the way to a healthier Shawnee County
“Expand-Focus Sequence”Expand
Focus
Expand
Focus
Expand
Focus
POSSIBLE PROBLEMS
PROBLEM DEFINED
POSSIBLE CAUSES
ROOT CAUSE IDENTIFIED
POSSIBLE SOLUTIONS
SOLUTION CHOSEN TO TEST
Shawnee County Health AgencyLeading the way to a healthier Shawnee County
Imposing a Change Before imposing a change, begin by asking
three key questions: What are you trying to accomplish? How will you know that a change is an
improvement? What changes can you make that will result in an
improvement? Define changes you believe will achieve your goal
Countermeasures
Shawnee County Health AgencyLeading the way to a healthier Shawnee County
Stage 1Step #5 - Develop an Improvement Theory Make a prediction – How will you know that a
change is improvement? (Measurement is essential!)
Plan What Where Who How When – timeline
Shawnee County Health AgencyLeading the way to a healthier Shawnee County
Stage 2Step #6 - Test the Theory
Just Do It!!!! Carry out the plan
During the process collect, chart, and display data to determine efficiency.
Document problems, unexpected observations
Shawnee County Health AgencyLeading the way to a healthier Shawnee County
Stage 3Step #7 - Study the Results Based on measurements
What worked? What didn’t work?
Shawnee County Health AgencyLeading the way to a healthier Shawnee County
Stage 4Step #8 - ACT Sustain if improvement
Monitor Develop new theory
If successful, plan another cycle to test it on a larger scale or under different conditions
If unsuccessful, test a different theory
Shawnee County Health AgencyLeading the way to a healthier Shawnee County
Stage 4Step #9 - Establish Future Plans Recognize, review, refocus your efforts
What went right? Where can we apply what we’ve learned? What’s next?
Shawnee County Health AgencyLeading the way to a healthier Shawnee County
9 Steps of Improvement
Focus Improve Sustain Honor
Plan – Do – Study – Act
Shawnee County Health AgencyLeading the way to a healthier Shawnee County
Describe Situation
Assemble Team
Develop aim statementDefine problem(s) / improvement needed
Examine Current Process
Decide on potential solutions
Collect supportive data-Surveys / Interviews-Nat’l, State, Local stat’s
-What’s important?-What’s broken/needs improvement?-Where’s the Mother Lode?
-Logic Model -Flow charts -Survey’s -Pareto chart -Line graph
-Include qualitative information -Check sheets-Standardization -Flow charts-Documentation -Training
Analyze the problem
PDSA Cycles
-Develop theory
-Test improvement theory
-Study Results
-ACT
-CELEBRATE!
-Flow Charts-5 Why’s
-Fishbone -Brainstorming-5 Why’s -Affinity Diagram-Pareto chart-SWOT Analysis -CIC Analysis-Stakeholder Analysis-Force Field Analysis -Bone Diagram
CQ
I
STAGE 4
STAGE 3
STAGE 2
STAGE 1
Shawnee County Health AgencyLeading the way to a healthier Shawnee County
Example #2
“QI Feud”
Shawnee County Health AgencyLeading the way to a healthier Shawnee County
Stage 1Step #1 - Getting StartedDescribe the Situation
During the last 5 months of the year there has been a increase in errors in paychecks
Shawnee County Health AgencyLeading the way to a healthier Shawnee County
78
195
1%
71%
0
34
68
102
136
170
204
238
272
Printed Non-printed
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
10/9/2008
Shawnee County Health AgencyLeading the way to a healthier Shawnee County
Stage 1Step #2 – Assemble the Team
Shawnee County Health AgencyLeading the way to a healthier Shawnee County
Define the Problem / Improvement Needed
“Errors in paychecks.”
“Reduce errors”What’s important?
Where’s the “Mother Lode?”
Printed checksWhat’s Broken? Needs Improvement?
Shawnee County Health AgencyLeading the way to a healthier Shawnee County
Stage 1Stage 1Step #3 – Examine Current Step #3 – Examine Current Process/ApproachProcess/Approach Printed Checks
Shawnee County Health AgencyLeading the way to a healthier Shawnee County
Where’s the “Mother Lode”?
27
723
46
92
100%
86%83%
71%
47%
0
20
40
60
80
100
120
140
160
180
Time Codes Benefits Withholdings Printing Other
Nu
mb
er
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
10/9/2008
Shawnee County Health AgencyLeading the way to a healthier Shawnee County
Defining the Problem
“Errors in paychecks.”
“Reduce errors”What’s broken?
What’s important?
Where’s the “Mother Lode?”
Printed checks
Time codes
Shawnee County Health AgencyLeading the way to a healthier Shawnee County
Problem StatementDuring the first five months of the year, time code errors accounted for 47% of all incorrect printed paychecks, which was 2X higher than the next highest contributor (non-printed).
Shawnee County Health AgencyLeading the way to a healthier Shawnee County
Time code errors accounted for 47%
of all incorrect paychecks
MATERIALSPEOPLE
PROCESS / METHODS
MACHINERY / EQUIPMENT
Out of date documents
Confusing Timesheets
Wrong codes entered
Software Incorrect
Entered incorrectly
Old codes used
Out of date documents
Invalid codes
Duplicate Entries Required
Paycheck reduction errors project
Table Updates
All Possible Causes
Shawnee County Health AgencyLeading the way to a healthier Shawnee County
Next Steps Step #4 - Potential Solutions
Time code errors accounted for 47%
of all incorrect paychecks
MATERIALSPEOPLE
PROCESS / METHODS
MACHINERY / EQUIPMENT
Out of date documents
Confusing Timesheets
Wrong codes entered
Software Incorrect
Entered incorrectly
Old codes used
Out of date documents
Invalid codes
Duplicate Entries Required
Paycheck reduction errors project
Table Updates
Shawnee County Health AgencyLeading the way to a healthier Shawnee County
“Expand-Focus Sequence”Expand
Focus
Expand
Focus
Expand
Focus
POSSIBLE PROBLEMS
PROBLEM DEFINED
POSSIBLE CAUSES
ROOT CAUSE IDENTIFIED
POSSIBLE SOLUTIONS
SOLUTION CHOSEN TO TEST
Shawnee County Health AgencyLeading the way to a healthier Shawnee County
Next Steps – Impose a Change Step #5 - Develop Improvement Theory
Target – 50% reduction in time code errors by 6/1/09
Step #6 – Do Test the Theory
Step #7 – Study The Results
Step #8 – Act Step #9 – Honor
CELEBRATE!!!
Shawnee County Health AgencyLeading the way to a healthier Shawnee County
Improvement
Shawnee County Health AgencyLeading the way to a healthier Shawnee County
Example #3
Shawnee County Health AgencyLeading the way to a healthier Shawnee County
Stage 1 Step #1 - Getting StartedThe Situation
“It appears (staff observations)” WIC clients are not keeping scheduled
appointments
Shawnee County Health AgencyLeading the way to a healthier Shawnee County
Collect supportive data Kansas WIC Program -Show Rates
72%
74%
74%
75%
77%
78%
84%
86%
86%
65% 70% 75% 80% 85% 90%
FU
RD
NE+
TOS
MC
RC
CP
NC
NEI
App
oint
men
t Typ
e
Series1
Shawnee County Health AgencyLeading the way to a healthier Shawnee County
Stage 1Step #2 – Assemble the Team
Nurses Dietitians Clerks
Shawnee County Health AgencyLeading the way to a healthier Shawnee County
Stage 1Defining the Problem
“WIC no-show rates.”
“Reduce no-show rates.”What’s broken / Needs improvement?
What’s important?
FU Appts”
Where’s the Mother Lode?
Shawnee County Health AgencyLeading the way to a healthier Shawnee County
Stage 1Stage 1Step #3 – Examine Current Step #3 – Examine Current Process/ApproachProcess/Approach Scheduling FU Appointments
Shawnee County Health AgencyLeading the way to a healthier Shawnee County
Collect supportive data Kansas WIC Program -Show Rates
72%
74%
74%
75%
77%
78%
84%
86%
86%
65% 70% 75% 80% 85% 90%
FU
RD
NE+
TOS
MC
RC
CP
NC
NEI
App
oint
men
t Typ
e
Series1
Shawnee County Health AgencyLeading the way to a healthier Shawnee County
What’s Broken / Needs Improvement?
Pareto Chart for WIC 33 percent fail for RC Appt Type
653
521
225 225
109 93 77 683 2
33.0%
59.4%
70.8%
82.2%
87.7%92.4%
96.3%99.7% 99.9%
0
200
400
600
800
1000
1200
1400
1600
1800
RC NE+ CP FU NEI MC NC RD TOS Other
Appointment Categories
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
Shawnee County Health AgencyLeading the way to a healthier Shawnee County
Defining the Problem“WIC no show rates.”
“Reduce no-show rates.”
What’s broken / Needs improvement?
What’s important?
“Re-cert appts”
Where’s the Mother Lode?
Shawnee County Health AgencyLeading the way to a healthier Shawnee County
Defining the Problem“WIC no show rates.”
“Reduce no-show rates.”
What’s broken?
What’s important?
“Re-certs”
Where’s the Mother Lode?
“?? – ”
Shawnee County Health AgencyLeading the way to a healthier Shawnee County
Stage 1Stage 1Step #3 – Examine Current Step #3 – Examine Current Process/ApproachProcess/Approach Scheduling Re-cert Appointments
Shawnee County Health AgencyLeading the way to a healthier Shawnee County
Problem Statement
During May 2008-July 2008. WIC Recertification (RC) appointments accounted for 33% of WIC “No-show” rates.
Shawnee County Health AgencyLeading the way to a healthier Shawnee County
Analyze All Possible Causes
Personal Barriers (for clients)
During May -July 2008, Recertification appointments
Accounted for 33% of WIC No Show rates.
Time
People/Staff Technology SPACE
Lack of space For clients
Transportation
Space being used for staff & storage
Reminder callsNot made
Too manyStaff scheduling
Lack of Auto-dialer
Lack of delegation Of who can schedule
Staff overwhelmed
Staff not Properly trained
Lack ofTraining/flexibilty
InefficientDistribution
Of tasks
Short-staffed
Client’s don’tTrust staff
Staff some-Times rude
Lackof
Clients notorganized
Appointmentavailability
Client’s workschedule
Client’s whoWork late need
Late clinichours
Appt. Duration times
Some toolong
IneffectiveUse of
Staff timeLack of training
= Identified Root Cause
Shawnee County Health AgencyLeading the way to a healthier Shawnee County
Defining the Problem“WIC no show rates.”
“Reduce no-show rates.”
What’s broken?
What’s important?
“Re-certs”
Where’s the Mother Lode?
“1) – Staff training ”
Shawnee County Health AgencyLeading the way to a healthier Shawnee County
Client Satisfaction SurveyPlease circle how well you think we are doing in
the following areas:
GREAT
5 (avg.67%)GOOD
4OK
3FAIR
2POOR
1
Ease of getting services:
Ability to get in to be seen 85 (64%) 37(28%) 11(8%) 0 0
Hours office is open 82 (62%) 41(31%) 8 (6%) 1 (1%) 0
Convenience of office location 83 (64%) 36 (28%) 9 (7%) 2 (2%) 0
Prompt return on calls 60 (46%) 43 (33%) 17(13%) 6 (5%) 4 (3%)
Time in waiting room 56 (43%) 47 (35%) 19 (14%) 8 (6%) 1(1%)
Staff: (Nurse/Dietitian)
Friendly and Helpful to you 96 (72%) 27 (20%) 8 (6%) 2 (2%) 0
Takes enough time with you 89 (67%) 32 (24%) 8 (6%) 3 (2%) 0
Explains what you want to know 91 (69%) 29 (22%) 9 (7%) 2 (2%) 0
Shawnee County Health AgencyLeading the way to a healthier Shawnee County
Defining the Problem“WIC no show rates.”
“Reduce no-show rates.”
What’s broken?
What’s important?
“Re-certs”
Where’s the Mother Lode?
1) – “Staff training ”
2) – “Prompt return of phone calls”
Shawnee County Health AgencyLeading the way to a healthier Shawnee County
Next Steps Step #4 – Potential Solutions Cross train staff Prompt return on phone calls
Need to conduct a phone call tally
Shawnee County Health AgencyLeading the way to a healthier Shawnee County
Next Steps – Impose a Change Step #5 – Develop Improvement Theory
Target –
Step #6 – Do Test Theory
Step #7 – Study The results
Step #8 – Act Step #9 – Honor
CELEBRATE!!!
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