Quality Management Reports

7/25/2019 Quality Management Reports

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THE EIGHT ELEMENTS OF TQM

Total Quality Management (TQM) is a management approach that originated in the 1950s andhas steadily become more popular since the early 1980s. Total quality is a description o theculture! attitude and organi"ation o a company that stri#es to pro#ide customers $ith productsand ser#ices that satis y their needs. The culture requires quality in all aspects o thecompany%s operations! $ith processes being done right the irst time and de ects and $asteeradicated rom operations.

To be success ul implementing TQM! an organi"ation must concentrate on the eight &ey

elements'1. thics

. *ntegrity+. Trust,. Training5. Team$or& -. eadership/. ecognition8. ommunication

Key Elements

TQM has been coined to describe a philosophy that ma&es quality the dri#ing orce behindleadership! design! planning! and impro#ement initiati#es. 2or this! TQM requires the help o those eight &ey elements. These elements can be di#ided into our groups according to their

unction. The groups are'

*. 2oundation 3 *t includes' thics! *ntegrity and Trust.**. 4uilding 4ric&s 3 *t includes' Training! Team$or& and eadership.***. 4inding Mortar 3 *t includes' ommunication.* . oo 3 *t includes' ecognition

I. Foundation

TQM is built on a oundation o ethics! integrity and trust. *t osters openness! airness andsincerity and allo$s in#ol#ement by e#eryone. This is the &ey to unloc&ing the ultimate

potential o TQM. These three elements mo#e together! ho$e#er! each element o erssomething di erent to the TQM concept.

1. Ethics 3 thics is the discipline concerned $ith good and bad in any situation. *t is a t$o6aceted sub7ect represented by organi"ational and indi#idual ethics. rgani"ational ethics

establish a business code o ethics that outlines guidelines that all employees are to adhere toin the per ormance o their $or&. *ndi#idual ethics include personal rights or $rongs.

. Integrity 3 *ntegrity implies honesty! morals! #alues! airness! and adherence to the actsand sincerity. The characteristic is $hat customers (internal or e ternal) e pect and deser#e to

recei#e. :eople see the opposite o integrity as duplicity. TQM $ill not $or& in an atmosphereo duplicity.

+. Trust 3 Trust is a by6product o integrity and ethical conduct. ;ithout trust! the rame$or& o TQM cannot be built. Trust osters ull participation o all members. *t allo$sempo$erment that encourages pride o$nership and it encourages commitment. *t allo$sdecision ma&ing at appropriate le#els in the organi"ation! osters indi#idual ris&6ta&ing or continuous impro#ement and helps to ensure that measurements ocus on impro#ement o

process and are not used to contend people. Trust is essential to ensure customer satis action.<o! trust builds the cooperati#e en#ironment essential or TQM.

II. ric!s

4asing on the strong oundation o trust! ethics and integrity! bric&s are placed to reach theroo o recognition. *t includes'

,. Training 3 Training is #ery important or employees to be highly producti#e. <uper#isors

are solely responsible or implementing TQM $ithin their departments! and teaching their employees the philosophies o TQM. Training that employees require are interpersonal s&ills!the ability to unction $ithin teams! problem sol#ing! decision ma&ing! 7ob management

per ormance analysis and impro#ement! business economics and technical s&ills. =uring thecreation and ormation o TQM! employees are trained so that they can become e ecti#eemployees or the company.

5. Team"or! 3 To become success ul in business! team$or& is also a &ey element o TQM.;ith the use o teams! the business $ill recei#e quic&er and better solutions to problems.Teams also pro#ide more permanent impro#ements in processes and operations. *n teams!

people eel more com ortable bringing up problems that may occur! and can get help rom

other $or&ers to ind a solution and put into place. There are mainly three types o teams thatTQM organi"ations adopt'

>. Quality impro#ement teams or e cellence teams (Q*Ts) 3 These are temporaryteams $ith the purpose o dealing $ith speci ic problems that o ten recur. Theseteams are set up or period o three to t$el#e months.

4. :roblem sol#ing teams (:<Ts) 3 These are temporary teams to sol#e certain problems and also to identi y and o#ercome causes o problems. They generally last

rom one $ee& to three months.



. ?atural $or& teams (?;Ts) 3 These teams consist o small groups o s&illed$or&ers $ho share tas&s and responsibilities. These teams use concepts such asemployee in#ol#ement teams! sel 6managing teams and quality circles. These teamsgenerally $or& or one to t$o hours a $ee&.

-. Leadershi# 3 *t is possibly the most important element in TQM. *t appears e#ery$here inorgani"ation. eadership in TQM requires the manager to pro#ide an inspiring #ision! ma&estrategic directions that are understood by all and to instill #alues that guide subordinates. 2or

TQM to be success ul in the business! the super#isor must be committed in leading hisemployees. > super#isor must understand TQM! belie#e in it and then demonstrate their belie and commitment through their daily practices o TQM. The super#isor ma&es sure thatstrategies! philosophies! #alues and goals are transmitted do$n through out the organi"ation to

pro#ide ocus! clarity and direction. > &ey point is that TQM has to be i ntroduced and led bytop management. ommitment and personal in#ol#ement is required rom top management increating and deploying clear quality #alues and goals consistent $ith the ob7ecti#es o thecompany and in creating and deploying $ell de ined systems! methods and per ormancemeasures or achie#ing those goals.

III. inding Mortar/. $ommunication 3 *t binds e#erything together. <tarting rom oundation to roo o theTQM house! e#erything is bound by strong mortar o communication. *t acts as a #ital lin&

bet$een all elements o TQM. ommunication means a common understanding o ideas bet$een the sender and the recei#er. The success o TQM demands communication $ith andamong all the organi"ation members! suppliers and customers. <uper#isors must &eep openair$ays $here employees can send and recei#e in ormation about the TQM process.

ommunication coupled $ith the sharing o correct i n ormation is #ital. 2or communication to be credible the message must be clear and recei#er must interpret in the $ay the senderintended.

There are di erent $ays o communication such as'>. =o$n$ard communication 3 This is the dominant orm o communication in anorgani"ation. :resentations and discussions basically do it. 4y this the super#isorsare able to ma&e the employees clear about TQM.

4. @p$ard communication 3 4y this the lo$er le#el o employees are able to pro#ide suggestions to upper management o the e ects o TQM. >s employees pro#ide insight and constructi#e criticism! super#isors must listen e ecti#ely tocorrect the situation that comes about through the use o TQM. This orms a le#el o

trust bet$een super#isors and employees. This is also similar to empo$eringcommunication! $here super#isors &eep open ears and listen to others.

. <ide$ays communication 3 This type o communication is important because it brea&s do$n barriers bet$een departments. *t also allo$s dealing $ith customersand suppliers in a more pro essional manner.

I%. &oo' 8. &ecognition 3 ecognition is the last and inal element in the entire system. *t should be

pro#ided or both suggestions and achie#ements or teams as $ell as indi#iduals. mployeesstri#e to recei#e recognition or themsel#es and t heir teams. =etecting and recogni"ingcontributors is the most important 7ob o a super#isor. >s people are recogni"ed! there can behuge changes in sel 6esteem! producti#ity! quality and the amount o e ort e horted to t he tas& at hand. ecognition comes in its best orm $hen it is immediately ollo$ing an action that anemployee has per ormed. ecognition comes in di erent $ays! places and time such as!

;ays 3 *t can be by $ay o personal letter rom top management. >lso by a$ard banquets! plaques! trophies etc.

:laces 3 Aood per ormers can be recogni"ed in ront o departments! on per ormance boards and also in ront o top management.

Time 3 ecognition can gi#e at any time li&e in sta meeting! annual a$ard banquets! etc.

$onclusion

;e can conclude that these eight elements are &ey in ensuring the success o TQM in anorgani"ation and that the super#isor is a huge part in de#eloping these elements in the $or&

place. ;ithout these elements! the business entities cannot be success ul TQM implementers.*t is #ery clear rom the abo#e discussion that TQM $ithout in#ol#ing integrity! ethics andtrust $ould be a great remiss! and in act it $ould be incomplete. Training is the &ey by $hichthe organi"ation creates a TQM en#ironment. eadership and team$or& go hand in hand. ac& o communication bet$een departments! super#isors and employees create a burden on the

$hole TQM process. ast but not the leastB recognition should be gi#en to people $hocontributed to the o#erall completed tas&. Cence! led by e ample! train employees t o pro#ide aquality product! create an en#ironment $here there is no ear to share &no$ledge! and gi#ecredit $here credit is due i s the motto o a success ul TQM organi"ation.

Implementing a Total Quality Management System

Generic Model for Implementing TQM

1. Top management learns about and decides to commit to TQM. TQM isidenti ed as one of the organization’s strategies.



. The organization assesses current culture! customer satisfaction! and"uality management systems.

#. Top management identi es core $alues and principles to be used!and communicates them.

%. & TQM master plan is de$eloped on the basis of steps 1! ! and #.

'. The organization identi es and prioritizes customer demands andaligns products and ser$ices to meet those demands.

(. Management maps the critical processes through )hich theorganization meets its customers’ needs.

*. Management o$ersees the formation of teams for processimpro$ement e+orts.

, . The momentum of the TQM e+ort is managed by the steeringcommittee.

-. Managers contribute indi$idually to the e+ort through hoshinplanning! training! coaching! or other methods.

1 . /aily process management and standardization ta0e place.

11. rogress is e$aluated and the plan is re$ised as needed.

1 . 2onstant employee a)areness and feedbac0 on status are pro$idedand a re)ard3recognition process is established.

Five strategies to develop TQM process

Strategy 1: The TQM element approach

The TQM element approach ta0es 0ey business processes and3ororganizational units and uses the tools of TQM to foster impro$ements.

This method )as )idely used in the early 1-, s as companies tried toimplement parts of TQM as they learned them.

45amples of this approach include "uality circles! statistical processcontrol! Taguchi methods! and "uality function deployment.

Strategy 2: The guru approach

The guru approach uses the teachings and )ritings of one or more of theleading "uality thin0ers as a guide against )hich to determine )here theorganization has de ciencies. Then! the organization ma0es appropriatechanges to remedy those de ciencies.

Strategy 3: The organization model approach

In this approach! indi$iduals or teams $isit organizations that ha$e ta0en aleadership role in TQM and determine their processes and reasons forsuccess. They then integrate these ideas )ith their o)n ideas to de$elopan organizational model adapted for their speci c organization.

This method )as used )idely in the late 1-, s and is e5empli ed by theinitial recipients of the Malcolm 6aldrige 7ational Quality &)ard .

Strategy 4: The Japanese total uality approach

8rganizations using the 9apanese total "uality approach e5amine thedetailed implementation techni"ues and strategies employed by /eming

rize:)inning companies and use this e5perience to de$elop a long;rangemaster plan for in;house use.

This approach )as used by <lorida o)er and =ight>among others>toimplement TQM and to compete for and )in the /eming rize.

Strategy !: The a"ard criteria approach

?hen using this model! an organization uses the criteria of a "uality a)ard!for e5ample! the /eming rize! the 4uropean Quality &)ard! or the Malcolm6aldrige 7ational Quality &)ard! to identify areas for impro$ement. @nderthis approach! TQM implementation focuses on meeting speci c a)ardcriteria.

&lthough some argue that this is not an appropriate use of a)ard criteria!some organizations do use this approach and it can result in impro$ement.

http://asq.org/learn-about-quality/malcolm-baldrige-award/overview/overview.html








TOT(L Q)(LIT* M(N(GEMENT

; >lso re erred as continuous quality impro#ement

; *s a philosophy de#eloped by =r. d$ard =emings

; onsidered as the Callmar& o highly success ul Dapanese management system

; *t is based on the premise that the indi#idual is the ocal element on $hich production and ser#ice depends

; *t is a management approach or an organi"ation! centered on quality based onthe participation o all its members and aiming at long term success throughcustomer satis action! and bene its to all members o the organi"ation and tosociety.

; *t is aimed at embedding a$areness o quality in all organi"ational processes.

∗ Quality is built into the service or product, rather than assuming that inspection of or removal of error lead to quality (kirk 1992). hus identifying and doing the right things, the right !ay the first time and problem prevention planning " not inspectionand reactive problem solving # leads to quality outcomes.

; *n TQM this philosophy is incorporated into the organi"ations culture and isre lected in all attitudes regarding hierarchies cost containment and humanrelations (ari&ian! 1991).

; The ultimate responsibility or TQM belongs to the top le#el management!cooperation and support must ilter rom the top o the organi"ation hierarchydo$n to the subordinates.

; TQM is a ne#er ending process e#erything and e#eryone in the organi"ation aresub7ect to continuous impro#ement e orts

∗ $o matter ho! good the product or service is, the Q% philosophy says, there isal!ays a room for improvement

Em#o"erment o' the em#loyees

; :ro#iding positi#e eedbac&s and rein orcing attitudes and beha#iors thatsupports quality and producti#ity

; 4ased on the premise that employees ha#e an in6depth understanding o their 7obs! belie#e they are #alued and eel encouraged to impro#e product or ser#icequality through ris& ta&ing creati#ity

# TQM trust employees to be &no$ledgeable! accountable! and responsible and pro#ides education or training or employees at all le#els

Three +asic #rinci#les o' TQM are to

1. 2ocus on achie#ing customer satis action

. <ee& continuous and long6term impro#ement in all the organi"ational processes andoutputs.

+. Ta&e steps to ensure the ull in#ol#ement o the entire $or& orce in impro#ing

quality.

Glasser . , +asic conditions that must +e met i' "or!ers are to do -uality "or!.

1. n#ironment must be $arm and supporti#e. The $or&ers must trust themanagement.

. ;or&ers must be as&ed to do only use ul or purpose ul $or&. They should belie#ethat they are contributing to a $orth$hile need.

+. ;or&ers must be as&ed to do the best they can.,. 2rom the time $or&ers are hired! lead6managers must guide the process o helping

them learn to e#aluate their $or& continually. 4ased on the ongoing e#aluation!lead6managers $ill then encourage the $or&ers to impro#e the quality o $hat theydo

5. Quality $or&s al$ays eels good.Total -uality management #rinci#les

1. reate a constancy o purpose or the impro#ement o products and ser#ice.. >dopt a philosophy o continual impro#ement.

+. 2ocus on impro#ing process! not on inspection o product.,. nd the practice o a$arding on business on price alone. *nstead! minimi"e total cost

by $or&ing $ith a single suppler.5. *mpro#e constantly e#ery process or planning! production and ser#ice.-. *nstitute 7ob training and retraining/. =e#elop the leadership in the organi"ation.8. =ri#e out ears by encouraging employees to participate acti#ely in the process.9. 2oster interdepartmental cooperation and brea& do$n barriers bet$een departments

10. liminate slogans! e hortations!! and target or $or& orce



11. 2ocus on quality! and not 7ust on quantityB eliminate quota system i they are in the place

1 . :romote team$or& rather than indi#idual accomplishment. liminate the annualratings or merit system

1+. ducateEtrain employees to ma imi"e personal de#elopment1,. harge all employees $ith carrying out the total quality management process.

TQM is $om#osed o' Three aradigms/1. Total . *n#ol#ing the entire organi"ation! supply chain! andEor product li e cycle

. Quality ' $ith its usual de initions! $ith all its comple ities

+. Management/ the system o managing $ith steps li&e :lan! rgani"e! ontrol!ead! <ta ! pro#isioning and the li&e.

∗ &nder Q%, the term total quality management is defined in terms of planning,organi'ing, directing, and controlling of all aspects of management process .

lan01o0 $hec! 0 (ct cycle

; *ntroduced by =emings.

F6 ind a person to impro#e

O 6 rgani"e a team that &no$s the process

$0 lari y current &no$ledge o t he process

) 6 nderstand causes o process #ariation

S6 elect the process impro#ement

6 lan impro#ement and continue data collection

1 6 o the impro#ement! data collection! and analysis

$ 6 hec& the results and lesson learned rom the team e ort

(0 ct to hold the gain and to continue to impro#e the process

asic assum#tions o' 1$( cycle

1. decisions should be based on acts instead o on hunches and intuition. people $ho per orms the $or& &no$ it best

+. team can ha#e more success than indi#iduals $or&ing alone,. teams need to be trained in problem sol#ing process

5. it helps to display in ormation graphically

1$( cycle method includes the 'ollo"ing

lan 6 plan the change; identi y opportunities; de#elop #ision statement; collect data to de ine problems and opportunities; use Q* tool to organi"e data and thin&ing

; decide on impro#ement initiati#es1o 6 implement the planed change

; implement initiati#es; test $ith trial run; identi y cost! people and materials; educate sta and management bout changes in process

$hec! 6 obser#e the e ect o change; monitor progress o initiati#es; meet $ith sta to discuss changes; delegate sta to monitor result; compare ne$ data $ith original data using Q* tools; use Q* tools to monitor results

(ct 6 ad7ust as necessary

; incorporate changes into department policies; in orm and educate all in#ol#ed; distribute ne policies to &ey i ndi#iduals; loo& or ne$ opportunities

FO$)S Methodology

The 2 @< methodology describes in a step$ise process ho$ to mo#e through theimpro#ement process.

2' 2ocus on impro#ement idea. This step as&s! F%;hat is the problemGH I;hat is theopportunityGH =uring this phase impro#ement opportunity is articulated and data are obtainedto support the hypothesis that an opportunity or impro#ement e ists.

' rgani"e a team that &no$s the $or& process. This means identi ying a group o sta members $ho are direct participants in the $or& process to be e aminedJthe point o 6ser#icesta . > team leader is identi ied $ho $ill appoint team members.

' lari y $hat is happening in the current $or& process. > lo$ diagram is #ery help ul or this. > detailed lo$chart can be analy"ed in t$o $ays to unco#er possible problems (macroand micro le#el).

* the e isting $or& process seems reasonable! $ith one or t$o areas needing impro#ement!then a micro6le#el analysis o your lo$ diagram is needed.

amine decision symbols (diamonds) that represent quality inspection acti#ities. 2or e ample! I>re resources a#ailableK.GH =iamond is a decision point. ither the resources area#ailable or they are not. an material! etc.! be eliminatedG =o some errors go undetectedG *sthe issue high priorityG This e amination $ill ensure limited re$or& and ma imum clarity.



amine each $or& process in the diagram or redundancy and #alue. * a step in the $or& process is repeated or does not ha#e any #alue or the costumer! it should be eliminated.

amine $or& processes or $aiting time areas. The $or& process should be changed toeliminate these $ait times.

amine all $or& processes or re$or& loops. > step should not be repeated. esources areal$ays limited!! especially in hospitals today.

hec&s that hand o s are smooth and necessary. Cand o s and times $hen a $or& process ishanded rom one sta person or department to another. Cand o s al$ays lea#e room or error (>dams&i! 00/). >#iation sa ety is characteri"ed by a collecti#e sense o communication andteam$or& that can be applied to patient care ( yndon! 00-).

@' @nderstand the degree o change needed. *n this stage! the team re#ie$s $hat it &no$s andand enhances its &no$ledge by re#ie$ing the literature! a#ailable data! and competiti#e

benchmar&s. Co$ are other health care organi"ations implementing processG

<' <olution' <elect a solution or impro#ement. The team can brainstorm and then choose the best solution. *t can then use the :=<> cycle to this solution. >n implementation plan should be used to trac& progress and the steps required. This i mplementation plan can be in the ormo a $or& plan or Aantt chart . This is a chart in the orm o a table that identi ies $hat acti#ityis to be completed! $ho is responsible or it! and $hen is it going to be done. *t outlines thesteps needed to implement the change.

enchmar!ing

>ccording to :atricia Lelly ( 008)'

*t is a tool used to compare producti#ity across acilities to establish per ormancegoals. The benchmar&ing data o ten pro#ides only comparable unit6o 6ser#ice

per ormance and does not re lect quality6o 6care indicators that can lin& quality patient care outcomes to producti#ity.

*t is the continual and collaborati#e discipline o measuring and comparing theresults o &ey $or& processes $ith those o the best per ormers.

*t is learning ho$ to adopt these best practices to achie#e through brea&through process impro#ement and build healthier communities.

*t ocuses on &ey ser#ices or $or& processes

Ty#es O' enchmar!ing Studies/

1 $linical enchmar! Study 3 re#ie$ outcomes o patient care

Financial enchmar!ing Studies0 amine costEcase charges and lengtho stay.

+ O#erational enchmar!ing Studies 3 re#ie$ systems that support care.*t is the &ey o benchmar&ing studies to be lin&ed to organi"ationalimpro#ements priorities to ensure that change and system redesign aresupported by senior administration.

&egulatory &e-uirement

Doint ommission on >ccreditation o Cealthcare rgani"ations(DC> ) has de#eloped standards to guide critical acti#itiesthat health care organi"ations per orm.

:reparing or an accreditation sur#ey gi#es a health careorgani"ation a $ealth o data and in ormation! $hich can beused to begin impro#ement strategies.



SENTINEL E%ENT OLI$* (N1 &O$E1)&ES

The Doint ommission adopted a ormal <entinel #ent :olicy in 199- to help hospitals thate perience serious ad#erse e#ents impro#e sa ety and learn rom those sentinel e#ents. are ulin#estigation and analysis o :atient <a ety #ents (e#ents not primarily related to the naturalcourse o the patient%s illness or underlying condition)! as $ell as e#aluation o correcti#eactions! is essential to reduce ris& and pre#ent patient harm. The <entinel #ent :olicye plains ho$ The Doint ommission partners $ith health care organi"ations that ha#ee perienced a serious patient sa ety e#ent to protect the patient! impro#e systems! and pre#ent

urther harm.

> sentinel e#ent is a :atient <a ety #ent that reaches a patient and results in any o theollo$ing'

• =eath• :ermanent harm• <e#ere temporary harm and inter#ention required to sustain l i e

>n e#ent can also be considered sentinel e#ent e#en i the outcome $as not death! permanentharm! se#ere temporary harm and inter#ention required to sustain li e. <ee list belo$.

<uch e#ents are called sentinel because they si gnal the need or immediate in#estigation andresponse. ach accredited organi"ation is strongly encouraged! but not required! to reportsentinel e#ents to The Doint ommission. rgani"ations bene it rom sel 6reporting in the

ollo$ing $ays'

• The Doint ommission can pro#ide support and e pertise during the re#ie$ o asentinel e#ent.

• The opportunity to collaborate $ith a patient sa ety e pert in The Dointommission%s <entinel #ent @nit o the ice o Quality and :atient <a ety.

• eporting raises the le#el o transparency in the organi"ation and promotes a cultureo sa ety.

• eporting con#eys the health care organi"ation%s message to the public that it isdoing e#erything possible! proacti#ely! to pre#ent similar patient sa ety e#ents in the

uture.The Doint ommission%s uni#ersal protocol is designed to pre#ent $rong6site! $rong6

procedure! or $rong6patient surgery. ?onetheless! or each hospital accredited by theommission since 00,! $rong6site surgery $as the leading sentinel e#ent reported.

;rong6site surgery e empli ies ho$ a sentinel e#ent can be lin&ed to a brea&do$n in sa etysystems and communication. ;hen e#aluating system sa eguards to pre#ent $rong6site!$rong6procedure! or $rong6patient surgery! organi"ational leaders need to as& such questionsas'

• *s there a problem $ith our policies or proceduresG• =oes our system ha#e adequate built6in redundancies and sa eguards or

practitioners to e ecti#ely double6chec& the correct site preoperati#elyG• ;hat orientation and training processes are related to the uni#ersal protocolG >re all

the right people participatingG• >re $e per orming periodic quality chec&s to determine $hether the uni#ersal

protocol is acceptable and being ollo$edG

2hy do sentinel e3ents occur4

Most sentinel e#ents result rom systemic problems rather than the mista&e or ailure o asingle indi#idual. *nadequate communication among healthcare pro#iders is the number6oneroot cause o sentinel e#ents. *n 00-! the second leading root cause $as incorrect assessmento a patient%s conditionB the third leading cause $as inadequate leadership! orientation! or training.

auses that may contribute to sentinel e#ents include greater patient acuity and multiplecomorbidities! greater dependence on medical technology! reduced lengths o stay! and

shortages o nurses and other healthcare $or&ers ($hich may decrease caregi#er continuity).>lso! a ter a hospital stay! the patient%s care may need to be coordinated $ith other departments! such as rehabilitation! long6term care! or home healthcare ser#icesB thesemultiple Ihand6o sH o communication about the patient%s plans o care $ithin a compressed

period may set the stage or a sentinel e#ent.

Handling a sentinel e3ent

> sentinel e#ent can be seen as a set o concentric circles! $ith the speci ic patient situation inthe innermost circle and the entire healthcare system in the outermost circle. ;hen anunto$ard outcome or a question o inappropriate care arises! healthcare pro essionals irstmust attend to the innermost circleJthe patient%s sa ety and $ell6being. * the e#ent in#ol#esmedical equipment! that item must immediately be ta&en out o ser#ice! bagged! and labeled

or in#estigation.

?e t! the e#ent must be communicated up the chain o leadership! and an occurrence report(or other report) must be submitted as required by the acility. ach healthcare organi"ationhas a policy regarding disclosure o ad#erse e#ents to patients and amilies. * you don%t &no$your organi"ation%s speci ic policy! re er to the policy manual or ris& management department.

&oot0cause analysis and action #lan

The Doint ommission requires that organi"ations conduct a root6cause analysis toidenti y contributing actors $ithin ,5 days o a sentinel e#ent or becoming a$are o thee#ent. This analysis ocuses on systems and processes! not indi#idual per ormance. >ll personsin#ol#ed $ith the e#ent in any $ay should participate in the analysis! as each may ha#e

important insights and obser#ations. The sooner root6cause analysis ta&es place! the betterJ $hile the circumstances are resh in participants% minds.

oot6cause analysis digs progressi#ely deeper into the e#ent! repeatedly as&ing $hy thee#ent occurred and e ploring in depth the circumstances that led to it! to determine $hereimpro#ements can be made. The analysis ma y identi y common and special causes! l eading toimplementation o an action plan or strategies to reduce the ris& o similar e#ents.

rgani"ational leaders and ris& managers should determine $hether the e#ent must bereported to the Doint ommission or other entity! such as a state healthcare regulatory agency.

The organi"ation must submit its root6cause analysis and action plan to the ommission$ithin ,5 days o the e#ent. The action plan should describe the organi"ation%s ris&6reductionapproach! set a de initi#e timeline! assign responsibility or implementation and o#ersight!speci y pilot testing as appropriate! and delineate strategies or measuring the plan%s

e ecti#eness. *n addition to addressing the innermost concentric circle o the sentinel e#ent!



the plan should spiral out to the larger circles enclosing the entire organi"ationJe#en! in somecases! to other healthcare systems.

* the sentinel e#ent must be reported to the ommission or other entity! representati#eso these groups might #isit the acility to chec& on compliance and adherence to the action

plan. rdinarily! the ommission doesn%t conduct an on6site re#ie$ unless it inds a potentialongoing immediate threat to patient health or sa ety or potentially signi icant noncompliance$ith its standards. ?onetheless! healthcare organi"ations should al$ays be ready or regulatory6body inspection and re#ie$.

eporting sentinel e#ents and their root6cause analyses and action plans to theommission broadens the ommission%s sentinel e#ent database. This! in turn! enhances&no$ledge about sentinel e#ents and helps reduce the ris& o these e#ents happening in other

acilities.The Doint ommission publishes sentinel e#ent alerts that identi y speci ic sentinel e#ents!along $ith their common underlying causes and steps to pre#ent them. rgani"ational leadersshould share these alerts $ith sta to promote education and incident pre#ention.

alance Scorecard

The balanced scorecard is a strategic planning and management system t hat is usede tensi#ely in business and industry! go#ernment! and nonpro it organi"ations $orld$ide toalign business acti#ities to the #ision and strategy o the organi"ation! impro#e internal and

e ternal communications! and monitor organi"ation per ormance against strategic goals.

*t $as originated by =rs. obert Laplan (Car#ard 4usiness <chool) and =a#id ?orton as a per ormance measurement rame$or& that added strategic non6 inancial per ormance measures to traditional inancial metrics to gi#e managers and e ecuti#es a moreNbalancedN #ie$ o organi"ational per ormance. The term balanced scorecard $as coined in theearly 1990s! the roots o the this type o approach are deep! and include the pioneering $or& o Aeneral lectric on per ormance measurement reporting in the 1950%s and the $or& o 2rench

process engineers.

Aartner Aroup suggests that o#er 50O o large @< irms ha#e adopted the 4< .More than hal o ma7or companies in the @<! urope and >sia are using balanced scorecardapproaches! $ith use gro$ing in those areas as $ell as in the Middle ast and > rica. > recentglobal study by 4ain P o listed balanced scorecard i th on its top ten most $idely used

management tools around the $orld! a list that includes closely6related strategic planning atnumber one.

The balanced scorecard has e#ol#ed rom its early use as a simple per ormancemeasurement rame$or& to a ull strategic planning and management system. The Ine$H

balanced scorecard trans orms an organi"ation%s strategic plan rom an attracti#e but passi#edocument into the marching orders or the organi"ation on a daily basis. *t pro#ides a

rame$or& that not only pro#ides per ormance measurements! but helps planners i denti y $hatshould be done and measured. *t enables e ecuti#es to truly e ecute their strategies.

This ne$ approach to strategic management $as irst detailed in a series o articlesand boo&s by =rs. Laplan and ?orton. The balanced scorecard approach pro#ides a clear

prescription as to $hat companies should measure in order to NbalanceN the inancial

perspecti#e. *t is a management system not only a measurement system that enablesorgani"ations to clari y their #ision and strategy and translate them into action. *t pro#ides

eedbac& around both the internal business processes and e ternal outcomes in order tocontinuously impro#e strategic per ormance and results. ;hen ully deployed! the balancedscorecard trans orms strategic planning rom an academic e ercise into the ner#e center o anenterprise.

ers#ecti3es

The balanced scorecard suggests that $e #ie$ theorgani"ation rom our perspecti#es! and to

de#elop metrics! collect data and analy"e itrelati#e to each o these perspecti#es'

The Learning 5 Gro"th ers#ecti3e

This perspecti#e includes employee training andcorporate cultural attitudes related to bothindi#idual and corporate sel 6impro#ement. *n a&no$ledge6$or&er organi"ation! people 66 theonly repository o &no$ledge 66 are the mainresource. *n the current climate o rapidtechnological change! it is becoming necessary

or &no$ledge $or&ers to be in a continuouslearning mode. Metrics can be put into place toguide managers in ocusing training unds $herethey can help the most. *n any case! learning andgro$th constitute the essential oundation or success o any &no$ledge6$or&er organi"ation.

Laplan and ?orton emphasi"e that NlearningN is more than NtrainingNB it also includes things li&ementors and tutors $ithin the organi"ation! as $ell as that ease o communication among$or&ers that allo$s them to readily get help on a problem $hen it is needed. *t also includestechnological tools.

The usiness rocess ers#ecti3e

This perspecti#e re ers to internal business processes. Metrics based on this perspecti#e allo$

the managers to &no$ ho$ $ell their business is running! and $hether its products andser#ices con orm to customer requirements (the mission). These metrics ha#e to be care ullydesigned by those $ho &no$ these processes most intimatelyB $ith our unique missions theseare not something that can be de#eloped by outside consultants.

The $ustomer ers#ecti3e

ecent management philosophy has sho$n an increasing reali"ation o the importance o customer ocus and customer satis action in any business. These are leading indicators' i customers are not satis ied! they $ill e#entually ind other suppliers that $ill meet their needs.:oor per ormance rom this perspecti#e is thus a leading indicator o uture decline! e#enthough the current inancial picture may loo& good.

*n de#eloping metrics or satis action! customers should be analy"ed in terms o &inds o customers and the &inds o processes or $hich $e are pro#iding a product or ser#ice to those

customer groups.

http://balancedscorecard.org/BSCResources/StrategicPlanningBasics/tabid/459/Default.aspx

http://balancedscorecard.org/Resources/Performance-Measures-KPIs



http://balancedscorecard.org/Resources/Performance-Measures-KPIs




The Financial ers#ecti3e

Laplan and ?orton do not disregard the traditional need or inancial data. Timelyand accurate unding data $ill al$ays be a priority! and managers $ill do $hate#er necessaryto pro#ide it. *n act! o ten there is more than enough handling and processing o inancialdata. ;ith the implementation o a corporate database! it is hoped that more o the processingcan be centrali"ed and automated. 4ut the point is that the current emphasis on inancials leadsto the unbalanced situation $ith regard to other perspecti#es. There is perhaps a need toinclude additional inancial6related data! such as ris& assessment and cost6bene it data! in thiscategory.

Strategy Ma##ing

<trategy maps are communication tools used to tell a story o ho$ #alue is created or theorgani"ation. They sho$ a logical! step6by6step connection bet$een strategic ob7ecti#es(sho$n as o#als on the map) in the orm o a cause6and6e ect chain. Aenerally spea&ing!impro#ing per ormance in the ob7ecti#es ound in the earning P Aro$th perspecti#e (the

bottom ro$) enables the organi"ation to impro#e its *nternal :rocess perspecti#e b7ecti#es(the ne t ro$ up)! $hich in turn enables the organi"ation to create desirable results in the

ustomer and 2inancial perspecti#es (the top t$o ro$s).

1ocumentation0E3aluation0(ction0Trend

(. 1ocumentation

2hat Is 1ocumentation4

• *t is the proper! systematic and permanent recording o in ormation• *t is an organi"ed $ay o documenting data as per time! place! circumstances! and

attribution• ?ursing documentation ser#es many di#erse! comple and important unctions rom

ensuring consistency o clinical care and good communication bet$een practitioners! to pro#iding e#idence i n a court o la$ that patients ha#e recei#ed

appropriate! high6quality! e#idence6based care

*mportant concepts that play a role in documentation'• <a ety. *n documentation! sa ety is to pro#ide care or the client and to yoursel by

means o recording all the assessments! planning! actions! and the inter#entionsyou%#e done $ith the client.

• onsistency o purpose. ecording all the assessment! planning! implementation!and other procedures done $ith the client! rom the diagnosis to prognosis.

• <tandardi"ation. @sing the standard $ay o recording all the data gathered or the patient%s care and all the procedures done to himEher

• *mpro#ement. >ssessing $hether the client%s condition has impro#ed $ith all the

inter#entions done to himEher to meet your goal.

E3aluation

e lection and >nalysis'

• *t is instrument is designed to assess learning progress and beha#ioral change throughanalysis o $ritten statements in re lection papers. The open6ended nature o the $ritingis intended to encourage sel 6directed re lection and e pression o both eelings andthoughts.

• amining the acti#ity or e#ent or trends and patterns and or e#idence o teacher or students trengths and $ea&nesses are the &ey element o analysis. The analysis has toinclude re lection on the intended learning outcomes o the lesson and the real outcomeso it. *t has to sho$ the essential strengths and $ea&nesses o the lesson! as $ell as are lection on $hat can be done to impro#e the deli#ery o the lesson and the learningoutcomes.

*ntegrati#e'

• > learning theory describing a mo#ement to$ard integrated lessons in helping studentsma&e connections across curricula. This higher education concept is distinct rom theelementary and high school integrated curriculum mo#ement.

• *ntegrati#e earning comes in many #arieties' connecting s&ills and &no$ledge rommultiple sources and e periencesB applying s&ills and practices in #arious settingsButili"ing di#erse and e#en contradictory points o #ie$B and! understanding issues and

positions conte tually.

(ction

Three Le3els o' Organi6ation/

• rgani"ational e#el 6 strategic! designEstructure! and deployment o resources• :rocess e#el 6 process impro#ement and reengineering inter#entions• DobE:er ormer e#el 6 coaching! per ormance management! and training

inter#entionsThree er'ormance needs that need to +e met at each le3el o' organi6ation/

• Aoals 6 speci ic standards or e pectations that customers ha#e or products or ser#ices

• =esign 6 con igurations that enables goals to be met e iciently• Management 6 practices that ensure goals are up6to6date and are achie#ed

ombining the three le#els o organi"ations $ith the three per ormance needs results in nine per ormance #ariables. 2ailure to manage these nine per ormance #ariables $ill lead to a



ailure to manage the business holistically. Thus! e#ery per ormance impro#ement e ort must be #ie$ed through this matri .

Q)(LIT* M(N(GEMENT TOOLS

7. rainstorming

4rainstorming is a method o eliciting ideas $ithout 7udgment or iltering. *t is o ten used inthe early stages o utures $or&shops and in many other conte ts. *t in#ol#es encouraging $ildand unconstrained suggestions and listing ideas as they emerge.

*t creates ne$ ideas! sol#es problems! moti#ates and de#elops teams. 4rainstorming moti#ates because it in#ol#es members o a team in bigger management issues! and it gets a team$or&ing together.

The goal in brainstorming is to thin& o all possible alternati#es! e#en those that mayseem Io targetH. 4y not limiting the possible alternati#es to only apparent appropriate ones!

people are able to brea& through habitual or repressi#e thin&ing patterns and allo$ ne$ ideasto sur ace. >lthough most o ten used by groups! brainstorming also may be used by peoplema&e decisions alone.

The main ad3antages are'

4rainstorming +rings ne" ideas on ho" to tac!le a #articular #ro+lem 3 the reethin&ing atmosphere encourages creati#ity! e#en imper ectly de#eloped thoughtsmay push the thin&ing o other participants.

ro+lems are de'ined +etter as -uestions arise 3 alternati#es appear in a ne$ or di erent perspecti#e and no#el approaches to an issue can arise during the process.

4rainstorming hel#s to reduce con'licts 3 it helps participants to see other points o #ie$ and possibly change their perspecti#e on problems. >ll participants ha#e equalstatus and an equal opportunity to participate.

The dra"+ac!s '

The im#ortance o' t he moderator is o'ten under0estimated. ten the t$o phasesare con used! ideas start to be discussed 7ust a ter they are thro$n out and thespeci ic #alue o this technique is $asted.

Sometimes the ideas #roduced are un"or!a+le. The outcomes depend on theability o the acilitator o maintaining the discussion ali#e. pponents may re use toconsider each otherNs ideas. *t is important to e plain to participants ho$ the results$ill be used to underline that they are not $asting their time.

rainstorming rocess

1. =e ine and agree the ob7ecti#e.

. 4rainstorm ideas and suggestions ha#ing agreed a time limit.

+. ategori"eEcondenseEcombineEre ine.

,. >ssessEanaly"e e ects or results.

5. :rioriti"e optionsEran& list as appropriate.

-. >gree action and timescale.

/. ontrol and monitor ollo$6up.

8. Flo"chart

> lo$chart is a diagram that represents a process or algorithm. The steps are represented by aseries o bo es or other speciali"ed s ymbols! and then connected $ith arro$s.

2hy )se a Flo"chart4

2lo$ charting allo$s brea&ing do$n any process into bite6si"ed sections and displaying themin shorthand orm. That $ay! the audience can easily see the logical lo$ and relationships

bet$een steps.

2lo$charts are an important tool across #arious industries and careers! since they are clear!concise method o displaying in ormation. :lus! lo$charts can con#ey data in a #isually

pleasing $ay! so your $or& loo&s pro essional and communicates its in ormation e ecti#ely.

2hen to Ma!e a Flo"chart

2lo$charts are ideal or communicating a step6by6step process to others. ;hen a process is particularly comple ! lo$charts allo$s ocusing intently on each step or element.

=ra$ing a lo$ chart might be help ul $hen'

• =e ining! analy"ing! or discussing a process (or a set o processes).• =ra$ing a step6by6step picture o the process or your o$n or others% understanding.• <tandardi"ing or inding areas or impro#ement in a process.

E1)$(TION FLO2$H(&T E9(M LES• :lan course$or& and academic requirements• reate a lesson plan or oral presentation• rgani"e a group or indi#idual pro7ect• <ho$ a legal or ci#il process! li&e #oter registration• :lan and structure creati#e $riting! li&e lyrics or poetry• =emonstrate character de#elopment or literature and ilm• epresent the lo$ o algorithms or logic pu""les• @nderstand a scienti ic process! li&e the Lrebs cycle• hart an anatomical process! such as digestion• Map out symptoms and treatment or diseasesEdisorders• ommunicate hypotheses and theories! li&e Maslo$%s hierarchy o needs



Sales:Mar!eting Flo"chart E;am#les

• :lot out the lo$ o a sur#ey• hart a sales process• :lan research strategies• <ho$ registration lo$s•

=isseminate communication policies! li&e an emergency : plan

usiness Flo"chart E;am#les• @nderstand order and

procurement processes• epresent an employee%s

tas&s or daily routine• @nderstand the paths that

users ta&e on a $ebsite or ina store

• =e#elop a business plan or product reali"ation plan

Manu'acturing Flo"chartE;am#les

• =enote the physical or chemical ma&eup o a

product• *llustrate the

manu acturing processrom beginning to end

• =isco#er and sol#eine iciencies in amanu act uring or

procurement process

$om#uter rogramming Flo"chart E;am#les• =emonstrate the $ay code is organi"ed• isuali"e the e ecution o code $ithin a program• <ho$ the structure o a $ebsite or application• @nderstand ho$ users na#igate a $ebsite or

program

Engineering Flo"chart E;am#les

• epresent process lo$s or system lo$s• =esign and update chemical and plant processes• >ssess the li e cycle o a structure• hart a re#erse6engineering lo$• =emonstrate the design and prototype phase o a

ne$ structure or product

<. Nominal Grou# Techni-ue

Nominal grou# techni-ue is a structured 3ariation o' small0grou# discussion toreach consensus. It gathers in'ormation +y as!ing indi3iduals to res#ond to -uestions#osed +y a moderator= and then as!ing #artici#ants to #rioriti6e the ideas or suggestionso' all grou# mem+ers. The process pre#ents the domination o the discussion by a single

person! encourages all group members to participate! and results in a set o prioriti"edsolutions or recommendations that represent the group%s pre erences.

Ho" to re#are 'or Nominal Grou# Techni-ue

The Meeting Room

:repare a room large enough to accommodate i#e to nine participants. rgani"e the tables in

a @6shape! $ith a lip chart at the open end o the @. Supplies

ach @6shaped table set up $ill need a lip chartB a large elt6tip penB mas&ing tapeB and paper!#encil= and <> ; ,> inde; cards 'or each #artici#ant.

Opening Statement

This statement clari ies member roles and group ob7ecti#es! and should include' a $arm$elcome! a statement o the importance o the tas&! a mention o the importance o eachmember%s contribution! and an indication o ho$ the group%s output $ill be used.



The Four Ste# rocess to $onduct Nominal Grou# Techni-ue

1. Aenerating *deas' The moderator presents the question or problem to the group in $ritten ormand reads the question to the group. The moderator directs e#eryone to $rite ideas in brie

phrases or statements and to $or& silently and independently. ach person silently generatesideas and $rites them do$n.

. &ecording Ideas/ Grou# mem+ers engage in a round0ro+in 'eed+ac! session to conciselyrecord each idea ?"ithout de+ate at this #oint@. The moderator "rites an idea 'rom agrou# mem+er on a 'li# chart that is 3isi+le to the entire grou#= and #roceeds to as!

'or another idea 'rom the ne;t grou# mem+er= and so on. There is no need to repeatideasB ho$e#er! i group members belie#e that an idea pro#ides a di erent emphasis or #ariation! eel ree to include it. :roceed until all members% ideas ha#e been documented.

+. 1iscussing Ideas/ Each recorded idea is then discussed to determine clarity andim#ortance. For each idea= the moderator as!s= A(re there any -uestions or commentsgrou# mem+ers "ould li!e to ma!e a+out the item4> This step pro#ides an opportunity

or members to e press their understanding o the logic and the relati#e importance o theitem. The creator o the idea need not eel obliged to clari y or e plain the itemB anymember o the group can play that role.

,. %oting on Ideas/ Indi3iduals 3ote #ri3ately to #rioriti6e the ideas. The 3otes are tallied toidenti'y the ideas that are rated highest +y the grou# as a "hole. The moderatoresta+lishes "hat criteria are used to #rioriti6e the ideas. To start! each group member selects the i#e most important items rom the group list and $rites one idea on each indecard. ?e t! each member ran&s the i#e ideas selected! $ith the most important recei#ing aran& o 5! and the least important recei#ing a ran& o 1.

5. > ter members ran& their responses in order o priority! the moderator creates a tally sheet onthe lip chart $ith numbers do$n the le t6hand side o the chart! $hich correspond to theideas rom the round6robin. The moderator collects all the cards rom the participants andas&s one group member to read the idea number and number o points allocated to each one!$hile the moderator records and then adds the scores on the tally sheet. The ideas that arethe most highly rated by the group are the most a#ored group actions or ideas in responseto the question posed by the moderator.

2hen to )se Nominal Grou# Techni-ue

?ominal Aroup Technique is a good method to use to gain group consensus! or e ample! $hen #arious people (program sta ! sta&eholders! community residents! etc.) arein#ol#ed in constructing a logic model and the list o outputs or a speci ic component is toolong and there ore has to be prioriti"ed. *n this case! the questions to consider $ould be'I;hich o the outputs listed are most important to achie#ing our goal and are easier tomeasureG ;hich o our outputs are less important to achie#ing our goal and are more di icult

or us to measureGH

1isad3antages o' Nominal Grou# Techni-ueequires preparation.

*s regimented and lends itsel only to a single6purpose! single6topic meeting.Minimi"es discussion! and thus does not allo$ or the ull de#elopment o ideas! and

there ore can be a less st imulating group process than other techniques.

(d3antages o' Nominal Grou# Techni-ueAenerates a greater number o ideas than traditional group discussions.4alances the in luence o indi#iduals by limiting the po$er o opinion ma&ers(particularly ad#antageous or use $ith teenagers! $here peer leaders may ha#e ane aggerated e ect o#er group decisions! or in meetings o collaborati#e! $hereestablished leaders tend to dominate the discussion).=iminishes competition and pressure to con orm! based on status $ithin the group.

ncourages participants to con ront issues through constructi#e problem sol#ing.>llo$s the group to prioriti"e ideas democratically.Typically pro#ides a greater sense o closure than can be obtained through groupdiscussion.

B. (''inity 1iagram

>lso called' > inity chart! L3D method ariation' Thematic >nalysis

The a inity diagram organi"es a large number o ideas into their natural relationships. Thismethod taps a team%s creati#ity and intuition. *t $as created in the 19-0%s by Dapaneseanthropologist Diro La$a&ita.

2hen to )se an (''inity 1iagram4• ;hen con ronted $ith many acts or ideas in apparent chaos.• ;hen issues seem too large and comple to grasp.•

;hen group consensus is necessary.Typical situations are'• > ter a brainstorming e ercise.• ;hen analy"ing #erbal data! such as sur#ey results.

(''inity 1iagram rocedure

Materials needed' stic&y notes or cards! mar&ing pens! large $or& sur ace ($all! table! or loor).

1. ecord each idea $ith a mar&ing pen on a separate stic&y note or card. (=uring a brainstorming session! $rite directly onto stic&y notes or cards i you suspect you$ill be ollo$ing the brainstorm $ith an a inity diagram.) andomly spread noteson a large $or& sur ace so all notes are #isible to e#eryone. The entire team gathersaround the notes and participates in the ne t steps.

. *t is #ery important that no one tal& during this step. oo& or ideas that seem to berelated in some $ay. :lace them side by side. epeat until all notes are grouped. *t iso&ay to ha#e IlonersH that don%t seem to it a group. *t is all right to mo#e a notesomeone else has already mo#ed. * a note seems to belong in t$o groups! ma&e asecond note.

+. The participants can tal& no$. :articipants can discuss the shape o the chart! anysurprising patterns! and especially reasons or mo#ing contro#ersial notes. > e$more changes may be made. ;hen ideas are grouped! select a heading or eachgroup. oo& or a note in each grouping that captures the meaning o the group.:lace it at the top o the group. * there is no such note! $rite one. ten it is use ulto $rite or highlight this note in a di erent color.

,. ombine groups into IsupergroupsH i appropriate



(''inity 1iagram $onsiderations

• The a inity diagram process lets a group mo#e beyond its habitual thin&ing and preconcei#ed categories. This technique accesses the great &no$ledge andunderstanding residing untapped in our intuition.

• ery important I=o notsH' =o not place the notes in any order. =o not determinecategories or headings in ad#ance. =o not tal& during step . (This is hard or some

peopleR)

• >llo$ plenty o time or step . Sou can! or e ample! post the randomly6arrangednotes in a public place and allo$ grouping to happen o#er se#eral days.

• Most groups that use these techniques are ama"ed at ho$ po$er ul and #aluable atool it is. Try it once $ith an open mind and you%ll be another con#ert.

• @se mar&ers. ;ith regular pens! it is hard to read ideas rom any distance.

&O LEM 1ES$&I TION TOOLS

Cospitals and other health care pro#iders deal $ith a host o problems besides treatment o sic& patients. This includes ser#ice deli#ery problems! management and people problems!logistics! and maintenance and resource allocation problems. @n ortunately! #ery e$ tools areused by management and the medical sta in addressing these problems. :roblems o ten recur or remain unsol#ed because o reliance on personal styles! sub7ecti#e approaches! and purelyqualitati#e approaches. Most o the methods and tools used by manu acturing and ser#ice

industries to sol#e quality problems can be applied in problem sol#ing in health care. Thesesimple tools ha#e pro#en e ecti#e in dramatically reducing i not eliminating de ects! ailures!$astes! and customer complaints in these businesses.

ar gra#hs

> bar graph is a series o bars representing successi#e changes in the #alue o a#ariable or di erent data sets. > simple bar graph can measure one set o data does not need tosubcategori"ed. The cluster bar graph can di#ide simple bar graph totals into subtotals. Thehistogram and pareto chart are bar graphs.

<imple bar graphs are also used to present categorical data! $here the groupings arediscrete categories. 4ar graphs consist o a series o labeled hori"ontal or #ertical bars $ith the

bars representing the particular grouping or category. The height or length o the bar representsthe number o units or obser#ations in that category (also called the requency).

>s an e ample! 2igure 5./ sho$s ho$ the percentage incidence o pressure ulcers#aries bet$een the #arious specialty areas. The categories are the specialty areas that are



identi i ed along the hori"ontal a is. The height o the columns corresponds to the pre#alenceo pressure ulcers reported on each o the areas.

$hec! Sheet: 1e'ect $oncentration 1iagram

hec& sheets are grids that can be used to collect and classi y ra$ data. They aregood tools or monitoring &ey per ormance indicators. That ra$ data can be used to generatehistograms! :areto charts! run charts! and other t ools that display in ormation graphically.

> hec& <heet or a =e ect oncentration =iagram is a simple data collection toolthat can help identi y the most important cause o a quality problem. *t can also be used togather in ormation on the problem or di erent aspects o the problem. This tool is use ul $henthe team has identi ied a number o causes or a number o problems or de ects! and $ants to&no$ $hich one is the most important.

$hec! Sheet rocedure

1. =ecide $hat e#ent or problem $ill be obser#ed. =e#elop operational de initions.

. =ecide $hen data $ill be collected and or ho$ long.

+. =esign the orm. <et it up so that data can be recorded simply by ma&ing chec& mar&s or s or similar symbols and so that data do not ha#e to be recopied or analysis.

,. abel all spaces on the orm.

5. Test the chec& sheet or a short trial period to be sure it collects the appropriate dataand is easy to use.

-. ach time the targeted e#ent or problem occurs! record data on the chec& sheet.

$hec! sheet 3s. chec! list/ :eople sometimes con use a chec& sheet $ith a chec& list. The list$e use or groceries and the report you get rom the auto repair shop $ith things chec&ed o a ter ser#ice (oil! ilter! tire pressure! tread! etc.) are e amples o a chec& list. The ollo$ing

table highlights some &ey di erences bet$een a chec& list and a chec& sheet.

2hen to use the chec! sheet/ @sing a chec& sheet is appropriate $hen the data can beobser#ed and collected repeatedly by either the same person or the same location. *t is also ane ecti#e tool $hen collecting data on requency and identi ying patterns o e#ents! problems!de ects! and de ect location! and or identi ying de ect causes.

Ty#es o' chec! sheets/ ommonly used chec& sheets are tabular check sheets or tally sheets !location check sheets and graphical or distribution check sheets .

Ta+ular chec! sheet or tally sheet/ The tally sheet is commonly used to collect data onquality problems and to determine the requency o e#ents. 2or e ample! the tally sheet isuse ul or understanding the reasons patients are arri#ing late or appointments! causes or delays in getting the lab results bac&! etc. *t is also use ul in determining requency o occurrence! such as number o people in the line or blood tests at -'00 am! -'15 am! etc.! tounderstand sta ing needs.

Location or concentration diagram/ ;hen you rent a car! you probably recei#e a document$ith the s&etch o the car $hich allo$s you to circle any damages! dents or scratches on thecar $ith a corresponding mar& on the diagram.

$hec! Sheet $hec! List

> tally sheet to collect data on requency o occurrence

> tool used to ensure all important steps or actionsha#e been ta&en

ustom designed by user ten a standard orm is used

ne o se#en quality tools ?ot one o the se#en quality tools

.g.' hec& sheet to document reasons or interruptions in

.g.' >ll items in case cart are present be oresurgery in



Gra#hical or 1istri+ution chec! sheet/ @sing the graphical orm! the person collecting thedata is able to #isuali"e the distribution o the data. 2or e ample! the number o people in lineat the registration des& at 15 minute inter#als could be counted to determine the sta ing needsand the si"e o the $aiting room.

Force Field (nalysis

e$in%s orce6 ield analysis pro#ides a rame$or& or problem sol#ing and plannedchange. <tatus quo is maintained $hen dri#ing orces equal the restraining orces! and change$ill occur $hen the relati#e strength o opposing orces changes. onsequently! $hen

planning change! the manager should identi y the restraining and dri#ing orces and assesstheir strengths.

=ri#ing orces may include pressure rom the manager! desire to please the manager! perception that the change $ill impro#e one%s sel 6image! and belie that the change $illimpro#e the situation. estraining orces include con ormity to norms! morals! and ethicsBdesire or securityB perception o economic threat or threat to one%s prestige and homeostasisBand regulatory mechanisms or &eeping the situation airly constant.

nce the dri#ing and restraining orces ha#e been identi ied! the manager determines their relati#e strengths. ;hich are the ma7or actors to$ard or resisting changeG;hich are important o moderately importantG ;hich ha#e little e ect or or against changeGThese might be listed in columns under Idri#ingH and IrestrainingH and ran&ed.

To help #isuali"e these orces! the manager can dra$ a diagram! $rite in &ey $ordsto identi y the orces! and dra$ arro$s to$ard the status quo line to represent the strength o the orces. The longer the line! the stronger the orce.

?e t! the manager plans strategies or reducing the restraining orces andstrengthening the dri#ing orces. Managers may do some e periential learning e ercises to

acilitate the change o group norms! e plain each person%s role in the change $ith emphasison security! and pro#ide some status symbols to reduce the threat to people%s prestige. Theyshould also help the $or&ers identi y ho$ the change $ill impro#e their situation. <tepsshould be ta&en to impro#e sel 6image. 2or instance! people may be taught ne$ tas&s to

prepare themsel#es $hen doing something ne$! and to impro#e their sel 6images. * managers percei#e that the $or&ers $ant to please them! they may i n orm the $or&ers that they desirethe change and gi#e positi#e rein orcement or it. Leeping the goals in mind! the manager should assess the results o implementing the strategies and re#ise plans as necessary.

2orce 2ield >nalysis is a method or listing! discussing! and e#aluating the #ariousorces or and against a proposed change. ;hen a change is planned! 2orce 2ield >nalysis

helps you loo& at the big picture by analy"ing all o the orces impacting the change and$eighing the pros and cons. 4y &no$ing the pros and cons! you can de#elop strategies toreduce the impact o the opposing orces and strengthen the supporting orces.

2orces that help you achie#e the change are called dri#ing orces. 2orces that $or& against the change are called restraining orces.

2orce 2ield >nalysis can be used to de#elop an action plan to implement a change.<peci ically it can'

1. =etermine i a proposed change can get needed support. *denti y obstacles to success ul solutions

+. <uggest actions to reduce the strength o the obstaclesTy#es o' Forces to $onsider

>#ailable resources >tttitudes o people alues

Traditions egulations =esires

ested interests :ersonal or group needs osts

rgani"ational structures :resent or past practices :eople

elationships *nstitutional policies or norms #ents

<ocial or organi"ational trends >gencies

The rocess

1. <tart $ith a $ell6de ined goal or change to be implemented

. =ra$ a orce ield diagram. ;rite the goal or change to be implemented at the top o a largesheet o paper. =i#ide the paper into t$o columns by dra$ing a line do$n the middle. abelthe le t column =ri#ing 2orces and label the right column estraining 2orces.

+. 4rainstorm a list o dri#ing and restraining orces and record them on the chart in the

appropriate column.,. nce the dri#ing and restraining orces are identi ied! as& the ollo$ing questions'

>re they #alidGCo$ do $e &no$GCo$ signi icant are each o themG;hat are their strengthsG;hich ones can be alteredG ;hich cannotG;hich orces can be altered quic&lyG ;hich ones only slo$lyG;hich orces! i altered! $ould produce rapid changeG;hich only slo$ change in the situationG;hat s&ills andEor in ormation is needed and a #ailable to alter the orcesG an $e get themG5. >ssign a score to each orce using a scale o 1 to 5! $ith 1 meaning $ea& and 5 meaning

strong. The score is based ona. The strength o the orce

b. The degree to $hich it is possible to in luence the orce

-. alculate a total score or each o the t$o columns

/. =ecide i the goal or change is easible. * so! de#ise a manageable course o action that'

<trengthens positi#e orces

;ea&ens negati#e orcesreates ne$ positi#e orces



Sam#le Force Field (nalysis 1iagram

Goal or #ro#osed change/ To ha#e no abandoned cars along city streets by May 1.

1ri3ing 'orces ?#ros@ &estraining 'orces ?cons@

*nterest in the problem has recently beene pressed by ad#ocacy groups.

The public ser#ice director supports the plan.

The city council supports the plan.

:ublic climate a#ors cleaning up the city.

ocal auto sal#age yards ha#e ageed to ta&e thecars at no cost.

Cealth department cites old abandoned #ehiclesas potential health ha"ards.

The de inition o abandoned cars is unclear to the public.

$ners o older cars eel threatened.

=i icult to locate abandoned cars.

;here to put the abandoned cars once identi iedG

pense in#ol#ed in locating and disposing o abandoned carsG

?eed a procedure to #eri y #ehicles declaredabandoned and noti y o$ners.

Line Gra#h: &un $hart

> run chart is a line graph that displays the #ariations in data o#er time. *t allo$s a quic& assessment o patterns and trends. *t is good or monitoring time6related trends and shi t in

processes.

The ine AraphE un hart is used to sho$ measurements made o#er speci ic periods o time.*t unctions basically as a running tally and is used chie ly to disco#er $hether there arecritical times $hen a problem occurs. ;hen a problem recurs! you can try to ind out $hy.

The purpose o the line graph is to identi y trends and other patterns in a process or to helpdecide $hether a target le#el has been reached. *t can indicate ho$ a process is $or&ing and

re#eal $hich areas need impro#ement and $hich are impro#ing. *t also allo$s to spot trendse#en in the early stages o data collection! long be ore there is enough in ormation to dra$ acontrol chart.

Ste#0+y0Ste# Instructions

1. =ecide $hat the chart $ill measure.

6 There is a need to choose $hat data $ill be collected o#er $hat period o time. The time period should be long enough to sho$ a trend.

. ol lec t data .6 Ma&e sure the data are bro&en do$n according to $hen the obser#ations $ere made. There$ill be a need o at least 10 to 1 data points to ha#e a meaning ul graph. *t is best to ha#edata points collected at e#enly spaced inter#als.

+. =ra$ the a es or the graph.

6 The y6a is indicates quantity! or #alues obser#ed. The 6a is sho$s the time $hen theobser#ation $as made (hours! days o the $ee&! months o the year! and so orth).

,. :lot the data points and connect them $ith a line.

6 4e sure to plot the data in the same order in $hich they $ere collected. onnecting the dots$ith a line pinpoints trends and patterns in the process being studied.

ene'its6> line graph is quic& and easy to construct and use. *t also pro#ides up6to6the6minute data.

1ra"+ac!s

6 > line graph is not a particularly sophisticated or sensiti#e instrument.

areto $hart

> :areto chart is a bar graph that displays categories o data in descending order o requency or signi icance rom the le t to the right. *t is named a ter :areto! an economist $ho

noticed that 80O o the $ealth in *taly in the nineteenth century $as controlled by 0O o the

population. The :areto principle is that most e ects come rom a de$ causes. nce the ma7or cause o a problem is identi ied! it can be problem sol#ed! leading to considerable impact.



:areto charts are e tremely use ul or analy"ing $hat problems need attention irst because the taller bars on the chart! $hich represent requency! clearly illustrate $hich#ariables ha#e the greatest cumulati#e e ect on a gi#en system.

The :areto chart pro#ides a graphic depiction o the :areto principle ! a theory maintaining that80O o the output in a gi#en situation or system is produced by 0O o the input.

The :areto chart is one o the se#en basic tools o quality control. The independent#ariables on the chart are sho$n on the hori"ontal a is and the dependent #ariables are

portrayed as the heights o bars. > point6to6point graph! $hich sho$s the cumulati#e relati#erequency! may be superimposed on the bar graph. 4ecause the #alues o the statistical

#ariables are placed in order o relati#e requency! the graph clearly re#eals $hich actors ha#ethe greatest impact and $here attention is li&ely to yield the greatest bene it.

2hen to )se a areto $hart

• ;hen analy"ing data about the requency o problems or causes in a process.• ;hen there are many problems or causes and you $ant to ocus on the most

signi icant.• ;hen analy"ing broad causes by loo&ing at their speci ic components.• ;hen communicating $ith others about your data.

areto $hart rocedure

1. =ecide $hat categories you $ill use to group items.. =ecide $hat measurement is appropriate. ommon measurements are requency!

quantity! cost and time.+. =ecide $hat period o time the :areto chart $ill co#er' ne $or& cycleG ne ull

dayG > $ee&G,. ollect the data! recording the category each time. ( r assemble data that already

e ist.)5. <ubtotal the measurements or each category.-. =etermine the appropriate scale or the measurements you ha#e collected. The

ma imum #alue $ill be the largest subtotal rom step 5. (* you $ill do optionalsteps 8 and 9 belo$! the ma imum #alue $ill be the sum o all subtotals rom step5.) Mar& the scale on the le t side o the chart.

/. onstruct and label bars or each category. :lace the tallest at the ar le t! then thene t tallest to its right and so on. * there are many categories $ith smallmeasurements! they can be grouped as Iother.H

<teps 8 and 9 are optional but are use ul or analysis and communication.8. alculate the percentage or each category' the subtotal or that category di#ided by

the total or all categories. =ra$ a right #ertical a is and label it $ith percentages.4e sure the t$o scales match' 2or e ample! the le t measurement that corresponds toone6hal should be e actly opposite 50O on the right scale.

9. alculate and dra$ cumulati#e sums' >dd the subtotals or the irst and secondcategories! and place a dot abo#e the second bar indicating that sum. To that sumadd the subtotal or the third category! and place a dot abo#e the third bar or thatne$ sum. ontinue the process or all the bars. onnect the dots! starting at the topo the irst bar. The last dot should reach 100 percent on the right scale.

areto $hart E;am#les

ample U1 sho$s ho$ many customer complaints $ere recei#ed in each o i#ecategories.

ample U ta&es the largest category!Idocuments!H rom ample U1! brea&s it

do$n into si categories o document6related complaints! and sho$s cumulati#e#alues.

* all complaints cause equal distress to thecustomer! $or&ing on eliminatingdocument6related complaints $ould ha#e themost impact! and o those! $or&ing onquality certi icates should be most ruit ul.

ie $hart: $ircle Gra#h

:ie charts compare relati#e si"e o di erent data set in a circle instead o as bars on graphs.=ata are collected and assigned percentages o the $hole. > circle is dra$n and di#ided into

proportional pieces equal to the percentage o each indicator subtotal. =i erent segment can be shaded di erently.

> pie chart is a di#ided circle! in $hich each slice o the pie represents a part o the $hole. Thecategories that each slice represents are mutually e clusi#e and e hausti#e. =ata $ith negati#e#alues cannot be displayed as a pie chart.

:ie charts can pro#ide a quic& o#erall impression o a data set! but do not o er #ery detailedin ormation. >dditional in ormation can be added into pie charts by inserting igures (e.g.!

percentages) into each segment o t he chart! or by pro#iding a separate table as a re erencetool. Co$e#er! some o the ad#antages o #isualising data are lost $hen igures or a separatetable are required to understand the data.

http://whatis.techtarget.com/definition/Pareto-principle

http://whatis.techtarget.com/definition/independent-variable


http://whatis.techtarget.com/definition/dependent-variable

http://whatis.techtarget.com/definition/Pareto-principle



http://whatis.techtarget.com/definition/dependent-variable



*t can be di icult to 7udge comparisons bet$een slices o the pie! particularly $hen there aremany slices or the slices are thin sli#ers. imiting a pie chart to our slices results in a moreinterpretable #isualisation. Many in the data #isualisation ield belie#e pie charts are al$aysinappropriate because o their interpretation di iculties. =espite that! they remain a popular type o data #isualisation.

E;am#le

alculating clic&6through rate

*n this e ample! the proportion o homeo$ners andrenters or each area are represented through piegraphs.

This e ample represents the age o program

participants as proportions o a $hole.

• =eciding $hether to use a piechart depends on the properties o

the data. :ie charts are e ecti#e or comparing a gi#en category (a slice o the pie)$ith the total (the $hole pie)! particularly $hen the category is close to 5 or 50

percent.

• The area o the slices o pie charts better represent relati#e si"e. Co$e#er! the lengtho bars in bar charts o er a better option to sho$ subtle di erences bet$eencategories than pie charts. 4ar charts represent data si"e more accurately and allo$

or easier comparisons bet$een data sets.• :ie charts should not be used to sho$ increases and decreases! numbers in each

category! or direct relationships bet$een categories in $hich one set o numbersdepends on another. *n the last case! a line graph $ould be a better ormat to use.

• >nother limitation o pie charts is that they do not sho$ changes o#er time! unlessdisplayed as a series o small multiples. #en then! comparing across multiple piecharts is di icult unless they ha#e #ery e$ slices! li&e the e ample sho$n abo#e.

• The complications described abo#e! especially related to human ability to 7udge andcompare areas! are e acerbated $hen pie charts are rendered in three dimensions.:ie charts should be displayed in t $o dimensions.

• ;hen creating a pie chart! sort the slices rom greatest to least! $ith the le t side o the greatest slice beginning at the top! at 0 degrees.

Scatter 1iagram

*t is a graph o points plottedB this graph is help ul in comparing t$o #ariables. Thedistribution o the points helps in identi ying the cause and e ect relationship 4et$een t$o#ariables.

> scatter diagram (also &no$n as a scatter plot) is a graphic representation o the relationship

bet$een t$o #ariables. *t helps us #isuali"e the apparent relationship bet$een t$o #ariablesthat are plotted in pairs. *n the <i <igma quality impro#ement =M>* methodology! scatter diagrams are usually used to e plore relationships in t he >naly"e :hase. They are used to help#eri y the potential root causes because the premise is that a change in the cause (the ) $ill

produce a change in the e ect (the S). >lthough $e $ould li&e to claim causation! based on ascatter diagram $e can only claim correlation.

The >naly"e :hase in =M>* is essentially a act6based search or cause6e ect relationships based on the ideas ormulated in the Measure :hase. ;e start $ith the symptom o a problem Jthe measurable Ie ectH (the S). ?e t! through the use o the cause6e ect diagram! $etheori"e about the possible IcausesH (the s). Then $e collect data and search or those

possible causes that ha#e the strongest in luence on the e ect. * $e can eliminate or controlthese causes! $e $ill eliminate or control the e ectB the symptom and the problem $ill begone.

;hile the cause6e ect diagram helps a team de#elop theories about possible causes! thescatter diagram helps them analy"e data to #eri y or dispro#e those theories. The scatter diagram is an ideal $ay to display data $hen an impro#ement team is trying to e#aluate acause6e ect relationship o paired S and data. :aired data $here the S and the are bothcontinuous is an ideal situation to use scatter diagrams. V?ote' <catter diagrams can also beused $ith ran&ed data and certain discrete s but $e%ll discuss that another t ime.W

4ecause the data on cause6e ect relationships almost al$ays display #ariation! the scatter diagram is better than a simple table o numbers or summari"ing in ormation. The graphicnature o the scatter diagram helps a team to IseeH the relationships bet$een the #ariables. To

be success ul in constructing and analy"ing scatter diagrams you $ill need a good theory!correctly paired data! accuracy! complete in ormation! and representati#e data. Sou must also

be a$are o the potential pit alls including strati ication! range o the data! range o operation!

e ect o scale! numerical summaries! con ounding actors! correlation $ithout physicalunderstanding! and data problems.

isual interpretation o scatter diagrams pro#ides a use ul! but sometimes limited! analysis o the relationship bet$een t$o #ariables. * a team is e amining many cause6e ect relationshipssimultaneously! they may ind it di icult to determine $hich has the strongest correlation.

alculating the correlation coe icients pro#ides a use ul enhancement to the scatter diagramsin these situations. This correlation coe icient is &no$n as :earson%s r. *n other cases! a teammay need to ha#e a more precise! mathematical description o the relationship bet$een the#ariables (i.e.! inding the descripti#e equation or the IcauseH #ariable to produce a desiredIe ectH). *n these situations! a regression analysis must be per ormed to enhance the scatter diagram.

http://betterevaluation.org/evaluation-options/BarChart

http://betterevaluation.org/evaluation-options/LineGraph

http://betterevaluation.org/evaluation-options/BarChart

http://betterevaluation.org/evaluation-options/LineGraph



Typical :atterns o orrelation are sho$n and described belo$'

Strong ositi3e/ * one #ariable increases at the same time the other #ariableincreases! they are said to be positi#ely correlated.

Strong Negati3e/ * one #ariable decreases at the same time the other #ariableincreases! or #ice #ersa! they are said to be negati#ely correlated.

$om#le;/ The data points are scattered in a cur#ed pattern. The shape may loo& li&ea rainbo$ or an arch. The t$o #ariables are correlated! though not linearly. >s increases! S irst increases! then it decreases (or #ice #ersa).

2ea! &elationshi#s/ > $ea& correlation does not necessarily mean that the actor being studied is not a cause. *t may simply be a $ea& cause or a cause that requiresthe presence o another contributing actor to bring about the e ect. *n this latter case! both the actor under study and the contributing actor are per ectly goodcausesB you 7ust need them both t o be acti#e simultaneously to get the e ect.

No &elationshi#/ The data points are scattered in a shapeless pattern. Sou canconclude that the t$o #ariables are not correlated o#er the ranges or $hich the data$as collected.

$ause (nd E''ect 1iagram

=e#eloped by =r Laoru *shi&a$a in 19,+. *t is also &no$n by the name o 1)*shi&a$a diagram! )2ishbone diagram.

This diagram is help ul in representing the relationship bet$een an e ect and the potential or possible causes that in luences it.

This is #ery much help ul $hen one $ant to ind out the solution to a particular problem that could ha#e a number o causes or it and $hen $e are interested in

inding out the root cause or it.

The cause and e ect diagram is an in#estigati#e tool. This is also called *shi&a$a=iagram. 4ecause o its shape! the diagram is also termed as 2ishbone =iagram.

There is a systematic arrangement o all possible causes $hich gi#e rise to the e ect in*shi&a$a diagram. 4e ore ta&ing up problem or a detailed study! it is necessary to list do$nall possible causes through a brainstorming session so that no important cause is missed. Thecauses are then di#ided into ma7or sources or #ariables.

;hen utili"ing a team approach to problem sol#ing! there are o ten many opinions as to the problem%s root cause. ne $ay to capture these di erent ideas and stimulate the team%s

brainstorming on root causes is the cause and e ect diagram! commonly called a ishbone.The ishbone $ill help to #isually display the many potential causes or a speci ic problem or e ect. *t is particularly use ul in a group setting and or situations in $hich little quantitati#edata is a#ailable or analysis.

The ishbone has an ancillary bene it as $ell. 4ecause people by nature o ten li&e to get rightto determining $hat to do about a problem! this can help bring out a more thoroughe ploration o the issues behind the problem 3 $hich $ill lead to a more robust solution.

To construct a ishbone! start $ith stating the problem in the orm o a question! such as I;hyis the help des&%s abandon rate so highGH 2raming it as a I$hyH question $ill help in

brainstorming! as each root cause idea should ans$er the question. The team should agree onthe statement o the problem and then place this question in a bo at the IheadH o the

ishbone.

The rest o the ishbone then consists o one line dra$n across the page! attached to the problem statement! and se#eral lines! or Ibones!H coming out #ertically rom the main line.These branches are labeled $ith di erent categories. The categories you use are up to you todecide. There are a e$ standard choices'

Matri; 1iagram

The matri diagram sho$s the relationship bet$een t$o! three or our groups o in ormation.*t also can gi#e in ormation about the relationship! such as its strength! the roles played by#arious indi#iduals or measurements.

<i di erently shaped matrices are possible' ! T! S! ! and roo 3shaped! depending on ho$many groups must be compared.

;hen to @se ach Matri =iagram <hape

All Rights Reserved, Juran Institute, Inc.6608 SSBBT Analyze.v2 7 . T

Patterns of Correlation

Strong, NegativeX

Y

X

Y

Strong, Positive

X

Y

Weak, Positive

X

Y

Complex

X

Y

NoneX

Y

Weak, Negative

Ty!ical atterns "# $"rrelati"n



Table 1 summari"es $hen to use each type o matri . >lso clic& on the lin&s belo$ to see ane ample o each type. *n the e amples! matri a es ha#e been shaded to emphasi"e the letter that gi#es each matri its name.

• >n 3shaped matri relates t$o groups o items to each other (or one group toitsel ).

• > T3shaped matri relates three groups o items' groups 4 and are each related to>. Aroups 4 and are not related to each other.

• > S3shaped matri relates three groups o items. ach group is related to the other t$o in a circular ashion.

• > 3shaped matri relates three groups o i tems all together simultaneously! in +6=.

• >n 3shaped matri relates our groups o items. ach group is related to t$oothers in a circular ashion.

• > roo 3shaped matri relates one group o items to itsel . *t is usually used along$ith an 3 or T3shaped matri .

Ta+le 7/ 2hen to use di''erently0sha#ed matrices

6shaped groups > 4 (or > >)

T6shaped + groups 4 > but not 4

S6shaped + groups > 4 >

6shaped + groups >ll three simultaneously (+6=)

6shaped , groups > 4 = > but not >

or 4 =

oo 6shaped

1 group > > $hen also > 4 in or T

6<haped Matri =iagram

This 6shaped matri summari"es customers% requirements. The team placed numbers in the bo es to sho$ numerical speci ications and used chec& mar&s to sho$ choice o pac&aging.The 6shaped matri actually orms an upside6do$n . This is the most basic and mostcommon matri ormat.

$ustomer &e-uirements

$ustomer D

$ustomer M

$ustomer R

$ustomerT

urity C X 99. X 99. X 99., X 99.0

Trace metals ?##m@ Y 5 J Y 10 Y 5

2ater ?##m@ Y 10 Y 5 Y 10 J

%iscosity ?c#@ 06+5 06+0 10650 156+5

$olor Y 10 Y 10 Y 15 Y 10

1rum

Truc!

http://asq.org/learn-about-quality/new-management-planning-tools/overview/matrix-diagram.html#L

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&ailcar

T6<haped Matri =iagram

This T6shaped matri relates product models (group >) to their manu acturing locations (group4) and to their customers (group ).

amining the matri in di erent $ays re#eals di erent in ormation. 2or e ample!concentrating on model >! $e see that it is produced in large #olume at the Te as plant and insmall #olume at the >labama plant. Time *nc. is the ma7or customer or model >! $hile >rlo

o. buys a small amount. * $e choose to ocus on the customer ro$s! $e learn that only onecustomer! >rlo! buys all our models. Zi g buys 7ust one. Time ma&es large purchases o > and=! $hile yle is a relati#ely minor customer.

roductsD$ustomersDManu'acturing Locations

S6<haped Matri =iagram

This S6shaped matri sho$s the relationships bet$een customer requirements! internal processmetrics and the departments in#ol#ed. <ymbols sho$ the strength o the relationships' primaryrelationships! such as the manu acturing department%s responsibility or production capacityBsecondary relationships! such as the lin& bet$een product a#ailability and in#entory le#elsBminor relationships! such as the distribution department%s responsibility or order lead timeBand no relationship! such as bet$een the purchasing department and on6time deli#ery.

The matri tells an interesting story about on6time deli#ery. The distribution department isassigned primary responsibility or that customer requirement. The t$o metrics most stronglyrelated to on6time deli#ery are in#entory le#els and order lead time. the t$o! distributionhas only a $ea& relationship $ith order lead time and none $ith in#entory le#els. :erhaps theresponsibility or on6time deli#ery needs to be reconsidered. 4ased on the matri ! $here

$ould you put responsibility or on6time deli#eryG

&es#onsi+ilities'or er'ormanceto $ustomer&e-uirements

6<haped Matri=iagram

Thin& o

meaning Icube.H4ecause this matriis three6dimensional! it isdi icult to dra$and in requentlyused. * it isimportant tocompare threegroupssimultaneously!consider using a three6dimensional model or computer so t$are that can pro#ide a clear #isualimage.

This igure sho$s one point on a 6shaped matri relating products! customers andmanu acturing locations. Zig ompany%s model 4 is made at t he Mississippi plant.

6<haped Matri =iagram

This igure e tends the T6shaped matri e ample into an 6shaped matri by including therelationships o reight lines $ith the manu acturing sites they ser#e and the customers $ho



use them. ach a is o t he matri is related to the t$o ad7acent ones! but not to t he one across.Thus! the product models are related to the plant sites and to the customers! but not to the

reight lines.

> lot o in ormation can be contained in an 6shaped matri . *n this one! $e can obser#e thated ines and Zip *nc.! $hich seem to be minor carriers based on #olume! are the only

carriers that ser#e yle o. yle doesn%t buy much! but it and >rlo are the only customers or model . Model = is made at three locations! $hile the other models are made at t$o. ;hatother obser#ations can you ma&eG

Manu'acturing SitesD roductsD$ustomersDFreight Lines

oo 6<haped Matri =iagram

The roo 6shaped matri is used $ith an 6 or T6shaped matri to sho$ one group o itemsrelating to itsel . *t is most commonly used $ith a house o quality! $here it orms the Iroo Ho the Ihouse.H *n the igure belo$! the customer requirements are related to one another. 2or e ample! a strong relationship lin&s color and trace metals! $hile #iscosity is unrelated to anyo the other requirements.

&oot $ause (nalysis

>s&ing I;hyGH may be a a#orite technique o your three year old child in dri#ing you cra"y! but it could teach you a #aluable <i <igma quality lesson. The 5 ;hys is a technique used in

the >naly"e phase o the <i <igma =M>* (=e ine! Measure! >naly"e! *mpro#e!ontrol) methodology. *t is a great <i <igma tool that does not in#ol#e data segmentation!

hypothesis testing! regression or other ad#anced statistical tools! and in many cases can becompleted $ithout a data collection plan.

4y repeatedly as&ing the question I;hyH ( i#e is a good rule o thumb)! you can peel a$aythe layers o symptoms $hich can lead to the root cause o a problem. ery o ten theostensible reason or a problem $ill lead you to another question. >lthough this technique iscalled I5 ;hys!H you may ind that you $ill need to as& the question e$er or more times t han

i#e be ore you ind the issue related to a problem.

ene'its o' the , 2hys• Celp identi y the root cause o a problem.• =etermine the relationship bet$een di erent root causes o a problem.• ne o the simplest toolsB easy to complete $ithout statistical analysis.

2hen Is , 2hys Most )se'ul4• ;hen problems in#ol#e human actors or interactions.• *n day6to6day business li eB can be used $ithin or $ithout a <i <igma pro7ect.

Ho" to $om#lete the , 2hys1. ;rite do$n the speci ic problem. ;riting the issue helps you ormali"e the problem

and describe it completely. *t also helps a team ocus on the same problem.. >s& ;hy the problem happens and $rite the ans$er do$n belo$ the problem.

+. * the ans$er you 7ust pro#ided doesn%t identi y the root cause o the problem thatyou $rote do$n in <tep 1! as& ;hy again and $rite that ans$er do$n.

,. oop bac& to step + until the team is in agreement that the problem%s root cause is

identi ied. >gain! this may ta&e e$er or more times than i#e ;hys.

, 2hys E;am#les

ro+lem Statement/ ustomers are unhappy because they are being shipped products thatdon%t meet their speci ications.

7. 2hy are customers being shipped bad productsG 3 4ecause manu acturing built the products to a speci ication that is di erent rom $hat thecustomer and the sales person agreed to.

8. 2hy did manu acturing build the products to a di erent speci ication than that o salesG 3 4ecause the sales person e pedites $or& on the shop loor by calling the head o manu acturing directly to begin $or&. >n error happened $hen the speci ications $ere beingcommunicated or $ritten do$n.

<. 2hy does the sales person call the head o manu acturing directly to start $or& instead o ollo$ing the procedure established in the companyG

3 4ecause the Istart $or&H orm requires the sales director%s appro#al be ore $or& can beginand slo$s the manu acturing process (or stops it $hen the director is out o the o ice).

B. 2hy does the orm contain an appro#al or the sales direct orG 3 4ecause the sales director needs to be continually updated on sales or discussions $ith the

.

*n this case only our ;hys $ere required to ind out that a non6#alue added signatureauthority is helping to cause a process brea&do$n.



et%s ta&e a loo& at a slightly more humorous e ample modi ied rom Marc .%s posting o ,2hys in the i <i <igma =ictionary.

ro+lem Statement/ Sou are on your $ay home rom $or& and your car stops in the middleo the road.

7.2hy did your car stopG 3 4ecause it ran out o gas.8. 2hy did it run out o gasG

3 4ecause * didn%t buy any gas on my $ay to $or&.<. 2hy didn%t you buy any gas this morningG

3 4ecause * didn%t ha#e any money.B. 2hy didn%t you ha#e any moneyG

3 4ecause * lost it all last night in a po&er game.5. 2hy did you lose your money in last night%s po&er gameG

3 4ecause *%m not #ery good at Iblu ingH $hen * don%t ha#e a good hand.>s you can see! in both e amples the inal ;hy leads the team to a statement (root cause) thatthe team can ta&e action upon. *t is much quic&er to come up $ith a system that &eeps thesales director updated on recent sales or teach a person to Iblu H a hand than it is to try todirectly sol#e the stated problems abo#e $ithout urther in#estigation.

, 2hys and the Fish+one 1iagram

The 5 ;hys can be used indi#idually or as a part o the i shbone (also &no$n as the cause ande ect or *shi&a$a) diagram. The ishbone diagram helps you e plore all potential or realcauses that result in a single de ect or ailure. nce all inputs are established on the ishbone!you can use the 5 ;hys technique to drill do$n to the root causes.

http://www.isixsigma.com/dictionary/5-whys/







$ontrol $hart

@nderstanding! monitoring and controlling #ariation in clinical #ariables is an integral part o clinical practice. hanges in clinical #ariables! such as blood glucose le#els or blood pressuremeasurements may be due to changes in the patientsN underlying condition or biological

processes! measurement error! or random #ariation. Monitoring systems need to be able todetect material changes in the clinical #ariable (i.e. detect a signal) rom bac&ground noise tosupport appropriate clinical decision6ma&ing. Monitoring systems must also minimi"e alse

positi#esEnegati#es that may arise rom bac&ground noise that could lead to inappropriateclinical decision6ma&ing. ecently! statistical process control charts (also &no$n as controlcharts) ha#e been ad#ocated or use in chronic disease monitoring.

<he$hart de#eloped a set o simple! graphical tools (control charts) or distinguishing bet$eenthe t$o types o #ariation. ontrol charts $ere originally de#eloped by ;alter <he$hart as atool or monitoring and controlling manu acturing processes. ontrol charts distinguish

bet$een t$o sources o #ariation' Ncommon causeN #ariation! $hich is intrinsic to any processand Nspecial causeN #ariation! caused by a actor e trinsic to the process. > &ey eature o thisclassi ication (common #ersus special cause #ariation) is that the actions required to addressthem are di erent. To reduce common cause #ariation! $e need to change the underlying

process in some undamental $ay and or special cause #ariation! $e need to ind the e trinsicactor and then act on it.

:rocess monitoring $ith control chartsis an important component $ithin ano#erall process e#aluation andimpro#ement rame$or& in healthcare.

ontrol charting methods! requently as part o <i <igma initiati#es! are beingused increasingly in healthcare! butgreater use o these and other qualityimpro#ement methods are needed.Training in the use o control chartingmethods is best accomplished $ithin ano#erall process impro#ement conte t!such as <i sigma! ean! or ean <i

<igma. *n addition to standard control charting methods used in other industries! special purpose charts or ri s&6ad7usted and rare e#ent data are particularly use ul. 2unnel plots arealso a #ery use ul! and relati#ely ne$! tool or e#aluating the relati#e per ormance o a number o healthcare pro#iders $ith respect to some outcome measure. These plots contain morein ormation than league tables and are less prone to misinterpretation.

Histogram

> histogram graphically demonstrates the requency $ith $hich #arious #alues o a particular #ariable occur in a set o data. The height o the bar indicates the requency o occurrence. *t isalso &no$n as 2requency =istribution. @ses o Cistogram are' to quic&ly and easilydemonstrate a data setNs distribution and t o compare t$o time periods! loo&ing or changes.

>d#antages'

6 :ro#ides quic& summary o lots o data.

6 *s easy to construct $ith spreadsheet so t$are.6 >llo$s rapid #isuali"ation o the center and #ariation o the distribution! in addition to adistributionNs shape.

=isad#antage'

6 =oes not pro#ide a de initi#e indication o a normal distribution.

&adar $hart

adar chart displays multi#ariate data inthe orm o a t$o6dimensional chart o more than three #ariables represented ona es starting rom the same point. adar chart is also called polar chart! spider chart! $eb chart! star chart or star plot.

Quality $ircles and Quality Teams

Quality $ircles ?general@

The idea o quality circles $as irst introduced bya number o large Dapanese irms in a systematicattempt to in#ol#e all their employees at e#eryle#el in their organi"ation%s dri#e or quality.

>ccording to the Q@> *TS * <C>?=4 L! a quality circle is a small group o

bet$een three and t$el#e people $ho do the



same or similar $or&! #oluntarily meeting together regularly or about one hour per $ee& in paid time! usually under the leadership o their o$n super#isor and trained to identi y! analy"eand sol#e some o the problems in their $or&! presenting solutions to management and $here

possible! implementing solutions themsel#es.

There are t$o main tas&s assigned to quality circles' the identi ication o problems and thesuggestion o solutions. > secondary aim is to boost the morale o the group throughattendance at the meetings and the ormal opportunity to discuss $or&6related issues.

Meetings are held in an organi"ed $ay. > chairman is appointed on a rotating basis and anagenda is prepared. Minutes are also ta&en. They ser#e as a use ul means o ollo$ing up

proposals and their implementation. The success o quality circles has been ound to dependcrucially on the amount o training that the participants are gi#en in the $ays and aims o thecircles.

Laoru *shi&a$a! a pro essor at To&yo @ni#ersity $ho died in 1989! is attributed $ith much o the de#elopment o the idea o quality circles. They created great e citement in the ;est in the1980 at a time $hen e#ery Dapanese management technique $as treated $ith great respect.Many irms in urope and the @nited <tates set them up! including ;estinghouse and Ce$lett

3:ac&ard. *t $as claimed at one time in the 1980 that there $ere as many as 10 M people participating in quality circles in Dapanese industry alone.

Co$e#er! the method also came in or a good deal o criticism. #en Doseph Duran! one o thet$o >merican post6$ar germinators o the quality idea (the other $as ;. d$ards =eming)!considered that quality circles $ere pretty useless i the company%s management $as nottrained in the more general principles o total quality management.

thers critici"ed the $ay in $hich the idea $as trans erred rom one culture to another $ithout any attempt to tailor it to local traditions. *t may! such critics suggested! be $ell suitedto Dapan%s participati#e $or& orce! but in more indi#idualistic $estern societies it became a

ormali"ed hunt or people to blame or the problems that it identi ied. The original intention$as or it to be a collecti#e search or a solution to those problems.

Quality circles ell rom grace as they $ere thought to be ailing to li#e up to their promise. >study in 1988 ound that 80O o a sample o large companies in the ;est that had introducedquality circles in the early 1980 had abandoned them be ore the end o the decade. *n his boo& IQuality' > ritical introductionH! Dohn 4ec& ord quotes the e ample o a $estern retailer thattoo& almost e#ery $rong step in the boo&. These included'

•

Training only managers to run quality circles! and not the sta in the retailoutlets $ho $ere e pected to participate in themB• <etting up circles $here managers appointed themsel#es as leaders and

made their secretaries &eep the minutes. This maintained the e istinghierarchy $hich quality circles are supposed to brea& out o B

• pecting sta to attend meetings outside $or&ing hours and $ithout pay• *gnoring real problems raised by the sta and ocusing on tri#ia

Quality circles in Health $are Setting ?s#eci'ic@

Cealthcare en#ironment represents a challenge to leaders and clinicians ali&e due to thenecessity to achie#e consistency in the quality o care that is pro#ided to all patients. >lthough

policies and procedures are $ritten to help $ith the uni ormity o the process and reduce

#ariation $ithin the healthcare acility! it is di icult to pre#ent mista&es and discrepancies.

Co$ to resol#e the lac& o consistency ta&ing place in the e ecution o procedures in thehealthcare settingG

To accomplish these tas&s! quality circles ha#e been considered as a easible alternati#e to promote peer collaborations! partnership! and &no$ledge allotment to optimi"e quality o carein all healthcare settings (*nno#ations! 01+). ase in point! peer quality circles play a role inengaging peers to achie#e mutually satis ying outcomes to impro#e the quality o care that isgi#en to patients (*nno#ations! 01+). This process includes an action plan and strategy toidenti y commonalities o care and treatment or patients to increase cohesi#eness ande iciency.

Cealthcare quality is also preser#ed using quality control circles in such areas as drug sa etyso that the li#es o patients are not compromised in prescribing drugs and ta&ing the proper dosages. Quality ontrol ircles initiate a series o actions $ith healthcare teams members toinspire teams to ta&e appropriate action! to share ideas and to create reciprocally help ulrelationships (Cu! 011). linical sta members must be prepared to $or& as a collecti#e unitto impro#e patient outcomes and to promote e iciency $hile reducing medication errors or these patients. Quality control circles are designed to initiate success ul con#ersation regardingthe de#elopment o ne$ programs! processes! and e iciencies that $ill lead to positi#e results

or patients and or employees. These e orts are e ecti#e contributors in rene$ing the spirito the organi"ation and its healthcare3dri#en agenda to impro#e the quality o care that is

pro#ided at all times (Cu! 011). Quality circles initiate con#ersations among practitioners or the good o the patients. They are the brains that come together to minimi"e and pre#entaccidents in the clinical area. The inal product o any quality circle is #ie$ed as better than

that o the indi#idual doing all the thin&ing and prescribing (:ope! an oyen and 4a&er!00 ).

The )se o' Quality $ircles

The use o quality circle in healthcare settings $as design to impro#e the quality o care gi#ento patients. The intention is to bring health care pro essionals together in the treatment o

patients and to come up $ith a treatment that both satis y the patient and reduce the ris& or polypharmacy. Quality circles ha#e accomplished se#eral bene its in the treatment o patients.Three $ays in $hich quality circles and eedbac& loops ha#e been used in health care settings.

• *denti ication o outstanding eatures or care

The use o quality circle helps identi y eature o care or patients in the same health population. This process helps bring uni ormity and standardi"ation o care or patientssu ering rom the same disease. *t helps also in identi ying $hat matters or patients and or the care pro#iders. This method bring the patient and the pro#ider together on ho$ to proceed$ith the treatment and $hat are the goals and ob7ecti#es to achie#e (:ope! an oyen! P4a&er! 00 ). *n pro#iding the use o eedbac& loops! pro#iders are able to re#ie$ patient%sconditions as a team and $or& together to better coordinate care or that indi#idual patient. *naddition! the quality circle helps identi y cultural obstacle to see&ing care and encourage theneed to see& care $hene#er needed.

• *denti ication o obstacles or change.

4y inding the reasons behind certain beha#iors! quality circles and eedbac& loops can help toidenti y barriers to practice change. <uccess $ill be more li&ely i the methods used toimplement change are chosen to address the pre#ailing barriers. The coming together o di erent entities helps in identi ying areas in $hich the procedures in use by the organi"ation

needs to be re#ie$ed or changed all together.



IThe comple structures and beha#iors o healthcare organi"ations are increasingly recogni"edas critical actors in determining the quality o care. Qualitati#e methods o er a potentialapproach to assisting leaders o organi"ations to appreciate some o the local issues to beconsidered $hen introducing ne$ ideas or trans orming systems o care. Co$e#er! moreresearch is needed to in#estigate $hich qualitati#e methods could be most use ul! and in $hatcircumstances they should be used (:ope! an oyen! P 4a&er! 00 )H. The need or collaboration is absolute in all areas o healthcare! and the need or change based on clinicalresults and data is and should more than $elcome. *n addition! those changes should be madea ter a series o consultation bet$een the clinical sta and the l eadership.

• *denti y the need or more researches.The use o quality circle and eedbac& loops has called or more researches and more e#idence

practice to be part o the de#elopment o change and progress in the care o patients. ;hat has been pro#en in $ith the use o quality circle is that no system can remain homogenous or toolong! especially in the healthcare setting. The system needs to be challenged and changes needto ta&e place no based on one%s inancial situation! need or reno#ation! but on the act thatclinical data demands it. The quality circles challenge the in statu#quo and demand change inthe system. <uch changes are o ten bene icial or the patients and the healthcare system in thesame $ay.

Summary

Cealthcare quality is also preser#ed using quality control circles in such areas as drugsa ety so that the li#es o patients are not compromised in prescribing drugs and ta&ing the

proper dosages. 4y its #ery de inition! quality circles $or& on impro#ing the quality o careor the patients. >t its origin! ;. d$ard =eming argued that the process should be used to

analy"e sources o #ariations that de#iate rom the customer satis action. *n the same $ay! thesame tool used in the healthcare setting $ould bring about the same goal $hich is to bringsatis action to the client but also impro#e the sa ety o care.

SOL)TION 1E%ELO MENT TOOLS

rioriti6ation Matri;

> prioriti"ation matri can help an organi"ation ma&e decisions by narro$ing options do$n b ysystematically comparing choices through the selection! $eighing! and application o criteria.:rioriti"ation matrices'

• Quic&ly sur ace basic disagreements! so disagreements can be resol#ed openly

• 2orce a team to narro$ do$n all solutions rom all solutions to the best solutions!$hich are more li&ely to increase chances or success ul program implementation

• imits hidden agendas by bringing decision criteria to the ore ront o a choice

• *ncreases ollo$6through by as&ing or consensus a ter each step o the process

Ho" To $onstruct ( rioriti6ation Matri;

There are three $ays to construct prioriti"ation matrices! but the Full (nalytical $riteriaMethod is detailed belo$. This speci ic method is best used in smaller groups (+68 people)!$hich require e$ options (5610 options) and e$ criteria (+6- criteria). This speci ic methodalso requires the team to r each complete consensus on criteria and options. <ta&es may be highi the plan ails.

7. Set a Goal. *n order to agree on the ultimate goal! your group should produce a clear goalstatement through consensus.

ample Aoal' 4uy a car or regular daily tra#el.

8. Set $riteria. reate a list o criteria by re#ie$ing a#ailable documents or guidelines. Theteam must come to a consensus on criteria and their meaning! or the process is li&ely to ail.

ample riteria' ost! reliability! e iciency! desirability

ample ptions' ?e$ he#rolet! @sed Mercedes! :re6 $ned 2ord! @ncle Cenry%sld lun&er

<. 2eigh $riteria 'or Im#ortance. @se a matri to $eigh each criteria against another! inorder to decide $hich criteria are most important.

(. 2rite $riteria. ;rite your criteria across the top o the columns. >dd e tra columns at theend or o$ Total and elati#e =ecimal alue (youNll use those later). ;rite your criteriaat the beginning o each ro$.

. 2eigh $riteria. 4egin the process o deciding $hich criteria are moreimportant. (<ince $e canNt compare acriterion against itsel ! $eNll start in thesecond cell o the irst column.)



*n this cell! as& yoursel $hether the criterion a+o3e (cost) is moreor less important than the criterion to the le't (reliability).

@se the ollo$ing $eighting system to indicate $hether itNs moreimportant! and by ho$ much'

7 [ Much more important, [ More important7 [ qually important

.8 [ ess important.7 [ Much less important

Note !hole number (1*, +, 1) should al!ays represent the desirable rating. -n somecases, this mean more of something (e.g., importance, reliability, educational value), and inothers it may mean less (e.g., cost, travel time).

This indicates that cost is more important 5 than reliability.

ach time you record a "eight in a ro$ cell! you must record its reci#rocal3alue in thecorresponding column cell.

;eight o 7 66X eciprocal #alue o .7;eight o , 66X eciprocal #alue o .8;eight o 7 66X eciprocal #alue o 7;eight o .8 66X eciprocal #alue o ,;eight o .7 66X eciprocal #alue o 7

The reciprocal #alue o 5 is 0. B this sho$s that relia+ility is less im#ortant (0. ) than cost .ontinue $eighting the remaining criteria and recording reciprocal #alues.

$. $alculate Totals. ;hen inished! total eachhori"ontal ro$ and enter the sum under o$Total. >dd all ro$ totals to reach a grandtotal.

1. $alculate $riteria 2eighting. =i#ide eachro$ total by the grand total! and enter thisunder elati#e =ecimal alue.

These relati3e decimal 3alues indicate ho$ relati#ely important each criterion is to you theyare no$ called your criteria "eighting .

Sou $ill use criteria $eighting to compare options at the end o the process! in <tep -.

B. 2eigh O#tions against $riteria. @se a set o matrices to $eigh options $ithin gi#encriteria! in order to start deciding $hich options best meet your criteria.

>. ;eigh ptions. @sing the same $eighting and method asabo#e! place one criterion in the upper le t corner o its o$nmatri ! and $eigh options against each other. @se $eights toindicate $hich option better meets the matri Ns single criterion.

&emem+er ' > $hole number (10! 5! 1) should al$ays representthe desirable rating. *n some cases! this mean more o something (e.g.! importance! reliability! educational #alue)! and inothers it may mean less (e.g.! cost! tra#el time).

10 [ Much less e pensi#e

5 [ ess e pensi#e

1 [ <ame cost

0. [ More e pensi#e

0.1 [ Much more e pensi#e



epeat this step $ith each criterion (cost!reliability! e iciency! desirability) using the sameoptions and $eighting method! until you ha#e amatri or each criterion. There $ill be as manymatrices as there are criteria. These relati#edecimal #alues indicate ho$ $ell each optionmeets a gi#en criterion they are no$ called your

option ratings.

4. ptional' ompile ption atings. Sou may

ind it help ul to put your option ratings romeach matri into a single table to minimi"econ usion.

,. $om#are O#tions. @sing another 6shaped matri ! compare each option based on allcombined criteria.

>. reate <ummary Matri . istyour criteria at the top o eachcolumn! along $ith their respecti#ecriteria $eighting #alues

rom <tep + . ;rite each option at the beginning o a ro$.

4. Multiply riteria ;eighting and ption atings. *n each cell! multiply the criteria$eighting #alues ( ound at the top o each column) by the option rating rom each matriin <tep , .

?e$ he#rolet option rating rom <tep , cost matri[ .78

@sed Mercedes option rating rom <tep , cost matri[ .<<

:re6 $ned 2ord option rating rom <tep , cost matri[ . 7

@ncle CenryNs ar option rating rom <tep , cost matri[ .,B

epeat this or each option and criterion! pulling #alues rom <teps + and ,.

. alculate o$ Total. >dd #alues across each ro$ to reach a r o$ total.

=. alculate Arand Total. >dd all ro$ totals to reach a grand t otal.

http://www.health.state.mn.us/divs/opi/qi/toolbox/prioritizationmatrix.html#step3







. alculate elati#e =ecimal alue. =i#ide each ro$ total by the grand total! and enter thisunder elati#e =ecimal alue.

-. $hoose the est O#tion (cross all $riteria . ompare the relati#e decimal #alues todecide $hich option is highest. This is the best choice gi#en options and criteria.

*n our e ample! a :re6 $ned 2ords seems to best meet the criteria or a car! because itsrelati#e decimal #alue is highest in the summary matri .

rocess 1ecision rogram $hart

The process decision program chart (:=: ) systematically identi ies $hat might go $rong ina plan under de#elopment. ountermeasures are de#eloped to pre#ent or o set those

problems. 4y using :=: ! you can either re#ise the plan to a#oid the problems or be ready

$ith the best response $hen a problem occurs.

2hen to )se 1 $

• 4e ore implementing a plan! especially $hen the plan is large and comple .• ;hen the plan must be completed on schedule.• ;hen the price o ailure is high.

1 $ rocedure

• btain or de#elop a tree diagram o the proposed plan. This should be a high6le#eldiagram sho$ing the ob7ecti#e! a second le#el o main acti#ities and a third le#el o

broadly de ined tas&s to accomplish the main acti#ities.• 2or each tas& on the third le#el! brainstorm $hat could go $rong.• e#ie$ all the potential problems and eliminate any that are improbable or $hose

consequences $ould be insigni icant. <ho$ the problems as a ourth le#el lin&ed tothe tas&s.

• 2or each potential problem! brainstorm possible countermeasures. These might beactions or changes to the plan that $ould pre#ent the problem! or actions that $ouldremedy it once it occurred. <ho$ the countermeasures as a i th le#el! outlined inclouds or 7agged lines.

• =ecide ho$ practical each countermeasure is. @se criteria such as cost! timerequired! ease o implementation and e ecti#eness. Mar& impracticalcountermeasures $ith an and practical ones $ith an .

Here are some -uestions that can +e used to identi'y #ro+lems.• ;hat inputs must be presentG >re there any undesirable inputs lin&ed to the good

inputsG• ;hat outputs are $e e pectingG Might others happen as $ellG• ;hat is this supposed to doG *s there something else that it might do instead or in

additionG• =oes this depend on actions! conditions or e#entsG >re these controllable or

uncontrollableG• ;hat cannot be changed or is in le ibleG• Ca#e $e allo$ed any margin or errorG• ;hat assumptions are $e ma&ing that could turn out to be $rongG• ;hat has been our e perience in similar situations in the pastG• Co$ is this di erent rom be oreG• * $e $anted this to ail! ho$ could $e accomplish thatG

1 $ E;am#le

> medical group is planning to impro#e the care o patients $ith chronic illnesses such asdiabetes and asthma through a ne$ chronic illness management program ( *M:). They ha#ede ined our main elements and! or each o these elements! &ey components. The in ormationis laid out in the process decision program chart belo$.

=otted lines represent sections o the chart that ha#e been omitted. nly some o the potential problems and countermeasures identi ied by the planning team are sho$n on this chart.

http://asq.org/learn-about-quality/new-management-planning-tools/overview/tree-diagram.html





2or e ample! one o the possible problems $ith patients% goal6setting is bac&sliding. The team li&edthe idea o each patientha#ing a buddy or sponsor and $ill add that to the

program design. ther areas

o the chart helped them plan better rollout! such asarranging or all sta to #isita clinic $ith a *M: programin place. <till other areasallo$ed them to plan inad#ance or problems! suchas training the *M: nursesho$ to counsel patients $hochoose inappropriate goals.

Tree 1iagram>lso called' systematic diagram! tree analysis! analytical tree! hierarchy diagramThe tree diagram starts $ith one item that branches into t$o or more! each o $hich branchinto t$o or more! and so on. *t loo&s li&e a tree! $ith trun& and multiple branches.*t is used to brea& do$n broad categories into iner and iner le#els o detail. =e#eloping thetree diagram helps you mo#e your thin&ing st ep by step rom generalities to speci ics.2hen to )se a Tree 1iagram

• ;hen an issue is &no$n or being addressed in broad generalities and you must mo#eto speci ic details! such as $hen de#eloping logical steps to achie#e an ob7ecti#e.

• ;hen de#eloping actions to carry out a solution or other plan.• ;hen analy"ing processes in detail.• ;hen probing or the root cause o a problem.• ;hen e#aluating implementation issues or se#eral potential solutions.• > ter an a inity diagram or relations diagram has unco#ered &ey issues.• >s a communication tool! to e plain details to others.

Tree 1iagram rocedure

• =e#elop a statement o the goal! pro7ect! plan! problem or $hate#er is being studied.;rite it at the top ( or a #ertical tree) or ar le t ( or a hori"ontal tree) o your $or& sur ace.

• >s& a question that $ill lead you to the ne t le#el o detail. 2or e ample'• 2or a goal! action plan or $or& brea&do$n structure' I;hat tas&s must be done to

accomplish thisGH or ICo$ can this be accomplishedGH• 2or root3cause analysis' I;hat causes thisGH or I;hy does t his happenGH• 2or go"into chart' I;hat are the componentsGH (Ao"into literally comes rom the

phrase I;hat goes into itGH•

4rainstorm all possible ans$ers. * an a inity diagram or relationship diagram has been done pre#iously! ideas may be ta&en rom there. ;rite each idea in a line belo$

( or a #ertical tree) or to the right o ( or a hori"ontal tree) the irst statement. <ho$lin&s bet$een the tiers $ith arro$s.

• =o a Inecessary and su icientH chec&. >re all the items at this le#el necessary or the one on the le#el abo#eG * all the items at this le#el $ere present or accomplished! $ould they be su icient or the one on the le#el abo#eG

• ach o the ne$ idea statements no$ becomes the sub7ect' a goal! ob7ecti#e or problem statement. 2or each one! as& the question again to unco#er the ne t le#el o detail. reate another tier o statements and sho$ the relationships to the pre#ioustier o ideas $ith arro$s. =o a Inecessary and su icient chec&H or each set o items.

• ontinue to turn each ne$ idea into a sub7ect statement and as& the question. =o notstop until you reach undamental elements' speci ic actions that can be carried out!components that are not di#isible! root causes.

• =o a Inecessary and su icientH chec& o the entire diagram. >re all the itemsnecessary or the ob7ecti#eG * all the items $ere present or accomplished! $ouldthey be su icient or the ob7ecti#eG

Tree 1iagram E;am#le

The :earl i#er! ?S <chool =istrict! a 001 recipient o the Malcolm 4aldrige ?ationalQuality >$ard! uses a tree diagram to communicate ho$ district6$ide goals are translated intosub6goals and indi#idual pro7ects. They call this connected approach IThe Aolden Thread.H

The district has three undamental goals. The irst! to impro#e academic per ormance! is partlysho$n in the igure belo$. =istrict leaders ha#e identi ied t$o strategic ob7ecti#es that! $henaccomplished! $ill lead to impro#ed academic per ormance' academic achie#ement andcollege admissions

ag indicators are long6ter m and resul ts3 orient ed. The lagindicator or academicachie#ement is egents%diploma rate' the percento students recei#ing astate diploma by passingeight egents% e ams.

ead indicators areshort6term and process6oriented. <tarting in

000! the lead indicator or the egents% diploma

rate $as per ormance onne$ ourth and eighth grade state tests.

2inally! annual pro7ects are de ined! based on cause3and3e ect analysis that $ill impro#e per ormance. *n 0003 001! our pro7ects $ere accomplished to impro#e academicachie#ement. Thus this tree diagram is an interloc&ing series o goals and indicators! tracingthe causes o system $ide academic per ormance irst through high school diploma rates! t henthrough lo$er grade per ormance! and bac& to speci ic impro#ement pro7ects.

http://asq.org/learn-about-quality/new-management-planning-tools/overview/relations-diagram.html

http://asq.org/learn-about-quality/new-management-planning-tools/overview/relations-diagram.html



Q)(LIT* IM &O%EMENT ($TI%ITIES

*t is important that standards or general practices encourage quality impro#ement and identi yopportunities to ma&e changes that $ill increase quality and sa ety or patients.

*t is critical the practice has a plan or carrying out any impro#ements it has identi ied as beingnecessary. Quality impro#ement acti#ities can encompass changes to the day6to6dayoperations o the practice (eg. scheduling appointments! normal opening hours! impro#ing

patient health record &eeping! changing the $ay patient complaints are handled! or alteringsystems in response to Fnear misses%). Quality impro#ement can also encompass acti#itiesspeci ically designed to impro#e clinical care or the health o the entire practice population.<ome o the quality impro#ement acti#ities mentioned belo$ are' clinical path$ays! Medical6

?ursing >udit! @tili"ation e#ie$ and omplaint >nalysis.

$linical ath"ays

linical path$ays! also &no$n as care path$ays! critical path$ays! integrated care path$ays!or care maps ! are one o the main tools used to manage the quality in healthcare concerningthe standardi"ation o care processes. *t has been sho$n that their implementation reduces the#ariability in clinical and impro#es outcomes. linical path$ays promote organi"ed ande icient patient care based on e#idence based practice. linical path$ays optimi"e outcomesin the acute care and home care settings. Aenerally clinical path$ays re er to medicalguidelines.

The goal o clinical path$ays is to standardi"e care! impro#e outcomes and reduce cost.linical :ath$ays are structured! multidisplinary plans o care designed to support the

implementation o clinical guidelines and protocols. They are designed to support clinicalmanagement! clinical and non6clinical resource management! clinical audit and also inancialmanagement. They pro#ide detailed guidance or each stage in the management o a patient(treatments! inter#entions etc.) $ith a speci ic condition o#er a gi#en time period! and include

progress and outcomes details.

linical :ath$ays aim to impro#e! in particular! the continuity and co6ordination o careacross di erent disciplines and sectors.

are :ath$ays can be #ie$ed as algorithms in as much as they o er a lo$ chart ormat o thedecisions to be made and the care to be pro#ided or a gi#en patient or patient group or agi#en condition in a step6$ise sequence.

linical :ath$ays ha#e our main components (Cill! 199,! Cill 1998)' a timeline! thecategories o care or acti#ities and their inter#entions! intermediate and long term outcomecriteria! and the #ariance record (to allo$ de#iations to be documented and analysed).

linical :ath$ays di er rom practice guidelines! protocols and algorithms as they are utilised by a multidisciplinary team and ha#e a ocus on the quality and co6ordination o care.

These are the bene its o linical :ath$ays'• <upport the introduction o e#idence6based medicine and use o clinical guidelines

• <upport clinical e ecti#eness! ris& management and clinical audit

• *mpro#e multidisciplinary communication! team$or& and care planning

•

an support continuity and co6ordination o care across di erent clinical disciplinesand sectorsB

• :ro#ide e plicit and $ell6de ined standards or careB

• Celp reduce #ariations in patient care (b y promoting standardisation)B

• Celp impro#e clinical outcomesB

• Celp impro#e and e#en reduce patient documentation

• <upport trainingB

• ptimise the management o resourcesB

• an help ensure quality o care and pro#ide a means o continuous qualityimpro#ementB

• <upport the implementation o continuous clinical audit in clinical practice

• <upport the use o guidelines in clinical practiceB

• Celp empo$er patientsB

• Celp manage clinical ris&B

• Celp impro#e communications bet$een di erent care sectorsB

• =isseminate accepted standards o careB

• :ro#ide a baseline or uture initiati#esB• ?ot prescripti#e' donNt o#erride clinical 7udgementB

• pected to help reduce ris&B

• pected to help reduce costs by shortening hospital stays

These are the problems and barriers to the introduction o linical :ath$ay'

• May appear to discourage personalised care

• is& increasing litigation

• =onNt respond $ell to une pected changes in a patientNs condition

• <uit standard conditions better than unusual or unpredictable ones

• equire commitment rom sta and establishement o an adequate organisationalstructure

• :roblems o introduction o ne$ technology

• May ta&e time to be accepted in the $or&place

• ?eed to ensure #ariance and outcomes are properly recorded! audited and actedupon.

ample'

https://en.m.wikipedia.org/wiki/Care_maps

https://en.m.wikipedia.org/wiki/Patient

https://en.m.wikipedia.org/wiki/Care_maps

https://en.m.wikipedia.org/wiki/Patient



Medical0Nursing (udit

?ursing audit is the process o collecting in ormation rom nursing reports and other documented e#idence about patient care and assessing the quality o care by the use o qualityassurance programmes. ?ursing audit is a detailed re#ie$ and e#aluation o selected clinicalrecords by quali ied pro essional personnel or e#aluating quality o nursing care.

Meaning

1. Quality 6 a 7udgement o $hat constitutes good or bad.

. >udit 6 a systematic and critical e amination to e amine or #eri y.

+. ?ursing audit '

(a) it is the assessment o the quality o nursing care

(b) uses a record as an aid in e#aluating the quality o patient care.

,. Medical audit 6 the systematic! critical analysis o the quality o medical care! including the procedures or diagnosis and treatment! the use o resources! and the resulting outcome andquality o li e or the patient.

ur#oses o' Nursing (udit

1. #aluating ?ursing care gi#en!. >chie#es deser#ed and easible quality o nursing care!

+. <timulant to better records!,. 2ocuses on care pro#ided and not on care pro#ider!

5. ontributes to research.Methods o' Nursing (udit

There are t$o methods'

a.@ &etros#ecti3e 3ie" 6 this re ers to an in6depth assessment o the quality a ter the patienthas been discharged! ha#e the patients chart to the source o data.

etrospecti#e audit is a method or e#aluating the quality o nursing care by e amining thenursing care as it is re lected in the patient care records or discharged patients. *n this type o audit speci ic beha#iors are described then they are con#erted into questions and the e aminer loo&s or ans$ers in the record. 2or e ample the e aminer loo&s through the patientNs recordsand as&s '

a. ;as the problem sol#ing process used in planning nursing careG b. ;hether patient data collected in a systematic mannerGc. ;as a description o patientNs pre6hospital routines includedGd. aboratory test results used in planning careGe. =id the nurse per orm physical assessmentG Co$ $as in ormation usedG

. ;ere nursing diagnosis statedGg. =id nurse $rite nursing ordersG >nd so on.

b.@ The concurrent re3ie" 6 this re ers to the e#aluations conducted on behal o patients $hoare still undergoing care. *t includes assessing the patient at the bedside in relation to pre6determined criteria! inter#ie$ing the sta responsible or this care and re#ie$ing the patientsrecord and care plan.

Method To =e#elop riteria '



1. =e ine patient population.

. *denti y a time rame$or& or measuring outcomes o care!

+. *denti y commonly recurring nursing problems presented by the de ined patient population!

,. <tate patient outcome criteria!

5. <tate acceptable degree o goal achie#ement!

-. <peci y the source o in ormation.

/. =esign and type o tool

:oints to be remembered'

a. Quality assurance must be a priority!

b. Those responsible must implement a programme not only a tool!

c. > co6ordinator should de#elop and e#aluate qualit y assurance acti#ities!

d. oles and responsibilities must be deli#ered!

e. ?urses must be in ormed about the process and the results o the programme!

. =ata must be reliable!

g. >dequate orientation o data collection is essential!

h. Quality data should be annuali"ed and used by nursing personnel at all le#els.

>d#antages o ?ursing >udit '

6 an be used as a method o measurement in all areas o nursing.

6<e#en unctions are easily understood!

6<coring system is airly simple!

6 esults easily understood!

6>ssesses the $or& o all those in#ol#ed in recording care!6May be a use ul tool as part o a quality assurance programme in areas $here accuraterecords o care are &ept.

=isad#antages o the ?ursing >udit '

6 it is not so use ul in areas $here the nursing process has not been implemented!

6many o the components o#erlap ma&ing analysis di icult! is time consuming!

6requires a team o trained auditors! deals $ith a large amount o in ormation! only e#aluatesrecord &eeping. *t only ser#es to i mpro#e documentation! not nursing care

(udit as a Tool 'or Quality $ontrol

>n audit is a systematic and o icial e amination o a record! process or account to e#aluate per ormance. >uditing in health care organi"ation pro#ide managers $ith a means o applyingcontrol process to determine the quality o ser#ice rendered. ?ursing audit is the process o analy"ing data about the nursing process o patient outcomes to e#aluate the e ecti#eness o nursing inter#entions. The audits most requently used in quality control include outcome!

process and structure audits.

7. utcome audit

utcomes are the end results o careB the changes in the patients health status and can beattributed to deli#ery o health care ser#ices. utcome audits determine $hat results i anyoccurred as result o speci ic nursing inter#ention or clients. These audits assume the outcomeaccurately and demonstrate the quality o care that $as pro#ided. ample o outcomestraditionally used to measure quality o hospital care include mortality! its morbidity! andlength o hospital stay.

. :rocess audit

:rocess audits are used to measure the process o care or ho$ the care $as carried out. :rocessaudit is tas& oriented and ocus on $hether or not practice standards are being ul illed. Theseaudits assumed that a relationship e ists bet$een the quality o the nurse and quality o care

pro#ided.

+. <tructure audit

<tructure audit monitors the structure or setting in $hich patient care occurs! such as theinances! nursing ser#ice! medical records and en#ironment. This audit assumes that a

relationship e ists bet$een quality care and appropriate structure. These abo#e audits canoccur retrospecti#ely! concurrently and prospecti#ely.

2or the e ecti#e quality control! the nurse manager has to play ollo$ing roles and unctions.

)tili6ation &e3ie"

@tili"ation re#ie$ (@ ) is the process used by employers or claims administrators tore#ie$ treatment to determine i it is medically necessary. >ll employers or their $or&ersNcompensation claims administrators are required by la$ to ha#e a @ program. This programis used to decide $hether or not to appro#e medical treatment recommended by a physician$hich must be based on the medical treatment guidelines .

The term utili"ation re#ie$ re ers to a retrospecti#e re#ie$ 66 the re#ie$ o treatmentsor ser#ices that ha#e already been administered! and re#ie$ o medical iles in comparison$ith treatment guidelines. *n the latter case! in ormation retrie#ed during a utili"ation re#ie$can be used as part o a system that creates the insurance companyNs guidelines or a gi#encondition. ;hen creating these documents! insurance companies not only use patiente periences but also re#ie$ ho$ physicians ! labs and hospitals handle the care o their

patients.

@tili"ation re#ie$ (@ ) is a sa eguard against unnecessary and inappropriate medical care. *tallo$s health care pro#iders to re#ie$ patient care rom perspecti#es o medical necessity!quality o care! appropriateness o decision6ma&ing! place o ser#ice! and length o hospitalstay.

http://www.dir.ca.gov/dwc/MTUS/MTUS.html

http://people.howstuffworks.com/becoming-a-doctor.htm

http://www.dir.ca.gov/dwc/MTUS/MTUS.html

http://people.howstuffworks.com/becoming-a-doctor.htm



$om#laint (nalysis

*ncreasingly companies are recogni"ing the #alue o a customer complaint in that it is reeeedbac& on their e perience! and an opportunity to not only resol#e a problem or that

particular customer but perhaps also or a much larger number o customers.

*n order to ans$er that $e need to loo& at the common barriers to collecting eedbac&'

1. $ulture. >re sta acti#ely encouraged to embrace customer eedbac&! e#en $henit%s a customer complaintG <ome companies ha#e a culture $here they belie#e their duty is to protect the organisation rom unscrupulous customers $ho are only in it

or themsel#es and are loo&ing to bene it rom the company%s approach to handlingcomplaints. This is o ten ocused around inancial bene it through compensation.ne company $e $or&ed $ith certainly had a situation $here the actions o a tiny

minority o customers had led sta to distrust all customers. > series o urban mythshad de#eloped throughout the company to the point $here all customer complaintsand returns $ere distrusted.

. Measurement. >re customer complaints measured by the yard or by their #alueGompanies that record the #olume o customer complaints and then place it on a

scorecard! $ith a target o reducing the #olume! are not only hiding the truth o $hatcustomers e perience but also aren%t bene itting rom the #alue o that eedbac&.Ca#ing a #ie$ o I$hat you don%t &no$ can%t harm youH is in act acing 180degrees in the $rong direction. =ri#ing the beha#iour o employees to a#oidrecording and reporting complaints can only be bad or the organisation.

+. Time. olleagues can be under enormous time pressure to handle a customer asquic&ly as possible and mo#e onto the ne t one. This can both be in a contact centreand in a more ace to ace situation. <urely i the customer has committed their timeto telling you about the issue the #ery least you can do is ind the time to listen tothemG losely associated $ith that is the time to accurately record the complaint!and clearly the time to resol#e the issue.

,. 1ata collection. Co$ easy at the point at $here the customer is complaining is it tocollect and accurately record that eedbac&G >re there standard data collection ieldsthat should be used to support trend analysis! yet also the opportunity to collectincident speci ic eedbac&G >re sta $ell brie ed on $hy they are collecting the

eedbac& and the importance o recording it accurately! rather than simply selectingthe irst option rom a dropdo$n menuG *s there a clear de inition o each data

collection ield to help remo#e any ambiguityG5. %alued. *s the customer complaint data collected proacti#ely used by the business!

both in terms o that speci ic transaction and more $idelyG *s the indi#idual E teamrecognised or the #alue o the le#el o detail they ha#e capturedG

-. Ma!ing it easy to com#lain. ompanies need to ensure that it is easy or customersto gi#e this #aluable eedbac&. ;e ha#e all been told Iyou%ll need to $rite that alldo$n in a letter and post it to head o iceH. Co$ e$ o us do that! but ho$ many o us simply choose to ta&e our business else$here! and tell our riends and colleagueso the company%s poor ser#ice.

MO& I1IT* (N1 MO&T(LIT* MEETINGS

:articipation in mortality and morbidity (MPM) or clinical re#ie$ meetings should beconsidered a Fcore% acti#ity or all clinicians. ;hile it is recogni"ed that di erent departments$ill ha#e di erent requirements and aims in relation to MPMEclinical re#ie$ meetings! themain principles are that they should be a orum or discussion o deaths! as $ell as other clinical ad#erse e#ents.

: *? *: <

>ll clinical departments are e pected to adhere to the ollo$ing principles'

• MPMEclinical re#ie$ meetings should be held on a regular! scheduled basis

• Meetings should be multidisciplinary! including clinicians rom nursing! medicaland allied health

• Meetings should be used to analyse critically the circumstances surroundingoutcomes o care. These should include selected deaths! serious morbidity andsigni icant aspects o regular clinical practice

• The ocus should be on the systems and processes o care and not on indi#idual per ormance

• ecommendations arising rom indi#idual cases should ocus on measures that can pre#ent similar outcomes or ad#erse incidents! or that $ill impro#e the processes o care pro#ided to this group o patients. These recommendations should not apportion

blame to indi#iduals

• >ctions to implement the recommendations should be initiated. *t is theresponsibility o the chair o the meeting to o#ersee progress in their implementation

• utcomes and decisions o these meetings should be documented in a brie report.

M T*?A<

&es#onsi+ilities

:articipation in MPMEclinical re#ie$ meetings should be considered a Fcore% acti#ity or all

clinicians. The responsibility or ensuring that this occurs resides $ith the duly appointedclinical department head.

#ersight o this acti#ity $ill occur through the appropriate net$or& directorE acility manager and the net$or&E acility patient sa ety and quality committee.

Organi6ation and $onduct

• Meetings should be held on a regular basis. The e pectation is thatthis $ill be at least monthly! unless speci ied other$ise by theappropriate net$or& directorE acility manager.

• The meetings should be scheduled $ell in ad#ance (i.e.! -61months)! $ith a set day! time and #enue to ma imi"e the clinicians%a#ailability to attend. > reminder should be ad#ertised in the clinical

area at least one $ee& in ad#ance o each meeting.

http://www.customerchampions.co.uk/cost-of-customer-complaints/

http://www.customerchampions.co.uk/cost-of-customer-complaints/



• Terms o re erence (T ) should be de#eloped and a copy gi#en toall committee members. T are to be updated annually.

• >ll le#els o sta 3 both 7unior and senior 6 in#ol#ed in the care o the patient should be in#ol#ed. They should be multi6disciplinary sothat clinicians rom all the rele#ant specialties and pro essional

bac&grounds (i.e.! medical! nursing! allied health) can attend. *ndetermining membership! consideration should be gi#en to clinicians

rom related specialties $ith $hom the department requentlyinteracts.

• > person should be elected as the chairperson. There should be adesignated person to ta&e notes o &ey indings at each meeting!$hich $ill assist in the compilation o a report.

• The chairperson! $ho should be a senior and respected member o thedepartment! $ill ha#e the role o initiating discussion and ensuringthat e#ery opportunity is ta&en to identi y and document actions or impro#ement. The hairperson may be di erent rom the person

presenting indi#idual cases.

• The chairperson is responsible or creating an atmosphere conduci#eto open discussion and should ensure that all members ha#e anopportunity to contribute.

> standing agenda should be de#eloped $hich should incorporate the ollo$ing elements'• e#ie$ o pre#ious minutes• e#ie$ o progress o outstanding recommendationsEactions• e#ie$ o deaths• e#ie$ o serious ad#erse e#ents• :resentation o clinical indicators• e#ie$ o **M< incidents (particularly those $ith principal incident type o clinicalmanagement)• e#ie$ o complaint• e#ie$ o cases requiring open disclosure • e#ie$ o ris& register.

&e3ie" o' 1eaths

=eath re#ie$ must include all those caused by! or associated $ith a health care inter#ention!rather than a result o the natural course o the illness. >t a minimum! these cases should beitemi"ed and the opportunity to discuss should e ist. =epending on #olume! the chair may$ish to highlight speci ic cases or presentation or more detailed discussion.

> common practice is or a nominated clinician to re#ie$ all deaths prior to the meeting and!in con7unction $ith the chair! decide $hich cases $ill bene it rom detailed presentation anddiscussion. ;here this happens! the opportunity must still e ist or clinicians to raise concernsabout any other deaths that ha#e not been presented in detail.

<ome deaths must be reported to e ternal bodies (e.g.! oroner! < *=@>! C><M! :eri6natalMortality committee). The act that an e ternal report has occurred should not be a reason or

dispensing $ith local re#ie$.

;hen presenting in ormation about death or ad#erse e#ents! either in detailed or summari"edtabular ormat! the in ormation should be de6identi ied (i.e.! patients should not be re erred to

by name).

;here cases are identi ied or presentation! clinicians rom outside the department $ho playeda signi icant role in the patient%s care! should be in#ited to attend.

2ocus should be on identi ying the issues related to any processes or systems o care thatcontributed to the death! not on the indi#iduals $ho pro#ided the care. :rimary questions toconsider or each case are'

• ;hat happenedG • * there $as a breach o a standard o care or an error! $hy did it happenG

• ;hat can be done to pre#ent a recurrenceG

=iscussions should ocus on measures that can be recommended or implemented! to pre#ent asimilar incident or ad#erse outcome. * issues raised represent substantial ris&s to thedepartment%s ability to deli#er its ser#ice! or to pro#ide sa e care! they should be re erred to thenet$or&E acility patient sa ety and quality committee or inclusion on its ris& register. Thedepartment must consider and document actions that can be ta&en to manage or minimi"e theris&.

S($ 7 1eaths Identi'iedThe local health district has a legislati#e responsibility to report <> 1 deaths through the*ncident *n ormation Management <ystem (**M<)! by means o a reportable incident brie ( *4) to the Ministry o Cealth. These are deaths associated $ith health care inter#ention in$hich it is thought that'

• >n error• > breach o an accepted standard o care• > systems ailure contributed to the cause o death

> root cause analysis ( >) must be conducted into all <> 1 deaths.<> 1 =eaths are usually identi ied close to the time o death! entered into **M< and an >initiated by the l inical Ao#ernance @nit. Typically! an > $ill be under$ay by the time the

case is being considered at an MPM meeting. This does not preclude its discussion. The deathshould stay on the agenda until the meeting has had the opportunity to re#ie$ the outcome andrecommendations o the >.

*n the e#ent that a death not been pre#iously identi ied as a <> 1! is re#ie$ed and themeeting concludes that it satis ies the criteria! it should be entered into **M< and clinicalgo#ernance unit noti ied as soon as possible.

End o' Li'e Management

*n each morbidity P mortality meeting! team meeting or case con erence! or each death! teammembers should consider'

• The circumstances o the death itsel including symptom control 6 $as the patient settled and peace ulG :ri#acy 6 in $hat setting did he or she dieG



• The preparation 6 $as amily made a$are the patient $as dyingG :rompts or discussion points can include'

=id the patient appear com ortableG;ere symptoms $ell controlledG=id the nurses ha#e access to medications to control symptomsG ;ere terminalcare: ? medications charted and a#ailableG;as the patient and amily a orded pri#acyG;as amily made a$are the patient $as dyingG

&e'erral o' Issues

=iscussions should be used or educational purposes! not or apportioning blame toindi#iduals. ;here serious concerns arise regarding a pattern o per ormance o an indi#idual!the chairperson should raise the matter con identially and independently o the MPM process!$ith the clinical department head! $ho is responsible or addressing per ormance managementissues. in addition! the director o clinical go#ernance should be noti ied! in accordance $iththe I omplaint or oncern about a linicianH policy directi#e (:= 00-\00/).

&e#orting

> brie report should be compiled a ter each meeting! $hich identi ies the cases discussed(either by medical record number (M ?)! or by initials and date o death) and the actions thatmust be ta&en as a result o the re#ie$ and discussions. * there are no recommendations or action! this should be recorded and all action items placed on the agenda or the ne t meeting.The report should be distributed $ithin the department.

> quarterly report must be submitted to the net$or& directorE acility manager and thenet$or&E acility patient sa ety and quality committee.

;here actions recommended by the MPM meeting cannot be implemented! this must bespeci ically highlighted to the net$or& directorE acility manager and the rele#ant acility or cluster management.

&e3ie" o' other Quality and atient Sa'ety Matters

MPM meetings pro#ide a #aluable $ay or departments to re#ie$ the quality o the care being

pro#ided and to identi y any opportunities or impro#ement. > &ey means is by re#ie$ing'• ther serious ad#erse e#ents (other than deaths)

• linical indicators $hich re lect per ormance

• e#ie$ o **M< incidents (particularly those $ith principal *ncident type o clinicalmanagement)

• e#ie$ o complaints

• e#ie$ o cases requiring open disclosure

• e#ie$ o ris& register.

*t is particularly #aluable or departments to identi y recommendations arising rom suchre#ie$s and ensure that actions occur in relation to them.

Sentinel E3ents

*n support o its mission to continuously impro#e the sa ety and quality o health care pro#ided to the public! The Doint ommission in its accreditation process re#ie$s hospitals%acti#ities in response to sentinel e#ents. The accreditation process includes all ullaccreditation sur#eys and! as appropriate! or6cause sur#eys! and random #alidation sur#eysspeci ic to #idence o <tandards ompliance ( < ).

• > sentinel e#ent is an une pected occurrence in#ol#ing death or serious physical or

psychological in7ury! or the ris& thereo . <erious in7ury speci ically includes loss o limb or unction. The phrase Ior the ris& thereo H includes any process #ariation or $hich a recurrence $ould carry a signi icant chance o a serious ad#erse outcome.

• <uch e#ents are called IsentinelH because they signal the need or immediatein#estigation and response.

• The terms Isentinel e#entH and IerrorH are not synonymousB not all sentinel e#entsoccur because o an error! and not all errors result in sentinel e#ents.

>ccredited organi"ations are e pected to identi y and respond to all sentinel e#ents occurringin the organi"ation by doing a thorough and credible root cause analysis! implementingimpro#ement to reduce ris&! and monitoring the e ecti#eness o the impro#ement.

rgani"ations that complete acceptable root 6cause analyses or sentinel e#ents $ill not be placed on accreditation.

<el 6 reporting a sentinel e#ent to the Doint ommission is not required. *t isrecommended that it &eep con idential and not reported to the media. <tate la$ protection o

pri#ileged and con idential in ormation against the ne$ #oluntary sel 6reporting requirementsshould be chec&ed be ore appro#ing institutional sentinel e#ents policies.

D >C sur#eyor $ho $ill conduct on on6site sentinel e#ent in#estigation as an hoc member to one o the hospitals peer re#ie$ committees as a temporary appointment or the sole

purpose o re#ie$ing root 6cause analysis to preser#e con identiality.

ther steps to sa eguard the con identiality o root 6cause analysis reports include theollo$ing'

1. <tamp Icon idential and pri#ilegedH on e#ery page o a sentinel e#ent report

. To ensure peer re#ie$ pri#ilege! ha#e all documents de#eloped by quali ied peer re#ie$ committee members

+. * the hospital%s attorney can establish that the document is protected asIattorney $or&3 product in anticipation o litigation or attorney client

pri#ileged in ormation!H ha#e each root 6 cause analysis re#ie$ed by counsel

,. Leep the report generic by not identi ying the patient or pro#ider

5. emo#e identi ications in reports to D >C and

-. onsult the legal council i D >C requires a re#ie$ o root6cause analysis tocon irm that the in ormation remains protected

The re#ie$able sentinel e#ent ta&es into account a $ide array o occurrences applicable to a

$ide #ariety o health care organi"ations. >ny or all occurrences may apply to a particular



type o hospital. The subset o sentinel e#ents that is sub7ect to re#ie$ by The Dointommission includes any occurrence that meets any o the ollo$ing criteria'

The e#ent has resulted in an unanticipated death or ma7or permanent losso unction not related to the natural course o the patient%s illness or underlying condition or

The e#ent is one o the ollo$ing (e#en i the outcome $as not death or ma7or permanent loss o unction not related to the natural course o the

patient%s illness or underlying condition)'

<uicide o any patient recei#ing care! treatment and ser#ices in asta ed around the6cloc& care setting or $ithin / hours o discharge

@nanticipated death o a ull6term in ant

>bduction o any patient recei#ing care! treatment! and ser#ices

=ischarge o an in ant to the $rong amily

ape! assault (leading to death or permanent loss o unction)! or homicide o any patient recei#ing care! treatment! and ser#ices

ape! assault (leading to death or permanent loss o unction)! or homicide o a sta member! licensed independent practitioner! #isitor!or #endor $hile on site at the health care organi"ation

Cemolytic trans usion reaction in#ol#ing administration o blood or blood products ha#ing ma7or blood group incompatibilities (>4 !

h! other blood groups)

*n#asi#e procedure! including surgery! on the $rong patient! $rongsite! or $rong procedure

@nintended retention o a oreign ob7ect in a patient a ter surgery or other in#asi#e procedures o <e#ere neonatal hyperbilirubinemia(bilirubin X+0 milligramsEdeciliter)

:rolonged luoroscopy $ith cumulati#e dose X1!500 rads to a singleield or any deli#ery o radiotherapy to the $rong body region or

X 5O abo#e the planned radiotherapy dose

$redentialing and $linical ri3ileging

The credentials and clinical pri#ileges process is a ormal mechanism or ensuring that qualityhealth ser#ices are pro#ided $ithin the range and scope o resources a#ailable. The process isrelated to quality assurance! ris& management and the impro#ement o health outcomes.Through the credentialing and clinical pri#ileging process only those medical practitioners$ho are appropriately quali ied! trained and e perienced! underta&e clinical care $ithin thescope o the delineated role o the health care acility.

$redentialing

redentialing enables an institution or managed care organi"ation to e#aluate a pro essional%s quali ications in order to determine appropriateness or a position.The credentialing process in#ol#es con irming a healthcare pro#ider%s licensure andauthori"ation to practice in the state! and any rele#ant certi ications! education! and

training. The process also requires #eri ying pro essional re erences and searchingor any past disciplinary actions! criminal history! and entries in the national

practitioner databan&s. redentialing requires primary source #eri ication.H Thismeans the hospital! or the credentialing organi"ation contracted to pro#ide thecredentialing ser#ice! must #eri y credentials the applicant claims to ha#e $ith theagency or institution that granted the license! degree or certi ication! i thosecredentials are rele#ant to the position or pri#ileges or $hich this health care

practitioner is being considered. The organi"ation must also e#aluate i any pasthistory $ould disquali y the practitioner or the position or pri#ileges beingrequested.

$linical ri3ileging

:ri#ileging is the process through $hich the health care practitioner is grantedauthority to pro#ide certain care and ser#ices to patients $ithin the healthcare

acility.

:ri#ileging is the process o pro essional peer e#aluation that is done by a selectcommittee $ithin an institution. *t is not a simple tas& and requires e#aluation o each person%s education! e perience! training! etc.! in order to determine a clinician%scapabilities. *n order or this process to occur! a acility must ormulate a system by$hich this process can occur in a reasonably e peditious! air $ay that can minimi"eris& to the institution and ma imi"e patient sa ety.

;hen pri#ileged! each practitioner must be in ormed o the pri#ileges they ha#e been granted $ithin the institution. The permitted patient care acti#ities may be thesame as those allo$ed by state and ederal la$s or they may be restricted by theinstitution. The delineation o pri#ileges may ollo$ se#eral ormats! such as ageneral description o a practitioner%s duties $ithin an instit ution or it may in#ol#e aspeci ic procedural listing o allo$able acts! such as suturing! punch biopsy! etc.

%ariance (nalysis

ariance analysis is an analytical tool that managers can use to compare actualoperations to budgeted estimates. *n other $ords! a ter a period is o#er! managers loo& at theactual cost and sales igures and compare them to $hat $as budgeted. <ome budgets $ill bemet and some $ill not.

There are se#eral important standard cost #ariances that are included in a typical #arianceanalysis' cost #ariances! material #ariances! labor #ariances! and o#erhead #ariances. >ll o these #ariances loo& at the di erence bet$een $hat e penses $ere actually incurred or the

period and $hat management set at the standard or budgeted e penses at the beginning o the period.



Quality Management Reports

Documents