Quality Improvement Tools

Gina M. Berg, PhD, MBA

Wesley Leadership Institute Quality Improvement Academy

 Learning Objectives
At the end of this lesson, you should be able to:
DESCRIBE • Improvement Model/PDSA
• Flowchart (process analysis)
• Brainstorming Benefit(s)
• 5 Whys (root cause analysis)
• Fishbone/Ishikawa diagram (root cause analysis)
• Pareto chart (rank order by importance)
• Control chart (performance over time)
• LEAN
• Six Sigma
Definitions

Quality Care Quality Improvement

(IOM, Crossing Quality Chasm, 2001) (Hastings Center, 2003)

 Safe
 Systematic, data-guided
activities designed to bring
 Timely about immediate improvements
 Effective in health care delivery in
particular settings
 Equitable

 Patient centered  Form of experiential learning

 Efficient
Developing QI Project

Why?
Why?
Why?
Why?
Why?
 IHI Model

1 What are we trying

to accomplish?

2 How will we know

that a change is an
improvement?

3 What changes can we

make that will result
www.IHI.org
Langley GL, Moen R, Nolan KM, Nolan TW, Norman CL, Provost LP. The
in an improvement?
Improvement Guide: A Practical Approach to Enhancing Organizational
Performance (2nd edition). San Francisco: Jossey-Bass Publishers; 2009.
 PDSA Cycle

Plan small process change

Implement or discard

Execute on small scale

Test or measure
Continuous Quality Improvement

Repeated Use of the Cycle Changes

That Result
in
A P Improvement
S D

A P
S D
Hunches
Theories
Ideas
Hit the mark
Flow Chart
 Picture of the separate steps of
a process in sequential order
(http://asq.org/)

 Document a process
 Develop understanding
 Study for improvement

 Communicate to others

 Planning a project
Complex
Sepsis Flow Chart
Brainstorming
 Spontaneous group discussion to produce ideas
for problem solving

 Amass information
 Stimulate creative thinking
 Develop new ideas
Fishbone Diagram: Purpose
 Cause and Effect Diagram
 Identifies causes of problems
 Sorts ideas into categories
 Methods

 Machines (equipment)
 Manpower (people)

 Materials

 Measurement

 Environment
Example: Fishbone Diagram
Example: Fishbone Diagram
 Why?

Five Whys?
Why?
Why?
Why?
Why?

 Iterative interrogative technique used to explore the

cause-and-effect relationships underlying a
particular problem
 Five iterations to reach underlying cause
 Six-Sigma tool
Machines
Examples: Fishbone Diagrams
Pareto Charts: Definition & Purpose
 Visual depiction of significance and cumulative
accountability
 Data driven
 Analysis of frequency of causes
 Prioritization/focuses attention on most significant

 Communication about cause significance with others

http://asq.org
Example: Pareto Chart
Example: Pareto Chart
Pareto Principle (80/20 Rule)
 80/20 Rule
 Law of the vital few
 Principle of factor sparsity

 For many events, roughly 80% of the effects come

from 20% of the causes (unequal distribution)

 Most things in life are not distributed evenly

 Throughput Example
Question Example

1
What are we trying to Improve efficiency of office visits
accomplish? Improve patient satisfaction

2
How will we know that a Decreased elapsed time from
change is an improvement? patient check-in to patient check-
out

3
What changes can we make
that will result in an
improvement?

www.IHI.org
Langley GL, Moen R, Nolan KM, Nolan TW, Norman CL, Provost LP. The
Improvement Guide: A Practical Approach to Enhancing Organizational
Performance (2nd edition). San Francisco: Jossey-Bass Publishers; 2009.
Throughput Flow Chart
T0
Scheduled
appointment ET7 = T1 to T7
time ET8 = T0 to T7
ET0

T1 T2 T3 T4
First Patient Nurse Patient
Contact ET1 “Arrived” ET2 ET3 “Ready”

ET4

T5 T6 T7
Provider Provider Done Patient
Start ET5 Or Nurse Needed ET6 Discharged
 Throughput Fishbone Diagram

Delay to First Contact Nurse Delay

Patient Late UA needed
Long Line Room not ready
Computer Issue With another patient
Other Other
Delays in
Supplies missing Didn’t check out Throughput
Review records Went to lab
Outside records missing Went to referral
Other Other

Delay to Physician Delay to Checkout

 Throughput Data Collection

Check In Delays N= 87 Nurse Delays N= 87

Patient arrived late 13 15% Room not ready 46 53%
Long line 17 20% UA needed prior 25 29%
Computer issue 26 30% With another patient 13 15%
Other 31 36% Other 28 32%

Physician Delays N= 87 Check Out Delays N= 87

Med student saw patient first 19 22% Patient didn’t stop at front desk 24 28%
Needed to review records 9 10% Patient went to lab 22 25%
Outside records missing 12 14% Patient went for referral 17 20%
Supplies missing 29 33% Other 4 5%
Throughput Pareto Chart
Throughput Pareto Chart
 Throughput Example
Question Example

1
What are we trying to Improve efficiency of office visits
accomplish? Improve patient satisfaction

2
How will we know that a Decreased elapsed time from
change is an improvement? patient check-in to patient check-
out

3
What changes can we make • Back office supports front desk
that will result in an • Standardize exam rooms
improvement? • Preview records day before

www.IHI.org
Langley GL, Moen R, Nolan KM, Nolan TW, Norman CL, Provost LP. The
Improvement Guide: A Practical Approach to Enhancing Organizational
Performance (2nd edition). San Francisco: Jossey-Bass Publishers; 2009.
Throughput Example

Repeated Use of the Cycle Changes

That Result
in
A P Improvement
S D

Preview patient records

A P Standardize exam rooms

S D
Back office supports front desk high volume
Ideas
Control Charts
 Single quality characteristic measured or computed
 Analysis indicates process
 In control: stable (variation only coming from sources
common to the process)
 Out control: Identify sources of variation

 Predict future performance

Control Charts
Six Sigma
 Problem-solving methodology
 Minimize mistakes (cost)
 Sigma scale is universal measure
Sigma Percent Defective Per Million
1 69% 691,462
2 31% 308,538
3 6.7% 66,807
4 0.62% 6,210
5 0.023% 233
6 0.00034% 3.4
7 0.0000019% 0.19
LEAN
 Maximize customer value while minimizing waste
 Seven Forms of Waste

Form of Waste Explanation

Transport Movement product/materials
Waiting Operator idleness
Overproduction More than customer requires
Defect Anything fails to meet specifications
Inventory Financial resources, at-risk
Motion Movement that does not add value
Extra Processing Process that does not add value
Problems are man-made, therefore
may be solved by man.
John F. Kennedy

The outcome depends upon the

knowledge and persistence
of the people involved.
Important Dates
Session Day/Date Time Venue Topic
06 Thursday, 3/24 Noon - 1pm Cessna Building QI Toolkit #4: Control Charts
07 Thursday, 4/28 Noon - 1pm Cessna Expand QI Knowledge #1: Error & Risk
08 Thursday, 5/26 Noon - 1pm Cessna Building QI Toolkit #5: TeamSTEPPS
09 Thursday, 6/23 Noon - 1pm Cessna Expand QI Knowledge #2: Just Culture
10 Thursday, 7/28 Noon - 1pm Cessna Expand QI Knowledge #3: High Reliability Org
11 Thursday, 8/25 Noon - 1pm Cessna Expand QI Knowledge #4: Disparities
12 Thursday, 9/22 Noon - 1pm Cessna Quality Forum Present QI Project (IHI Prep)
* WLI QIA typically meets 4th Thursday of month; please note12/3 is first Thursday due to holidays
 THANK YOU
EVERYDAY YOU SHOULD ASK YOURSELF

HOW CAN I IMPROVE?

Wesley Leadership Institute Quality Improvement Academy