Hill Country Memorial Hospital Process Problem Solving Tool

PDCA Worksheet, page 1

THEME:
Completed (Date/By Who):
Updated:
Plan (part 1): Current State Background
CLARIFY
1. What is happening?
2. What should be happening (in an ideal state)?
3. What is the measure thats not where it should be? (The
metric that isnt good enough)
BREAK IT DOWN
4. What do you think is happening? Ask yourselves:
Where is the problem occurring?
What exactly is going wrong?
When does it happen? Who is involved?
When did it start? Is it getting better or worse?
TARGET
5. Set a goal (By when? Do what? To what? How much? As measured by?)
Example 1: By 12/31, customer satisfaction with responsiveness will improve from 75% to 95% on Press Ganey.
Example 2: By 9/31, compliance with completing all fields on the registration page will improve from less than 50%
to 95% as measured by monthly audits of 50% of files.
By this date:
This:
This will become this:
As measured by:
6. Check that your target isnt just about what to do, but instead has a clear result. It should be measurable (a
number) and focused on the problem you are working on. Also make sure you know where to get the numbers.

Now, GO - LOOK - SEE

ANALYZE
7. Go watch the proces. Any surprises?
Why is the problem occurring?
Why is that occurring?
Why is that occurring?
Why?
Keep asking why until you get to major cause or root
cause.

Hill Country Memorial Hospital Process Problem Solving Tool

PDCA Worksheet, page 2

Plan (part 2)
Completed (Date/By Who):
DEVELOP COUNTERMEASURES/SOLUTIONS (Ideas for fixing it!)
Generate as many ideas as you can. Come up with at least 6 methods to solve the problem. Include
1. Innovate! Find at least 1-2 best practices
(someone else who has solved a similar problem)
and list them here. (Assign someone or the whole
team to look online, talk to others, or research)
2. Innovate! Get a marker and some large paper
and get thinking!
a. Pretend there are no limits on resources,
staffing, time, etc. How would you fix it in that
scenario?
b. What is the craziest possible way to fix the
problem that would work? Is there any new
technology that could be included?
c. Think of another industry. How would
someone in that industry think about solving the
problem?
d. Look back at the ROOT CAUSE you came
up with. Do your ideas directly impact it? Come
up with a few more!
3. Whats the best idea? Select and list it.
4. Does the idea cause harm, break any regulatory
requirements, or fall outside HCM values?
5. What will the idea cost in dollars, supplies, and
manpower? What will it save?
6. Is the idea an Intelligent Risk? (value to
customer outweighs the risk of not doing anything)
7. Who will be affected by the idea? What do they
think?
8. What measures will you use to check if the idea
is working?

Hill Country Memorial Hospital Process Problem Solving Tool

PDCA Worksheet. Page 3

Do
Completed (Date/By Who):
DEVELOP PLAN AND IMPLEMENT
Action Steps (sample create your own table below!)
1. Notify key stakeholders (case managers) and get
input on idea
2. Develop new admission packet FAQ sheet
3. Ask team and case managers to review materials,
make changes
4. Watch how staff does admission, write down the
workflow. Do a time study.
5. Educate ED staff on new packet at their staff
meeting
6. Develop survey for patients on new information,
make copies
7. Pilot use of new packet in the ER for all Carries
patients for 2 weeks
8. Evaluate effectiveness of pilot based on patient
surveys and Carries notes.
9. Make needed changes to process
Action Steps

by When
9/12/2014
9/12/2014
9/19/2014
9/26/2014
10/4/2014
10/19/2014
10/19/2004
10/31/2014
11/15/2014
by When

Hill Country Memorial Hospital Process Problem Solving Tool

PDCA Worksheet. Page 4

Completed (Date/By Who):

MONITOR RESULTS
1. What about the change is working? Why?
2. What about the change isnt working? Why?
3. What are the metrics showing?
4. What changes need to be made? When and
who will make them?
ACT
STANDARDIZE
1. Is this a successful process?
2. Where else does it need to be implemented?
3. What departments/areas have similar processes
that could benefit from this improvement?
4. Who will submit this as a Best Practice to be
passed along? By when?
5. Who will work on taking the change through the
process management worksheet? (Process owner)

Who
Carrie
Mary
Harry
Larry
Mary
Carrie
Carrie
All
Harry
Who