Quality Improvement Tools and Techniques: 2007

An MPRO Self-Instructional Module

Patricia L. Baker, RN, MS

22670 Haggerty Road, Suite 100, Farmington Hills, MI 48335 ~ www.mpro.org

Tools for the Continuous Quality Improvement Journey

Objectives
Identify common quality improvement (QI) tools used to focus on important problems List tools for identifying problem causes Recognize tools for defining solutions Review tools used to develop QI plans Plan to display QI data

MODEL for IMPROVEMENT

Reference: Langley, G.J.; Nolan, K.M.; Nolan, T.W.; Norman, C.L.; and Provost, L.P. (1996). The Improvement Guide, San Francisco, CA: JosseyBass Publishers

Continuous Quality Improvement

P
A

Tools to Identify the QI Focus

Define the problem areas Compare the current state with the desired state Check alignment with organizational mission and goals

Tools to Identify Focus

Brainstorming Idea writing Impact analysis Pareto Diagram Problem statement Selection grid

Brainstorming

A focused creativity technique designed to collect multiple ideas about an issue Benefits

Encourages creative thinking Generates a large number of ideas Gets all team members involved Eliminates fear of criticism Increases the number of options

Brainstorming Rules

No criticisms or compliments No discussion No questions Speed is important Think broadly Develop wild, outrageous ideas Build on ideas of others Listen Do not interrupt Quantity is important

Brainstorming Steps
1. Clarify the brainstorming objective 2. Write the objective at the top of the flip chart 3. Review brainstorming rules 4. Determine process: free flow or take turns 5. Record each idea on the flip chart 6. Continue until all ideas are exhausted 7. Clarify each idea after all ideas are listed 8. Group like ideas together

Idea Writing

Individual brainstorming on paper Benefits

Idea notes may be written before the team meeting Protects anonymity Idea notes shared at the meeting Includes those who cannot attend

Impact Analysis

Survey technique to discover the impact or effect of a situation or problem Benefits

Confirms the problem or project is worthwhile Indicates the severity of the problem Often uncovers new information Allows for sharing of thoughts, opinions, and ideas

Pareto Diagram

Bar chart that demonstrates the distribution of issues that cause most of the problems Benefits

Applies the 80/20 rule Focuses on the 20% of the work that cause 80% of the problems Gives the biggest return for your efforts Helps explain problem to others

Pareto Diagram
Reasons women do not get mammograms May, 2003
15 10 5 0
Fear No insurance Forgot Test not ordered

12 8 7 3 Total

Problem Statement

Defines and summarizes the issue or problem Benefits

Spells out the impact of the current state Defines the opportunities of the desired state Explains the expected impact of correcting the situation Delivers a consistent message

Define Goals

What are we trying to accomplish? SMART Goals

Specific Measurable Attainable Realistic Timely

Tools to Understand the Cause

Clarify the process

Flow chart the process Fishbone or Cause and Effect Diagram Impact analysis Data Pareto Diagram

Determine cause

Flowchart the Process

A diagram of the sequence of steps in a work effort Benefits

Clarifies current knowledge of process Demonstrates the work flow Examines parts of a process and their relationship to each other Identifies the sources of variation for each step from start to finish Points out unnecessary complexity, inefficiency, and redundancy Develops a common understanding

Flowchart Steps

Involve those most knowledgeable about the process Define the boundaries (beginning and end) List the work activities, decisions, and documents Place the activities, decisions, and documents in the order that they occur Connect the activities with arrows

Diabetic Patient Registers

Nurse/MA reviews the diabetic flowsheet

NO A1C due?

YES
Nurse/MA obtains blood sample and documents results

Patient escorted to exam room

Diabetic Foot Exam Needed

NO

YES
Nurse/MA conducts foot exam and documents on foot exam form Physician/PA/NP enters exam room Physician/PA/NP reviews documentation

Physician/PA/NP examines patient and completes documentation

Patient checks out at receptionist

Patient Leaves Office

Fishbone or Cause & Effect Diagram

Explores and displays the identified causes and relationships leading to a specific outcome Benefits

Involves multiple team members Allows grouping of information Displays related causes Gives ideas for goals Points out data needs Provides ideas for solutions Presents big picture of the problem Easy to understand

Fishbone or Cause & Effect Steps 1. Agree on the problem statement or outcome 2. Identify major cause categories 3. Brainstorm reasons for each of the major causes 4. Clarify the diagram 5. Post for others to review

Fishbone or Cause & Effect Diagram

Employees Materials Equipment

Outcome

Methods

Environment

Examine Solutions

Tools to generate solutions

Brainstorming Impact analysis Pareto Diagram Flowchart Fishbone Collaboration with others Literature

Select a Change Option

What change can we make that will result in improvement? Tools

Decision matrix Selection grid Multi-voting Cost-benefit analysis Force Field Analysis

Decision Matrix

Easy to Do

Hard to Do

High Pay Off

A.

B.

Low Pay Off

C.

D.

Selection Grid
Criteria

Worthwhile
Options
A 4 yes 2 no 3 yes 3 no 5 yes 1 no 2 yes 4 no

Cost
3 yes 3 no 5 yes 1 no 2 yes 4 no yes 4 no 4 yes 2 no

Admin Support
3 yes 3 no 4 yes 2 no 3 yes 3 no 3 yes 3 no

Criteria #4

Criteria #5

6 yes

Multi-voting

A group decision-making technique designed to reduce a large list of ideas to a manageable number. Benefits

Eliminates peer pressure Equal participation Allows for consensus Gains buy-in among the team

Multi-voting Steps
1. List ideas or options on flip chart or chalk board 2. Each team member votes for their top three choices 3. Clarify among the team and eliminate choices with one or zero votes 4. Each team member selects top two choices from the remaining list 5. Repeat the process until the top one or two ideas have been selected

Cost-benefit Analysis

Determine the financial impact by comparing the costs and benefits Benefits

Evaluates the cost of a change Supports decision-making Provides supporting documentation for QI teams recommendation

Force Field Analysis

Identify and discuss forces that support or interfere with a change Benefits

Identifies obstacles Lists supporting elements Suggests action steps

Force Field Analysis

Current State Driving Forces Restraining Forces Desired State

Determine Measures

How will we know that a change is an improvement? What are the data needs? Consider:

Data collection methods Data analysis plan Accountable persons

Check List

A method to systematically record data from observations or historical sources Benefits

Easy-to-use form Minimal data collector training Efficient and fast data collection Detects patterns and trends

Check List
Steps Decide on data to collect Clarify definitions Decide on time period for collection Select sample size Decide who will collect data Design and test the check list Distribute form and collect the data Tally and evaluate

Develop Action Plan

Brainstorm Force Field Analysis Political action plan Presentation

Action Plan
Action Plan Project Name: _________________________________ Goal (s) What are we trying to accomplish? 1. Steps What needs to be done? Project Lead: ________________ Date: ________________ Accountability Who will do it? Deadline When will it be done? Monitoring How is it going? What progress has been made?

2.

3.

4.

5.

Political Action Plan

A communication strategy designed to inform and gain support Benefits

Share information Build support Receive feedback Build consensus Eliminate surprises

Presentation

A communication technique to share information and obtain feedback Benefits

Deliver a consistent message Gain understanding Elicit support Teach and share Receive ideas

Presentation Strategies

Be prepared The three tells Use visual aids

Storyboard Slides Diagrams, charts, and graphs

Practice

Continuous Quality Improvement

P A

Continuous Quality Improvement

P A D

Pie Chart

A picture depicting parts of the whole Benefits

Easily understood Draws interest Good visual

Bar Chart: Aspirin at Arrival for AMI Patients

100.0 80.0
Percent (%)
80.5 80.0 95.2

60.0 40.0 20.0 0.0 Michigan National Benchmark

Run Chart

Number of Foot Exams performed per M onth

40 30 20 10 0
JULY

New flow sheet

Total Foot Exams

AUG

SEP

OCT

NOV

DEC

Continuous Quality Improvement

May your QI journey be fun, interesting, and successful!

QI References
Brassard M, Ritter D. The Memory Jogger II. GOAL/QPC, Methuen, MA, 1994. Brassard M, Joiner BL. The Team Memory Jogger. GOAL/QPC and Joiner Associates Inc, Methuen, MA, 1995. Langley GJ, Nolan KM, Nolan TW, Norman CL, and Provost LP. The Improvement Guide. Jossey-Bass Publishers, San Francisco, 1996. Scholtes PR. The Team Handbook. Joiner Associates, Inc. Madison, WI. 1988.

Creativity References
DeBono E. Serious Creativity. New York: Harper Collins, 1993. Higgens JM, 101 Creative Problem Solving Techniques, Winter Park, FL: New Management Publishing Company, 1994. Plsek PE, Creativity, Innovation, and Quality. Milwaukee, WI: ASQC Quality Press, 1997. Van Oech R, A Whack on the Side of the Head. New York: Warner Books, 1983.

Continuing Education (CE) Contact Hours

Answer the post test questions

Minimum passing score = 76% Minimum correct answers = 19/25 Complete the evaluation Print your certificate

Thank You for Reading This SIM

Additional Information
Patricia L. Baker RN, MS Director, Staff Development 248-465-7324 pbaker@mpro.org

Carol J. Grubba, RN, MSN, BC Project Manager, Continuing Education 248-465-7337 cgrubba@mpro.org

This material was prepared by MPRO, the Medicare Quality Improvement Organization for Michigan, under contract with the Centers for Medicare & Medicaid Services, an agency of the U.S. Department of Health and Human Services. 7SOW-MI-CE-05-05

22670 Haggerty Road, Suite 100, Farmington Hills, MI 48335 ~ www.mpro.org

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