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STEP 1

PROBLEM
IDENTIFICATION
AND
PRIORITIZATION
1
STEP 1: PROBLEM IDENTIFICATION AND PRIORITIZATION
INSTRUCTIONS:
1. USING THE BRAINSTORMING TECHNIQUE, NOMINATE PERCEIVED
PROBLEMS IN THE WORKPLACE.

LIST OF PROBLEMS

2 2
STEP 1: PROBLEM IDENTIFICATION AND PRIORITIZATION
INSTRUCTIONS:
2. TRIM DOWN THE LIST OF PERCEIVED PROBLEMS BY GROUPING
TOGETHER SIMILAR IDEAS. ALL CAUSES MUST BE ELIMINATED BUT
NOTE THE CAUSES FOR STEP#3.

LIST OF PROBLEMS PROBLEM OR CAUSE?

CAUSE - Factor contributing to occurrence of problem


PROBLEM - Effect/End-result cause/s. 3 3
STEP 1: PROBLEM IDENTIFICATION AND PRIORITIZATION

INSTRUCTIONS:
3. CLASSIFY THE CONTROLLABILITY OF THE PROBLEMS.

LIST OF PROBLEMS I C U

NOTE:

Controllable the process is fully owned by the team members themselves; the boundaries of the process are within the
circles responsibility; circle members are the one performing the activities within the process.
Uncontrollable beyond the teams control
Interface - involvement of the other section or unit or department in the process
4 4
STEP 1: PROBLEM IDENTIFICATION AND PRIORITIZATION

INSTRUCTIONS:
4. VERIFY EXISTENCE OF THE PROBLEM.

LIST OF CONTROLLABLE INITIAL DATA COLLECTED


PROBLEMS

Put hypothetical data


in each of controllable
problem.

5 5
SAMPLE

List Of Controllable Problems Initial Data Collected


1. Increasing number of send out From 2004 to 2005, we have gathered a total
exams referred to our affiliated of 44,230 send out exams from a total of
laboratories 128,183 exams received.
2. Typographical errors of time in From March 17-21, 2006, there were 28
and out printed in their lab result errors in typing of results out of 844 exams
(in-house) done and released.
3. Long waiting time of patients at From March 17-21, 2006, there were a total
Laboratory Reception upon of 47 patients out of 58 patients who have
claiming of results waited for more than 5 minutes upon
receiving their result/s

6
STEP 1: PROBLEM IDENTIFICATION AND PRIORITIZATION

INSTRUCTIONS:
5. CLASSIFY PROBLEMS ACCORDING TO ITS SIGNIFICANCE.

LIST OF
Initial data
CONTROLLABLE Significance Action taken
collected
PROBLEMS
1.
2. Conclude whether the
Conclude whether
controllable problem is to Go or No Go
3. significant or simple with the problem

4. concern

5.
6.
NOTE:
Simple concern are 5S related issues; problems with obvious or ready solution; the extent of problem is relatively
small against its target performance.

7
SAMPLE
Lists of Controllable Initial Data Collected Significance Action
Problems Taken
1. Increasing number of From 2004 to 2005, we have
send out exams referred to gathered a total of 44,230 send out
Significant No Go
our affiliated laboratories exams from a total of 128,183 exams
received.

2. Typographical errors of From March 17-21, 2006, there were


time in and out printed in 28 errors in typing of results out of Significant Go
their lab result (in-house) 844 exams done and released.

3. Long waiting time of From March 17-21, 2006, there were


patients at Laboratory a total of 47 patients out of 58
Reception upon claiming of patients who have waited for more Significant Go
results than 5 minutes upon receiving their
result/s 8
STEP 1: PROBLEM IDENTIFICATION AND PRIORITIZATION

INSTRUCTIONS:
6. PRIORITIZE PROBLEMS THROUGH DATA-BASED CONSENSUS.
USE PRIORITIZATION TOOL.

SIGNIFICANT CRITERIA
TOTAL
PROBLEMS 1 2 3
1.
2. SCORE
Choose criteria that will aid you in selecting a priority
3. problem from among the significant problems.
4.
Put a score per criteria.
5.
6.
7.
8.

9
SAMPLE

CRITERIA
SIGNIFICANT
TOTAL
PROBLEMS Frequency Importance Feasibility

2. Typographical errors of
time in and out printed in 1 5 3 9
their lab result (in-house)
3. Long waiting time of
patients at Laboratory
3 5 5 13
Reception upon claiming
of results

LEGEND: DISPOSITION: 10 and above - GO


High - 5 points
Medium - 3 points
Low - 1 point
STEP 1: PROBLEM IDENTIFICATION AND PRIORITIZATION

PRIORITY PROBLEM
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________

TENTATIVE PROBLEM STATEMENT


________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________

11
SAMPLE

PRIORITY PROBLEM

Long waiting time of patients at Laboratory Reception upon


claiming of results

TENTATIVE PROBLEM STATEMENT

From March 17-21, 2006, there were a total of 47 patients


out of 58 patients who have waited for more than 5 minutes
upon receiving their result/s

12
STEP 2
UNDERSTANDING
THE PRESENT SYSTEM

13
STEP 2: UNDERSTANDING THE PRESENT SYSTEM
WORKSHOP INSTRUCTIONS

1. Construct a flow chart to describe the process in which


the problem occurs; indicate the beginning and end of
the process.

2. What data will you collect to prove the existence of the


problem? Indicate the standard of performance. Supply
the data, based on your experiences, to prove that
theres a problem (refer to the formulation of system)

3. Formulate the (a) final problem statement, and the (b)


tentative objective statement

Continuous Quality Improvement in the


Hospital
STEP 2: UNDERSTANDING THE PRESENT SYSTEM

INSTRUCTIONS:
1. REVIEW THE CURRENT SYSTEM AND STANDARD.

TITLE OF THE PROCESS: _______________________

PERSON RESPONSIBLE FLOWCHART DESCRIPTION

NOTE: 1. FLOWCHART THE CURRENT PROCESS RELATED TO THE PRIORITY PROBLEM NOT THE IDEAL OR SHOULD BE.
AGREE ON THE SCOPE OF THE PROBLEM.

2. SAMPLE FORMAT ABOVE CAN BE MODIFIED ACCORDING TO INSTITUTIONS PREFERRED FORMAT.

15
SAMPLE

TITLE OF THE PROCESS: PROCESS IN CLAIMING LABORATORY RESULTS


PERSON
FLOWCHART DESCRIPTION
RESPONSIBLE
START

USING THE MICROPHONE,


CALL NUMBER ON QUE CALL PATIENT S NUMBER.
LAB
RECEPTION STAFF
ASK PATIENTS NAME AND THE ASK FOR ANY ID.
LAB DATE AND TYPE OF EXAMS ASK FOR THE LABORATORY
RECEPTION STAFF BEING CLAIMED EXAMINATIONS DONE AND
WHEN.

LAB
RECEPTION STAFF VERIFY PATIENTS DATA TAKEN ONCE THE INFORMATION HAS
IN THE LABORATORY BEEN OBTAINED, CHECK THE
REMITTANCE LOGBOOK LABORATORY REMITTANCE
LOGBOOK TO CONFIRM IT.

A 16
SAMPLE

TITLE OF THE PROCESS: PROCESS IN CLAIMING LABORATORY RESULTS


PERSON
FLOWCHART DESCRIPTION
RESPONSIBLE

LAB
RETRIEVES PATIENTS RESULTS FROM THE FILE, GET THE
RECEPTION STAFF COPY OF THE PATIENTS
ON FILES
LABORATORY RESULT/S.
PATIENT

SIGNS THE RELEASING LET THE PATIENT SIGN IN THE


NOTEBOOK RELEASING NOTEBOOK.
LAB
RECEPTION STAFF
ISSUES RESULTS TO PATIENT GIVE THE RESULT TO PATIENT

END
17
STEP 2: UNDERSTANDING THE PRESENT SYSTEM
WORKSHOP INSTRUCTIONS

2.2 VALIDATE THE EXISTENCE OF THE PROBLEM

DATA COLLECTION PLAN


DATA HOW WILL WHEN WILL TOOLS FOR
DATA TO BE WHO WILL
SOURCE AND DATA BE DATA BE DATA
COLLECTED COLLECT DATA
LOCATION COLLECTED COLLECTED PRESENTATION

NOTE: IDENTIFY THE DATA NEEDED; SPECIFY ASSIGNMENT OF MEMBERS AND SET DEADLINES; AGREE ON THE
METHODS TO USE FOR COLLECTING DATA; SUMMARIZE DATA USING QC TOOLS; INTERPRET AND EXPLAIN
INFORMATION.

Continuous Quality Improvement in the


Hospital
STEP 2: UNDERSTANDING THE PRESENT SYSTEM
WORKSHOP INSTRUCTIONS

3. a) FINALIZE THE PROBLEM STATEMENT.

FINAL PROBLEM STATEMENT:

NOTE: ELEMENTS OF EFFECTIVE PROBLEM STATEMENT: SHOULD CONTAIN THE FOLLOWING : WHAT, WHERE,
EXTENT, WHEN

Continuous Quality Improvement in the


Hospital
EXAMPLE

Problem Statement

Based on the data gathered in March 17-21, 2006


at AMC-Main Branch, Clinical Laboratory
Department- Reception Area, there were a total of
47 patients out of 58 patients (81%) who have
waited for more than 5 minutes upon receiving
their result/s.

Continuous Quality Improvement in the


Hospital
STEP 2: UNDERSTANDING THE PRESENT SYSTEM
WORKSHOP INSTRUCTIONS

3. b) FORMULATE THE OBJECTIVE STATEMENT.

TENTATIVE OBJECTIVE STATEMENT:

NOTE: ELEMENTS OF EFFECTIVE OBJECTIVE STATEMENT: SHOULD CONTAIN THE FOLLOWING : S- SPECIFIC, M-
MEASURABLE, A- ATTAINABLE, C- CHALLENGING, T- TIME- BOUND (SMACT).

Continuous Quality Improvement in the


Hospital
EXAMPLE

Tentative Objective Statement

To reduce the percentage of patients who


waited for more than 5 minutes from
81% to 5% by the end of June 2006.

Continuous Quality Improvement in the


Hospital
STEP 3
ANALYSIS
OF
ROOT CAUSES

25
STEP 3: INSTRUCTIONS

1. Identify the root causes of the problem use


brainstorming and cause effect diagram.
1.1 Draw balloon tree
1.2 Draw fishbone diagram

2. Plan data collection data you will collect,


methods and tools.

3. Use appropriate tool/s to present data.


3.1 Create Pareto chart
3.2 Draw Pareto graph
4. Formulate the final objective statement.
Continuous Quality Improvement in the
Hospital
BALLOON TREE TEMPLATE.

Continuous Quality Improvement in the


Hospital
STEP 3: ANALYSIS OF THE ROOT CAUSES

INSTRUCTIONS:
1. IDENTIFY PROBABLE CAUSES.

MATERIAL MACHINE MAN

PROBLEM

ENVIRONMENT METHOD
NOTE: NOMINATE PROBABLE CAUSES OF THE PROBLEM USING THE FISHBONE DIAGRAM; SUB-CAUSES SHOULD REACH AT
LEAST 5TH WHY LEVEL; RELATIONSHIP BETWEEN CAUSES AND EFFECTS MUST BE CLEARLY UNDERSTOOD.

Continuous Quality Improvement in the


Hospital
SAMPLE

CAUSE AND EFFECT DIAGRAM


STAFF-RELATED PATIENT-RELATED
Staff still asking patients Patient dont know what and
information and the exams done when the exams were done
3
Only verbal
Staff still locates/verifies Instruction on the
patients info in the Can not remember release of result
remittance logbook

The only reference is No patients copy of


1 the remittance the tests done 2
logbook Long Waiting
Time of Patients
in Claiming
It takes time to locate results Results can not be Laboratory
located Results

Staff still locates patients info


in the remittance logbook Misfiled Results

4 5
No Standard Procedure Results not properly
in Claiming of Result arranged

METHOD ENVIRONMENT
29
STEP 3: ANALYSIS OF THE ROOT CAUSES

INSTRUCTIONS:
3. VALIDATE PROBABLE ROOT CAUSES. IDENTIFY CONTROLLABILITY
OF THE VERIFIED ROOT CAUSES.

PROBABLE VALIDATION FINDINGS CONTROLLABILITY CONCLUSION


ROOT CAUSES METHOD
CONCLUDE
WHETHER
TRUE CAUSE
OR
NOT TRUE CAUSE

NOTE: COLLECT DATA FOR EACH ROOT CAUSES IDENTIFIED AND DRAW CONCLUSION FOR EACH ROOT CAUSE; CLASSIFY
EACH ROOT CAUSE IF IT IS W/N CONTROL, BEYOND CONTROL OR INTERFACE.

Continuous Quality Improvement in the


Hospital
SAMPLE

VA L I DAT I O N O F P R O B A B L E C AU S E - E X A M P L E
Root Causes Validation Method Findings Controllability Conclusion
(April 24-28, 2006)
1. The only reference on Actual -Based on the data gathered, C TRUE
what and when the exam was Observation our receptionists consumed an CAUSE
done is the remittance average of 8 minutes in
logbook. verifying patients info in the
remittance logbook
2. No patients copy of the Actual -Charge slips (for cash basis) C TRUE
tests done Observation and diagnostic requests are CAUSE
taken from the patients.
3. Verbal Instruction on the Actual -Out of 490 patients who were C TRUE
release of result. Observation instructed verbally there were CAUSE
a total of 120 patients who
claimed their result/s as
instructed.
4. No Standard Process in Actual -Out of 3 laboratory C TRUE
Claiming of result. Observation receptionist, all of them have CAUSE
different process in claiming
laboratory results.
5. Results are not properly Actual -Based on the actual C NOT A
arranged Observation observation, results are filed TRUE
and sorted
Continuous Quality alphabetically
Improvement in the per CAUSE
10/2/2017 31
Hospital
month.
STEP 3: ANALYSIS OF THE ROOT CAUSES
INSTRUCTIONS:
CREATE A PARETO CHART
EX:
STEP 1. ARRANGE FACTORS FROM HIGHEST TO LOWEST.
STEP 2. COMPUTE THE PERCENTAGE OF EACH DATA ITEM
Ex: 20 / 50 x 100 = 40 %
STEP 3. COMPUTE FOR THE CUMULATIVE PERCENTAGE
Ex: 0 + 40% = 40%
40% + 20% = 60%
STEP 4. DRAW THE PARETO DIAGRAM
STEP 5. INTERPRET THE RESULTS AND IDENTIFY THE VITAL FEW
CAUSES (80-20 RULE).
STEP 6: PUT THE TITLE ON THE DIAGRAM.

Percentage Cumulative
CAUSES Frequency
total %

TOTAL
Continuous Quality Improvement in the
Hospital
SAMPLE

Percentage Cumulative
CAUSES Frequency
total %

Long queue for food 20 40.00% 40.00%


Dirty wares and dining utensils 10 20.00% 60.00%
Others 8 16.00% 76.00%
Food served no longer hot 7 14.00% 90.00%
Late replenishment of continuous coffee 3 6.00% 96.00%
Dirty linens (table cloth) 2 4.00% 100.00%

TOTAL 50 100%

33
SAMPLE

PARETO CHART OF CUSTOMER COMPLAINTS ON DIETARY SERVICES

50 100.00%
45 90.00%
40 80.00%
35 70.00%
30 60.00%
25 50.00%
TOTAL
20 40.00% cumulative %

15 30.00%
10 20.00%
5 10.00%
0 0.00%
B. Long queue E. Dirty wares F. Others A. Food served C. Late D. Dirty linens
for food and dining no longer hot replenishment (table cloth)
utensils of continuous
coffee
STEP 3: ANALYSIS OF THE ROOT CAUSES

INSTRUCTIONS:
4. SET FINAL OBJECTIVE STATEMENT.

FINAL OBJECTIVE STATEMENT:

NOTE: RE-STATE THE OBJECTIVE; CONTROLLABILITY OF THE REAL CAUSES MUST BE CONSIDERED IN THE OBJECTIVE; SET
TARGET PERFORMANCE BASED ON THE TEAMS CAPABILITY; FOLLOW THE SMACT RULE.

Continuous Quality Improvement in the


Hospital
SAMPLE

FINAL OBJECTIVE STATEMENT

To reduce the percentage of patients


who waited for more than 5 minutes
from 81% to 5% by the end of June 2006
at the Laboratory Reception of AMC.

Continuous Quality Improvement in the


10/2/2017 36
Hospital
STEP 4
SELECTION OF BEST
ALTERNATIVE
SOLUTIONS

37
STEP 4: SELECTION OF BEST ALTERNATIVE SOLUTION

INSTRUCTIONS:
1. GENERATE ALTERNATIVE SOLUTIONS FOR EACH REAL ROOT CAUSE.
EVALUATE AND SELECT BEST ALTERNATIVE SOLUTIONS.

TRUE ALTERNA Controllabi- ADVAN DIS- Criteria Decision

Total
CAUSE TIVE lity TAGES ADVANTAG ABCD
SOLUTION ES

NOTE: BEST ALTERNATIVE SOLUTION MUST SIGNIFICANTLY REDUCE THE ROOT CAUSE IT IS ADDRESSING.

38
SAMPLE

CRITERIA FOR SELECTING BEST SOLUTIONS:

Formula: A + B + C + D
CRITERIA
A Effectiveness of
solution Overall Disposition:
B Probability of 10 points and above= GO
success Below 10 points= NO GO
C Ease of
implementation
D Reasonable cost
LEGEND: RATING 4 () (EXCELLENT)
3 () (SATISFACTORY)
2 () (GOOD)
1 ( ) (POOR)
39
SAMPLE
Selection of Best Alternative Solution
TRUE ALTERNA Controllabili ADVAN DIS- Criteria Decision

Total
CAUSE TIVE ty TAGES ADVANTAG ABCD
SOLUTION ES
Issue - Less - Non-
duplicate paper to conformity
charge slip use to financial
Controlla 2 2 1 4
to patient - Less audit NO GO

9
ble
1. The only effort
reference from
on what staff
and when Formulate a -Check - Additional
the exam claim stub sheet form for
was done is form style printing
the - - Additional
remittance Controlla Presenta work to 3 4 3 3

13
logbook. ble ble staff GO
- All of
the info
needed
included 40
SAMPLE
Selection of Best Alternative Solution
Writes - Less paper - No space to
exams done to use write in the
and its - No O.R.
releasing Contro additional - Needs to 2 2 1 2
NO GO

7
time to llable expenses make 3
official copies
receipt - Additional
work to staff
Formulate a -Check sheet - Additional
claim stub style form for
2. No patients form Contro - Presentable printing 3 3 3

13
4 GO
copy of the tests llable - All of the - Additional
done info needed work to staff
included
Writes - Less paper - Needs to
exams done to use write all the
and its - No patients info
releasing additional and exam
Contro 2 2 1
time in a expenses - Can be 4 NO GO

9
llable
scratch misidentified
paper as a trash
- Additional
work to staff 41
SAMPLE
Selection of Best Alternative Solution
Formulate -Check sheet - Additional
a claim style form for
stub form - printing
Presentable - Additional
- All of the work to staff
info needed
3 4 3 3

13
Controllable included
GO
3. Verbal
Instruction
on the
release of
result.
Post - Less paper - May not be
Releasing to use seen by
time in the patients
Reception 2 2 1 4
Controllable NO GO

9
area

42
SAMPLE
Selection of Best Alternative Solution

Revision of - Documented - Additional


work and process to be
instruction standardized followed by
to include process staff
the process
of claiming
4 3 2 4

13
results Controllable
GO
4. No
Standard
Process in
Claiming
of result.
- Adopt - Acquire - May not be
claiming process thru appropriate
process of Bench- to our set-up
other marking 2 2 2 2
laboratorie Controllable NO GO

8

s

43
STEP 4: SELECTION OF BEST ALTERNATIVE SOLUTION

INSTRUCTIONS:
3. identify details of the solutions. Draw an action plan by doing Gantt
Chart

Implementation date (can be


on a weekly or monthly basis)

Activity Person
In-Charge

List the activities


that need to be Draw a horizontal bar to mark
carried out to the start and end of the activity
implement the
solution
SAMPLE

Gantt Chart on Implementation of the new work instruction in


claiming of laboratory results
Activity Year 2006 In-Charge May June July Aug

1. Revision of Work I. in Juliet/


claiming results Rhanty

2. Implementation of Juliet/
revised Work Instruction Rhanty

3. Evaluation of the Juliet/


results Rhanty

4. Standardization Juliet/
Rhanty

Legend: Target

45
STEP 4: SELECTION OF BEST ALTERNATIVE SOLUTION

INSTRUCTIONS:
4. IDENTIFY POTENTIAL PROBLEMS THAT MAY OCCUR. DRAW
PREVENTIVE AND CONTINGENCY PLAN BY USING POTENTIAL
PROBLEM ANALYSIS TABLE.

POTENTIAL PROBLEM ANALYSIS


MOST
TRUE BEST POTENTIAL PREVENTIVE CONTINGENT PERSON
LIKELY TARGET
CAUSE SOLUTION PROBLEM ACTION ACTION RESPONSIBLE
CAUSE

46
SAMPLE

True Best Potential Most Preventive Contingent Person Target


Cause Solution Problem Likely Action Action Responsi
Cause ble

Incomplete Overlooked Formulate a -Double


entry of standard list checking of
Verbal patients of info to be claim stub Jocelyn
instructi exam accomplishe vs. patients
Formulate d request May 5,
on on
a claim
the - No claim - Lost or Complete - Verify 2006
stub form stub
release misplaced the info patients
presented
of result by patient listed in the exams done Rhea
by patient
encoding at Bizbox
process
Revision - Staff not - Staff Conduct - Place a
weekly reminder
of work following unaware of process note
No instruction the revised the revised review for in the
to include process process the Rhanty
standard laboratory. Reception
procedur the area May 5,
e in process of - 2006
claiming claiming Disseminate
of result results the revised Juliet
Process
during group
meetings
47
STEP 5
SOLUTION
IMPLEMENTATION

48
INSTRUCTION:

Prepare a plan for monitoring to


include data to be collected,
methods for collection,
tools for presentation of data
STEP 5: SOLUTION IMPLEMENTATION

MONITORING PLAN
WHO
HOW WILL WHEN WILL TOOLS FOR
DATA TO BE DATA SOURCE WILL
DATA BE DATA BE DATA
COLLECTED AND LOCATION COLLECT
COLLECTED COLLECTED PRESENATION
DATA

50
SAMPLE

MONITORING PLAN
DATA SOURCE HOW WILL WHEN WILL TOOLS FOR
DATA TO BE WHO WILL
AND DATA BE DATA BE DATA
COLLECTED COLLECT DATA
LOCATION COLLECTED COLLECTED PRESENTATION
1. Total no. AMC Main Tallying AMC Main June 2-6, Bar Graph
of patients Clinical the total Laboratory 2006
claiming Laboratory number of Reception-
their lab Reception patients On Duty
results Area who
2. Total waited
number of more than
patients 5 minutes
who to claim
waited their lab
more than results
5 minutes
in claiming
their lab
results
STEP 6
EVALUATION OF
RESULTS

52
STEP 6: EVALUATION OF RESULTS

INSTRUCTIONS:
1. PREPARE A COMPARATIVE DATA (HYPOTHETICAL) OF BEFORE AND AFTER
IMPLEMENTATION. USE APPROPRIATE TOOLS.

2. ENUMERATE TANGIBLE AND INTANGIBLE BENEFITS.

3. MAKE A SUMMARY OF DIFFICULTIES AND LEARNING THE TEAM HAS


EXPERIENCED.

4. MAKE A REVISED FLOWCHART (IF NECESSARY)

53
SAMPLE

BEFORE AFTER
No Standard Procedure in Claiming of Revision of work instruction to include the
Result process of claiming results

START START

Calls patients number on Calls patients number on


queue queue
Asks patients name &
the date and type of Receives claim stub from
exams being claimed patient

Verifies patients data Retrieves patients


taken in the laboratory results on files
remittance logbook
Allows patient to sign the
Retrieves patients releasing notebook
results on files

Allows patient to sign the Issues results to patient


releasing notebook

END
Issues results to patient

54
END
BEFORE AFTER
No Standard Procedure in Claiming of Revision of work instruction to include
Result the process of claiming results

START START

Calls patients number on Calls patients number on


queue queue

Asks patients name and


Receives claim stub from
the date and type of
patient
exams being claimed

Verifies patients data 37% Retrieves patients results


taken in the laboratory Reduction on on files
remittance logbook Process
Allows patient to sign the
Retrieves patients results releasing notebook
on files

Allows patient to sign the Issues results to patient


releasing notebook

END
Issues results to patient
Date Standardized: Aug. 14, 2006
Observation and continuous
55
END monitoring until Standardized.
SAMPLE

90
80
Before: 81%
70
60
percentage

50
40
30
94.07% Reduction
20
10
After: 4.8%
0
March 17- 21, 2006 June 2-6, 2006

results given > 5 minutes

Analysis:
The team attained 4.8 % of patients with waiting time of more than 5
minutes before they received their results, in which it even exceeded their
goal of 5% target.
56
SAMPLE
Evaluation of Results
Included in claim Stub Delegated to Lab Staff Delegated to patient

1 2 3 4 5
mins
min min min min min
N
Activities
O

10

20

10

40
20

50

40

60

30
40

60
10
20
30
40
50
60

30
40

60
10

50

10

50
60

30
40
50
60

20

50
1

20
30

10
20

30
0 2 3 4 5 6
secs 1 0 0 0 0 0
0

Before
Calls patients no.
1
on queue After

Before
2 Asks patients info
After

Verifies patients Before 8minutes


3
data in logbook After

Before
Retrieves patients
4
results on file After

Allows patient to Before


5 sign in releasing
logbook After
81.8%
Before
6
Issues results to
patient After
Improvement
Lead time (Before): 11 minutes 20 seconds
Lead Time (After): 2 minutes 20 seconds 57
SAMPLE

Tangible Benefits
Computation of Gross Probable Savings:
No. of Patients waited > 5 min Before Costs After Costs
(5 days) (5 days)
Probable loss of income 47 P 11, 750 3 P 750
(refund)
GROSS SAVINGS P 2,200/day
Cost of Improvement:
Item Quantity Unit Price
1 ream P 280/ ream
RISO of Claim Stub (3,000 pieces of claim stub)
1 claim stub/ patient 10 cents / piece
TOTAL P 11.50/day

Cost of Improvement:
Gross Savings Cost of Improvement Net Probable
Savings
P 2,200/day P 11.50/day P 2,188.50/day
SAMPLE
A

Intangible Benefits 5
I 4 B

In the process 3
2
Criteria Befor Targe After H 1 C
e t 0

A. Knowledge in QCC 2 4 4
G D
B. Interest in QCC 1 4 3
Circle Level F E

C. Teamwork & Camaraderie 2 4 4


D. Ability to solve problems 2 4 4
E. Value of cooperation 3 4 4
LEGEND:
F. Communication with 2 4 3 5Excellent
other dept. 4Very Good
3Good
Individual Level 2Average
1Fair
G. Improve self 2 4 4
confidence
H. Acquired new skills 1 4 5
59
I. Improved leadership 2 4 4
SAMPLE
Intangible Benefits
Impact to the Organization
Develop People Depend on each other

Delight Customers Deliver on Commitments


Other Intangible Effects:
More utilized staff
60
More productive time
STEP 7
STANDARDIZATION

61
STEP 7: STANDARDIZATION

INSTRUCTION:
PREPARE A WRITTEN DOCUMENTATION OF THE NEW SOP BY USING THE
5W AND 1H.

WHAT WHEN WHERE WHO WHY HOW


What to Effective What Person Objective Monitoring
Standardize Date Area Responsible

62
SAMPLE

Standardization
WHAT WHEN WHERE WHO WHY HOW
What to Effective What Person Objective Monitoring
Standardize Date Area Responsible
Claim Stub Aug 15, 2006 Laboratory Jocelyn To reduce Actual
Reception Rhea the Observation
percentage Interview
of patients
waited for
more than 5
minutes
which is
81% to 5%
by the end
of June 200
Revised WI to Aug 30, 2006 Laboratory Juliet Review
include the Reception Rhanty
process of
claiming results

63
STEP 8
SELF-EVALUATION
AND
FUTURE PLANS

64
STEP 8: SELF- EVALUATION AND FUTURE PLANNING

INSTRUCTION:
1. IDENTIFY GOOD AND BAD POINTS IN GOING THRU EACH OF THE PROBLEM
SOLVING STEP. USING A RADAR CHART, ASSESS TEAMS SKILLS IN
APPLYING QC TOOLS AND TECHNIQUES THEN PREPARE A TEAM
DEVELOPMENT PLAN.
2. MAKE A RADAR CHART

TEAM DEVELOPMENT PLAN


ACTIVITIES PERSON SCHEDULE RESOURCES
RESPONSIBLE NEEDED

65
SAMPLE

TEAM DEVELOPMENT PLAN

PERSON SCHEDULE RESOURCES


ACTIVITIES
RESPONSIBLE NEEDED
Refresher on Step Dr. Gomez 4th Week of Nov CQI Training
3 of QI Module
Methodology Training Materials

Data Gathering Dra. Villanueva 2nd Week of Dec

66
SAMPLE
KNOWLEDGE ON QI METHODOLOGY AND 7 BASIC QC TOOLS
LEVEL 0 NOT HEARD ABOUT IT
LEVEL 1 CAN DO IT WITH SUPERVISION
LEVEL 2 CAN DO IT ALONE PROB ID/ PRIORITIZATION
LEVEL 3 CAN TEACH OTHERS
HISTOGRAM UNDERSTANDING PRESENT SYSTEM

SCATTER 3
DIAGRAM ANALYSIS OF ROO CAUSES

2
FORMULATION OF
CONTROL
ALTERNATIVE
CHART
1 SOLUTIONS

0
ISHIKAWA 0 1 2 3 SOLUTION
DIAGRAM 3 2 1 0 IMPLEMENTATION

PARETO CHART EVALATION OF


1 RESULTS

2
GRAPHS STANDARDIZATION
BEFORE
3 SELF EVALUATION/ FUTURE PLANS
AFTER CHECKSHEET
BRAINSTORMING
FUTURE PLANS

1. ____________________________________
____________________________________
____________________________________

2. ____________________________________
____________________________________
____________________________________

68
10/2/2017 Continuous Quality Improvement in the Hospital
SAMPLE

FUTURE PLANS

1. To institutionalize this project to other CSI


branches and to other departments.

2. To tackle our next QC Project: Increasing


Doctors Complaint pertaining to Laboratory
Results Accuracy

69
10/2/2017 Continuous Quality Improvement in the Hospital
OUTLINE OF PRESENTATION
COMPLETED CQI PROJECT
INTRODUCTION (ORGANIZATIONAL PROFILE)

CIRCLE HISTORY

ABSTRACT OF THE PROJECT (NOT MORE THAN MORE THAN 100 WORDS)

ACTIVITY PLAN

STEP 1 PROBLEM IDENTIFICATION AND PRIORITIZATION

STEP 2 UNDERSTANDING THE PRESENT SYSTEM

STEP 3 ANALYSIS OF THE ROOT CAUSES

STEP 4 SELECTION OF BEST ALTERNATIVE SOLUTION

STEP 5 SOLUTION IMPLEMENTATION

STEP 6 EVALUATION OF RESULTS

STEP 7 STANDARDIZATION

STEP 8 SELF- EVALUATION AND FUTURE PLANNING


70
SAMPLE

CIRCLE HISTORY
The Disclaimers was formed in March 2006 which composed of 6 members from
the Laboratory Department of Alabang Medical Clinic-Main Branch.

ABSTRACT OF THE PROJECT


Our primary goal in the laboratory department is to give our patients not just on-
time, but also accurate and precise results as well. This depends on our
laboratory staff performance. However, it has been observed that there is a long
waiting time of our patients upon claiming their results which may lead to
patients dissatisfaction and complaint. This also affects the process flow in our
reception and our staffs productivity.
For this reason, our team was prompted to formulate solutions that will help
solve these problems.
SAMPLE

ACTIVITY PLAN
Activities Year 2006 March April May June July August

1. Circle Formation
2. Problem Identification &
Prioritization
3. Understanding the present
system
4. Problem Statement
5. Objective Statement
6. Root Cause Analysis
7. Validation of Root Causes
8. Formulation of Best Solution
9. Solution Implementation
10. Evaluation of Results
11. Standardization
12. Future Plans/ Self-
Evaluation
Legend: Target
Actual