Academic Pediatric Association

QUALITY

IMPROVEMENT TRAINING: Module #4

More QI Tools More QI Tools

to Better Understand the Systemto Better Understand the System

This work is supported by a grant from The Centers for Disease Control & Prevention.

National Partnership for Adolescent Immunization

PI: Peter SzilagyiCoordinators: Christina Albertin, Nui

Dhepyasuwan

Ed MarcuseCindy RandJan Schriefer (QI

expert)Stanley SchafferJanet SerwintWilliam Stratbucker

Donna D'AlessandroWilliam AtkinsonPaul DardenSharon Humiston

(moderator)Keith Mann (QI

expert)

FACULTY & CONSULTANTS

This is part of the APA series on Quality Improvement. The examples focus on adolescent immunization, but the principles are widely applicable. The series includes:1. Overview: The Model for Improvement and

Deming’s System of Profound Knowledge 2. Improvement cycles and the psychology of

change 3. Initiating a QI project4. More tools to better understand the

system5. How will we know that a change is an

improvement? An introduction to QI measurement

6. Changes we can make that will result in improvement

Module 4 Objectives

After viewing this segment, you will be able to describe the development and purpose of each of the following tools for understanding the system:FlowchartsCause and effect diagramsThe 5 whys technique

Flowcharts

FlowchartsWhat: Draw a picture of your process as a team

High-level flowchart - shows the process in 6-12 steps, useful early to show major activity blocks

Detailed flowchart – shows dozens of steps; useful later to identify rework loops and process complexity

Purpose: Coming to agreement on what the process really is. This helps the team understand the process and develop ideas about how to improve it.

Who: All the groups involved (there will likely be as many versions of the process as there are people)

http://www.ihi.org/knowledge/Pages/Tools/Flowchart.aspxhttp://tipqc.org/qi/jit/tools/flowcharts/

IHI’s Sample High-Level Flowchart: Ischemic Heart

Disease Patient Flow

http://www.ihi.org/knowledge/Pages/Tools/Flowchart.aspx

IHI’s Sample High-Level Flowchart: Ischemic Heart

Disease Patient Flow

http://www.ihi.org/knowledge/Pages/Tools/Flowchart.aspx

http://asq.org/learn-about-quality/process-analysis-tools/overview/flowchart.html

From American Society for Quality

http://asq.org/learn-about-quality/process-analysis-tools/overview/flowchart.html

The same process as a

detailed flowchart

To see a sample (fictional) flowchart on “HPV Vaccination in a Pediatric

Residency Clinic”

https://www.dropbox.com/s/lmsr8arhjh88bqi/Teen%20Immunization_work_flow-SAMPLE.pdf

How to Make a Flowchart

Prepare:Right people Right levelRight boundaries - beginning and ending

Step-by-step:Starting at the top, ask, “What’s next?” Put each step under last, on a “sticky

note”Where you disagree, lay the options side-

by-side; come back later, and discuss which is preferable.

Completing Your Flowchart

Use software to documentYou may need to

Gather infoRevise the flowchart as more is

understood about the actual process

QUESTION #1: Which 1 of the following is FALSE regarding flowcharts?

A.  A high-level flowchart shows a process in 6-12 steps and is useful early in the QI project for shining a light on the major blockages.

B. The main purpose for creating a flowchart is to come to agreement on what the process really is, which, in turn, helps the team understand the process and develop ideas about how to improve it.

C. As far as possible, the main clinic administrator should be the only one to have input into the creation of the flowchart so it reflects the way the process should go.

D. When flowcharts are formally produced (using software), decision points in the process are shown as diamonds.

QUESTION #1: Which 1 of the following is FALSE regarding flowcharts?

Cause and effect

diagrams

Cause and Effect Diagrams(aka “Fishbone Diagram”)

What: A graphic display of a listPurpose: Permits identification

and organization of a list of factors thought to cause a problem or affect variation; can also be used as a Root Cause Analysis Tool

Who: All the people involved http://www.ihi.org/knowledge/Pages/Tools/CauseandEffectDiagram.aspx http://tipqc.org/qi/jit/tools/cause-and-effect-diagram/

TrainingMotivation Motivation

NursingProviders

Schedulers

Motivation

Training

Training

Better handout for reluctant

parents

Standing order instruction sheets

MD recommendation is

not strong No return appts set up

Adolescent immunization record

scattered

Computers slow

Lack of automated reminder system

Sample Cause & Effect Diagram

Typical Categories for Major Causes

Equipment, Methods, Materials, People, Environment/Measurements/Procedures

Who, What, When, Where

People, Provisions (Supplies), Procedures, Place, Patients/Families

Steps of Process

Sample Cause & Effect Diagram Process Type

•No expectation for vaccination•No parent for consent

•No info given•Registration unfriendly (per survey)

•Conversation is social; not educational•Some nurses are anti- vaccine (per rumor)

•Hurried! No time to answer “in depth” questions

YES

YES

RECOMMEND VACCINE?

NO

NOFAMILY ACCEPTS?

•No good info sheet•Providers not trained to answer succinctly

•Delayed if busy

•Med room is 30 steps from most exam rooms

How to Make a Cause and Effect Diagram

Fill in each of the following:Large arrow pointing to the name

of the problem or issueThe branches off the large arrow

represent main categories of potential causes.

Smaller branches, representing sub-categories (can be a list of items)

The 5 whys technique

The ‘5 Whys’What: Repetitive questioning,

looking for deeper levels of the problem’s root causes

Purpose: To overcome the tendency to be satisfied with superficial answers and get at root causes

Who: QI team

http://www.ihi.org/knowledge/Pages/ImprovementStories/AskWhyFiveTimestoGettotheRootCause.aspxhttp://www.isixsigma.com/tools-templates/cause-effect/determine-root-cause-5-whys/

An example of the 5 Whys

1. Why does our clinic have such low rates of HPV vaccination for boys? Because the doctors forget to order it.

2. Why do the doctors forget to order it? Because some of our doctors only work part-time…Are they even aware that it’s a routine recommendation or why it’s important

3. Why would the part-time attendings be unaware…Because there hasn’t been any kind of in-service for the part-time attendings.

4. Why hasn’t there been an in-service for the part-time attendings? Because it would cost the office a lot to bring them all in for an extra hour and they’d want food, too.

5. Why would we have to bring them in? There’s an online learning module…

QUESTION #2. Which of the following is FALSE regarding the tools discussed in this module?

A. The ‘5 Whys’ is a simple tool, easy to complete without statistical analysis.

B. Equipment, Methods, Materials, Why, and Environment/Measurements/Procedures are major categories that are commonly used in Cause and Effect Diagrams.

C. Who, What, When, and Where are major categories commonly used in Cause and Effect Diagrams.

D. Use of Cause and Effect Diagrams helps identify and organize factors believed to cause a problem.

QUESTION #2. Which of the following is FALSE regarding the tools discussed in this module?

This module highlights just a few tools to help understand the system. There are many more options. The more you QI projects you do, the more tools you will want in your tool bag.

Garbage in, garbage out

By understanding a system, one may be able to predict the consequences of a proposed change.

W.E.Deming

SummaryIn this module, we discussed the development and

purpose of a few tools for understanding the system:

1.Flowcharts are a graphic display of your process, used to help understand what the process really is

2.Cause and effect diagrams (or fishbone diagrams) are a graphic display of a list, used to identify and organize factors thought to cause a problem or affect variation.

3.The 5 whys technique is repetitive questioning, looking for deeper levels of the problem’s root causes.

The End of Module #4of Module #4

IHI. Science of Improvement: How to Improvehttp://www.ihi.org/knowledge/Pages/HowtoImprove/ScienceofImprovementHowtoImprove.aspx