QI Chapter6

Guide to Analytic Improvement tool

Step1 : Define the improvement goal Step2: Analyze current practices Step3: Design and implement improvements Step4: Measure success

Surveys

questionnaires or interviews used to obtain information from a group of individuals about a process, product, or service.

Top-down flowchart

the major steps in a process are arranged sequentially across the top and the detailed steps are listed under each major step. Unlike a detailed flowchart , a top-down flowchart does not include decision points or other steps that might be causing inefficiencies.

Elements of the Project Plan

-Budget for the project -Schedule the project work and people -Project Schedule

Force Field Analysis

A requinque for identifying and visualizing the relationships between significant forces that influence a problem or goal.

Nominal group technique

A structured form of multi-voting

questionnaire

Form containning questions to which subjects respond.

High-level flowchart

Maps major process steps minor steps in the process have not been included

More Qualitative Tools • Decision matrix

Used to systematically identify, analyze, and rate the strength of relationships between sets of information

Deployment flowchart

a chart that shows the steps in a process and identifies the people or groups involved in each step; sometimes called a cross-functional flowchart

Improvement Tools

• Diagrams, charts, techniques, and methods used during an improvement project (also called analytic tools)

Planning is Key

• Planning is important even for one-person projects in which there is no team. • There are consequences for absent or inadequate planning

Definition of "Project"

-A project is a temporary endeavor undertaken to produce a unique product, outcome, service or result1 -A project is special work, and not part of day-to-day activities.

Completing the Project Report

-A report of the project and its outcomes must be prepared. -The Joint Commission and Magnet both require quality improvement efforts and the report documents those efforts -The report can follow the format of the project plan, or if another template is better, it can use any format that facilitates the reader's understanding.

Plan Elements—Scope 2.Define the Scope of the Project

-Answer the following question: What work will have to be done to complete the project?This will depend on the objectives and products of the project, and the methodology.Typically nursing projects require a literature review, data collection and analysis, and reports, as well as other work. -Boundaries of the project: what is and is not included in the work of the project? -The way projects get expanded (called "scope creep") is somebody decided to require additional products be added to the project. That violates the boundaries of the project because additional projects are outside of the project definition. -How will boundaries be protected? Specifically, how will the Project Manager respond to requests to add products to the project once the project has already begun? -Constraints limiting the scope: Resources (money, time, personnel), support of staff and administration, conflicting demands of other projects and priorities, policies, procedures, rules -Essential approvals, and written sign-offs needed to conduct the project—It is the project manager's duty to find out what all approvals are needed, and to secure those approvals, in writing.

Brainstorming Steps

-Assess/analyze effects or results of each proposed solution. This discussion focuses on "What will happen if we implement this idea?" During this process, ideas are often edited and changed to make them work better. (All ideas continue to be retained at this point). -Now, it is time to prioritize ideas and options. A useful tool has people rank ideas in the list. A variety of techniques are used here. Multi-Voting is one, but there are others. -Agree on actions to be taken and a schedule or timescale for the selected idea(s) to be implemented -Develop a project plan to implement the quality improvement project.

Products or Deliverables

-Defining these is a key part of the project definition. -The team leader must make sure everybody associated with the project or who has approval authority over the project is clear about what the deliverables are and agrees to those deliverables in writing. Without this, misunderstandings about the project are likely to occur.

Evaluation plan

-Evaluate process—did the project use an effective strategy? Were/are tasks being completed on time? -Evaluate outcome—were the products of the project produced? -Evaluate quality—were the products of the project of acceptable quality -Did the project finish on time? -Were the costs within budget? -Was the final report submitted on time? -Overall, was the project a success? Why or why not?

Work breakdown structure

-It is important to specify specific tasks involved in the project. -People seldom want to commit to a project if they don't know what will be required of them. A breakdown of all the pieces of work that must be done for the project will help people decide whether they want to join the team or not -Each task must be specified, along with the date of completion, and the person assigned to the task

Elements of the QI Project Plan 1. Project Definition

-Name the project (name should be short, catchy, & memorable) -State the project's purpose -Define the product(s) of the project (deliverables) -Identify the stakeholders -Create a start and end date for the project -Develop a schedule for project team meetings -Identify all the people who must give approval for the project to go forward

Required Resources Team Roster

-Once the tasks are known, it is time to select the people who will perform the tasks. Project success is greatly dependent upon having the right people AND allocating adequate time for them to work on the project. -Create a team list: members, role of each member -Ensure that the team represents all major stakeholders -Specify general duties of each member of the team -Specify % time each member is assigned to work on the project

Budget for the project

-Once the tasks have been delineated and the people selected, it is necessary to budget for the time of the people who will work on the project, and for all the equipment, supplies, and other cost items needed to do the work of the project -Budgeting is beyond the scope of this course, but you will have a budgeting course later in the curriculum.

Elements of the Project Plan 3.Stakeholder analysis

-The key benefit of a careful stakeholder analysis is reduction in the likelihood of unintended consequences due to lack of coordination among staff & departments -Unintended negative results on other departments can not only cause disruption to their operations, but also lead to enmity and retaliation against the people doing the project -Identify all people and departments that will be affected. Consider other nursing departments, central supply, Lab, pharmacy, the medical staff, social services, PT, OT, Pastoral Services, etc. A project can inadvertently create havoc in hospital operations if it makes changes that negatively affect the work of other departments. -Consider how this project will affect different shifts and their workload if this is a unit based project.

Schedule the project work and people

-The schedule now can be built so that tasks that must be completed first are scheduled first, and so the schedule works for the people who join the project team. -It is crucial to success that the project stay on target and on time. A key leader duty is to follow up with people to be sure their assigned tasks are being completed in a timely fashion. -To be sure everyone on the team knows the schedule, a Gantt chart is often used so people can quickly visualize all the tasks and when each task is to be completed.

Five whys

-Used to find the underlying causes of performance problems -Used to identify causes of problems when using fishbone diagrama form of analysis that delves into the causes of problems by successively asking what and why until all aspects of the situation, process, or service are reviewed and contributing factors are considered.

Flowchart

-Used to identify and document the flow or sequence of events in a process -Used to develop an optimal new process during the solution stage Graphic representation of a process

Stakeholder Analysis

-Used to identify the individuals or groups that would be affected by a proposed process change for the purpose of gaining stakeholder support for the change -a tool used to identify groups and individuals who will be affected by a process change and whose participation and support are crucial to realizing successful outcomes

Identifying a Problem's Causes

-When a problem has been selected for improvement, it is first necessary to discover what the causes of the problem are. ・Seldom does one person have all the relevant information. ・To analyze a problem's roots, we perform what we call a "root cause analysis", and the first step in that process is to create a "fishbone diagram" ・Brainstorming is a common approach

Communications plan

-Who is responsible for providing communications? -Who receives communications? -What will be communicated? -How will information be communicated? -When is info communicated? -Keep people in the loop through good communication strategies, e.g., 1. Regular meetings & progress updates 2. Newsletters for large projects 3. Posters that inform about the project 4. Award events and parties -When (and how) should the information be communicated? 1. Regular reports or newsletters? 2. Only at the beginning, middle, and end? 3. As needed? How is "needed" defined? 4. Who is responsible for generating and distributing the reports? 5. Written or oral communications? 6. Will different people need different information?

survey steps

1, Define the survey objectives 2, Identify the people to be surveyed. 3, Select the survey population 4, Construct the survey 5, Test the survey, and prepare the final draft 6, Administer the survey.

Qualitative tools

1. Assess/analyze effects or results of each listed problem or solution. This discussion focuses on "What will happen if we select/implement this item?" During this process, ideas are often edited and changed to make them work better. (All ideas continue to be retained at this point). 2. Then, the facilitator may ask the group to identify items to be discarded. Items may be eliminated because the group agrees they are unlikely to produce the desired outcomes, are unrealistic, or for some reason are going to be impossible or suboptimal to implement. (Items should be greatly reduced during this process). 3. Then the ideas must be prioritized. One technique for this is multi-voting.

Rework Facts

1. Up to 50% of all work is rework in software development 2. About 30% of construction work is rework 3. About 33% of all software projects are failures & end up abandoned • Careful planning is the best insurance one can "buy" for providing the highest probability of a successful outcome of a project. • Even so, planning feels boring to many who just want to get started! • Worse, planning isn't highly visible and sometimes superiors view the time delay needed for planning as a sign of "nothing is being done" • Including managers in planning processes may help you get the time needed to properly plan the project

Risk Management Plan

4. A project should have a risk management plan that: -Identifies likely risks -Provides a planned response should a risk event occur -Addresses risks that include people, technology, processes, organizational, & environmental influences -A key risk is opposition from staff members or managers -Hospitals, businesses, and any other place people gather become "political" rather quickly. Not only do people tend to resist change, they also do not like anything that might challenge their status in the group, and any new project will be seen in that light by some of the people. Anticipate who might oppose the project and plan for how to "seduce" their support

Project Schedule

A Gantt chart provides a visual of the work schedule

structured brainstorming

A group problem-solving technique wherein the team leader asks each participant to generate a list of ideas for the topic under discussion and then report them to the group in a nonjudgmental manner. pros:in that each person has an equal chance to participate. Cons:in that it discourages spontaneity and is restrictive.

Project Work Plan Elements

A project should have a work plan that includes the following elements: 1. Project Definition 2. Defined scope of work 3. Stakeholder Analysis 4. Risk Management Plan 5. Work breakdown and List of Tasks 6. A project team 7. A budget for the project 8. A work schedule 9. A Communication plan 10. An evaluation plan 11. A plan for the Project Report

Nominal group technique

A structured form of multi-voting used identify and rank issues.

Communicating Improvement Projects quality storyboard

A tool that visually communicates the major elements of an improvement project. ・Team information ・Project focus ・Analysis of current situation ・Proposed solutions ・Solutions executed(timeline) ・Effectinvess of solutions

Brainstorming Process

Brainstorming Process Should Follow These Steps 1. Gather materials. At the least you will need a flip chart (or several), magic markers to write on the chart(s), and tape to tape pages on the wall. 2. Make sure the room is comfortable and the table or tables are round to facilitate equal discussion. Have comfortable chairs, coffee, water, juice and perhaps other refreshments. 3. Define and agree on the rules of the meeting. The key rule is no idea may be criticized. Many times a powerful manager/leader is excluded from the meeting so he/she doesn't dominate and shut down creativity. Another rule: Keep to the time schedule. When an activity is over, its over. 4. Define and agree on the objective-it should be simple, such as "how to reduce falls in our unit", or "how to reduce wrong-patient errors in our unit", etc. Or perhaps the objective is to identify an item for quality improvement. 5. Define and agree on the objective. It should be simple, such as "how to reduce falls in our unit", or "what are the most important quality problems in our unit"? 6. During the random collection of ideas the facilitator must record every idea on the flip-chart. Failing to record a member's idea is a way to shut down creativity by implying some people's ideas are not welcome. 7. Take a break after the brainstorming session. The next work is not so creative; it focuses on organizing the ideas 8. Categorize/condense/combine/refine. Post all the ideas on the wall, and as the facilitator leads the members in reviewing ideas, categorize them according to some scheme. For example, several ideas may suggest some training. Put all the training ideas together. Others may focus on patient dissatisfiers, or new equipment or technology, or processes/procedures that need improvement, etc. 9. Then search for duplicates among the ideas and eliminate duplicates. All ideas except duplicates are retained at this point.

cause and effect diagram

Graphical representation of the relationship between outcomes and the factors that influence them; sometimes called Ishikawa or fishbone diagrams.

Multi-voting

Multi-voting: This is often used when there are a large number of people involved (more than 12 or so). -Each person is given 10 "vote" stickers to use to vote for their favorite items on the list. -The person may use no more than 4 votes on any one item, but other than that, may place his/her vote stickers in any way he or she wishes. -After all have voted, the votes for each item are counted and the item with the most vote "wins". If voting on a list of problems to address, the problem with the most votes will be addressed first. -Generally the facilitator makes a list of all items and specified the number of votes each item received. This list is saved for future consideration of quality improvement projects.

Brainstorming

Used for creative exploration of options & generating ideal in an environment free of criticism

Affinity diagram

Used to organize ideas, issues, or opinions into groupings based on the relationships between items

Multi-voting

Used to pare down a broad list of ideas and to establish priorities

Decision Matrix

a chart used to identify, analyze, and rate the strength of relationships between sets of information, especially useful for looking at large numbers of decision factors and assessing each factor's relative importance.

Planning Matrix

a diagram that shows tasks needed to complete an activity, the persons or groups responsible for completing the tasks, and an activity schedule with deadlines for task completion

Multi-voting

a group decision-making technique used to reduce a long list of items to a manageable number by taking a series of structured votes. Is used to pare down a broad down a broad list of ideas and establish priorites.

detail flowchart

all the steps and activities that occur in the process and includes decision points, waiting periods, tasks frequently redone,, and feedback loops.

workflow diagram

an illustration of the movement of employees or information during a process. Workflow diagram are used to document how work is executed and to identify opportunities for improvement.

Affinity Diagram

charts used by improvement teams to organize ideas and issues, gain a better understanding of a problem, and brainstorm potential solutions.

Interviews

formal discussions between two parties in which information is exchanged

unstructured brainstorming

free-form; participants contribute ideas as they come to mind. Pros:participants can build on each other's idea in a relaxed atmosphere. Cons: less assertive or lower-ranking participants(such as non leadership staff)may choose not to speak up.

Gratt Chart

graphic representations of a planning matrix that displays project activities as bars measured against a horizontal time scale.

Type of flowchart

high-level detailed deployment top-down chart -High-level flowchart Maps major process step -Detailed flowchart Maps all process steps and activities

silent brainstorming

participants write their ideas on small slips of paper, which are collected and posted for everyone to see. Pros:everyone 's ideas are captured regardless of his or her level of assertiveness or position in the organization's hierarchy. Cons: group does not build the synergy of an open session. Often used in combination with other brainstorming techniques.

The primary difference between the results of multi-voting and the results of nominal group technique

the improvement team considers the total point count for each item (adding up the values of each vote) as well as the number of votes each item received.

Qualitative tools

used to generate ideas, set priorities, maintain direction, determine causes of problems, and clarify processes. These are typically activities performed in groups. • Brainstorming • Multi-voting • Nominal group technique

Quantitative tools

used to measure performance, collect and display data, and monitor performance. These are typically statistical processes performed by the project statistician (although the statistics are usually simple, and a nurse who has taken a statistics course can function as the project statistician. • Used in performance assessment and performance improvement -Bar graph -Check sheet -Control chart -Histogram -Line graph -Pareto chart -Scatter diagram

Brainstorming

• Brainstorming is a very useful approach to determining causes and effects when a problem has been defined. It is also an excellent way to generate new ideas and solutions to correct problems or improve performance. • For the brainstorming approach to work, there must be an explicit and enforced rule that all ideas may be safely expressed, no matter how different, unrealistic, or "far fetched" the idea might be. • Brainstorming is difficult and for participants in a work setting, politically risky. It ignores the existing "pecking order" and demands that everybody's ideas be valued. This is not normal in human work groups where there is the usual "in crowd" who expect to wield all the power and make all the decisions. The ones with status may resist listening to (much less accepting) ideas from those of lesser status. And ones with status have many techniques for putting down and keeping down those of lower status. • However, in brainstorming, everybody's ideas are equally valuable. The leader must find effective ways to get the low status people to share ideas. • This is crucial as Brainstorming is a creative process. Creativity requires great freedom and emotional safety to be successful. The process needs to involve everybody, and especially the "oddballs" on the team. • Often, the best solutions arise out of an initially "silly" idea. "Oddballs are people who don't think like the rest of the group. Their ideas are usually ignored or ridiculed, so they learn not to share. However, these are the very people who are most likely to generate a truly innovative idea that gets worked on, refined, and turned into an effective solution. • Everyone in a brainstorming session must feel completely free to mention ideas, even if they are "silly" or "unrealistic". Criticism or ridicule of an idea will destroy a brainstorming session instantly. • The opposite of brainstorming is "groupthink" and in groupthink, only one or a few people are "allowed" to have ideas, which everyone else is expected to applaud and adopt.

Planning is Key to Success

• Planning is usually the key to success of a project • Typically, 30% of the effort invested in a successful project will be spent on project planning. • But, it can be difficult to get superiors to agree to spend the time/money required for adequate planning. • A mechanism is needed to all parties are clear about what the project is, what its results are to be, and what resources will be invested in the project. • This mechanism can (& should) be a project plan

Consequences of Failure to Plan

• Rework • Outcomes not achieved • Cost over-runs & waste • Human frustration and damage to people's careers

What is Rework?

• Rework means that work done on the project was the wrong work, or work done incorrectly and so must be redone. • Alternatively, people may get frustrated or discouraged and decide to discard the work done, thus abandoning the project. • In either case, resources were wasted. • An important resource that gets wasted when a project (or several projects) fail is loss of workforce confidence in management.

Qualitative tools

• The problem with groupthink is that no innovative ideas get expressed. • When everything in the business is proceeding well, and all problems are getting solved quickly and successfully (with old solutions or just the boss's ideas), brainstorming may not be necessary. • When a business environment is changing rapidly, the old ways of thinking will produce only old "tried and true" solutions, which are already not working, or we wouldn't need the brainstorming session. • When conditions are changing—especially when things are changing fast, , "tried and true" solutions are the most comfortable. People rarely want to change under good conditions, and under threat, they want to "hunker down", and do what they were already doing harder. Unfortunately, that approach is likely to bring a business crashing down.

brainstorming technique (3)

・structured brainstorming ・unstructured brainstorming ・silent brainstorming