ch 6

suppliers

physician front desk u/s tech radiologist

questions about input

who provides and receive the input

questions about output

who receives the output where does the service go what happens to it

tools for action planning

worksheets: A guide for planning implementation to help ask the questions that are central to developing a thorough and clear plan. objective: possible objective: preventive steps key steps to ensure successful implementation who, when review/assessment benefits/expected results actual results

document

weird rectangle signifies the need to document activity

tool 12 relationship diagram

A relationship diagram allows the team to take the information gained in the affinity chart and develop leader pairs. The relationships are then evaluated.

tool 8 flow chart

A simple flowchart is a crude picture of process steps in sequence, each contained in a box and connected with arrows to the steps that come before and after.

tips on cause and effect diagram

Agree on the problem statement before you begin. Involve people close to all aspects of the problem. Some causes may appear on more than one bone.

construction of a relationship diagram

Arrange headings in a circle. Label the headings A, B, C, and so on. Draw relationship arrows. Starting with A and working around the circle, draw directional arrows showing perceived relationships between all the headings. Don't force relationships that are not clear. Count the number of arrows leaving each item. Write that number next to the item. Draw conclusions. It there is an item that drives several other, and if that header is able to be changed, it would be a logical focus for further exploration.

construction of an affinity chart

Ask questions. Answer. The group needs to brainstorm responses to questions. Record. Ask as many as three people to act as recorders. Have them alternate recording so that the session is not held up. Post. Record the ideas on flip chart paper on a board, etc. Organize. Do this without any talking or discussion. Let the group move the ideas around to form clusters. Name the clusters. Rotate the clusters so that those that relate to each other are adjacent. Transfer to paper

growth/gratification for team members

Better problem-solving skill among us Faith in the prospect of solving problems No more cynicism harmony among us

better interdepartmental collaboration

Better relationships between departments Less frustration when things go wrong More efficient operations Teamwork; less turf

tool 9 brainstorming

Brainstorming is not only powerful and exciting, but it can be lots of fun. Through the use of brainstorming, people involved get a chance to contribute and respond in a non-threatening atmosphere. Ideas will surface which otherwise may never have been discovered.

cause and effect diagram

Cause-and-effect diagrams allow you to find the root causes throughout the process. Solutions can be clearly formed by defining the "effect" you wish to achieve and then dissecting a problem into causes

construction of tree diagram

Clarify your purpose -If you want to find root causes, ask why. -If you want to generate alternatives, ask how. -If you want to clarify an idea or break it down into its elements, ask what we mean by this and what are its components. Generate alternative causes, tactics, or tasks related to your core statement, goal, or idea. Evaluate your ideas and narrow them down to a manageable number. Have each team member code each element as either feasible, don't know, or impossible. Then reach a consensus on the elements you want to place at the second level of your tree.

construction of force field

Clearly define the improvement you are planning and write it down as a statement at the upper right-hand side of a sheet of paper so that the group can focus on it. Across the top of a large sheet of paper, draw a horizontal line representing the continuum of performance related to your goal. Draw a line down the middle of the page to represent the current performance level. Brainstorm the driving forces and then the restraining forces that affect this performance level. List the driving forces on the left under an arrow pointing in the direction of the performance level. List the restraining forces on the right under an arrow pointing back towards the middle, showing that the performance is being held back. Narrow the lists to include only forces that have the greatest potential to help you reach your goal. Select three or four driving forces that group members think they can realistically strengthen and an equal number of restraining forces they believe can be weakened

why-why diagram

Diagram moves from L to R. Traditional decision tree. For example, problem is "new product sales are poor". 5 causes: poor product design, ineffective distribution, too high a price, and failure to identify target market. Causes of each subproblem can be identified by asking why again.

Gantt charts are

Gantt charts are horizontal bar charts that show the time relationship among steps in an implementation plan. -Along the left side of the chart are the steps in the plan. Along the top or bottom are time intervals. -Each step is represented by a line starting at the planned beginning date and ending at the planned completion date. -The chart can show parallel activities and the relative time the steps take -The finished chart shows the minimum time you need to complete the plan, the appropriate sequence of steps, and which steps can be accomplished at the same time.

precautions uses of decision making

Focus on your primary goal. You will avoid conflict if everyone is in agreement about the goal. Results of a decision matrix are only as good as the quality and relevance of the criteria you select. Garbage in, garbage out. Hold criticism until you have generated an array of possibilities. Some alternatives may become more viable when viewed among many others. Take care not to throw out anything until you have a sufficient number from which to select. Trust your instincts if the results bother you. If you know that a solution will not work, despite its being the best, don't spend time spinning your wheels. Recognize that some solutions are simple and some are not. Don't give in to one-dimensional answers when you know there is much more to it.

tool 15 tree diagram

For all types, the point is to discover how you can dissect a problem into its root causes, break those root cause into secondary causes, and then generate a plan for solutions. The solutions can be mapped in exactly the same way.

Uses of Brainstorming

Generate a list of problems to tackle Find alternative solutions to a problem. Find factors that contribute to a problem. Generate alternative problem statements. List obstacles that might interfere with the successful implementation of a plan. Many, many others.

How to conduct a brainstorming session

Generation, Clarification, and Evaluation

heightened customer satisfaction

Happier patients More physician cooperation Happier physicians

uses of a force field diagram

Helps people to quickly generate and display factors or forces that have an impact on their achievement of a particular objective. To identify improvement opportunities. To identify key causes that, if altered, would have a positive impact on a solution. To evaluate the likelihood that a new program or proposed improvement would result in the desired benefits. To help think through a realistic implementation plan that includes countermeasures designed to diminish restraining forces or barriers, as we as strategies to capitalize on driving forces.

tool 14 decision matrixes

It forces you to take into consideration criteria such as reality, cost, and acceptability, and then use the solution which meets the most criteria. It allows you to quickly profile each group member's views about the relative strengths and weaknesses of alternatives and graphically see the extent to which they agree or disagree.

cause and effect diagrams are multileveled

Level 1 asks what the causes are of the effect. Level 2 asks what causes each of those causes. Level 3 asks what causes those causes. And so on until the root causes are exposed. The root causes tend to be the causes at the lowest level, those that are concrete, those that are directly controllable, and when eliminated or reduced, those that relieve the problem

construction of flow chart

List the steps involved in a process using direct observation, brainstorming, or consultation with the people involved in the steps. Ask questions about inputs, throughputs, and outputs of the process such as:

tips for a flow chart

Make sure you involve the right people in making the flowchart, including those who actually do the work, suppliers to the process, customers, and managers and supervisors involved in its control. Use many sheets of flip chart paper, Post-itTM notes, etc., so that you can move steps around flexibly until you think you have positioned all of them correctly. With complicated processes, do a crude flowchart with only the major steps and then break them down into sub-steps. Remind yourself that the time is worth the effort because your data collection and problem-solving rely on your flowchart's accuracy and thoroughness.

tips on generation phase

Quantity, not quality. The more, the better. Discussion, judgment, and criticism are all suspended. Build on others' ideas. Practicality is unimportant Three-word minimum per idea; otherwise, it's difficult to know what is being suggested. Six or seven word maximum; otherwise, you will hear speeches. Record every idea. Do not let anyone break the rules. Move quickly. The session should last only 5 or 10 minutes.

remember for force fields

Remember to use a clearly defined improvement that is narrow in scope and keep your lists very short. The most common mistake here is to take too much information and try to sift through the overload

uses of decision matrix

To select among alternative problems To select among alternative causes To select among alternative countermeasures or solutions To select among alternative implementation steps

U/S tech sipoc

S: U/S Tech I: notified of patient P: retrieve request o: scans patient c: radiologist

construction decision matrixes

Select the criteria for evaluating your alternatives. Spend as much time as necessary to agree on criteria because these are the guiding principles by which you will evaluate alternatives. Write the criteria in the boxes along the top of a matrix chart. Decide on the relative weight of each criterion. The more important it is, the higher weight it should receive. List the alternative problems or solutions in the left-hand column. Have each group member independently rate each alternative according to each criterion and fill out his or her matrix, writing a 1, 2, or 3 in each box opposite the alternatives and below the criteria. Have each member total his or her score for each row by multiplying the rating in each box by the weight assigned to the numbers in that column. On the right, there should be a total score for each alternative. Tally the scores by adding up al members' scores for each alternative. Summarize the results by listing the alternatives from high to low. Use the results to reach a decision. Look at the top-rated alternatives and discuss them further. If important criteria have been left out, then alter your criteria and redo the ratings until the group feels the results provide a sound basis for decision making.

concrete improvements

Solutions to problems Fewer fires to put out Results that satisfy administrators

A. Initial Brainstorm

Solutions to problems Results that will satisfy administrators Good feelings among us Happier patients Fewer fires to put out Harmony among staff Faith in the possibility of solving problems Teamwork among staff Teamwork between departments More physician cooperation Happier physicians No more cynicism Better relationships between departments Less frustration when things go wrong More efficient operations Better problem-solving skills among us

uses of a relationship diagram

Sort out the relationships among numerous complex ideas. Identify problems, forces, or causes that, if removed, would have major effects. Separate symptoms from causes, identifying the root causes that drive the symptoms. Create a tree diagram that sequences the tasks or elements in your implementation plan

key steps in action planning

State the end result that would mean a significant improvement to your process. Identify the actions needed to achieve the result, (brainstorming), and the resources needed to complete each action. Put these steps in sequential order, (flowchart), and allow for parallel or concurrent actions. Identify anticipated problems and how you plan to prevent or handle them. Assign responsibilities and set performance standards. Determine the deadline for completing the overall plan and the start-to-finish dates for each step. Identify your methods for monitoring implementation and intended and unintended effects - in time for corrective action. Identify indicators and people who will review and act on the data. Decide who, if anyone, must approve the plan before implementation.

construction of cause and effect diagram

Summarize your problem statement. -Write your problem statement in as few words as possible in a box at the pointed end of a log arrow; the spine of the fish. Determine the headers. -These are the categories you want to use to trigger thinking about possible causes. -Connect these to the spine with arrows (also known as bones or branches). -Make these as generic as possible such as material, machine, people, or methods. Determine what elements of each category are contributing to the effect. - These are the subsidiary causes that influence the effect in question. -Write those on bones or branches coming off the category lines. Continue to search for the causes of the causes in each branch until you reach what you think is the root cause of each bone. -(Rule of thumb is five times for each bone.) Clean out the diagram before testing the theories reflected in it. -Not all of the causes generated will turn out to be pertinent, so eliminate those that do not directly relate to the cause. Narrow down your theories. -Ask for input, vote on them, do a relationship diagram, etc. to rule out causes that are not easily changed or over which you have no control

decison

The diamond signifies that a decision is made here. It indicates a branch point. The nature of the decision is written inside the diamond in the form of a question. Each alternative path or branch is labeled with a possible answer. The answer determines the path or branch taken to the next step.

evaluation phase

The group considers the list and rules out duplications, irrelevant ideas, or ideas considered beyond its scope or power. Screen and sort the list to narrow down the list of ideas to a select few.

clarification phase

The group reviews the list to ensure that everyone is clear about what all the items mean. This clarification is important before ideas are judged so that in later discussion, unclear ideas are not dismissed along with unworkable ideas.

uses of flowcharts

The most beneficial result of using flowcharts is that you will be able to see a process and follow it without running behind people all over your institution

activity

The rectangle reflects a single process step. Briefly describe the step inside the box.

benefits of affinity charts

They are fun to do. They relieve confusion about questions and issues that have complex, multifaceted answers. They enable a group to manipulate dozens of ideas in a very short amount of time. They build group consensus rapidly. They spark participation from everyone, including people who do not usually participate. They also reduce the participation of the people who typically dominate

generation phase

This phase can be either structured or unstructured. The leader reviews the rules with group members, clearly state the question or purpose, writes it as the header on a flip chart and then invites and records responses

uses of cause and effect diagram

To help team members generate and articulate their theories about causes by providing a simple, straightforward structure for productive brainstorming. To sift through and organize the brainstormed items within the basic categories. To search for solutions to problems

uses of tree diagram

To identify root causes. To generate alternatives. To evaluate countermeasures. To tell an improvement story. To clarify ideas. To generate a plan. To see what is currently being done related to a goal. To create a contingency plan in the face of anticipated obstacles. Tree diagrams are easier to complete and read than cause-and-effect diagrams. Use affinity charts and relationship diagrams to generate your main goals and then use the tree diagram for the details.

questions about throughput

what is done with input what checks or test are preformed what happens if the step does not pass the test

action planning model

Use a flowchart to look at the improvement you want to implement. Brainstorm what is needed to implement the improvement. Put these steps together using affinity charting. Redraw the flowchart based on your steps in sequential order. List the resources needed at each step; people, supplies, approvals, time, etc. Use force-field analysis to anticipate problems or restraining forces. Revise the flowchart accordingly. Hold a focus group for troubleshooting problems. Create a tree diagram that graphically shows your implementation plan. Draw a Gantt chart that shows each activity over time with assigned responsibilities. Tell the whole story with a storyboard.

finished with a flowchart when

You have connected all inputs to outputs. The flowchart shows both the parallel activities and the sequence of events. The chart includes all decisions that affect the flow of the process. The chart shows all possible paths that things, work, and/or people take, even the unexpected. You have listed all responsible parties across the top of your chart. Without losing the chronological sequence, place each activity and decision in the process under the people responsible. If possible, do a walk-through or observation of the actual process to verify the flowchart

tool 10 infinity charts

affinity charting is a process for generating an abundance of ideas, opinions, perceptions, issues, or activities and then organizing them into natural groups of related items affinity charts come from brainstorming sessions

resulting 2 part affinity chart

teams objective concrete improvements heightened customer satisfaction the values we want to guide us better interdepartmental collaboration growth/gratification for team members

complex flowcharts

include symbols for activities such as: decisions, waits, stops, starts, arrows, and documentation

stop and start

is a circle shows the start or end of a process

wait

is in the shape of a D, signifies a delay or waiting period

tool 16 action planning

needs to begin with a worksheet. A worksheet is a broad overview of the problem, obstacles, and results expected. CQI is based on total involvement, so this step cannot be skipped. The tree diagram, decision matrix, Gantt Chant, and storyboard make up the entire process of action planning.

arrows

point out the direction of flow from one activity or decision to the next

Force Field Analysis

provides a means with which to look at all the forces which affect the status quo, and then determine which are positively contributing and which are restraining. When forces create a balance, that is, opposing forces are equal, a static force field or frozen condition exists Change happens when one type of force overwhelms another. Performance declines when restraining forces overpower driving forces, resulting in inhibition of improvement or solutions. When driving forces overpower restraining forces, performance improves.

front desk sipoc

s: front desk i request p: notifies u/s tech o: scans patient c: u/s tech

Radiologist sipco

s: radiologist I: patient films P: reviews o: rescans or not c: patient

physician sipoc

s:physician I: patient orders p: request for exam o: request written c: front desk

Storyboards can be used to show:

shots, camera's point-of-view, lighting, details about characters, locations

how-how tree diagram

solution/how

Tools for Targeting Improvement

the success in continuous quality improvement lies in the understanding you gain through the knowledge and use of the appropriate tools.

SIPOC

to identify suppliers (S), inputs (I), processes (P), outputs (O), and chart (C)

uses of affinity charts

to solve a problem that has many possible causes . To develop a top-priority problem statement about a vast and vague problem. To set objectives from a variety of possible choices. To sift through many possible solutions