Compass & Map

"If we knew what it was we were doing, it would not be called research, would it?" - Albert Einstein 

Quality Improvement  Roadmap

CHOOSE YOUR TEAM

Step

1

Project Sponsor - has executive authority and serves as a link to senior management

 

Team Lead - individual with enough clout to help implement new changes and the authority to allocate the time and resources

 

QI Expert - may have familiarity with QI methods and understands the processes and procedures

 

Local Experts - “front-line” staff whose daily work occurs in the area that is the focus of the improvement. 

 

Outside Perspective - an individual who is not directly involved in the process and can provide a “fresh perspective”

 

QI Project Manager - usually the QI Team Leader or Local Expert who provides organization and management for the project

Model for Improvement/PDSA Cycle 

Develop and aim statement

What are we trying to accomplish?

Develop Measures

How will we know out changes will work?

Identify ideas for change

What changes will result in an improvement?

PDSA1.png

Act

Plan

Study

Do

cycle_edited.png

Using a scientific QI methodology ensures a standardized and rigorous approach to improving care and closing gaps without missing a crucial step. The underlying principles of analysis, measurement and review are consistent across all methodologies. Disciplined application of all steps is more important than the choice of improvement method. These methods are tools that can be part of your QI armamentarium and each of them can be applied to the same Qi initiative. Remember, one nice thing about QI projects that differs from clinical research is that they are adaptive.

The Model for Improvement (MFI)/PDSA cycle sets to answer 3broad questions before testing the plan. The PDSA cycle itself involved the testing, implementation, analyzing the effects of implementation and acting to either adjust the implementations if they don't work, or implement and sustain them if they do. 

There are going to be a lot of acronyms and new tools you aren't used to. Think of this method as a protocol, similar to what you would see in clinical research. It provides structure, and structure provides consistency.

DEVELOP AN AIM STATEMENT

Step

2

Quality improvement requires selecting aims that should be should be Specific, Measurable, Attainable, Relevant and Time Based. A good statement includes the following:

SMART.png

What are we trying to accomplish? - this is the long term outcome to "improve", "reduce" or "increase". etc.

Why is it important? - answer why you should even bother doing this project

Who is the target population? - Who or what specifically is the project focused on

When will this be completed? - what is the specific time period to complete the project?

How will this be carried out? - This is the methods or QI tools you will use in your project

What are out measurable goals? - Give 4-5 short term goals that will help achieve the overall aim

PDSA1.png

DEVELOP MEASURES

Step

3

Measurement of change is a key ingredient to a strong QI project. If you have ever changed something, you likely had some kind of data to assess the improvement (e.g., before and after pictures). Measures help show results and achievements toward your desired goal and also helps replace personal subjectivity. Instead, you have data to actually show if the changes you make are improving your current process. As you collect data for your project, you should include four types of measures, which are linked to your project aim and goals. 

There are FOUR measures to consider when developing a QI project...

While it is critical to have quantitative measures, qualitative data including stories from customers/staff and before and after pictures are important to add richer meaning to your results. In addition, these items will be critical to fully communicate the success of your project as well as help spread your improvements to other areas in your organization. Once measures are established, it is important to define the measures and develop a plan for collecting the data (e.g. how will it be collect, how often, who will collect it, etc.) A measurement plan can be used to summarize the details of your data collection plan. As you collect your data, use a run chart or other graphs to display the data. Additionally, as part of your measurement plan, you should begin to think about how you are going to capture data to calculate a Return on Investment (ROI) for your project. ROI will help provide additional data to show the importance and impact of the improvements.

Structure Measures

Assess the static resources needed to improve processes and outcomes (i.e. equipment, machinery, necessary locations)

Process

Measures

Gives an indication of the parts and steps that you hypothesized would lead to improved outcome (i.e. number of times central lines are performed)

Outcome

Measures

Assess system performance by measuring the result of healthcare to patients or the community (i.e. infections after central line placement)

Balance

Measures

Reflect the potential unintended consequences that arise from a QI project (i.e. delayed placement of central line placement)

IDENTIFY CHANGE IDEAS

Step

4

There are many tools thatBefore you can make an improvement, it is important to understand how your current process works. There are many tools that can be used to assess current processes and identify areas that require improvement. Let's take a look at some of these tools. Keep in mind, these are just tools. you do not have to use all of them when designing a QI project. Choose what makes the most sense for the question you are trying to answer.  

gemba.png

Tool #1: Gemba Walk ("the real place")

Before you can make an improvement, it is important to understand how your current process works. A great way to accomplish this is to conduct an observational walk by going to where the work is done (also referred to as the Gemba Walk). It is important to observe the process (and flow) firsthand so that you can see how the process is actually performed versus how you think it is performed. It is best to schedule a time when your entire QI team can conduct the Gemba walk together. 

 

As you observe the process you should document each step of the process, record the time it takes to complete each step in the process and the time to complete the entire process. Record any wait times to during the steps of the process and document any "waste" that you see during the process. 

7 Steps to the walk

Pick a theme

Prepare your team

Focus on process, not people

Be where the value stream is

Record your observations

Have an extra pair of eyes

Follow up

7 Questions to ask

What task are you doing now

Is there a standard process for completing this task?

Are you encountering problems while completing this task?

What causes the problem?

How do you find the root cause of the problem?

How can you fix the problem?

Who do you contact if you need any help with a problem?

Tool #2: The 8 wastes

Defects

Overproduction

Waiting

Non-utilized talent

Transportation

Inventory

Motion

Over Proessing

Carrying out additional tests because results of previous samples were lost

Waiting for a pathology test result to come back before discharge

Moving patients around the hospital

Staff having to walk for 10 minutes between wards

Requesting additional tests which could be avoided

Administrative tasks done by consultants which could be done by more junior staff

Patients waiting to be triaged, email inbox, telephone queues

Inputting the same information into different data capture systems

TIMWOODS is a useful mnemonic that identifies the 8 areas of waste that need to be eliminated. These particular examples illustrates the potential waste in a healthcare environment and is used as a template in identifying common areas where waste occurs. 

Tool #3: Value Stream Map

Value stream mapping allow you to review the steps of your current process using the data gained on the Gemba walk. This allows you to review your current process through the eyes of your patients and begin to categorize each activity within the process based. A value stream map is used to show the flow of materials and information in one of your processes and was developed to help you improve and optimize flow throughout your organization.

 

Value stream mapping allows you to answer the following:

 

  1. What activities add value?

  2. What activities do not add value but are necessary? 

  3. What activities do not add value and are not necessary?

This visual depiction of your process greatly helps the team analyze the process, see where the flow is interrupted or stopped, and highlight opportunities to reduce waste and improve the process. 

Value Stream Map.png

Tool #4: Swim Lane Diagrams

Swim lane diagrams are another tool that may help enhance the current organizational process

Swim Lane Chart.png

Tool #5: Spaghetti Diagrams

Spaghetti diagrams are another tool that may help enhance the current organizational process

Spaghetti.png

Tool #6: The Five Whys

With these tools, you want to focus your improvement efforts on eliminating non-value added activities and reducing non-value added but necessary activities. In addition, for projects aimed at improving health outcomes or improving the process' effectiveness, you want to identify changes that will increase the value added nature of the process (e.g., adding an evidence-based component to your current process, such as incorporating a referral to an evidence-based smoking cessation program in a project aimed at improving care for diabetic patients). Do not put a “Band-Aid” on the problems, make sure to drill down to the root cause analysis. 

 

The 5 Whys is one method of finding the root of the problem

 

The 5 Whys works like this:

  • Write down the problem you’re having so everyone on your team can focus on it specifically.

  • Ask why the problem occurred.

  • If your first answer isn’t the root cause of the problem, ask why again.

  • Repeat this step at least 5 times to find the true root cause of the problem.

  • You can ask why more than 5 times, but it seems that after 5 whys are asked, you will have clarity on the cause of your problem.

Why?

Problem Statement

"There is a puddle on the floor"

Why?

Why?

Why?

There is a faulty control valve

The overhead pipe is leaking

There is too much pressure in the pipe

Why?

The control valve is not being maintained

Root Cause: Control valves are not on a maintenance schedule

Tool #7: Fishbone/Ishikawa diagram

fishbone diagrams are another tool to find the root cause of a problem

Fishbone diagram.png

Tool #8: Impact Matrix

Many times you may develop a long list of change ideas. Work with your team to prioritize the change ideas to work on first. Changes that are easiest to implement and will have the largest benefits to the organization may be what you want to focus efforts on firstUsing an Impact Matrix to help prioritize your changes ideas. In an impact matrix you make a list of activities that need accomplished and you organize them based on impact and effort. You then tackle them in order of those requiring the lease effort with the highest impact. 

Impact matrix.png

Tool #9: Pareto Diagram

A Pareto Diagram displays the differences between groups of data, allowing teams to identify the largest issues facing the process. The y-axis represents a cumulative percentage and a defect frequency, while the x-axis represents the groups of response variables displayed as bars, such as machine design or machine parts. This chart is often lauded as one of the most important tools in for helping teams uncover the 20% of sources that cause 80% of problems in their processes.

Pareto Chart.png

Tool #10: Kaizen (continuous improvement)

Kaizen translates to "change good." It is a tool in the sense that it is the practice of continually observing, identifying, and implementing incremental improvements in the process. It encourages all managers and employees to be involved in the process of improvements. Kaizen ensures that waste will be gradually reduced through the collective talents and knowledge of everyone in the company working together to change the smallest inefficiencies daily. Further, applied in personal practice, Kaizen leads to continuous self-improvement as a continuous cycle of self-criticism, courage and breaking status quo to achieve your true potential as an individual and a leader. 

Kaizen.png

Kai

Zen

Change

Good

Self-Criticism

Break Status Quo

Courage

"KAIZEN"
Continuous Self-Improvement
"HANSEI"
"To live for others"
Process
"KAIRYO"
Continuous Improvement
Results of
   Kaizen

Flow, Lean tools, Standard work, Value stream maps, Visual management, etc.

Leadership, Train the trainer, On-the-job Training, Go to Gemba, Strategy development, etc.

New facilities, Computer systems, New equipment, Research, etc.

Tool #11: Poka-Yoke (mistake proof)

Poka-yoke is a Japanese term that means "mistake proofing." It is a process by which employees work to identify and eliminate the causes of human errors throughout the manufacture and production processes. For example, a poka-yoke could be changing the phrasing on machine buttons to eliminate worker confusion or it could be adding a safety brake to mobile equipment to prevent accidents.

No Poka-Yoke

With Poka-Yoke

Other tools that may be useful... 

  • Focus Groups

  • Surveys

  • Brainstorming sessions

  • Interviews with staff/patients

Don’t get overwhelmed by all these tools, remember QI projects are adaptive and not based on protocol. These are just tools to help keep it systematic, and you certainly don’t need to use all of them, or even most of them. Choose what makes the most sense for the question your are trying to answer. 

PDSA Cycle

Step

4

Act

Plan

Study

Do

cycle_edited.png

Ok, not that you have an understanding of some of the tools that helps identify change ideas, lets move to the next step in the process.  That is the testing and implementation phase, or the Plan, Do, Study, Act cycle. You want to test and retest any plan you have before you implement any change ideas on a large scale. Therefore, a PDSA cycle isn’t typically a 1 time deal, it is done over and over on escalating scales until a resolution to the problem is achieved. Due to potential staff resistance, it's important to test changes on a small scale (e.g., one person, one form, one provider, one session, etc.) and under different circumstances before implementing the changes. To do this, use the Plan-Do-Study-Act cycle to help plan and carry out small tests for each change. 

As you test your changes, remember...

  • Scale down the time period for testing

  • Include feedback from staff and patients

  • Keep staff informed and Involve stakeholders

  • Test with volunteers or a "friendly audience" first

  • Identify ways to collect useful data during each test

  • Learn from failures

  • Test over a wide range of conditions (i.e. during day and night)

PDSA1.png

Plan

  • Objective of the cycle

  • Question and predictions

  • Plan to carry out cycle (who, what, where, when)

Do

  • Carry out the plan

  • Document problems and unexpected observations

  • Begin data analysis

Study

  • Complete data analysis

  • Compare data predictions

  • Summarize what was learned

Act

  • What changes are to be made?

  • Are you ready to implement change?

  • Try something else?

SUSTAIN PROJECT IMPROVEMENTS

Step

5

Unfortunately, most QI projects are not successful, because they are not sustained. It is critical to assess individual and institutional culture for QI. Success often hinges on adoption and behavior change by front-line providers. Once you have tested and identified changes that successfully improve your process, it is important to sustain and hardwire them into your organization.

 

There are five areas your team should focus on when sustaining your improvements: 

  1. Involve and inform your senior leaders 

  2. Assign ownership to an individual (i.e., QI Coordinator, team lead—there is not a right answer and may vary by project) 

  3. Hardwire improvements by involving all staff (i.e., training for staff, job performance, job descriptions, etc.) 

  4. Communicate improvements to clients and allow them to create accountability 

  5. Continuously measure and monitor results to ensure your new process is still working - reduce the amount of data you have been collecting and chose one or two overall measures that will give you a snap shot of the process

Involve Senior Leaders
Assign Ownership
Hardwire Improvements
Communicate
Continuously Measure

PUBLISHING YOUR FINDINGS

Step

6

SQUIRE 2.0 - revised Standards for QI Reporting Excellence

The SQUIRE guidelines provide a framework for reporting new knowledge about how to improve healthcare. They are intended for reports that describe system level work to improve the quality, safety, and value of healthcare, and used methods to establish that observed outcomes were due to the intervention(s). A range of approaches exists for improving healthcare.  SQUIRE may be adapted for reporting any of these. Authors should consider every SQUIRE item, but it may be inappropriate or unnecessary to include every SQUIRE element in a particular manuscript.

squire.png
Wong, et al. J Grad Med Educ, 2016
Promoting Organizational Values
Technology