Quality Improvement

1. DO MEASUREMENTS
What is not measured cannot be managed &
controlled

2. Create standards
Variation is the enemy of quality

3. USE QUALITY TOOLS

 TOOLS

Devices used in understanding and

improving processes.

http://www.businessdictionary.com/definition/seven-tools-of-quality.html
 BASIC QUALITY TOOLS FOR SERVICE
IMPROVEMENT

a. Process Flow Chart

b. Fishbone
c. Root Cause Analysis
d. Work Simplification
e. Failure Mode and Effect
Analysis
PROCESS FLOW CHART

A diagram that uses graphic symbols to

depict the nature and flow of the steps
in a process.
Purposes of the Flowchart
1. To develop understanding of how a process is done.
2. To study a process for improvement.
3. To communicate to others how a process is done.
4. When better communication is needed between
people involved with the same process.
5. To document a process.
6. When planning a project.
The Key to success
1. Start with the big picture
2. Observe the current process
3. Record process steps
4. Arrange the sequence of steps
5. Draw the Flowchart
Example
ROOT CAUSE ANALYSIS (RCA)

• Root Cause Analysis is a METHODOLOGY that

enables your to ask “WHY and “HOW” in a
structured and objective way.
• Reveals all influencing and casual factors that
lead to the problem
When is it used?

• When the problem involves human

interaction
• Day to day
1. Easy to use
2. Easy to use
3. Introduces people to problem solving method
4. Prevents “band aid” solutions
Drawbacks
1. Not data driven
2. Biasing results
3. Limited to personal experience
4. Does not account for multiple causes
“5 WHYS”
The nurse gave the wrong drug to the wrong patient .

WHY?
Statement: because she forgot to identify the patient.
WHY?
Statement: because she was in a hurry.
WHY?
Statement: because she was atending to 18 patients (category1-3)
WHY?
Statement: because 1 staff is absent and no pull out was given
WHY?
Statement: because the manager said they can manage.
CAUSE AND EFFECT
DIAGRAM
• Aka FISHBONE
• the brainchild of Kaoru Ishikawa

• used to explore all the potential or real causes (or inputs)

that result in a single effect (or output).
Benefits of FISH BONE
1. Helps determine root cause
2. Encourages group participation
3. Uses an orderly, easy-to-read format
4. Indicates possible causes of variation
5. Increases process knowledge
Major Categories:

Equipment,
policies,
procedures,
People
Example:
 In making a fishbone:
• Be sure everyone agrees on the effect or problem statement
before beginning.
• For each node, think what could be its causes. Add them to
the tree.
• Consider splitting up overcrowded branches.
• Consider which root causes are most likely to merit further
investigation.
WORK SIMPLIFICATION

A scientific approach to study work processes with a

view to simplifying the processes such that the work
process becomes more efficient & effective &
thereby raises productivity, reduces wastage of labor
effort, materials, space, time & energy in the process
of delivering services
 WORK SIMPLIFICATION TECHNIQUES

1. ELIMINATE UNNESSARY STEP

2. CHANGE THE SEQUENCE OF EVENT

3. COMBINE RELATED STEPS

4. ADD RESOURCE OR CAPACITY

INSTRUCTION: SIMPLIFY THE PROCEDURE FROM WAKING UP TO
REACHING OFFICE ON TIME

Waking up 5 MINUTES

Turn off alarm clock 1 MINUTE

Stand up 5 MINUTES

Exercise/jogging inside
15 MINUTES
around the house

Take a shower 20 MINUTES

Dress up 20 MINUTES

Take Breakfast 15 MINUTES

Read newspaper 15 MINUTES

Kiss wife 5 MINUTES

Drive to office 30 MINUTES

141 MINUTES
10 MINUTES
Reach the office
WORKSHOP
ROOT CAUSE AND FISHBONE WORKSHOP

Discuss among your group mates. SHARE a significant

safety error or a near error that you encountered.

a. Make a Root cause analysis (for probable cause)

b. Make a FISHBONE
PROCESS FLOW AND WORK SIMPLIFICATION
WORKSHOP

Discuss among your group mates and identify a process in

your workplace that is “challenging” or needs to be
improved.
a. draw the process from start to end
b. identify steps which can be improved(using any or a
combination of the work simplification steps)
c. present the “new process”
 Why Use FMEA?

Aimed at prevention of failure

Doesn’t require previous bad
experience or close call
Makes systems more robust (less
27
prone to systemic failures)
 When to Conduct an FMEA
• Early in the process improvement investigation
• When new systems, products, and processes are being
designed
• When existing designs or processes are being changed
• When carry-over designs are used in new applications
28
• After system, product, or process functions are defined,
but before specific hardware is selected or released to
manufacturing
 Examples

History of FMEA
• First used in the 1960’s in the Aerospace industry
during the Apollo missions
• In 1974, the Navy developed MIL-STD-1629
regarding the use of FMEA
• In the late 1970’s, the automotive industry was 29
driven by liability costs to use FMEA
• Later, the automotive industry saw the advantages
of using this tool to reduce risks related to poor
quality
 Rationale for FMEA in Healthcare
Historically…
 Accident prevention has not been a primary
focus of hospital medicine
 Misguided reliance on “faultless” performance
by healthcare professionals
 Complex hospital systems were not designed 30

to prevent or absorb errors; they are reactively

changed and are not typically proactive
 Rationale for FMEA in Healthcare
If FMEA were utilized, the following
vulnerabilities might have been recognized
and prevented:

 Medical center power failure

 MRI Incident – ferromagnetic objects 31

 Medical gas error (Poka Yoke)

 Look-alike medication errors
 The Healthcare Failure Mode Effect
Analysis Process

Step 1- Define the Topic

Step 2 - Assemble the Team
Step 3 - Graphically Describe the Process
Step 4 - Conduct the Analysis
Step 5 - Identify Actions and Outcome
Measures
HFMEA & RCA
Similarities
• Interdisciplinary team
• Develop flow diagram
• Systems focus
• Actions & Outcome
measures
• Scoring matrix
(severity/probability)
• Triage questions, cause &
effect diag., brainstorming
Differences
• Preventive v. reactive
• Analysis of Process v.
chronological case
• Choose topic v. case
• Prospective (what if)
analysis
• Detectability & Criticality
in evaluation
• Emphasis on testing
intervention
 KEY SOURCE MATERIAL FOR AN FMEA

PAPERWORK TURN STEAM ON

LOAD DMF LOAD DICY LOAD 2MI 1
TO DICY TANK

BILL OF MATERIALS SCALE ACCURACY

LOAD ACCURACY LOAD ACCURACY
LOAD ACCURACY
Process Map
ISO PROCEDURES PREHEATING
CLEANLINESS ENVIRONMENT
ENVIRONMENT
(HUMIDITY)
REWORK (HUMIDITY)
RAW MATERIAL RAW MATERIAL
RAW MATERIAL
MIXER SPEED
MIXER SPEED

FMEA
Failure Mode
• The way in which a specific process input fails.
 If it is not detected and either corrected or removed, it may cause a
negative “Effect” to occur
 Can be associated with a defect (in discrete manufacturing) or a process
input variable that goes outside of specification
 Anything that an operator can see that’s wrong is considered a Failure Mode
 Note 1: Just because a dimension is out of spec (a Failure Mode), it does not imply
with 100% certainty that the product will not function (an effect)
 Note 2: Just because the process is improperly setup (a failure cause), it does not
imply with 100% certainty that the dimension will be out of spec (a Failure Mode)
Identify failure modes and their Determine and assess actions
effects Identify causes of the failure Prioritize
modes
and controls
The FMEA Form - The Analysis Section

Process Potential Potential S O D R Action

Potential Current Section
Step/ Failure Failure E C E P
Causes Controls
Input Mode Effects V C T N 
What is the 0 0
How can 0 0

Effect on the this be If risk is too

Outputs? 0 0
found?
0 0 high, what
What can can be
go wrong 0 What are 0 0 0
done?
with the the
0 0 0 0
Process Potential
Step? 0 Causes? 0 0 0

What is
the How How often is the How well can Estimated
Process serious is cause likely to we detect a risk is “Sev” x
Step such an occur and result cause before it “Occ” x “Det”
Effect? in a Failure creates a
Mode? Failure Mode
and Effect?
 Rating Definitions Typical Scales

Rating Severity
Severity Occurrence
Occurrence Detection
Detection
High 10 Hazardous without warning Very high and almost Cannot detect
inevitable

Loss of primary function High repeated failures Low chance of

detection

Loss of secondary function Moderate failures Moderate chance of

detection

Minor effect Occasional failures Good chance of

detection

No effect Failure unlikely Almost certain

Low 1 detection

Note : Determine if your company has rating scales and rules.

In some companies, rating a “10” on severity may have legal consequences.
Severity Ranking
Occurrence Ranking
Detection Ranking
REMEMBER
When
• An effect of Failure has a Severity of 8 or higher
• The product of Severity & Occurrence is high
• When the RPN is high
• > 75 or whatever your business decides

• The RPN is calculated for the entire process or design first

• Failure Modes with the highest RPN = Highest Priority!