Performance Improvement Methodology

(FOCUS – PDCA)

DR. KHAN ZAHEED

MBA.HOSPITAL MANGEMENT
Mastering In Clinical Audit Edinburgh University U.K.
Certificate in Healthcare Quality & Patient Safety
Institute for Healthcare Improvement(IHI)
Cambridge, USA

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 Safe health workers,
Safe patients

Theme: Slogan:
Health Worker Safe health
Safety: workers, Safe health workers,
Safe patients
A Priority for Safe
Patient Safety patients

Call for action: Safe health workers,

Safe patients
Speak up for
health worker
safety!
Safe health workers,
Call for action: Safe patients
Speak up for health worker safety!
2
• Quality
• The degree to which health services for individuals and
population increases the likelihood of desired outcome and
• are consistent with current professional knowledge.

• PDCA
• A scientific method utilized to improve processes. Acronym
components: PLAN the improvement, DO the
• improvement, collect and analyze data, CHECK and study the
results, ACT to improve the process and hold gains.
• Also known as the Shewart cycle, Deming cycle, or learning
cycle of change.
 OBJECTIVE
• Understand quality improvement using
FOCUS PDCA Model for Improvement

• Let’s make our health system healthier

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 History

• FOCUS-PDCA, created by the Hospital Corporation of

America (HCA), is a systematic process improvement
method.
• FOCUS -PDCA is an extension of the Deming or
Shewhart Cycle which includes Plan-Do-Check-Act.

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 Leadership commitment

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Everyone “Just Doing Their Best”

DR KHAN QM
Aligning the Arrows

DR KHAN QM
 Find

Select Organize

PDCA

Understand Clarify

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 The method for improvement
FOCUS PDCA
Find - an opportunity for improvement
Organize- a team
Clarify- The current process
Understand- the resources of the
problem and the process variation
Select- The improvement

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 The model for improvement

What are we trying to accomplish?

How we will know that a change is an improvement?

What change can we make that will result in an improvement?

ACT PLAN

CHECK DO

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 Seven Quality Tools
– 1-Flow Charts
– 2-Cause and Effect Diagrams
– 3-Check sheets
– 4-Histograms
– 5-Pareto Charts
– 6-Control Charts
– 7-Scatter Diagrams

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 THE SEVEN BASIC TOOLS

Control Chart
Pareto Chart

*
* *
* *
*
* *
*
Scatter Plot Ishikawa Chart
Flow Charts

Check sheets
Histogram

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SEVEN BASIC QUALITY TOOLS IN CORELATION WITH PDCA CYCLE
SEVEN Steps of PDCA CYCLE
BASIC
QUALITY Plan Do Check Act Check
TOOLS Problem Implement Process Solutions Result
Identification solution Analysis development evaluation

Flow chart

Cause &
Effect
diagram
Check sheet
Pareto
diagram
Histogram
Scatter plot
Control
chart
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 Find - an opportunity for improvement
OVR
Patient /staff satisfaction
survey
Indicators

1. Infection rates.
2. Performance appraisal (evaluations).
3. In-service program evaluations.
Committee meetings.
4. New services
5.

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 What Is the Problem and How Do You
Know It Is a Problem?
• Tell about customer’s experience.
• No blaming of others.
• No imbedded solutions in the problem
statement.
• Give benchmarking data.
• Be brief.
• Describe only one problem.

DR KHAN QM
 Organize- a team
What are the Four Stages of Team Development?

• Forming
• Storming
• Norming
• Performing

• Every effective team

goes through these
life cycle stages

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 rganize a team

• Size – large enough to include all disciplines or

departments involved, but small enough to be
workable.
• Membership –
• include all knowledge/skills/departments stake holders
needed to address the process in question
• Resources – money, time, materials, training, etc.
• roles/responsibilities –

DR KHAN QM
 Clarify- The current process

If you can’t describe what you are doing

“

as a process, you don't know what you are

doing”
W.Edeward Deming

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 larify current knowledge of the
process Flowcharting creates a shared
understanding of the process among
Describe process the team members
Why :
•To document
•To understand
•To Delay solutions
•How ?
•Chart alone ( walk through , add periodic
events)
•Combine
•Revise DR KHAN QM
 SYMBOLS IN FLOWCHART

START/END

PROCESS STEP
NO

DECISION
YES

CONNECTOR A

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 LINEAR FLOWCHART
EXAMPLE
A
Producing the “Plan of the day” start

Collect inputs Type Smooth

Draft POD Sign POD

Type Rough
Make Copies
Retype POD

Submit to XO
Distribute

Ok?
End

A
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 Understand- the resources of the
problem and the process variation
CAUSE AND EFFECT
BASIC LAYOUT
Manpower Methods
(people) (Procedures)

EFFECT

Materials Machines
Environment
(Policies) (Plant)

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 Pareto Charts
The Pareto Chart (see Figure 11) is a tool that helps teams see
which causes or problems occur most frequently.
A classic Pareto Effect is observed
when 20% of causes contribute to 80% of overall problems.

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 A system designed for errors
Root causes
here!
Patient
gets
Pharmacists wrong
Pharmacy mistake one drug
Open stocks look drug for
formulary; alike drugs another
Doctors can
write
illegibly and Nurses
abbreviate Nurses
care for misread Patients don’t
orders many speak up
orders Residents do not
patients review orders
Nurses do not check
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 Select- The improvement
How does the Hospital establish Priorities for defining
which process needs to be improved?

 High Risk
 High Volume
 High Cost
 Problem prone

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 The statement of objectives can be
guided by the SMART mnemonic
• Specific
• Measurable/Meaningful
• Attainable
• Relevant/Results oriented
• Time-bound

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 Select- The improvement
Time-
bound

Relevant
/Results Specific
orient
SMART

Measurable/
Attainable
Meaningful

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 The model for improvement
AIM
What are we trying to accomplish?
MEASURE
How we will know that a change is an improvement?
CHANGE
What change can we make that will result in an improvement?

ACT PLAN

CHECK DO

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What are we trying to accomplish?

AIM

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 EXAMPLE Poor aim statements:
“Through the implementation of an electronic medical record
(EMR), our chronic disease patients will get better care.”
or
“We will create a truly interdisciplinary team to provide
specialized patient-centred care for those with chronic
conditions.”
Good aim statements
“We will improve management of diabetes patients served at
the Brown Street Clinic. By May of next year, we will aim to
increase the percentage of patients meeting their targets for
A1C and blood pressure from 35% to 75%.”
or
“We will reduce wait times for new patients referred to our
specialty clinic from 53 days to 26 days. We will accomplish this
within seven months.”
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 How we will know that a change is an improvement?

“Indicator is a quantitative measurement that is rate based

(numerator and denominator) that is trended over time for
comparison to standards benchmarks) and used with quality
improvements project. Indicators may be clinical or managerial
initiative”.

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Structure Indicator.
• Describes characteristics of the setting that supports and has an
impact on care
• (examples: availability of approved least restraint devices on a
unit, RN - patient ratio)

 Process indicator.

• Measures an activity that is carried out to care for patients.

• Focuses on the nature and amount of care nurses provided
during the hospital stay (examples rate of patients on fall
prevention program, nurse satisfaction).

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 Outcome indicator.
• Describes the patient’s status at the defined time
following care interventions.
• Measures the result of nursing care/process (examples:
pressure ulcer preventive rate, fall injury rate)
 Balancing measures look at a system from different
perspectives. In other words, are changes designed
• to improve one part of the system causing new problems
in other parts of the system?
• Examples include staff satisfaction, financial implications
and restraint rates.

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 QUALITY MANAGEMENT DEPARTMENT
DATA COLLECTION TOOL MONTH :JANUARY-MARCH
YEAR :
Description of Indicator
Indicator Name: Patient Identification Error
Numerator: Numberof Patient Identification Error in one quarter
Denominator: Total Number of Total patients in one quarter
Selection Criteria: Unique patient medical record number and complete particular name
Target:00%
Frequency: Quarterly
Source of Data: Pre-analytical, Analytical, Post-analytical data record
Responsible Party: Laboratory Q.I coordinator
Reported to: LaboratoryDirector/ Medical Director / QPS and RM Officer

Type of Indicator: Structure Process Outcome

% of
Section Criteria Total No. Remarks
Compliance
 Number of Patient Identification
0
Error in one quarter 0%
LABORATORY
 Total Number of Total patients in
19182
one quarter

Verified by:Quality Management Officer APPROVED BY

Data collected by:Lab Q.I
Designee Name: :LABORATORY HOD
Signature: Signature : Signature
______________________
 You can use PDSA cycles to develop change ideas,
test small-scale changes and implement changes across
your area and organization
• Step 1 PLAN
• State the purpose of the PDSA — are you developing a
change idea, testing a change or implementing a
change?
• What is your change idea?
• What indicator(s) of success will you measure?
• How will data on these indicators be collected?
• Who or what are the subjects of the test?
• How many subjects will be included in the test and
over what time period?
• What do you hypothesize will happen? All 7QC
Tools
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 PDCA

• Step 2 DO
• Conduct the test.
• Document any problems and
unintended consequences.
 SEVEN BASIC
PDCA QUALITY TOOLS Steps of PDCA
CYCLE
Study/Check
• Step 3 Process Analysis

STUDY/Check Flow chart

• Analyze the data Cause &

and study the Effect diagram 
Check sheet
results 
• Compare the data Pareto diagram
to your predictions. 
Histogram
• Summarize and Scatter plot
reflect on what was 
learned. Control chart

SEVEN BASIC QUALITY TOOLS IN CORELATION WITH PDCA CYCLE

SEVEN BASIC
QUALITY TOOLS Steps of PDCA
CYCLE • Step 4 ACT
Act • Refine the change
Solutions
development idea, based on
Flow chart  lessons learned from
Cause & the test.
Effect diagram
Check sheet
• Prepare a plan for
Pareto diagram the next test.
Histogram

Scatter plot 
Control chart
 SEVEN BASIC QUALITY TOOLS IN CORELATION WITH PDCA CYCLE
SEVEN BASIC Steps of PDCA CYCLE
QUALITY
TOOLS Plan Do Check Act Check
Problem Implement Process Solutions Result
Identification solution Analysis development evaluation

Flow chart  
Cause &
Effect diagram  
Check sheet   
Pareto diagram   
Histogram  
Scatter plot   
Control chart   
 SAMPLE Quality Improvement Story Board
1. Describe the OFI identified in 2.a. Identify the team members who will 3. Collect data regarding the
address the issue. Define the Team current situation. Use any or all of
Name
Team Members
Role the following:
unstructured. John Team Leader

STRATEGIC PLAN Mary

Bob
Coach
Teacher
Susan Custodian
Bill Secretary
Jane Driver construct and use.
Wayne Student
RUN CHART
BAR CHART

Measurement
b. Establish operational definitions to be used.

Category
Average
Brainstorming
the customer, or to test a group for
Problem Survey Results In Percent Time
SURVEY Statement
Total
A 1 3 1 1 6
1. xxxxxxxxxx
2. xxxxxxxxxx B 3 4 4 2 13
CHECKLIST
3. xxxxxxxxxx C 2 1 3 3 9
Date Total
D 4 2 2 4 12
Operational
Category 1 Data Data
Definitions
NGT Category 2 Data Data

Category 3 Data Data

*
Category 4 Data Data

6. Report results.
4. Identify causes for the current 5. Develop a plan for improvement and
situation. how success will be measured.
a visual listing of possible
FORCE FIELD ANALYSIS
Driving Restraining
Forces Forces

improvement team wants

Cause Cause
Affinity Diagram

EFFECT and/or Pilot Project

Action plan development represents the critical stage

Cause Cause Cause construct and use.
ACTION PLAN Imagineering RUN CHART
BAR CHART and/or

Measurem ent
Category
Average

Survey Results In Percent

Time

DR KHAN QM
 Pledges:
1. Patientswill be at the heart of all we do.
2. We will provide consistently high quality health care.
3. We will continuously improve patient safety standards.
4. We will sustain and develop excellence in Quality
improvement.
5. We will sustain and develop excellence in education and
training.
6. We will promote Patient's and human rights and equalities.
7. We will work with health partners to improve health and
reduce health inequalities.
8. We will work with social care partners to provide care for
those who are most vulnerable.
9. We will make the best use of hospital resources .
10. We will provide and support the leadership to achieve
these pledges.