E VERY SYSTEM IS PERFECTLY DESIGNED

TO GET THE RESULTS IT GETS

O BJECTIVES
 To gain an understanding of what quality
improvement is
 Understand the domains of quality improvement

 To present the Model for Improvement and PDSA cycle

 Understand Root Cause Analysis- Fish Bone.

 Apply PDSA and Fish Bone Analysis to QI

W HAT IS QUALITY ?

 Definition of quality depends on

stakeholders
 The patient
 The health care provider
 Manager of the hospital or clinic
 Ministry of Health
Q UALITY
Quality is the degree to which health services for
individuals increase the likelihood of desired
health outcomes and are consistent with current
professional knowledge

IOM, Medicare. A strategy for Quality Assurance,

1990, p21
Q UALITY
Doing the
- right thing for the
- right person at the
-right time in the
-right way

Eisenberg. Testimony to Congress, 1999

 6 P ILLARS OF Q UALITY
 Safety-Avoid injuries to patients from the care that is intended
to help them. Minimizes risks and reduces harm
 Accessible- delivering health care that is timely,
geographically reasonable, and provided in a setting where
skills and resources are appropriate to medical need;
 Equitable-No variation in the quality because of personal
characteristics such as gender, race, ethnicity , geographic
location and SES. Closes gaps in health status
 Effective-Match care to science; avoid overuse of ineffective
care and underuse of effective care
 Efficient- Maximizes resources and reduce waste.
 Patient Centered-Honor the individual and respect choice.
Takes into account the preferences and aspirations of
individual service users and the cultures of their communities;
C OMPONENTS OF A Q UALITY S YSTEM
 A high quality health care system is one which is
reliably STEEP
 S afe
 T imely
 E ffective, E fficient
 E quitable and
 P atient-Centered

IOM. Crossing the Quality Chasm, 2001

W HAT IS Q UALITY I MPROVEMENT ?

 A formal approach to the

analysis of performance and
systematic efforts to improve it
 A method for ensuring that all
the activities necessary to
design, develop and implement a
product or service are effective
and efficient with respect to the
system and its performance

 It is not a static concept, but

rather a continuous process
 Different from Quality
Assurance
HOW IS QUALITY IMPROVEMENT DIFFERENT
FROM QUALITY ASSURANCE???
 Q UALITY I MPROVEMENT VERSUS Q UALITY
A SSURANCE
QualityImprovement QualityAssurance
Whatcanwedoto Whatwentwrong?
improve?
Proactive Reactive
Avoidsblame OftenPunitive
FostersSystemchange Triestofindwhowasatfault

Focusesontheentire Focusesonthespecific
system incident
Q UALITY I MPROVEMENT Combined and unceasing
efforts of everyone —
healthcare professionals,
patients and their families,
researchers, payers, planners
and educators — to make the
changes that will lead to
better patient outcomes
(health), better system
performance (care) and better
professional development-
Batalden BMJ
T O IMPROVE A SYSTEM …
 You need a good understanding of the system

 You need to understand where it is

failing - Identify what is wrong
 Make sure it is the step that needs fixing

 Then you can implement a change to the

“system”
D OMAINS OF QUALITY I NTERVENTIONS
D OMAINS
 Leadership- center of any QI initiatives,
strong and committed leadership to QI.
 Information- QI is dependent on measuring
change( baseline and follow up measurements),
information transparent and accessible
 Patient and Population engagement- play
so many roles within health systems- financing
care, working in partnership with health
workers , and are sometimes be the final arbiter
of what is acceptable and what is not across all
the dimensions of quality.
 D OMAINS
 Organisational Capacity- multidimenstional
- National Level.
- Hospital/Clinic Levels
- Community Levels

 Model of care-
 Address all 6 dimension of the quality of care
and improvement
 Integrated responses- span the entire
continuum of care- prvention
R OLES AND R ESPONSIBILITIES
Q UALITY I MPROVEMENT M ODELS AND
T OOLS

 Model for Improvement = Three questions +

PDSA cycle
 RCA =Root Cause Analysis
 FADE = Focus, Analyze, Develop, Execute and
Evaluate
 Six Sigma
 CQI = Continuous Quality Improvement
 TQI = Total Quality Management
 7 step method
 R OOT C AUSE A NALYSIS (RCA)
- ERROR ANALYSIS TOOL

 RCA is a systematic, formalized approach to

reviewing an adverse event and identify root
causes
 RCA allows for

 focusing on the problem ( what, how and

why the problem)
 Identify and agreeing on factors leading to
the problem
 Developing of effective corrective actions
R OOT C AUSE A NALYSIS
The practice of RCA is predicated on the belief that
problems are best solved by attempting to correct or
eliminate root causes, as opposed to merely addressing
the immediately obvious symptoms.

Directing corrective measures at root causes, it is hoped

that the likelihood of problem recurrence will be
minimized.

Recognizes that complete prevention of recurrence by a

single intervention is not always possible.

RCA is often considered to be an iterative process, and is

frequently viewed as a tool of continuous improvement
.
Learned readily by mid level and senior managers
G ETTING TO THE R OOT C AUSE
 Make sure that the right people are in the room (
choosing the team)
 Ensure a safe, non-punitive environment

 Start with an overview of the processes related to

the event
 Focus on issues, not individuals

 Let everyone provide input, but keep the focus on

the event and related processes.
N OT A “S TAND A LONE ” S OLUTION
 RCA is a strategy that complements other quality
improvement activities
 Complemented by a PDSA cycle
 THE SAFETY CASE
 A laboratory aide was cleaning one of the gross
dissection rooms where the residents work. This aide
was a relatively new employee who had transferred
to the department just a few days prior to the event.
When she was cleaning the sink in the dissection
room, she accidentally ran her thumb along the
length of a dissecting knife — an injury that required
10 to 15 stitches. Since there had been other less
serious accidents in this room and several previous
attempts to address the safety issues had not been
effective, the department completed a root cause
analysis.

Williams P. Techniques for root cause analysis

Q UESTIONS TO C ONSIDER
 What happened? Why did it happen?
 When and where did the occur?
 What are usual, recommended processes/practices for
this type of care/device/procedure?
 Were all steps followed, in the correct order?

 Were all providers trained and competent?

 Are there other factors to bring up?

 A SK 5 WHY QUESTIONS
 The laboratory aide was cut by a dissection knife.
 The knife was left by the sink.
 The area was not cleared on the previous day.

 Clearing is not a daily habit.

 Standard operating procedures/documentation

for clearing do not exist.

Williams P. Techniques for root cause analysis

C ATEGORIES OF E RRORS
T HE E INDHOVEN CLASSIFICATION MODEL FOR A MEDICAL DOMAIN

Williams P. Techniques for root cause analysis

C ATEGORIES OF E RRORS
T HE E INDHOVEN CLASSIFICATION MODEL FOR A MEDICAL DOMAIN *

Williams P. Techniques for root cause analysis

 C ATEGORIES OF E RRORS
T HE E INDHOVEN CLASSIFICATION MODEL FOR A MEDICAL DOMAIN

Williams P. Techniques for root cause analysis

 B ENEFITS OF RCA/ C AUSE AND E FFECT
A successful RCA program:
 Increases collaboration and sharing of information

 Allocates resources to meaningful root causes as identified.

 Encourages accountability and follow-up on all levels

 Identifies solutions to share with other areas of your

facility/system
 Promotes a culture of safety

 Promotes team building

 Easy to do, quickly learned by mid level managers

H ELPFUL T OOLS

 Causal Tree
 Fishbone diagram is helpful to keep focus on
evidence-based risk factors.
 Fishbone “spines” often include:

 Patient-specific factors
 Caregiver factors
 Equipment factors
 Environmental factors
 Systems factors
A C AUSAL T REE
S TEPS IN RCA/ C AUSE AND E FFECT
General process for performing RCA
 Define the problem.
 Gather data/evidence.
 Identify problems that contributed to problem
(Causal Factors).
 Find root causes for each Causal Factor.
 Develop solution recommendations.
 Implement the solutions.
C AUSE AND E FFECT D IAGRAMS - F ISH
BONE D IAGRAM

 Cause and Effect Diagram Defined

 The cause and effect diagram is also
called the Ishikawa diagram or the
fishbone diagram.
 It is a tool for discovering all the
possible causes for a particular effect.
 The major purpose of this diagram is to
act as a first step in problem solving by
creating a list of possible causes.
 F ISHBONE D IAGRAM
Purpose: Graphical
representation of the trail leading
to the root cause of a problem

How is it done?
• Decide which quality
characteristic, outcome or
effect you want to examine
• Backbone – draw straight line
• Ribs – categories
• Medium size bones – secondary
causes
• Small bones – root causes
 RCA/C AUSE AND E FFECT D IAGRAMS
 Constructing a Cause and Effect Diagram
 First, clearly identify and define the problem or
effect for which the causes must be identified. Place
the problem or effect at the right or the head of the
diagram. “head of the fish”
 Identify all the broad areas of the problem. ( the
quality domains)
 Write in all the detailed possible causes in each of
the broad areas. ( secondary causes)
 Each cause identified should be looked upon for
further more specific causes. ( root causes)
 View the diagram and evaluate the main causes.
 Set goals and take action on the main causes.
D OMAINS OF QUALITY I NTERVENTIONS
I SHIKAWA F ISH B ONE
Ishikawa (Fishbone) Diagram
A CTION P LAN
 You may identify several root causes- Identify what
root causes you may wish to address
 Suggestions for improvement should be discussed for
each one
 By the end of the meeting a list of action items should
be developed, with identified key stakeholders and a
time line for completion
S UPPORT AND F OLLOW -U P
 A high level of energy usually occurs after a successful
RCA
 Staff are motivated to make identified changes

 Provide resources to support them

 Collect data to determine if the
changes are effective
 Share data with RCA participants
 Share results of success.
L ETS CONDUCT A FISH BONE ANALYSIS
 C OMPARING H EALTH S YSTEMS
Compare Guyana’s health system with another health
system
Use 3 health inputs- health workforce, health financing and
health services
Outline:
1. Review/ Abstract
2. Comparison/Results
3. Discussion ( health system peformance, impact)
4. Conclusion
5. Correct referencing
6. Minimum of 3- maximum 4pages, Arial 12 font
20% of the course grade- Due on 14 th December
M ODEL FOR I MPROVEMENT
= T HREE QUESTIONS + PDSA CYCLE
Q UALITY I MPROVEMENT
W. Edwards Deming
 American statistician, professor,
author, lecturer, and consultant
 Improved production in the U.S.
during World War II and in
Japan after the war
 Pioneer – use of statistical
analysis to achieve better
industrial quality control –
‘quality movement’
T HE T HREE Q UESTIONS

 The Model for Improvement begins

with three fundamental questions

 1. The Aim: What are we trying to accomplish? (How

good do we want to get and by when?)
 2. The Measures: How will we know a change is an
improvement?
 3. The Changes: What change can we make that will
result in improvement?
E XECUTING THE QI MODEL

1. Form a team
2. Three Questions: The Aim,
The Measures, The changes
3. Test changes - PDSA
Cycle
4. Implement changes that
work
5. Spread the changes to
other areas
  To come up
T HE TEAM with the
right team
 Why? you have to
have an idea
 Need different perspectives of what your
 Active brainstorming aim is…
 It’s a lot of work
 Increased buy-in by staff
 Different levels of support (e.g.
management)
 People who bring various expertise
to the process and are familiar
with different parts of the
processes.
G OOD TEAM

 Thinks
 Makes collective decisions
 Outputs- ideas and suggestions- arrived at in a
collaborative manner
 Atmosphere of collaboration and cooperation rather than
competition
 Belief that that each member is accountable for the
success or failure of the team.
 Sense of trust so that there can be communication and a
free expression of opinion.
 Recognize that disagreement may be a positive factor.

 A good team evaluates the performance of the team

periodically to see if it is on target.
 P HASES OF TEAM DEVELOPMENT
 When someone joins a team, he or she needs to
understand that teams go through a series of stages in
development. Teams behave differently at each stage.

Those stages are

1.Forming,
2. Storming,
3. Norming, and
4. Performing.

The team leader who is developing a new team

needs to pay attention to each of the stages.
S TAGE 1: F ORMING

 Team members feel excitement, anxiety and

uncertainty, sit back and size up the situation,
very few will take the initiative, depend on the
team leader for direction and structure.
 The team leader needs to recognize what
people want and provide structure, provide a
sound orientation, a clear framework for the
team to operate, a definition of goals and
clarification of the roles so the team has a clear
understanding of what they will be doing.
S TAGE 2: S TORMING
 Expected part of team formation ( most difficult stage)
 Members could become disappointed and
disillusioned, frustrated with the amount of work ..
 Storm about any part of the process, the work, the
timeframe or meeting time.
 Arguments, with each other and become testy or
overzealous.
 Cliques can form, power struggles

In actuality - beginning to understand each other.

- An effective leader will become the facilitator and use
this opportunity to allow members to problem-solve
their issues.
During this time, productivity will stall
S TAGE 3: N ORMING
the members become a team.
o Individual roles become clear
o Team members are more satisfied.
o Animosities are replaced with trust, respect and
support.
o They are accepting the ground rules, understanding
their roles in the team structure and the other
members.
o Increased level of satisfaction as the team begins to
solve major problems.
o The team develops cohesion, a common goal.

o The team starts to make progress

S TAGE 4: PERFORMING
 Team members are now experienced at working
together and feel progress is being made.
 Solve problems, implement change

 There is a return of excitement and energy in the

team
 Team satisfaction increases with the progress
E FFECTIVE TEAMS
 Three kinds of expertise
 System leadership
 Clinical -Technical expertise
 Day to day leadership - Project
leader
 B RAINSTORMING

Rules
• Diverse group
• Go around room and get input from all – one idea
per turn
• Continue until ideas are exhausted
• No criticism
• Group ideas that go together
• Look for answers
 W HO ARE YOU LOOKING FOR IN A QI TEAM
???
 Who knows the work?
 • Who will be impacted?
 • Who would be a good champion?

 • Who has veto power?

 Who has power to make things work?

T HE A IM

What are we trying to accomplish?

T HE A IM
 Time specific and
measurable
 Target a defined
population
 Manageable
 Realistic

It has to be important to those

involved
E XAMPLES OF A IMS
 Achieve greater than 95% compliance among patients on
ARV treatment within the 12 months period
 Reduce waiting time at the Chest Clinic to less than 30
minutes within the next 9 months
 Reduce the average length of hospitalization for TB
patients to 2 weeks by the end of 2015
 Increase to 100% the provision of discharge summaries
patients upon discharge by the end of 2015
D EFINE Y OUR TEAM
 AIM- Achieve greater than 95% compliance
among patients on ARV treatment within the 12
months period at the National care and
Treatment Center

 Team Lead-??
 Technical Expert??

 Day to Day Leader ?

 Additional Members??
Y OUR TEAM

 Team leader: Head of the NCTC,

 Technical expert: Head of the Social Work
Department
 Day to day leader (project leader): the senior
counsellor
 Additional team members: other counsellors,
outreach workers, nurses, patient advocate
/support group
T HE A IM

 Lets write some Aims based on

your RCA and define your team
based on your exercice of the
RCA
M EASUREMENT - H OW WILL WE KNOW THAT A
CHANGE IS AN IMPROVEMENT ?

 Measurement is
critical for testing and The Aim
implementing changes
The Measure

 Different from The Change

measurement for
research ( How is it ACT PLAN

different ????)
STUDY DO
 M EASUREMENT
Measurement for Measurement for
Research Improvement
Purpose To discover new knowledge To bring new knowledge into
daily practice
Tests One large blind test Many sequential, observable
tests
Biases Control for as many biases Stabilize the biases from test to
as possible test
Data Gather as much data as Gather just enough data to learn
possible, just in case and complete another cycle
Duration Can take a long time Short duration
E FFECTIVE MEASUREMENTS
 Plot data overtime
 Seek usefulness and not perfection
 Use sampling
 Integrate measurement into daily
routine
 Use qualitative as well as
quantitative data
M EASUREMENT
 3 types of measures for quality
improvement
 Outcome measures
 Process measures
 Balancing measures
 (+/- Structure Measures)
O UTCOME M EASURE
 = Where are we ultimately trying to go
 Are your changes actually leading to
improvement
 How does the system impact the values of
patients, their health and wellbeing?
 What are impacts on other stakeholders such as
payers, employees, or the community?
P ROCESS M EASURES
 To affect an outcome you have to improve your
processes
 Are the parts/steps in the system performing as
planned? Are we doing the right things to get there
?Are we on track in our efforts to improve the
system?
 Are the parts/steps in the system performing as
planned
B ALANCING M EASURES

 Tells you if changes designed to improve one part of

the system are causing new problems in other parts of
the system
 Eg: For reducing time patients spend on a ventilator
after surgery : Make sure reintubation rates are
not increasing
 For reducing patients' length of stay in the hospital:
Make sure readmission rates are not increasing
D EVELOPING C HANGES

 What change can we

The Aim
make that will lead
to improvement? The Measure

 Not all changes lead The Change

to improvement, all
improvement ACT PLAN

requires changes
STUDY DO

 Depends what you

are trying to change
C HANGE CONCEPTS …

… are general ideas, with proven

merit and sound scientific or logical
foundation that can stimulate
specific ideas for changes that lead
to improvement.

Nolan & Schall, 1996

 C HANGE CONCEPTS FOR IMPROVEMENT
The general approach that could be used to generate
ideas for change that could lead to improvement.
1. Eliminate waste
2. Improve work flow
3. Optimise Inventory
4. Change the Work environment
5. Producer and Customer Interface
6. Manage Time
7. Focus on variation
8. Error proofing
The improvement guide by Langley
C HANGE C ONCEPTS
 Eliminate Waste - an activity or resource that
does not add value

 Improve Work Flow

 Optimize Inventory - is your work being held

up because items are not properly organized or
available
 C HANGE C ONCEPTS
 Change the Work Environment (does the
work culture enhance or impede change)

 Manage Time

 Focus on Variation - what aspect of the

system vary and make your outcomes
unpredictable

 Focus on Error Proofing (checklist)

B ASIC TECHNIQUES IN DETERMINING WHAT
CHANGE IS NEEDED

 Critical Thinking
 Flow Chart/Diagram
 Benchmarking
 Compare to best practice
 Using Technology
 Barcodes for medications
 Creative Thinking
 Become a patient for a day
 Using Change Concepts
C RITICAL T HINKING
 Use a Flow Chart/Diagram
 Visual of the proposed change
 Everyone see the change in the same way.

 Making complex issues simple and

understandable.
 Clearly identifies the steps that do not add value
to the client ( delays, breakdown in
communication, excessive use of transportation
etc)
F LOW C HART /D IAGRAM
 It helps team members gain a shared
understanding of the process and use this
knowledge to collect data, identify
problems, focus discussions, and identify
resources.

 It serves as a basis for designing new

processes.
F LOW C HART /D IAGRAM
 High-level flowchart , showing six to 12 steps,
gives a panoramic view of a process

 Detailed flowchart is a close-up view of the

process, typically showing dozens of steps. These
flowcharts make it easy to identify rework loops
and complexity in a process .
E XAMPLE : H IGH L EVEL F LOW C HART

From: http://www.hciproject.org/improvement_tools/improvement_methods/analytical_tools/flowchart
E XAMPLE : D ETAILED F LOW C HART

From: http://www.hciproject.org/improvement_tools/improvement_methods/analytical_tools/flowchart
T ESTING C HANGES : PDSA C YCLE

All improvement will require change,

but not all change will result in
improvement.
T ESTING C HANGES

 Why test changes (even if they are already

proven elsewhere)?
 To learn how to adapt the change to the
particular conditions in your setting
 To evaluate the costs and side effects
 To minimize resistance when
implementing the change in the
organization
 Increase your belief that the change will
result in improvement
WHAT IS THE PDSA C YCLE ?

 A process improvement approach to

evaluate change
 This model allows for integration of new
and existing systems.
 This model promotes small scale rapid
cycle change over short periods of time.
 PDSA C YCLE
 Enables rapid testing and learning
 Allows for incremental testing (Instead of spending
weeks or months planning out a comprehensive change,
then putting it into practice only to find that it is
fundamentally flawed)
 Increases collaboration and sharing of information

 Allocates resources to meaningful root causes as

identified.
 Encourages accountability and follow-up on all levels

 Identifies solutions to share with other areas of your

facility/system
 Promotes a culture of safety

 Promotes team building

PDSA C YCLE
 P lan
 D o the change ACT PLAN

 S tudy the results

 A ct on the results

STUDY DO
T HE PDSA C YCLE FOR L EARNING AND
I MPROVEMENT

Act Plan
- What changes - Objective
are to be - Questions and
made? predictions (W hy?)
- Plan to carry out
- Next cycle? the cycle
(who, what, where, when)

Study Do
- Complete the analysis - Carry out the plan
of the data - Document problems
- Compare data to and unexpected
predictions observations
- Summarize what - Begin analysis
was learned of the data
 W HAT D O W E M EAN BY R APID C YCLE
I MPROVEMENT ?
 Let’s PLAN
 What do we want to improve?
 What change should we test?
 What is our anticipated
outcome?
Plan
- Objective
- Questions and
predictions (Why?)
- Plan to carry out
the cycle
(who, what, where, when)
Plan for data collection
( who what when and where)

 Theorize

MAKE A PLAN FOR

THE CHANGE
W HAT D O W E M EAN BY R APID C YCLE
I MPROVEMENT ?

 Let’s DO
 Put the theory into practice
 Map the new plan

 Carry out the change on a

small scale or pilot basis
 Evaluate change with
qualitative and quantitative
data
CARRY OUT THE
PLAN
Do
- Carry out the plan
- Document problems
and unexpected
observations
-Record data and
-Begin data analysis
W HAT D O W E M EAN BY R APID C YCLE
I MPROVEMENT ?
 Let’s STUDY
 Evaluate and determine -
the degree of success.
 Determine what, if any,
modifications are
required.
Study
- Complete the analysis
SUMMARISE WHAT of the data
- Compare data to
predictions
WAS LEARNT - Summarize what
was learned
W HAT D O W E M EAN BY R APID C YCLE
I MPROVEMENT ?

Let’s ACT Act Plan

• Adopt - What changes - Objective
are to be - Questions and
 by testing on a larger scale in made? predictions (Why?)
- Plan to carry out
a new cycle the cycle
- Next cycle?
• Adapt (who, what, where, when)

 based on lessons learned

from the test
Study Do
• Abandon - Complete the analysis - Carry out the plan
 By trying something of the data - Document problems
- Compare data to and unexpected
different predictions observations
- Summarize what - Begin analysis
was learned of the data
DETERMINE WHAT
CHANGES ARE TO BE
MADE AND CONTINUE
PDSA C YCLE - ITERATIVE LEARNING (
DEDUCTIVE AND I NDUCTIVE LEARNING APPROACHES
Deductiv
e
learning
Act Plan
- What changes - Objective
are to be - Questions and
made? predictions (W hy?)
- Plan to carry out
- Next cycle? the cycle
(who, what, where, when)

Study Do
- Complete the analysis - Carry out the plan
of the data - Document problems
- Compare data to and unexpected
predictions observations
- Summarize what - Begin analysis
was learned of the data

Inductive
learning
PDSA C YCLE - ITERATIVE LEARNING (
DEDUCTIVE AND I NDUCTIVE LEARNING APPROACHES
R EPEATED USE OF THE PDSA CYCLE
A S THE SCALE OF THE TEST INCREASES WE MOVE
FROM QUALITATIVE TO QUANTITATIVE EVIDENCE
T HE IMPROVEMENT PROCESS

Project mission Project

Ongoing monitoring team
Outcome
Future plans

Project phase Conceptual flow of process

Customer grid
Sustaining
Data
improvement
-fishbone
phase
-Pareto chart
1
1 month -run charts
5
-SPC charts
Diagnostic
Annotated run Impact 2 phase
chart SPC phase 4
charts
3
Intervention phase
A 2 months
S P D S
2 months D
S P A Plan a change
A A
Do it in a small test
D A S P Study its effects
P
S P D Act on the result
D
Sourced from: NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement
( www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf )

SPC – statistical process control

M ORE THAT ONE CYCLE AT A TIME

OUTCOMES
E XAMPLE ( Q UALITY I NSIGHTS )

Reducing MRSA
F ILLING OUT A WORKSHEET
D ID YOU GET THERE ?
 Think back to the three questions for
improvement:

• What are we trying to accomplish?

• How will we know that a change is an
improvement?
• What changes can we make that will result in an
improvement?
E XECUTING THE M ODEL FOR
I MPROVEMENT

 Form a team
 Three Questions: The
The Aim
Aim, The Measures, The
changes
The Measure
 Test changes - PDSA
Cycle
The Change
 Implement changes that
work
 Spread the changes ACT PLAN

STUDY DO
 A SSIGNMENT -20%
 Four posters- 5 persons per group.
 Identify a problem, Provide a background to the
problem- eg teenage pregnancy, suicide, still births why?
What is the magnitude of the problem in Guyana?
 Conduct a RCA.

 Apply the three step QI tool, Use the PDSA worksheet

 Prepare a Poster

 Poster Presentation- include the role each member

played.
 Assignment will be graded by three independent experts

 Poster presentation- maximum of 20 minutes to make

presentation
 Timelines- Monday December 15 th at 1500 hours
P OSTER
 Quickly orient to problem.
 A logical layout and be easy to comprehend in a couple of
minutes
 Specific sections (such as the background, RCA, Aim the
PDSA, results and conclusions) are easy to locate on the
poster
 Avoid large blocks of text and long sentences;

 The type/font size is large enough to be read at a distance of

1.5 meters (five feet). The smallest type should at least be 18
pts for text and 36 pts for headings. Try to keep your word
count as low as possible
POSTER
 Supporting images (graphs, tables, illustrations,
photographs…) can be very helpful and are often
necessary to display results. Make sure that the
images are easy to understand, and not
overloaded with information;
 Make sure there is enough contrast between the
color of the type and the poster's background.
 O PTIONS - PRESENTATION
 Poster??
 Print of slides and arrange on the wall??
 Assistance in printing?? Whether the school could
provide
 Need pins, scotch tape.

 Send me your question??

 Make sure that it is a public health issue.
G ROUPS .
Group1 Group2 Group3 Group4
Onasanya Raynell Vishyala Davon
Dwight Akima Sasha Yanita
Keisha Moya Gregory Liza
Chandra rennard Tashi Jennifer
Quincy Donna Aloric Shellon
Randy
Q UALITY C ONTROL T OOLS
 Pareto chart
 Histogram
 Process flow diagram

Quality Improvement: Problem Solving

 Check sheet

 Scatter diagram

 Control chart

 Run chart

 Cause and effect diagram

 Q UALITY T OOL

Flow Charts
Purpose: F LOW C HARTS
Visual illustration of the sequence of operations
required to complete a task
 Schematic drawing of the process to measure or improve.
 Starting point for process improvement
 Potential weakness in the process are made visual.
 Picture of process as it should be.
Benefits:
 Identify process improvements
 Understand the process
 Shows duplicated effort and other non-value-added steps
 Clarify working relationships between people and
organizations
 Target specific steps in the process for improvement.
Benefits F LOW C HARTS
• Simplest of all T OP D OWN
flowcharts
• Used for planning
new processes or Measure Analyze Improve Control
examining existing
Hardware Fleet leader
one Problem report Customer input procurement reports

• Keep people focused Hardware return Stress analysis Customer

coordination
Service reports

on the whole process Failure analysis Heat transfer Compliance Operational

statistics
analysis verification

How is it done? Life analysis Documentation

• List major steps Substantiation FAA approval

• Write them across top
of the chart
• List sub-steps under
each in order they
occur
 F LOW CHARTS
Benefits L INEAR
 Show what actually happens
at each step in the process
 Show what happens when
non-standard events occur Toolbox
 Graphically display
processes to identify
redundancies and other
wasted effort
How is it done?
 Write the process step inside
each symbol
 Connect the Symbols with
arrows showing the
direction of flow
 Q UALITY T OOL
S AMPLE L INEAR F LOW
END
5 - Action Assignee
performs detail
analysis of failure. No
Start Requests failure
analysis as needed. 11 - Fleet Analysis
Still monitors failure to
failing? ensure corrective
action is effective.
1- Fleet Analysis
Yes
utilizes data
Yes
warehouse reports to 6 - Action Assignee
create and distribute documents
a selection matrix. investigation 10 - FRB determines
required corrective
findings.
action - i.e. QAM or
supplier corrective
2 - Other Groups action.
compile data as
determined by FRB.
7 - Action Assignee 9 - FRB Categorize
reports investigation Failure: Workmanship,
results to FRB. Still component, material,
3 - FRB meets to No
analyze data. failing? maintenance, or
design. Also fleet
wide or RSU.

4 - FRB selects 8 - Fleet Analysis

candidate problems monitors failed item
for additional to ensure failure has
investigation. been corrected.
P ARETO CHART
30 28
% Complaints

25

Quality Improvement: Problem Solving

20
16
15
12 12
10
6
5 4 3
0
Loose Stitching Button Material
Threads flaws problems flaws

7 Quality Tools
P ARETO 70 (64)
C HART
60

50

Percent from each cause

40

Quality Improvement: Problem Solving

30

20
(13)
(10)
10 (6)
(3) (2) (2)
0

Causes of poor quality

H ISTOGRAM

25

Quality Improvement: Problem Solving

20
Frequency

15

10

Category

7 Quality Tools
H ISTOGRAM

40

Quality Improvement: Problem Solving

35
30
25
20
15
10
5
0 1 2 6 13 10 16 19 17 12 16 20 17 13 5 6 2 1
F LOWCHARTS
 Flowcharts
 Graphical description of how work is done.
 Used to describe processes that are to be improved.

Quality Improvement: Problem Solving

7 Quality Tools
F LOW D IAGRAMS
" Draw a flowchart for whatever you do. Until
you do, you do not know what you are doing, you
just have a job.”

Quality Improvement: Problem Solving

-- Dr. W. Edwards Deming.
F LOWCHART
Activity

Quality Improvement: Problem Solving

Yes
Decision

No

7 Quality Tools
 Quality Improvement: Problem Solving
F LOWCHART
 Quality Improvement: Problem Solving
F LOW D IAGRAMS
 Quality Improvement: Problem Solving
F LOW D IAGRAMS
P ROCESS C HART S YMBOLS

Operations
Inspection

Transportation

Delay

Storage
C ROSSING THE Q UALITY C HASM
“ Quality problems occur typically
not because of failure of
goodwill,
knowledge, effort or resources
devoted to health care, but
because
of fundamental shortcomings in
the
ways care is organized”

Trying harder will not work:

changing systems of care
will!

a new HEALTH system for the 21 st century (IOM, 2001)

 T HE C ROSSING THE Q UALITY C HASM S ERIES
To Err is Human (1999)

Crossing the Quality Chasm - A New Health System for the 21 st Century (2001)

Leadership by Example (2002)

Fostering Rapid Advances in Health Care (2002)

Priority Areas for National Action (2003)

Health Professions Education (2003)

Keeping Patients Safe – Transforming the Work Environment of Nurses (2004)

Patient Safety – Achieving a New Standard for Care (2004)

Quality through Collaboration – the Future of Rural Health (2005)

Improving the Quality of Health Care for Mental and Substance-use Conditions
(2005)