PERFORMANCE PERFORMANCE IMPROVEMENT IMPROVEMENT
““What is it and how is it done? “What is it and how is it done? “
20022002
Presented by:Presented by:
John F. Neale, DDS, MPHJohn F. Neale, DDS, MPH
CAPT, USPHS (ret.)CAPT, USPHS (ret.)
Course OutlineCourse Outline
IntroductionIntroduction NNMC PI programNNMC PI program Process/OutcomesProcess/Outcomes Dimensions/FunctionsDimensions/Functions Identifying projects/indicators for Identifying projects/indicators for
your departmentyour department ToolsTools
Learning ObjectivesLearning Objectives
At the completion of this session, At the completion of this session, participants should be able to do the participants should be able to do the following:following:
• Define & discuss the the varying definitions of qualityDefine & discuss the the varying definitions of quality• Define FOCUS-PDCA & apply to daily tasks & Define FOCUS-PDCA & apply to daily tasks &
departmental PI activitiesdepartmental PI activities• Define process/outcome & how you apply to your PIDefine process/outcome & how you apply to your PI• Define the Dimensions of Performance & apply to PIDefine the Dimensions of Performance & apply to PI• Describe various PI tools and how they are usedDescribe various PI tools and how they are used
What is QUALITY?What is QUALITY?
Meeting or exceeding the customer’s Meeting or exceeding the customer’s expectations the first time and every expectations the first time and every timetime
In Healthcare: The degree to which In Healthcare: The degree to which health services for individuals and health services for individuals and populations increase the likelihood of populations increase the likelihood of desired health outcomes and are desired health outcomes and are consistent with current professional consistent with current professional knowledgeknowledge
What is QUALITY?What is QUALITY?
How do you define quality?How do you define quality?
How do you think your How do you think your department’s customers define department’s customers define quality?quality?
CustomersCustomers
Who are your department’s customers?Who are your department’s customers?
ExternalExternal
Internal Internal
What is Performance What is Performance Improvement?Improvement?
JCAHO defines PI as: “The JCAHO defines PI as: “The continuous study and adaptation of continuous study and adaptation of a healthcare organization’s functions a healthcare organization’s functions and processes to increase the and processes to increase the probability of achieving desired probability of achieving desired outcomes and to better meet the outcomes and to better meet the needs of individuals and other users needs of individuals and other users of services.”of services.”
What Performance What Performance Improvement is Improvement is NOTNOT
Peer ReviewPeer Review Customer Satisfaction SurveysCustomer Satisfaction Surveys Quality Control ActivitiesQuality Control Activities Routine Monitoring and EvaluationRoutine Monitoring and Evaluation
All of the above activities are ways All of the above activities are ways to gather data to identify where to gather data to identify where performance can be improvedperformance can be improved
What is a Process?What is a Process?
““A goal directed, interrelated A goal directed, interrelated series of actions, events, series of actions, events, mechanisms, or steps. An mechanisms, or steps. An interrelated series of events, interrelated series of events, activities, actions, mechanisms, or activities, actions, mechanisms, or steps that transform inputs into steps that transform inputs into outputs.”outputs.”
What is an OUTCOME?What is an OUTCOME?
““The result of the performance (or The result of the performance (or non-performance) of a function(s) non-performance) of a function(s) or process(es).”or process(es).”
FunctionsFunctions
C o n tin u um o f C a re
E d u ca tion
C a re o f P a tie n ts
A sse ssm e nt o f P a tie n ts
P a tie n t R ig h ts &O rg a n iza tio n E th ics
P a tie n t - F o cu sedF u n c tio ns
S u rve illa n ce , P re ve n tion& C o n tro l o f In fe c tion
M a n ag e m e n t In fo rm a tion
H u m a n Re so u rces
E n v iro nm e n t o f C a re
L e a d e rsh ip
Im p ro v in g O rg a n iza tionP e rfo rm a n ce
O rg a n iza tionF u n c tio ns
G o ve rn a n ceM a na g e m e ntM e d ica l S ta ff
N u rs in g
S tru c tu re s w ith F u n c tio ns
JC A H OH o sp ita l A cc red ita tio n S e rv ice
Dimensions of Dimensions of PerformancePerformance
A p p ro p ria te n e ss
E ffica cy
D o in g th e R ig h t T h ing
R e sp e c t/C a ring
E ffic ie n cy
S a fe ty
C o n tin u ity
E ffe c tive n e ss
T im e lin e ss
A va ila b ility
D o in g th e R ig h t T h in g W e ll
P E R F O R M A N C E
Performance Improvement Performance Improvement toolstools
Flow chartFlow chart Cause & effect or fishbone diagramCause & effect or fishbone diagram Pareto chartPareto chart Control chartsControl charts HistogramsHistograms Scatter diagramScatter diagram Run chartRun chart
Flow ChartFlow ChartFlow Chart
Step Customer Group 1 Group 2 Group 3
Copy and paste text and objects to create your own
flowchart
Select Drawing toolbar from Options (Mac) or View
(PC).
In Excel 97-2000, use Autoshapes to draw and
connect objects.
Who
Plan
Do
Check
Act
Y
N
To copy all Flowchart "objects"
Use Cntl-Shift-A
Activity 2
Document
Decision?
Activity 1Request
for Product
Request Satisfied
Cause and Effect DiagramCause and Effect Diagram
ProcessMaterials
Machines
People
Why?
Why?
Why?
Why?
Why?
Why?
Why?
Why?
Why?
Why?
Why?
Why?
Why?
Why?
Why?
Why?
During (time), Pareto accounted for 50% of problem which was 3X higher than desired and caused customer dissatisfaction.
Problem Statement
To copy all fishbone "objects"Use Cntl-Shift-A
Pareto ChartPareto ChartSample Pareto Chart
416243641416969
109111
99%96%
92%
85%
77%
69%
56%
42%
21%
0
65
130
195
260
325
390
455
520
Internal Med& SpecClinics
AncillaryDepts
Family Med Walk-in OB/GYN Emerg Med Peds Nursing Clinic Clerks OTHER
Department
Num
ber o
f Err
ors
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
n=520
Control ChartControl ChartP Chart for Broken Appointments
CL=0.23
0
0.1
0.2
0.3
0.4
0.5
0.6
Date/Time/Period/Number
Prop
ortio
n of
app
oint
men
ts m
isse
d
P
UCL
+2 sigma
+1 sigma
Average
-1 sigma
-2 sigma
LCL
HistogramHistogramSample Histogram
0
0.5
1
1.5
2
2.5
3,099
to
3,170
3,170
to
3,241
3,241
to
3,312
3,312
to
3,383
3,383
to
3,454
3,454
to
3,525
3,525
to
3,596
3,596
to
3,667
3,667
to
3,738
3,738
to
3,809
3,809
to
3,880
3,880
to
3,951
3,951
to
4,022
V alues
n=24
Sigma=
261.4
Max=3,
950.0
Min=3,
100.0
Mean=
3,535Median=
3,525
Scatter DiagramScatter DiagramSample Scatter Diagram
-0. 5
0
0. 5
1
1 . 5
0 5 00 1 000 1 5 00 2 000 2 5 00 3 000 3 5 00 4 000 4 5 00
C a l o ri e s c o n su me d
n =1 4
Run ChartRun Chart
0
2
4
6
8
10
12
Series1
The PI MindsetThe PI Mindset
Doing whatever it takes to ensure• the best service• the best outcome• customer satisfaction• employee satisfaction• financial success
The PI MindsetThe PI Mindset
Continuously examining processes and seeking opportunities for improvement that will:• benefit customers• improve our results• make us more efficient• maximize the quality of everything we do
It is no longer “if it ain’t broke, don’t fix It is no longer “if it ain’t broke, don’t fix it,” it is now “even if it ain’t broke, it,” it is now “even if it ain’t broke, improve it.”improve it.”
If 99.9% were good If 99.9% were good enoughenough
Every year there would be:
20,000 prescription errors made
15,000 newborn babies dropped during delivery
32,000 missed heartbeats per person.
Every month there would be:
1 hour of unsafe drinking water
Every week there would be:
500 incorrect surgical procedures performed
Every day there would be:
2 unsafe landing at O’Hare airport
Every hour there would be:
22,000 checks deducted from the wrong bank accounts.
16,000 pieces of mail lost by the US Postal Service
Hospital Corporation of America Hospital Corporation of America Performance Improvement Performance Improvement
MethodologyMethodology
FF ind an opportunity for ind an opportunity for improvementimprovement
OO rganize a team rganize a team
CC larify the process larify the process
U U nderstand variations nderstand variations
SS elect the elect the improvement improvement
P lanP lan
D oD o
C heckC heck
A ctA ct
Find an opportunity to Find an opportunity to improveimprove
How or where do we find opportunities for How or where do we find opportunities for improvement?improvement?• Ongoing monitoring activities such as: Ongoing monitoring activities such as:
Safety/RM/IC/PISafety/RM/IC/PI• Customer feedback (patient or staff Customer feedback (patient or staff
satisfaction surveys)satisfaction surveys)• OutcomesOutcomes• Strategic PlanningStrategic Planning• New servicesNew services
Organize a teamOrganize a team
Size – large enough to include all Size – large enough to include all disciplines or departments involved, but disciplines or departments involved, but small enough to be workable.small enough to be workable.
Membership – include all Membership – include all knowledge/skills/departments needed to knowledge/skills/departments needed to address the process in questionaddress the process in question
Resources – money, time, materials, Resources – money, time, materials, training, etc.training, etc.
roles/responsibilities – see team roles/responsibilities – see team guidelines in the Service Unit PI planguidelines in the Service Unit PI plan
Clarify current knowledge Clarify current knowledge of the processof the process
Break the process down into its component Break the process down into its component parts or steps in order to better parts or steps in order to better understand how it works and to find areas understand how it works and to find areas where the process varies from its where the process varies from its purpose.purpose.• Flow chartFlow chart• Cause & effect or fishbone diagramCause & effect or fishbone diagram• ResearchResearch• LiteratureLiterature• Past experiencePast experience
Potential Sources of Variation - Potential Sources of Variation - Why things don’t turn out as Why things don’t turn out as plannedplanned
o People *Not trained or oriented to a procedure
*Forget to perform a step in a complex process
o Machinery *Machine malfunctions
*Different machines used
o Materials *People use different procedures
o Methods *Missing steps or unpredictable sequence
or tasks
o Conditions *Different environments such as changes in
weather, shift work
Understand causes of Understand causes of process variationprocess variation
Collect and analyze data on the various Collect and analyze data on the various steps in the process identified in the steps in the process identified in the previous step to see where problems previous step to see where problems or inefficiencies occuror inefficiencies occur• Pareto diagrams – the 80/20 rulePareto diagrams – the 80/20 rule• Run chartsRun charts• Control chartsControl charts• HistogramsHistograms
Select the step(s) in the Select the step(s) in the process that will be process that will be improvedimproved
Use the results your “C” and “U” Use the results your “C” and “U” activities to identify the step or activities to identify the step or steps in the process that steps in the process that contribute the majority of the contribute the majority of the process variation.process variation.
PlanPlan
How will the improvement be done?How will the improvement be done? Who will do it?Who will do it? What is the Timeline for implementation?What is the Timeline for implementation? What Outcomes are desired?What Outcomes are desired? How much will it CostHow much will it Cost What Training or Education is needed?What Training or Education is needed? Is a Trial Period or Pilot Program Is a Trial Period or Pilot Program
indicated?indicated? What data will need to be collected to What data will need to be collected to
monitor the changes?monitor the changes?
DoDo
Implement the PlanImplement the Plan Schedule needed trainingSchedule needed training Collect the needed dataCollect the needed data Pilot Test the plan if appropriatePilot Test the plan if appropriate
CheckCheck
Collect and Analyze data to Collect and Analyze data to determine the following:determine the following:• Did the action work?Did the action work?• Did you achieve the desired Did you achieve the desired
outcomes?outcomes?• Is the process working as predicted, Is the process working as predicted,
or is further refinement needed?or is further refinement needed?
ActAct
Change processes or further tweak the Change processes or further tweak the Plan if needed to achieve desired Plan if needed to achieve desired outcomesoutcomes
Repeat the PDCA cycle as needed to Repeat the PDCA cycle as needed to maximize improvementmaximize improvement
Finalize and implement full scaleFinalize and implement full scale Develop New flow chart and/or New P/P Develop New flow chart and/or New P/P
for the redesigned processfor the redesigned process Educate/orient patients and staffEducate/orient patients and staff Story board & report to communicate Story board & report to communicate
results to staff and customersresults to staff and customers
Identifying opportunities for Identifying opportunities for improvement in your improvement in your departmentdepartment
OutcomesOutcomes ProcessProcess Strategic PlanningStrategic Planning PrioritizingPrioritizing Staff/Customer feedbackStaff/Customer feedback
