QI & PDSA for Public Health
Debra Tews, MAMichigan Dept. of Community
HealthPPHC Pre-Session
Bay City, MI10/26/2010
Plan
Do
Study
Act
1
A brief overview of QI including PH definitions for Quality and QI
An intro to PDSA from Michigan’s Quality Improvement Guidebook
An intro to QI tools
Today’s Focus
2
What is Quality in Public Health?
“Quality in public health is the degree to which policies, programs, services and research for the population increase desired health outcomes and conditions in which the population can be healthy.”
Public Health Quality Forum 3
So How Can One Define Quality Improvement for
Public Health?
Use of a deliberate and defined improvement process, such as Plan-Do-Check [Study]-Act, which is focused on activities that are responsive to community needs and improving population health. It refers to a continuous and ongoing effort to achieve measurable improvements in the efficiency, effectiveness, performance, accountability, outcomes, and other indicators of quality in services or processes which achieve equity and improve the health of the community.
Accreditation Coalition 20094
Why QI in Public Health?
QI Can:Reduce costs and
redundancyEliminate wasteStreamline
processesEnhance ability to
meet service demand
Increase customer satisfaction
Improve outcomes
Tough Economic Tough Economic Times Require a Times Require a
Different Different Approach!Approach!
5
Is it QI or is it QA?
Quality Improvement
GOES BEYOND Quality
Assurance!
6
Doing Both?
QUALITYASSURANCE relates to Monitoring & Compliance.
It GUARANTEES quality.
Standards met? Deficiencies corrected?
QA is . . . . . reactive!
QUALITY IMPROVEMENT relates to Learning & Improving.
It RAISES quality.
Quality can’t always be assured. Ongoing efforts to identify opportunities for improvement are needed. QI relies on measurement & data-driven decisions to improve outcomes.
QI is . . . . . proactive!7
Principles of QIFrom the Public Health Memory Jogger
Pocket Guide of QI Tools:
Develop a strong customer focus
Continually improve all processes
Involve employees
Mobilize both data and team knowledge to improve decision making
8
Three Key Questions !!!1. What are we
trying to accomplish?
2. How will we know that a change is an improvement?
3. What changes can we make that will result in improvement?
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Change Vs. Improvement
Edwards Deming: Of all changes observed, about 5% were improvements, the rest at best were illusions of progress!
To move beyond illusions of progress, a QI method (PDSA) and QI tools are needed.
Embracing Quality in Local Public Heath: Michigan’s QI Guidebook explains the PDSA method and suggests tools. 10
Snapshot: Plan-Do-Study-Act (PDSA)
Plan
DoStudy
Act
11
Some Common Tools of QI
Process Mapping
Cause and Effect/Fishbone Diagrams
Five Whys
Run Charts
Pareto Charts
Check Sheets
Understand Your Process Understand Your Process & Make Sense of Your & Make Sense of Your Data!Data!
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QI: Assembling the Pieces
Listen to LHD customers
Use data to make data-driven decisions
Continually improve processes in your LHD
Use recognized QI methods and tools
Work together; a team approach is best.
Ask the 3 Key Questions!13
What Do Users Say?
“We now have staff eager to use the same tools/methods to evaluate performance and make improvements in other areas of our work” MLC-3 LHD
“The PH focus of the Guidebook helps with the application of QI methods; it becomes ‘real’ for participants . . . we can ‘look through our public health windows’” Allegan LHD
“For any PH agency interested in learning QI and how PH can apply these principles/methods, I would recommend they start with this Guidebook” Saginaw LHD
“The Guidebook has been a road map for our team as we navigate our way down this new path of improving our processes” MMDHD
“I refer to the Guidebook often even though I know the steps” MI
Mentor
14
There’s More . . . “The Guidebook has been
incredibly useful for QI work, serving as the primary textbook for teaching QI throughout the department” MI Mentor
“The Guidebook helps with capacity building . . . it would not be possible to spread QI methodologies easily without it” Muskegon LHD
“The Guidebook is used in our QI meetings as an effective discussion and clarification tool; it generates comfort levels” Allegan LHD
“The Guidebook is the glue that
holds the whole effort together”
MI Consultant
15
QI Resources for Public Health
www.accreditation.localhealth.net and www.phf.org
16
Another Resource for QI Tools
http://www.langfordlearning.com
17
Using QI Tools
There are many tools that can help you meet the goal of
improving your work processes and services
18
PDSA and Using QI Tools
Using tools as part of the PDSA cycle Some tools will be useful in the planning
stage Others will help you to implement your QI
project And/or will help you study the impact of
your process change
19
Useful QI Tools
Process Mapping Check Sheets Pareto Charts Cause and Effect Diagrams
Fishbone Diagrams The 5 Whys
Run Charts
20
PROCESS MAPPING
Sometimes called Flow Charting…
21
QI Works on Existing Processes
A process is a series of steps or actions performed to achieve a specific purpose
It describes how things get done
Your work is made up of many processes
22
What is a Process Map?
A pictorial representation of the sequence of actions that describe a process
23
Why is Process Mapping Important?
It’s an opportunity to learn about the work being done
It involves documenting the obvious, as well as all that which goes without saying
Helps to discover inconsistencies Most processes today are undocumented Helps to control the “evolution” of a
process
24
Process Maps are Used To
Document the way we do our work
Analyze and improve on processes
25
How Do We Prepare to Process Map? (1)
Assemble the QI Team Agree on the process you want to
document Agree on the purpose of the process Agree on beginning and ending points
26
How Do We Prepare to Process Map? (2)
Agree on the level of detail to be displayed
Begin by preparing an outline of steps
Identify and recruit other people that should be involved
27
What are the Symbols Used in Process
Mapping? Start and End of the Process:
A process Activity:
A process Decision:
A Break in the process:
28
Helpful Tips to Keep in Mind
Process Map what is, the actual process
Process Mapping is dynamic
Clearly define the boundaries of the process
29
Example: Process Map of Conference Approvals
Process
Do a Process Map that documents the process used to obtain approval to attend conferences.
30
The Simplest Map
31
A More Detailed Map
32
Mapping the True Process
33
More Useful Tips
Other exercises can help you identify the process you want to map
There is no single right way to Process Map
Process Mapping is not an end in itself Process Maps, once created, can be useful
in a variety of settings
34
Summing Up Process Mapping
We Process Map to learn
We Process Map to document a baseline of performance
We Process Map to discover where data may be hiding
35
QI Scenario: Process Mapping Exercise
Highlighting Excellence Health Department
Improvement sought-Improved Customer Satisfaction with health department services
Improve performance connecting clients with services
Please take a moment to read the Scenario write-up that is in your handouts
36
37
CHECK SHEETS
Observing a Process
38
What is the Purpose of a Check Sheet?
To turn observational data into numerical data From records Newly collected
To find patterns using a systematic approach that reduces bias
Use check sheets when data can be observed or collected from your records
39
Check Sheets Step by Step (1)
Step 1 Decide what to observe Define key elements Establish shared understanding
Step 2 Identify where, when, & how long Think about confounding factors
o That you want to eliminateo That you want to study
40
Check Sheets Step by Step (2)
Step 3 Design your check sheet Develop a protocol
41
Problem/Project Name: Name of Observer: Other:
Location of Data Collection: Dates of Observation:
Dates of Data Collection Total
Event
A
B
C
Total Grand Total
Check Sheets Step by Step (3)
Step 4 Identify and train your observers Practice & adjust
Step 5 Collect data Review & adjust
Step 6 Summarize data across observations &
observers Study the results
42
Tips for Using Check Sheets
Make sure you’re getting clean data Define, train, check, adjust, & repeat! Consider and address potential sources of bias
Use “other” categories sparingly
Strike a balance Fine vs. inclusive categories Few vs. many categories
43
Check Sheet Exercise (1) When customers report dissatisfaction with LHD
services, staff track the primary reason for customer complaints
They believe dissatisfaction may be caused by several conditions that they can document
Use your handout to set up the check sheet for this situation
44
Check Sheet Exercise (2)
45
Problem: Client Dissatisfaction Name: A. Martin Time: 9-5
Location: Excellence Health Department’s Customer Service Department
Dates: Week of 9/6, 9/13, 9/20, 9/27, 10/4, 10/11, 10/18
DateTotal
Reason 9/6 9/13 9/20 9/27 10/4 10/11 10/18
Service not offered 3 4 3 2 3 4 0 19
Service was difficult to access
10 12 6 3 0 0 0 31
Long wait times 0 0 2 3 6 1 0 12
Poor staff interaction
2 2 1 2 0 0 1 8
Inaccurate information
2 3 1 2 1 0 1 10
Total 17 21 13 12 10 5 2 80
PARETO CHARTS
80% of the problem
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What is the Purpose of Pareto Charts? (1)
To identify the causes that are likely to have the greatest impact on the problem if addressed
“80% of the effects come from 20% of the causes”
To bring focus to a small number of potential causes
47
What is the Purpose of Pareto Charts? (2)
To guide the process of selecting improvements to test
Use when you have, or can collect, quantitative or numeric data on several potential causes
48
Pareto Charts: Step by Step (1)
Step 1 Identify potential causes of the problem you
wish to study
Step 2 Develop a method for gathering your data
o Historical datao Collection of new data
49
Pareto Charts: Step by Step (2)
Step 3 Collect your data Each time the problem occurs, make note of
the primary cause
Step 4 Order your results & calculate the percentage
of incidents that fall into each category
50
Pareto Charts: Step by Step (2)
Step 5: Display your data on a graph….
51
Pareto Charts: Step by Step (3)
Step 6 Make sense of your results by examining your
data
52
Tips for Using Pareto Charts
You’ll only learn about causes that you investigate - be inclusive!
Check and double check your data
Results can be used in more than one way and they can be used differently at different points in time
53
Pareto Chart Exercise
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Problem: Client Dissatisfaction Name: J. Heany Time: 9-5
Location: Excellence Health Department’s Customer Service Department
Dates: Week of 9/6, 9/13, 9/20, 9/27, 10/4, 10/11, 10/18
DateTotal
Reason 9/6 9/13 9/20 9/27 10/4 10/11 10/18
Service not offered 3 4 3 2 3 4 0 19
Service was difficult to access
10 12 6 3 0 0 0 31
Long wait times 0 0 2 3 6 1 0 12
Poor staff interaction
2 2 1 2 0 0 1 8
Inaccurate information
2 3 1 2 1 0 1 10
Total 17 21 13 12 10 5 2 80
BREAK TIME (10 MINUTES)
55
CAUSE & EFFECT DIAGRAMS
Moving from treating symptoms to treating causes
56
Seeing Beyond the Tip of the Iceberg
57
The Symptom
The Cause
Problem Solving & Root Cause
When confronted with a problem most people like to tackle the obvious symptom and fix it
This often results in more problems
Using a systematic approach to analyze the problem and find the root cause is more efficient and effective
Tools can help to identify problems that aren’t apparent on the surface (root cause)
58
What is the Purpose of Fishbone Diagrams?
To identify underlying or root causes of a problem
To identify a target for your improvement that is likely to lead to change
59
Construction of a Fishbone Diagram (1)
Draw an arrow leading to a box that contains a statement of the problem
60
Effect/Problem
Construction of a Fishbone Diagram (3)
Draw smaller arrows (bones) leading to the center line, and label these arrows with either major causal categories or process categories
61
Cause 1
Effect/Problem
Cause 2
Cause 3
Cause 4
Construction of a Fishbone Diagram (2)
Then for each cause identify deeper root causes
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Cause 1
Effect/Problem
Cause 2
Cause 3
Cause 4
Berrien County FishboneRoot causes for lack of BCHD general PH articles
63
Minimal articles
Effect
Causes
People/StaffMedia Relations
TopicsProcess
No long-term arrangements
Secluded media team
One writer, poor health
Articles for events only
Confusion/duplication
No time to develop
Sporadic writing
Another Fishbone Diagram
64
Obese Children
Life Style
PolicesEnvironment
TV ViewingNo Time For Food Prep
No Outdoor Play
Unsafe
Juices
Bottle Pacifier
Less Fruits and Veg.
Less Income Maternal
Choices
Less Exercise @ School
Curriculum
No Sidewalks
Unhealthy Food Choices
Few Community Recreational Areas or Programs
Built Environment For Strollers Not Toddling
Less Indoor Mobility
TV Pacifier
UnsafeHousing
Sodas/Snacks
Decreased Breast Feeding
Early Feeding Practices
Genetics
Syndromes
Genes
Pre NatalPractices
Excess Maternal Weight Gain
Over Weight Newborn
Over WeightPre School
Tips for Using Fishbone Diagrams
Find the right problem or effect statement
Find causes that make sense and that you can impact
Make use of your results
65
Fishbone Diagram Exercise
Create a Fishbone Diagram using the Pareto Chart you made in your last exercise
Listing effect(s), major causes, and data related causes (root) on the diagram
It is OK if data related causes show up in more than one major cause area
66
THE 5 WHY’S
More Cause and Effect
67
What is the 5 Whys?
A question asking method used to explore the cause/effect relationships underlying a particular problem
The goal is to determine the ROOT CAUSE of a problem
68
An Example of the 5 Whys
My car will not start. (the problem) Why? - The battery is dead. (first why) Why? - The alternator is not functioning. (second why) Why? - The alternator belt has broken. (third why) Why? - The alternator belt was well beyond its useful
service life and has never been replaced. (fourth why) Why? - I have not been maintaining my car according to
the recommended service schedule. (fifth why, root cause)
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The 5 Whys and Hows
This technique is easy to use and apply But it requires skill to use The answers should be grounded in
observation and data Avoid deductive reasoning with this
technique
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Limitations of the 5 Whys
Does not always lead to root cause identification
Can lead to bad judgment calls when used in the absence of data
Process changes are then made that address the wrong root cause
This can make the situation worse
71
Use Data to Overcome Limitations
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Summing Up Cause and Effect
Use Fishbone and 5 Whys to explore and graphically display in increasing detail all of the possible causes related to the problem
Use Fishbone and 5 Whys to find dominant causes rather than symptoms
Use Fishbone and 5 Whys to identify the root cause of the problem we seek to improve
73
5 Whys Exercise
Perform 5 whys on the two causes that received the greatest number of responses as shown in the Pareto Chart (Service was difficult to assess and Service not offered).
74
RUN CHARTS
Tracking Process Performance
75
What is the Purpose of Run Charts?
To study data measured over time
Run charts help to: Study the performance of a process Identify trends Measure change in performance following a
change in process
Use when you have, or can collect: Quantitative data Data measuring the performance of a process Data collected over time
76
Run Charts: Step by Step (1)
Step 1 Decide what data you need Determine the timeframe Determine the number of data collection points
Step 2 Gather your data
77
Run Charts: Step by Step (2)
Step 3 Graph your data
o On the Y-axis, set up a scale that corresponds with your measure
o On the X-axis, set up a scale that corresponds with your measurement timeframe
o Plot your data on the chart, placing one dot at each measurement point
o Draw a line through your dotso Calculate the mean score and draw a line at the
meano Mark the timing of your process change on the line
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Example Run Chart
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Number of New BCCCP Clients by Month in 2007 and 2008
05
101520253035404550
Janu
ary
Febru
ary
Mar
chApr
ilM
ayJu
ne July
Augus
t
Septe
mbe
r`
Octobe
r
Novem
ber
Decem
ber
Month
Nu
mb
er o
f N
ew C
lien
ts
2007 2008
Run Charts: Step by Step (3)
Step 4 Make sense of your results by examining your
datao Does the mean reflect an appropriate level of service
or outcome of your process?o Is there a trend that should be investigated?o Do you see a shift in your data? Are there 8 or more
consecutive points on one side of the center line?o Do you see a trend in your data? Are there six
consecutive jumps in the same direction (up or down)?
o Do you see a pattern in your data? Does a pattern recur eight or more times in a row?
80
Tips for Using Run Charts
Every process will have some variation
Be sure to track data over a long enough period of time
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Run Chart Exercise
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Month Response rate in ‘08
Response rate in ‘09
January 2 1.8
February 2.3 1.9
March 2.2 2
April 2.5 3.5
May 2.6 3.8
June 2.2 3.9
July 2.1 4
August 1.9 4.1
September 1.9 4.3
October 2 4.5
November 2.1 4.5
December 2.2 4.5
Quality Improvement Resources
Michigan’s QI Guidebook
The Public Health Memory Jogger II
Quality Improvement Resources Handout
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Working Session
Bringing QI into your Programs
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Working Session Exercise 1
Identify Two WIC Program or Health Division Areas where QI Processes would be Helpful
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Working Session Exercise 2
Identify which Front Line, Middle Management and Administrative Staff need to be Involved in QI Problem Solving in the work processes you prioritized for improvement in Exercise 1
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Working Session Exercise 3
Four Essential Elements to creating an internal environment supportive to QI: Policy Leadership Core Values Resources
Identify Three Key Means to Build Support for and Initiate QI Processes in Your Organization
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Q & A
Please feel free at this time to email any questions you may
have about the training and/or exercises
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BREAK – 10 minutes Upcoming Events:
February 23 – WIC Coordinator Webcast March 6 – Anthropometric Training, Flint March 7 – Lab Training, Flint March 21,22 – CPA Training, Grand Rapids
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BREAK – 10 minutes
2012 WIC Training & Educational Conference
Make your Hotel Accommodations NOW…
events.mphi.org
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