health pei pursuing quality & excellence · 2018. 5. 3. · overall health pei initiatives...

Health PEI Pursuing Quality & Excellence

Quality Board Standard

Version 11 June 1, 2016

Quality Board Standard Work

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Table of Contents 1.0 Introduction ....................................................................................................................................................................................................... 4

2.0 Components to a Health PEI Quality Board ....................................................................................................................................................... 4

3.0 Quality Huddles .................................................................................................................................................................................................. 7

4.0 Appendix of PQ&E Documents .......................................................................................................................................................................... 8

4.1 A3 Report ....................................................................................................................................................................................................... 9

4.2 Communication Plan .................................................................................................................................................................................... 10

4.3 Flow Map ..................................................................................................................................................................................................... 11

4.4 Measurement Plan ....................................................................................................................................................................................... 12

4.5 Pareto Chart(s) ............................................................................................................................................................................................. 13

4.6 Run Chart(s) ................................................................................................................................................................................................. 14

4.7 PDSA Sheet(s) ............................................................................................................................................................................................... 15

4.8 Control Plan.................................................................................................................................................................................................. 16

4.9 Safety Cross .................................................................................................................................................................................................. 17

4.10 Value Stream Map at the Unit/Service Level ............................................................................................................................................... 18

4.11 Value Stream Map at the Provincial Unit/Service Level .............................................................................................................................. 19

4.12 Health PEI Strategic Plan on a Page ............................................................................................................................................................. 20

4.13 Quality Improvement Team Indicators ........................................................................................................................................................ 21

4.14 Visit Pyramid ................................................................................................................................................................................................ 22


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4.15 Required Organizational Practises……………………………………………………………………………………………………………………………………………………………23

Revision History ....................................................................................................................................................................................................... 24


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1.0 Introduction The purpose of this document is to define standard work for the Quality Boards in facilities across Health PEI.

Displaying current, relevant and consistent information on unit Pursuing Quality & Excellence (PQ&E) initiatives and overall Health PEI

improvement information for staff and management is important to ensure consistency in expectations, goals and processes. Identifying and

displaying relevant information in appropriate settings and in a consistent manner throughout Health PEI will improve communication of critical

project information amongst teams and management.

A Quality Board is the medium through which project teams can continuously monitor project and system performance visually. Quality Boards

show the links between the analysis that team complete and the improvements implemented. They also allow all members of the team to see

how their ideas and efforts are contributing to the overall goal and project.

2.0 Components to a Health PEI Quality Board Quality Boards are placed on a wall within a unit/service and can be a corkboard, whiteboard, or just space on a wall. It is designed to

communicate to staff and management, critical information regarding the quality improvement including project specifics and provincial

monitoring metrics. Quality Boards should be located in an area where they are easily visible and accessible for staff and management and

should be in an area where a group congregating will not impede traffic flow. Locations such as staff rooms, areas close to nursing desks, or

hallways/wide corridors are fantastic spots for Quality Boards.

The Quality Board is divided into thirds, 20” across and 36” high. The first two thirds on the left hand side of the board is dedicated to

information regarding a specific PQ&E initiative, consider the local side of the board. The remaining third is dedicated to information relating to


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overall Health PEI initiatives and/or provincial metrics. All Quality Boards will have a Pursuing Quality & Excellence title across the top, the name

of the unit/facility/service above the local side of the board, and Health PEI Overview over the provincial side of the board.

Figure 1 is an example of a quality board.


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Figure 1: Example of Health PEI Quality Board


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The normal contents of a quality board are listed below, along with the suggested standardized layout. Figure 2 outlines the contents which

should be posted on a quality board. For details documents related to PQ&E projects, see Appendix A

Figure 2: Content List of Quality Board

Pursuing Quality & Excellence Quality Board

Your Unit Quality Improvement Health PEI

UNIT METRICS

- Quality Improvement Team

Indicators

- Value Stream Map metrics

- Safety Cross

- Run Charts

- Pareto Charts

UNIT PLANS

- QIT Work plan

- PQ&E project timelines

- SHN Bundles

- CMOC Work

- Unit initiatives

HEALTH PEI STRATEGIC PLAN ON A PAGE

PROVINCIAL METRICS

- Value Stream Map metrics at provincial level

- QIT

- Patient Satisfaction

- Staff Satisfaction

VISIT PYRAMID

PROJECT/QIT WORK

- A3 or Project Charters

- Communication plans

- Measurement plans

- Plan-Do-Study-Act Cycles

- Control plans

- Spread plans

CELEBRATION POINTS

- Success points

- Good news stories

- Patient stories

SUSTAINING MEASURES

- Continued measures to ensure

sustainability


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3.0 Quality Huddles In conjunction with Quality Boards, Quality Huddles are a quick standup meeting for all staff in the area to communication about the

performance of the area and to update on any PQ&E projects.

To conduct a Quality Huddle, all staff meets around the Quality Board and the Manger, Clinical Lead or Clinical Educator lead the discussion.

Huddle Agenda 1. Discuss and share the information necessary for the day in an exception reporting format 2. Discuss the safety cross

Discuss Safety Cross target and progress

Reasons the measures or targets are not met on either the measures or safety cross 3. Discuss any and all projects that are taking place. What is going on, who is doing what etc.

Overview of the A3 to highlight and updates and/or changes

Overview of the Communication Plan to highlight and updates and/or changes

Progress update on project, measures

Review current PDSA cycles and the action plans for each PDSA and update accordingly

Who should participate? All Staff

Length of time 5- 10 min

How often? Quality Huddles should occur daily at the start of shift

or set time agreed upon by staff


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4.0 Appendix of PQ&E Documents


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4.1 A3 Report

A3 Page 1 A3 Page 2

Unit/Service VSM

Provincial Health

PEI VSM for Unit/

Service

PEI Strategic Plan

2013-2016 on a

Page

Quality Improvement

Team Indicators

Quality Improvement

Team Indicators

Pareto Charts

Communications

Plan

Page 1

Communications

Plan

Page 2

PDSA Sheets

Picture of Process

Map

Pursuing Quality & Excellence

Measurement Plan

Run Charts

Safety Cross (Monthly)

Control Plan

Name of Unit/Facility Health PEI Overview

Visit Pyramid

ITEM NAME

A3 Report

WHAT ITEM INDICATES

The A3 Report illustrates and measures project progress and status. The A3 enables a team to keep within scope of the project and to provide updates to other staff who may be interested in the project progress.

HOW TO UPDATE ITEM

The A3 Report is updated after each phase of the DMAIC cycle to illustrate progress in the project. The updated A3 is posted to the Quality Board after each team day.

WHEN TO USE ITEM

The A3 Report is used as the key communication tool during the DMAIC cycle and should be reviewed at each Quality Huddle.


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4.2 Communication Plan

A3 Page 1 A3 Page 2

Unit/Service VSM

Provincial Health

PEI VSM for Unit/

Service

PEI Strategic Plan

2013-2016 on a

Page

Quality Improvement

Team Indicators

Quality Improvement

Team Indicators

Pareto Charts

Communications

Plan

Page 1

Communications

Plan

Page 2

PDSA Sheets

Picture of Process

Map


Measurement Plan

Run Charts


Control Plan


Visit Pyramid

ITEM NAME

Communication Plan

WHAT ITEM INDICATES

The Communication Plan outlines what questions staff may have about the project and also identifies how the project and questions are to be communication. Several different mediums are often applied to ensure understanding.

HOW TO UPDATE ITEM

The Communication Plan is updated after each phase of the DMAIC cycle to communication questions staff may have in each phase of the project. The updated plan is posted to the Quality Board after each team day.

WHEN TO USE ITEM

The Communication Plan is used in each phase of the DMAIC cycle and should be reviewed during the Quality Huddle.


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4.3 Flow Map

A3 Page 1 A3 Page 2

Unit/Service VSM

Provincial Health

PEI VSM for Unit/

Service

PEI Strategic Plan

2013-2016 on a

Page

Quality Improvement

Team Indicators

Quality Improvement

Team Indicators

Pareto Charts

Communications

Plan

Page 1

Communications

Plan

Page 2

PDSA Sheets

Picture of Process

Map


Measurement Plan

Run Charts


Control Plan


Visit Pyramid

ITEM NAME

Flow Map (or picture of)

WHAT ITEM INDICATES

A Flow Map is a type of process map which outlines the steps in a defined process. A flow map is usually created in the Define phase of a project to help to identify where waste or improvements can be made in the process.

HOW TO UPDATE ITEM

A Flow Map is updated when a particular step or the process itself has changed. Future state maps can also be drawn in the context of a project to help identify what a process should look like. The flow map can be a digital picture of the actual larger map created by the team at their event day.

WHEN TO USE ITEM

The Flow Map is used in the Define phase, and may be used at the Improve phase as well to determine what the future state should look like.


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4.4 Measurement Plan

A3 Page 1 A3 Page 2

Unit/Service VSM

Provincial Health

PEI VSM for Unit/

Service

PEI Strategic Plan

2013-2016 on a

Page

Quality Improvement

Team Indicators

Quality Improvement

Team Indicators

Pareto Charts

Communications

Plan

Page 1

Communications

Plan

Page 2

PDSA Sheets

Picture of Process

Map


Measurement Plan

Run Charts


Control Plan


Visit Pyramid

ITEM NAME

Measurement Plan

WHAT ITEM INDICATES

The Measurement Plan identifies the “who, what, where, when and how” measures will be collected within the scope of the project. There are usually a minimum of two measurement periods: (1) Baseline measure, and (2) Post Improvement measure.

HOW TO UPDATE ITEM

The Measurement Plan is updated for each measurement period that occurs within the project so that the team is clear on the details.

WHEN TO USE ITEM

The Measurement Plan is used in the Measure and Improve phase.


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4.5 Pareto Chart(s)

A3 Page 1 A3 Page 2

Unit/Service VSM

Provincial Health

PEI VSM for Unit/

Service

PEI Strategic Plan

2013-2016 on a

Page

Quality Improvement

Team Indicators

Quality Improvement

Team Indicators

Pareto Charts

Communications

Plan

Page 1

Communications

Plan

Page 2

PDSA Sheets

Picture of Process

Map


Measurement Plan

Run Charts


Control Plan


Visit Pyramid

ITEM NAME

Pareto Chart(s)

WHAT ITEM INDICATES

A Pareto Chart is a line and bar graph represented together which highlights the most common sources of defects or the highest occurring defects.

HOW TO UPDATE ITEM

A Pareto Chart is created using the baseline measure, and at least a post improve Pareto Chart is also created. Pareto charts are used when defects or frequencies of something are measured.

WHEN TO USE ITEM

A Pareto Chart is used in the Analyze phase and measures should be reviewed during the Quality Huddle to determine if the team is meeting targets.


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4.6 Run Chart(s)

A3 Page 1 A3 Page 2

Unit/Service VSM

Provincial Health

PEI VSM for Unit/

Service

PEI Strategic Plan

2013-2016 on a

Page

Quality Improvement

Team Indicators

Quality Improvement

Team Indicators

Pareto Charts

Communications

Plan

Page 1

Communications

Plan

Page 2

PDSA Sheets

Picture of Process

Map


Measurement Plan

Run Charts


Control Plan


Visit Pyramid

ITEM NAME

Run Chart(s)

WHAT ITEM INDICATES

A Run Chart is a graph that displays data that is time sequenced. Run charts are used to determine if a process shifts over time.

HOW TO UPDATE ITEM

A Run Chart is created using the baseline measure and the post improve data is typically added to the same graph to easily identify if there has been a shift in the process. These can be handmade or electronically created. Run charts are used only when we are measuring over time.

WHEN TO USE ITEM

A Run Chart is used in the Analyze phase and measures should be reviewed during the Quality Huddle to determine if the team is meeting targets.


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4.7 PDSA Sheet(s)

A3 Page 1 A3 Page 2

Unit/Service VSM

Provincial Health

PEI VSM for Unit/

Service

PEI Strategic Plan

2013-2016 on a

Page

Quality Improvement

Team Indicators

Quality Improvement

Team Indicators

Pareto Charts

Communications

Plan

Page 1

Communications

Plan

Page 2

PDSA Sheets

Picture of Process

Map


Measurement Plan

Run Charts


Control Plan


Visit Pyramid

ITEM NAME PDSA Sheet(s)

WHAT ITEM INDICATES

PDSA stands for Plan-Do-Study-Act, which refers to a rapid test of change. It is through PDSAs that our improvements are implemented. For each improvement, a PDSA sheet will detail what the plan is, what needs to occur in order to implement the plan, a review of how the implementation is going, and if any changes need to occur, it will identify and outline those changes.

HOW TO UPDATE ITEM

Each PDSA is updated as the implementation of the improvement progresses. Should a PDSA need another round or a restart, a PDSA ramp can be initiated. These can be updated on the board with pen or pencil as activities are completed by the team.

WHEN TO USE ITEM

PDSA Sheets are used in the Improve phase and should be reviewed during the Quality Huddle to when improvements are being implemented.


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4.8 Control Plan

A3 Page 1 A3 Page 2

Unit/Service VSM

Provincial Health

PEI VSM for Unit/

Service

PEI Strategic Plan

2013-2016 on a

Page

Quality Improvement

Team Indicators

Quality Improvement

Team Indicators

Pareto Charts

Communications

Plan

Page 1

Communications

Plan

Page 2

PDSA Sheets

Picture of Process

Map


Measurement Plan

Run Charts


Control Plan


Visit Pyramid

ITEM NAME

Control Plan

WHAT ITEM INDICATES

A Control Plan identifies what controls have been implemented, what type of control they are, validation to ensure that the control will sustain the change, and what measures are associated with the control to ensure sustainability (6 data points).

HOW TO UPDATE ITEM

A Control Plan is completed during the Control phase of a project; it is update if a control or measurement needs to be adjusted and provides a communication of the change to staff. These can be updated on the board with pen or pencil as activities are completed by the team.

WHEN TO USE ITEM

A Control Plan is used in the Control Phase and should be reviewed during the Quality Huddle to ensure that the controls are sustaining the change.


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4.9 Safety Cross

A3 Page 1 A3 Page 2

Unit/Service VSM

Provincial Health

PEI VSM for Unit/

Service

PEI Strategic Plan

2013-2016 on a

Page

Quality Improvement

Team Indicators

Quality Improvement

Team Indicators

Pareto Charts

Communications

Plan

Page 1

Communications

Plan

Page 2

PDSA Sheets

Picture of Process

Map


Measurement Plan

Run Charts


Control Plan


Visit Pyramid

ITEM NAME

Safety Cross

WHAT ITEM INDICATES

The safety cross is a visual measurement tool to help the team identify daily at Quality Huddles if their goals are being met. This cross can be used to identify the absence of something i.e. a fall or medication error or the presence of something like identified near misses or staff safety concerns raised daily.

HOW TO UPDATE ITEM

Each day during the Quality Huddle, if the team has met their goal, color the square on that particular date GREEN, otherwise, if they did not meet their goal, color the square RED. Each month a new safety cross will be put up on the board.

WHEN TO USE ITEM

A Safety Cross should be used every day by the team and assessed during the Quality Huddle.


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4.10 Value Stream Map at the Unit/Service Level

A3 Page 1 A3 Page 2

Unit/Service VSM

Provincial Health

PEI VSM for Unit/

Service

PEI Strategic Plan

2013-2016 on a

Page

Quality Improvement

Team Indicators

Quality Improvement

Team Indicators

Pareto Charts

Communications

Plan

Page 1

Communications

Plan

Page 2

PDSA Sheets

Picture of Process

Map


Measurement Plan

Run Charts


Control Plan


Visit Pyramid

ITEM NAME Value Stream Map at the Unit/Service Level

WHAT ITEM INDICATES

A Value Stream Map at the Unit/Service Level provides an overview of the performance of that unit/service based on four key dimensions: Demand; Capacity, Efficiency; Quality. Each unit/service will have a set of metrics which will “tell a story” about the unit/service. A legend will be provided for each unit/service as the metrics are often different.

HOW TO UPDATE ITEM

This item will be updated quarterly and provided to senior leadership via Business Objects. Each leader must ensure the Quality Board is updated with the most recent Value Stream Map.

WHEN TO USE ITEM

This item should be used to identify areas for improvement and monitor that successes have been sustained by observing that the metrics are moving in the right direction. This will be reviewed at the Quality Huddle.


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4.11 Value Stream Map at the Provincial Unit/Service Level

A3 Page 1 A3 Page 2

Unit/Service VSM

Provincial Health

PEI VSM for Unit/

Service

PEI Strategic Plan

2013-2016 on a

Page

Quality Improvement

Team Indicators

Quality Improvement

Team Indicators

Pareto Charts

Communications

Plan

Page 1

Communications

Plan

Page 2

PDSA Sheets

Picture of Process

Map


Measurement Plan

Run Charts


Control Plan


Visit Pyramid

ITEM NAME

Value Stream Map at the Provincial Level for the Unit/Service

WHAT ITEM INDICATES

A Value Stream Map at the Provincial Unit/Service Level provides an overview of the performance of that unit/service rolled up at a provincial level based on four key dimensions: Demand; Capacity, Efficiency; Quality. Each unit/service will have a set of metrics which will “tell a story” about the unit/service. A legend will be provided for each unit/service as the metrics are often different.

HOW TO UPDATE ITEM This item will be updated quarterly and provided to senior leadership via Business Objects. Each leader must ensure the Quality Board is updated with the most recent Value Stream Map.

WHEN TO USE ITEM

This item should be used to identify areas for improvement and monitor that successes have been sustained by observing that the metrics are moving in the right direction. This will be reviewed at the Quality Huddle.


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4.12 Health PEI Strategic Plan on a Page

A3 Page 1 A3 Page 2

Unit/Service VSM

Provincial Health

PEI VSM for Unit/

Service

PEI Strategic Plan

2013-2016 on a

Page

Quality Improvement

Team Indicators

Quality Improvement

Team Indicators

Pareto Charts

Communications

Plan

Page 1

Communications

Plan

Page 2

PDSA Sheets

Picture of Process

Map


Measurement Plan

Run Charts


Control Plan


Visit Pyramid

ITEM NAME Health PEI Strategic Plan on a Page

WHAT ITEM INDICATES

The Health PEI Strategic Plan on a Page is a summary of the current Strategic Plan. It includes Health PEI’s mission, vision and values, and outlines the details of our goals for current plan.

HOW TO UPDATE ITEM

The Health PEI Strategic Plan on a Page will only be updated once a new strategic plan is approved by the Board.

WHEN TO USE ITEM This item is used for information and communication purposes to staff and should be reviewed once a week during one of the Quality Huddles.


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4.13 Quality Improvement Team Indicators

A3 Page 1 A3 Page 2

Unit/Service VSM

Provincial Health

PEI VSM for Unit/

Service

PEI Strategic Plan

2013-2016 on a

Page

Quality Improvement

Team Indicators

Quality Improvement

Team Indicators

Pareto Charts

Communications

Plan

Page 1

Communications

Plan

Page 2

PDSA Sheets

Picture of Process

Map


Measurement Plan

Run Charts


Control Plan


Visit Pyramid

ITEM NAME Quality Improvement Team Indicator(s)

WHAT ITEM INDICATES

Each area within Health PEI has a quality improvement team which selects indicators based on their yearly work plan. This Quality Improvement Team Indicator template is filled out with the results of work that the Quality Improvement team has completed.

HOW TO UPDATE ITEM

The Quality Improvement Team Indicators are updated annually when the team presents to Quality Council. HIU Specialists will update the template and send to the quality team. Quality team members will post on the quality boards at their sites.

WHEN TO USE ITEM

The Quality Improvement Team Indicators should be used monitor progress on the indicator monthly and report back to Quality Council.


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4.14 Visit Pyramid

A3 Page 1 A3 Page 2

Unit/Service VSM

Provincial Health

PEI VSM for Unit/

Service

PEI Strategic Plan

2013-2016 on a

Page

Quality Improvement

Team Indicators

Quality Improvement

Team Indicators

Pareto Charts

Communications

Plan

Page 1

Communications

Plan

Page 2

PDSA Sheets

Picture of Process

Map


Measurement Plan

Run Charts


Control Plan


Visit Pyramid

ITEM NAME Visit Pyramid

WHAT ITEM INDICATES

The Visit Pyramid is a communication tool which illustrates which leaders will be visiting the unit/site during the month. This provides staff with an idea as to when which leaders will be onsite.

HOW TO UPDATE ITEM

As each leader visits the unit, he or she will check off on their attendance. Visit pyramids will be provided to each Director and will be distributed through the directors.

WHEN TO USE ITEM

The Visit Pyramid Indicators should be used monitor which leaders have visited the unit and have attended a quality huddle. As each leader visits the unit, he or she will check off on their attendance.


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4.15 Required Organizational Practices

ITEM NAME Required Organizational Practices

WHAT ITEM INDICATES

In the Accreditation Canada Qmentum accreditation program, Required Organizational Practices (ROPs) are evidence informed practices addressing high-priority areas that are central to quality and safety. Accreditation Canada defines an ROP as an essential practice that organizations must have in place to enhance patient safety and minimize risk.

HOW TO UPDATE ITEM

Periodically visit https://www.accreditation.ca/rop-handbooks for the most up to date ROP’s that affect your service area.

WHEN TO USE ITEM

Item should be use to help further embed ROP’s in your services area to support Health PEI’s system wide pursuit of Accreditation with Excellence.

https://www.accreditation.ca/rop-handbooks


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Revision History

1) Original September 4, 2013 DGS. 2) Revised March 10, 2014 3) Revised October 15, 2015