planning project-breast cancer screening-ppp

7/29/2019 Planning Project-Breast Cancer Screening-PPP

1/63

Diploma In Total QualityManagement For Health Care

Reform

Quality Planning Project Prepared By

Dr. Ashraf A. Monem

MD,MRCP,PHD,CPHQAUC Instructor

2012

Breast Cancer Screening


2/63

Breast Cancer

Screening


3/63

Two tests are commonly used by healthcare providers to screen for breastcancer

Mammogram

Clinical breast exam (CBE)


4/63

Mammogram

A mammogram is an x-ray of the breast.This test may find tumors that are toosmall to feel. A mammogram may also find

ductal carcinoma in situ, abnormalcells inthe lining of a breast duct, which maybecome invasive cancerin some women.The ability of a mammogram to find breast

cancermay depend on the size of thetumor, the density of the breast tissue, andthe skill of the radiologist.
http://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=45775&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=45944&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=304766&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=46634&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=45674&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=44636&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=46476&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=46441&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=45741&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=444971&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=444971&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=46683&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=46551&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=46551&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=46683&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=444971&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=444971&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=45741&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=46441&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=46476&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=44636&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=45674&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=46634&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=304766&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=45944&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=45944&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=45944&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=45775&version=Patient&language=English


5/63

Clinical breast exam. (CBE)

A clinical breast exam is an exam ofthe breast by a doctor or other healthprofessional. The doctor will carefully

feel the breasts and under the armsfor lumps or anything else that seemsunusual.

If a lump or other change is found bymammogram or clinical breast exam,follow-up tests may be needed.
http://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=304715&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=304715&version=Patient&language=English


6/63

General idea about the project

Samannod General Hospital decided tointroduce the service of mammogramfor early detection of breast cancer

among females as a result ofcontinuously increasing incidence ofbreast cancer.


7/63

Steps of Quality planning project

Measure

Establish Project

Identify Customers

Discover Customer Needs

Develop Product

Develop Process

Develop Process Controls/Transfer to Operations


8/63

Step 1:Establish Project

Mission statement

Goals

Team structure

Tree diagram

Planning net work


9/63

Mission statement

To introduce a mammogram service as ascreening test for females above the age of40 and high risk females with a positive

family history of breast cancer wishing toinvestigate herself.

This service will start within two months aftercoordination between radiology and general

surgery department, and it will be provided ata reasonable cost that females can afford.


10/63

Goals

1. To provide a screening test with high sensitivity andspecificity for early detection of breast cancer.

2. To provide this service at a reasonable cost femalescan afford 20% lower than market price.

3. To provide the service within reasonable time 15-20min. from reaching the hospital.

4. To provide a full detailed report about the findings ofthe test within 10 days after finishing examination.

5. To provide the service to at least 50 females/week.6. To increase the hospital revenues by about 1.000.000

within two years of operation.


11/63

Team structure

It is a cross-functional team formed of ChiefExecutive officer (CEO) ,the quality director and

a representatives from the following departments:-

Radiology department

Surgery department

Reception

Finance

Purchasing department

Supplier company

Biomedical engineering department

Volunteers from Patients


12/63

Tree Diagram

In tree diagram each step is furtherdefined by key activities and tasks tobe done.

The primary goals are subdivided tosecondary project goals or activitiesand activities are subdivided to the

major tasks that are most related to thefirst level goals.

C t fl di


13/63

Design formammography

unit

Identifycustomers

Discover

customerneeds

Developproduct

Developprocess

Create flow diagram

List customers&prioritize

Survey / interview keycustomers

Plan more datacollection

Complete needsanalysis

Select sample

Design / test questions

Send questionnaires /arrangeinterviews

List single dimension needs

Translate

Determine unit of measure &sensor

Develop features &goals

Optimize features &goals

Set & publish finalproduct design

Determine methods

Develop high level features & goals

Develop detailed features & goals

Determine methods

Optimize

Publish final product features &product features goals

Review productgoals

Identify operatingconditions

Collect info. onalternative process

Ensure complete understanding ofproject goals by all team members

User understanding of theprocess

How the process will be used

Environment of use

Design the process anatomy

Review the current processanatomy


14/63

Select generalprocess design

Process flow diagram

Testing of process the design

Identify processfeatures &goals

Select initial process features &goals

Set &publish final processfeatures&goals

Developprocesscontrol /

transfer tooperation

Choose controlsubjects

Identify objective of the process

Select control subject

Establishmeasurement

Develop unit of measure

Develop sensor

Establish

standards ofperformance

Set targets

Develop control methods

Set checking criteria

Measure actualperformance

Chart indicators

Develop detailed workinstructionsCompare to thestandards

Check results

Select appropriate action

Take action onthe difference

Analyze process

Make contingency plan

Troubleshoot


15/63

Planning Network

It is a highly useful tool for taking acomplex or long term project anddividing it into specific tasks .

Some tasks are performed sequentiallywhile other tasks on different paths donot depend on each other and can beperformed simultaneously.

It is often developed based on a treediagram


16/63

The project will start by 1st of December, and end by 22nd March

CRITICAL PATH: The path with the largest total elapse time labeled by green colors.Lost time for any of these tasks would put the entire project behind schedule


17/63

Step 2:Identify Customers

High level flow diagram

Detailed flow diagram

Internal Customers list External customers list

Prioritization matrix

Vital few customers


18/63

High level flow diagram

It is a graphic representation of thesequence of steps in a given processto produce some outputs.

It is used to determine who thecustomers are and as a basis forimproving the process that is being

planned.


19/63

Registration

Arrangement for appointment with thesurgeon and radiologist

Writing thereportTaking history

Clinical examination

Performing the mammogram

Delivery of thereport

Taking history


20/63

Detailed flow diagram

It is a more detailed diagram that showthe sequence of steps needed toaccomplish each activity within each

block of the high level flow diagram. It identifies the process inputs, all

internal and external customers, keycustomer interfaces, the processoutputs and the overall boundaries ofthe project.


21/63

Start

Female calls the hospital to arrange for an

appointment

Female registers her data Registration log

Radiology clerk arrange for appointment with the surgeon and

radiologist

Female attends to the

hospital on registereddate

NoYes

Arrange for another

appointmentPatient meets the surgeon

The surgeon takes full historyPt. medical file

The surgeon examines her breasts and

axaillae

The surgeon refers her to the

radiologist

Referral report

The radiologist makes the mammogram

The radiologist writes the report

The radiology secretary asks female to come

to have the report within maximum 10 days

Mammo. report

End


22/63

List of internal customers

1. Surgeon

2. Radiologist

3. Technicians

4. Nursing5. Reception

6. Administrative staff

7. Financial staff

8. Care coordinator

9. Supplier of medical equipments

10. Medical record staff

11. Medical engineering personnel


23/63

List of external customers

1. Females above 40 years

2. Females with positive family history.

3. Relatives.

4. Health insurance organizations.5. Media.

6. MOH.

7. Pathologists.

8. Radiotherapist.

9. Chemotherapist.


24/63

Impact (Prioritization) Matrix

It organizes data into sets of items to

be compared. The diagram

graphically shows relationships and/or evaluates the strengths of

relationships between the items in

each set.


25/63

Impact matrix of internal customersOptions Criteria

Internalcustomers

Directrelation to

performance of the test

Quality ofthe testresults

Directrelation

with patientsatisfaction

Reputation Total score

Surgeon 5 5 9 5 24

Radiologist 9 9 9 9 36

Technicians 9 5 5 3 22

Nursingstaff

3 3 3 3 12

Reception 0 0 0 3 3

Administrative staff

0 0 0 3 3

Financialstaff

0 0 0 3 3

Supplier 0 9 5 3 17

Medicalrecord staff

0 0 3 3 6

Carecoordinator

0 0 5 3 8

Medicalengineeringpersonnel

0 5 3 3 11

Legend: Major impact : 9

Moderateimpact : 5

Minor impact : 3

No impact : 0


26/63

Impact matrix of external customers

Legend: Major impact :

9 Moderate

impact : 5 Minor impact :

3 No impact : 0

Options Criteria

Externalcustome

rs

Impacton

market

share

Reputation

Total

revenue

Ability toshut me

down

Competit

ion rank

Total score

Patients 9 9 9 3 9 39

Relatives 9 9 5 3 3 29

Healthinsuranc

eorganiza

tions

9 5 5 3 3 25

Media 0 9 9 3 3 24

MOH 5 3 3 9 3 23

Pathologists

0 0 0 3 3 6

Radiotherapist

0 0 0 3 3 6

Chemotherapist

0 0 0 3 3 6


27/63

Pareto analysis

Pareto Analysis is a useful approach

to sorting out customer priorities.

The Pareto principle states thatcustomers can be divided into two

categories:-

1. Vital few2. Useful many


28/63

Pareto analysis of internal customers

So the vital Few internalcustomers are:-

Radiologists Surgeon Technician

Item Frequency Cumulativefrequency

Radiologist 25 25%

Surgeon 17 42%

Technician 15 57%

Supplier 12 69%

Nurses 8 77%

Medicalengineeringpersonnel

8 85%

Coordinator 6 91%

Medical record

staff4 95%

Administrativestaff

2 97%

Financial staff 2 99%

Reception 1 100%


29/63

Pareto analysis of external customers

So the vital Few external

customers are:-

Patients Relatives

Health insurance organizations

Item

Frequency Cumulative

frequencyPatients 25 25%

Relatives 18 43%

Healthinsurance

organizations

16 59%

Media 15 74%

MOH 15 89%

Radiotherapist 4 92%

Chemotherapist 4 96%

Pathologists 4 100%


30/63

Step 3:Discover Customers

Needs

Data collection

Customer need spread sheet

Needs analysis spread sheet Establishing of measures &sensors


31/63

Data collection )Survey)

Is a special type of data collection

Data is provided by individuals andsummarized statistically to representthe view of relevant population

Data collected often concern softerissues like opinions and satisfaction.


32/63

Survey for external customer

How would you like to register?

a) by phone b) by mail c) at the hospital it self

Would you like to be examined bya) by female doctor b) by male doctor c) No difference

How would you like to receive the report?a)By mail b) By E-Mail C) By hand

How would you like to learn self examinationa) By professional health staff b) CD

Time of providing the servicea) 9 p.m:1a.m b)10 p.m :2 a.m c) 11 p.m:3 a.m

Are you satisfied with the provided service?

a) satisfied b) not satisfied c) neutral


33/63

Survey for internal customer

What is the relevant time would you like to

stay atwork?

a) 6 hrs b) 8 hrs c) 5 hrs in the morning & 5 hrs at

night

Is the physical environment is comfortable forwork?

a) Yes b) No

Would you like to attend training course?

a) Yes b) No The frequency of training course

a) Every 3 months b) Every 6 months c) Annually


34/63

Customer Needs Spread Sheet

It a simple matrix spread sheet ,used tocorrelates customers and their needs.

It should include the vital few internaland external customers.

Correlate the relationship betweencustomers on the left hand column of

the spreadsheet and the needs listedon the top row.


35/63

Customer needs spreadsheet

Customer needs

CustomersWritten

clear report

Confidentiality ofmedical

information

Protectedrecords

Radiationsafety

practices

Safemammogram

unit

Sufficientstaff

555555Patients

355553Relatives

513553Health insurance

organizations

555553Radiologists

535533Surgeon

001553Technician

231924302820Total

Customer needs spreadsheet ( cont )


36/63

Customer needs spreadsheet ( cont. )

Customer needs

Customers Qualitycontrol

program

Timeavailability of

service

Qualifieddoctors

Trainedtechnicians

High qualityequipment

Trainedemployees

Measuresto ensurefollow upon time

3555555Patients

0553335Relatives

3313533

Health

insuranceorganizations

5155515Radiologists

5153315Surgeon

5005511Technician

21152124261424Total

Legend :

5 = strong relation

3 = moderate relation

1 = weak relation0 = no relation


37/63

Needs Analysis spreadsheet

It usually looks like a blend of severaltree diagrams, showing all primarycustomer needs broken down into a

single dimension that can be measuredand addressed by individual initiatives.

Each primary need could be brokendown into secondary need(s) and eachsecondary need could be broken downinto tertiary need(s).

Needs analysis spreadsheet


38/63

Needs analysis spreadsheet

Tertiary needsSecondary needsPrimary needs

Unit away from outpatient clinics &inwards

Unit away from areas of crowd ness

Radiation safetypractices

Availability & accessibility ofinternational radiology precautions

Unit complies with all laws &regulations pertaining to radiological

& mammography services

Written policies for safety & forfacing disasters

Process for regular monitoring ofradiology staff

Staff radiation exposure monitored

Insulated mammogram unit

Safe mammogram unitRegular maintenance of the unit

Device capable to detect early &small lesions

Recent devices of high technology

High quality equipmentOf trusted brand name

Training program for techniciansWell trained technicians-with

identified training needs & Issuing atraining planTrained technicians


39/63

Needs analysis spreadsheet ( cont. )

Tertiary needsSecondary needsPrimary needs

Records protected against fires &floods

Safe storage of recordsProtected records

Computerized filling system to

facilitate retrieval of data

Previous & subsequent records

are kept

Measures to ensure

follow up on time

A pre-prepared report format

Report includes description ofdetected abnormalities with clearassessment categories for cases ,recommendations for subsequent

follow up studies and suggestssurgeon consultation in high

probability category of breastcancer

Written clear report

Computerized report formsReports delivered in not more than

10 daysRapid results


40/63

Establish Units of Measurement &Sensors

Measurement unitis a defined amount ofsome quality feature that permit evaluationof that feature in numbers, like hours of

time to provide the service. Sensoris a method or instrument of

measurement that carries out theevaluation and states the findings innumbers in terms of the unit of measure,like clock for telling time


41/63

Measures & Sensors

SensorsMeasuresNeeds

Distance measuring scaleDistance between unit &nearest clinic or inward

Unit away from outpatientclinics & inwards

Check listY / NAvailability & accessibility of

international radiologyprecautions

Written policy& procedures

for disastersY / N

Policies for safety & for facing

disasters

Report of health appraisal ofradiology staff

Y / NProcess for regular

monitoring of radiology staff

Check listUnit is lead insulated acc. To

international precautionsInsulated mammogram unit

Maintenance registerY / NRegular maintenance of the

unit

Mammography filmsCapability to detect lesions of

. sizeDevice capable to detect early

& small lesions

Purchasing contractOf .. Or .. nameOf trusted brand name

Training registerY / NTraining program for

technicians


42/63

Measures & Sensors ( cont. )

SensorsMeasuresNeeds

Evaluation form/Check listY/NRecords protected against

fires & floods

Computer programsY / NComputerized filling systemto facilitate retrieval of data

Computerized report

Y/NsA pre-prepared report format

Computerized reportY / NComputerized report forms


43/63

Step 4:Develop Product

Affinity diagram

High level service /product features&goals spreadsheet


44/63

Affinity diagram

Based on the data collected from theprevious step, the team can prioritize andgroup together those needs which relate to

similar functionality. This tool save time and ensure efficient

utilization of scarce resources.

It clusters related needs then prioritize these

sets of needs to ensure that the mostimportant needs receive the most attention.


45/63

Affinity diagram

ReportsRecordsTraining needsHigh quality

needsSafety needs

A pre-preparedreport format

Recordsprotected against

fires & floods

Training programfor technicians

Device capable todetect early &small lesions

Unit away fromoutpatient clinics

& inwards

Computerized report

forms

Computerizedfilling system to

facilitate retrievalof data

Of trusted brand

name

Availability &accessibility of

internationalradiology

precautions

Regularmaintenance of

the unit

Written policiesfor safety & forfacing disasters

Process for

regularmonitoring ofradiology staff

Insulatedmammogram unit

Regularmaintenance of

the unit


46/63

High level service /product features &

goals spreadsheet

High level product features mean thatfeatures are stated in broad terms, thatencompass other more detailed

features. Appropriate features should consider :-

An entirely new functionality

Replacing old features with new ones

Eliminating the unnecessary.


47/63

The product goal should be SMARTand follow the concept of optimizationwhich include:-

Meeting the customer needs

Meeting the Supplier needs

Meet competition

Minimize the combined costs

High level service features & goals spreadsheet


48/63

High level service features & goals spreadsheet

Service features

Customer needs

Device

capable todetectearly &small

lesions

Regularmaintenance of the

unit

Insulatedmammogr

am unit

Staffradiationexposuremonitored

Plan forfacing

disasters

Written policiesfor safety

Compliance withlaws & regulationspertaining toradiology&

mammography

Unit awayfromoutpatientclinics &inwards

05555555Radiation safety

55555530High quality Service

00000000Well trainedtechnicians

00005330Protected records

30000000Written clear report

00000000On time follow upensured

00000010Rapid results

Devicecapable to

detect lesionof .. size

Preventivemaintenance

of the unitonce monthly

Walls &floors of theunit are lead

insulated

Filmbadgefor each

technician

100% of stafftrained on

Plan forfacing

disasters

Safety policiesupdated on a six

monthly basis

Compliance with latestupdated laws &

regulations

At least 100m distance

between unit& inwardsand clinics

Service featuregoals

81010101513125Total

High level service features & goals spreadsheet (cont.)


49/63

g g p ( )

Service features

Customer needs Rapiddelivery ofthe report

Previous &subsequentrecords are

kept

Clearassessmentcategoriesfor cases

Detailedreport

Recordsprotectedagainstfires &

floods

Experiencedtechnicians

Trainingprogram fortechnicians

Oftrustedbrandname

00000305Radiation safety

53531535High quality service

10130550Well trainedtechnicians

05115000Protected records

03551153Written clear report

33535010On time follow upensured

50000111Rapid results

Reportdelivered notlater than 10

days fromrequest andwithin 5 days

in case ofpositive report

Records are

kept for 5years fromdate of

procedure

Casescategorized as

(negative,Bgfindings,

probably Bg

findings ,suspiciousabnormality ,

highlysuggestive ofMg , known

biopsy provenMg)

Reportincludes

descriptionof detected

abnormalities &recommend

ations forsubsequent

follow upstudies

Records are

kept in fire &waterresistantcabinets

Certified licensed

technicians withminimum 2 years

experience

Monthly training

of all techniciansincluding on jobtraining sessions

Of .. Or. name

Service feature goals

1414171512151514Total

Legend :5 = strong relation

3 = moderate relation1 = weak relation0 = no relation


50/63

Step 5:Develop Process

Process anatomy

Process flow diagram

Process features & goals spreadsheet

P t


51/63

Process anatomy

It is a coherent structure which bindsor holds the process together.

It guides the flow of the work from start

to finish.

Shows in schematic form where thevarious sub-processes reside, how

they are linked together, and where theinputs enter and the outputs go.


52/63

Process anatomy may be :-

Autonomous

Assembly tree

Procession (assembly line)

P t


53/63

Process anatomy

Item Process Processanatomy

Macro process Mammogram unit Assembly tree

Sub process Registration Assembly tree

Clinical

examination

Procession

Performing the

mammogram

Procession

Report Procession


54/63

HIGH LEVEL FLOW DIAGRAM(PROCESSANATOMY)

Registration

Clinical examination

Performing

mammogram

Report Delivering the report Writing the report

Arrangement forappointment

Billing

Preparing the patient

Positioning

History takingLocal examination


55/63

Process anatomy

Mammogram unit

Registration Clinicalexamination

Performing

mammogram

Report

Arrangement forappointment

Billing History Localexamination

Preparing the

patient

positioning

Writing Delivering

P f t & l


56/63

Process features & goalsspreadsheet

More or less it resembles the productfeatures &goal spreadsheet.

The process features can be

categorized under procedures,methods, equipments and supplies,materials, people, training andknowledge and other resources.

The process goals are like other goalsshould be SMART


57/63


58/63

Step 6:Develop process controls

Feedback loop

Process control spreadsheet

Feedback loop


59/63

Feedback loop

Feedback loop is the tool formonitoring the actual performance of aprocess and keeping it performing as it

was designed


60/63

Step 6Step 6

Compare to

standard

Measureactual

performance

EstablishedControl s tandard

Identifyproblem Diagnosecause Remedycause

ok

Not ok

Trouble shoot


61/63

Process control spreadsheet

This tool will enable the team to identify:-

1. The control subject.

2. The target goal

3. Criteria for taking action4. Who takes action

5. What action they take

6. Where they do it

7. When they do it

8. How they do it


62/63

Every 3 months

for 3 days

Training

unit

Prepare for

trainingsessions

Head of

radiologydepartment

defective testsMore than 2%

Zero level

of defectivetest

Calculate theradiation

emission every

month

Mammogram unit

Proper Dose&time ofexposure

Radiologist&

technician

If the radiationexceed the safety

limits

100% safeProcedure

Whendiscovered

In thesecretary

office

Checkcoping&printingservices

Chiefexecutive

officer

Patientcomplaining from

delaying report

Within 10days

After each

patient

At

mammogram unit

Cleaning the

equipmentafter every

patient

NursePatient

complaining fromdermatological

infection

100%

Disinfectedequipments

Checkappointment

every day

Trainingunit

Trainsecretaries

Head ofradiology

department

More than 2%error

100%accuratereports


63/63

planning project-breast cancer screening-ppp

Documents