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7/30/2019 (2009-04-14) Problem Solving Cycle.pdf
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y:
.. , . ., . .
Quality Coordinator / Risk Management OfficerMr.Mr. TarekTarek HawariHawari, R.N., R.N.
Head Nurse ICU
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C ass cat on o Qua ty Too s
PROCESS TOOLS STATISTICALy ra ns orm ng
y Cause and Effect y Control Charts
Diagram.y Flowchart
y
Pareto charty Run chart
y Multivoting
y Histogram
y
matrix.
2
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OTHER CLASSIFICATIONS:
yProblem identificationywith ideas as Focus
.yWith number as Surve .
y
Problem analysis
ywith ideas as Force field analysis
3y
w num er as on ro c ar s.
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OTHER CLASSIFICATIONS:y Idea creating tools as A inity diagram, brainstorming, brain-
writing, and nominal group technique).
, .
y Cause analysis tools (as fishbone diagram, force fieldanal sis, Pareto chart, and scatter dia ram).
y Planning tools (as activity chart, arrow diagram, flow chart,force field analysis relations diagram, tree diagram).
y Evaluation tools (as ACORN test, Decision matrix, multi-voting).
-Graphs, Histogram, process capability, survey, Pareto chart,run chart, scatter diagram, etc
4
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JURAN TRILOGY
Quality
Planning
ControlQualityImprovement
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1. Identif in roblems/ o ortunities for
improvement.
.
3. Selecting the team.
4. na yz ng an stu y ng t e pro em toidentify its root causes.
5. Developing solutions and actions for
improvement.6. Implementing and evaluating quality
im rovement efforts.
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IIdentify P roblem
Define the problemo erationall
Select theteam
H old theain
Monitor P ro ress
la
Act
RootCausesA nal sis
n
Do
CheckIImplement
C orrective
Action
IdentifSolution
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Identifying problems and selectingopportunities for improvement.
y Available data of monitoring and/or survey.
y
xp ore nown area o rustrat on.y Suggestion boxes, staff meeting and focus group.
y Patient feedback or complaints.
y .
y Supervision remarks.
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BRAINSTORMINGDESCRIPTION:
No criticism
generatealargeideasinaNO judgment
.
How?y Generationphase
y Clarification
hasey Evaluationphase Cost
Magnitude
9
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Uses of Brainstormin :
y Brainstorm ideasy Brainstorm factors that allow one to search for root
causes.
y Brainstorm ideas about the development of acustomer satisfaction survey in the community.
y (( so it is used for other tools))
10
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Criteria for Selecting a Problem:
y
A problem that is felt to be important by staffor clients;
yA roblem that is within our control and
authority to change;
ere ene o e so u on w e grea er
or equal to the cost and effort to solve theproblem.
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PRIORITY MATRIXy A Prioritization Matrix is a useful technique that
team members can use to achieve consensus about anissue.
y The Matrix helps you rank problems or issues
(usually generated through brainstorming) by aparticular criterion that is important to yourorganization.
y Then ou can more clearl see which roblems arethe most important to work on solving first.
12
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Uses:y
To
determine
what
your
users
or
your
team
members
programorhealthservice.
13
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y In the first column write down the roblems that werementioned in the brainstorming session.
y In the second to fourth columns, define your criteria.Examples of some typical criteria are:
y Frequency: How frequent is the problem? Does it occur
often or only on rare occasions?y Importance: From the point of view of the users, what
are t e most mportant pro ems at are t eproblems that you want to resolve?
eas y: ow rea s c s a we can reso ve eproblem? Will it be easy or difficult?
14
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Priorit MatrixProblem Frequency Importance Feasibility Total
Points
Ranking
15
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:
from 1- 10 for each criterion used so that the
y Total all the votes together. The totals help you
see c ear y ow o pr or ze e pro ems.y You can rank the problems according to the total
points. If more than problem get the same total
points, it is wise to repeat the rating for the twoproblems to make one of them higher (It is betterthat no problems have same scores to facilitate
the ranking).16
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Priorit MatrixProblem Importance Frequency Easy to
Manage
Effect
Of
Total Priority
Solution
1 8 7 6 7 28 3
2 9 10 10 8 37 1
3 8 7 7 8 30 2
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Defining the problem operationally.
y A gap between actual performance and performanceas prescri e y gui e ines an stan ar s.
y Indicate cause;
y ;
y Affix blame.
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The problem statement should answer the following:y at s t e pro em
y How you know it is a problem.
yHow frequent or how long the problem existed.
y Where the problem begins and ends.
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I Ste 3:
Choosing a team.
The team should comprise:
y Those who are affected by the process.y Those who work in different stages of the process.
y Those who make decision related to the roblem.
y Those who identified the problem.
understand the problem, those who can help, and
those who have technical ex ertise.
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I Ste 4:Analyzing and studying the problem to
en y s roo causes.
na yz ng epro em eg ns yunderstandin howthe rocess
actuallyoperates.
It
is
important
to
,
and
to
identify
the
root cause
of
the
problem.
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Tools for Analyzing the Problem Include:
y ow ar . s a grap c represen a on othe sequence of steps that are performed in a
y A Cause and Effect Diagram. It is an orderly.
y IndepthStudies. Thesestudiesmustgo.
examinerootcausesbasedonclinicalrecords
reviews
healthcenter
re ister
data
staff
or
patientinterviews,andservicedeliveryobservations
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FLOWCHARTSy
A Flowchart is a picture of aprocess.
,
portrays sequentially and in,
step in a process or program or
.
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FLOWCHARTS-cont.
y
Flowchart outlines the sequence andre a ons p o e p eces o e process.
y , .
yThe process described by flowcharts can beanything : administrative , service process ,or aplan for quality improvement process.q y p p
24
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FLOWCHARTS-cont. Starty Flowcharts tend to use
recognizable symbols.Activit
y The basic symbols :y A Circle start/end
y A rectangle (activity)
yA diamond (decision)
DecisionNo
Document
y An arrow (direction).
y DocumentYes
25
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Uses of Flowcharts:y
Understand processes.yConsider ways to simplify processes.
.
y Identify problems.
yHelps in identifying indicators.
mp emen a new process .
26
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Types of Flowcharts:
y
High-Level FlowchartyDetailed Flowchart
yDeployment or Matrix Flowchart
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Construction of a Flowchart:
1. Define the process to be diagrammed.2. Gather information of how the process
.
3. Trial process flow and arrange the stepsin proper sequence.
. accuracy . Make changes if necessary.
30
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onstruct on o a owc art:.
format is most appropriate.
.
of the process to be flowcharted.
inputs?y What signals the end of the process? What is/are the final output(s)?
Step 3. Identify the elements of the flowchart by asking:y Who provides the input for this step? Who uses it?
y What is done with the input? What decisions are madewhile the input is being used?
y
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y Step 4. Review the first draft of the flowchart to see
whether the steps are in their logical order.Areas that are unclear can be represented
with a cloud symbol, to be clarified later.y Ste 5. After a da or two review the flowchart with
the group to see if everyone is satisfied with
e resu . s o ers nvo ve n e process
if they feel it reflects what they do.
32
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Construction Rules:
yDefine the boundaries of the process clearly.
y se t e s mp est sym o s as poss e.
yMake sure that every feedback loop has an escape.
yThere is only one output arrow out of a processbox.
yDo not assign a technical expert to draw the
flowchart. Process owner who actuall erformthe process should construct the flowchart.
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Fishbone Dia ram
y
In other words a cause-and-effect diagram is atool to gather and uncover the ROOT causesof a Health Problem.
yThe ualit roblem is usuall stated as anegative outcome (effect) of a process.
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STEPS :1. Start with the effect
on the far ri ht side ofthe diagram and draw a box
.
2. Draw a horizontal line to Problem
e e o e pro em.
3. Determine the categoriesof the causes of theproblem
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STEPS :4. Determine and define the major categories which
describe the system or process under review, e.g.,
5ps: (or) 5ms:
Peo le Man ower
Provisions Materials
Procedures Methods
Place Measurements
40
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STEPS :6. Identify possible Finally Draw Accurate
causes.
7. Evaluate the draftdiagram as a team todetermine the accuracyof the placement of the
su causes .
42
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Uses of Fishbone Dia ram:y
To identify and organize causes of problem.yTo provide a graphic output of a detailed
ra nstorm ng sess on y organ z ng t oug tinto Categories.
y
To identify factors that lead to success.
43
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as c ayout oCause and Effect Diagrams
Manpower Methods
EFFECT
Materials
Policies
Machines
(Plant)Environment
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Include:
y A Flow Chart. It is a graphic representation of
the se uence of ste s that are erformed in aspecific process.
.
arrangement of theories about causal factors.n ep u es. eses u esmus go
beyonddocumentingtheproblem.Theyshould
x min
r t
n
lini lr r
reviews,healthcenterregisterdata,stafforpatientinterviews,andservicedeliveryo serva ons
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Data Collection Will Help To:
y Verify existence of a problem.
y Analyse source of variation.
y Determine relative importance of different causes.
,displayandinterpretdata usingsomebasic
,
,chart, scatterdiagram,etc.
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PARETO CHART
yA Pareto chart is a specialized form of a bar
events (causes) in descending order. Therefore,
the chart visually shows which causes aremore si nificant. This chart is based on thePARETO Principle :
20% of the causes ( 80-20 rule) .
50
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a y ng ems n a omp a onTableCausesforLateArrival NumberofOccasions Percentage
Familyproblems 8 11
Hadtotakethebus 4 6
Traffictieup 32 44
c
Badweather 3 4
Total 73
100
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CausesforLateArrival Numberof Percentage Cumulative
(DecreasingOrder) Occasions Percentage
Traffic tieu 2
Woke up late 20 28 72
Family problems 8 10 82
Sick 6 8 90
Hadtotakethebus 4 6 96
Bad weather 3 4 100
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Steps:100 P100
categories. 80
ercent
y a e t e e t vert ca ax s
with counts and right axis60
50
w t percentages - .
yAdd the percentage value ofENT
40
2028
33
each bar and calculate the
cumulative total for each bar. Patie
Nosy
Order
Only
Routi
Nosp
Untra
Delay
PER
0 08
smoveda
tem yspecialist
nepharmacist
eprocedure
ificForm
edNurse
ofDoctor
54
REASON
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85
78
75
87.5
80%
90%
6262.5
%60%
70%
epercen
34.137.5
50
Per
cen
40%
50%
Cumulati
16.
27.
25
20%
30%
0.82.4
5.46.27
0
12.5
0%
10%
Waiting for
investigations
Waiting for
operation
Waiting for
consultation
Personal reasonsTeaching &
exams
PO/IM drug
administration
Waiting for
referral
Waiting for blood
availability
Reason
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Uses of Pareto Chart:y To focus on the major causes of the problem i.e.
Focus attention on Vital few instead of the trivialmany.
y . .
determining the important risk factors to the.
y To evaluate the effectiveness of the improvement
- -Caution:
56
Try to use objective data instead of opinions and votes.
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HISTOGRAMS
y
Ahisto ram
is
sim l
astatement
of
data
collected
andcategorizedbyvariousgroupstorepresentaictureofthesituationthatwasinvesti ated.
y So,
fromthe
histogram
the
CQI
team
shows
how
o tent e erentva uesoccur.
58
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SCATTER DIAGRAM
y A scatter diagram is a 4.0
grap use w en youneed to display what
T
3.5
3.0
appens to one var a e
when another variables
B.
2.5
2.0
c anges o e erm ne erelation between two
AGE of MOTHER
32302826242220181614
1.5
var a es.
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y
This diagram is used in4.0
combination with aFish-bone (cause-and-
3.5
effect diagram.
B
.WT
.
2.5
e ex en o w c evariables relate is called
32302826242220181614
2.0
1.5
AGE of MOTHER
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Patterns of Scatter Diagrams:
E
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Developing Solution and Action for
y
A solution ma be ver strai ht forward: it ma beas simple as reminding staff about clinical guidelinesthrou h su ervision or in service trainin . Solution
may also take the form of job aids such as wall chartsand checklists.
y Some problem, however, are more difficult to solve
because they require procedural redesign.
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Force-Field Analysisy Force-field analysis was developed by Kurt Lewin. It
identifies forces that help and those that hinderreaching the desired outcome.
y t ep cts a s tuat on as a a ance etween two sets
of forces: one that tries to change the status quo andone a r es o ma n a n .
reducing the hindering forces and encouraging the
.
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Force-Field Analysisy When used in problem analysis, force-field analysis is
especially helpful in defining more subjective issues, such
as mora e, managemen , e ec veness, an wor c ma e.
y Force-field anal sis also helps keep team membersgrounded in reality when they start planning a change bymaking them systematically anticipate what kind ofresistance they could meet.
Caution:
If a significant force is omitted, then its impact can
negatively affect a plan of action. All significant forces or
actors must e nc u e an cons ere .
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Force-Field Analysis+ _
I Ste 6:
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Implementing and evaluating qualitymprovemen e or s.
y*
y Check *Act
,
continue limited monitoring. Team should modify solutionsas needed and should full document results and lessonslearned.
Disseminate the new process so that others can learn from theexperience. The team may then repeat the qualityimprovement cycle.
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PDCA C cle
(Act)
(Check)
.
(DO)
study
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When to Use It:y GanttChartsprovideagraphicguideforcarrying
t
ri
f
tiviti
h win
th
t rt
tduration,andoverlapofactivities.
y antt artsaremostuse u nt ep ann ng
stages,to
mark
when
each
activity
should
start
and
.
y GanttChartsarealsousefulforkee in trackofprogress
and
rescheduling
activities
if
progress
is
slowed.
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IdentifyProblems DefineProblem Team RootCause
na ys s
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ExampleExample:
y A QI team was formed to look at the problem.
ey co ec e a a a ou wa ng mes or samp eof patients during a one month period
and sometimes as long as five hours to be admitted tothe hos ital.
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Scatter Diagram of Patient Waiting time versusOccu anc rate
300250
aitin
150sof
tim
e
50inut
50 60 70 80 90 100
Percentage of occupancy
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Suggested Plan for Admitting Patients:Suggested Plan for Admitting Patients:
1. Occupancylevel
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