ACT

PLANSTUDY

DO

Plan Continuous

Improvement

Define the System

Standardize Improvement

Study the Results

Assess Current Situation

Try Out Improvement

Theory

Analyze Causes

Purpose:

•Describe the characteristics of the system to be studied

•Prepare for gathering data

•Purpose is always to meet the students’ need

Outcome:

•Complete Description of the system

•Project Statement/Goal

•Data Gathering Plan

Pgs 66-90

What is the problem? Why are we selecting it? What is the current way this process is done? What are the key measures for these

processes? What is important about this process? The purpose of this strategy is to improve

__________ as measured by ____________.

What is the problem? Why are we selecting it? What is the current way this process is done? What are the key measures for these

processes? What is important about this process? The purpose of this strategy is to improve

__________ as measured by ____________.

Flow Chart (Picture of the current process)

Process Diagram

Measures (To determine current level of performance and gauge

future improvements)

Data Gathering Plan

Check Sheet

Run chart

Flow Chart (Picture of the current process)

Process Diagram

Measures (To determine current level of performance and gauge

future improvements)

Data Gathering Plan

Check Sheet

Run chart

Purpose:

•Have current and ongoing knowledge of the system’s performance

•Understand the patterns and trends in baseline data

Outcome:

•Analysis of baseline data

•Identification of special causes of variation

Pgs 92-100

How big of a problem is it? What data do I have that shows the

current level of performance (baseline data) of the area I’m trying to improve?

What does the data tell us? New insights from the data?

How big of a problem is it? What data do I have that shows the

current level of performance (baseline data) of the area I’m trying to improve?

What does the data tell us? New insights from the data?

Why Collect Data?Why Collect Data? Gain a better understanding Track progress Analyze gaps Set, monitor and evaluate goals Make decisions based on fact

Why Collect Data?Why Collect Data? Gain a better understanding Track progress Analyze gaps Set, monitor and evaluate goals Make decisions based on fact

Affinity Diagram Cause & Effect – Fishbone Pareto Diagram

(Identify key culprits of the problem) Charts using data collected from data

gathering plan: control chart, bar chart, histogram, run chart

Affinity Diagram Cause & Effect – Fishbone Pareto Diagram

(Identify key culprits of the problem) Charts using data collected from data

gathering plan: control chart, bar chart, histogram, run chart

Purpose:

• Identify & verify possible common causes of variation in the system being studied

• Generate improvement theory

Outcome:

• Improvement theory

If we…

Then we…..

As measured by….

Pgs 102-106

What are the root causes that are producing the results I’m getting- as evident in the baseline data?

What are the root causes that are producing the results I’m getting- as evident in the baseline data?

Cause and Effect Diagram (Focusing on Key Culprits)

Fishbone DiagramRelations DiagramPareto Diagram

Cause and Effect Diagram (Focusing on Key Culprits)

Fishbone DiagramRelations DiagramPareto Diagram

Purpose:

• Test the Improvement Theory

Outcome:

• A test of the research-based theory

• New data collected after the theory has been tried

If we do this … (improvement theory based on root causes)

Then we… (expected results)

As measured by… (data gathering plan- results will be compared to baseline data collected in “Define the System”)

• How will I test the theory?• What will I do differently?• What actions will be carried out?

• Based on the root causes, what can I do differently to produce more positive results?

• How will I test the theory?• What will I do differently?• What actions will be carried out?

• Based on the root causes, what can I do differently to produce more positive results?

• Force Field Analysis (To anticipate road blocks or barriers of the proposed change)

• Action Plan (Road Map to carrying out plan)

• Run Chart, Scatter, Bar Chart (to collect data)

• Force Field Analysis (To anticipate road blocks or barriers of the proposed change)

• Action Plan (Road Map to carrying out plan)

• Run Chart, Scatter, Bar Chart (to collect data)

Purpose:

• Check to see if the Improvement Theory worked

Outcome:

• A data-based decision to act on (standardize) or abandon the actions taken to improve the system.

• An explanation of why the results turned out the way they did (positive or negative)

• Did my improvement theory work?• Was the theory effective in raising

performance? • How does this new data compare

to the baseline data?• What data do I have that shows the

new level of performance?

• Did my improvement theory work?• Was the theory effective in raising

performance? • How does this new data compare

to the baseline data?• What data do I have that shows the

new level of performance?

• Tools to compare the data collected (after the improvement theory was implemented) to baseline data

• Charts to display the results• Implementation notes• If results were favorable, discuss

how to standardize

• Tools to compare the data collected (after the improvement theory was implemented) to baseline data

• Charts to display the results• Implementation notes• If results were favorable, discuss

how to standardize

• If the results were favorable in “Study the Results” it is time to standardize

• Create a new flow chart that represents the new way the system should operate

• Communicate changes in the system to all stakeholders

• If the results were favorable in “Study the Results” it is time to standardize

• Create a new flow chart that represents the new way the system should operate

• Communicate changes in the system to all stakeholders

• Display the PDSA story board that shows how the system was improved

• Ensure all stakeholders understand the new way the system is to operate

• Create a data gathering plan to ensure that the system continuous to work effectively

• Look for another aspect of the same system to improve (look back to the Pareto Diagram to select the next “culprit”

• Display the PDSA story board that shows how the system was improved

• Ensure all stakeholders understand the new way the system is to operate

• Create a data gathering plan to ensure that the system continuous to work effectively

• Look for another aspect of the same system to improve (look back to the Pareto Diagram to select the next “culprit”

Susan Leddick

An Organizer and IntegratorAn Organizer and Integrator

Plan

Leadership

Student Needs

Processes

Results/Goal

Faculty & Staff

Measures/Data Analysis/Knowledge Management