QI & PDSA for Public Health

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?

9

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!

12

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


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


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

46

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


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


Step 5: Display your data on a graph….

51


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

54

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


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


Then for each cause identify deeper root causes

62

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)

69

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

70

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

72

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


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

78

Example Run Chart

79

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


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

81

Run Chart Exercise

82

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

83

Working Session

Bringing QI into your Programs

84

Working Session Exercise 1

Identify Two WIC Program or Health Division Areas where QI Processes would be Helpful

85


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

86


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

87

Q & A

Please feel free at this time to email any questions you may

have about the training and/or exercises

88

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

89

BREAK – 10 minutes

2012 WIC Training & Educational Conference

Make your Hotel Accommodations NOW…

events.mphi.org

90

Documents

QI & PDSA for Public Health