decision making methods and tools - ashnha.com · delphi method is a combination of brainstorming,...

Decision Making Methods and Tools

CPHQ PreparationData Analysis

Alaska CPHQ 03-22-2017

Linda Michel, WSHA, Director Rural Quality and Performance Improvement

Perception

Finished files are the resultof years of scientific study

combined with the experienceof years...


Finished files are the resultof years of scientific study

combined with the experienceof years...

Perception


Perception


Decision-Making Methods

Brainstorming –Use when a list of possible ideas are needed.

• Free flowing ideas• No censoring, • Explaining, • Discussion,• No dollars attached,• Judgement of ideas as they are generated.

• Team can build upon the ideas of others.• Discussion of ideas comes at a later point in the process.

Good tools to use with this are Cause and Effect Diagram and the Tree Diagram.


Six Steps of Brainstorming

1. Definition of the subject and direction of the session.

2. Allowing time for initial and individual thought.

3. Establishing a time limit for the entire session.

4. Requesting ideas, according to the predetermined structure.

5. Keep circling the issues until all ideas are recorded.



Multivoting

Use after a brainstorming session to identify the key focus items for the team by:

• Looking at the list and combining similar items (renumber).• Having each team member list the items he/she thinks are

the most important.• Tallying votes.• Eliminating lowest scores.• Repeating process until list has a appropriate number for the

team to handle and the top priority is identified.



Nominal Group Technique (Brainstorming on Paper)

Use for a controversial topic by:• Posing the question to be answered (written for all to see) and

clarify as needed.• Having group write down their ideas individually.• Listing all items with no discussion as you list them.• Clarifying the ideas one at a time, and discuss as needed.• Having sticky notes or cards for each team member and have them

write one selection of their choice on each and rate them from the highest to the lowest (ex: if instructed to list 5, then #5 is the most important).

• Collecting cards and tally votes, marking each item with the value on the card.

The item with the largest number becomes the team priority.Alaska CPHQ 03-22-2017

Let’s Brainstorm

I have been asked to plan a meal room service program for my facility. My first objective is to brainstorm with the team I have assembled to decide what all we must consider before designing the program.

Room Service

Hours

Staffing

Customers

Menu

Equipment

Ordering

Delivery

Meaning who receives room service meals?

Family or other Care Providers ?

ER Patients

Providers

In Patients

What conditions?

After how many hours of stay?


Delphi Method (Combo)

Delphi method is a combination of brainstorming, multivoting, and nominal group techniques.

• Used for face to face or remote meetings (by email or mail)

• After each step of the process, one person receives all the data, votes, suggestions etc., compiles it, and sends it out for the next round, etc., until consensus is reached.


How Delphi Works

To reach team consensus concerning a goal or task:• You can with start a questionnaire, or a list of possible options

can be drafted by the team or team leader.• Distributed to team members with a request for comments,

questions, objectives, criteria etc. as appropriate.• Could include a requirement to vote, concerning the team goal,

task, or project.• The questionnaire, or option list is circulated anonymously,

during, before, after or in place of the team meeting.• Each time the list is revised and recirculated it includes a request

for comments, questions, objectives, criteria etc. as appropriate. • After each round, the questionnaire or option list is revised and

recirculated until consensus is reached. • Verbal discussion is used at each team meeting to review the

results and gain consensus.Alaska CPHQ 03-22-2017

Flow Charting

The flow chart is sometimes called the process flow chart.

A graphical display of a process as it is know by the authors, owners, and users of the process.

Outlines the sequence and relationship associated with the process until the team comes to a common understanding and knowledge about how the process works.

Beginning and End Question Actions


Flow Charting

Finding an Event Venue Venue

Right Size No Keep

Looking

Yes

Date Available

Yes

No Keep Looking

Right Amenities No Keep

LookingYesReserve


Cause and Effect

Use to:

• Identify and organize possible causes of problems,

• Identify factors that will lead to success, and/or

• As part of a root cause analysis.


Cause and Effect

Causes Effects

Eliminate Bathroom Falls

Also known as Ishikawa or Fishbone Diagram

EnvironmentGrab Bars Location

Floors Wet

Toilet Paper Holder

Door SticksLighting


Ethnicity not in computer

Cause and Effect (Fishbone)

Scenario:There is a lack of data in your facility on Race and Ethnicity of the patients you serve. You need to analyze the reasons this data might not be getting recorded in order for improvement to occur.

Stigma about ethnicity

Patients

Don’t like to be asked

Equipment

Location – Lack of privacy

Hard to enter data

Limited access to translators

Clerks also answer phones

Language Barriers

Can’t read

Procedures

Computer program too complicated

Staff

New staff not properly oriented

Too busy for extra questions

Do not like to ask question

Causes Effects

Record Ethnicity and Race


Tree Diagram

Use when:

• It is crucial that a step/task not be overlooked,

• A specific task has become the focus, but it is a complicated task to complete, and/or

• There have been numerous roadblocks to implementation.


Tree Diagram

100% Employee Influenza Immunization

Before Meeting

Choose Appropriate

Team

Send out Meeting Notice

Send Out Agenda

Book Meeting Space

Notify C-Suite of Meeting

Set Time Frame for Reporting

Back

During Meeting

Reasons For

Reasons Against

Possible Exclusions

Draw Up Draft Policy

Make Decision

After Meeting

Forward Draft Policy to C-Suite

Plan for roll out of policy

Plan for giving immunizations

Wait for revisions or

okay

Distribute Policy


Prioritization Matrix

A tool used to select one option from a group of alternatives.

A Likert Scale (1=lowest significance/importance, 5 = highest significance/importance) is typically used for this matrix.

Example: “You need to improve access to the clinic for patients.”

Steps:1. Determine options, problems or solutions. This could be

done through brainstorming and/or multi-voting.2. Determine the criteria to be utilized to help make a decision

regarding the priority order. This criteria should all be phrased either positively or negatively so that rating is consistent.


Quality Impact Criteria

Prioritization Matrix

Clinic Access Options

Safety Patient Outcome

Patient Satisfaction

Cost Total Score

Toll Free # 1 3 5 2 11

Longer Hours 3 5 4 4 16

Physicians Numbers

5 5 1 2 13

3. Each column must be scored vertically. For instance you would rate safety should be rated for all 3 options, then patient outcome, patient satisfaction etc.

4. You can do this ranking with the entire team brainstorming together to determine who goes in each box, or have each team member submit their specific numbers to the team leader, who then combines the numbers into the final sheet.


An Activity Network Diagram is a good way to identify the sequence and timelines of tasks.

You could use this diagram when you have a complex task, or when simultaneous implementation of several tasks must be coordinated.

You make an activity network diagram by:

• Listing all necessary tasks, one per sticky note or card, needed to complete the project from start to finish.

• Put the sticky notes (or cards) in sequence needed for the project to reach completion.

• Identify places in the paths where there are connections to other tasks and can not be initiated until a point in another path is reached (example: you can not put the roof on before you have the supporting framework constructed).

Activity Network Diagram


Activity Network Diagram

Example: “My facility is buying a “new state of the art” CT for a brand new space that is shelled in but not finished. The project needs to be coordinated so the machine is up and running on time in order to minimize loss of revenue. I am asking my team to help me make an activity network diagram.”

Pick Vendor6-15-16

Final Plan Design8-1-16

State Approval

9-1-16

Electrical9-30-16

Plumbing9-30-16

H-Vac10-2-16

Lead lined sheetrock10-12-16

Paint and flooring

10-20-16

Installation10-21-16

Choose Arch/Build

6-30-16


Deployment Chart (Planning Grid)

Helps organize key steps in the project to reach goal(s).

Schedules for complex tasks and subtasks.

Used for a task for which the time for completion is known.

Used to determine who has responsibility for the parts of a plan or project.

Responsible Task BudgetCost

Due Date

Linda Review vendors quotes 0.00 8-15-16

Robert Take plans to state office for approval

120.00 8-28-16

Gloria Coordinate contractors 560,000 9-6-16


Stratification

A way of analyzing whether a problem does or does not exist, or to identify patterns.

It breaks the whole down into parts. For instance, you could stratify UTI’s by organisms, catheterizations, surgical procedures, and by nursing units.

Example: “Let’s look at the patients on unit two who are complaining their dinner is cold.”

Unit 1 Unit 2

Food cooked 4:40 pm 4:40 pm

Food plated 4:55 pm 4:55 pm

Food delivered 5:00 pm 5:15 pm


4:40

4:50

5:15

4:19

4:26

4:33

4:40

4:48

4:55

5:02

5:09

5:16

5:24

Cooked Plated Presented

Patients Dinner Meal

Unit A Unit B

5:00

Stratified Chart


A Run Chart is just that. It shows a running record of a process over time, and can be used for any type of data.

May also be referred to as a Line Graph or a Trend Chart.

Can be used for a comparison in one group or a comparison between two groups.

It is the tool of choice for continuous or measured data.

It is best used for:• Problem identification• Data analysis• Outcome evaluation

It can include a horizontal mean or medial line.

Run Chart


Run Chart

Example: With summer here and accidents in rural areas on the rise, we want to see the variation in patients reaching the ED in that 1st Critical Hour. We plan to record by month so must keep data on each accident arrival.

We have developed criteria forwhat level of injury we will measure that is most importantto that 1st Critical Hour, and we will extract the data in a joint effort with the EMS Service in the areas.


Month Average Minutes PatientsJanuary 51 154 3

February 62 370 6

March 45 90 2

April 31 95 3

May 21 330 7

June 65 260 4

July 45 45 1

August 38 150 4

September 78 390 5

October 38 75 2

November

December

Run Chart

We have data for 10 months of the year, and as received will add to the data.

We divided the total number of minutes to arrival in the ER from time of accident by how many patients we had that met the established criteria.

We know we are interested in the 60 minute mark, so that will be the benchmark.


51

62

45

31

21

65

45

38

78

38

0

10

20

30

40

50

60

70

80

90Average Minutes to ED Arrival After Major Accident by Month

Run Chart


Display of comparisons between different groups.

For example. You have been asked to display surgery volumes of Gallbladder, Hysterectomies and Ortho for the last 6 months.

Bar Chart

GB’s Hyster. Ortho

14 12 19

2

4

6

8

10

1

2

14

1

6

18

2

0

Gallbladder Hysterectomies Ortho

14

12

19

0

Quality Leaders 06-16-2016 Alaska CPHQ 03-22-2017

Histogram (Type of Bar Chart)

Histogram shows the frequency of “one” continuous variable, and summarize groups of data.

Plotting the frequency of each interval reveals the pattern of the data, showing spread and outliers.

The grouping of the x axis should be equal sized, for example, with ranges defined.

The difference between a Histogram and a Bar Chart is the ranges on the Histograms where the Bar Chart has separate groups on each bar, such as, for example, nurses, aides, providers.

Example: “You want to know the correlation of the HIPAA test given to staff that have been employed 1-5 years, and the average scores dependent on years employed.”


Histogram (Type of Bar Chart)

1-2 yr 2-3 yrs 3-4 yrs 4-5 yrs 5+ yrs

70 88 76 82 97

60

70

80

90

100

70

76

82

88

97

1-2 yr. 3-4 yrs. 4-5 yrs.2-3 yrs. 5 + yrs.

Aver

age

Scor

e

Years Employed Alaska CPHQ 03-22-2017

Pareto Chart

A simple Pareto Chart can be utilized to determine where to begin improvement efforts on a particular strategy.

Example: “The radiology patients keep complaining about the wait time for their procedures, so you want to know why that is happening. You brainstorm the possible factors and then study how often they happen.”

Brainstorming resulted in these possible factors:• No notification that the patient has arrived (Communication)• Not enough staff due to call ins (Staff Call-ins)• Not enough staff due to trauma in ER (Trauma)• Not enough staff due to unknown surgery case needing x-ray (Surgery)• Not an appropriate x-ray room available for particular exam

(Equipment)

The team decides to study these factors for 1 month. There were 84 delays during the month.


Pareto Chart

Communication Staff Call-ins Trauma Surgery Equipment

57 7 5 3 12

60

50

40

30

20

10

57

12

75 3

Communication

0

Staff Call-insEquipment Trauma Surgery

Wai

t Tim

e in

Min

utes

DelaysAlaska CPHQ 03-22-2017

So now you know it is communication, but are not exactly sure where the communication failure is happening. You want to study this further, so you might use an advanced Pareto Chart.

20% of the whole represents 80% of the problem is the theory behind this charting. So you brainstorm again and come up with:

• Communication between admitting and radiology• Communication between lead and technologist• Communication to patient about reasons for delays• Communication between technologist and radiologist• Unclear procedure communication from provider• Confusion by patient about scheduled procedure time• Lack of communication regarding patient prep

Advanced Pareto Chart


Advanced Pareto Chart

Admitting Lead/Tech Delays Tech/Rad Provider Time Prep

16 4 1 2 3 30 1

0

5

101520

25

30

35

40

45

50

30

16

4 3 2 1 10%

20%

40%

60%

80%

100%

80%

60

Time Admitting Lead/Tech Provider Tech/Rad Delays Prep

85%90%

95%5598.5%

60%


Scatter or Plot Diagram

Used when you want to determine the extent to which two variables are related to one another (for instance quality and process).

Example: “There is a perception that the heart measured by the monitor is not correct, and the nurse taking the heart rate manually is more accurate.”

The staff will have to duplicate and do the heart rate both by monitor and manually for at least 25 data points.


Scatter (or Plot) Diagram

Manual Monitor

80 80

60 60

100 100

70 72

92 92

60 62

75 75

65 65

70 70

85 85

90 90

75 75

100 100

110

90

70

50

40

100

80

60

40 50 60 70 80 90 100 110

Positive correlation – both methods are accurate

Man

ual

Monitor


RN Tenure ADE’s

1 yr 5

2 yrs 3

3 yrs 7

4 yrs 1

5 yrs 6

6 yrs 2

7 yrs 4

8 yrs 1

9 yrs 9

10 yrs 3

11 yrs 5

12 yrs 7

Scatter (or Plot) Diagram

Measured over a 2 year period

ADE’

s

Tenure

1 2 3 4 5 6 7 8 9 10 11 12

1

2

3

4

5

6

7

8

9

0

No correlation between RN Tenure and ADE’sAlaska CPHQ 03-22-2017

Quality Methods and Tools

Problem Identification

Data Analysis

Solution Planning

Outcome Evaluation

Flow Chart X X X

Run Chart X X X

Cause and Effect (Fishbone) X X X

Bar Chart/Histogram X X

Pareto Chart X X X

Scatter Diagram X X

Brainstorming X X X X

Nominal Group Technique X

Multi-voting X X X

Delphi Method X

Tree Diagram X

Activity Network Diagrams X X

Prioritization Matrix X X

Tool


What to Use?

1. You need ideas for a new sleep lab? After assembling the team, what method would you use to get started?

2. Some in the group will not speak up, what kind of voting would you use to get their opinions?

3. Good ideas have come up and, you have reduced them to 4 major tasks, but those tasks seem overwhelming. What would you use to prioritize the work?

4. Snow storm of the century! Been snowing consistently for 3 days and police have instructed non vital personnel to stay home. They have informed you that it will take another 4 days to get the streets plowed. Thank goodness you still have power and internet connectivity. You must continue on with planning your project. What method could you use?

5. You have identified the problems but need to know where exactly the real problems lie. What would show you 80% of the problem?


6. It seems that somedays the ER admits take longer to process and get to their rooms, but ER says no, everyone gets processed and to the floor within the 45 time limit. What could you chart to show them the average times on a daily basis?

7. What need to analyze volumes of surgical procedures in 2014 as compared to 2015 in orthopedics and gynecological cases. What chart would you use to display the data?

8. The night shift says the heat runs cold during their shift and the day shift says it runs hot during their shift. Maintenance says it runs the same temperature all the time. What could you do once you have collected the data to see if the correlation really exist?

9. What are two diagrams you can use when up against a time line or multi-step project?

10. You need to begin an Root Cause Analysis on an adverse event. You have assembled the needed team. What would be a good way to display their thoughts on what issues may have contributed to this event?

What to Use?


decision making methods and tools - ashnha.com · delphi method is a combination of brainstorming,...

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