East Central Regional Hospital
PERFORMANCE
IMPROVEMENT
REFRESHERLL Quality Management DepartmentRevised 11/03
This is a Typical Organizational
Direction !
?
?
This is the Preferred Organizational
Direction !
Our Mission
To provide quality mental health/developmental disabilities care and
treatment to our consumers
East Central Regional Hospital
Our Vision
To use resources, creativity, and innovation to become a
CENTER OF EXCELLENCE.
East Central Regional Hospital
Performance Improvementis a continuous effort of assessment,
evaluation and adaptation by an organization to improve the outcome of services, processes and functions.
Performance Improvement is every employee’s
concern!
No matter what your job, you play an important role in
helping provide quality patient care.Performance Improvement is on-
going!
Being committed to quality doesn’t mean reaching a goal, then quitting.
Even when something is working well, there is room for improvement.
BrainstormingAffinity Diagram
Cause and Effect Diagram (“Fishbone”)Flow Chart
ChecksheetsLine Graph
Pareto Chart Histograms
Performance Improvement Tools
HOW DO WE KNOW WHICH TOOLS TO USE?
Tools for generating ideas, setting priorities, providing direction,
understanding root causes, and helping to understand processes:
BrainstormingAffinity Diagram
Cause and Effect Diagram (“Fishbone”)Flow Chart
,
Performance Improvement Tools
(These are Qualitative Tools which focus on data describing consumers, occurrences & conditions)
Creativity Large Number of Ideas All team members involved Sense of ownership in decisions Input to other Tools
BrainstormingWhat is Brainstorming ?
A tool used by teams for creative exploration of options in
an environment free of criticism.
Benefits of Brainstorming
Brainstorming Ground Rules Active participation by everyone No discussion Build on others’ ideas Display ideas as presented Set a time limit Clarify and combine
What Is An Affinity Diagram?
A tool that gathers lots of “language data”, like ideas and opinions and then sorts and groups the related ideas.
Display Ideas
Sort Ideas into Related Groups
Drawing Finished Affinity
Superheader
Header
Idea
Idea
Idea
Header
Idea
Idea
Idea
Header
Idea
Idea
Idea
LL- QM DEPT.
What Is A Cause and Effect Diagram ?
(“Fishbone Diagram”)A tool that helps identify, sort, and display possible causes of a problem in a process.
Benefits of Using a Cause and Effect Diagram: Encourages group participation Uses an orderly, easy-to-read format Increases knowledge of what is happening in the process
Methods
Effect
People
Environment
Equipment
Methods
Late for Work
People
Environment
Equipment
Cause & Effect Diagram
EXAMPLE: Why are employees late for work?
Out of gas
Son misplaced books
Forgot to set clock
caught by train
Dog needed walking
car wouldn’t start
Tried a new route
Raining hard
LL QM Dept.
What Is A Flow Chart?
A diagram that uses graphic symbols to show the nature and flow of steps in a process.
Benefits of Using a Flow Chart: Promote process understanding Provide a tool for training Identify problem areas and improvement opportunities
Symbols Used in Flowcharts
Start/End
Process Step
Decision No
Yes
ConnectorMeasurement M
An example of a Flow Chart
D ec ide to eatlunc h
D id I br inglunc h?
G et lunc h fromrefr igerator
G o to Central
Kitc hen?
G et m oney. G o to Kitc hen
Eat lunc h
S elec t food anddrink
P ay for lunc h
G o to lounge D is c ard tras h G o to off ic e
Eat lunc h
T ake tray totray line
G o offc am pus ?
G et w allet andc ar keys
G et in to c arD ec ide w here
to eat D rive to lunc h O rder lunc h P ay for lunc h
Eat lunc h D is c ard tras h G et in to c ar D rive to w ork G o to off ic eP ut w allet and
keys aw ay
Res um e w ork
G o to off ic eP ut w allet and
keys aw ay
F orget lunc h,go to m eeting
ins teads top
S top
Yes
Yes
Yes
N o
N o
N o
L unch
Statistical Tools used for measuring performance, collecting and displaying data, and monitoring performance over
time:
Check Sheets Line Graph Pareto Chart Histograms
Performance Improvement Tools(These are Quantitative Tools and focus on specific measurement units)
CHECKSHEETS
Record data for further analysis, provide a historical analysis and introduce data collection methods.
TIME
(Minutes)
Time of Day8 109 11 12 1 32
0
10
5
15
20
25
Turn-around time
1-5 min
6-10 min
11-15 min
16-20 min
Dwl 11/03
What Is A Line Graph?
A line graph that shows results of a process over time.
Why Use Line Graphs? Analyze and check the data for patterns Monitor process performance Communicate process performance
Number of Restrictive Procedures Used Per Shift
0
2
4
6
8
10
Month
# P
rocedure
s U
sed
DayEveningNight
(The chart above is an example only, not an actual representation of restrictive procedures used)
What Is A Pareto Chart?
A graph using a set of bars to show how often a problem occurs.
Why use a Pareto Chart? Breaks big problems into smaller pieces Identifies most significant factors Shows where to focus efforts and improvement opportunities Allows better use of limited resources
05
1015202530354045
Number of Patients
Reason
Reasons Patients are Readmitted within 30 Days
Stopped takingmedicationsMajor life change
No Where to Stay
Commission of Crime
Other
(The chart above is an example only, not an actual representation of reasons for re-admissions)
What Is A Histogram?
A bar chart that shows the distribution of data.It’s like a “snapshot” of the process.
When are Histograms used? To summarize large data sets in a picture form Compare measurements to expectations Communicate information to the team Assist in decision making
05
1015202530354045
Number of Patients
Wait Times
Time Required to be Scheduled for Podiatry Appointment
2 Weeks or less2-4 WeeksMore than 4 Weeks
(The chart above is an example only, not an actual representation of appointment wait times)
What Is Data Collection?
Data Collectionis
obtaining useful information.
The issue is not: How do we collect data?It is: How do we obtain useful data?
Why Collect Data?
To establish a factual basis for making decisions
“I think the problem is……….”becomes
“The data indicate the problem is…..”
FOCUS-PDCAFOCUS-PDCAPerformance Improvement ModelPerformance Improvement Model
DOCHECK
PLAN
Improvement Data Collection
Improvement Data Collection Data Analysis
Data for process improvement
Find a process to improve
Organize a team that knows the process
Clarify current knowledge of the process
Understand causes of process variation
Select the process improvement
ACT To hold gain To continue improvement
Examples of Quality in a Hospital Setting JCAHO 1992
Find A Process to Improve
ThinK: High Volume? High Risk?Problem Prone? Externally mandated?Who will benefit from the process improvement? How does it fit the mission?
Organize a Team that knows the process
ThinK: Does the team include members who do the work & know the process ?
Clarify Current Knowledge of the Process ThinK: What are the things that contribute to the process not working the way we expect it will? Is this the actual flow of the process or the perceived flow?
?
?
?Perceived Actual
Understand Causes of Process Variation
ThinK: Can we use the data collected to determine specific, measurable andcontrollable variations?
Select the Process Improvement
ThinK: What changes can be made to improve the process?
Can we test the changes in a pilot project?
Plan the improvement and continued data collection.
ThinK: How do we make the changes that were selected as possible solutions and what are our goals and targets and how can we reach them?
Do the improvement, data collection and analysis
ThinK: As we begin the process improvement are we getting the results/outcomes we expected? Are there any surprises?
Check and study the results
ThinK: If there were surprises or unexpected outcomes, can we do anything about them? Has the process improvement been successful, or will it be necessary to modify the change?
Act to hold the gain and continue to improve the process.
ThinK: How will the improvement be implemented beyond the pilot, if one was used, and can the team find another potential improvement within the process? Are we prepared to return to “Plan” orearlier steps in the FOCUS-PDCA if needed?
FOCUS-PDCAFOCUS-PDCAPerformance Improvement ModelPerformance Improvement Model
DOCHECK
PLAN
Improvement Data Collection
Improvement Data Collection Data Analysis
Data for process improvement
Find a process to improve
Organize a team that knows the process
Clarify current knowledge of the process
Understand causes of process variation
Select the process improvement
ACT
To hold gain To continue improvement
Examples of Quality in a Hospital Setting JCAHO 1992
If necessary, you can start the FOCUS-PDCA again!
East Central Regional Hospital
Working together to improve Services, Safety and Quality of Care for all our consumers!