tqm qip indonesia sept 2014 participants copyb
TRANSCRIPT
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Total Quality Management:
Quality Improvement Process
Jakarta, Indonesia
September 30, 2014
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Learning Objectives
Acquire a shared concept of quality
Become familiar with the principles of Total Quality Management (TQM)
Gain experience in using the 7-step quality improvement process
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Quality
Meeting customer needs and reasonable expectations
Doing right things right (integrity of function and composition)
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Doing Right Things Wrong Doing Right Things Right
Submitting a report on time, Analyzing patient needs
but with many errors & meeting those needs
Doing Wrong Things Wrong Doing Wrong Things Right
Patient waits a long time Making no errors while
in the wrong line collecting data no one uses
Process Done Incorrectly Process Done Correctly
W
ron
g P
roce
ss
R
igh
t P
roce
ss
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Total Quality Management
TQM
A way of ensuring customer satisfaction through the involvement of all employees in
learning how to reliably produce and deliver
quality goods and services
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Quality Teams
environment for employees to work together
Together Everyone Achieves More
developing skills and abilities
promoting communication and teamwork
enhancing quality of work life
improve quality of products and services
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TQM Principles
Customer satisfaction
Management by Fact
Respect for People
P-D-C-A (Plan-Do-Check-Act)
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Principles of TQM
Customer Satisfaction
Identifying the customer
Establishing valid requirements
Internal customer - people within your
office or organization
External customer - people outside your office or organization
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Valid Requirements
Standards of quality work agreed upon by customer and supplier
Current, realistic, measurable
Meet customer needs and reasonable expectations
Meet agency responsibilities
FBS lab request form completely and legibly
filled out and submitted to the hospital laboratory
on or before 4:00 pm prior to
day of blood collection
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Principles of TQM
Management by Fact
Enhance credibility and integrity
Gives common framework for understanding what is being done
Makes communication more certain
Makes execution of plans more predictable
Makes evaluation more credible
Evidence-based
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Quality Indicators
Measures of how well we are meeting our customers needs and reasonable expectations
Number of surveillance reports submitted late
Percent of CBC results released within 4 hours of receipt of specimen
Percent of sputum smears that are unsatisfactory
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Principles of TQM
Respect for People
Keeping people informed
Train people
Help people communicate
Delegate responsibility and authority
Create a sense of purpose in the workplace
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Rules of Conduct
Respect each person
Share responsibility
Criticize only ideas, not people
Keep an open mind
Question and participate
Attend all meetings
Listen constructively
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Principles of TQM
P - D - C - A
Corresponds to the way we operate
Common language and clear model
Act Plan
Check Do
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Plan
Begin by setting goals
based on customer needs
Plan how to achieve the
goals
Do Implement or try out the
plan to see how it works
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While doing it, gather and
analyze data to find out
what happened, what
worked and what didnt (are you closer to your
planned goal?)
Based on the analysis,
act to improve the
process
Check
Act
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Quality Improvement (QI)
Process Systematic data-based approach to problem
solving
Series of steps to be taken in the improvement process
Provides a standard way of communicating team progress
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Steps in QI Process
1 Reason for Improvement
2 Current Situation Plan
3 Analysis
4 Countermeasures Do
5 Results Check
6 Standardization
7 Future Plans Act
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Quality Control Tools
Checksheet
Pareto Chart
Ishikawa Fishbone Diagram
Histogram
Scatter Diagram
Graphs (line, bar, pie)
Control Chart
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Step 1: Reason for Improvement We have a Problem!
Objective: identify a theme (problem area) and reason for working on it
Activities:
research for themes (brainstorm, survey, interviews)
consider customer needs in selecting theme
set indicator to track the theme
determine how much improvement is needed
describe procedure in problem area (flowchart)
schedule QI story activities
Tools: graph, control chart, flowchart
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Brainstorming
Quantity of ideas not quality
Phases:
generation clarification evaluation
Uses: collect improvement opportunities (themes)
identify possible causes (Fishbone)
suggest possible countermeasures
identify barriers and aids
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Rules of Brainstorming
Clearly state purpose
Each person takes a turn, in sequence, around the group*
Present one thought at a time
Do not criticize or discuss any idea
Build on ideas of others
Record ideas where visible for group
* its okay to pass
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Multivoting
Objective: reduce the number of items to a manageable few (3-5)
Steps:
First vote: each person votes for as many
items as desired then circle items with high
no. of votes
Second vote: each person votes for a no. of
items = half the no. of circled items
Third vote: continue until the list is reduced to
3-5 items
Never multivote down to only one item!
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Theme Selection Matrix Themes Customers Impact on Customer X Need to Improve = Overall
Scale: 1 = None 2 = Somewhat 3 = Moderate 4 = Very 5 = Extreme
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Theme Selection Matrix
25
5
5
TB
Symptomatics
Quality
Assurance for
AFB Smears
15
3
5
Physicians,
Patients
Release of Blood
Culture results
15
3
5
Physicians,
Patients
Antimicrobial
Susceptibility
Testing
10
2
5
Malaria
suspects
Quality
Assurance for
Malarial Smears
Over-all
Score
Need for
Improve-
ment
Impact on
Customer
Customer Theme
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Flowchart Picturing the Process
ending or beginning
action
direction
decision
Sequence what is, not the ideal!
? Y
N
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Flowchart for Water Chlorination
Guimba, Nueva Ecija
Sanitary
Inspector is
assigned to
chlorinate
water sources
Increase
no. of
diarrhea
cases
Test wells Use for
drinking
Chlorinate
PHC media
available
Condemn
well
Test well
Y
N
(-)
(+)
(+)
(-)
-
TB
Symptomatics
AFB Smear
(3 times)
Smear
Result
Neg. Smear (3 spc.)
Chest X-ray
Reading
Results
Negative X-ray Positive X-ray
Screening by DiagnosticCommittee
Results
Inactive TB(Stable/Healed/Fibrosis)
Symptomatic treatment,
Surveillance only
Active TB
TB Treatment
Positive Smear 2 or 3 spc.
DOTS
symptomatic treatment,
surveillance only
Flowchart for TB
Symptomatics
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Step 2: Current Situation What exactly is the Problem?
Objective: select a problem for improvement
Activities:
data collection (checksheet)
stratify theme from various viewpoints (Pareto chart)
write problem statement
set target for improvement
Tools:
checksheet, histogram, Pareto chart
Graph used in step 2 should also be used in step 5!
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Checksheet or Tally Sheet
a form for systematic data collection
categories: what, who, where, when, how
not why?
basis for constructing Pareto chart, graphs
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Pareto Chart
a search for significance
stratification tool to identify the vital few vs. the trivial many
graphic depiction of 80-20 rule
helpful in prioritization
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Reasons for Wasted AFB Smears (N=135)
Claveria Municipal Health Office, Jan Dec 1999
0
15
30
45
60
75
90
105
120
135
Salivary Specimens Incorrect Staining
Procedure
Contaminated slides No med tech
available
0
100
50
Number Percent
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How to do a Pareto Chart
1. Identify data needed and collect (checksheet)
2. Define categories - sort data and tally
3. Construct graph
bars arranged in decreasing order (touching)
left axis for actual data
right axis for percent of total
cumulative line from zero
4. Analyze and interpret graph
Is there a Pareto pattern?
5. If no Pareto pattern, try different stratification
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Problem Statement Who, What, When, Where
States the effect not the cause
Focuses on gap between what is and what should be
Measurable
Specific
Stated in a positive manner (not a question)
Focuses on the pain
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Problem Statements
In 2010, an average of only 75% of Pap smears taken per month were
of satisfactory quality.
In January 2014, the average waiting time at health center A was
1.5 hours.
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Theme: Patient waiting time at health center
Indicator: Average patient waiting time
Problem Statement: In June 2010, the average patient
waiting time was 50 minutes.
Target: By January 2011, the average patient waiting
time will be 30 minutes.
Step 1: Reason for Improvement
Step 2: Current Situation
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Step 3: Analysis What is causing the problem?
Objective: Identify and verify root causes of the problem
Activities:
do cause and effect analysis (Ishikawa Diagram)
identify actionable root causes
select root cause with greatest impact
verify selected root cause with data
Tools:
Ishikawa diagram, Pareto chart, scatter diagram,
etc.
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Ishikawa (Fishbone) Diagram Cause and Effect Analysis
Effect
P.S.
A
PS = Prob. Statement, RC = Root Cause
B
C
D
RC
RC RC
RC
Why?
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Generic Categories for Fishbone
Methods
Machine Materials
Environment
P.S.
People
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Come on, lets get moving!
I agree, we cant be late again!
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How might we determine our major categories?
1. Generic - People, Methods, Machine, Material,
Environment
2. Process - Break down the process into major activities.
3. Brainstorm - Team brainstorms causes of the problem, then segments ideas into major categories.
4. Pareto - Breakdown effect (of problem statement)
into components
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How is it done?
1. Draw diagram starting at right building major categories left.
2. Write the effect of the problem statement in the rightmost box.
3. Determine major categories.
4. Once completely drawn, start with the major category most likely
to produce an actionable root cause and ask why? (5 times)
Major Category
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5. Now revisit each sub-bone or sub-category for additional causes;
that is move back to a2 and ask again why a2 occurs, then ask again
why a1 occurs, and so on.
6. Complete the entire fishbone or category before moving on.
7. Cloud actionable root causes.
8. After completing the diagram, we must verify suspected root
causes with data.
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Few FLSWs have smears taken by SHC staff
Ishikawa Diagram
SHC not FLSW friendly
User fees
LGU lacks funds No mandate to serve FLSWs
Sanitation code requires only RFSWs to go to SHC
Painful procedure
Wrong position
FLSW not properly instructed by staff
STI
Do not use condom
Condom not available
Lack of condom supply Instrument
not properly lubricated
Use of water only
No KY jelly supply
Staff is rushing
Work overload
Lack of trained staff
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Why is it useful?
It helps teams reach a common understanding of
problems, exposes gaps in knowledge, directs teams
towards actionable methods for reducing their
problems, and it is easy to use.
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Scatter Diagram
Shows the relationship between two quantitative variables (positive correlation, negative correlation, no correlation)
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When is it used?
It is used almost exclusively in step three to find
relationships between suspected root causes and the
effect of the problem.
Scatter Diagram
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Step 4: Countermeasures What are we going to do about what is causing the problem?
Objective: Plan and implement countermeasures that will correct root causes of the problem
Activities:
develop countermeasures attack root causes
meet customers valid requirements
cost beneficial
develop action plan
who, what, when, where, how
barriers and aids (Force Field Analysis)
implement countermeasures
Tools: countermeasures matrix, cost estimates, barriers & aids, action plan
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Countermeasures Matrix
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PROBLEM STATEMENT
ROOT CAUSES
COUNTER MEASURES
PRACTICAL METHODS
EFFECTIVENESS
FEASIBILITY OVER-ALL
ACTION
Improper Disposal of Waste Blood Components
No SOP for recording
Create SOP Chief Med Tech to formulate SOP
5
5
25
y
No orientation of lab staff on waste mgt.
No maintenance team
Re-orient lab staff
Create
maintenance team
Give orientation during lab meeting
Post guidelines and procedure for disinfection at the lab
COH to assign maintenance personnel
PHO to assign maintenance personnel
5
5
5
3
5
5
5
2
25
25
25
6
y
y
y
N
Worn-out PVC connection
Repair worn-out connections
Ask COH for repair
5
5
25
y
No written request to replace PVC pipe
make written request to AO
Med tech to submit written request to AO
5
4
20
y
Countermeasures Matrix
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How is it done?
1. Identify CM and PM.
2. Brainstorm barriers, list on left.
3. Brainstorm aids, list on right.
4. Rank each as H, M or L.
5. For each barrier, try to identify an aid.
6. Connect with lines.
7. Unconnected barriers need action
otherwise not feasible.
Barriers and Aids Analysis
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Step 4: Countermeasures
Countermeasures Matrix
Barriers and Aids (Force Field Analysis)
consider people, environment, equipment, funds
Action Plan
who, what, when, where, how, budget
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How is it done?
1. Break CM into manageable components.2. List activities that must be done to ensure a
successful implementation.
3. Identify resources for each task.4. Address remaining barriers and any actions to
overcome them.
5. Brainstorm for anything possibly missed.
Action Plan
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As we can see, it is not necessarily detailed.
The point is that we make a plan and stick to it. If we present
this plan to management and do not follow through, without good
reason, the team (and teamwork) may be looked upon poorly.
Action Plan
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Problem statement: From October to December 2001, 0% of blood
units transfused to patients were fully screened.
Improvement Target: By July 2002, at least 10% of blood units
transfused to patients each month will be fully screened.
Countermeasure: Assign medical technologist to do blood screening
Practical Method: Request training for medical technologists to
include HIV testing
Number Task/
Project
Due Date Assigned
To
Date
Assig
ned
Status/
Remarks
1 Select med
tech
June 4 N. Ha-chac May 1 Based on interest
and experience
2 Prepare
Training
materials
July 1 H. Baraquia May 1 Check with
Ministry of
Health
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Step 5: Results How well did we do in eliminating the problem?
Objective: confirm that the problem and its root cause(s) have decreased and target improvement
has been met
Activities:
before and after comparison using same indicator (use same graph or chart)
if Yes then go to Step 6 (standardization)
if No then go back to Step 3 (analysis) or 4 (countermeasure)
Tools: Pareto chart, Control chart, Histogram, Graph
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Figure 5. Percent of Blood Units Transfused to Patients that are fully screened by Month,
Oct 2001 Oct 2002
0
10
2030
40
50
60
7080
90
100
Oct
Nov
Dec Ja
nFe
bMar
Apr
May
June
July
Aug
Sept O
ct
Percent of Units
2001 2002
Original Target
Intervention
NewTarget
Improving Blood Screening Service
in Sultan Kudarat Province, Philippines
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Step 6: Standardization How do we maintain our gains?
Objective: Prevent the problem and its root causes from recurring
Activities:
assure that countermeasures become part of daily work
[work process, standards]
train employees on new process/standards
[explain purpose]
establish periodic checks
consider other areas for replication
Tools: control charts, graph, procedures, training
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Standardization will not be
achieved simply by documents.
Standards must become a part
of the thoughts and habits of the workers.
-- Dr. Hitoshi Kume
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Incorporate countermeasures
into our daily work.
Flowchart the process.
Establish a monitoring system.
Prepare written guidelines.
Train employees.
Consider how to replicate.
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Step 7: Future Plans What next?
Objective: evaluate teams effectiveness and plan what to do about remaining problems
Activities:
review lessons learned
What was done well?
What could be improved?
What could be done differently?
analyze and evaluate any remaining problems
plan further actions
Tools: action plan
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Future Plans
Objectives:
1) See that remaining components of
problem areas are addressed.
2) Review P-D-C-A lessons learned.
Critical Question: What do we do
about remaining problems and how
can we do better next time?
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1. Reason for 2. Current 3. Analysis 4. Counter-
Improvement Situation Measures
5. Results 6. Standardization 7. Future Plans
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Quality is within
your reach!