Untangling Quality Improvement
Tools
CAH/Small Rural Learning Community
Lynne Hall
s2
Flow Charts
Objectives
Describe the quality control and the
management and planning tools used in
quality improvement
 Explain how to use the various
performance improvement tools to
implement the quality management

What is Quality?
According to Merriam-Webster Online
Dictionary, Quality is:
 A degree of excellence : grade
 A distinguishing attribute : characteristic
<possesses many fine qualities>
Total Quality Management (TQM)
A management approach to achieve longterm success
 Everyone in the organization participates
in improving processes, services, patient
care, and the culture where they work
 TQM takes strong commitment from
leaders in your organization

Quality Tools

Key: Manage what you measure
◦ What process needs work?
Gather data
Change process
Act on data
Quality Tools

Key: Manage what you measure
◦ What process needs work?
Gather data
Change process
Act on data
◦ Present data to leadership!!
TOOLS AND
TECHNIQUES
How do I decide which improvement
area needs to be address first?
You can use:
 Flow Chart
 Check Sheet
 Pareto Chart
 Brainstorming
 Nominal Group Technique
 Root Cause Analysis
Brainstorming

Process
◦ Define the topic
◦ Ask each person for 5 ideas on the subject
◦ Give them a couple of minutes to write them
down
◦ Ask for ideas and list them on a flipchart
◦ Review / clarify / combine like ideas
◦ Revisit and revise the list later in the meeting
or at the next meeting
Brainstorming

Methods
◦ Have people use sticky notes and stick on a
flipchart
◦ Take turns around the room until everyone
says pass
◦ Have each team member write one idea on a
sheet of paper and pass it to the next person
can add to or build off other statements
◦ This is your chance to think outside the box!!
Nominal Group Technique
Can enhance one or more dimensions of
effectiveness of decision-making groups
 NGT provides:

◦ more unique ideas,
◦ more balanced participation between group
members,
◦ increased feelings of accomplishment, and
◦ greater satisfaction with idea quality and
group efficiency
Nominal Group Technique
The nominal group technique is particularly
useful:
 When some group members are much
more vocal than others.
 When some group members think better in
silence.
 When there is concern about some
members not participating.
 When the group does not easily generate
quantities of ideas.
Nominal Group Technique
The nominal group technique is particularly
useful:
 When all or some group members are new
to the team.
 When the issue is controversial or there is
heated conflict.
 When there is a power-imbalance between
facilitator and participants or participants:
the structure of the NGT session can
balance these out.
Flow Chart
Identifies problems and opportunities
 Helps define scope of process
 Documents a process
 Analyzes process for improvements

Flow Chart
Not toasted
Get
Bread
Toasted?
Add Peanut
Butter
Add Jelly
Enjoy!
Toasted
Check Sheet
Used for data collection
 Measure/track:

◦
◦
◦
◦

Process
Problems
Causes
Other performance factors
Helps with pareto charts and other
display tools (pie charts, run charts)
Check Sheet

Application for Check Sheets:
◦ Provides consistent data collection
◦ Identifies and defines problems /
opportunities
◦ Sets priorities
◦ Identifies root causes
◦ Used for follow-up and verify results
Check Sheet

Getting started:
◦
◦
◦
◦
◦
◦
◦
Determine the data to be gathered
Decide on the frequency
Design a checksheet
Train users
Mark appropriately (checks or hashmarks)
Compile results
Analyze and graph data
Check Sheet
Making a PB & J Sandwich
Data Analyst ___________
Process Step
Date/Time start
Date/Time Stop
Pareto Chart
A special type of bar chart
 Helps focus team on components of the
problem that has the biggest impact
 Based on the Pareto Principle

◦ 80% of the effects we see are due to 20% of
the causes
The data are easy to gather
 They are easy to construct
 Easy to interpret

Pareto Chart
Root Cause Analysis
Interdisciplinary REVIEW of the process
surrounding an event (actual or near)
to develop prevention strategies





When – Unplanned Event (REACTIVE)
What – Tool for Review
Why - Review Process Steps
Who – Organizational Leadership AND Frontline Caregivers
How – Correct Process to Prevent Future Event
FOCUS on process NOT person
 Appropriate use
 Consistent use
Next:
Describe the problem
 Check Sheet
 Pareto Chart
 Histogram
 Pie chart
 Stratification
Next:
Arrive at a statement that describes the
problem in terms of what is specifically,
where it occurs, when it happens, and its
extent
 Check Sheet
 Pareto Chart
 Histogram
 Pie chart
 Stratification
Stratification

Utilizes the data to “slice and dice”
◦ What are the differences
◦ What are the similarities

Consider this application anytime you
want to collect data
Stratification
Factors
Examples
Who
• Department
• Individual
• Customer Type
What
• Type of Complaint
• Defect Category
• Reason
When
• Month, quarter
• Day of week
• Time of Day
Where
• Region
• Department
• Unit
Histograms


Used with either continuous data or counts
of attributes (discrete data)
Shows distribution of the data
◦ Highs and lows


Allows you to see variation in the data
Helps answer questions:
◦ Is the process centered on the customer
requirement
◦ Does the process miss the customer requirement
◦ Is the process skewed with unexpected points
Histograms
Pie Chart
A circular chart that illustrates a
proportion of the data
 Works particularly well when the slices
represent 25 to 50% of the data

Pie Chart
What are all the possible Causes of
the Problem?
Check Sheet
 Cause & Effect Diagram
 Brainstorming
 Root Cause Analysis
 Failure Mode Effect Analysis
 Force Field Analysis

What are all the possible Causes of
the Problem?
Check Sheet
 Cause & Effect Diagram
 Brainstorming
 Root Cause Analysis
 Failure Mode Effect Analysis
 Force Field Analysis

Cause and Effect Diagram
Also know as Fishbone
 Basically a structured Brainstorming
 Establishes categories of potential causes
 Gives focus to help begin process and
data analysis
 This IS NOT a way of identifying which
idea is the “culprit”

Cause and Effect Diagram
People
Equipment
Floor is wet
No handrails
Nurses not rounding
Call lights not answered
Falls
Non-skid footwear
Education
of family
Methods
Failure Modes and Effects Analysis
Helps anticipate problems so you can take
steps to correct, reduce and eliminate
(PREVENT problems or anticipated) risks
 Identifies ways a change in a process,
product or service that may cause
unintended problems

Failure Modes and Effects Analysis
1.
2.
3.
4.
5.
6.
Brainstorm all the potential ways the
change in the process could fail
List these failure modes
Identify the potential cause of these
failures
Develop a rating scale
Rate each of the factors
Multiply the 3 numbers together to get
the Risk Priority Number
Failure Modes and Effects Analysis
Multiply the 3 numbers together to get the
Risk Priority Number
◦ Start with the failures that have the highest
RPN’s discuss for each failure ways to
eliminate the causes, the chance of it
reoccurring, ect
◦ Assign responsibilities for each action
identified
Force Field Analysis
Helps teams proactively build support and
neutralize blocking factors to an
impending change
 Application

◦ Determining solutions
◦ Identifies and removes obstacles
◦ Plans and implements a process change or
solution
Force Field Analysis
1.
2.
3.
4.
Clarify the change or solution to be
analyze
Divide a flipchart page into two halves
Brainstorm forces for and against the
change
Start with the driving forces and and
identify ways to:
1. Reinforce the support
2. Make the support more visible in your plans
3. Link your solution to that support
Force Field Analysis
5. Categorize the restraining forces as
follows:
◦ Blocks – regulations, policies, laws
◦ Constraints – resources, budget, time
◦ Illusions – “That’s not what we have done
before”
6. Identify steps to neutralize restraining
forces
7. Determine which neutralizing actions are
necessary and build into your plans
Force Field Analysis
Agree on basic cause(s) of the
problem
Check Sheet
 Pareto Chart
 Scatter Diagram
 Brainstorming
 Nominal Group Technique

Agree on basic cause(s) of the
problem
Check Sheet
 Pareto Chart
 Scatter Diagram
 Brainstorming
 Nominal Group Technique

Scatter Diagram
Allows you to test hypothesis about the
causes of the problems
 Uses paired data: Do these have an effect
on one another?

Scatter Diagram
Scatter Diagram
Positive correlation
between the two
data points
 Example: Positive
correlation between
more falls at change
of shift

Scatter Diagram
Negative correlation
between the two
 Example: Less falls
happen during shift
change

Scatter Diagram
Indicates a complex
relationship
 Example: More falls
happen at change of
shift on Tuesdays

Scatter Diagram
No correlation at all
between the two
 Example: Falls don’t
depend on shift
change

Presenting Data to Leaders and Others
Run Charts
 Pie Chart
 Bar Graphs

Presenting Data to Leaders and Others
Run Charts
 Pie Chart
 Bar Graphs
 Pareto Chart
 Scatter diagram

Develop an effective and implementable
solution and action plan
Run Charts
 Pie Chart
 Bar Graphs
 Pareto chart
 Scatter Diagram

Run Charts – watching performance
over time
 Purpose: to
measure and track a key
input, process, or output measure
over time
Run Charts – watching performance
over time
Run charts got their name because of the practice of
counting “runs” or sequences of consecutive points of
either side of the median
 Too many or too few clusters are a signal that something
special is happening within your process
 Graphs of data show improvement over time
 Tool for assessing the effectiveness of change

RUN CHARTS
Run charts have a variety of benefits:

Help improvement teams formulate aims by
depicting how well (or poorly) a process is
performing
◦ Identifying problems, opportunities (trends, patterns, or
output measure over time)
◦ Determining potential root cause(s)
◦ Follow-up and verification of results

Provides a quick look at a process
Monitoring Improvement…
RUN CHARTS
1. Plot your
data.
2. Find your
mean or
average
3. Identify
runs
4. Look for
Special
Cause
Variation
5. Note any
changes
made in
the process
Monitoring Improvement…
RUN CHARTS
1. Plot your
data.
2. Find your
mean or
average
3. Identify
runs
4. Look for
Special
Cause
Variation
5. Note any
changes
made in
the process
Implemented new
fall process
Monitoring Improvement: Run
Chart Rules


Common Cause Variation – the random
variation associated with a process (No
process is a straight line)
Special Cause Variation – a difference in the
normal process variation
◦ Six or more consecutive increasing or decreasing
points
◦ Nine or more consecutive points on the same
side of the median
◦ 14 or more consecutive points alternating up and
down around the median
Bar Graphs
Used for data that is not related to one
another or is not continuous
 Use for independent data

Bar Graphs
s62
Check
Flow
Charts Sheet
Pareto
Charts
Check
Sheet
Histogram
Brainstorming
Nominal
Group
Technique
What is my improvement area?

Check
Sheet

Pareto
Charts
Pie
Chart
Root Cause
Analysis
Stratification
Describe the Problem
Check
Sheet
Check
Sheet
Cause of the Problem
Root Cause
Analysis
Check
Sheet
Check
Sheet
References
http://asq.org/learn-about-quality/totalqualitymanagement/overview/overview.html
 Melum, Mara Minerva and Sinioris, Marie
Kuchuris; 1992;Total Quality Management
 http://www.emathzone.com/tutorials/basi
c-statistics/scatter-diagram.html
