Academic Pediatric Association
QUALITY
IMPROVEMENT
TRAINING:
Module #4
This work is supported by a grant from
The Centers for Disease Control & Prevention.
More QI Tools
to Better Understand the System
National Partnership for
Adolescent Immunization
PI: Peter Szilagyi
Coordinators: Christina Albertin, Nui Dhepyasuwan
FACULTY & CONSULTANTS
 Donna D'Alessandro
 Ed Marcuse
 William Atkinson
 Cindy Rand
 Paul Darden
 Jan Schriefer (QI expert)
 Sharon Humiston
 Stanley Schaffer
(moderator)
 Keith Mann (QI expert)
 Janet Serwint
 William Stratbucker
This is part of the APA series on Quality
Improvement. The examples focus on
adolescent immunization, but the principles
are widely applicable. The series includes:
1. Overview: The Model for Improvement and
2.
3.
4.
5.
6.
Deming’s System of Profound Knowledge
Improvement cycles and the psychology of change
Initiating a QI project
More tools to better understand the system
How will we know that a change is an
improvement? An introduction to QI measurement
Changes we can make that will result in
improvement
Module 4 Objectives
After viewing this segment, you will be
able to describe the development and
purpose of each of the following tools
for understanding the system:
 Flowcharts
 Cause and effect diagrams
 The 5 whys technique
Flowcharts
Flowcharts
 What: Draw a picture of your process as a team
 High-level flowchart - shows the process in 6-12
steps, useful early to show major activity blocks
 Detailed flowchart – shows dozens of steps; useful
later to identify rework loops and process complexity
 Purpose: Coming to agreement on what the
process really is. This helps the team understand
the process and develop ideas about how to
improve it.
 Who: All the groups involved (there will likely be
as many versions of the process as there are
people)
http://www.ihi.org/knowledge/Pages/Tools/Flowchart.aspx
http://tipqc.org/qi/jit/tools/flowcharts/
IHI’s Sample High-Level Flowchart:
Ischemic Heart Disease Patient Flow
http://www.ihi.org/knowledge/Pages/Tools/Flowchart.aspx
IHI’s Sample High-Level Flowchart:
Ischemic Heart Disease Patient Flow
http://www.ihi.org/knowledge/Pages/Tools/Flowchart.aspx
From American Society for Quality
http://asq.org/learn-about-quality/process-analysis-tools/overview/flowchart.html
The same process as
a detailed flowchart
http://asq.org/learn-aboutquality/process-analysistools/overview/flowchart.html
To see a sample (fictional) flowchart on
“HPV Vaccination in a Pediatric Residency Clinic”
https://www.dropbox.com/s/lmsr8arhjh88bqi
/Teen%20Immunization_work_flowSAMPLE.pdf
How to Make a Flowchart
 Prepare:
 Right people
 Right level
 Right boundaries - beginning and ending
 Step-by-step:
 Starting at the top, ask, “What’s next?”
 Put each step under last, on a “sticky note”
 Where you disagree, lay the options side-by-side;
come back later, and discuss which is preferable.
Completing Your Flowchart
 Use software to document
 You may need to
 Gather info
 Revise the flowchart as more is
understood about the actual process
QUESTION #1: Which 1 of the following is
FALSE regarding flowcharts?
A. A high-level flowchart shows a process in 6-12 steps and is
useful early in the QI project for shining a light on the major
blockages.
B. The main purpose for creating a flowchart is to come to
agreement on what the process really is, which, in turn, helps
the team understand the process and develop ideas about
how to improve it.
C. As far as possible, the main clinic administrator should be the
only one to have input into the creation of the flowchart so it
reflects the way the process should go.
D. When flowcharts are formally produced (using software),
decision points in the process are shown as diamonds.
QUESTION #1: Which 1 of the following is
FALSE regarding flowcharts?
A. A high-level flowchart shows a process in 6-12 steps and is
useful early in the QI project for shining a light on the major
blockages.
B. The main purpose for creating a flowchart is to come to
agreement on what the process really is, which, in turn, helps
the team understand the process and develop ideas about
how to improve it.
C. As far as possible, the main clinic administrator should be the
only one to have input into the creation of the flowchart so it
reflects the way the process should go. As far as possible, all
the groups involved in the process should have input into the
creation of the flowchart.
D. When flowcharts are formally produced (using software),
decision points in the process are shown as diamonds.
Cause and effect
diagrams
Cause and Effect Diagrams
(aka “Fishbone Diagram”)
 What: A graphic display of a list
 Purpose: Permits identification and
organization of a list of factors thought to
cause a problem or affect variation; can also
be used as a Root Cause Analysis Tool
 Who: All the people involved
http://www.ihi.org/knowledge/Pages/Tools/CauseandEffectDiagram.aspx
http://tipqc.org/qi/jit/tools/cause-and-effect-diagram/
Sample Cause & Effect Diagram
PEOPLE
ENVIRONMENT
Nursing
Providers
Motivation
Training
Motivation
Training
Schedulers
Low rate of
HPV
Motivation
Training
immunization
Better handout
for reluctant
parents
MD
recommendation is
No return
not strong
appts set up
Standing order
instruction sheets
MATERIALS
for 11-12 yr
old patients
Computers
slow
Adolescent
immunization record
scattered
METHODS
Lack of
automated
reminder
system
EQUIPMENT
Typical Categories for Major Causes
 Equipment, Methods, Materials, People,
Environment/Measurements/Procedures
 Who, What, When, Where
 People, Provisions (Supplies), Procedures,
Place, Patients/Families
 Steps of Process
Sample Cause & Effect Diagram
Process Type
PATIENT
ARRIVES
PATIENT
CHECKS IN
OBTAIN
WEIGHT AND
VSs;
GO TO EXAM
ROOM
PROVIDER
DOES H&P
•No info given
•Registration unfriendly
(per survey)
•No expectation for
•Conversation is social;
vaccination
not educational
•No parent for
•Some nurses are anticonsent
vaccine (per rumor)
•Hurried! No time to
answer “in depth”
questions
RECOMMEND
VACCINE?
YES
FAMILY
ACCEPTS?
•No good info sheet
•Providers not trained to
answer succinctly
NO
NO
YES
GIVE ORDER
TO NURSE
•Delayed if busy
NURSE GETS
VACCINE
•Med room is 30 steps
from most exam rooms
NURSE GIVES
VACCINE;
DOCUMENT
PATIENT
DISCHARGE
How to Make a
Cause and Effect Diagram
Fill in each of the following:
 Large arrow pointing to the name of the
problem or issue
 The branches off the large arrow
represent main categories of potential
causes.
 Smaller branches, representing subcategories (can be a list of items)
The 5 whys
technique
The ‘5 Whys’
 What: Repetitive questioning, looking for
deeper levels of the problem’s root causes
 Purpose: To overcome the tendency to be
satisfied with superficial answers and get at
root causes
 Who: QI team
http://www.ihi.org/knowledge/Pages/ImprovementStories/AskWhyFiveTimestoGettotheRootCa
use.aspx
http://www.isixsigma.com/tools-templates/cause-effect/determine-root-cause-5-whys/
An example of the 5 Whys
1. Why does our clinic have such low rates of HPV vaccination
for boys? Because the doctors forget to order it.
2. Why do the doctors forget to order it? Because some of our
doctors only work part-time…Are they even aware that it’s a
routine recommendation or why it’s important
3. Why would the part-time attendings be unaware…Because
there hasn’t been any kind of in-service for the part-time
attendings.
4. Why hasn’t there been an in-service for the part-time
attendings? Because it would cost the office a lot to bring
them all in for an extra hour and they’d want food, too.
5. Why would we have to bring them in? There’s an online
learning module…
QUESTION #2. Which of the following is
FALSE regarding the tools discussed in
this module?
A. The ‘5 Whys’ is a simple tool, easy to complete
without statistical analysis.
B. Equipment, Methods, Materials, Why, and
Environment/Measurements/Procedures are major
categories that are commonly used in Cause and
Effect Diagrams.
C. Who, What, When, and Where are major categories
commonly used in Cause and Effect Diagrams.
D. Use of Cause and Effect Diagrams helps identify and
organize factors believed to cause a problem.
QUESTION #2. Which of the following is
FALSE regarding the tools discussed in
this module?
A. The ‘5 Whys’ is a simple tool, easy to complete
without statistical analysis.
B. Equipment, Methods, Materials, Why People, and
Environment/Measurements/Procedures are major
categories that are commonly used in Cause and
Effect Diagrams.
C. Who, What, When, and Where are major categories
commonly used in Cause and Effect Diagrams.
D. Use of Cause and Effect Diagrams helps identify and
organize factors believed to cause a problem.
By understanding a system,
one may be able to
predict the consequences
of a proposed change.
W.E.Deming
This module highlights just a few tools to
help understand the system.
There are many more options.
The more you QI projects you do, the more
tools you will want in your tool bag.
Garbage in, garbage out
Summary
In this module, we discussed the development and
purpose of a few tools for understanding the system:
1. Flowcharts are a graphic display of your process,
used to help understand what the process really is
2. Cause and effect diagrams (or fishbone diagrams) are
a graphic display of a list, used to identify and
organize factors thought to cause a problem or affect
variation.
3. The 5 whys technique is repetitive questioning,
looking for deeper levels of the problem’s root
causes.
The End
of Module #4
IHI. Science of Improvement: How to Improve
http://www.ihi.org/knowledge/Pages/HowtoImprove/ScienceofImproveme
ntHowtoImprove.aspx