QI & PDSA for Public Health
Act
Plan
Study
Do
Debra Tews, MA
Michigan Dept. of
Community Health
PPHC Pre-Session
Bay City, MI
10/26/2010
1
Today’s Focus
A
brief overview of
QI including PH
definitions for
Quality and QI
 An
intro to PDSA
from Michigan’s
Quality
Improvement
Guidebook
 An
intro to QI tools
2
What is Quality in Public Health?
“Quality
in public
health is the degree
to which policies,
programs, services
and research for the
population increase
desired health
outcomes and
conditions in which
the population can be
healthy.”
Public Health Quality Forum
3
So How Can One Define Quality
Improvement for Public Health?
Use of a deliberate and defined improvement
process, such as Plan-Do-Check [Study]-Act, which
is focused on activities that are responsive to
community needs and improving population health.
It refers to a continuous and ongoing effort to
achieve measurable improvements in the efficiency,
effectiveness, performance, accountability,
outcomes, and other indicators of quality in services
or processes which achieve equity and improve the
health of the community.
Accreditation Coalition 2009
4
Why QI in Public Health?
Tough Economic
Times Require a
Different Approach!
QI Can:
 Reduce costs and
redundancy
 Eliminate waste
 Streamline
processes
 Enhance ability to
meet service demand
 Increase customer
satisfaction
 Improve outcomes
5
Is it QI or is it QA?
Quality
Improvement
GOES
BEYOND
Quality
Assurance!
6
Doing Both?

QUALITYASSURANCE relates to Monitoring & Compliance.
It GUARANTEES quality.
Standards met? Deficiencies corrected?
QA is . . . . . reactive!

QUALITY IMPROVEMENT relates to Learning & Improving.
It RAISES quality.
Quality can’t always be assured. Ongoing efforts to identify
opportunities for improvement are needed. QI relies on
measurement & data-driven decisions to improve outcomes.
QI is . . . . . proactive!
7
Principles of QI
From the Public Health Memory Jogger
Pocket Guide of QI Tools:

Develop a strong customer focus

Continually improve all processes

Involve employees

Mobilize both data and team knowledge to
improve decision making
8
Three Key Questions !!!
1. What are we
trying to
accomplish?
2. How will we know
that a change is
an improvement?
3. What changes
can we make
that will result in
improvement?
9
Change Vs. Improvement
Edwards Deming: Of all
changes observed, about 5%
were improvements, the rest at
best were illusions of progress!
To move beyond illusions of
progress, a QI method (PDSA)
and QI tools are needed.
Embracing Quality in Local
Public Heath: Michigan’s QI
Guidebook explains the PDSA
method and suggests tools.
10
Snapshot: Plan-Do-Study-Act (PDSA)
Act
Study
Plan
Do
11
Some Common Tools of QI

Process Mapping

Cause and
Effect/Fishbone
Diagrams

Five Whys

Run Charts

Pareto Charts

Check Sheets
Understand Your Process &
Make Sense of Your Data!
12
QI: Assembling the Pieces

Listen to LHD customers

Use data to make datadriven decisions

Continually improve
processes in your LHD

Use recognized QI
methods and tools

Work together; a team
approach is best.

Ask the 3 Key Questions!
13
What Do Users Say?


“We now have staff eager to use the
same tools/methods to evaluate
performance and make improvements in
other areas of our work” MLC-3 LHD
“The PH focus of the Guidebook helps
with the application of QI methods; it
becomes ‘real’ for participants . . . we can
‘look through our public health windows’”
Allegan LHD

“For any PH agency interested in learning
QI and how PH can apply these
principles/methods, I would recommend
they start with this Guidebook” Saginaw
LHD

“The Guidebook has been a road map for
our team as we navigate our way down
this new path of improving our processes”
MMDHD
“I refer to the
Guidebook often
even though I
know the steps”
MI Mentor
14
There’s More . . .


“The Guidebook has been
incredibly useful for QI work,
serving as the primary textbook
for teaching QI throughout the
department” MI Mentor
“The Guidebook helps with
capacity building . . . it would
not be possible to spread QI
methodologies easily without it”
Muskegon LHD

“The Guidebook is used in our
QI meetings as an effective
discussion and clarification tool;
it generates comfort levels”
Allegan LHD
“The Guidebook is
the glue that holds
the whole effort
together”
MI Consultant
15
QI Resources for Public Health
www.accreditation.localhealth.net and www.phf.org
16
Another Resource for QI Tools

http://www.langfordlearning.com
17
Using QI Tools
There are many tools that can
help you meet the goal of
improving your work processes
and services
18
PDSA and Using QI Tools
Using tools as part of the PDSA cycle
 Some tools will be useful in the planning
stage
 Others will help you to implement your QI
project
 And/or will help you study the impact of
your process change

19
Useful QI Tools
Process Mapping
 Check Sheets
 Pareto Charts
 Cause and Effect Diagrams




Fishbone Diagrams
The 5 Whys
Run Charts
20
Sometimes called Flow Charting…
PROCESS MAPPING
21
QI Works on Existing Processes

A process is a series of steps or actions
performed to achieve a specific purpose

It describes how things get done

Your work is made up of many processes
22
What is a Process Map?

A pictorial representation of the sequence
of actions that describe a process
23
Why is Process Mapping
Important?
It’s an opportunity to learn about the work
being done
 It involves documenting the obvious, as
well as all that which goes without saying
 Helps to discover inconsistencies
 Most processes today are undocumented
 Helps to control the “evolution” of a
process

24
Process Maps are Used To

Document the way we do our work

Analyze and improve on processes
25
How Do We Prepare to Process
Map? (1)
Assemble the QI Team
 Agree on the process you want to
document
 Agree on the purpose of the process
 Agree on beginning and ending points

26
How Do We Prepare to Process
Map? (2)

Agree on the level of detail to be displayed

Begin by preparing an outline of steps

Identify and recruit other people that
should be involved
27
What are the Symbols Used in
Process Mapping?

Start and End of the Process:

A process Activity:

A process Decision:

A Break in the process:
28
Helpful Tips to Keep in Mind

Process Map what is, the actual process

Process Mapping is dynamic

Clearly define the boundaries of the
process
29
Example: Process Map of
Conference Approvals Process

Do a Process Map that documents the process
used to obtain approval to attend conferences.
30
The Simplest Map
31
A More Detailed Map
32
Mapping the True Process
33
More Useful Tips
Other exercises can help you identify the
process you want to map
 There is no single right way to Process
Map
 Process Mapping is not an end in itself
 Process Maps, once created, can be useful
in a variety of settings

34
Summing Up Process Mapping

We Process Map to learn

We Process Map to document a baseline of
performance

We Process Map to discover where data
may be hiding
35
QI Scenario: Process Mapping
Exercise
Highlighting Excellence Health Department
 Improvement sought-Improved Customer
Satisfaction with health department
services
 Improve performance connecting clients
with services
 Please take a moment to read the
Scenario write-up that is in your handouts

36
37
Observing a Process
CHECK SHEETS
38
What is the Purpose of a Check
Sheet?

To turn observational data into numerical
data


From records
Newly collected

To find patterns using a systematic
approach that reduces bias

Use check sheets when data can be
observed or collected from your records
39
Check Sheets Step by Step (1)

Step 1




Decide what to observe
Define key elements
Establish shared understanding
Step 2


Identify where, when, & how long
Think about confounding factors
o
o
That you want to eliminate
That you want to study
40
Check Sheets Step by Step (2)

Step 3


Design your check sheet
Develop a protocol
Problem/Project Name:
Name of Observer:
Location of Data Collection:
Dates of Observation:
Dates of Data Collection
Other:
Total
Event
A
B
C
Total
Grand
41
Total
Check Sheets Step by Step (3)

Step 4



Step 5



Identify and train your observers
Practice & adjust
Collect data
Review & adjust
Step 6


Summarize data across observations &
observers
Study the results
42
Tips for Using Check Sheets

Make sure you’re getting clean data


Define, train, check, adjust, & repeat!
Consider and address potential sources of bias

Use “other” categories sparingly

Strike a balance


Fine vs. inclusive categories
Few vs. many categories
43
Check Sheet Exercise (1)

When customers report dissatisfaction with LHD
services, staff track the primary reason for
customer complaints

They believe dissatisfaction may be caused by
several conditions that they can document

Use your handout to set up the check sheet for
this situation
44
Check Sheet Exercise (2)
Problem: Client Dissatisfaction
Name: A. Martin
Time: 9-5
Location: Excellence Health Department’s
Customer Service Department
Dates: Week of 9/6, 9/13, 9/20, 9/27,
10/4, 10/11, 10/18
Date
Reason
9/6
9/13
9/20
9/27
10/4
10/11
10/18
Total
Service not offered
3
4
3
2
3
4
0
19
Service was difficult
to access
10
12
6
3
0
0
0
31
Long wait times
0
0
2
3
6
1
0
12
Poor staff interaction
2
2
1
2
0
0
1
8
Inaccurate
information
2
3
1
2
1
0
1
10
17
21
13
12
10
5
2
80
Total
45
80% of the problem
PARETO CHARTS
46
What is the Purpose of Pareto
Charts? (1)
 To
identify the causes that are likely to have the
greatest impact on the problem if addressed

“80% of the effects come from 20% of the
causes”
 To
bring focus to a small number of potential
causes
47
What is the Purpose of Pareto
Charts? (2)
 To
guide the process of selecting improvements
to test
 Use
when you have, or can collect, quantitative
or numeric data on several potential causes
48
Pareto Charts: Step by Step (1)

Step 1


Identify potential causes of the problem you
wish to study
Step 2

Develop a method for gathering your data
o
o
Historical data
Collection of new data
49
Pareto Charts: Step by Step (2)

Step 3



Collect your data
Each time the problem occurs, make note of
the primary cause
Step 4

Order your results & calculate the percentage
of incidents that fall into each category
50
Pareto Charts: Step by Step (2)

Step 5: Display your data on a graph….
51
Pareto Charts: Step by Step (3)

Step 6

Make sense of your results by examining your
data
52
Tips for Using Pareto Charts

You’ll only learn about causes that you
investigate - be inclusive!

Check and double check your data

Results can be used in more than one way
and they can be used differently at
different points in time
53
Pareto Chart Exercise
Problem: Client Dissatisfaction
Name: J. Heany
Time: 9-5
Location: Excellence Health Department’s
Customer Service Department
Dates: Week of 9/6, 9/13, 9/20, 9/27,
10/4, 10/11, 10/18
Date
Reason
9/6
9/13
9/20
9/27
10/4
10/11 10/18
Total
Service not offered
3
4
3
2
3
4
0
19
Service was difficult
to access
10
12
6
3
0
0
0
31
Long wait times
0
0
2
3
6
1
0
12
Poor staff
interaction
2
2
1
2
0
0
1
8
Inaccurate
information
2
3
1
2
1
0
1
10
17
21
13
12
10
5
2
80
Total
54
BREAK TIME (10 MINUTES)
55
Moving from treating symptoms to treating causes
CAUSE & EFFECT DIAGRAMS
56
Seeing Beyond the Tip of the
Iceberg
The Symptom
The Cause
57
Problem Solving & Root Cause

When confronted with a problem most people
like to tackle the obvious symptom and fix it

This often results in more problems

Using a systematic approach to analyze the
problem and find the root cause is more efficient
and effective

Tools can help to identify problems that aren’t
apparent on the surface (root cause)
58
What is the Purpose of
Fishbone Diagrams?
 To
identify underlying or root causes of a
problem
 To
identify a target for your improvement that is
likely to lead to change
59
Construction of a Fishbone
Diagram (1)

Draw an arrow leading to a box that contains a
statement of the problem
Effect/Problem
60
Construction of a Fishbone
Diagram (3)

Draw smaller arrows (bones) leading to the
center line, and label these arrows with either
major causal categories or process categories
Cause 1
Cause 3
Effect/Problem
Cause 2
Cause 4
61
Construction of a Fishbone
Diagram (2)

Then for each cause identify deeper root
causes
Cause 1
Cause 3
Effect/Problem
Cause 2
Cause 4
62
Berrien County Fishbone
Root causes for lack of BCHD general PH articles
Causes
Topics
Process
Articles for events only
No time to develop
Confusion/duplication
Effect
Minimal articles
Secluded media team
Sporadic writing
One writer, poor health
No long-term arrangements
People/Staff
Media Relations
63
Another Fishbone Diagram
Pre Natal
Practices
Early Feeding
Practices
Excess Maternal
Weight Gain
Over Weight
Newborn
Decreased Breast
Feeding
Bottle Pacifier
Juices
Less Fruits and Veg.
Life Style
No Time For
Food Prep
TV Viewing
Sodas/Snacks
No Outdoor Play
Less
Income
Maternal
Choices
Built Environment For
Strollers Not Toddling
Unsafe
Obese Children
Unhealthy Food
Choices
Genes
Curriculum
Less Indoor Mobility
Syndromes
TV
Pacifier
Genetics
Few Community
Recreational
Areas or Programs
Over Weight
Pre School
Environment
No Sidewalks
Less Exercise @ School
Polices
64
Tips for Using Fishbone
Diagrams

Find the right problem or effect statement

Find causes that make sense and that you can
impact

Make use of your results
65
Fishbone Diagram Exercise
Create a Fishbone Diagram using the
Pareto Chart you made in your last
exercise
 Listing effect(s), major causes, and data
related causes (root) on the diagram
 It is OK if data related causes show up in
more than one major cause area

66
More Cause and Effect
THE 5 WHY’S
67
What is the 5 Whys?

A question asking method used to explore the
cause/effect relationships underlying a particular
problem

The goal is to determine the ROOT CAUSE of a
problem
68
An Example of the 5 Whys






My car will not start. (the problem)
Why? - The battery is dead. (first why)
Why? - The alternator is not functioning. (second why)
Why? - The alternator belt has broken. (third why)
Why? - The alternator belt was well beyond its useful
service life and has never been replaced. (fourth why)
Why? - I have not been maintaining my car according to
the recommended service schedule. (fifth why, root
cause)
69
The 5 Whys and Hows
This technique is easy to use and apply
 But it requires skill to use
 The answers should be grounded in
observation and data
 Avoid deductive reasoning with this
technique

70
Limitations of the 5 Whys
Does not always lead to root cause
identification
 Can lead to bad judgment calls when used
in the absence of data
 Process changes are then made that
address the wrong root cause
 This can make the situation worse

71
Use Data to Overcome
Limitations
72
Summing Up Cause and Effect
Use Fishbone and 5 Whys to explore and
graphically display in increasing detail all
of the possible causes related to the
problem
 Use Fishbone and 5 Whys to find dominant
causes rather than symptoms
 Use Fishbone and 5 Whys to identify the
root cause of the problem we seek to
improve

73
5 Whys Exercise

Perform 5 whys on the two causes that
received the greatest number of responses
as shown in the Pareto Chart (Service was
difficult to assess and Service not offered).
74
Tracking Process Performance
RUN CHARTS
75
What is the Purpose of Run
Charts?
 To
study data measured over time
 Run



Study the performance of a process
Identify trends
Measure change in performance following a change in
process
 Use



charts help to:
when you have, or can collect:
Quantitative data
Data measuring the performance of a process
Data collected over time
76
Run Charts: Step by Step (1)

Step 1




Decide what data you need
Determine the timeframe
Determine the number of data collection points
Step 2

Gather your data
77
Run Charts: Step by Step (2)

Step 3

Graph your data
o
o
o
o
o
o
On the Y-axis, set up a scale that corresponds with
your measure
On the X-axis, set up a scale that corresponds with
your measurement timeframe
Plot your data on the chart, placing one dot at each
measurement point
Draw a line through your dots
Calculate the mean score and draw a line at the
mean
Mark the timing of your process change on the line
78
Example Run Chart
Number of New Clients
Number of New BCCCP Clients by Month
in 2007 and 2008
50
45
40
35
30
25
20
15
10
5
0
ry
ry
ch
a
a
r
u
a
nu
M
br
e
Ja
F
ril
p
A
M
ay
ne
u
J
ly
Ju
r
r`
er
st
er
e
e
b
u
b
b
b
g
to
em cem
em Oc
v
Au
t
p
No
De
Se
Month
2007
2008
79
Run Charts: Step by Step (3)

Step 4
 Make sense of your results by examining your
data
o
o
o
o
o
Does the mean reflect an appropriate level of
service or outcome of your process?
Is there a trend that should be investigated?
Do you see a shift in your data? Are there 8 or
more consecutive points on one side of the center
line?
Do you see a trend in your data? Are there six
consecutive jumps in the same direction (up or
down)?
Do you see a pattern in your data? Does a pattern
recur eight or more times in a row?
80
Tips for Using Run Charts

Every process will have some variation

Be sure to track data over a long enough
period of time
81
Run Chart Exercise
Month
Response
rate in ‘08
Response
rate in ‘09
January
2
1.8
February
2.3
1.9
March
2.2
2
April
2.5
3.5
May
2.6
3.8
June
2.2
3.9
July
2.1
4
August
1.9
4.1
September
1.9
4.3
October
2
4.5
November
2.1
4.5
December
2.2
4.5
82
Quality Improvement Resources

Michigan’s QI Guidebook

The Public Health Memory Jogger II

Quality Improvement Resources Handout
83
Working Session
Bringing QI into your Programs
84
Working Session Exercise 1

Identify Two WIC Program or Health
Division Areas where QI Processes would
be Helpful
85
Working Session Exercise 2

Identify which Front Line, Middle
Management and Administrative Staff
need to be Involved in QI Problem Solving
in the work processes you prioritized for
improvement in Exercise 1
86
Working Session Exercise 3

Four Essential Elements to creating an
internal environment supportive to QI:





Policy
Leadership
Core Values
Resources
Identify Three Key Means to Build Support
for and Initiate QI Processes in Your
Organization
87
Q&A
Please feel free at this time to
email any questions you may
have about the training and/or
exercises
88
BREAK – 10 minutes

Upcoming Events:
 February 23 – WIC Coordinator Webcast
 March 6 – Anthropometric Training, Flint
 March 7 – Lab Training, Flint
 March 21,22 – CPA Training, Grand Rapids
89
BREAK – 10 minutes
2012
WIC Training &
Educational Conference
Make your Hotel
Accommodations NOW…
events.mphi.org
90