Chapter Quality Network Asthma Project - Quality Improvement Questionnaire
Chapter Physician Leader Name ______________________
Chapter: _________________________________________
Date__________________
Instructions:
For each skill, method or tool please assess yourself by placing a number from the 1-100 scale provided on the form. Your assessment can be anywhere
along this scale and may vary widely from skill to skill (e.g. Aim and Measures 85 and PDSA cycle 37). Refer to the detailed glossary at the end of this
document for accurate definitions of terms.
Please complete each method, tool, skill & content area.
IF YOU ASSESS YOURSELF AT THE:
Awareness Stage:
You are saying you know what tool is and would rate yourself somewhere between 1 and 20 on the assessment scale based on your familiarity
with the method, tool or skill.
Skill Stage:
You are saying you can apply in identified situations (e.g. if someone tells you that it is appropriate to use a control chart in this situation you could
use a control chart). You would rate yourself somewhere between 21 and 40 on the assessment scale.
Knowledge Stage:
You are saying you know how, when, and where to use the method, skill or tool (you can
identify for yourself that a control chart is needed
in this situation). You would rate yourself somewhere between 41 and 60 on the assessment scale
Understanding Stage:
You are saying you have experience with the method, tool, or skill to the point that you can adapt it to a situation and can explain why you are
using it to others (e.g. you can explain why you chose a control chart in this situation, and why you chose this specific type of control chart). You
would rate yourself somewhere between 61 and 80 on the assessment scale.
Expert Stage:
You are saying you can teach the theory and the use of the method, skill or tool (e.g. you can teach others when to use a control chart rather than
some other tool, which of the several control charts to select in a given situation and the theory behind control charts) . You would rate yourself
somewhere between 81 and 100 on the assessment scale.
Source: Adapted from instrument developed by Associates in Process Improvement, 2005.
1
Instructions: please assess
yourself by placing a number from
the 1-100 scale provided on the
form. Please reference the
glossary at the end of this
document.
Category
Model for Improvement
Awareness
Do I know what it
is?
Specific Method, Tool, or Skill
Assessment Scale:
Select a number anywhere
on scale
1
10
20
Skill
Can I apply in
identified situations
with help?
21
30
40
Knowledge
Do I know how,
when, and where to
use?
41
50
60
Understanding
Do I have
experience? Can I
adapt, explain
why?
61
70
80
Expert
Can teach theory
and use of method
81
90
100
Aim and Measures
Learning Structure
PDSA Cycle
Use of Data (basic stats)
Developing Changes
Testing Changes
Designing for Reliability
Implementing Changes
Spreading Changes
Science of Improvement
Viewing Systems
Research vs. Improvement
Flow Diagram
Linkage of Processes
Gathering Information
Operational Definitions
Forms for Collecting Data
Sampling Methods
Source: Adapted from instrument developed by Associates in Process Improvement, 2005.
2
Instructions: please assess
yourself by placing a number from
the 1-100 scale provided on the
form. Please reference the
glossary at the end of this
document.
Category
Understanding Variation
Awareness
Do I know what it
is?
Specific Method, Tool, or Skill
Assessment Scale:
Select a number anywhere
on scale
1
10
20
Skill
Can I apply in
identified situations
with help?
21
30
40
Knowledge
Do I know how,
when, and where to
use?
41
50
60
Understanding
Do I have
experience? Can I
adapt, explain
why?
61
70
80
Expert
Can teach theory
and use of method
81
90
100
Run Chart
Attribute Control Charts
(p,c,u,)
Continuous Control Charts (X
and MR, Xbar and S)
Pareto Chart
Frequency Plot/Histograms
Evidence Based Decision-Making
Teamwork
Leading teams effectively, Managing group decision-making,
etc
Leadership of Improvement
Quality as a strategy
Leading Change
Organizational Change, Managing the change process with
stakeholders
Chronic Care Model
Source: Adapted from instrument developed by Associates in Process Improvement, 2005.
3
Glossary
Knowledge, Skills, Methods, or Tools for Improvement
Category
Foundational
Knowledge Base,
Method, Tool, or
Skill
System of
Profound
Knowledge
Deming Chain
Reaction
Model for
Improvement
Description of Knowledge Base, Skill, Method, Tool
A concept developed by W. E. Deming by which to organize the special knowledge required to understand
and optimize organizations. The system of profound knowledge has four parts: Appreciation of a System,
Understanding Variation, Theory of Knowledge, and Psychology.
The theory that relates improvement of quality to the financial and business aspects. Different chain
reactions exist for the three strategies or improving quality by reducing errors, reducing cost while
maintaining technical quality and expanding customer expectations to increase demand.
Charter
A tool to initiate a project by beginning to answer the first three questions of the Model for Improvement.
The charter communicates the purpose of a team or individual involved in an improvement effort. The
charter directly answers the fundamental improvement question, "What are we trying to accomplish and
begins to answer the 2nd and 3rd questions (measures and changes).
Learning Structure
A diagram (version of tree-diagram) that organizes the theory of improvement for a project. The structure
connects Aim, measures and creates an organization of the changes
PDSA Cycle
A structure for learning and improvement. One of the components of the Model for Improvement. The four
steps in the cycle are: Plan, Do, Study, Act. Use of the Cycle promotes iterative learning through questions,
predictions, actions, data collection, and synthesis. It is also known as the Deming cycle, Shewhart cycle, and
the PDSA cycle.
Use of Data
(including basic
statistics)
Use of data for learning, e.g. identifying information in the patterns of variation in data and using this to
guide actions for improvement. Includes understanding the value of plotting data over time, the pitfalls of
viewing before/after data and an understanding of common sources of bias. Also understanding the
differences between purpose of data used for improvement, accountability and research
Developing
Changes
Aiding others to develop more powerful changes than those previously tried. Includes diving deeply into an
understanding of process and systems, using creative thinking techniques (e.g. change concepts, concept
triangle, provocations) and making use of new or existing technology.
Testing Changes
Putting a change into effect on a temporary basis using the PDSA cycle. Trying change, typically on a small
scale first, then using multiple PDSA cycles increasing size, scope, and conditions under which change is
tested to improve confidence, staff readiness and reduce cost of failure prior to implementation.
Source: Adapted from instrument developed by Associates in Process Improvement, 2005.
4
Teamwork
Viewing Systems
Gathering
Information
Implementing
Changes
Using the PDSA cycle to make the change a permanent part of the way things are done. Implementation
involves engaging the infrastructure of the organization such as staff training, documentation,
compensation, supply or equipment requirements, hiring, policy, procedures, measurement, etc.
Implementation takes longer than testing and typically involves more resistance to change. Developing
strategies to mitigate resistance to change is part of implementation.
Conducting
Meetings
Includes understanding how to structure team meetings so they are more effective and efficient. Includes
knowledge related to clarifying roles and responsibilities of team members, team leader, facilitator,
technical consultant and management sponsor, clarifying agenda items, timeframes, expected outcomes,
decision making methods, meeting documentation and physical environment for the meeting.
Group Dynamics
Improving team functioning through understanding of how individuals behave when in a group. Includes
understanding of the need for clarity of purpose (charter), clarity of behavioral expectations (norms), typical
stages of group development, use of discussion and of dialogue, avoidance of “group think” and methods
for evaluating, monitoring and improving group interaction in meetings.
Flow Diagram
A graphic representation of a series of activities that define a process. The diagram shows the stages of a
process as inputs are being transformed into outcomes. There are different types of flow diagrams including
top-down, complexity, ideal flow, and group-matrix.
Linkage of
Processes
A method to develop a view of a system composed of processes linked together to accomplish the purpose
of the system.
Operational
Definition
A definition that gives communicable meaning to a concept by specifying how the concept is applied within
a particular set of circumstances.
Form for
Collecting Data
A form for collection of data that provides an organized method to record required data and additional
observations to be used in analysis. Often a part of a PDSA Cycle.
Surveys
A method of collecting information directly from people about their feelings, motivations, plans, beliefs,
experiences and backgrounds.
Benchmarking
The process of measuring products, services, and practices against the best performers or those companies
recognized as industry leaders.
Sampling Methods Selection of units for study. Different sampling methods include judgment sampling, simple random
sampling, proportionate random sampling, systematic sampling, and stratified sampling.
Source: Adapted from instrument developed by Associates in Process Improvement, 2005.
5
Organizing
Information
Understanding
Variation
Creativity
Methods
A collection of techniques for tapping into the unconscious mind for new ideas that lead to different ways of
attacking a problem or accomplishing a task. Also called lateral thinking methods. Methods include six
thinking hats, provocations, random word, and concept triangle.
Affinity Diagram
A method to summarize qualitative data into groups with a common theme
Cause and Effect
Diagram
A tool for organizing a group’s current knowledge regarding a problem or issue. Useful for recording ideas in
a brainstorming session (also called a fishbone diagram or an Ishikawa diagram).
Matrix Diagrams
Method used to arrange data to help the user understand important relationships. Displays the relationship
between two groupings (e.g. criteria for a supply and vendors under consideration, or steps in a process and
the departments involved). It is especially useful for developing a change and deciding where to test it.
Tree Diagrams
Used to visualize the structure of a problem, plan or any other opportunity of interest. Helps in thinking
systematically about each aspect of the problem or plan. It has also been called a “systematic diagram”. The
tree diagram allows the graphical view of different level of details about a problem or plan
Run Chart
Control Chart
Pareto Chart
Relationships
A graphical record of a quality characteristic measured over time.
A method used to distinguish between variation in a process due to common causes and variation due to
special causes. It is constructed by obtaining measurements of some characteristic of a process,
summarizing with an appropriate statistic, and grouping the data by time period, location, or other process
descriptive variables. There are many different types of control charts, depending on the statistic analyzed
on the chart.
A tool for helping focus our efforts by identifying how frequently categories of events occur
Frequency Plot
A tool to display data which presents to the user basic information about the location, shape, and spread of
a set of data. (also called histogram or dot plot)
Capability
A prediction of the individual outputs of a characteristic from a process. If a process is found to be stable,
the process capability can be determined. The prediction from a capability calculation can be compared to
specifications to determine whether the process can produce outcomes that meet the specs
Scatter Plots
A tool for showing relationships between two variables. Pairs of data are plotted together on scales set at
right angles to each other.
Source: Adapted from instrument developed by Associates in Process Improvement, 2005.
6
Two-Way Tables
A tabular representation of the relationship between pairs of variables. (Similar to a scatter plot)
Source: Adapted from instrument developed by Associates in Process Improvement, 2005.
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