Case Analysis Essay
Case Analysis Essay
Patient Safety Case Analysis Paper – Instructions Instructions: First read the case you have chosen from the case repository on blackboard thoroughly AND review the “Learning from Defects” tool provided. This tool was developed and adapted by the Quality and Safety Research Group led by Professor Pronovost et al to help health care providers identify and learn from defects utilizing a systems approach. The contributory factors framework helps providers gain a deeper appreciation of harm as it occurs usual
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ly due to breakdown of systems (multiple factors). It steers clear of blame and punitive behavior and encourages teams to focus on learning. Attempt ALL four questions in response to the case provided below as though you are part of the team investigating. What happened, why (contributory factors), key contributory factors that led to the event. Be sure to categorize your contributory factors into patient factors, caregiver factors, task, teamwork and communication etc. Please use QI tools such as flow chart, cause and effect/fishbone and pareto charts to justify your interventions. These charts should be part of your appendices. Suggest interventions so that such events will not occur in the future (be sure that the interventions you suggest address the key contributory factors). Then provide measures that you will assess to know if your suggested interventions are working. Assume that you have implemented your recommendations. How will you know that these worked to reduce/eliminate risk? What measures would help confirm improvements. Please include an abstract as your first page and include titles and sub-titles (e.g. what happened, why (contributory factors), key contributory factors etc. Try to be objective and use facts from the case. It is recommended that you take time reading the case and ascertain key contributory factors prior to suggesting any intervention. You may use additional sheets of paper to make rough notes, provide your rationale for choices/additional descriptions, flow chart etc. You should prepare an outline first for your case analysis. Feel free to visit your instructor during office hours for any questions that you may have concerning this assignment. Format and page length: APA 6.0 format, and between 6-8 pages excluding appendices and cover page– see syllabus for other details. Academic Integrity: Save assign plagiarism Grading Rubric: Your responses will be graded on the basis of clarity of thought, originality, accuracy and specificity of content, and the approach utilized in analyzing the defect and providing recommendations. Possible maximum points by question: Question # 1 (10 points), Question # 2 (40 points), Question # 3 (40 points), Question # 4 (10 points). Total = 100 points 1|Page Learning from Defects Problem Statement: Healthcare organizations could increase the extent to which they learn from defects. We define learning as reducing the probability that a future patient will be harmed. Most often clinicians recover from mistakes by reducing risks to the patient who suffered a defect. While we need to recover, we also need to learn or reduce risk to future patients. What is a Defect? A defect is any clinical or operational event or situation that you would not want to happen again. These could include incidents that you believe caused patient harm or put patients at risk for significant harm. Purpose of Tool: The purpose of this tool is to provide a structured approach to help caregivers and administrators identify the types of systems that contributed to the defect and follow-up to ensure safety improvements are achieved. Who Should Use this Tool: ▪ Clinical departmental designee at Morbidity & Mortality Rounds ▪ Patient care areas as part of the Comprehensive Unit Based Safety Program (CUSP) All staff involved in the delivery of care related to this defect should be present when this defect is evaluated. At a minimum, this should include the physician, nurse and administrator and other selected professions as appropriate (e.g. medication defect include pharmacy, equipment defect should include clinical engineering). Investigation Process How to Use this Tool: Complete this tool on at least one defect per month. In addition, departments should investigate all of the following defects: liability claims, sentinel events, events for which risk management is notified, case presented at Morbidity & Mortality rounds and healthcare acquired infections. Investigation Process I. Provide a clear, thorough and objective explanation of what happened. II. Review the list of factors that contributed to the incident and check off those that negatively contributed and positively contributed to the impact of the incident. Negative contributing factors are those that harmed or increased risk of harm for the patient; positive contributing factors limited the impact of harm. Rate the most important contributing factors that relate to the incident. III. Describe how you will reduce the likelihood of this defect happening again by completing the tables. Develop interventions for each important contributing factor and rate each intervention for its ability to mitigate the defect and ability to be implemented. Identify 2-5 interventions that you will implement. List what you will do, who will lead the intervention, and when you will follow-up on the intervention’s progress. IV. Describe how you know you have reduced the risk. Survey frontline staff involved in the incident to determine if the intervention has been implemented effectively and risk has been reduced. V. Summarize your findings using the one page Case Summary tool (Appendix F). COPYRIGHT ©2007 THE QUALITY AND SAFETY RESEARCH GROUP RELEASE 8.0, REVISED 3/9/09 1 I. What happened? (Reconstruct the timeline and explain what happened. For this investigation, put yourself in the place of those involved, in the middle of the event as it was unfolding, to understand what they were thinking and the reasoning behind their actions/decisions. Try to view the world as they did when the event occurred.) II. Why did it happen? Below is a framework to help you review and evaluate your case. Please read each contributing factor and evaluate whether it was involved. If so, did it negatively contribute (increase harm) or positively contributed (reduce impact of harm) to the incident. Rate the most important contributing factors that relate to this event. Contributing Factors (Example) Negatively Contributed Positively Contributed Patient Factors: Patient was acutely ill or agitated (Elderly patient in renal failure, secondary to congestive heart failure.) There was a language barrier (Patient did not speak English) There were personal or social issues (Patient declined therapy) Task Factors: Was there a protocol available to guide therapy? (Protocol for mixing medication concentrations is posted above the medication bin.) Were test results available to help make care decision? (Stat blood glucose results were sent in 20 minutes.) Were tests results accurate? (Four diagnostic tests done; only MRI results needed quickly— results faxed.) Caregiver Factors Was the caregiver fatigued? (Tired at the end of a double shift, nurse forgot to take a blood pressure reading.) Did the caregiver’s outlook/perception of own professional role impact on this event? (Doctor followed up to make sure cardiac consult was done expeditiously.) Was the physical or mental health of the provider a factor? (Provider having personal issues and missed hearing a verbal order.) Team Factors Was verbal or written communication during hand offs clear, accurate, clinically relevant and goal directed? (Oncoming care team was debriefed by out-going staff regarding patient’s condition.) Was verbal or written communication during care clear, accurate, clinically relevant and goal directed? (Staff was comfortable expressing his/her concern regarding high medication dose.) Was verbal or written communication during crisis clear, accurate, clinically relevant and goal directed? (Team leader quickly explained and direct his/her team regarding the plan of action.) Was there a cohesive team structure with an identified and communicative leader? (Attending physician gave clear instructions to the team.) COPYRIGHT ©2007 THE QUALITY AND SAFETY RESEARCH GROUP RELEASE 8.0, REVISED 3/9/09 2 Contributing Factors (Example) Negatively Contributed Positively Contributed Training & Education Factors Was provider knowledgeable, skilled & competent? (Nurse knew dose ordered was not standard for that medication.) Did provider follow the established protocol? (Provider pulled protocol to ensure steps were followed.) Did the provider seek supervision or help? (New nurse asked preceptor to help her/him mix medication concentration) Information Technology/CPOE Factors Did the computer/software program generate an error? (Heparin was chosen, but Digoxin printed on the order sheet.) Did the computer/software malfunction? (Computer shut down in the middle of provider’s order entry.) Did the user check what he/she entered to make sure it was correct? (Provider initially chose .25mg, but caught his/her error and changed it to .025mg.) Local Environment Was there adequate equipment available and was the equipment working properly? (There were 2 extra ventilators stocked & recently serviced by clinical engineering.) Was there adequate operational (administrative and managerial) support? (Unit clerk out sick, but extra clerk sent to cover from another unit.) Was the physical environment conducive to enhancing patient care? (All beds were visible from the nurse’s station.) Was there enough staff on the unit to care for patient volume? (Nurse ratio was 1:1.) Was there a good mix of skilled with new staff? (There was a nurse orientee shadowing a senior nurse and an extra nurse on to cover senior nurse’s responsibilities.) Did workload impact the provision of good care? (Nurse caring for 3 patients because nurse went home sick.) Institutional Environment Were adequate financial resources available? (Unit requested experienced patient transport team for critically patients and one was made available the next day.) Were laboratory technicians adequately in-serviced/ educated? (Lab tech was fully aware of complications related to thallium injection.) Was there adequate staffing in the laboratory to run results? (There were 3 dedicated laboratory technicians to run stat results.) Were pharmacists adequately in-service/educated? (Pharmacists knew and followed the protocol for stat medication orders.) Did pharmacy have a good infrastructure (policy, procedures)? (It was standard policy to have a second pharmacist do an independent check before dispensing medications.) Was there adequate pharmacy staffing? (There was a pharmacist dedicated to the ICU.) Does hospital administration work with the units regarding what and how to support their needs? (Guidelines established to hold new ICU admissions in the ER when beds not available in the ICU.) COPYRIGHT ©2007 THE QUALITY AND SAFETY RESEARCH GROUP RELEASE 8.0, REVISED 3/9/09 3 Review the above list of contributing factors and identify the most important factors related to this event. Rate each contributing factor on its importance to this event and future events. Contributing Factors Importance to current event, 1 (low) to 5 (high) Importance to future events, 1 (low) to 5 (high) III. How will you reduce the likelihood of this defect happening again? Develop an intervention for each of the important contributing factors identified above. Develop interventions to defend against the 2 to 5 most important contributing factors. Refer to the Strength of Interventions* chart below for examples of strong and weak interventions. Then, rate each intervention on its ability to mitigate the contributing factor and on the team’s belief that the intervention will be implemented and executed. Make an action plan for 2-5 of the highest scoring interventions. Interventions to reduce the risk of the defect COPYRIGHT ©2007 THE QUALITY AND SAFETY RESEARCH GROUP RELEASE 8.0, REVISED 3/9/09 Ability to mitigate the contributing factor, 1 (low to 5 (high) Teams belief that the intervention will be implemented and executed, 1 (low) to 5 (high) 4 Select 2-5 of the highest scoring interventions and develop an action plan for implementation. Specific interventions you will do to reduce the risk of the defect? Strength of Interventions * Weaker Actions Intermediate Actions Double Check Checklists/ Cognitive Aid Warnings and labels Increased Staffing/Reduce workload New procedure, memorandum or policy Redundancy Training and/or education Who will lead this effort? Follow up date Stronger Actions Architectural/physical plant changes Tangible involvement and action by leadership in support of patient safety Simplify the process/remove unnecessary steps Standardize equipment and/ or process of care map New device usability testing before purchasing Engineering Control of interlock (forcing functions) Enhance Communication (read-back, SBAR etc.) Additional Study/analysis Software enhancement/modifications Eliminate look alike and sound- a-likes Eliminate/reduce distractions • Adapted from John Gosbee, MD, MS Human Factors Engineering • Remember sometimes a weaker action is your only option. COPYRIGHT ©2007 THE QUALITY AND SAFETY RESEARCH GROUP RELEASE 8.0, REVISED 3/9/09 5 IV. How will you know the risk is reduced? Ask frontline staff who were involved in the defect if the interventions reduced the likelihood of recurrence of the defect. After the interventions are implemented complete the “Describe Defect” and “Interventions” sections and have staff complete this survey by rating the interventions. Describe Defect: Interventions COPYRIGHT ©2007 THE QUALITY AND SAFETY RESEARCH GROUP RELEASE 8.0, REVISED 3/9/09 Intervention was effectively implemented, 1 (low) to 5 (high) Intervention reduced the likelihood of recurrence, 1 (low) to 5 (high) 6 THE 7 BASIC QUALITY TOOLS QUALITY TOOLS • Purpose: provide the means for making decisions. • No particular tool is mandatory, any one may be helpful, depending on the circumstances. • 95% of a company’s problems can be solved using these tools. • These are basic tools designed for simplicity. • Only one requires any significant training. 7 BASIC QUALITY TOOLS • FLOW CHART • CAUSE AND EFFECT DIAGRAMS • CHECK SHEET • HISTOGRAMS • PARETO CHART • SCATTER DIAGRAM • CONTROL CHARTS Question: Why do we use these tools? QUALITY TOOLS CAN… • Help to identify and prioritize problems quickly and more effectively • Assist with the decision making process • Simple but powerful tools for use in continuous improvement activity • Provide a vehicle for communicating problems and resolutions through-out the business • Provide a way of extracting information from data collected. STRATIFICATION • The 7 Quality Tools are useful when collecting data of daily activities and analyzing them to detect and solve problems, and an important concept for data analysis is STRATIFICATION. • Stratification mean classification of data in to a couple of layers, and each layer is a subset of the population. • Through stratification different statuses from the same data is retrieved. • What layers are considered for data analysis is crucial when identifying problems. Example of Stratification • Number of births per year • Number of births by gender per year • Number of births by mom’s economic status by gender per year • deliveries per week • deliveries per day of the week per week • deliveries by hour per day of week per week • DANAGER: When using stratification ensure it is value added • Back to the 7 Quality Tools FLOW CHARTS • Purpose: Illustrates the steps in a process • Uses: – Analyzing a process (e.g. relating one setp in the process to others) – Initiate process improvements (e.g. non-value added steps) – Indicates where in the process to take measurements and collect data • DANGER: including assumed or desired steps • Note: The utility of the chart will correlate directly to its accuracy. Flow charts • Flowcharts – Used to identify and document the flow or sequence of events in a process – Used to develop an optimal new process during the solution stage Most Common Symbols Used in Flowcharts Start/End Decision Process Step No Yes Copyright 2013 Health Administration Press Types of Flowcharts Prescription logged into pharmacy computer by clerk Customer gives prescription to pharmacy clerk Medication container placed on shelf Medication container labeled • High-level flowchart – Maps major process steps Prescription passed to pharmacist Prescription filled by pharmacist Customer summoned to pharmacy counter Medication given to patient Process stops here No • Detailed flowchart – Maps all process steps and activities Inpatient admission occurs Notification sent electronically to the HIM department Does patient have old records? Yes Are all old records in HIM department? Yes Retrieve records located in HIM department Send records to filing desk to have any loose paperwork, test results, etc. filed in records Copyright 2013 Health Administration Press Log-out records in chart tracking system and send to correct nursing unit No Locate and retrieve records located outside of HIM department Types of Flowcharts • Deployment flowchart – Maps process steps and identifies the people involved in each step Train Employees in One Department Training Department Department Needing Training Finance Department Confirm training monies available Identify number of staff needing training Select training date Book meeting room Arrange catering Book trainer Arrange for audiovisual equipment Photocopy training materials Notify participants Run training event Charge expenses to department budget • Top-down flowchart – Maps major steps across the top; shows minor steps under each major step Copyright 2013 Health Administration Press Step 1 Step 2 Step 3 Step 4 1a 2a 3a 4a 1b 2b 3b 4b 1c 2c 3c 4c 2d 2e 4d Example: Flow Chart CAUSE AND EFFECT DIAGRAMS • Purpose: to identify as many possible factors for an effect or problem and sort the causes into useful categories. • When to use? – Identifying possible factors – When team’s thinking falls into a “rut” • Fishbone (most common) – Generic categories: Methods, Machines, Materials, Manpower, Measurement, Mother Nature Cause and Effect • Cause-and-effect diagram – Used to identify all possible causes of an effect (a problem or an objective) Environment Procedures Effect Equipment People Copyright 2013 Health Administration Press HOW TO CREATE A FISHBONE CAUSE AND EFFECT DIAGRAM Manpower Machines Methods Problem Statement “Effect” Management Mother Nature Measurement Materials Maintenance Simple Fishbone Diagram Example Non-compliant patients People Unpleasant side effects Medication too expensive Policies Procedures Inconsistent patient education Patient not taking hypertension medication Pharmacy hours of operation Plant CAUSE AND EFFECT DIAGRAMS • Other fishbone categories: – Plan, Policies, Procedures, Plant, People – Customers, Suppliers, Shipping, Warehouse… • 5 WHYS: a method for getting to the root cause. – Can also be used during the construction of the fishbone diagram. • GROUP ACTIVITY TIME – Let determine the cause of a particular problem. Please give me a problem statement and we’ll use the 6M’s. GROUP ACTIVITY TIME Manpower Machines Methods Problem Statement “Effect” Mother Nature Measurement Materials CAUSE AND EFFECT DIAGRAMS Now What? • Categorize (e.g. not probable, probable, very probable) • Regression analysis (requires in-depth training) • Design of experiments (requires in-depth training) • Lets go back to our example and determine what our next steps will be. • Do you remember the first time you heard about a check list with regards to data collection? Example of a Check List CHECK SHEET • WHAT: A structured and prepared form. • PURPOSE: To collect and analyze data so decisions can be based on facts • WHEN: – When data can be observed and collected by the same person or at the same location. – When collecting data on the frequency or pattern of events, problems, defects, defect location, defect causes, etc. – When collecting data from a production process. • Data can further be used to create a histogram, bar chart and Pareto chart Simple Check Sheet Example – Reasons why patients do not take their medication – hypertension non-compliance Factors/Barriers Unpleasant side effects Inconsistent patient education Medication too expensive Pharmacy hours of operation Number of times A Check List Can Become … A Bar Graph HISTOGRAM • WHAT: A frequency distribution bar graph • USES: – Illustrates how often each different value in a data set occurs – Allows us to make sense of data – Allows use to see patterns that are difficult to see in tables of numbers • DANGER: Before making any conclusions from a histogram, it must be confirmed the process was operating normally during the time period being studied Language of Histograms What do they tell us? SCATTER DIAGRAM • WHAT: Scatter diagram graphs PAIRS of numerical data. • PURPOSE: To look for a possible relationship • DANGER: Even if the scatter diagram shows a relationship, do not assume one variable causes the other. Both variable may be influenced by a third. Scatter Diagram Examples Graph 1 – strong correlation (linear) Graph 2 – moderate correlation Graph 3 – no correlation Also – quadratic, exponential, sinusoidal, and others PARETO CHART • What: Bar graph organized with the longest bars on the left and the shortest to the right • Purpose: Problem identification tool — Visually depicts which issues are more significant • Use when… – Analyzing data about the frequency of problems/causes in a process – There are many problems/causes and there is a need to focus on the most significant – Analyzing broad causes by looking at their specific components – Communicating data to others PARETO PRINCIPLE 20/80 RULE • THE IDEA THAT 20% OF THE CAUSES GENERATES 80% OF THE RESULTS With the Pareto chart we are identifying the “vital few” from the “trivial many”. PARETO CHART EXAMPLE CONTROL CHARTS • What: A statistical graphical representation used to study how a process changes over time • Purpose: To distinguish between variation in a process resulting from common causes, and variation resulting from special causes. • Data are plotted in time order. • Graphs include a central average line, a upper control limit line and a lower control limit line determined from historical data. Statistical Process Control Chart USL LSL Source: Kelly, D. L. 2006. Applying Quality Management in Healthcare, 2nd Edition. Chicago: Health Administration Press. “Out of Control” Types of Control Charts • Variable (continuous data – measureable) • • • • • • X-bar Chart (average) R chart (range) s chart (deviation) X chart (single data point – individual) Moving range chart XmR (individual with moving range) • Attribute (discrete data – count) • • • • p chart (percentage of defective units) np chart (number of defective units) c chart (number of defects per unit) u chart (average number of defects per unit) OTHER TOOLS • 5 WHYs (previously mentioned) • Brainstorming • Time Line • Fault Tree Analysis • Process Analysis 5 WHY’S – an example • Problem — Why is memorial A deteriorating faster than the other memorials? – – – – – Why? –washed more frequently Why? –more bird droppings Why? –birds attracted to monument Why? –more fat spiders around it Why? –more tiny insects during evening hours – Why? –illumination attracts more insect – Solution • Illuminate an hour later in evening 5 WHYs Process Best Practice PROBLEM PROBLEM WHY? WHY? WHY? WHY? WHY? WHY? WHY? WHY? WHY? WHY? WHY? WHY? WHY? WHY? WHY? WHY? WHY? ROOT CAUSE MULTIPLE POTENTIAL ROOT CAUSES BRAINSTORMING POP QUIZ EVERYONE ☺ QUALITY TOOLBOX SUMMARY The 7 Quality Tools are… QUALITY TOOLBOX SUMMARY • These are TOOLS, and not the only tools • They can be used alone or in combination • They can be used by the individual and groups • Generally, they do not require mastership to be used • And remember to “Document” them – photos work great 7 QUALITY TOOLS QUESTIONS? FYI 7 NEW QUALITY TOOLS for… • Innovating • Communicating • Planning • Tools – – – – – – – Affinity diagrams (for brain storming) Arrow diagrams (can be simple or used with CPM & PERT) Matrix data analysis Matrix diagrams Program decision program charts Relationship diagrams Tree diagrams Disclaimer: All of the information provided in this presentation was obtained from various internet webpages and compiled by Susan Batchilder Diagrams, charts, techniques, and methods used during an improvement project (also called analytic tools) ▪ Quantitative improvement tools are used to measure performance, collect and display data, and monitor performance. ▪ Qualitative improvement tools are used to generate ideas, set priorities, maintain direction, determine causes of problems, and clarify processes. Copyright 2013 Health Administration Press Used in performance assessment and performance improvement ▪ Bar graph ▪ Check sheet ▪ Control chart ▪ Histogram ▪ Line graph ▪ Pareto chart ▪ Scatter diagram Type of Complaint Tally Total 14 Product Defect Service 6 Billing Error 2 8 Shipping Error Totals 30 Effect 30 30 20 20 10 10 0 A B C D E F G H 0 40 30 20 10 0 B G A D H C E F Copyright 2013 Health Administration Press Suspected Cause 5 10 15 20 25 30 Brainstorming ▪ Used for creative exploration of options in an environment free of criticism Multi-voting ▪ Used to pare down a broad list of ideas and to establish priorities Nominal group technique ▪ A structured form of multi-voting Copyright 2013 Health Administration Press Affinity diagram ▪ Used to organize ideas, issues, or opinions into groupings based on the relationships between items Topic Header Topic Header Topic Header Idea Idea Idea Idea Idea Idea Idea Idea Idea Copyright 2013 Health Administration Press Decision matrix/Prioritization Matrix ▪ Used to systematically identify, analyze, and rate the strength of relationships between sets of information Your Total Evaluation Criteria Proposed Solution Probability of Success Ease of Implementation CostEffectiveness Hold online meetings Start meetings on time Create meeting agenda Allow staff to suggest agenda items Ranking key: 4 = excellent; 3 = very good; 2 = satisfactory; 1 = poor Copyright 2013 Health Administration Press Impact on Staff Satisfaction Group Average Five Whys/ Root Cause Analysis ▪ Used to find the underlying causes of performance problems Copyright 2013 Health Administration Press Workflow diagram ▪ Used to show the movement of people, materials, paperwork, or information during a process Copyright 2013 Health Administration Press Surveys (also considered a quantitative tool) ▪ Used to gather quantitative and qualitative information Types of surveys ▪ Questionnaires: paper or electronic instruments that the respondent completes independently ▪ Interviews: conducted with the respondent face to face or over the phone Copyright 2013 Health Administration Press 1. 2. 3. 4. 5. 6. Define the survey objectives. Identify the people to be surveyed. Select the survey population. Construct the survey. Test the survey and prepare the final draft. Administer the survey. Copyright 2013 Health Administration Press Force field analysis ▪ Used to identify and visualize the relationships between significant forces that influence a problem or goal Copyright 2013 Health Administration Press Stakeholder analysis ▪ Used to identify the individuals or groups that would be affected by a proposed process change for the purpose of gaining stakeholder support for the change Stakeholder Stakeholder Incentives Stakeholder Support Action(s) Radiology receptionists • • More work for receptionists Reception area not staffed for extra duties − Do time study to determine how this change will affect receptionists’ workload Radiology technicians • • Less clerical work for technicians Could reduce opportunities to interact with patients ++ Monitor patient satisfaction surveys to determine whether reduced interactions affect radiology department satisfaction scores Radiologists • Increased number of X-rays performed each day ++ No action needed; group supports the changes Copyright 2013 Health Administration Press Planning matrix ▪ Used to show the tasks needed to complete an improvement activity, the people or groups responsible for completing the tasks, and the deadlines for completion Gantt Chart: Graphic representation of a planning matrix Copyright 2013 Health Administration Press Quality storyboard ▪ Used to summarize the major elements of a completed improvement project Copyright 2013 Health Administration Press Quantitative tools ▪ Used for measuring performance, collecting and displaying data, and monitoring performance Qualitative tools ▪ Used for generating ideas, setting priorities, maintaining direction, determining causes of problems, and clarifying processes Copyright 2013 Health Administration Press Measurement How are we doing? Help answer these questions: ▪ How does the process work Yes Assessment Are we meeting expectations? No Improvement How can we improve performance? now? ▪ What can we improve? ▪ How do we improve it? ▪ How should we measure and track performance? Copyright 2013 Health Administration Press ▪ Step 1 Select a Problem/Process (Plan) ▪ Step 2 Define Current Process ▪ Step 3 Find Root Causes ▪ Step 4 Develop Action Plans ▪ Step 5 Try It ▪ Step 6 Review Results ▪ Step 7 Make Changes/Hold Gains (Do) (Check) (Act) Theories Plan Act- Plan Act- Plan Application Do-Study Do-Study Do-Study The nature of true learning…………. Check Sheet Fishbone Diagram Histogram Pareto Chart Flow Chart Copyright 2008 Health Administration Press. All rights reserved. Run Chart Scatter Diagram 8-67 Identifying the problem and defining it Linking problem solving AND process improvement Improve what matters to customers AND the Organization Data: The Great Equalizer Stratify, Classify and Clarify Identify people closest to the process Gather data/knowledge Identify first and last step (Macro to micro) Intermediate steps Map process using flow chart Ask – What are the possible causes to this problem? Use a fish bone/cause and effect Identify cause categories – Affinity diagram good Brainstorm and collect data Place causes in categories Look for repetitive causes in bones Confirm causes with data – Consensus /Nominal Group technique Think small and learn fast ▪ Good is the enemy of great… don’t think perfect solutions all the time… Use criteria based solutions Do not fall into trap of arbitrary goals – should be helpful measures – Priority matrices Just do it, but…. ▪ Follow the plan as it was designed ▪ Document any changes to the plan along with reasons why the change happened ▪ Take measurements to measure progress Connect real causes with real effects ▪ Purpose of PDCA is to learn from experience which root causes can be eliminated and which activities should continue as they are Step essentially ask ” Did we do what we said we were going to do and did it have the positive effect that we said it would have? Focus on both the process and the results ▪ Do not forget – Lessons Learned ▪ Discuss what worked well, what did not Stop – ‘N – Go P I Z Z A Small pizza delivery business with 6 shops Rapid growth followed by 6 month decline in volumes Customers leaving Top management formed a mixed team – store managers, kitchen staff and delivery personnel ? Why ? What needs to be done to fix problem ▪ Step 1 Select a Problem (Plan) Run Chart Average monthly volume of deliveries (per shop) 2700 2400 2100 1,951 deliveries 1800 Unit Volume 1500 1200 900 600 300 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec ▪ Step 1 Select a Problem (Plan) Pareto Chart Types of customer complaints Total=2520 October-December (across 6 shops) 100% 2500 (1890) 2000 75 Total # of customer complaints 1500 50 1000 500 0 (220) Late deliveries Wrong order 25 (206) (117) (87) Cold food Taste Other Illustration note: Delivery time was defined by the total time from when the order was placed to when the customer received it. ▪ Step 1 Select a Problem (Plan) Pareto Chart Late delivery complaints Total=1890 October-December (across 6 shops) (391) 400 (358) 350 (313) 300 # of Late Delivery Complaints (295) (275) (258) 250 200 = Other = Friday 150 100 = Saturday 50 0 C A B Shops F D E ▪ Step 2 Define Current Process (Plan) Process for producing and delivering Stop ’N Go Pizza Receive order Prepare ingredients Return to shop Bake pizza Receive payment Assemble order Deliver order ▪ Step 3 Find Root Causes (Plan) Cause & Effect/Fishbone Diagram Reasons for late pizza deliveries Machinery/Equipment People Unreliable cars Low pay No money for repairs No capacity for peak periods Ovens too small High turnover Poor handling of large orders High turnover Lack of experience Kids own junks No teamwork No training Don’t know town High turnover Drivers get lost Rushed Poor training Poor use of space Poor training Get wrong information Run out of ingredients High turnover Don’t know Poor use town of space Inaccurate High turnover ordering Lack of Poor training dispatching Many new streets Methods People don’t show up Low pay High turnover Materials Late pizza deliveries on Fridays and Saturdays ▪ Step 3 Find Root Causes (Plan) Run Chart Average turnover rate of employees (company-wide) % 70 60 50 43.25% 40 30 20 10 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec ▪ Step 3 Find Root Causes (Plan) Run Chart Average training hours of new employees 14 12 10 Average # of Hours 8 8 hours 6 4 2 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec ▪ Step 4 Develop Action Plans (Plan) Tree Diagram Before shift Reduce turnover rate of employees (company-wide) At convenient times Deliver training conveniently After shift At convenient locations Reduce turnover through improved training in all facets of operation During shift At shop At home Develop videos Hold trainee interest Use texts Use role play Deliver training effectively Evaluate each other Improve performance Pre/post tests Set clear performance standards ▪ Step 4 Develop Action Plans (Plan) (.19) (.01) Total Cost (.60) (.19) Time Tasks & Options Feasibility Criteria & Weighting Effectiveness Prioritization Matrix Train before shift 7.70 Train during shift 3.78 Train after shift 1.77 Train at the shop 7.70 Train at home 5.29 Develop videos 8.83 Use texts 4.16 Use role play 8.89 Evaluate each other 7.70 Pre/post test 8.83 Set clear performance standards 8.89 = 9 Excellent = 3 Fair = 1 Poor The total = the sum of [rating values x criteria weighting] For example, to find the total of the “Train before shift” row, do the following: [ (9) x .60] + [ (9) x19] + [ (3) x.19] + [ (3) x.01] = 7.70 Note: Weighting values of each criterion came from a matrix not shown. Task options come from the most detailed level of the Tree Diagram shown on the previous slide. Selecting the best training program components ▪ Step 4 Develop Action Plans (Plan) Matrix & Gantt Chart Combined President Human resources Tasks * Employees Responsibility Managers New training program timeline January February March April Train at the shop before the shift Develop videos Us e ro le p lay Evaluate each other Use pre/post test Set clear performance standards = Primary responsibility = Secondary/team member = Need information to/from * These were the highest rated tasks from the Prioritization Matrix on the previous slide. ▪ Step 4 Implement the solution or process change (Do) ▪ Follow the plan as designed ▪ Implement changes on a small scale at first ▪ Follow the plan and monitor measures and milestones ▪ Document any changes to the plan ▪ List reasons why the change happened ▪ Publicize progress through newsletters and storyboard updates Review Results (Check) Pareto Charts Before employee training 2500 2000 Total # of Customer Complaints ▪ Step 6 75% 1500 1000 500 0 Late Deliveries 8% 5% 3% Wrong order Cold food Taste Other After employee training 1000 800 9% 53% 600 400 20% 14% 200 0 Late Deliveries Selection Taste 5% 5% 3% Wrong order Cold food Other ▪ Step 6 Review Results (Check) Run Chart Average turnover rate of employees (company-wide) 80 70 60 50 % 44% 40 30 20 10 0 Aug Sep Oct Nov De c J an Fe b Ma r Apr Ma y J un J ul ▪ Step 6 Review Results (Check) Run Chart Average delivery time (company-wide) 40 35 Average Time (in minutes) 28 minutes 30 25 20 15 10 5 0 Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul ▪ Step 7 Make Changes/Hold Gains (Act) Radar Chart Team evaluation of itself after new training Results X 5 4 3 2 Standardization Teamwork X 1 X Note: The “x” mark indicates the team’s average performance rating while the shaded area indicates the range of ratings within the team. Impact on Customers Use of Tools
