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The Quality Improvement Journey: From TQM to QI

HIVQUAL WorkshopJune 24, 2011

Dan Belanger Terry Hamilton Lawrence Hansley

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Agenda Welcome and Introductions SWOT Analysis Small Group Exercise Total Quality Management Key Tools and Techniques Origins of Quality Management Histogram Small Group Exercise Continuous Improvement 6 Sigma Lean Lean Small Group Exercise The Model for Improvement

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Ice Breaker: SWOT Analysis Small Group Exercise Your HIV QM Committee is considering

adding consumers to the HIV QM Committee

To understand the pros and cons you decide to do a SWOT Analysis (strengths, weaknesses, opportunities and threats)

Using the worksheet in your packet, each group brainstorms a SWOT analysis and reports back

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Quality Roots

The roots of Total Quality Management can be traced to early 1920's production quality control ideas, and concepts developed in Japan beginning in the late 1940's and 1950's, pioneered there by Americans Feigenbaum, Juran and Deming

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Total Quality Management (TQM) Total Quality Management features:

the customer-supplier interfaces, (external and internal customers and suppliers)

an organizational commitment to quality the importance of communicating this quality

commitment the acknowledgement that the right

organizational culture is essential for effective Total Quality Management

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Tools and Techniques

An array of tools and techniques is used for identifying, measuring, prioritizing and improving processes critical to quality

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Process Improvement Tools

These process improvement tools and techniques include: PDSA (plan, do, study, act) Cycle Flow-charting Cause and effect diagram, Brainstorming Pareto Analysis

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Act

What changes are to be made?

Next cycle?

PlanObjectiveQuestions and predictions (why)Plan to carry out the cycle (who, what, where, when)

Study Complete the

analysis of the dataCompare data to

predictionsSummarize

what was learned

DoCarry out the planDocument problemsand unexpectedobservationsBegin analysis of the data

The PDSA cycle for learning and improvement

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Commonly Used Flow Chart Symbols:Purpose: Graphic depiction of how a

process worksUse: 1) visualize and understand a

process; 2) consider ways to simplify; 3) recognize unnecessary steps;4) identify who will be involved in or

effected by improvement processCaution: 1) flowchart must reflect

real process; 2) people who know the process

must be involved; 3) be sure the flowchart focuses on

the identified problem

Task or Step

Terminator

Decision

Wait symbol

Flow Charts

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Flow Chart Example

Patient arrives at front desk

Client in system?Receptionist asks client

to complete paperwork for new clients and return it to front desk

NO

Ask client to be seated in the Waiting room

YES

HR Counselortakes client into Counseling Room

ETC.

Front Desk Staff Asks Client for Name & Searches Database

Client Arrives at Drop-In Center

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CAUSE-AND-EFFECT DIAGRAMSAMPLE

Low show ratefor appointments

Procedures People

Patients

Patient unawareof appointment

Computer

System downfor routinemaintenance

Skeleton

Equipment Environment

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BrainstormingPurpose: To provide a freewheeling environment in which everyone is encouraged to participate.

Use: generate new ideas/insightsdraw out experiences of each participant when creative ideas have been suppressed by groupCaution:ideas will need elaboration discussion impedes & limits flow of ideas

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Feigenbum, Juran and Deming

Quality Management resulted mainly from the work and theories of Americans who took the messages of quality to Japan in the 1950's: Joseph Juran W Edwards Deming Armand Feigenbaum

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W Edwards Deming

placed great importance and responsibility on management, at both the individual and company level, believing management to be responsible for 94% of quality problems.

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Deming’s 14 Point Management Plan Create constancy of purpose towards

improvement of product and service Adopt the new philosophy. We can no longer

live with commonly accepted levels of delay, mistakes and defective workmanship

Cease dependence on mass inspection. Instead, require statistical evidence that quality is built in

End the practice of awarding business on the basis of price

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Deming’s 14 Point Plan Continued Find problems. It is management’s job to

work continually on the system Institute modern methods of training on the

job Institute modern methods of supervision of

production workers, The responsibility of foremen must be changed from numbers to quality

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Deming’s 14 Point Continued Drive out fear, so that everyone may work

effectively for the company Break down barriers between departments Eliminate numerical goals, posters and

slogans for the workforce asking for new levels of productivity without providing methods

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Deming’s 14 Point Continued Eliminate work standards that prescribe

numerical quotas Remove barriers that stand between the

hourly worker and their right to pride of workmanship

Institute a vigorous program of education and retraining

Create a structure in top management that will push on the above points every day

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Dr Joseph M Juran

developed the quality trilogy – quality planning, quality improvement and quality control.

Good quality management requires quality actions to be planned out, improved and

controlled. The process achieves control at one level of quality

performance, then plans are made to improve the performance on a project by project basis, using tools and techniques such as Pareto analysis.

This activity eventually achieves breakthrough to an improved level, which is again controlled to prevent

any deterioration.

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Pareto Chart Purpose

Compare the various factors that contribute to an overall effect.

Indentify the “vital few” (factors that, warrant the most attention) from the “useful many” (factors that, while useful to know about, have relatively smaller effect).

Based on the Pareto Principle which suggests that most effects are the result of relatively few causes, that is, approximately 80% of effects come from 20% of potential causes.

Analyzing Data

21Analyzing Data

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Juran

Juran believed quality is associated with customer satisfaction and dissatisfaction with the product

emphasized the necessity for ongoing quality improvement through a succession of small improvements

projects carried out throughout the organization.

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Juran’s 10 Points to QI

Build awareness of the need and opportunity for improvement

Set goals for improvement Organize to reach the goals Provide training Carry out projects to solve problems

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Juran’s 10 Points to QI Continued Report progress Give recognition Communicate results Keep score of improvements achieved Maintain momentum

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Armand V Feigenbaum

Feigenbaum was the originator of “total quality control”, often referred to as total quality.

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Feigenbaum’s Definition of Total Quality Control

“An effective system for integrating quality development, quality maintenance and quality improvement efforts of the various groups within an organization, so as to enable production and service at the most economical levels that allow full customer satisfaction”.

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Feigenbaum’s 3 Steps to Quality:

Quality leadership Modern quality technology Organizational commitment

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Late 1950’s Japanese who developed new concepts in response to the Americans

Dr Kaoru Ishikawa Shigeo Shingo Dr Genichi Taguchi

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Ishikawa’s 7 Basic Tools of Quality Pareto analysis which are the big problems? Cause and effect diagrams what causes the

problems? Stratification how is the data made up? Check sheets how often it occurs or is done? Histograms what do overall variations look like? Scatter charts what are the relationships between

factors? Process control charts which variations to control

and how?

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Cause-and-Effect Diagram Organizes and displays all causes and sub-causes that

may influence a problem, outcome, or effect Helps push people to think beyond the obvious causes,

(money, time) to find some causes that they can fix/improve

Helps organize potential solutions and make clear who should be involved in solutions

Encourages a balanced view Demonstrates complexity of the problem

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HIV-infected homeless youth not Receiving HIV primary care

Individual factors

Individual factors

Social factors Social Factors

History of physical/emotional/sexual abuse

Poor Resources

Incarceration Stigma

Survival sex

Poor access to resources

Cause and Effect Diagram of HIV-infected Homeless Youth

Not Receiving HIV Primary Care

Drug/Alcohol abuse

Foster care system

Family conflict/neglect/abandomnment

Individual factors

Sexual minority

Unstable Housing

Low Self-efficacy

Poor condom use

Poor condom use

Low educational attainment

Mental health disorder

Violence

Discrimination

Laws

Policies

EconomicsPoor access to resources

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HistogramsPurpose

Used to display the variation in continuous data like time, weight, size or temperature

Helps teams recognize and analyze patterns in data that are not apparent simply by looking at a table of data, or by finding the average or median

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What’s our Pattern Here?Group Discussion(10 Minutes)

Number of days for follow-up GYN appointment

Source: Institute for Healthcare Improvement

Analyzing & Displaying Data

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Shigeo Shingo

Associated with Just-in-Time manufacturing, The Use of a checklist- humans can forget or make

mistakes the inventor of

the single minute exchange of die (SMED) system, in which set up times are reduced from hours to minutest

Poka-Yoke (mistake proofing) system. In Poka Yoke, defects are examined, the production system stopped and immediate feedback given so that the root causes of the problem may be identified and prevented from occurring again.

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The Mistake Proofing System Shingo distinguished between “errors”,

which are inevitable, and “defects”, which result when an error reaches a customer

the aim of Poka-Yoke is to stop errors from becoming defects.

Defects arise because errors are made and there is a cause and effect relationship between the two.

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Dr Genichi Taguchi

believed it is preferable to design

product that is robust or insensitive to variation in the manufacturing process, rather than attempt to control variations during actual manufacture

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Taguchi’s 3 Quality Stages

System design Parameter design Tolerance design

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Kaizen or Continuous Improvement The aims of a Kaizen organization are

typically defined as: To be profitable, stable, sustainable and

innovative. To eliminate waste of time, money, materials,

resources and effort and increase productivity. To make incremental improvements to systems,

processes and activities before problems arise rather than correcting them after the event.

To create a harmonious and dynamic organization where every employee participates and is valued.

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Key concepts of Kaizen

Everyone involved in a process or activity, however apparently insignificant, has valuable knowledge and participates in a working team or Kaizen group

Everyone is expected to participate, analyzing, providing feedback and suggesting improvements to their area of work.

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Key concepts of Kaizen continued

Every is a key word in Kaizen: improving everything that everyone does in every aspect of the organization in every department, every minute of every day.

Evolution rather than revolution: continually making small, 1% improvements to 100 things is more effective, less disruptive and more sustainable than improving one thing by 100% when the need becomes unavoidable.

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Key concepts of Kaizen

Every employee is empowered to participate fully in the improvement process: taking responsibility, checking and co-coordinating their own activities. Management practice enables and facilitates this.

Every employee is involved in the running of the company, and is trained and informed about the company. This encourages commitment and interest, leading to fulfillment and job satisfaction.

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The Quality Circle

The idea of the quality circle was first introduced by Japanese business as a way to involve all employees in their organization’s quality program.

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Quality Circles

A quality circle is a group of 3 to 12 co-workers who agree on a volunteer basis to meet together regularly to identify and analyze problems and to brainstorm solutions

Solutions are presented to management Quality Circle participants in some cases may

implement solutions

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1970’s-1980’s Western Gurus:Philip B Crosby Known for the concepts of

“Quality is Free” “Zero Defects”, 4 Absolutes of Quality

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Crosby’s 4 Absolutes of Quality

Quality is conformance to requirements The system of quality is prevention The performance standard is zero defect The measurement of quality is the price of

non-conformance

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Tom Peters

identified leadership as being central to

the quality improvement process, discarding the word

“Management” for “Leadership”. The new role is of facilitator, and the basis is

“Managing by walking about” (MBWA), enabling the leader to keep in touch with customers, innovation and people, the three main areas in the pursuit of excellence.

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Tom Peters

believes that, as the effective leader

walks, at least 3 major activities

are happening: Listening suggests caring Teaching values are transmitted Facilitating able to give on-the-spot help

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Framework for Measuring Healthcare Quality

In 1966 Avedis Donabedian developed the first conceptual framework to measure the quality of healthcare

Measure quality by assessing structures, processes, outcomes of care

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National Health Service (UK)

NHS Improvement has over 10 years improvement experience

Use practical knowledge and “how to” approach to help improve the quality and productivity of services

Use innovative approaches as well proven improvement methodology.

Integrates sociological concepts into improvement work

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Six Sigma

Since the 1920's the word 'sigma' has been used by mathematicians and engineers as a symbol for a unit of measurement in product quality variation

3.4 parts - or defects - per million In the mid-1980's engineers in Motorola Inc

in the USA used 'Six Sigma' as a name for an in-house initiative for reducing defects in production processes

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Motorola

In the late-1980's following the success of the above initiative, Motorola extended the Six Sigma methods to its critical business processes

in-house 'branded' name for a performance improvement methodology

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Motorola’s Definition of Six Sigma "...Six Sigma has evolved over the last two decades

and so has its definition. Six Sigma has literal, conceptual, and practical definitions. At Motorola University (Motorola's Six Sigma training and consultancy division), we think about Six Sigma at three different levels:

As a metric As a methodology As a management system Essentially, Six Sigma is all three at the same time."

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Six Sigma Methodology

Understanding and managing customer requirements

Aligning key business processes to achieve those requirements

Utilizing rigorous data analysis to minimize variation in those processes

Driving rapid and sustainable improvement to business processes.."

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Six Sigma Leaders and Teams Six Sigma team leaders (Black Belts) work

with their teams (team members will normally be people trained up to 'Green Belt' accreditation) to analyze and measure the performance of the identified critical processes.

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the DMAIC model for process improvement.DMAIC is commonly used by Six Sigma project

teams and is an acronym for: Define opportunity Measure performance Analyze opportunity Improve performance Control performance.."

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DMAICT process elements

D - Define opportunity M - Measure performance A - Analyze opportunity I - Improve performance C - Control performance, and optionally: T - Transfer best practice (to spread the

learning to other areas of the organization)

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HHCs Past

HHC examples… Chronic Care Collaboratives

Ambulatory Care Redesign

1,000,000 Lives Campaign

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BREAKTHROUGH- HHCs Improvement System

History of LeanKaizenDriven by metrics to right sizeStaff teams

Value= What the customer wants

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Rapid Improvement Event- (R.I.E.)

Hallmarks Planned, team-based event Fresh-eyes and pros 1 wk, intensive, facilitated Specific follow-up to sustain

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Breakthrough- Impact at HHC

From start to now, ~$150 million in revenue or decreased expenses

≥ 8,800 employees have participated

~700 R.I.E.s

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TOOLS We Know

Pick ChartPareto ChartRoot Cause AnalysisPDSA Brainstorming

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A3

STORY Paper and pencil!

9 boxes Eliminate MUDA or Waste

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A3 Boxes

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Reason for Action

succinct problem statement, burning platform

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Initial State

where you are now

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Target State

where you want to be

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Gap

Analysis difference between boxes 3 and 4

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Solution approach

ideas/ways for closing the gaps

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Rapid Experiments

tests of the Solution Approaches

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Completion Plan

what is left to do after the RIE week

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Confirmed State

how achievement of Target State is measured

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INSIGHTS

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8 Wastes

1. Over Production2. Waiting3. Transport4. Extra Processing5. Inventory6. Motion7. Defects8. Unused Human Potential

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6S

Sort Straighten Scrub Safety Standardize Sustain

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5 Why’s

Why? Why? Why? Why?

Why? Determines Root Cause

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Just Do It

Type of improvement activity.Solution is known. Does not require R.I.E. Put in place with limited resources

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Exercise 1 Increase clinician participation in monthly QI meeting by 10%1

Reason for Action

Increase clinician participation in monthly QI meeting

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Initial State

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Target State

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Gap

Analysis

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Solution approach

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Rapid Experiments

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Completion Plan

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Confirmed State

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INSIGHTS

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PICK Chart-Do the High Benefit / Low Difficulty actions now ! Identify Actions then and

group into BENEFIT DIFFICULTY

P PossibleHigh benefit, Make a plan how to do

it.

I ImplementHigh Benefit, Easy to Do.

Implement Now

C ChallengeLow benefit, but easy to do

K Kick OutLow benefit and difficult to do.

Kick it out !

1

2

3

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7

8

9

CI P

K5

Impa

ct

Difficulty

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Exercise IIPick Chart

a. Increase by 15% the number of MSM who have at least 4 kept medical appointments during the year.

b. Engage 3 consumers 2x each month in QI planning activities.

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Summary

QI is a strategyMany toolsMany opportunitiesJust Do It!

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Model for Improvement

Developed by Associates in Process improvement

Simple elegant Captures the central concepts and core

principles of Quality improvement in a clear, concise fashion

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What are we trying to accomplish?

How will we know that a change is an improvement?

What change can we make that will result in improvement?

Act Plan

Study Do

Model for Improvement

Model for

Improvement

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Conclusion

The same basic principles guide Quality Improvement and Quality Management Methodologies

The specific methodology used is not as important as the commitment to quality improvement principles, taking action and improving the quality of care

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Resources

Bruce Agins,MD Clemens Steinbock Kevin Garrett Alan Chapman 2004-2009 Institute for Healthcare Improvement The Economist Newspaper Copyright 2011 Associates in Process Improvement www.Businessballs.com National Health Service, www.improvement.nhs.uk Copyright 1994-2005 Motorola, Inc. Toyota Production Systems Mark R. Chassin and Jerod M. Loeb, The Ongoing Quality

Improvement Journey: Next Stop, High Reliability Health Affairs on April 25, 2011

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Further Reading

Beckford, J., “Quality: A Critical Introduction”, Routledge, London, 1998; 4th edn, 2002

Crosby, P., “Quality is Free: The Art of Making Quality Certain”, McGraw-Hill, 1979

Ishikawa, K., “What is Total Quality Control?The Japanese Way”, Prentice Hall, 1985

Juran, J., “Juran on Planning for Quality”, Free Press, New York, and Collier Macmillan, London, 1988

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Special Thanks to…

Terry Hamilton Lawrence Hansley HHC

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And…

Thank you!!!!