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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
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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
1
Reason for Action
succinct problem statement, burning platform
2
Initial State
where you are now
3
Target State
where you want to be
4
Gap
Analysis difference between boxes 3 and 4
5
Solution approach
ideas/ways for closing the gaps
6
Rapid Experiments
tests of the Solution Approaches
7
Completion Plan
what is left to do after the RIE week
8
Confirmed State
how achievement of Target State is measured
9
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
2
Initial State
3
Target State
4
Gap
Analysis
5
Solution approach
6
Rapid Experiments
7
Completion Plan
8
Confirmed State
9
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
46
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!!!!