using the tree diagram to improve complex projects

Using the Tree Diagram to Improve Complex Projects

Earlier in the chapter we discussed the use of the tree diagram for planning (see Figure 21-3). In this section we will discuss using the tree diagram for breaking down complex improvement projects. The first tree diagrams presented will employ the questions from the Model for Improvement for guidance in breaking down the project from the aim of the project to questions that can lead to possible improvement cycles. We will then conclude this discussion with a healthcare example that employs the use of the Planning type tree diagram over the time of the project. This example will show how improvement concepts can be developed into potential changes that will lead to a desired vision developed by an improvement team.

Examples of the Tree Diagram Integrating the Model for Improvement to Address Complex Projects

Figure 21-7 has been borrowed from the Improvement Guide to show the complexity of various types of improvement efforts from the very simple to the most complex. For the next example of using the Tree Diagram we will focus on an example that is aimed at improving a process to gather data from sales within an organization.

Figure 21-7: Complexity of Level of Various Improvement Projects – Focus is on Improving a Process in an Organization

The tree diagram depicted in Figure 21-8 generally follows the flow of the Three Questions in the Model for Improvement:

1. What are we trying to Accomplish? General Description Project Objectives describe objectives to support the overall general description

and the answer to question one. In this example we are trying to “ Improve the process by which we gather data from the product sales force…”

Using the Tree Diagram to Improve Complex Projects © API/September 2006 1

2. How will we know that a change is an improvement For each objective, a measure(s) is selected to answer question two in the

Model for Improvement. Identifying measures related to the objectives usually provides some intermediate measures for the project (see Improvement Guide p.55).

3. What changes do we need to make? For this question, questions are posed that need to be answered by the people

leading the project. These questions can lead to appropriate PDSA cycle. Also added are appropriate Change Concepts (Reference: Improvement Guide, p. 295) that can lead to changes and ideas that can be tested immediately.

Figure 21-8: Tree Diagram Using the Three Questions to Improve a Sales Process


1 .What are we trying to accomplish?

3. What changes can we make that will lead to improvement?

2 .How will we know a change is an improvement?

Improvement Objectives Questions to Answer Change Concept/ Ideas/ Measures

B14 / Implement arequest form and web link

D28 / Implement ameasurement process &report

A9, D34, D27, G53 /Engagement guidelines toassess survey needs

Engagement guidelines toadvise partners

B18, E38 / Communicateresponses

E42 / Communicatechange based onfeedback

A5, B20, G51, I68 /Widespread executivesponsorship for a singleprocess

H59, F46 / Develop achecklist for survey launch

Items in Green

–

answer the question “What can we do right now?”

Standardize the survey launch process

M – Client satisfaction(Collect data)

Describe Project:(check one)

_ X_ Redesign existingProcess(es), product or service

___ Design new process(es), Product or service

___ Improve the system as a Whole (mainstay, drivers & support processes)

Brief Description: (include description above)

Improve the process by which we gather data from the Product Sales Force & increase knowledge retention of key sales performance indicators (time spent, satisfaction, etc…)consistently through a single point of capture.

Create request process & measures

M - Process utilization rate (Collect data)

Improving sales data collection & usage

M - # of Surveys Received by Sales, & Time Spent on Surveys (Collect data)

How do we make it easy for people to engage the team to deliver surveys?

How do we assess whether a survey is needed or not with the existing TimeAnalysis survey in place & other data collected?

What alternate methods can we advise the internal partner to use?

How is the outcome tracked, monitored and used for questions asked?

Sales: Have the decision makers heard the sales feedback?

To create cadence in the sales work week how do we create consistency?

How do we draw new clients into the process?

How do we ensure consistent delivery of the survey process?

How do we measure the resources needed to support the process?

















H59, F46 / Develop achecklist for survey launch

Items in Green

–

answer the question “What can we do right now?”

Standardize the survey launch process

M – Client satisfaction(Collect data)


_ X_ Redesign existingProcess(es), product or service

___ Design new process(es), Product or service

___ Improve the system as a Whole (mainstay, drivers & support processes)


Improve the process by which we gather data from the Product Sales Force & increase knowledge retention of key sales performance indicators (time spent, satisfaction, etc…)consistently through a single point of capture.

Create request process & measures

M - Process utilization rate (Collect data)

Improving sales data collection & usage

M - # of Surveys Received by Sales, & Time Spent on Surveys (Collect data)

How do we make it easy for people to engage the team to deliver surveys?

How do we assess whether a survey is needed or not with the existing TimeAnalysis survey in place & other data collected?

What alternate methods can we advise the internal partner to use?

How is the outcome tracked, monitored and used for questions asked?

Sales: Have the decision makers heard the sales feedback?

To create cadence in the sales work week how do we create consistency?

How do we draw new clients into the process?

How do we ensure consistent delivery of the survey process?

How do we measure the resources needed to support the process?

Figure 21-9: Planning Chart Using Action Items from the Tree Diagram

PDSA Cycles & Activities Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8Implement Request Form Implement Measures Develop Guidelines Test Guidelines Implement Guidelines Develop Process for Responses Test Response process Implement Response Process Survey Decision Makers Standardize Survey Process Test Survey Implement New Survey Process

Once the tree diagram is detailed to a useful state, the actions associated with Question Three of the Model for Improvement can be placed in time order. Figure 21-9 describes the flow of the various action items and PDSA cycles developed from the questions that need to be answered in the project and potential changes developed by consideration of the Change Concepts (Reference: Improvement Guide, p. 295).

The tree diagram can also be used to scope large complex projects that would have multiple application of the Model for Improvement. Figure 21-10 shows the relative position of our next example as improvement of a subsystem for sales support within a large international corporation. As we focus on the tree diagram in Figure 21-11, we see that each of the objectives is large enough to incorporate an improvement effort for each objective. In this organization, the term “Charter” is reserved for a document that will guide the deployment of several “Improvement Plans.” Figure 21-12 describes this breakdown of individual improvement objectives at the Charter level to four individual Improvement Plans. All efforts are being guided by the Model for Improvement.

Figure 21-10: Complexity of Level - Focus is on Improving a Subsystem


Figure 21-11: Tree Diagram Using the Three Questions to Improve the Sub-system for Technical Support within a Large Technology Company

Figure 21-12 describes how the project was managed using a Charter to guide four Improvement Plans. The project measures were connected to the overall charter. For each of the four objectives it was deemed appropriate to have a separate Improvement Plan to guide the effort. The Model for Improvement was then used to manage and coordinate the overall project.


1. What are we trying to accomplish?

3. What changes can we make that will lead to improvement?

2. How will we know a change is an improvement?


___ Redesign existing Process(es), product or service___ Design new process(es), Product or service_X_ Improve the system as a

Whole (mainstay, drivers & support processes)

Brief Description: (include

description above)

Improve the system for technical support, reducing costs while maintaining customer satisfaction.

FY06 Strategic objectives specifically target $15M in cost reduction to improve GM% by 11%. The majority of the cost reduction is targeting in the mainstay of the system.

What knowledge is most useful?

How does it affect resolution of customer case (should be 2x faster, if not a defect)?

Does customer has better experience?

General Description of Project

Project ObjectivesQuestions to Answer

(Potential Cycles)

16. Find & remove bottlenecks27. Give people access to information40. Focus on outcome for a customer

Possible Change Concepts to Apply

M: CSI/top 20 in regionM: CSI for non-top in reg.

Provide a differentiated customer experience for

strategic customers, and a more basic experience for

non-strategic. (reduce over-delivery)

M: cost/incident, vol. self-solve vs. assisted solve

Improve the “self-solve” web capabilities (greater

coverage across products for knowledge, patches,

upgrades, defect management) shifting

away from resources for assisted solve

M: reduced cost/case, reduced variation per supplier

Reduce supplier cost/case for assisted solve from partners, contractors and 3rd parties.

M: reduced cost/case, cost attribute per classification

Reduce support costs for older versions of products, low GM% accounts, cost of supporting products with high defects

What system(s) are most useful for capturing customer knowledge?

How should the process and system use be deployed?

What are measures of effectiveness of this process relative to the overall system?

What gaps in current KM are most needed to improve the customer’s self-solve usage?

What process changes are needed to ensure we fulfill those knowledge gaps initially and on-going?

What costs are involved in the fulfillment of the knowledge gaps and how does this impact the overall delivery of service to customers?

What measures are needed to ensure we maintain an effective system of delivery for both assisted and self-solve processes?

What are the variations in supplier costs/case and what are some of the main reasons for these?

What opportunities do we have for improving the system by which suppliers provide service/support on our behalf, esp. to reduce average costs?

Which older product versions (>n-2) have the greatest impact on support delivery cost/call today? What are the reasons?

Which accounts have the greatest impact on cost/call and overall costs (GM), and what are the reasons?

What products currently have high defect rates that are impacting costs, and what steps are needed to reduce the impact of these?

40. Focus on the outcome for a customer39. Coach customer to use product / service43. Outsource for “free” - suppliers provide knowledge51. Standardization of processes

45. Work with Suppliers16. Find & remove bottlenecks

45. Work with suppliers (CPE partners)39. Coach customer to use product/service (training, KP, NRCE)

7. Reduce classifications9. Match amount to the need11. Change tgts / set points (SLO)

1.

2.

3.

4.





description above)








(Potential Cycles)
































1.

2.

3.

4.

Figure 21-12: Tree Diagram Using the Three Questions to Improve the Sub-system for Technical Support within a Large Technology Company

Using the Planning Type Tree Diagram to Guide a Complex Project in Healthcare

The tree diagram in Figure 21-13 describes the use of “planning” type tree diagram to guide a project towards accomplishing a desired vision. In this diagram we have four concepts that are driving the current changes. From these current changes, potential changes have been identified that will be necessary to move the overall effort to the desired vision.

Figure 21-14 describes a project in a Healthcare system where changes are being developed, tested and implemented to improve the relationships between healthcare professionals and patients. The team started off with several guiding principles:

You Know Me; Changes to establish the relationship with the patient The Care Team; Changes to be made by key contacts in the care team Collaboration; Changes to better understand and work with the patient Options and Tools; Methods and Tools to enhance communication and the

relationship.






description above)








(Potential Cycles)
































1.

2.

3.

4.

Improvement Plan 1

What are we trying toaccomplish?

How will we know that achange is an improvement?

What change can we make thatwill result in improvement?

Model for Improvement

PlanAct

DoStudy

Improvement Plan 2





PlanAct

DoStudy

Improvement Plan 3





PlanAct

DoStudy

Improvement Plan 4





PlanAct

DoStudy

System Measures

TOTAL SALES

190

210

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From these concepts, changes known to the team were identified that could be tested now. As the team developed and tested and these changes, other potential changes were identified. In addition to this thought process, the team used the overall vision to develop other potential changes that would be required to move the team to accomplishing their vision. As the team developed the plan for these changes they also included a timeline to forecast when the changes could be integrated into the system.

Figure 21-13: Using the Planning Type Tree for Planning Changes Over Time Directed to a Desired Vision in Healthcare – Conceptual Example


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Mar. 20063 Mos.

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Current Change

Current Change

Current Change

Planned Change

Planned Change

Planned Change

Potential Change

Potential ChangePotential Change

Potential Change

Team Vision

The team’s vision/ personalization of the concept design

PROJECT TIMELINE

Figure 21-14: Using the Planning Type Tree for Planning Changes Over Time Directed to a Desired Vision in Healthcare – Detailed Example

Summary

This paper has discussed several key points related to using tree diagrams to breakdown complex improvement projects:

1. The Model for Improvement and use of the Three Questions can be used in conjunction with the Tree Diagram to break down improvement projects.

2. Obvious PDSA cycles can be identified and testing started on changes that can lead to improvement.

3. Time lines can be constructed to give guidance to the team.

4. Larger projects can be scoped down using the Tree Diagram. Charters can be used to manage these larger projects with sub-charters or improvement plans.


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Kp.org sign-up kiosks & info

Patient contact preferences

Nickname in header

Mar. 20063 Mos.

TODAY

Receptionist co-located with team

CA reviews after visit summary with patient

RN pre-screening charts

Proactively identifying patient needs

Reaching out to patient and subsequent follow-up

Telephone visitsGroup visitsHealth Assessments

New roles for members of the care team based on the work

Ask patients to do collaborative goal setting during visit

Build Care plan into chart – consistent place

Virtual visits with agreeable members

Action plans based on evidence-based care developed with patients

e-visits as the standard mechanism for follow-up

New members of the care team based on the work

What matters to patient addressed by care team

Collaborative care plan guides all interactions

Panel View tool to manage patients

The care team, supported by

optimizing the

relationship-based care of a population of

patients

PROJECT TIMELINE

Pre-visit prep with patients to elicit what matters

References

Bowles, John. The Society of Automotive Engineering’s Failure Modes and Effects Analysis (Proposed Document) 1996.

Juran, J.M., Gryna, Frank. Juran’s Quality Control Handbook Fourth Edition New York: McGraw-Hill Book Company. 1988.

Mizuno, S., ed. Management for Quality Improvement: The 7 New QC Tools. Cambridge, MA: Productivity Press, Inc. 1988.

Shiba, Shoji, Alan Graham, David Walden. A New American TQM: Four Practical Revolutions in Management. Portland, OR: Productivity Press. 1993.

Wilson, Paul F., Larry D. Dell, Gaylord F. Anderson. Root Cause Analysis: A Tool for Total Quality Management. Milwaukee: ASQC Quality Press. 1993.

Exercises

1. Consider a recent problem in your organization and develop a problem tree diagram.

2. Select a work objective that is currently a challenge and develop a planning type tree diagram.


Appendix: Healthcare Examples of the Tree Diagram


Prepared by: Martha Frederickson


Describe Project:(check one)_X_ Redesign existing Process(es), product or service___ Design new process(es), Product or service___ Improve the system as a



To improve the care provided to heart failure patients by including evidenced based interventions thereby decreasing readmission rates

100% of patients will have standardized order set used

99% of pts will receive smoking cessation advice

99% of pts will receive LVF assessment and ACEI/ARB’s as appropriate

How can we automate this with Excellian (computerized documentation system)

How can we assess if LVF assessment is planned for after DC or done prior to adm?

How will we know if ACEI/ARB was considered but contraindicated?

Is smoking history getting consistently assessed on admission?

How do we ensure all providers know what elements need to be included in dc instructions?

How do we get this on the chart for every patient?

E41/H59/B18:Work with Care Coordinators to put paper order set on chart and follow up to ensure it is completed

B17: Develop computerized order set for HF patients

H59/B18/B19: Include check boxes on order set that indicate these elements

Care of Heart Failure Patients at XYZ Hospital

How do we ensure providers use it and fill it in on each patient?

B17: Make this a required field on admission profile and/or on order set

99% of pts will receive comprehensive dc instructions

How do providers document instructions given?

Decrease ALOS What other factors influence ALOS beyond 4 core measure?

Do these pts follow a typical path?

Are there commonalities among pts with targeted LOS?

H59/B18/B19: Include check boxes on order set that indicate these elements

G51: Create a standard HF pathway

E41/E40: Have Case managers follow HF patients while hospitalized

9/8/2006

Improvement Objectives Questions to Answer Change Concept/ Ideas PDSA (gant) Measures

Develop a process and provide pre- and post-rehab conditioning parameters f or Anesthesiology at time of patient admission for surgery.

Describe Project: (check one) ___ Redesign existing Process(es), product or service __Design new process(es), product or service ___ Improve the system as a



To decrease the risk and occurrence of post-op respiratory complications af ter elective general and vascular surgery in at-risk patients by initiating a pre-op pulmonary assessment and conditioning/ rehabilitation program. This will be achieved by: Physician engagement –

identif y patient candidates well in advance of surgery date

Development of a Pulmonary Rehab Express program for preop patients

Availability of documentation of rehab parameters upon arrival on day of surgery

Develop a standardized pre-op pulmonary rehab referral f orm and process to begin use in physician offi ce through Pulm Rehab to Pre-Surgical Screening (PSS). I nclude I CD9 codes f or insurance coverage.

Develop procedure and educate surgeons, Anesth., Pulmonologists, offi ce staff , PSS and patients (develop educational materials).

Develop Rehab Express program to accommodate elective general and vascular surgery patients with pre-op chronic respiratory risks (optimal length of time for conditioning is projected at 2 weeks)

Potential additional measures: decrease post-op length of stay, cost per case and readmission for respiratory conditions.

Can Pulmonary Rehab handle added volume? Do they have a program already or one that could be adapted to this? Are there forms that could be used/modified for this program?

Will busy and different office staffs and PSS cooperate and support this new initiative? Teach office staff, Pulm Rehab and PSS the process. Teach office staff, Pulm Rehab and PSS the process. Will this program be cost effective? What happens if a patient’s insurance will not cover or the patient does not have insurance? What if there is less than 2 weeks before surgery?

Will Anesthesia utilize pulmonary rehab information, find it of value?

What if there is less than 2 weeks before the surgery?

Will office, Pulm Rehab and PSS staff support ongoing evaluation & improvement of the process? Pilot the whole process on one or two patients to work out the bugs. Include office, Pulmonary Rehab and PSS stgff in evaluation and revision of process.

Will timing of NSQIP data be timely enough to monitor the process?

Category and continuous data on patients referred, rehab program completed and pulmonary status measure improvement.

Will surgeons agree with the need for pre-op pulmonary conditioning and refer in advance of boarded elective surgery? What’s the degree of belief that this program is needed by surgeons, anesthesiologists & pulmonologists?

Decrease post-op pulmonary complications including dyspnea, prolonged ventilator dependency and pneumonia.

Develop alliance/cooperative relationships (37)

Coach customers to use product / service (39)

Standardization (51)

Use a coordinator (41)

Conduct training (31)

Enable access to information

Standardization –

create a formal process (51)

Develop

operational definitions (53)

Conduct training

(31) Use proper

1. Pulm Rehab capacity/program evaluation PDSA 2. 4/12/2006 Surgery QA Committee- surgeon buy-in PDSA 3. 4/28/06 first patient referral (elective AAA) 5/2 assessment completed, 5/5 PR Express began PDSA 4. PDSA 5. PDSA

How will we attribute complications to pre-op pulmonary risk?

Will patients agree to the program, stick with it once it is started?

Will there be enough patients referred in order to evaluate and do statistical analysis?

Engage/use the physicians and office staff in ongoing evaluation/process improvement.

Prepared by: Laura DeSantis


using the tree diagram to improve complex projects

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