(2009-04-14) Problem Solving Cycle.pdf

7/30/2019 (2009-04-14) Problem Solving Cycle.pdf

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y:

.. , . ., . .

Quality Coordinator / Risk Management OfficerMr.Mr. TarekTarek HawariHawari, R.N., R.N.

Head Nurse ICU


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C ass cat on o Qua ty Too s

PROCESS TOOLS STATISTICALy ra ns orm ng

y Cause and Effect y Control Charts

Diagram.y Flowchart

y

Pareto charty Run chart

y Multivoting

y Histogram

y

matrix.

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OTHER CLASSIFICATIONS:

yProblem identificationywith ideas as Focus

.yWith number as Surve .

y

Problem analysis

ywith ideas as Force field analysis

3y

w num er as on ro c ar s.


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OTHER CLASSIFICATIONS:y Idea creating tools as A inity diagram, brainstorming, brain-

writing, and nominal group technique).

, .

y Cause analysis tools (as fishbone diagram, force fieldanal sis, Pareto chart, and scatter dia ram).

y Planning tools (as activity chart, arrow diagram, flow chart,force field analysis relations diagram, tree diagram).

y Evaluation tools (as ACORN test, Decision matrix, multi-voting).

-Graphs, Histogram, process capability, survey, Pareto chart,run chart, scatter diagram, etc

4


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JURAN TRILOGY

Quality

Planning

ControlQualityImprovement


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1. Identif in roblems/ o ortunities for

improvement.

.

3. Selecting the team.

4. na yz ng an stu y ng t e pro em toidentify its root causes.

5. Developing solutions and actions for

improvement.6. Implementing and evaluating quality

im rovement efforts.


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IIdentify P roblem

Define the problemo erationall

Select theteam

H old theain

Monitor P ro ress

la

Act

RootCausesA nal sis

n

Do

CheckIImplement

C orrective

Action

IdentifSolution


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Identifying problems and selectingopportunities for improvement.

y Available data of monitoring and/or survey.

y

xp ore nown area o rustrat on.y Suggestion boxes, staff meeting and focus group.

y Patient feedback or complaints.

y .

y Supervision remarks.


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BRAINSTORMINGDESCRIPTION:

No criticism

generatealargeideasinaNO judgment

.

How?y Generationphase

y Clarification

hasey Evaluationphase Cost

Magnitude

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Uses of Brainstormin :

y Brainstorm ideasy Brainstorm factors that allow one to search for root

causes.

y Brainstorm ideas about the development of acustomer satisfaction survey in the community.

y (( so it is used for other tools))

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Criteria for Selecting a Problem:

y

A problem that is felt to be important by staffor clients;

yA roblem that is within our control and

authority to change;

ere ene o e so u on w e grea er

or equal to the cost and effort to solve theproblem.


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PRIORITY MATRIXy A Prioritization Matrix is a useful technique that

team members can use to achieve consensus about anissue.

y The Matrix helps you rank problems or issues

(usually generated through brainstorming) by aparticular criterion that is important to yourorganization.

y Then ou can more clearl see which roblems arethe most important to work on solving first.

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Uses:y

To

determine

what

your

users

or

your

team

members

programorhealthservice.

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y In the first column write down the roblems that werementioned in the brainstorming session.

y In the second to fourth columns, define your criteria.Examples of some typical criteria are:

y Frequency: How frequent is the problem? Does it occur

often or only on rare occasions?y Importance: From the point of view of the users, what

are t e most mportant pro ems at are t eproblems that you want to resolve?

eas y: ow rea s c s a we can reso ve eproblem? Will it be easy or difficult?

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Priorit MatrixProblem Frequency Importance Feasibility Total

Points

Ranking

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:

from 1- 10 for each criterion used so that the

y Total all the votes together. The totals help you

see c ear y ow o pr or ze e pro ems.y You can rank the problems according to the total

points. If more than problem get the same total

points, it is wise to repeat the rating for the twoproblems to make one of them higher (It is betterthat no problems have same scores to facilitate

the ranking).16


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Priorit MatrixProblem Importance Frequency Easy to

Manage

Effect

Of

Total Priority

Solution

1 8 7 6 7 28 3

2 9 10 10 8 37 1

3 8 7 7 8 30 2


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Defining the problem operationally.

y A gap between actual performance and performanceas prescri e y gui e ines an stan ar s.

y Indicate cause;

y ;

y Affix blame.


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The problem statement should answer the following:y at s t e pro em

y How you know it is a problem.

yHow frequent or how long the problem existed.

y Where the problem begins and ends.


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I Ste 3:

Choosing a team.

The team should comprise:

y Those who are affected by the process.y Those who work in different stages of the process.

y Those who make decision related to the roblem.

y Those who identified the problem.

understand the problem, those who can help, and

those who have technical ex ertise.


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I Ste 4:Analyzing and studying the problem to

en y s roo causes.

na yz ng epro em eg ns yunderstandin howthe rocess

actuallyoperates.

It

is

important

to

,

and

to

identify

the

root cause

of

the

problem.


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Tools for Analyzing the Problem Include:

y ow ar . s a grap c represen a on othe sequence of steps that are performed in a

y A Cause and Effect Diagram. It is an orderly.

y IndepthStudies. Thesestudiesmustgo.

examinerootcausesbasedonclinicalrecords

reviews

healthcenter

re ister

data

staff

or

patientinterviews,andservicedeliveryobservations


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FLOWCHARTSy

A Flowchart is a picture of aprocess.

,

portrays sequentially and in,

step in a process or program or

.


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FLOWCHARTS-cont.

y

Flowchart outlines the sequence andre a ons p o e p eces o e process.

y , .

yThe process described by flowcharts can beanything : administrative , service process ,or aplan for quality improvement process.q y p p

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FLOWCHARTS-cont. Starty Flowcharts tend to use

recognizable symbols.Activit

y The basic symbols :y A Circle start/end

y A rectangle (activity)

yA diamond (decision)

DecisionNo

Document

y An arrow (direction).

y DocumentYes

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Uses of Flowcharts:y

Understand processes.yConsider ways to simplify processes.

.

y Identify problems.

yHelps in identifying indicators.

mp emen a new process .

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Types of Flowcharts:

y

High-Level FlowchartyDetailed Flowchart

yDeployment or Matrix Flowchart

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Construction of a Flowchart:

1. Define the process to be diagrammed.2. Gather information of how the process

.

3. Trial process flow and arrange the stepsin proper sequence.

. accuracy . Make changes if necessary.

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onstruct on o a owc art:.

format is most appropriate.

.

of the process to be flowcharted.

inputs?y What signals the end of the process? What is/are the final output(s)?

Step 3. Identify the elements of the flowchart by asking:y Who provides the input for this step? Who uses it?

y What is done with the input? What decisions are madewhile the input is being used?

y

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y Step 4. Review the first draft of the flowchart to see

whether the steps are in their logical order.Areas that are unclear can be represented

with a cloud symbol, to be clarified later.y Ste 5. After a da or two review the flowchart with

the group to see if everyone is satisfied with

e resu . s o ers nvo ve n e process

if they feel it reflects what they do.

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Construction Rules:

yDefine the boundaries of the process clearly.

y se t e s mp est sym o s as poss e.

yMake sure that every feedback loop has an escape.

yThere is only one output arrow out of a processbox.

yDo not assign a technical expert to draw the

flowchart. Process owner who actuall erformthe process should construct the flowchart.

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Fishbone Dia ram

y

In other words a cause-and-effect diagram is atool to gather and uncover the ROOT causesof a Health Problem.

yThe ualit roblem is usuall stated as anegative outcome (effect) of a process.

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STEPS :1. Start with the effect

on the far ri ht side ofthe diagram and draw a box

.

2. Draw a horizontal line to Problem

e e o e pro em.

3. Determine the categoriesof the causes of theproblem

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STEPS :4. Determine and define the major categories which

describe the system or process under review, e.g.,

5ps: (or) 5ms:

Peo le Man ower

Provisions Materials

Procedures Methods

Place Measurements

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STEPS :6. Identify possible Finally Draw Accurate

causes.

7. Evaluate the draftdiagram as a team todetermine the accuracyof the placement of the

su causes .

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Uses of Fishbone Dia ram:y

To identify and organize causes of problem.yTo provide a graphic output of a detailed

ra nstorm ng sess on y organ z ng t oug tinto Categories.

y

To identify factors that lead to success.

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as c ayout oCause and Effect Diagrams

Manpower Methods

EFFECT

Materials

Policies

Machines

(Plant)Environment

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Include:

y A Flow Chart. It is a graphic representation of

the se uence of ste s that are erformed in aspecific process.

.

arrangement of theories about causal factors.n ep u es. eses u esmus go

beyonddocumentingtheproblem.Theyshould

x min

r t

n

lini lr r

reviews,healthcenterregisterdata,stafforpatientinterviews,andservicedeliveryo serva ons


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Data Collection Will Help To:

y Verify existence of a problem.

y Analyse source of variation.

y Determine relative importance of different causes.

,displayandinterpretdata usingsomebasic

,

,chart, scatterdiagram,etc.


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PARETO CHART

yA Pareto chart is a specialized form of a bar

events (causes) in descending order. Therefore,

the chart visually shows which causes aremore si nificant. This chart is based on thePARETO Principle :

20% of the causes ( 80-20 rule) .

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a y ng ems n a omp a onTableCausesforLateArrival NumberofOccasions Percentage

Familyproblems 8 11

Hadtotakethebus 4 6

Traffictieup 32 44

c

Badweather 3 4

Total 73

100


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CausesforLateArrival Numberof Percentage Cumulative

(DecreasingOrder) Occasions Percentage

Traffic tieu 2

Woke up late 20 28 72

Family problems 8 10 82

Sick 6 8 90

Hadtotakethebus 4 6 96

Bad weather 3 4 100


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Steps:100 P100

categories. 80

ercent

y a e t e e t vert ca ax s

with counts and right axis60

50

w t percentages - .

yAdd the percentage value ofENT

40

2028

33

each bar and calculate the

cumulative total for each bar. Patie

Nosy

Order

Only

Routi

Nosp

Untra

Delay

PER

0 08

smoveda

tem yspecialist

nepharmacist

eprocedure

ificForm

edNurse

ofDoctor

54

REASON


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85

78

75

87.5

80%

90%

6262.5

%60%

70%

epercen

34.137.5

50

Per

cen

40%

50%

Cumulati

16.

27.

25

20%

30%

0.82.4

5.46.27

0

12.5

0%

10%

Waiting for

investigations

Waiting for

operation

Waiting for

consultation

Personal reasonsTeaching &

exams

PO/IM drug

administration

Waiting for

referral

Waiting for blood

availability

Reason


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Uses of Pareto Chart:y To focus on the major causes of the problem i.e.

Focus attention on Vital few instead of the trivialmany.

y . .

determining the important risk factors to the.

y To evaluate the effectiveness of the improvement

- -Caution:

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Try to use objective data instead of opinions and votes.


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HISTOGRAMS

y

Ahisto ram

is

sim l

astatement

of

data

collected

andcategorizedbyvariousgroupstorepresentaictureofthesituationthatwasinvesti ated.

y So,

fromthe

histogram

the

CQI

team

shows

how

o tent e erentva uesoccur.

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SCATTER DIAGRAM

y A scatter diagram is a 4.0

grap use w en youneed to display what

T

3.5

3.0

appens to one var a e

when another variables

B.

2.5

2.0

c anges o e erm ne erelation between two

AGE of MOTHER

32302826242220181614

1.5

var a es.

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y

This diagram is used in4.0

combination with aFish-bone (cause-and-

3.5

effect diagram.

B

.WT

.

2.5

e ex en o w c evariables relate is called

32302826242220181614

2.0

1.5

AGE of MOTHER

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Patterns of Scatter Diagrams:

E

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Developing Solution and Action for

y

A solution ma be ver strai ht forward: it ma beas simple as reminding staff about clinical guidelinesthrou h su ervision or in service trainin . Solution

may also take the form of job aids such as wall chartsand checklists.

y Some problem, however, are more difficult to solve

because they require procedural redesign.


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Force-Field Analysisy Force-field analysis was developed by Kurt Lewin. It

identifies forces that help and those that hinderreaching the desired outcome.

y t ep cts a s tuat on as a a ance etween two sets

of forces: one that tries to change the status quo andone a r es o ma n a n .

reducing the hindering forces and encouraging the

.


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Force-Field Analysisy When used in problem analysis, force-field analysis is

especially helpful in defining more subjective issues, such

as mora e, managemen , e ec veness, an wor c ma e.

y Force-field anal sis also helps keep team membersgrounded in reality when they start planning a change bymaking them systematically anticipate what kind ofresistance they could meet.

Caution:

If a significant force is omitted, then its impact can

negatively affect a plan of action. All significant forces or

actors must e nc u e an cons ere .


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Force-Field Analysis+ _

I Ste 6:


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Implementing and evaluating qualitymprovemen e or s.

y*

y Check *Act

,

continue limited monitoring. Team should modify solutionsas needed and should full document results and lessonslearned.

Disseminate the new process so that others can learn from theexperience. The team may then repeat the qualityimprovement cycle.


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PDCA C cle

(Act)

(Check)

.

(DO)

study


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When to Use It:y GanttChartsprovideagraphicguideforcarrying

t

ri

f

tiviti

h win

th

t rt

tduration,andoverlapofactivities.

y antt artsaremostuse u nt ep ann ng

stages,to

mark

when

each

activity

should

start

and

.

y GanttChartsarealsousefulforkee in trackofprogress

and

rescheduling

activities

if

progress

is

slowed.


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IdentifyProblems DefineProblem Team RootCause

na ys s


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ExampleExample:

y A QI team was formed to look at the problem.

ey co ec e a a a ou wa ng mes or samp eof patients during a one month period

and sometimes as long as five hours to be admitted tothe hos ital.


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Scatter Diagram of Patient Waiting time versusOccu anc rate

300250

aitin

150sof

tim

e

50inut

50 60 70 80 90 100

Percentage of occupancy


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Suggested Plan for Admitting Patients:Suggested Plan for Admitting Patients:

1. Occupancylevel


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Documents

(2009-04-14) Problem Solving Cycle.pdf