In this course you will learn about the importance of quality in healthcare and how you can contribute by implementing a quality improvement (QI) project to improve processes of care and patient outcomes. You will learn about powerful tools to add to your QI ‘toolbox’ during short lectures and reflective exercises. You will apply these tools to the implementation of a QI project in your own practice setting or an area of personal improvement. At the completion of the course, you will have a storyboard that captures your QI project success to share with others. The QI project will be considered within the context of interprofessional teams and from a systems perspective. The objective of this course is to empower you, the working healthcare professional, to improve your knowledge and skills in the science of quality improvement so that you can take action in your own clinical setting to improve the quality of care for your patients and their families.
Application
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Del curso dictado por Case Western Reserve University
Take the Lead on Healthcare Quality Improvement
20 calificaciones
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Conoce a los instructores
Mary A. Dolansky, PhD, RNAssociate Professor, Frances Payne Bolton School of Nursing; Director, QSEN Institute; VA Quality Senior Nurse Fellow, Louis Stokes Cleveland VA
Shirley Moore, PhD, RN, FAANEdward J. and Louise Mellen Professor of Nursing and Associate Dean of Research
Frances Payne Bolton School of Nursing
Mamta K Singh, MD, MSPhysician Director of the Center of Excellence in Primary Care Education, Louis Stokes Cleveland VA; Associate Professor of Medicine, School of Medicine
[MUSIC]
Hi. Welcome to Module 4: The Application.
Where in this module,
you're going to be learning about how you can create system tools.
Specifically, a fish bone diagram and a process flow chart.
Centering on our worksheet, so
you can kind of just get oriented where we are in the process.
In the prior applications, you completed steps one and two, where in
step one you looked at the global aim of what you're really trying to improve.
And then in step two, you went out into the literature and out into the industry,
and out into the internet, to find out what others were doing, and
what evidence was out there related to your problem.
Now you're going to be moving to step three, where you're going to be
focusing in on your context of care, where you're trying to do the improvement.
And when you do step three, you're really using the knowledge of the system and
these tools will help you to get there.
So the first tool in understanding the system is the fish bone diagram, or
a cause effect diagram.
The cause effect diagram gets constructed after the problem is identified.
So this fish bone diagram will assist you in reach a common understanding of
what the problem really is.
You need to discuss what may cause or
impact the improvement, and doing this process with stakeholders is the key.
It is useful when creating the fish bone diagram
to generate ideas and root causes of what the problem is at hand.
Here's an example of a fish bone diagram with the fish outline so
you can understand how it got its name.
At the head of the fish, or at the eye of the fish is the problem.
And at the scales, are all the reasons that your team identifies as root
causes for why that problem occurred.
The real strength of this tool, is that it gives the opportunity for team members
to think about and think deeply about all the reasons for why this may be occurring.
This is important in health care,
because as health care professionals we're usually very quick to think we need to
know the answer, but using this tool forces us to pause and really think
in detail about what are all the things that may be contributing to this problem.
When we do this, it helps us to get at better answers.
It helps us to look more globally about options for our interventions.
The process of creating a cause effect or a fish bone diagram,
is first to identify the outcome or effect that you want to study.
Now you can use either positive or a negative framework, such as,
what are the elements that contribute to good patient satisfaction?
If you came at the fish's head with that positive piece,
you would look at all the things that contribute to a good patient satisfaction,
the positive framework.
In contrast, you can also put at the head of the fish,
what are the causes of poor patient satisfaction?
Or a negative framework.
It doesn't really matter which position you take, positive or negative.
But what is essential is that all of the contributing factors are related to
either positive or negative.
You don't want to confuse those pieces.
Regardless of which framework is used, the causes and effects must correlate.
For example, if the effect is stated in the negative,
then the identified causes should be what contributes to that negative cause, and
not what may make the negative causes go away.
Just to ensure that you understand that if you have a positive framework,
that means that you're looking at good patient satisfaction, and
the contributing factors then are all things that lead to the good satisfaction.
And in contrast, if you're looking at the causes of poor patient satisfaction,
then all of the causes would be things that related to the negative outcome.
The next step then is to brainstorm ideas for possible causes.
So you get your team together, and you think about all the possible causes for
why the problem is happening, or why the positive outcome is happening.
And you want to review this list of potential causes with your team.
Next you want to identify some general categories for the listed items, such as,
you could categorize them by causes, so the major categories in the fish's bones
could be people, equipment, methods, materials, and work environment.
Another way to categorize the bones of the fish could be by characteristics.
So you could look at the accuracy,
courtesy, proficiency, ease of use or time.
You can also categorize the bones on the fish according to
issues associated with the various steps of the process.
So looking at what starts the process and then what finishes the process.
Then you want to review your list and identify which category best
describes the item, and then draw a blank cause and effect diagram.
So you want to fill it in.
Fill in the categories that your team just brainstormed and identified.
And then you want to list the ideas on a diagram under those
appropriate cause categories that you just listed.
The next strategy for application for knowledge of the system, are flow charts.
Flow charts help identify all the steps in a process by
using a standard symbols and arrows.
It helps to illustrate redundant steps.
And it can be use to describe the current process or
design any of new processes that you would like to institute.
It also identifies bottlenecks or where there's problem areas.
So this flow chart is a nice tool for looking at the system, and
it will identify areas for your improvement efforts.
The flow charts symbols are standardized and the start always occurs with
an oval and this is what starts the process and also ends the process.
And typically we write the words start, and end in the ovals.
The next symbol that's standard is the rectangle, and
the rectangle is just a process step.
So we use a lot of rectangles in our process flow charts.
The next symbol is a diamond, and the diamond signifies a decision.
Next, is a circle, and circles are connectors.
They're usually small circles and we usually put a letter in the circle to
indicate where that connector then will connect to.
And lastly, we use arrows.
And the arrows are directional so that it demonstrates the flow for that process.
Here's an example of a flow chart.
And you can see the process starts and ends with the ovals, that the process
steps are with the rectangles, decisions are with the diamonds, and
you can see then out of the diamonds are arrows and
lines that indicate what happens when that decision is made.
And lastly, the connector circle indicating where the flow
chart connects to.
Page two, A to A connects with the circle, and then the process ends with the oval.
Some hints for developing flow charts, is that it's really important to
define where this process starts, and where this process ends.
And many times, as healthcare professionals we really don't think in
that expanded, chronological point.
We usually sort of begin our processes in the middle and
aren't really expanding it to the beginning and the end.
But it's very important to really expand out so
you are looking at the whole system.
Also, there's no such thing as a perfect flow chart because it
can constantly be changing and really is a dynamic tool.
It is important to somewhat keep it simple because if it gets too out of hand,
it is hard for people to really look at it, and it's hard for
you to share the flow chart to assist with your improvement efforts and it's
also important to think in broad terms to start with and then add in details later.
So it's important to start simply and then add in details as you go along.
It's really important to think about the system.
So you're creating this flow chart of the current process before you're
thinking about changes.
And this is a common problem with healthcare professionals, is that we're
always jumping to what we think we should change, before really stepping back and
looking at the system, creating this process flow chart and
trying to understand what is going on so
that the changes that we do institute, will result in improvement.
Many times when we think we know the answer, it's usually not the right answer,
and usually our improvement efforts fail.
The flow chart also validates that this is how the process actually works, and
not just how you think or hope it works.
So what type of flow chart do you want?
You can get and start with a macro level flow chart, or
the view from 30,000 feet, or the forest view.
An example of this is listed below, where you're recruiting an Ambulatory Care
physician, and it gives sort of the large view of this process.
But then as you are with your team and
your team decides that you really want to improve this process, you get together and
you start determining what are the more detailed aspects of that flow chart.
Then you can move to the microlevel view;
the view on the ground, or the view of the trees.
And in this example, then you blow up, or you provide more detail to this process.
And in this exercise of looking at the system,
here you will be able to identify opportunities for change to be made.
And surprisingly,
you will find that the opportunities are not what you thought in the beginning.
The flow chart then, you need to clearly define what part of
the process is to be charted before you begin.
Again, the process starts here and ends here.
The other thing you need to consider, is the perspective of this flow chart.
Should it be drawn from the patient's perspective, or
should it be drawn from the staff member's perspective?
You may even want to entertain doing it from both perspectives,
to see where there is opportunity for improvement.
When you're doing the flow chart,
you really want to solicit the group’s input as to what are the steps.
Really important here in your team is to have front line personnel,
front line staff to tell you what it really is like in the process.
Then you write the steps on little sticky notes, and
place these sticky notes on a flip chart.
And you don't want to do anything in permanent ink yet.
You kind of want to be able to pick off those temporary sticky notes and
move them around a little bit.
And then, once you have consensus regarding the order of the sticky notes or
the steps, then you want to connect all the sticky notes with lines and
arrows to provide the structure for your process flow chart.
Who are the players in creating the flow chart?
You really want some content experts, and that's really you.
The person who is very interested in making the improvement.
As I mentioned, you also want staff level employees who perform the tasks in order
for them to provide you with what they see as the process.
Also important to have some management people at this time, so
that they can provide their perspective kind of that higher level view.
And the last person you want in here, is a process improvement expert.
That's the person like you.
What are some questions that you can ask to guide the flow chart development?
As the facilitator and as the improvement expert that you're becoming, you can say,
and then what do we do? And then how is that done?
So these kinds of questions then help the team to
keep moving on developing what the process entails.
You can also ask, does anything have to happen before I do this step?
This helps the team to step back and really think about the prior steps.
You can also say, are there any steps where a delay occurs?
This is a really important component.
Also, why do we do this step?
Helps the team to really think about the meaningfulness of this step.
And helps them to think about, is this wasteful that we're doing this?
And then lastly, are you sure this is a process step?
Hm, could it be a decision point,
where we should be making a decision, rather than a process step?
So as you're becoming a quality improvement expert,
you'll be able to facilitate this process with your team,
in order to ensure that the process that you are modeling or creating, is accurate.
Test the flow chart when you have it completed.
Here, you want to just determine, are the symbols used correctly?
There should be only one arrow out of a process step box.
And if there's more than one arrow, it may need to become a decision point.
And you also want to ask, are the process steps identified clearly?
Lastly, when you're evaluating your end product,
you want to see if all the loops are closed.
Does everything bring you to the end of the process?
And the last step is you want to validate the flow chart with your staff.
That really are carrying out the process but were in a part of your group.
So you want to take your process diagram or process flow chart, and share it with
other healthcare professionals and say hey, is this the process, is this true?
And you're going to probably get some great feedback.
The next part I'd like to talk about are process and timeline charts.
A process chart is utilized to document each step in
the process that requires some time and description.
A review of description causes a team to identify the overall purpose of each step,
and if it's one of value, then the steps are determined to be of value or of waste.
Wasted steps are defined as noted in the key, and
then the overall goal is to streamline each process so
that all the steps are value added, and that a customer would pay for.
Here's an example of a process chart that you can use in your work ahead.
The benefit of using these system tools,
are that it gets everyone speaking the same language.
You're in an interprofessional team,
all working on the goal of looking at the system or the processes of care.
Another benefit, is that it allows the discovery of unexpected details.
And it downplays the process arrogance piece so
that everyone sees that they really don't understand the process,
and that it's requiring many different voices and opinions and
perspectives to get the full picture of what actually is happening.
Another real benefit is that your product is portable.
You can go and get other people's ideas and take that process map with you or that
fish bone with you, and use it as a shared model of what actually is happening.
Your assignment for this week is to create a fish bone diagram and
a process flow chart,
specifically related to the improvement project that you're interested in.
You're going to find some helpful templates that will help to assist you
with this assignment.
That completes the application component of Module 4.
In this application, you learned a few tools to assist you with knowledge of
the system, really helping you to understand what system factors are at
play for your improvement effort.
We think that these tools will assist you.
[MUSIC]
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