This course provides students with a set of tools and methodologies to plan and initiate a Problem Solving or Quality Improvement project. The first module presents methods for selecting, scoping and structuring a project before it is even initiated. It also introduces the project classifications of implementation and discovery. The second module describes the A3 problem solving methodology and the tool itself. Further in that same module, the student is shown tools to identify problems in flow, defects, and waste and to discover causes, brainstorm, and prioritize interventions. Module 3 shows a methodology within the implementation class. These methods are designed to overcome emotional and organizational barriers to translating evidence-based interventions into practice. The fourth and last module looks at one more way to approach improvement projects in the discovery class. These tools are specifically for new, out-of-the-box design thinking.
Scope
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Del curso dictado por Johns Hopkins University
Planning a Patient Safety or Quality Improvement Project (Patient Safety III)
36 calificaciones
De la lección
Project Selection Strategy and Tools You Can Use
In this module, you will see the process for defining, scoping, selecting and prioritizing improvement initiatives. Further, you will learn necessary team characteristics and organizational support structures.
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Bob Hody
Hello. We're now going to talk about
scope and the importance of scope in project selection.
Let's think about scope as a fence.
There are two purposes of a fence.
One is to keep things on the inside from going
out and the other is to keep things on the outside from coming in.
That's about the best thing I can explain
the work of scope in our project and how it impacts.
First, what shall we improve and/or not improve?
We want to be very specific about that.
Which locations, procedures, departments?
Think about that in terms of the work that you're doing.
So for example, we have two emergency departments where I work.
One is the pediatric department and one is the adult department.
We could choose to do both departments or perhaps just one.
So for example, if we chose to do the peds department,
we want to put that inside the fence.
And so, our pediatric emergency department is what we want to work
on and we might specifically say for clarity,
excluding the adult emergency department.
We want to be very, very specific to the degree we can about what we're working on.
The steps of the process come into play too.
So if we're thinking about an improvement effort within the emergency department,
are we talking about from the time the patient
presents to the time they're dispositioned,
or are we talking about perhaps, triage or registration?
Sometimes, in many cases actually,
we don't know what we don't know,
and we want to cast that wider net and maybe temporarily say,
okay it's going to be the entire emergency department,
we don't know which steps yet.
Later on we'll collect data and that'll lead us to get to the steps and limit that scope.
What improvement methods are off limits?
So we have to be a little bit careful about that
because any time you're doing an improvement project,
the staff always wants to know how will this impact me.
So you might want to say right from the get-go that there
will be no staff reductions as result of the work we're doing.
Money is always an interesting thing too.
So for the most part, we've been very fortunate.
We've done a lot of our improvement efforts,
low cost or no cost.
But one of the most devastating things that can happen
down the line is you select a project
or you select an area of work focus and basically nothing is said about the money.
And then you go through the phases and at
some point you have this great improvement idea.
It's only going to cost $25,000.
And you're so excited, and your team's jazzed about the whole thing,
you go to your camp and say, wow look at this,
we can fix this problem for only $25,000.
And your champion gives you a funny look and said,
we don't have $25,000.
And then you have to slump your shoulders and go
back to your team and explain to them why that idea is no good.
So if you can get that up front in terms of,
is there a budget or isn't there.
It can eliminate a lot of problems down the line.
What shall not be harmed.
First do no harm.
A lot of times we can sacrifice efficiency
but the alternative is we sacrifice some safety element.
So you need to understand and need to articulate upfront that this effort will not
sacrifice or harm patients in any manner or their families or staff.
So let's look at the fence if you will.
And in this fence we're going to show
our QI initiative or QI effort in the middle and that's the fence
surrounding it and we're going to put it in the form of an equilateral triangle
for those of you who need a little tutoring in geometry,
that means all three sides of the triangle are equal.
At the bottom, that's the scope,
that's the work we're doing.
What's in the fence, what's out.
On one of the legs,
we have time, the element of time.
So a certain scope of work is going to take a certain time to complete it.
And on the last side we have resources or cost.
It could be the number of people who will be involved in the effort.
So for example, if we were working with two emergency departments,
we'd need resources both from the adult and
the pediatric side versus if we are working on one the resources would be limited.
In some cases, if you do have a budget,
the larger it is typically the cost goes higher.
Now, what happens, if we increase that scope,
it could be due to just your champion pushing you to do something
bigger or it's a situation where we just pick something too big.
The time is going to take longer and alternatively,
the resources and costs are going to be more.
So, it's okay again as I said earlier to scope it a little large
upfront with the understanding that you're going to make the smaller over time.
There's an old saying,
bunts and singles win baseball games.
The truth is here too that you can get something and do it much
faster with fewer resources if you scope it down a little bit smaller,
you don't need to hit the homeruns every time.
So let's look at some examples.
In terms of trying to scope and you may not get there
immediately but this would show you the evolution of a scope.
You might start out with,
we're going to focus on patient and family centered care.
That's our priority, that's the organizational priority.
There might be a goal behind that, okay.
In terms of partnering with families and others,
to eliminate preventable harm,
and optimize patient outcomes and experience.
So that's the next tier down from that, the wording.
And then getting a little more granular, how do we measure that?
We measure that through our HCAHP scores,
patient experience measures and maybe it's
the aggregate score we're going after fall of HCAHPs.
Next, okay, we could trickle that down,
okay what's the next level down.
It might be the domain within HCAHPs of physician communication.
So we've determined that our physician communications doors are largely
driving those patient experience measures in aggregate.
Then we get down to, okay,
what's another level that we could
see here and it's the question during your hospital stay,
how often the doctors explain things in a way you could understand.
Now, we're getting to the part where that's where we want to focus on.
That's the piece that we can scope to and probably
get a reasonable result in a reasonable period of time.
A great tool to try to hone the scope down a little bit it's called the SIPOC,
stands for supplier, inputs,
process, outputs, and customers.
And each one has a little bit of a lane here.
And for example, the suppliers.
There are people or entities that provide inputs or things to the process.
So these are people, suppliers are people.
The inputs are the things,
the things the process needs to function.
The processes are always very high level,
four to eight process steps.
We're not getting into minutiae,
we're not getting into a detailed process maps,
it's about the 500 foot level of the process.
The outputs are similar to the inputs but this is the things that the process produces.
And likewise, the customers are
the people or entities who are receiving the things if you will,
the outputs from the process. So let's see how this plays out.
Pharmacy example.
So here we have the pharmacy and the first thing you want to do is you want to
articulate what are those high-level process steps.
And we have those indicated here,
it's the time from the time the doctor submits the script to
the time the patient picks up the script and the high-level steps in between.
What are the outputs? And I'm not going in any particular order here,
the only first mandatory step is listing the processes,
the outputs are those.
It's could be anything from prescription instructions or filled order, what's in queue.
The customers who receives those.
Well, the patients, the providers,
the pharmacy techs, the pharmacist.
They would be customers and this by the way is not a detailed list as a high-level list.
You can get a little more granular.
What are the things that these processes need?
Well, they need patient information scripts,
physician order entry system,
patient insurance.
Who supplies those?
Patients, providers, pharmaceutical companies, insurance companies.
So at the end, now we have a detailed listing of what the suppliers are,
what the customers are, so the people in the process,
you might want to think about it later on for the people in your team.
The inputs were possibly things could go
wrong and the outputs might be measurable factors.
So looking at all of that, we might decide
collectively and this is a little bit of a subjective tool.
We might decide collectively as a team that,
hey our biggest area of problems are where the pharmacist checks for conflicts,
this is only example.
So in that case, okay,
we want to identify the inputs that possibly produce
the most defects or possibly the most severe defects.
We want to focus on the biggest problem area and now we've taken
the whole pharmacy script process and we've broken it down to
the area where we can focus.
The next two we'll talk about is the Pareto Chart.
So it identifies the most important categories using that Pareto principle,
routinely known as that 80/20 rule,
where the 80% of what we're seeing involves 20% of the things,
the inputs to the process.
So we're trying to focus down on what could go wrong, where, and when.
It's basically a glorified bar chart,
just sorted high to low,
where it's counting the number of times,
we're seeing each one of these things happening,
in this case it's reasons why
we're delayed for surgery and you're starting from high to low.
It's used for data.
They've been categorized into distinct groups so it's what we call attribute data.
I'll give you an example this momentarily.
And it includes possibly a cumulative percentage.
That's the red line that you see across the top.
And what we're looking for is we're looking to see when
that line hits 80% because that's that Pareto rule at work,
that 80% of what we're seeing is caused by those 20%.
So let's use an example,
articulate a little bit more on that one.
So the problem is late first case starts,
we want to identify those reasons for those late starts and sum add up those occurrences.
And then last but not least,
we're using that Pareto tool to isolate,
identify those higher frequency issues,
the reasons where we can get the most effectuation.
And then you see it one filled out completely
here and sometimes we have the other category,
the other categories that check all, catch all category,
you have to be a little bit careful of this one because if you
wind up getting the vast majority of your responses are other,
that means you have to detail into what's driving that other.
So we're looking for the contributing factors that are driving the results we're seeing.
So in this particular case,
the first three categories add up to over
80% and we might choose to work on
one or perhaps all three of those and limit the scope to those.
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