Quality Improvement (QI - PowerPoint Presentation

Quality Improvement (QI) Understanding the Cause and Effect Diagram Gregg M. Reed, MPHQI Council

Quality Improvement in Accreditation “Quality improvement is the foundationof [Public Health Accreditation Board] PHAB’s accreditation program, to the extent that a health department attains accreditation status only if it embodies a culture of quality improvement.”American Public Health AssociationQuality Improvement in Public Health: It Works! (2012)

Summary Definition of Quality Improvement Continuous/ongoing processMeasureable change Monitor factors/disproportions impacting qualityAchieve equity/uniform processes within a system to improve health

Agenda Review Quality Improvement Tools10 minutesGroup Work on Cause and Effect Diagram and 5 Whys30 minutesReview Group Work10 minutesDiscussion and Next Steps10 minutes

Cyclical Continuous Improvement PLAN DOCHECK/STUDYACT

Stating the Problem “A problem well stated is a problem half solved”Charles Kettering, an American inventor An AIM Statement or Problem StatementIf you can’t describe what you are doing as a process, you don’t know what you’re doing. – W. Edwards DemingA Flow ChartDescribing the Problem Process

General Approach Issue to Consider: Delay in Travel ReimbursementBrainstorm & Consolidate Data (Affinity Diagram)Flow Chart Existing Process (Examine Process to see where problem might be -Identified Delay)Cause & Effect Diagram – Greatest ConcernDrill down to root causes (Five Whys)Gather DataTranslate Data into Information Analyze Information and develop solutions (Solution and Effect Diagram) Flow Chart New Process Monitor new process and Hold the Gains

What is a Flow Chart A diagram that represents the sequence of operations in a process.Used to identify the actual flow/sequence of events in a process Helps to determine:What is going on?Are there delays?What are the next steps?How can we improve this process?

Gather Reciepts No Travel Reimbursement (Out-of-State) Do you have the required original receipts? Return from travel Yes 1 Do you fill out the travel voucher? Yes No Yes No 1 Contact Accounting on how to proceed Employee review travel voucher and sign Employee receives check by inside mail Submit original voucher and original receipts to accounting Give to division director and/or section cheif for signatures Audited and determined acceptable? E mployee emailed No Accounting stamps with date received Entered into Peoplesoft Returned to Employee Unpaid Can you get the required original receipts? Give proper information and documentation to support person. 2 2 Make copies and date stamp Complete Travel Voucher and paper clip original reciepts 2 Payment Processed No Yes Direct Deposit set up for Employee? Yes Accounting picks up check from state treasury office Employee account credited

March Flow Chart Findings BottlenecksHand-offsRedundancyRework loopsWait or delays

What is an Affinity Diagram? A tool for assimilating and understanding large amounts of information.Group large amounts of (team/partner generated) information into themes for further analysis .Used to categorize and identify ideas.Helpful after describing the process (flow chart).Provides direction and impact

Lack of Training and Unclear Process Lack of Organization Accounting Expectations vs. RealityUnnecessary Steps for Traveling IndividualWorkload and AvailabilityTravel Voucher ProblemsOtherNot knowing policies and procedures (new/updated)Employee organizing/saving receipts needed Accounting thinks people know the process, but they don't. Not knowing reimbursment rates Availability of individuals needed for signatures Travel voucher is not intuitive Incorrect deposit information in PeopleSoft (Old accounts are saved) Lack of written procedures/policies Lack of traveler organization (some receipts in luggage/purse/pocket) Lack of assistance from accounting Which rates to use on travel days Individual gets backed up due to workload when returning. Form not filled out properly Lack of training how to fill out during orientation Have multiple receipts in different areas - have to take time to gather Did something accounting doesn't like ( ie ; booking flight with Expedia) Knowing if you quality for breakfast, lunch, dinner Availability of division directors/section chiefs to sign Did not complete form properly No set individual to do the process. Everyone has to be trained. Who does the training on completing the form Unclear expectations from accounting Knowing or locating per diem rates Only one person in accounting who audits out of state travel Form returned due to problem or lack of information/ documentation Employee not familiar with policies /procedures , too much time to find answers Unnecessary questions from accounting Traveler has to find GSA rates to complete form and then rechecked by accounting People needed to answer questions out of the office or unavailable Incorrect or outdated form, then employee has to redo Lack of training Unknown processing time from accounting Signer Out or Messy Desk Unsure of process Individual workload or time Lack of training Support staff have to take time to ask traveler for clarification Forget due to lack of out-of-state travel Time available to complete the process Not knowing which receipts needed What receipts are needed Offsite people have to mail original receipts Lack of knowledge on which receipts are required Wrong type of receipt (hotel must have amount charged and zero balance)

Accounting Procedures Human Error Delay in Supervisor ApprovalStaff Time LimitationLack of KnowledgeTechnology LimitationsAccounting timelinesMissing receipts/No original receiptsPriority level with supervisors (to get signatures)Administrative support has conflicting priorities Separation of incurred costs (personal vs. required receipts) Potential for People Soft to be down or unable to enter into the system Questions on receipts Inclusive of all cost categories Individual questions asked to the supervisor Staff are out of the office- illness/AL Knowledge of allowable and reimbursable expenses Employee doesn't have direct deposit Errors found after review Sharing ground transportation and needing separation Division Director or Section Chief not available for signature Staff are not in the office (field staff, etc.) Protocol for defined standards for reimbursement Clarification is needed challenge of management review and signature in a timely manner Difficult for employee to track where in the process the form is at Knowledge of reimbursement process- who does what Accounting too busy Completing travel reimbursement is not a priority to individual Don't how to fill out the form correctly Employee too busy to fill out form or forget to fill it out Don't know perineum amounts Knowledge of the funding source/categories Lack of standardization of how the form is completed Not familiar with the travel policy

What is a Cause and Effect Diagram Uses of this DiagramOrganize the themes and factors generated in an Affinity Diagram Identify and categorize issues about the causes of problems Display the information graphically

Cause and EffectStep 1 DELAY IN TRAVEL REIMBURSEMENTWrite the problem statement on the right side of the page; this is known as the effect.

Step 2 Generate ideas about the main causes of the effectand write them to the left of the effect; these are the main cause headers. For example: “A” = Lack of Training and Unclear Process DELAY IN TRAVELREIMBURSEMENTC B A = LACK OF TRAINING AND UNCLEAR PROCESS

Step 3 DELAY IN TRAVEL REIMBURSEMENTC B A = LACK OF TRAINING AND UNCLEAR PROCESS Draw arrows from each main cause header to the backbone.

Step 4 Under each main cause header, list ideas that support it as the sub-cause; Draw arrows from each sub-cause tothe main branch header arrow. For example: 1= Employee Organizing/saving receipts neededDELAY IN TRAVELREIMBURSEMENT C B 2 1 3 2 1 2 3 A = LACK OF TRAINING AND UNCLEAR PROCESS 1 = Not Knowing Policies and Procedures

5 WHYS Analysis Process will identify the root causes of the effect.Begin with a sub-cause selected by your group. Not Knowing Policies and Procedures_____ WHY?___________________________________ WHY?___________________________________ WHY?___________________________________ WHY?___________________________________ WHY?

Group Work (Divide Room into Half) (Optional) Compile additional Main Cause Headers and sub-causes, if neededComplete an applicable Cause and Effect DiagramHang the diagram on the wall using provided suppliesComplete 5-WHYS analysis on sub-causes of each Main Cause HeaderChoose a group spokesperson to presentPlease conclude by 1:40pm (30 minutes)

Discussion

Next QI Tool Learning Session Solution and Effect DiagramsJune 17th11 am to 12 pmCapital: AV Rooms 210 & 212 Contact Susan Mormann or Kelly Nagel with questions