Quality Improvement
James Pappas, MD, MBA
The speaker does not have any relevant financial relationships with any commercial interests
AIM
A3
AIM
What is Root Cause?
Root Cause is the lowest point in the cause and effect chain that
we can affect within our span of control or sphere of influence.
OUTSIDE,
UNCONTROLLED
ENVIRONMENT
Injury
Fall
Tripping
hazard
Electrical
cords on
floor
Lack of
electrical
outlets
Poor
building
design
Root Cause
SPHERE OF INFLUENCE
(Influence or persuasion only)
MAP
Draw the initial process map then walk
 Physically follow the process as documented from beginning to end. The
purpose is to understand what is being done and why it is being done.
 Gather information about existing problems and roadblocks. Include data
regarding:
•
•
•
•
Flow volumes/rates
Cycle (rework/delays)
Value (value-add/non-value-add)
Costs: COPQ & operating
•
•
•
•
•
Handoffs
Quality (DPMO, Capability)
Action Triggers
Automated vs. Manual Steps
Data (Sources & Uses)
MAP
Looking at each process step for:
 Bottlenecks or constraints
 Sources of delay
 Extra handling
 Errors being fixed instead of prevented (rework)
 Role ambiguity (don’t know who…)
 Redundancy
 Duplications
 Unnecessary steps, waste
 Cycle time
MAP
VERSIONS OF A MAP
AT LEAST THREE
What You Think It Is... What It Actually Is... What You Would Like..
This is what we Need!
MEASURE
Measurement’s Role
1.
You can’t manage what you can’t measure!
2.
What gets measured gets done.
3.
Measurement impacts behavior.
© 2012 The Quality Group - All Rights Reserved v5.0
MEASURE
1.
2.
3.
4.
5.
Performance Measurement
Select what to measure
Hint: think Y=f(X)
Develop operational definitions
Identify data source
Prepare collection and sample plan
Implement and refine measurement




Integral to measuring the extent of the “customer’s problem”
Measure how well your process is performing before you start
your improvement effort – baseline.
Measure your process after your improvement effort
– Did you achieve your goal?
Measure how good the results are
– Measure System Analysis
PDSA
PDSA
CyclIng
Plan
•
Objectives, predictions, plan the cycle,
plan for data collection
Do
•
Test the plan, Document the results and
record data; begin analysis of the data
Study
•
Complete the analysis of data, compare to
predictions, summarize learning's
Act
•
What changes are to be made? Adjust
the plan for the next cycle