CQI in Action:
How to “Win It in a Minute”
Mary Beth Cox, MSW, MPH
Virginia MIECHV Program
[email protected]
Overview
• Learn about CQI
• What is CQI?
• QI vs. QA
• Components of successful CQI project
• FOCUS First
• The Model for Improvement
• Plan-Do-Study-Act Cycles
• Strategies to integrate CQI into regular routines
• Tips for Success
• Practice CQI: Stack Attack!
Why do CQI?
3 Key Messages
• In today’s climate, being able to
consistently and repeatedly measure and
improve is essential. Not a trend!
• CQI is do-able. You Can Do This!
• It works best when you keep your
population at the center of everything
you do. Family-centered!
• A continuous and ongoing
effort to achieve
measureable improvements
in quality
• For example, improve efficiency,
effectiveness, performance,
accountability, outcomes
• Use of a model supported
by strategies, methods and
tools
• A repeatable set of steps
that work best if they
become a routine part of
your business operations
• Evaluation
• Research
• A report card
• A way to assess or judge
programmatic or staff
performance
• A basis for making funding
decisions
• A pass/fail or right/wrong
process
• A trend
QA vs. QI
Embracing Quality in Public Health: A Practitioner’s Quality Improvement Guidebook;
Office of Accreditation and Quality Improvement is operated out of the Center for
Healthy Communities at the Michigan Public Health Institute. January 2012;
available online at http://mphiaccredandqi.org/Guidebook.aspx
Is it QI or QA?
https://jeopardylabs.com/play/home-visiting-qi-or-qa
Do we understand CQI?
Do we understand the difference between
QI and QA?
Now Let’s focus!
FOCUS First
•Find an opportunity to improve.
•Organize a team who understands the process.
•Clarify the current knowledge of the issue or process. In
this stage, you are gathering the "who, what, when, and
where.”
•Understand the cause of process variation. Here, you
ask yourself the "why" question.
•Select the piece of the process you want to improve.
ind an opportunity to improve.
• What does our data tell us?
• What would we like to improve?
• What do we *need* to improve?
Depression Screening Rate (% of women enrolled in the last 90 days
(March 1, 2015- May 31, 2015) with a documented depression screen
within 60 days of first home visit)
100%
100%
100%
100%
100%
100%
100%
100%
100%
90%
90%
80%
80%
70%
# Sites
Below Mean:
9
71%
70%
71%
64%
62%
60%
57%
50%
50%
Depression Screening Rate (% of women enrolled in
the last 90 days (March 1, 2015- May 31, 2015) with
a documented depression screen within 60 days of
first home visit)
50%
40%
30%
20%
15%
9%
10%
0%
0%
0%
0% 0% 0%
FOCUS First
•√Find an opportunity to improve.
•Organize a team who understands the process.
•Clarify the current knowledge of the issue or process. In
this stage, you are gathering the "who, what, when, and
where.”
•Understand the cause of process variation. Here, you
ask yourself the "why" question.
•Select the piece of the process you want to improve.
The Role of the CQI Team
• “Core” team that ensures
QI processes move forward
and brings in other key
members as necessary
• 5-7 people is ideal
• Important to have a Team
Charter
• Diverse representation of
skills and perspectives
• Meet frequently enough to
ensure a good pace and
meet the demands of the
project
The Team Charter
FOCUS First
•√Find an opportunity to improve.
•√ Organize a team who understands the process.
•Clarify the current knowledge of the issue or process. In
this stage, you are gathering the "who, what, when, and
where.”
•Understand the cause of process variation. Here, you
ask yourself the "why" question.
•Select the piece of the process you want to improve.
Practical Tools to help focus
Understanding an issue or
process
• Brainstorming
• Fishbone Diagram
• Process Map
• Check sheet
• Driver Diagram
• Run Charts
• Etc.
Root cause analysis
• Check sheet
• 5 Why’s
• Affinity Diagrams
• Pareto Chart
• Gant Chart
Tracking Improvement
Check sheet
 Run Charts
 Etc.

Model for
Improvement
Model for Improvement
Answer: Aim Statement
• Improvement requires setting aims.
• The aim should be SMART:
• Specific
• Measurable
• Achievable
• Realistic
• Time-bound
• It should also define the specific
population of patients or
other system that will be affected.
Model for Improvement
Answer: Establish Measures
Teams use quantitative measures to
determine if a specific change actually
leads to an improvement.
Measuring for Improvement
Purpose
Improvement
Accountability
Research
Understanding the
Process
Comparison
To bring new knowledge
into daily practice
Reassurance
Evaluating change
To discover new
knowledge
Data
Gather just enough data
to learn and complete
another test of change
Large amounts of
data
Gather as much data as
possible just in case
Duration
Small tests of significant
change to accelerate the
pace of improvement
Long periods of
time
Can take long periods of
time to obtain results
Often in the past
Long and in the past
Short and current
Model for Improvement
Selecting Changes
Ideas for change may come from…
• Your Root Cause analysis (Process map,
Fishbone diagram, etc.)
• A Driver Diagram
• Literature / evidence of effectiveness
• Ideas of peers, experts in the field
• Creative thinking techniques
• Get your team’s input and decide together
Model for Improvement
The PDSA Cycle
The Plan-Do-Study-Act (PDSA) cycle is
shorthand for testing a change in the real
work setting — by
• Plan: Identifying and analyzing the
problem.
• Do: Developing and testing a potential
solution.
• Study: Measuring how effective the test
solution was, and analyzing whether it
could be improved in any way.
• Act: Implementing the improved solution
fully.
The PDSA
Worksheet
Scale of Testing
Commitment
None
Moderate
High
Low / Large
Very small
scale test
Very small
scale test
Very small
scale test
Low / Small
Very small
scale test
Very small
scale test
Small scale
test
High / Large
Very small
scale test
Small-scale
test
Large-scale
test
High / Small
Small scale
test
Large scale
test
Implement
Belief in Change /
Cost of failure
Model for Improvement
Repeat Cycles and Next Steps
Implementing Changes
After testing a change on a small scale,
learning from each test, and refining the
change through several PDSA cycles,
the team may implement the change on
a broader scale — for example, for an
entire pilot population or on an entire
unit.
Spreading Changes
After successful implementation of a change
or package of changes for a pilot population
or an entire unit, the team can spread the
changes to other parts of the organization or
in other organizations.
Pause and Reflect
TIPS FOR SUCCESS:
Your CQI Team should….
•Meet at least 1/month but I recommend more
frequent at first
•Be patient – change, and learning something
new, takes time
•Be a platform to share and learn, and help
move your program forward on the selected
topics
•Not be about right/wrong
•Welcome and include all voices
TIPS FOR SUCCESS:
Beginning the Journey
•Keep it simple and start small
•Test new approaches and use caution when
testing “more of the same”
•The process will likely NOT be linear (or a
clean circle)
•Your pace may not match others’ pace; that’s
OK (probably)
TIPS FOR SUCCESS:
PDSA
• Assure your CQI Team members contribute
• Avoid starting with a large-scale project
• Use a PDSA Worksheet and don’t skip steps
• Choose a QI effort related to a familiar process,
program or area
• Start with short, small, simple tests
• 1-2 weeks in length
• “What can be done by next Tuesday?”
• Unanticipated results are not failures. They are
learning opportunities for your next trial.
Stack attack
Continuous Quality Improvement
in Action
Mary Beth Cox, MSW, MPH
Home Visiting Program Coordinator
& Improvement Advisor
Virginia Home Visiting Team
Goal: Teams will experience the Model for
Improvement in Action by playing Stack Attack
together!
Question
Answer
What are we trying to
achieve?
By the end of the session, all teams will
achieve Stack Attack in less than 1 minute.
How will we know if a
change is an
improvement?
Teams will time each Stack Attack game and
track their progress towards achieving 1
minute.
What changes can we
make that will result in
improvement?
 Plan, Do, Study, Act
Stack Attack!
The Goal
• Place 36 standard-sized plastic
drinking cups into a perfectly-aligned
triangular tower, and then take the
cups down one diagonal line at a
time. Restack the cups as you
dismantle the tower.
• Complete this task in one minute or
less to win the game.
Equipment Needed
• 36 standard-sized plastic drinking
cups (like solo cups)
• A table
• A timer or stop watch (Find it on your
phone!)
• Nerves of steel
Play
• To start, face the table and the stack of cups.
• Start the timer
• Pick up the stack of cups and begin creating a triangular-shaped
tower. Row sizes: 8, 7, 6, 5, 4, 3, 2, 1
• Deconstruct the tower and restack the cups. Start with the single cup
at the top of the tower, take the cups down in diagonal columns.
• Stop the timer when all cups are back in the stack.
The Rules
• If the tower falls at any time during the game, proceed from where
you left off. (MORE DIFFICULT: Start over from the beginning.)
• If the tower falls after the last cup is placed, proceed to restacking
the cups.
• The cups must be removed in the diagonal fashion in order to count.
Simple Rules
1.
2.
Work with people at your table; you are a ‘team’
Designate 5 roles:
1.
2.
3.
4.
5.
Team leader
Lead “Stacker” (Can rotate – up to you)
Data recorder
Quality expert
Coach(es)
3. Use the PDSA Worksheets; Do not skip a step!
4. Only one design change per PDSA cycle
Let’s Play!
• This first time – Just play the game and establish your baseline!
Ready, Set, PDSA!
1.
2.
3.
4.
PLAN: What is your strategy to successfully Stack Attack? Team
leader – Lead your team in a discussion of how to proceed!
DO: Play the game. Lead stacker – Stack those cups! Coach –
advise them on how to proceed! Quality control – Ensure they
are following the rules. Then discuss – how did it go?
STUDY: Data Recorder - measure and record the time it took in
seconds.
ACT: Review your test as a team. Should you Adapt, Adopt, or
Abandon your design? What is your next step?
Let’s Record and Graph the Results
Team
1
2
3
4
5
6
7
8
9
10
11
Baseline –
Trial 1
Trial 2
Trial 3
Trial 4
Pause and Reflect
What did you take away
from this exercise?
How can you use CQI in
your Home Visiting
Program?
CQI Resources
-Stack Attack in Action video
https://www.youtube.com/watch?v=YAHCax66rrM
-How to Play Stack Attack, About.com
http://gameshows.about.com/od/minutetowinitgames/g/minute-To-WinIt-Stack-Attack-Game.htm
-The Institute for Healthcare Improvement www.IHI.org
Case studies, YouTube mini-trainings, More in-depth training on CQI
-MindTools www.mindtools.com
For information about Brainstorming, Process Mapping, Fishbone
Diagrams and More!
-Embracing Quality in Public Health: A Practitioner’s Quality Improvement
Guidebook; Michigan Public Health Institute. January 2012;
http://mphiaccredandqi.org/Guidebook.aspx