Process Improvement Exercise - 7 Steps to improve Work Performance

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Sustainable Management Development Program

Division of Public Health Systems and Workforce Development Center for Global Health

U.S. Centers for Disease Control and Prevention http://www.cdc.gov/globalhealth/SMDP/

| iii

Process Improvement

CONTENTS

Introduction

Sustainable Management Development Program ... viii

Acknowledgements ... iii

Process Improvement for Public Health Professionals

About this Course ... viii

Target Audience ... viii

Learning Objectives ... viii

Typical Schedule ... ix

Icon Glossary ... ix

Overview of Process Improvement

Definitions... 1

The Seven Step Approach ... 1

Case Example ... 3

Step 1: Define Process

Introduction ... 5

Identify Processes ... 6

Process Levels and Boundaries ... 8

Select Process ... 10

Define Customers ... 12

Products and Services ... 14

Definition of Quality ... 15

Understand Customer Wants and Needs ... 16

Identify Other Stakeholders ... 17

Flowchart ... 21

Summary Step 1: Define Process ... 26

Step 2: Measure Process Performance

Introduction ... 27

Measurement Good Practice ... 28

The Performance Gap ... 30

Definitions... 30

iv | CONTENTS Collect Data ... 35 Check Sheet ... 35 Stratification ... 38 Pareto Chart ... 39 Variation ... 42 Problem Statement ... 49 Improvement Objective ... 50

Summary Step 2: Measure Process Performance... 52

Step 3: Analyze Causes of Variation

Introduction ... 53

Cause and Effect ... 54

Example of Creating a Fishbone Diagram ... 56

Multivote ... 64

Verify Cause ... 66

Summary Step 3: Analyze Causes of Variation ... 67

Step 4: Generate & Plan Improvement Ideas

Introduction ... 68

Plan, Do, Study, Act ... 70

Breaking Down the Task ... 71

Summary Step 4: GENERATE & PLAN IMPROVEMENT IDEAS ... 77

Step 5: Implement Change

Introduction ... 79

Summary Step 5: Implement Change ... 80

Step 6: Study Results of Change

Introduction ... 82

Case Example: Implementing the New Educational Material ... 83

Summary Step 6: Study Results of Change ... 85

Step 7: Act Accordingly

Introduction ... 87

Summary Step 7: Act Accordingly ... 89

Applied Learning Project

About This Section ... 91

CONTENTS | v

Process Improvement Checklists

Define Process ... 93

Measure Process Performance ... 94

Analyze Causes of Variation ... 95

Generate & Plan Improvement Ideas ... 96

Implement Change ... 97

Study Results of Change ... 98

Act Accordingly ... 99 Course Conclusion ... 100

Resources

Web Sites ... 101 Further Reading ... 101

Appendices

Appendix A Glossary of Terms ... 104

Appendix B Course Evaluation Form – Day 1 ... 105

Appendix C Course Evaluation Form – Day 2 ... 107

SUSTAINABLE MANAGEMENT DEVELOPMENT PROGRAM | vii

Introduction

SUSTAINABLE MANAGEMENT DEVELOPMENT PROGRAM

SMDP works with ministries of health, educational institutions, nongovernmental organizations, and other partners to strengthen

leadership and management skills and systems to improve public health in low resource countries.

Program Strategy

SMDP strengthens leadership and management skills and systems through—

 Integration with country public health priorities.

 Strategic partnerships.

 Technical assistance and training.

 Policy and systems development.

 Advocacy and education.

 Evaluation.

For more information, visit http://www.cdc.gov/globalhealth/SMDP/.

ACKNOWLEDGEMENTS

Dr. Hailu Negassa, CDC Ethiopia Dr. Tekeste Kebede, CDC Ethiopia Donald M. Berwick, MD, MPP, FRCP,

President and CEO Institute for Healthcare Improvement Lloyd Provost, Associates in Process Improvement

viii | ABOUT THIS COURSE

Process Improvement for Public Health

Professionals

ABOUT THIS COURSE

The goal of this course is to enable you to implement the seven steps of process improvement in your own work environment and to deal with problems efficiently and effectively.

TARGET AUDIENCE

This course is designed for supervisors and managers in public health services, typically at district-level. You will probably manage a small team of staff. You are responsible for delivering essential public health services. You and your staff always want to do a better job. Sometimes your

manager will define a problem that you have to resolve.

LEARNING OBJECTIVES

This workshop will introduce tools and techniques to complete seven steps to improve work processes in a public health organization. When participants complete this workshop they will be able to:

1. Define a process.

2. Measure process performance. 3. Analyze causes of variation.

4. Generate and plan improvement ideas. 5. Implement changes.

6. Study the results of changes.

7. Act according to the results of the study.

 Apply at least five process improvement tools to achieve objectives 1 to 7.

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ONS | 1 ng ve r. t e at ctice. ols

2 | THE SEVEN STEP APPROACH

Use this notes section for jotting down Guiding Principles:

CASE EXAMPLE | 3

CASE EXAMPLE

To learn how to apply the process improvement steps and tools, and to understand how they link together, we will use one case example throughout.

We will work through the seven-step method using the example of the delivery of Antiretroviral Therapy (ART) for Human Immunodeficiency Virus (HIV) infection in a community health center.

Acquired Immunodeficiency Syndrome (AIDS) is a disease of the body’s immune system caused by the human immunodeficiency virus (HIV). The death of infection-fighting white blood cells leaves the body vulnerable to life-threatening conditions such as infections and cancers.

Voluntary Counseling and Testing (VCT) for HIV usually involves two counseling sessions: one before taking the HIV test, known as pre-test counseling, and one following the test, when the results are given, often referred to as post-test counseling.

VCT centers and counselors often use rapid HIV tests that only require a drop of blood or some cells from the inside of one’s cheek.

CD4 cells are one type of infection-fighting white blood cells. The CD4 cell count is a measure of the number of CD4 cells in a sample of blood. The CD4 cell count is one of the most useful indicators of the health of the immune system and the progression of HIV/AIDS.

ART is a treatment with drugs that inhibit the ability of retroviruses, such as HIV, to multiply in the body.

The case example deals with the process of customers attending VCT clinics and receiving counseling and testing.

If their test is positive, patients may be eligible for ART based on the CD4 count and other criteria defined in the guidelines for ART from the World Health Organization. If eligible for ART, patients will receive regular supplies of ARV drugs and counseling to ensure adherence.

STEP 1: DEFINE PROCESS | 5

Step 1: Define Process

INTRODUCTION

Define Process Check List



Processes identified.



A process selected.



Customer defined.



Products and services identified.



Customers’ wants and needs understood.



Other Stakeholders identified.



Existing process is understood.

You will begin by identifying all the processes for which you are totally or partially responsible.

Within your group you will then work to identify the most important work processes using a list of criteria.

Now you can define your customers and the products and services they receive from your selected process.

Finally you can show in detail how you organize your work process to deliver products and services to the customers of the process.

The questions you will answer in step one are as follows. 1. “What do I do?”

2. “For whom do I do it?”

3. “What products and services do I provide?” 4. “What do they want and need from me?”

6 | IDENTIFY

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IDENTIFY PROCESSES | 7 What is the process in the scenarios listed below?

In a district hospital people are experiencing long wait times at the pharmacy.

The process is:

In a clinic pregnant women are not being tested for HIV. The process is:

8 | PROCESS

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Exerccise 3: Se 1. Review 2. Consid (previo 3. Decide rest of elect Proce w your list o der each on ous page). e which pro f the trainin Our Ch ess to Imp of processes e’s potentia cess is goin g. hosen Proc prove s from Exer al impact o ng to be the cess: rcise 2 (pag n the four c e group’s fo EXERCISE ge 9). criteria ocus for the

E 3 | 11 e

12 | DEFINE CUSTOMERS

DEFINE CUSTOMERS

A customer is any person who receives a product or service from a process. The term is used broadly—no financial transaction need occur. As public health workers, we serve the people who receive our services or products; they are considered our customers.

The people we serve can be external to the organization, such as clients and families, or they can be internal, such as work colleagues.

ART Customers

 People living with HIV/AIDS,  Friends, family, relatives, and  The local community.

Exerccise 4: De 1. As a gr fine Custo roup, list th C omers he custome Customers

rs of your cchosen proc

EXERCISE

cess.

14 | PRODUCTS AND SERVICES

PRODUCTS AND SERVICES

Products and services can be tangible or intangible—a thing, information, knowledge, a procedure, or a function.

Examples of ART Products and Services:

 ART medications

 CD4 count test results

 Condoms

 ART treatment information

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eeds for ser or public he t their want necessarily TY | 15 en rvice ealth ts y fair

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and Need er from Exe needs of th ercise. . nts and Ne ds ercise 4 (pa he products eeds age 13). and services

IDENTIFY OTHER STAKEHOLDERS | 17

IDENTIFY OTHER STAKEHOLDERS

A stakeholder is one person, or group of persons, having an interest or concern in a particular process resulting from some direct or indirect involvement. They can generally be categorized as customers, suppliers, controllers, and providers.

 Customers receive a product or service. The term is used broadly—

no financial transaction need occur.

 Providers comprise key staff, including professionals, managers,

partners, and subcontractors, who carry out the process.

 Suppliers provide goods, services, and information to the

organization or process but do not carry out the work.

 Controllers define, regulate, and influence the organization or

process. Controllers include regulators, legislators, funding agencies, expert advisory committees, and trustees. Technical standards are often set by controllers.

18 | IDENTIFFY OTHER STAK ART

KEHOLDERS

Exerccise 7: Id 1. Select group. 2. Identif chosen 3. Use th 4. How ca activiti List yo dentify Sta a spokespe fy the peop n process. e stakehold an you invo es? ur ideas on akeholders erson in you le or organ der analysis olve your st n the next p ID s ur team to nizations wh s template t takeholders page. DENTIFY OTHER present ba ho have a s to help you s in improve R STAKEHOLDE ck to the w stake in you u. ement ERS | 19 whole ur

20 | IDENTIFY OTHER STAKEHOLDERS

FLOWCHART | 21

FLOWCHART

Use a flowchart to:

 Understand the current process.

 Identify where there are opportunities for improvement.

 Design improvements to the process.

The flowchart will also illustrate the level of the process and allow your team to clarify its focus.

HIV/AIDS Voluntary Counseling and Testing

The next activity in the flow is pre-test counseling.

This activity is in a rounded rectangle because it is the start of the flowchart

Arrows link symbols and show the direction of the flow

Because this is an activity it is drawn in a rectangle

22 | FLOWCHART

Next there is the first of four key questions. The first question is whether the patient agrees to the test. This is a question which has to be answered either yes or no.

If they do not agree to take the test but agree to more

counseling the flow loops back into providing more pre-test counseling.

This shape is called a connector. It allows you to flowchart over many pages.

Because this is a decision it is drawn as a diamond with two outcomes

FLOWCHART | 23

This connector links with the previous. Any number of connectors can be used as required

24 | FLOWCHART

Example: Complete Flowchart

Yes No No Yes Yes No Still have specimen? Yes No

Exerccise 8: Flo 1. Use yo 2. Define proces 3. Write t 4. Ask yo flowch 5. Contin arrows 6. When of a qu paths. 7. Repeat 8. Write t 9. Select group. owchart Y our chosen the beginn ss. the beginni ourself “Wha art in a rec ue mapping s. a decision uestion in a Each path t steps 4 to the ending a spokespe Your Proce process. ning and the

ng steps of at happens ctangular bo g out the st point is rea a diamond a must reent o 6 until the boundary/s erson in you ess e end—the f the proces s next?” Add ox. teps and co ached, write and develop ter the proc e last step i step in an o ur team to e boundarie ss in an ova d the step t onnect them e the decisi p the decisi cess or exit n the proce oval. present ba FLOWCHA s of the al. to the m with one-on in the fo ion result t somewher ess is reach ck to the w RT | 25 -way orm re. hed. whole

26 | SUMMA

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uality is sat or service w or public hea he voice of nd needs an se a flowch pportunities S

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28 | MEASUREMENT GOOD PRACTICE

MEASUREMENT GOOD PRACTICE

 Measure what is important, as defined by customers’ needs, stakeholders’ needs and technical standards, whether it is easy or difficult.

 Make sure data to be collected and analyzed represent exactly what your operational definition states as the measure.

 Keep measurement simple if you can. The purpose is to gain insight into the real operation, or the “voice of the process.”

 Data gathering should not interfere with normal work as little as possible.

 The data gathered should provide a reasonable representation of the process as it operates under normal conditions. For example, do not gather data over a holiday, or only on a Monday night shift.

 Don’t reinvent the wheel. If the data you require already exist in a usable format, then use them. If the data exist, but are not in a usable format, you need to aggregate the data into a usable format.

 If there are no data you can use to better understand your process, you will need to design a method for gathering the data.

 If there are no agreed-upon definitions of what should be measured to meet customer needs and technical standards in your process, you will need to create these.

 You should record and report raw numbers and percentages. If you have very low numbers, show the raw numbers, not percentages, in graph form, otherwise your report will be misleading.

Example: In a team of five people, one person is trained (20%). After improvement, two out of the five are trained (40%). The improvement has doubled the percentage of persons trained from 20% to 40%, however; only one additional person was trained.

 Don’t average percentages.

Example: If in January 30% (3/10), in February 10% (2/20), and in March 2% (2/100) of the Disease Surveillance Reports in District X had errors, the percentage for the first quarter is not 14% (the average of 30%, 10% and 2%). The percentage per quarter must be calculated from the original data, in this case 7/130, which results in 5.4%.

MEASUREMENT OF GOOD PRACTICE | 29 Homework Notes: Measurement Good Practice

30 | THE PE

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MEASUR

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how well w . They help he gap betw performanc help your o nd agreed-d be review of our custo re can be ge ful and sha he operatio

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ting our tec nage with fa nt process t. n make dec . ly because ge. nly from a en stakehold ition. al points at ents, chnical stan acts. performanc cisions and technical re clear defini ders then it t which to m ndards and ce and the take action equirement ition. If the t is often measure wi Desired Current ns ts thin

SOURCES OF MEASURES | 31

 Within the process.

Remember, process improvement is a systematic, data based method for improving the quality of processes.

You will base your decisions and actions on data from the process you are improving.

Customer measures are generated from the voice of the customers and

their wants and needs. These typically include effective treatment, a safe environment, timely care, confidentiality, respect and dignity.

Stakeholder measures are generated from key stakeholders’ wants.

Often it is the funding agencies’ measures that receive priority.

Technical measures are generated from best practices as defined by

scientific research. These measures are often disease-specific and based on medical protocols.

Process measures are taken at key points in the process. They are not

usually of direct interest to customers and other stakeholders. They are selected because they have a significant impact on the process outcomes. Examples include the availability of medical supplies, the number of

people trained in a topic, availability and correct functioning of critical equipment, and the turnaround times for laboratory tests.

Some of your measures will be more important than others. Some, such as patient safety and effective treatment, should be pre-requisite.

Their importance may vary over time. During the start-up of a program, meeting the technical measures may be more important than the

stakeholder ones. Throughout the program certain customer measures will always be important. As the program matures, showing the funding agencies that their measures are being achieved will be critical to further funding.

32 | CASE EXAMPLE: ART MEASURES

CASE EXAMPLE: ART MEASURES

Type of Measure Measure Operational Definition

Customer Measure/s Effectiveness of treatment CD4 improvement above

target

Timeliness of training Time from testing positive to receiving appropriate ART regimen if meeting criteria Stakeholder

Measure/s

Number of new patients Initiated ART during the

reporting period in a program

Number of current patients Individuals on ART at the end of a reporting period Number of cumulative patients The total number of

individuals ever on ART since the start of the Emergency Plan Technical Measure/s Compliance with rapid test

protocol

Follow laboratory quality assurance protocol Process Measure/s Referral time from VCT to ART Time in days from

post-counseling referral for individuals tested positive to first attendance at ART clinic

Laboratory turn around time Time in hours or minutes from specimen collected to when results presented to physician

Adherence rates Percentage of ART patients

who self-report adherence to the prescribed regimen over the last three months

Exerc Proc Type Mea Cust Mea Stak Mea Tech Mea Proc Mea cise 9: Id 1. As a gr 2. Consid measu below. 3. Now d measu 4. Limit y type. 5. Summa cess: e of asure tomer asure/s keholder asure/s hnical asure/s cess asure/s dentify Me roup, refer der custome re? Put you o the same res. Remem yourself to n arize your m Measure asures back to yo er measures ur choices a e for stakeh mber to rec no more tha measures in O D C ur flowchar s first. Wha and reasons holder, tech

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34 | SELECT

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e. The data ance measu athering th e CHECK SHE n the previo of the rest you need to be able to e because t -adherence were read ures you ha he data. EET | 35 ous of o the e ily ave

36 | CHECK SHEET

A check sheet is a simple table that is used to gather data. It enables you to answer the question “how often are certain events happening?”

The check sheet is often the first tool in interpreting data, helping you move from opinions to facts. It should be designed to be easy to use. Below is an example of a check sheet that gathers data on the number of people missing their ART appointments per week at five clinics.

Locations

Number of people who missed weekly appointments

Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Totals Total

#

appts _{missed Percent missed}

Clinic A 8 70 11.4 Clinic B 7 75 9.3 Clinic C 16 64 25.0 Clinic D 12 76 15.8 Clinic E 11 97 11.3 Totals # people who missed appointments 6 2 26 5 6 5 4 54 Total # scheduled appointments 50 65 45 52 61 49 60 382 Percent missed 12. 0 3.1 57.8 9.6 9.8 10.2 6.7 14.1

CHECK SHEET | 37 You may already have data that are reported frequently—daily, weekly or monthly. These data can be plotted over time. If historical data are not available, at least six data points will need to be collected before

improvement ideas are tested.

In other cases it may be too costly, or too disruptive, to gather data frequently. You may have to use fewer data points. These may be annual or semi-annual, and in some cases, generated by sample measurement techniques.

If you collect data before improvement and then after an idea is implemented, remember the following:

You must collect the data that measure the process in the same way. Use the same method, a comparable time period for the measurements, and the same data collection tool.

If there is seasonality in the process, or perhaps local variations such as holidays, collect data at the same time of the year.

38 | STRATI

STRAT

FICATION

TIFICATIO

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ON

nalyze the c fication, a t roups (strat k about wha ata results. raphical loc e bar chart kly. is example fy by clinic we stratify tart to ask xample why eek three? hem? Anoth pt during w r clinics mig 0.00 10.00 20.00 30.00 40.00 50.00 60.00 70.00 1 Percent Perce collected da technique u ta) of data at kind of s . They could cation. below, peo you would (see next p y the percen more focus y did clinics Are they in her questio eek three? ght adopt? 1 2 ent of people ata on a pro used to divi about the p ubgroups m d include, f ople missing want to se page). nt of people sed questio s B, D and n a similar g n is why do Does clinic 3 4 W  who missed  ocess probl de a set of problem. might have for example g ART appo ee the data e not attend ons. E experienc geographic oes clinic B c B have a d 5 Week  appointmen em we ofte f data into m a meaning e, age, gend ointments a for each cl ding the ap ce higher n location? W have 100% different sy 6 7 nts per week en use meaningful ful influenc der, time, o are reported inic. You w ppointments non-attenda What else co % attendan ystem that t 8 ce on or d would s we ance ould ce, the

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the most im fact that ty originate fro ese are the e 80% of th 80% of reve m 20% of yo e critical few Week 5 Week d appointmen e informatio which the va e cumulativ mportant fa pically a ma om a minor e critical few he dental w enue. our supplie w causes of k 6 Week 7 nts by clinic PARETO CHA on from the alues being ve value is ctors, or cr ajority of th rity of the w causes. work. ers. ften reduce Clinic A Clinic B Clinic C Clinic D Clinic E RT | 39 e ritical he e the

40 | PARETO CHART

Below is a Pareto chart showing the distribution of data entry errors per 10,000 by different satellite laboratories.

Only two laboratories account for approximately 80% of the data entry errors per 10,000.

Data entry errors by Satellite Laboratories

5 5 10 40 50 90 100 200 725 1275 100% 100% 99% 98% 96% 92% 88% 80% 51% 0 312.5 625 937.5 1250 1562.5 1875 2187.5 2500

Kapahulu Kaneohe Kalihi Kahalu Kuakini Kapiolani Kaui Kaheka Kailua Kona

Satellite Laboratories D a ta en tr y errors p er 10, 0 00 en tr ie s 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% n=2500

PARETO CHART | 41 Homework: Questions About Check Sheets,

42 | VARIATION

VARIATION

In process improvement we refer to two types of variation.

Common causes are due to the process itself. They are inherent in the

design, implementation and operation of the process. Common cause variation remains the same from day-to-day.

Special causes come from sources outside the process. They relate to

some special event. It is sensible to investigate the actual reason for the variation. That reason may be operator error, extreme weather

conditions, or some other condition that does not occur regularly within the process.

The majority of critical causes come from the process—common causes. Unless these common causes are addressed there will be no long-term improvements.

Special causes can also give us information about the process, but the way we address them is different. We don’t want to overreact to a special cause.

Sometimes a special cause can give us ideas for improvement that when implemented will reduce common causes.

If you mix up special and common causes, you may take actions that will increase variation.

Run Charts

Run charts help us monitor the process and distinguish between special and common causes of variation. They also provide the evidence as to whether an implemented improvement idea has been successful or not. A run chart is just a graph in which a process measure is plotted over time. A “run” exists when a number of consecutive points lie on one side of the mean.

Count the number of points in each run. If any are unusually long, this might be a signal of a special cause, or the beginning of a common cause shift.

Whether a run is unusual or not depends on the number of data points plotted.

Num If the strong shift. You w to lon We a The d atten Decem Some patien mber of Dat 10 20 30 e run contin g evidence want ensure ng-term imp re now goin data are fro

ding per m mber 2004 ething happ nts being te ta Points nues longer that the sy e that your provements ng to analy om a VCT cl onth. There is well abo pened durin ested. Run leng many con below the than the n ystem has c improveme s. yze a real ru linic. The m e are 30 da

ove any oth ng this mon th is signif nsecutive d e mean number of d changed be ents addres un chart. measure is t ata points in ers and is l th that was Dec 200 above a be spec happen was att Mean = 96 points excl ficant if th data points 5 7 10 data points ecause of a ss common the number n total. likely to be s attributab 04. This poin any others an cial. Somethin ned during this ributable to s

60 based on 11 luding the spec

VARIATIO

ere are thi s above or indicated it common c n causes lea r of people special. ble to more t is well nd is likely to ng s month that pecial event. 1 data cial cause ON | 43 s r t is cause ading

44 | VARIATTION This d distor If we are a data point i rting the re project the bove the m is excluded sult. e mean from mean. from the c m April 200 calculation o 05, all of the Fro are me so sig of the mean e following om this point e above the p ean. There ar a run of 6-7 s gnal of a comm n to avoid data point on 6 points previous re 18 points, should be a mon cause. s

Aroun cause of peo This w pre-te The d an im in peo If we have nd April 200 e or, if susta ople attend was when t est counsel data run wa mportant off ople coming move forw occurred a 05, a signal ained, a co ding the clin

the mayor o ing and a r as maintain ficial receivi g forward f ward in time round Octo l occurred. mmon caus nic. of the city w rapid HIV te ed so we co ing a test c for voluntar e, it appear ober 2005. This could se shift lead was shown est. ould conclu contributed ry testing. s that some Mayor receiv d be a temp ding to a la on televisio ude that the to a sustai ething sign r ves VCT VARIATIO porary spec arger numb on receiving e promotion ned increas ificant may ON | 45 ial er g n of sed y

46 | VARIATTION This c chart comm Overa chang The r and c coincided w shows an a mon cause,

all the run c ges, which run chart is common ca with a new n association improveme chart shows increased t a heuristic uses. It wa national HIV between t ent. s that the d the attenda (rule of th s develope V awarenes his campaig data contain ance. umb) tool t ed in the ea Mayor receiv ss campaig gn and a su n two comm to help dist rly 20th _Cen r ves VCT n. The run ustained, mon cause tinguish spe ntury. National campaign ecial

VARIATION | 47

Case Example: ART Adherence Run Chart

Month Patients 3 Months Adherence # Patients End of Month % Adherence Jan-04 83 181 45.9% Feb-04 105 184 57.1% Mar-04 107 184 58.2% Apr-04 103 187 55.1% May-04 65 187 34.8% Jun-04 113 194 58.2% Jul-04 113 199 56.8% Aug-04 74 200 37.0% Sep-04 94 201 46.8% Oct-04 78 204 38.2% Nov-04 77 204 37.7% Dec-04 125 205 61.0% Jan-05 97 210 46.2% Feb-05 115 213 54.0% Mar-05 82 217 37.8% Apr-05 118 218 54.1% May-05 97 220 44.1% Jun-05 119 221 53.8% Jul-05 99 224 44.2% Aug-05 86 225 38.2% Sep-05 135 225 60.0% TOTALS 2085 4303

48 | VARIATTION

Casee Example:: ART Adhherence RRun Chart

Mean 48

Targ

8%

PROBLEM STATEMENT | 49

PROBLEM STATEMENT

The data show the gap between current process performance (baseline) and the desired process performance.

You will now state this gap as a problem.

The problem statement should concisely communicate the process problem so that all the stakeholders can understand.

The problem statement states: Problem Statement Who? What? When? Where? How Many?

If you are using percentages in the problem statement to state “how many,” also document the raw numbers, so others will understand what those percentages represent.

Example:

Problem Statement

Who? Clinic’s patients.

What? Self-reported adherence to ART.

When? Jan-04 to Aug-05.

Where? Our clinic.

How Many? 48.5%.

From Jan 04 to Aug 05 only 48.5% of our clinic’s patients reported adhering to ART when the technical standard specifies 70%.

50 | IMPROVEMENT OBJECTIVE

IMPROVEMENT OBJECTIVE

Objectives describe your intent in measurable terms and allow you to evaluate your progress.

Objectives should be written in such a way that they answer the questions:

Improvement Objective

What is the problem? Where is it?

What do we want to do? By when?

Example:

Improvement Objective

What is the problem? Current ART self-reported adherence

is 48.5% (mean).

Where is it? Our clinic.

What do we want to do? Improve self-reported ART adherence

to 70% (mean).

By when? End of May 2006.

We will improve the ART self-reported adherence for our clinic from a mean of 48.5% to 70% by the end of May 2006.

Exerc Obje Prob Who Wha Whe Whe How Imp Wha Whe Wha By w cise 11: Y ective 1. As a gr you ha estima data. 2. Then w 3. Presen blem State o? at? en? ere? w Many? rovement at is the pro ere is it? at do we wa when? Your Probl roup, write ave access t tes. The pr write a prec nt these for ement Objective oblem? ant to do? lem Statem a problem to them. If roblem stat cise improve discussion ment and statement not, just fo tement mus ement obje . IMPROVEM Improvem . Use your or training p st be based ective. MENT OBJECTIV ment own data if purposes, u d on accurat VE | 51 f use te

52 | SUMMA

SUMM

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54 | CAUSE AND EFFECT

CAUSE AND EFFECT

Asking “why?” is the basis of cause-and-effect analysis.

A useful tool for analyzing cause and effect is the fishbone diagram. Your problem statement is written into the “head” of the fishbone diagram. Possible causes are shown on the “bones” of the major cause categories. Problem Statement Major Cause Category Major Cause Category Major Cause Category Major Cause Category Major Cause Category Major Cause Category

CAUSE AND EFFECT| 55 First we generate lots of possible causes through group techniques, such as brainstorming. We then group similar causes on the bones of the fishbone diagram. Finally, we give each of the bones a name to represent the major cause category.

Why We Use Brainstorming

56 | EXAMPLE OF CREATING A FISHBONE DIAGRAM

EXAMPLE OF CREATING A FISHBONE DIAGRAM

An HIV/AIDS Voluntary Counseling and Testing (VCT) team brainstormed why they were not meeting the new attendance targets set by the

ministry of health.

In ten minutes they generated 30 possible causes. Here are just a few. 1. High turnover of nurses.

2. Interruptions in supply of test kits. 3. Reagent shortages.

4. Shortage of space. 5. Power outages.

6. Staff has additional duties. 7. Data collection incomplete.

The team then drew a fishbone with six bones and wrote the problem statement in the head.

EXAMPLE OF CREATING A FISHBONE DIAGRAM | 57 VCT Clinic not able  to meet the new  targets set by the  Ministry of Health  VCT Clinic not able  to meet the new  targets set by the  Ministry of Health          High turnover of nurses 

Because this was the first cause it could be placed on any bone

58 | EXAMPLE OF CREATING A FISHBONE DIAGRAM   VCT Clinic not able  to meet the new  targets set by the  Ministry of Health      VCT Clinic not able  to meet the new  targets set by the  Ministry of Health  High turnover of nurses Interruptions in 

supply of test kits  _{This cause was not}

similar to the first so it was placed on a different bone Data collection  incomplete  Shortage of space Power outages Interruptions in  supply of test kits  High turnover of nurses Staff has additional  duties 

EXAMPLE OF CREATING A FISHBONE DIAGRAM | 59 Data collection incomplete  Power outages Shortage of space Staff has additional  duties  High turnover of nurses Interruptions in  supply of test kits  VCT Clinic not able  to meet the new  targets set by the  Ministry of Health  Staffing  Records  Lab Supplies  Environment 

The team named this bone staffing because all of the causes related to staffing issues

60 | EXAMPLE OF CREATING A FISHBONE DIAGRAM

The n You c diagra TPN i contro Your contro It is b contro assign In the  Hi  In  Re  Sh  Po  St  Da This r memb This r totally The t proce sectio They to the Doing were next step w can use this

am to a mo s designed ol. team decid ol to improv better to foc ol (P). Thos ned to othe e ART case igh turnove nterruptions eagent shor hortage of s ower outage taff has add

ata collectio represented bership, an reduced the y (T) or par team used m ess to addre on. then prepa e region an g the flowch reporting lo was to ident s method, T ore manage for you to des whether ve, partially cus on caus se causes o er teams or example w er of nurses s in supply o rtages (P), space (N), es (N), ditional duti on incomple d the team’ d their resp e list from t rtially (P) in multivote to ess first. We ared a flowc d then to th hart showed ower numb E

ify the caus TPN, to red eable and re select thos r an individ y (P) or not ses over wh over which individuals we made th s (N), of test kits ies (P) and, ete (T). ’s view at th ponsibilities the original n their cont o select inc e’ll learn m chart of how he ministry d where da bers than w EXAMPLE OF C ses on whic uce the cau elevant list. se causes o dual cause i t (N). hich you ha you have n s. e following (N), , he time, wi s. thirty caus trol. complete da ore about m w data wer y. ata were be were actually CREATING A FIS ch to focus. uses from t . over which y s totally (T ave total (T no (N) contr decisions. th the curre ses to ten, w ata collectio multivoting re gathered eing lost an y justified. SHBONE DIAGRA . the fishbone you have m ) within its T) or partial rol can be ent team which were on as the in the next d and repor d how they AM | 61 e most e t ted y

62 | EXAMPLLE OF CREATIN Ca

NG A FISHBONE ase Examp

E DIAGRAM

Exerc You a agree more Once are u select proble cise 12: Ex

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64 | MULTIVOTE

MULTIVOTE

Multivoting is a technique to help set priorities. It can be used in many circumstances, but in process improvement we can use it to narrow the list of improvement ideas. The team can then more thoroughly examine the remaining options.

Before starting a multivote you must make the voting decision clear. In this case it is “which are the critical few causes of a problem?”

1. Record the list for everyone to see on a flipchart. 2. Eliminate duplications.

3. Each member is allowed a number of votes equal to approximately one third the number of causes. 4. Provide individuals with sticky dots– one per vote.

5. Individuals use their dots to select the items they consider important. All dots can be placed on one item or spread across a number of items.

ART Example

Item

(Process/Measure/

Cause/Improvement) Votes Number

Lack of social support ☻☻☻☻ 4

Stigma ☻☻☻☻ 4

Drug interaction ☻☻☻ 3

Mental health ☻☻ 2

Other non HIV/AIDS related

illnesses ☻☻☻ 3

Side effects ☻☻☻☻ 4

Low-level of patient knowledge ☻☻☻ 3

Inappropriate language or culture ☻☻☻☻☻☻ 6

Poor communication ☻☻☻ 3

Poor education materials ☻☻☻☻☻☻☻☻ 8

In this example you can see the team selected poor education materials as a priority.

If there are several items with similarly high scores, lower items could be eliminated and the process repeated with a shortened list.

Exerccise 13: Se 1. As a te identifi partiall 2. Combin 3. Fill in t 4. Each m approx 5. Add up Cau elect a Cri eam, condu ied from yo ly (P) in yo ne any obv the multi-vo member is a ximately on p the votes uses Our itical Caus uct a full mu our fishbone ur control. vious duplica ote table. allowed a n e third the and enter r Chosen C se ultivote usin e diagram, ates. number of v number of the totals i Vote Critical Cau ng the caus which are t votes equal f causes. n the multi es use MULTIVO ses you totally (T) o to vote table. Numbe OTE | 65 or er

66 | VERIFY

VERIFY

Y CAUSE

Y CAUSE

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n Check Lis of variation en verified ES OF VARIATI st Brainsto Fishbone diagram Multivote ON | 67 orm, e, e

68 | GENERA

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torm all the similar idea that these ese on a fli ct a multivo which will h ng the critic mber—no ju e a small nu then it is n oceed to pl Ideas e possible w as. groupings pchart ote to selec have, if imp cal cause of udgment or umber of im not necessa anning. ways to add don’t overla ct the one o plemented, f the proble r criticism! mprovement ary to do an dress your c ap. or two impr the most i em. t ideas, all nother mult INTRODUCTI critical caus rovement mpact on of which yo ti-vote. In t ON | 69 ses. ou this

70 | PLAN, D

PLAN,

DO, STUDY, ACT

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Now t rema Shew typica If it w your We n idea(s It is p but th result Gene than To pla break in wh it is m and t T

UDY, ACT

that you ha ining steps whart-Demin ally applied wasn’t succe idea altoge ow need to s). possible to a hen it is har ts. rally it is be two. an the chan king down t hich order. I more compl ask lists. ave one or t . Steps 4 to ng circle for to an impr essful, eithe ether and tr o think abou apply sever rd to under est to apply nge we use the task into If the chang icated we m two improv o 7 are base r continuou rovement id  Plan impr  Do i  Stud from work  Act If the imp standardiz communic er revise yo ry somethin ut how to im ral improve rstand whic y one chang e good proje o smaller o ge is not co might need vement idea ed on the in us process i dea. n how to im rovement id it, preferab dy the resu m studying y k? on the stud provement i ze this new cate it to ot our improve ng else. mplement t ement ideas ch ideas are ge at a time ect manage ones, decidi omplex we to use wor

as, you can nternationa mprovemen mplement yo dea. ly first on a ults. What d your results dy results. idea was su w way of wo thers. ement idea the selected s to a proce e responsib e and certa ement disci ng who wil might use rk breakdow n take the ally recogniz nt. The circ our a small scal did you lear s? Did the i uccessful, orking and or abando d improvem ess at one t le for the ainly no mo iplines, such l do what, simple lists wn structur zed cle is e. rn dea n ment time, re h as and s. If res

BRAEKING DOWN THE TASK | 71

BREAKING DOWN THE TASK

In planning a project the first step is to start with the end in mind. What is your goal? What will it look like when your task is complete?

The project, in this case an improvement idea, needs to be well defined. For process improvement planning, tools like the Work Breakdown Structure (WBS) are usually sufficient.

The WBS organizes and defines exactly what work needs to be done to successfully implement your improvement idea.

You will create a WBS by dividing your project into manageable activities and tasks that can be easily implemented and monitored by the

improvement team.

An activity is an action in a WBS that requires effort, resources, and time. It comprises a series of tasks, which in turn may comprise more tasks. The WBS also shows when the activities and tasks must be completed and who will complete them.

72 | BREAKING DOWN THE TASK

Case Example: ART Improvement Idea WBS

Use more diagrammatic and pictorial ART education Form stakeholder development team

Recruit people on ART

IMPROVEMENT

IDEA ACTIVITIES TASKS

Research what is currently available Promote ideas Produce materials Test materials

Engage HIV/AIDS activists

Contact group in SA

Collect examples of best practice

Estimate cost/benefits

Promote to MOH

Organize community meetings

Finalize conceptual design

Select printer

Chose preferred design

Proof read materials

Print first batch for test sites

Case Acti Task Fina conc desi Sele Cho desi Proo mate Print for te Pay Exerc e Example: vity: Produ k alize ceptual gn ect printer se preferre gn of read erials t first batch est sites printer cise 15: P 1. Review 2. Write t 3. Agree add th 4. Consid comple 5. Use on : ART Imp uce materi Who Tekeste Petros ed _Tekeste Ashena Printer Carolyn Plan an Im w the chang this change all the main em to the t der each act

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74 | BREAKING DOWN THE TASK

6. List the tasks and for each one identify who is going to complete the task and by when.

7. Add any additional comments in the space provided. 8. Prepare to present your work.

BREAKING DOWN THE TASK | 75

Work Breakdown Structure Template

IMPROVEMENT IDEA

76 | BREAKING DOWN THE TASK

Task Table List

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