tqm qip indonesia sept 2014 participants copyb

Total Quality Management:

Quality Improvement Process

Jakarta, Indonesia

September 30, 2014

Learning Objectives

Acquire a shared concept of quality

Become familiar with the principles of Total Quality Management (TQM)

Gain experience in using the 7-step quality improvement process

Quality

Meeting customer needs and reasonable expectations

Doing right things right (integrity of function and composition)

Doing Right Things Wrong Doing Right Things Right

Submitting a report on time, Analyzing patient needs

but with many errors & meeting those needs

Doing Wrong Things Wrong Doing Wrong Things Right

Patient waits a long time Making no errors while

in the wrong line collecting data no one uses

Process Done Incorrectly Process Done Correctly

W

ron

g P

roce

ss

R

igh

t P

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ss

Total Quality Management

TQM

A way of ensuring customer satisfaction through the involvement of all employees in

learning how to reliably produce and deliver

quality goods and services

Quality Teams

environment for employees to work together

Together Everyone Achieves More

developing skills and abilities

promoting communication and teamwork

enhancing quality of work life

improve quality of products and services

TQM Principles

Customer satisfaction

Management by Fact

Respect for People

P-D-C-A (Plan-Do-Check-Act)

Principles of TQM

Customer Satisfaction

Identifying the customer

Establishing valid requirements

Internal customer - people within your

office or organization

External customer - people outside your office or organization

Valid Requirements

Standards of quality work agreed upon by customer and supplier

Current, realistic, measurable

Meet customer needs and reasonable expectations

Meet agency responsibilities

FBS lab request form completely and legibly

filled out and submitted to the hospital laboratory

on or before 4:00 pm prior to

day of blood collection

Principles of TQM

Management by Fact

Enhance credibility and integrity

Gives common framework for understanding what is being done

Makes communication more certain

Makes execution of plans more predictable

Makes evaluation more credible

Evidence-based

Quality Indicators

Measures of how well we are meeting our customers needs and reasonable expectations

Number of surveillance reports submitted late

Percent of CBC results released within 4 hours of receipt of specimen

Percent of sputum smears that are unsatisfactory

Principles of TQM

Respect for People

Keeping people informed

Train people

Help people communicate

Delegate responsibility and authority

Create a sense of purpose in the workplace

Rules of Conduct

Respect each person

Share responsibility

Criticize only ideas, not people

Keep an open mind

Question and participate

Attend all meetings

Listen constructively

Principles of TQM

P - D - C - A

Corresponds to the way we operate

Common language and clear model

Act Plan

Check Do

Plan

Begin by setting goals

based on customer needs

Plan how to achieve the

goals

Do Implement or try out the

plan to see how it works

While doing it, gather and

analyze data to find out

what happened, what

worked and what didnt (are you closer to your

planned goal?)

Based on the analysis,

act to improve the

process

Check

Act

Quality Improvement (QI)

Process Systematic data-based approach to problem

solving

Series of steps to be taken in the improvement process

Provides a standard way of communicating team progress

Steps in QI Process

1 Reason for Improvement

2 Current Situation Plan

3 Analysis

4 Countermeasures Do

5 Results Check

6 Standardization

7 Future Plans Act

Quality Control Tools

Checksheet

Pareto Chart

Ishikawa Fishbone Diagram

Histogram

Scatter Diagram

Graphs (line, bar, pie)

Control Chart

Step 1: Reason for Improvement We have a Problem!

Objective: identify a theme (problem area) and reason for working on it

Activities:

research for themes (brainstorm, survey, interviews)

consider customer needs in selecting theme

set indicator to track the theme

determine how much improvement is needed

describe procedure in problem area (flowchart)

schedule QI story activities

Tools: graph, control chart, flowchart

Brainstorming

Quantity of ideas not quality

Phases:

generation clarification evaluation

Uses: collect improvement opportunities (themes)

identify possible causes (Fishbone)

suggest possible countermeasures

identify barriers and aids

Rules of Brainstorming

Clearly state purpose

Each person takes a turn, in sequence, around the group*

Present one thought at a time

Do not criticize or discuss any idea

Build on ideas of others

Record ideas where visible for group

* its okay to pass

Multivoting

Objective: reduce the number of items to a manageable few (3-5)

Steps:

First vote: each person votes for as many

items as desired then circle items with high

no. of votes

Second vote: each person votes for a no. of

items = half the no. of circled items

Third vote: continue until the list is reduced to

3-5 items

Never multivote down to only one item!

Theme Selection Matrix Themes Customers Impact on Customer X Need to Improve = Overall

Scale: 1 = None 2 = Somewhat 3 = Moderate 4 = Very 5 = Extreme

Theme Selection Matrix

25

5

5

TB

Symptomatics

Quality

Assurance for

AFB Smears

15

3

5

Physicians,

Patients

Release of Blood

Culture results

15

3

5

Physicians,

Patients

Antimicrobial

Susceptibility

Testing

10

2

5

Malaria

suspects

Quality

Assurance for

Malarial Smears

Over-all

Score

Need for

Improve-

ment

Impact on

Customer

Customer Theme

Flowchart Picturing the Process

ending or beginning

action

direction

decision

Sequence what is, not the ideal!

? Y

N

Flowchart for Water Chlorination

Guimba, Nueva Ecija

Sanitary

Inspector is

assigned to

chlorinate

water sources

Increase

no. of

diarrhea

cases

Test wells Use for

drinking

Chlorinate

PHC media

available

Condemn

well

Test well

Y

N

(-)

(+)

(+)

(-)

TB

Symptomatics

AFB Smear

(3 times)

Smear

Result

Neg. Smear (3 spc.)

Chest X-ray

Reading

Results

Negative X-ray Positive X-ray

Screening by DiagnosticCommittee

Results

Inactive TB(Stable/Healed/Fibrosis)

Symptomatic treatment,

Surveillance only

Active TB

TB Treatment

Positive Smear 2 or 3 spc.

DOTS

symptomatic treatment,

surveillance only

Flowchart for TB

Symptomatics

Step 2: Current Situation What exactly is the Problem?

Objective: select a problem for improvement

Activities:

data collection (checksheet)

stratify theme from various viewpoints (Pareto chart)

write problem statement

set target for improvement

Tools:

checksheet, histogram, Pareto chart

Graph used in step 2 should also be used in step 5!

Checksheet or Tally Sheet

a form for systematic data collection

categories: what, who, where, when, how

not why?

basis for constructing Pareto chart, graphs

Pareto Chart

a search for significance

stratification tool to identify the vital few vs. the trivial many

graphic depiction of 80-20 rule

helpful in prioritization

Reasons for Wasted AFB Smears (N=135)

Claveria Municipal Health Office, Jan Dec 1999

0

15

30

45

60

75

90

105

120

135

Salivary Specimens Incorrect Staining

Procedure

Contaminated slides No med tech

available

0

100

50

Number Percent

How to do a Pareto Chart

1. Identify data needed and collect (checksheet)

2. Define categories - sort data and tally

3. Construct graph

bars arranged in decreasing order (touching)

left axis for actual data

right axis for percent of total

cumulative line from zero

4. Analyze and interpret graph

Is there a Pareto pattern?

5. If no Pareto pattern, try different stratification

Problem Statement Who, What, When, Where

States the effect not the cause

Focuses on gap between what is and what should be

Measurable

Specific

Stated in a positive manner (not a question)

Focuses on the pain

Problem Statements

In 2010, an average of only 75% of Pap smears taken per month were

of satisfactory quality.

In January 2014, the average waiting time at health center A was

1.5 hours.

Theme: Patient waiting time at health center

Indicator: Average patient waiting time

Problem Statement: In June 2010, the average patient

waiting time was 50 minutes.

Target: By January 2011, the average patient waiting

time will be 30 minutes.

Step 1: Reason for Improvement

Step 2: Current Situation

Step 3: Analysis What is causing the problem?

Objective: Identify and verify root causes of the problem

Activities:

do cause and effect analysis (Ishikawa Diagram)

identify actionable root causes

select root cause with greatest impact

verify selected root cause with data

Tools:

Ishikawa diagram, Pareto chart, scatter diagram,

etc.

Ishikawa (Fishbone) Diagram Cause and Effect Analysis

Effect

P.S.

A

PS = Prob. Statement, RC = Root Cause

B

C

D

RC

RC RC

RC

Why?

Generic Categories for Fishbone

Methods

Machine Materials

Environment

P.S.

People

Come on, lets get moving!

I agree, we cant be late again!

How might we determine our major categories?

1. Generic - People, Methods, Machine, Material,

Environment

2. Process - Break down the process into major activities.

3. Brainstorm - Team brainstorms causes of the problem, then segments ideas into major categories.

4. Pareto - Breakdown effect (of problem statement)

into components

How is it done?

1. Draw diagram starting at right building major categories left.

2. Write the effect of the problem statement in the rightmost box.

3. Determine major categories.

4. Once completely drawn, start with the major category most likely

to produce an actionable root cause and ask why? (5 times)

Major Category

5. Now revisit each sub-bone or sub-category for additional causes;

that is move back to a2 and ask again why a2 occurs, then ask again

why a1 occurs, and so on.

6. Complete the entire fishbone or category before moving on.

7. Cloud actionable root causes.

8. After completing the diagram, we must verify suspected root

causes with data.

Few FLSWs have smears taken by SHC staff

Ishikawa Diagram

SHC not FLSW friendly

User fees

LGU lacks funds No mandate to serve FLSWs

Sanitation code requires only RFSWs to go to SHC

Painful procedure

Wrong position

FLSW not properly instructed by staff

STI

Do not use condom

Condom not available

Lack of condom supply Instrument

not properly lubricated

Use of water only

No KY jelly supply

Staff is rushing

Work overload

Lack of trained staff

Why is it useful?

It helps teams reach a common understanding of

problems, exposes gaps in knowledge, directs teams

towards actionable methods for reducing their

problems, and it is easy to use.

Scatter Diagram

Shows the relationship between two quantitative variables (positive correlation, negative correlation, no correlation)

When is it used?

It is used almost exclusively in step three to find

relationships between suspected root causes and the

effect of the problem.

Scatter Diagram

Step 4: Countermeasures What are we going to do about what is causing the problem?

Objective: Plan and implement countermeasures that will correct root causes of the problem

Activities:

develop countermeasures attack root causes

meet customers valid requirements

cost beneficial

develop action plan

who, what, when, where, how

barriers and aids (Force Field Analysis)

implement countermeasures

Tools: countermeasures matrix, cost estimates, barriers & aids, action plan

Countermeasures Matrix

PROBLEM STATEMENT

ROOT CAUSES

COUNTER MEASURES

PRACTICAL METHODS

EFFECTIVENESS

FEASIBILITY OVER-ALL

ACTION

Improper Disposal of Waste Blood Components

No SOP for recording

Create SOP Chief Med Tech to formulate SOP

5

5

25

y

No orientation of lab staff on waste mgt.

No maintenance team

Re-orient lab staff

Create

maintenance team

Give orientation during lab meeting

Post guidelines and procedure for disinfection at the lab

COH to assign maintenance personnel

PHO to assign maintenance personnel

5

5

5

3

5

5

5

2

25

25

25

6

y

y

y

N

Worn-out PVC connection

Repair worn-out connections

Ask COH for repair

5

5

25

y

No written request to replace PVC pipe

make written request to AO

Med tech to submit written request to AO

5

4

20

y

Countermeasures Matrix

How is it done?

1. Identify CM and PM.

2. Brainstorm barriers, list on left.

3. Brainstorm aids, list on right.

4. Rank each as H, M or L.

5. For each barrier, try to identify an aid.

6. Connect with lines.

7. Unconnected barriers need action

otherwise not feasible.

Barriers and Aids Analysis

Step 4: Countermeasures

Countermeasures Matrix

Barriers and Aids (Force Field Analysis)

consider people, environment, equipment, funds

Action Plan

who, what, when, where, how, budget

How is it done?

1. Break CM into manageable components.2. List activities that must be done to ensure a

successful implementation.

3. Identify resources for each task.4. Address remaining barriers and any actions to

overcome them.

5. Brainstorm for anything possibly missed.

Action Plan

As we can see, it is not necessarily detailed.

The point is that we make a plan and stick to it. If we present

this plan to management and do not follow through, without good

reason, the team (and teamwork) may be looked upon poorly.

Action Plan

Problem statement: From October to December 2001, 0% of blood

units transfused to patients were fully screened.

Improvement Target: By July 2002, at least 10% of blood units

transfused to patients each month will be fully screened.

Countermeasure: Assign medical technologist to do blood screening

Practical Method: Request training for medical technologists to

include HIV testing

Number Task/

Project

Due Date Assigned

To

Date

Assig

ned

Status/

Remarks

1 Select med

tech

June 4 N. Ha-chac May 1 Based on interest

and experience

2 Prepare

Training

materials

July 1 H. Baraquia May 1 Check with

Ministry of

Health

Step 5: Results How well did we do in eliminating the problem?

Objective: confirm that the problem and its root cause(s) have decreased and target improvement

has been met

Activities:

before and after comparison using same indicator (use same graph or chart)

if Yes then go to Step 6 (standardization)

if No then go back to Step 3 (analysis) or 4 (countermeasure)

Tools: Pareto chart, Control chart, Histogram, Graph

Figure 5. Percent of Blood Units Transfused to Patients that are fully screened by Month,

Oct 2001 Oct 2002

0

10

2030

40

50

60

7080

90

100

Oct

Nov

Dec Ja

nFe

bMar

Apr

May

June

July

Aug

Sept O

ct

Percent of Units

2001 2002

Original Target

Intervention

NewTarget

Improving Blood Screening Service

in Sultan Kudarat Province, Philippines

Step 6: Standardization How do we maintain our gains?

Objective: Prevent the problem and its root causes from recurring

Activities:

assure that countermeasures become part of daily work

[work process, standards]

train employees on new process/standards

[explain purpose]

establish periodic checks

consider other areas for replication

Tools: control charts, graph, procedures, training

Standardization will not be

achieved simply by documents.

Standards must become a part

of the thoughts and habits of the workers.

-- Dr. Hitoshi Kume

Incorporate countermeasures

into our daily work.

Flowchart the process.

Establish a monitoring system.

Prepare written guidelines.

Train employees.

Consider how to replicate.

Step 7: Future Plans What next?

Objective: evaluate teams effectiveness and plan what to do about remaining problems

Activities:

review lessons learned

What was done well?

What could be improved?

What could be done differently?

analyze and evaluate any remaining problems

plan further actions

Tools: action plan

Future Plans

Objectives:

1) See that remaining components of

problem areas are addressed.

2) Review P-D-C-A lessons learned.

Critical Question: What do we do

about remaining problems and how

can we do better next time?

1. Reason for 2. Current 3. Analysis 4. Counter-

Improvement Situation Measures

5. Results 6. Standardization 7. Future Plans

Quality is within

your reach!