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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/

PROCESS IMPROVEMENT

| iii

Process Improvement CONTENTS

Introduction 

Sustainable Management Development Program ................................................................... v 

Acknowledgements .................................................................................................................. v 

Course Overview 

About this Facilitator’s Guide .................................................................................................. vi 

Target Audience ...................................................................................................................... vi 

Learning Objectives ................................................................................................................. vii 

Materials and Equipment ....................................................................................................... viii 

Workshop Schedule ................................................................................................................ ix 

Class Preparation Checklist ..................................................................................................... x 

Classroom Setup ...................................................................................................................... x 

Resources 

Internet Sites ........................................................................................................................... xi 

Textbook .................................................................................................................................. xi 

Further Reading ...................................................................................................................... xi 

Instruction Notes 

Icon Glossary ......................................................................................................................... xiii 

Course Instruction 

Day One ................................................................................................................................... 1 

Day Two ................................................................................................................................. 37 

Day Three ............................................................................................................................... 76 

Appendix 

Appendix A Datasets for Exercise 16 .................................................................................. 109 

PROCESS IMPROVEMENT

iv |

PROCESS IMPROVEMENT

SUSTAINABLE MANAGEMENT DEVELOPMENT PROGRAM | v

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

Dr. Elliot Raizes, Medical Officer, Care & Treatment, GAP

PROCESS IMPROVEMENT

vi | COURSE OVERVIEW

Course Overview ABOUT THIS FACILITATOR’S GUIDE

This guide is designed to provide you the materials and direction to successfully deliver the Process Improvement workshop in a classroom environment. It assumes a basic level of understanding and skill of the content that is presented. It is strongly recommended that you participate in a process improvement project in the local public health environment before teaching this workshop.

This guide includes notes about what to say and do during the class, as well as materials to help you prepare and conclude the course.

Please read the description of the target audience carefully, as well as the learning objectives. By correctly positioning the course you can set reasonable expectations for the participants.

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.

PROCESS IMPROVEMENT

COURSE OVERVIEW | vii

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:

Define a process.

Measure process performance.

Analyze causes of variation.

Generate and plan improvement ideas.

Implement changes.

Study the results of changes.

Act according to the results of the study.

Apply at least three process improvement tools to achieve the above objectives.

PROCESS IMPROVEMENT

viii | COURSE OVERVIEW

MATERIALS AND EQUIPMENT

MATERIALS EQUIPMENT

For the Instructor: For the Instructor: This Facilitator Guide. 1 flip chart & stand per participant

team. 2 flip charts & stands for

instructor. Whiteboard. Icebreaker materials. Exercise materials. 3 envelopes each containing a

different dataset.

LCD projector. Computer with MS PowerPoint®. Digital camera. Tennis ball or equivalent and

stopwatch.

For the Participant: For the Participant: Participant Workbooks. Ample supply of sticky notes. Pens and paper. Comment Cards.

None needed.

Copies of PowerPoint slides are not needed and should not be given out.

PROCESS IMPROVEMENT

COURSE OVERVIEW | ix

WORKSHOP SCHEDULE

TIMES DAY 1 DAY 2 DAY 3

Morning 8:30 – 12:00

Introduction and Overview

What is a process?

Review Day 1

Flowcharts

Review Day 2

Pareto Chart

Analyzing causes for variation

Fishbone Diagrams

BREAK Process boundaries

and levels

Listing processes

Selecting process to improve

Present flowcharts

Summary of Step 1/ Introduce Step 2

Measuring good practice

Types of measures

Selecting a critical cause

LUNCH Afternoon 1:00 – 4:30

Defining customers

Identifying products and services

Listing customer wants and needs of products and services

Quality

Identifying measures

Selecting a measure

Generating and selecting improvement ideas

Planning an improvement project for your selected idea

BREAK Identifying

stakeholders

Discussion and questions Day 1

Run Chart – the process tells its story

Preparing problem statements and improvement objectives

Discussion and questions-Day 2

Implementing Change and studying its results

Discussion and questions-Day 3

Homework Read measurement good practice

Read Check Sheet, Stratification and Pareto Chart

Review and evaluate workshop

PROCESS IMPROVEMENT

x | COURSE OVERVIEW

CLASS PREPARATION CHECKLIST

TASK

Obtain & test LCD projector.

Obtain and test computer.

Obtain and test digital camera.

Obtain adequate number of flipchart packages, including stands, paper, and markers (one for every team of participants).

Obtain adequate supply of sticky notes, graph paper, pens, and paper.

Obtain tennis ball and stopwatch.

Copy participant materials. For each participant:

Participant Workbook.

Applied Learning Project workbook.

Workshop Evaluation forms.

Prepare envelopes with datasets for exercise 16 (see appendix).

CLASSROOM SETUP Create teams of 4-6 people.

Organize the teams around shared processes, if possible.

Group by type of organizations or programs if it is not possible to organize teams by shared process.

It will be easier if everyone can relate to the process the team will select.

Arrange the room so that each team has one desk/table.

Arrange the seats so that everyone can see the screen.

Set 1 flipchart and pad at each desk/table.

Place plenty of sticky notes and pens on each desk.

PROCESS IMPROVEMENT

RESOURCES | xi

Resources INTERNET SITES WHO MAKER (Managers taking Action based on Knowledge and Effective use of resources to achieve Results.) http://www.who.int/management/strengthen/en/index.html

Institute for Healthcare Improvement. http://www.ihi.org/ihi http://www.ihi.org/ihi

American Society for Quality. http://www.asq.org/

Creativity Techniques. http://www.mycoted.com/Category:Creativity_Techniques

Mind Tools. http://www.mindtools.com/

Baldrige National Quality Program. http://www.quality.nist.gov/

iSix Sigma. http://www.isixsigma.com/

Deming Electronic Network. http://deming-network.org/

National Quality Center inc., HIVQUAL Project.http://www.nationalqualitycenter.org/

TEXTBOOK The Memory Jogger: A Pocket Guide of Tools for Continuous Improvement by Michael

Brassard. Goal/QPC; 2nd edition (June 1988).

FURTHER READING Juran's Quality Handbook by J.M. Juran and A. Blanton Godfrey, McGraw-Hill

Professional; 5Rev Ed edition (September 1, 2000).

Out of the Crisis by W. Edwards Deming, The MIT Press (August 11, 2000).

PROCESS IMPROVEMENT

xii | RESOURCES

The Six Sigma Handbook: The Complete Guide for Greenbelts, Blackbelts, and Managers at All Levels, Revised and Expanded Edition by Thomas Pyzdek, McGraw-Hill; 2nd revised edition (March 20, 2003).

The Team Handbook Third Edition (Spiral-bound) by Barbara J. Streibel, Brian L. Joiner, Peter R. Scholtes, Joiner/Oriel Inc; 3rd edition (March 24, 2003).

Understanding Variation: The Key to Managing Chaos (Hardcover) by Donald J. Wheeler SPC Press, Inc.; 2nd Revised edition (January 2000).

Curing Health Care: New Strategies for Quality Improvement (Paperback) by Donald M. Berwick, A. Blanton Godfrey, and Jane Roessner, Jossey-Bass; 1st edition (October 15, 2002).

The Memory Jogger II (Spiral-bound) by Michael Brassard (Author), Diane Ritter, Goal/QPC; 1st edition (January 15, 1994).

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LEARNING OBJECTIVES

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processes in your organization.processes in your organization.

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8 | DAY ONE Plain=Script Bold=Instructions Italics=Answers

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Process Improvement has practical Process Improvement has practical applications to Public Healthapplications to Public Health

PROCESS IMPROVEMENT RESULT

Allocate pediatric ward beds

Introduced protocol on interdepartmental referrals and collaboration

Availability of beds balances demand

Collect sputum specimens

Health officer & patient educationIncrease in TB patients having sputum collected

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STAKEHOLDERS

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The customer is one type of stakeholder. There are three other categories:

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BUILD A FISHBONE DIAGRAM (continued)

WORKBOOK PAGE: 57

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Finally, we assign a name to each of the bones to represent the major cause category (e.g., Records, Staffing, Lab Supplies, and Environment).

Power outages

Build a Fishbone DiagramBuild a Fishbone Diagram

RECORDSRECORDS STAFFINGSTAFFING

ENVIRONMENTENVIRONMENT LAB SUPPLIESLAB SUPPLIES

Data collectionincomplete

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WORK BREAKDOWN STRUCTURE (WBS)

WORKBOOK PAGE: 72

SCRIPT/KEY POINTS

Start with the end in mind.

Organize and define what needs to be done.

Define when the activities need to be completed and who will complete them.

Work Breakdown Structure (WBS)Work Breakdown Structure (WBS)

1.1. Start with the end in mindStart with the end in mind——List the List the project objective.project objective.

2.2. Determine the resources required to Determine the resources required to complete it.complete it.

3.3. Determine the tasks needed in order to Determine the tasks needed in order to complete the project.complete the project.

4.4. Continue to break tasks down in order to Continue to break tasks down in order to identify specific resource requirements.identify specific resource requirements.

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PROCESS IMPROVEMENT: NEXT STEPS

SCRIPT/KEY POINTS

Review next steps

Upon completion of this workshop and return to your country, our expectations include:

o Adapting these materials as appropriate.

o Arranging to teach process improvement to selected in-country trainees.

o Monitor and evaluate trainee’s projects.

o Use SMDP TA, as needed.

o Graduate trainees.

Distribute evaluation sheets

Allow time for students to complete the Day 3 evaluation sheets

Be sure to complete the evaluation sheets for today’s session. Thank you for your attention and hard work during this workshop.

Process Improvement Process Improvement Next StepsNext Steps

1.1. Return to country.Return to country.2.2. Adapt materials.Adapt materials.3.3. Arrange teachings of process Arrange teachings of process

improvement.improvement.4.4. Teach process improvement to selected Teach process improvement to selected

‘‘inin--countrycountry’’ trainees.trainees.5.5. Monitor traineeMonitor trainee’’s projects (x2) at work s projects (x2) at work

site.site.6.6. Use SMDP TA as required.Use SMDP TA as required.7.7. Evaluate traineeEvaluate trainee’’s projects.s projects.8.8. Graduate trainees.Graduate trainees.

PROCESS IMPROVEMENT

APPENDIX | 107

Appendix

Appendix A Datasets for Exercise 16 .................................................................................. 109

PROCESS IMPROVEMENT

108 |

PROCESS IMPROVEMENT

APPENDIX: DATASETS FOR EXERCISE 16 | 109

APPENDIX A DATASETS FOR EXERCISE 16

Dataset One:

Aug-05 38.20%

Sep-05 37.70%

Oct-05 61.00%

Nov-05 46.20%

Dec-05 54.00%

Jan-06 37.80%

Feb-06 54.10%

Mar-06 44.10%

Apr-06 53.80%

May-06 44.20%

Jun-06 38.20%

Jul-06 65.00%

PROCESS IMPROVEMENT

110 | APPENDIX: DATASETS FOR EXERCISE 16

Dataset Two:

Aug-05 68.00%

Sep-05 57.00%

Oct-05 80.00%

Nov-05 64.00%

Dec-05 74.00%

Jan-06 57.00%

Feb-06 63.00%

Mar-06 64.00%

Apr-06 73.00%

May-06 64.00%

Jun-06 58.00%

Jul-06 84.00%

PROCESS IMPROVEMENT

APPENDIX: DATASETS FOR EXERCISE 16 | 111

Dataset Three:

Aug-05 28.00%

Sep-05 37.00%

Oct-05 60.00%

Nov-05 34.20%

Dec-05 14.00%

Jan-06 27.00%

Feb-06 23.00%

Mar-06 24.00%

Apr-06 13.00%

May-06 24.00%

Jun-06 38.00%

Jul-06 40.00%