samaritan institute conference, © 2011 linda laganga 1 quality and performance improvement...

Samaritan Institute Conference, © 2011 Linda LaGanga 1

Quality and Performance Improvement

Samaritan Institute Annual Conference, August 5, 2011

Linda LaGanga, Ph.D., LPC, NCCDirector of Quality Systems &

Operational ExcellenceMental Health Center of Denver

Denver, CO, [email protected]

Websites for Publications and Presentations: https://secure.smhcd.org/OutcomesPubs.aspxhttp://leeds-faculty.colorado.edu/lawrence/apptsched/


Quality Systems and Operational Excellence

StaffTools,

ProcessesKnowledge

Consumers

Continuous Quality Improvement

ProjectCoordination Quality Systems

Analysis

Training & Staff Development

Health Information Systems Management

Clinical Quality Improvement

Research, Development,Evaluation

Consumer AdvocacyOperational

Excellence

CheckCheck DoDo

PlanPlanActAct


Learning Objectives

This workshop is designed to help you:

1.Analyze your current approaches to quality improvement 2.Select appropriate activities to strengthen your quality improvement program3.Develop and interpret flow charts to improve processes4.Facilitate effective brainstorming sessions5.Apply tools of quality for problem solving and process improvement6.Develop effective quality improvement plans7.Find and utilize resources for training and dissemination of QI tools


1. The Tools of Quality2. Continuous Improvement: The Deming Wheel 3. The Six Sigma Cycle 4. Choosing Appropriate Measures5. Developing a Quality Improvement Plan6. Resources for Continuous Improvement

Workshop Topics


The Seven Basic Tools of Quality

• A fixed set of graphical techniques identified for addressing issues related to quality

• Suitable for people with little formal training in statistics

• Developed in Japan after World War II (late 1940s-1950s)

• “Democratizing Statistics”


1. The Cause-and-Effect diagram– Fishbone chart/diagram– Ishikawa diagram

2. Check sheet3. Histogram4. Pareto chart5. Control chart6. Flow chart7. Scatter diagram

What are the Seven Basic Tools?


Brainstorming• Not one of the actual 7 Tools• Idea generation• Plays a crucial role

– Problem solving– Quality improvement– Analysis

• Flow of ideas• Allow time• Do not critique ideas in this phase!


Selected Tools: Cause-and-Effect Diagram

• Also known as an Ishikawa or fishbone diagram

• Identify and illustrate the relationships between an effect, an outcome, or a problem and hunches about the possible causes or factors that contribute to it

• Articulate theories about root causes and their own inter-relationships


Steps in a Cause-and-Effect Diagram

1) Summarize your problem statement.2) Determine the headers (i.e., categories to trigger

thinking about possible causes).3) Determine what elements each category are

contributing to the effect.4) Continue to dig for the causes in each branch until

you reach the root cause of each bone.5) Clean out the diagram before testing the theories

reflected within it.6) Narrow down your theories.

Samaritan Institute Conference, © 2011 Linda LaGanga Quality & Process Improvement, DSCI 6440

10

Construction of aCause-and-Effect Diagram

1) Summarize your problem (spine of the fish).

2) Determine headers/categories and draw these as lines attached to the spine (bones/branches).

Long waits in X-ray

Materials Methods

Equipment People

Long waits in X-ray


11

Construction of aCause-and-Effect Diagram

3) Add subsidiary categories/contributing causes (additional branches to the main category lines).

Materials Methods

Equipment People

Long waits in X-ray


Fishbone Suggested CategoriesManufacturing Industries

(The 6 Ms)• Machines • Methods • Materials • Measurements • Mother Nature

(Environment) • Manpower

(People)Service Industries (The 4 Ps)• Policies• Procedures• People • Plant/Technology


• Ever had a problem withclinical documentation?

• What can wediscover through a framework of People, Procedures, Policies, and Plant(Technology)?

• Opportunities for improvement?

Fishbone Diagram Example


Illustration of a Tool:Check Sheet


Illustration of a Tool: Histogram• Frequency distribution• Number of observations or population members

in each category

• This example could be number of residents in each age range

• Scores on a 50-point quiz• Weights of domestic pets


Selected Tools: Pareto Charts• Steps:– Gather data by category– Sort from high to low– Calculate percentage and cumulative percentage

– Only first five categories shown above– Graph to see the “vital few” versus “trivial many”

Category of complaint Percentage Cumulative%Number of complaints

Wait for doctor 26.79% 26.79% 150Ease of appointment 20.00% 46.79% 112Ease of phoning 17.68% 64.46% 99Convenient hours 16.43% 80.89% 92Courtesy of receptionist 6.25% 87.14% 35


Pareto Chart of Complaints Datawith full set of categories

Samaritan Institute Conference, © 2011 Linda LaGanga

Selected Tools: Control Chartsfor monitoring variation between samples

p-chart

0.00

0.10

0.20

0.30

0.40

0.50

T1R1 T2R1 T3R1 T4R1 T1R2 T2R2 T3R2 T4R2 T1R3 T2R3 T3R3 T4R3 T1R4 T2R4 T3R4 T4R4

Sample number

Por

tion

of B

lue

M&

Ms

p

LCL

p-bar

UCL

• Elements of a control chart– Calculated process average– Calculated control limits– Plotted observations


Selected Tools:Process Flow Charts

Use a Flowchart?

Collect Rewards for Radical

Process Improvement

Languish in PitifulProcess Pitfalls

Who wouldn’t?

Who, me?

No

Yes


Flowchart Example: Pharmacy Prescriptions

Psychiatrist faxes Rx to pharmacy of choice or gives consumer a hardcopy of Rx to take to pharmacy.

START: New prescription?

YesConsumer sees psychiatrist.

Consumer requests refill by phone or in person from filling pharmacy.

No

Consumer is on DH plan?

END

MHCD psychiatrist FAXes Rx to DH.

DH prescriber receives and signsRx.

Rx filled and consumer picks it up at DH pharmacy.

Yes

continue


Rx filled and consumer picks up medications.

Yes

Refills remaining in filling pharmacy’sSystem?

No

END

Pharmacy contacts provider.

Provider okays refills.


Illustration of a Tool: Scatter Diagram

0

2

4

6

8

10

12

14

16

18

0 1 2 3 4 5 6 7

Length of Stay (in days)

Tot

al C

harg

e (i

n $0

00s)

• Two-dimensional plot of data• Does there appear to be relationship?



Workshop Topics


• Based on Deming’s concept that continuous improvement is a never-ending cycle

• Steps1. Plan2. Do3. Check4. Act

• Who created the Deming Wheel?

Continuous Improvement: The Deming Wheel Continuous Improvement: The Deming Wheel


Steps in the Deming Wheel:Assess Your QI Process

1. Plan– Define and Select a Problem or Process– What is the improvement opportunity?– What can data tell us?

• Example using global data• Example of clinic no-show data


11

Disease Burden in North America, 2004

0 2,000,000 4,000,000 6,000,000 8,000,000 10,000,000

Mental

Cardiovascular

Cancer

Unintentional injuries

Sense organ

Respiratory

Nervous system

Musculoskeletal

Digestive

Intentional injuries

Diabetes

Disability-adjusted life years lost

Premature Death

Disability

Data from World Health Organization (2004) as reported in Mental Health First Aid training, ©2007


U.S. Adults with a Mental Disorder in Any One Year

9

Type of Mental Disorder % Adults

Anxiety disorder 18.1 .

Major depressive disorder 6.7 .

Substance use disorder 3.8 .

Bipolar disorder 2.6 .

Eating disorders 2.1 .

Schizophrenia 1.1 .

Any mental disorder 26.2 .

Data from World Health Organization (2004) as reported in Mental Health First Aid training, ©2007


Appointment Data


– Describe the current process: • What are the steps and decision points? • Where can the process proceed differently?

– Possible causes of problems: • What are the root causes?• Addressing the problems or the symptoms?

– Determine a solution• Workable? • Action Plan with clear target objectives

Step 1: Plan (continued)


2. Do•Pilot or small-scale initial implementation•Following the plan?

– Milestones– Measures– Timing

•How to gauge your progress?

The Deming Wheel: Step 2Assess your performance of this step


3. Check•Measure progress and success•Working as planned?•Unexpected/unintended consequences?•How to measure success?



4. Act•Assess results•Recommend changes•Continue improvement where needed•Standardize changes•Celebrate results!



How’s Your Process Working?

CheckCheck DoDo

PlanPlanActAct

Continuous Improvement



Workshop Topics


The Six Sigma CycleThe Six Sigma Cycle

• Steps– Define– Measure– Analyze– Improve– Control

• Where was it invented?• What was its initial focus?

– Industry– Meaning of Six Sigma = 6σ


Six-Sigma Quality3.4 defects per million opportunities

36

FREQUENCY

Most observations are at the Target Value

Variance = σ, which is so small that 6σ fit between Target and Tolerance Limits


Comparison: Deming Wheel and Six Sigma

Deming Wheel Six Sigma

ElementsElements PDCA DMAIC

PhilosophyPhilosophy Incremental Continuous Improvement

Quantifiable Value, High Financial Return

ApproachApproach Repeat the cycle applied to the same process

Monitor and control to sustain improvements, move on to next project

Tools EmphasizedTools Emphasized Tools of Quality Advanced Statistics



Workshop Topics


Choosing Appropriate Measures

• What’s important?• Why is it important?• To whom is it important?• What are the problems?• How do we know how we’re doing?


• Examples from Clinical Peer Review• Required for community mental health centers in Colorado

– Conduct peer reviews– Use results to improve quality– Broadly defined

• Measure:– Compliance = % of records in conformance with requirements– Treatment plans signed by consumers?– Treatment plan uses at least

2 consumer strengths?

Measurement


Measurement: Examples from Peer Review (years past)What are opportunities to improve measurement?

T1 T2

II. ISP

1. Did the consumer/parent/guardian participate in the ISP? 82% 79%

2. Are the consumer’s strengths that are listed in the Intake integrated into the ISP?

75% 78%

3. Does the ISP effectively capture all MHCD and external services (i.e. coordination with PCP)

82% 80%

4. Are Objectives and Methods measurable and specific? 88% 91%

5. Is the ISP up to date? 88% 91%

6. Is the 6-month case review up-to-date? 76% 71%

III. Progress Notes

1. Does treatment in notes match ISP objectives? 93% 93%

2. Are the consumer’s strengths, listed in the Intake and ISP integrated into the service delivery and Progress Notes?

77% 79%

3. Do notes follow the approved format with all sections completely filled out?

91% 94%


1. Event data: Appointments and their status2. Process data: Steps and time to complete a process

Measurement: Examples from Lean Process Improvement


Appointments scheduled and no-show rates before and after lean improvement

Appointments Scheduled

0

100

200

300

400

500

Mon Tue Wed Thu Fri

Before

After

No-Show Rates

0%

5%

10%

15%

20%

Mon Tue Wed Thu Fri

Before

After


Lean Process Improvement: One Year AfterRapid Improvement Capacity Expansion

RICE Results• Analysis of the1,726 intake appointments for the one year

before and the full year after the lean project • 27% increase in service capacity

– from 703 to 890 kept appointments) to intake new consumers

• 12% reduction in the no-show rate – from 14% to 2% no-show

• Capacity increase of 187 additional people who were able to access needed services, without increasing staff or other expenses for these services

• 93 fewer no-shows for intake appointments during the first full year of RICE improved operations.

• Annual cost savings (expense avoidance):$90,000 - $100,000 for staffing


Comparing process steps: Before and After

• Before:• Total steps with recurrent steps (worst case with

3 instances of steps 4 and 5) = 3 x 3 + 5 = 14• After

• Total steps with recurrent steps (worst case with 2 instances of steps 4 and 5) = 2 x 3 + 6 = 12

• Eliminates 2 steps


Comparing process time and lag time:

• Before: • Total time (minimum possible) = (30+50+60 minutes) + 2 days

= 2 days 2 hours and 20 minutes• Total time (maximum if consumer is admitted on 4th call) • = 5 weeks 4 hours and 5 minutes

• After:• Total time (minimum possible) = Same as above• Total time (maximum if consumer is admitted on 3rd call) • = 1 week 3 hours and 10 minutes

• Process and lag time reduction of worst case:• > 4 weeks


Process Improvement• Accomplished by involving clinicians and consumers• Reconfiguration for timely and consumer-friendly

access• Measured

– Increased intakes– Decreased no-show rates– Decreased delays to access

LaGanga, L.R. (2011). Lean service operations: Reflections and new directions for capacity expansion in outpatient clinics. Journal of Operations Management, 29(5), 422-433.


Lean Process Improvement:Express Intake: Fast Track Project

Clinician Time to do Intake

0%

10%

20%

30%

40%

50%

60%

70%

0.50 1.00 1.50 2.00 2.50 3.00 3.50 4.00

Hours

Cas

es

Before Fast Track

After Fast Track

LaGanga, L. R., & Lawrence, S. R. (2009). POMS Proceedings and Presentation, May 2, 1:30 p.m., Knave.


Measures of Perceptions

• Customers• Consumers/Clients/Patients• Employees


(1) Recovery Marker Inventory(RMI)

(Staff rating of member progress in recovery on eight dimensions. Used to inform clinical & program decisions - every 2 mo.)

(3) Recovery Measure by Consumer (RMC)

(Consumer’s rating of their own recovery on five dimensions – all members every 6 months)

(2) Promoting Recovery in Organizations (PRO)

(Consumer evaluation of how specific programs and staff are promoting recovery - random sample 1x per yr.)

To what degree is

RECOVERY happening?

Multiple perspectives Multiple dimensions Change over time

Clinical Outcomes and Recovery Data

(4) Recovery Needs Level (RNL)

(Suggests best level of services for stage of recovery)


Recovery Marker Indicators


Specialized Control Charts Helps Us to Understand a Consumer’s Recovery Changes and Variability

Compared to All Other Consumers:


Employee Perceptions• Annual Staff Satisfaction Survey

– Common HR Items– Organization-specific initiatives– Numeric Scoring– Open-ended Comments

• Gallup Q12: Three x yearly– 5-point scale

• 5 = Strongly Agree, 1 = Strongly Disagree– “I know what’s expected of me at work”– “I have the materials and equipment to do my job”– “In the last seven days I have received recognition or praise for doing

good work”– “This last year, I’ve had opportunities to learn and grow”



Workshop Topics


Developing a Quality Improvement Plan• Samaritan Accreditation Standards• The Center shall develop a Quality /

Performance Improvement Program that includes:

A. a written description of the QI/PI programB. compiling and analyzing data on at least one clinical

and at least one administrative function annuallyC. accountability to the Center board of directors

D. at least annual public reporting of QI/PI results


Developing a Quality Improvement Plan: Tips from MHCD’s Experience since 1995

A. A written description What processes are important to improve? How will you measure them? Who and how often? Framework or philosophy

PDCA DMAIC CQI/TQM Principles

Customer focus Data-driven Employee involvement Cross-functional / interdisciplinary teams


Developing a Quality Improvement Plan: Tips from MHCD’s Experience since 1995, Applied to

Samaritan Accreditation Standards

B. Compiling and Analyzing Data– Choose clinical and administrative functions

• Examples– Adult Outpatient– Children and Families– Intake Process– Grants Management– Employee Satisfaction/Engagement/Retention

– Select meaningful measures– Apply Tools of Quality


C. Accountability to the Center board of directors– Consider board priorities, backgrounds, interests– Measure baseline and change over time– Analyze change– Other projects and milestone completion

D. At least annual public reporting of QI/PI results– Annual plan and report

Developing a Quality Improvement Plan: Tips from MHCD’s Experience since 1995,

Applied to Samaritan Accreditation Standards


Developing a Quality Improvement Plan: Tips from MHCD’s Experience since 1995, Applied to

Samaritan Accreditation Standards

Balance Comprehensiveness with Conciseness!– Elicit input– Edit for consistency and conciseness– Present with illustrations of importance and results!



Workshop Topics


• Books and Printed Materials– The Memory Jogger 2: Tools for Continuous Improvement and Effective

Planning, ISBN 978-1-57681-113-9 or see www.MemoryJogger.org– Evans, James R. and William M. Lindsay, Managing for Quality and

Performance Excellence, 8th edition, South-Western, 2010, ISBN-13: 978-324-783-205-4, ISBN 10: 0-324-783205

– Foster, Thomas. Managing Quality, 4th Edition, Prentice-Hall, 2010, ISBN-10: 0136088503ISBN-13: 9780136088509

– Harry, Michel and Richard Schroeder, Six Sigma: The Breakthrough Management Strategy Revolutionizing the World's Top Corporations, Random House, 2005, ISBN 0-385-49438-6

Resources for Continuous Improvement


• Web sites– The American Society for Quality: www.asq.org– Tools of Quality:

http://asq.org/learn-about-quality/seven-basic-quality-tools/overview/overview.html

– www.isixsigma.com Tools and Templates

Resources for Continuous Improvement


Quality and Performance Improvement

Samaritan Institute Annual Conference, August 5, 2011

Linda LaGanga, Ph.D., LPC, NCCDirector of Quality Systems &

Operational ExcellenceMental Health Center of Denver

Denver, CO, [email protected]

Websites for Publications and Presentations: https://secure.smhcd.org/OutcomesPubs.aspxhttp://leeds-faculty.colorado.edu/lawrence/apptsched/

samaritan institute conference, © 2011 linda laganga 1 quality and performance improvement...

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