PROCESS IMPROVEMENT
A
Resource
for
Healthcare
Prepared By:
Lee Elliott
and
Donald G. Sluti, Ph.D.
Contents
Preface
The Authors
1. Introduction
Section 1 SPC Tools: Determining How Well the Process
is Functioning
2. Understanding the Process
3. Hearing the Process
4. Understanding What the Process is Telling You
5. Delivering What the Customer Wants
Section 2 Process Improvement Tools: Making the Process
Work Better
6. Root Cause Analysis
7. Developing Potential Solutions
8. Implement and Follow-up
9. Team Dynamics
Section 3 Related Tools: Understanding and Refining the Process
10. Finding and Eliminating Wasted Effort
11. Failure Mode and Effects Analysis (FMEA)
12. Other Models of Process Improvement
13. Cost of Quality
14. Project Management
Suggested Reading
Chapter 1
Introduction
There are things happening in healthcare that we never dreamed of years ago. Medications are being produced that cure diseases that were thought to be incurable. Surgical procedures are being performed that repair anomalies that no one thought could be repaired. Anyone who has been in healthcare for any length of time has to be simply awestruck by the impact advances in technology have had on the quality of care provided to our patients. It is truly an exciting time.
At the same time, we feel burdened by the pressures put on us by such things as government regulations, insurance companies, or financial limits. These aspects of healthcare may not be so exciting.
One of the recent entrants into the healthcare arena can further enhance the quality of care we provide and also help us with some of the more burdensome aspects of our jobs. This involves defining more clearly what the “customer” wants and then consistently delivering — at a minimum —what the customer wants. In fact, the goal is to surprise and delight the customer with the care given or service provided. At the same time that this is being done, the work involved is done with a minimum of wasted effort and mistakes. Higher quality, higher customer satisfaction, less effort and fewer mistakes — these certainly warrant careful attention from those of us who work in healthcare.
The Joint Commission For Accreditation of Healthcare Organizations (JCAHO) provided a label for this recent entry: Continuous Quality Improvement (CQI). CQI is an exceptionally powerful approach to optimizing performance. By incorporating a management philosophy and implementing tools for understanding and improving the processes in the organization, levels of quality can be attained that are not attainable without CQI.
An example of the management philosophy typically required for CQI is as follows: 1
• People want to do good work.
• The person who does the job knows the most about that job.
• More can be accomplished by working collaboratively to improve the system than by working individually or by working around the system.
• People are motivated by meaningful feedback about problems to be solved, being involved in determining how to best solve problems and seeing whether the changes made had the desired effect.
• A structured approach to resolving problems using graphical techniques for feedback produces better solutions than an unstructured process (e.g., the ordinary group discussion that is used at most meetings).
• A cooperative, collaborative relationship between labor and management is significantly more effective than an adversarial relationship.
• Improving quality inevitably leads to reduced waste and re-work (i.e., doing it again because it was done incorrectly the first time) thereby increasing productivity.
In addition to a management philosophy, CQI in an organization is usually structured around a model. This provides structure to the performance improvement effort. A model that works well in healthcare was developed by Roey Kirk, a CQI consultant. Kirk’s model is attractive because it is similar to the scientific method that is familiar to many who work in healthcare. Her model is shown in Exhibit I-12.
Exhibit I-1
PERFORMANCE IMPROVEMENT ACTION PATH
Kirk’s model indicates that the CQI effort is started by clearly defining the problem to be addressed. Next, figure out what causes the problem. Third, develop a potential solution and try it out on a limited scale (i.e. conduct a pilot test). If it works in the limited test, then implement it fully. Monitor the process to make certain it improves as it should.
If the potential solution does not work in the testing phase, go back to a prior step in the model and continue to work until a solution is found that does work and continues to work. The performance improvement effort does not stop until the desired improvement in the process is clearly achieved — then, improve the process more.
There are some tools that are used to achieve optimal process improvement. These tools make it possible for the philosophy to be applied to the management of an organization and to the process improvement model.
The tools of CQI come in two categories. The first category is statistical process control (SPC). These tools will let you know if the process is consistently providing what the customer wants. This set of tools is discussed in Section One.
The other category of tools that make up CQI are used with groups of people —teams —to improve processes. A significant component of the CQI philosophy involves recognition that the people who are most knowledgeable about a process are those who are involved in the process. Moreover, given the complexity of many processes, it is not common that any one person knows all that is needed to improve the process. As such, it makes sense to bring together teams made up of people who are involved in the process and who, when considered as a group, know the entire process. The tools to be used with teams, the process improvement tools, are discussed in Section Two.
There are several “things” related to CQI that can be used to further enhance process improvement. These are discussed in the third section and include finding and eliminating wasted effort, ways to minimize the frequency of process failures and the impact of failures that
occur, other models that can be used in CQI, cost of quality, and tools for managing process improvement projects.
It is important to emphasize that the goal of CQI is to consistently provide, at a minimum, what the customer wants and to do so without the cost of waste and re-work. The organization that is successful is consistently meeting or exceeding customer desires. Those that don’t will go away (for more on this, see Quality Wars).3
141
EXERCISES
Chapter 1
1. Discuss the concept of quality. How has “quality,” as defined by the customer, changed over time.
2. How good is quality in healthcare? How do you know?
3. The definition of quality used here is, “consistently meets, and where possible,
exceeds customers’ expectations,” What are the implications of this definition for healthcare?
References:
1. GOAL/QPC (1988). A Pocket Guide of Tools For Continuous Improvement (pp. 45). Methuen, MA: GOAL/QPC.
2. Kirk, R. (1994). Quality Management and leadership skills. Training program presented at Saint Francis Medical Center, Grand Island, NE.
3. Main, J. (1994). Quality Wars. New York: Macmillan.
Section 1
SPC Tools:
Determining How Well the Process is Functioning
Continuous Quality Improvement (CQI) requires that we understand that all work gets done in processes; therefore, there is no work being done in healthcare that is not part of a process. As a consequence, if we are to improve the quality of our work, we must understand our processes.
The section begins with a brief overview of what a process is and some terminology needed to describe work done in a process. It also provides tools for describing a process – flowcharts. These tools are diagnostic in that they can clearly show where the process is flawed, unnecessarily complex, has improper work assignments, etc.
Measurement is discussed next. Processes are mute. The only “sounds” you’ll hear from a process are complaints from customers or comments made by those involved in working within the process. Unfortunately, it is well known that many customers just walk away without a sound. As such, a process could be seriously flawed without anyone being aware of it at all. In order to understand what is happening within a process, you have to give it a way to communicate. It has to have a voice. Measurement is the way to “communicate” directly with the process.
Once you give the process a voice, you need to have a way to make sense of what the process is telling you. There are two approaches. One is to take a snapshot of the data. You do this by developing a histogram. This will show you the distribution, or shape, of the data and how the data fits relative to the process specifications; i.e., performance expectations of the process. At a glance, the process will tell you if it can do what is expected of it. Histograms are only a snapshot. They allow you to look at the process at a single point in time. A second and more powerful tool available for understanding a process is to use a control chart. The processes we will be the most interested in are not one-shot events. Rather, we are interested in those that happen again and again. The power of a control chart is that it provides a way for the process to tell you how it is changing over time.
There is a catch. No process yields absolutely consistent results every time. Even the output of processes that are working as they should will vary. This is expected. This is referred to as “natural” or “common cause” variation.
However, there are times when something is happening to the process that changes it more than you would expect. When this happens, there is “assignable cause” or “special cause” variation indicating the process is not working as it should. A control chart is the device you use to separate natural variation (noise) that happens in a process that is working as it should be working from assignable cause variation (signal) that shows that something is wrong – the process is becoming ill.
Because control charts are so powerful, they will permit you to hear the process telling you that something is wrong very early in the illness. If you wait until you begin to hear customer complaints, the process already may be severely ill. Therefore, waiting to hear complaints before acting to correct the process will likely only serve to make the correction more complex, difficult and time consuming. Control charts can tell you that action is needed before you start hearing complaints; they encourage proactive management.
Can the process perform as expected? That is, is it operating within specifications? If so, the process is capable. However, it is important that you not look at the capability of a process if the process has assignable cause variation. If the process has such variation, it is not stable, it is out of control. As such, it is simply not predictable; anything can happen. It can’t consistently meet expectations. Therefore, before looking at capability, the process must be in control.
To do a capability study, someone has to decide what is acceptable performance. That is, you need to set the specifications. There is no single way to do this. You may, for example, contact other hospitals, look at relevant databases, or check into government standards. Somehow, based on research or experience, you need to decide what the top end of your specifications are, or “upper specification limit” (USL), the bottom end of your specifications, or the “lower specification limit” (LSL), and your “target, or nominal specification.”
Using specifications and a histogram, you will be able to establish how the process is performing at a single point in time. Using these specifications and a control chart, you will be able to see how the process is performing over a period of time.
Your goal for the process is for it to be in control and capable over time. That is, it should consistently deliver what the customer wants. But is that good enough? Is consistently performing as expected the ultimate goal? Should we adhere to the old adage “If it ain’t broke, don’t fix it?” The answer comes from the management philosophy of CQI: continuously strive to improve.
Processes that are not performing consistently (we say they are “not in control”) need to be improved to remove whatever is producing the assignable cause variation. Processes that are not capable need to be improved so they can meet expectations. Processes that are both in control and capable need to be improved so that they can yield even higher quality. In short, good enough just might not be good enough. And, “if it ain’t broke, don’t fix it” is an adage that is no longer relevant. The new adage is “If it ain’t broke, improve it.” Therefore, to accomplish the first step in the Kirk model, select processes that are not in control, not capable, or that are targeted for further improvement in the organization’s strategic plan for quality.
Chapter 2 Understanding the Process
What is a process?
The concept of a process is based on the notion that each of us receives input and we change that input in a manner that will meet the needs of someone or something. That is, a supplier, or vendor, provides us with inputs. We act on those inputs and provide outputs to a customer. In diagram format, the notion of a process looks like this: