2011 Jones and Bartlett Publishers LLC

The Meaning of Life – Processes Rule Donald E. Lighter, MD, MBA © 2011

Health Care as Processes • All of health care consists of linked processes – Clinical care – Administrative processes – Pharmaceutical production and distribution – Hospital services – DME, home health • Process analysis and improvement tools are key to quality improvement © 2011 Jones and Bartlett Publishers, LLC

Process Analysis Tools • Flowcharts • Relationship Diagrams • Matrices © 2011 Jones and

Flowcharts • Relates inputs to outputs through process steps • Several types – depending on needs – Basic flowchart – PERT Diagram – Cost of Quality Analysis – Critical to Quality Analysis – Deployment Flowchart – Requirements and Measurements Tree – Top-Down Flowchart © 2011 Jones and Bartlett Publishers, LLC

Basic Flowchart • Provides method of outlining steps in process • Use of standard terminology and diagrams (Figure 3. 2) • Most frequently used type of flowchart • Procedure 1. Outline steps in process 2. Order the steps 3. Separate steps into operations and procedures – Operations = performed on input – Procedures = steps in process 4. Determine decision points 5. Connect the shapes © 2011 Jones and Bartlett Publishers, LLC

PERT Chart • Critical Path Method – US Navy for Polaris sub project • Defines critical path and resource allocation • Identifies slack resources and time constraints • Procedure 1. Create flowchart 2. Determine duration of each step, start, end times 3. Create PERT statistics 4. Complete boxes in PERT diagram 5. Calculate total time for process 6. Evaluate possible QI interventions, e. g. to reduce slack or duration © 2011 Jones and Bartlett Publishers, LLC

Deployment of Flowchart • Process evaluation of flowchart and assignment of responsibilities • Helps team take ownership of process • Defines roles in achieving quality • Procedure • Flowchart or brainstorm process • List all individuals involved in the process • Link individual(s) to each step in process • Determine steps with multiple individuals responsible • Have individuals flowchart details of their section of process, look for conflicts © 2011 Jones and Bartlett Publishers, LLC

Matrices • Various configurations, depending on number of related variables • Defined by shape – – L-shaped T-shaped Y-shaped X-shaped • Defined by type of relationship – – – Decision Performance-Importance Is-Is Not Plan-Results Requirements Effective-Achievable © 2011 Jones and Bartlett Publishers, LLC

L-Shaped Matrix Most common • • Relates two variables – Examples = monthly office visits; annual revenues; visits by provider • Example January February March April May June Total Pediatrics 563 872 743 498 459 401 3, 536 Family Practice 493 784 792 509 632 384 3, 894 Internal Medicine 287 345 408 392 410 273 2, 115 OB 308 297 310 283 312 294 1, 804 GYN 194 234 219 229 175 215 1, 266 © 2011 Jones and Bartlett Publishers, LLC

T-shaped matrix • Compares two variables with a third variable • Allows combination of two L-shaped matrices for more clarity and more information • Creates rapid comparison of variables • Example Total Revenues $328, 149 $478, 354 $264, 842 $298, 674 $342, 139 Total Expenses $287, 138 $294, 189 $163, 247 $112, 190 $116, 329 Clinic Pediatrics Family Practice Internal Medicine Obstetrics Gynecology 3, 536 3, 894 2, 115 1, 804 1, 266 589 649 353 300 211 Total Visits Average Visits/mo © 2011 Jones and Bartlett Publishers, LLC

Decision Matrix • Application – Selection of best choice from group of options – Narrowing a list of problems or solutions to critical choices – Optimization of long lists • Uses numbering system to rank choices – Team is polled to rank importance of a choice • May be a problem or a solution – Numbering system is consistent between choices to allow comparisons – Scores may be weighted by importance © 2011 Jones and Bartlett Publishers, LLC

Medical Risk Legal Risk Choice score 5 4 Pre-registration Registration Pre-service Relatively high risk if serious condition not treated 3 Risk attenuated due to contact with staff 2 Triage period, risk assessed precisely If problem not treated, risk of suit high 3 Non-medical staff making assessments legal risk high 3 Risk of medical personnel making error 1 1 Service Risk assessed and treated 1 1 Post-service Patient may not follow-up with treatment Institution liable for lack of followup 2 Risk of medical staff making error Effect on Other Departments 3 Staff usually adequate, little effect on other departments 1 Staff training could put load on HR department Ability to Change Rate of Change Score 2 1 Qualified staff easy to find 1 Qualified staff must be trained in procedures 2 2 Nursing staff shortage; could hurt other units Difficult to find staff quickly and train for ER 3 3 ER Medical staff well established 1 Other areas would be in charge of contacts Improving facilities easy, staff increases relatively easy 2 Qualified staff can be found quickly or transferred 2 Slow due to shortage of nurses 34 34 3 27 Slow due to staff resistance 3 3 25 Very hard due to extra work effort in other areas Slow due to need to increase capacity in other areas 3 36 Staff well established, change difficult 3 © 20112 Jones and Bartlett Publishers, LLC 3

X-shaped matrix • Relates four variables in groups of one variable related to two others • Example - X Product 1 X X Product 2 X X Product 3 X X Product 4 X X Product 5 Indemnity PPO POS HMO Lab Package 1 Lab Package 2 Lab Package 3 Lab Package 4 X X MD Net 1 X X X MD Net 2 X X X MD Net 3 X X X MD Net 4 X X X X MD Net 5 X X © 2011 Jones and Bartlett Publishers, LLC

Performance-Importance • Defines a group of matrices that relate two variables • Can relate any two variables – these are the most common • Relates customer perceptions of importance of organization’s goods and services to the customer’s perceptions of organizational performance © 2011 Jones and Bartlett Publishers, LLC

Example P-I Matrix Questions: Significance of A? Significance of B? Significance of C? ©

Another P-I Example Questions: Significance of A? Significance of B? Significance of C? ©

Plan-Results Matrix • Compares plans to results • Used to evaluate the success of

Y-shaped matrix • Similar to T-matrix, but allows comparison of each group to the

Specialized Flowcharts © 2011 Jones and Bartlett Publishers, LLC

Relationship Diagrams • • Relations Diagram Tree Diagram Ishikawa Diagram (Fishbone) Workflow Diagram ©

• Relationship Diagrams Characteristics – Indicates cause and effect relationships – Allows identification of inputs and outputs – Can be produced in matrix format • Procedure – List all concepts and issues; combine some if necessary – Link concepts and issues using arrows indicating cause and effect • Practical considerations – If list is too long, diagram becomes impracticable – May need to reduce scope of process or combine issues and concepts © 2011 Jones and Bartlett Publishers, LLC

An Alternative View – Relationship Matrix New Software Install Servers Install Workstations Financial impact X X X Build support capability X Security X X X Easy access to workstations X Offsite access to system X X Train staff X X X Train physicians X X © 2011 Jones and Bartlett Publishers, LLC

Tree Diagram • Characteristics – Used to move from general concepts to specific actions – Useful when many potential paths exist • Procedure – Define goal – Determine steps to achieve goal – Dissect pathways (steps) into branches to complete the tree – Re-evaluate the tree to ensure that all tasks have been accounted for – Create implementation plan © 2011 Jones and Bartlett Publishers, LLC

Implement medical management Decrease cost of care Implement quality management QI presentation to payers Negotiate increased rates with payers Contracting strategic plan Design training program Install UM decision support system Evaluate software market Provider advisory teams Install QI information system System implementation plan Train QM Staff Improve marginmanaged care business Marketing survey Gain provider support Increase rate per contract Marketing proposal Train UM staff Increase capitation revenue Market direct to consumers Demonstrate quality to payers Increase number of contracts Merger/Acquisition decision tree Improve image of clinic (marketing) Tree Diagram Merge or acquire Design training program © 2011 Jones and Bartlett Publishers, LLC Create proposal and Implementation plan

Tree Diagrams - Applications • Determining list and usefulness of different approaches to solving a problem – Complexity of tree – Size of tree • Root cause analysis (Root Cause or Why Diagram) • Creating path for decision making © 2011 Jones and Bartlett Publishers, LLC

Scheduling system allows overbooking Scheduled too close together Why-Why Diagram Procedure times not well defined New staff not aware of spacing needs Available time inadequate for volume Complexity not well identified Procedures take too long Clinical consultations not done prior to procedure Room 3 has old machine Transporters scheduled at wrong times Patients Wait Too Long in Radiology Transport not uniform Too long between transfers Equipment inadequate for complex cases Nurses notified late Patients not released on time from floor Transport not available on time Equipment not adequate in Room 3 Re-takes on xrays too frequent © 2011 Jones and Bartlett Publishers, LLC New technicians

Critical to Quality Analysis • Method of studying inputs and outputs of a process, especially for troubleshooting • Useful in creating Clinical Practice Guidelines by identifying potential medical review criteria • Procedure 1. Flowchart process 2. Ask “Who, what, when, where, how” of inputs 3. Record answers on flowchart 4. For each input, list needs, e. g. correct input, on time delivery, etc. 5. For each output, list customer needs and whether the output meets needs © 2011 Jones and Bartlett Publishers, LLC

Critical to Quality Analysis • Critical to Quality Steps – Steps where input determines the next step in the process – Measurements can determine if inputs or outputs are meeting needs – Quality of the output can be hurt or helped – Steps where extra effort can improve quality • Trouble answering questions? – Flowchart may not be sufficiently detailed • Customer feedback may help © 2011 Jones and Bartlett Publishers, LLC

Critical Input Critical to Quality Analysis Critical Output © 2011 Jones and Bartlett Publishers,

Workflow Diagram • Characteristics – Diagram of flow of resources using a floor plan or process diagram – Used to examine traffic flow • Procedure – Determine process element moving within the system – Determine the realm or section of the process in which movement occurs – Diagram realm – Determine movement pattern and place on diagram – Evaluate for improvement © 2011 Jones and Bartlett Publishers, LLC

Root Cause Analysis Finding the underlying cause © 2011 Jones and Bartlett Publishers, LLC

What is RCA? • The ultimate detective work – finding the cause of an “error” • Structured method of finding an underlying problem or series of problems • Occurs after an error has occurred • Principles: – Directing improvement efforts at the underlying causes of a process problem is more effective than simply trying to correct the erroneous process output. – Effective RCA is methodical and reproducible. Following a set procedure for RCA produces the best results. – Typically, defects and errors have more than one underlying cause, i. e. a defective process rarely has just one problematic process step. – For the analysis and resulting interventions to be effective, the RCA must establish all root causes so that effective improvement initiatives may be generated. © 2011 Jones and Bartlett Publishers, LLC

RCA Procedure • Define the problem using RCA tools and by gathering and analyzing process data. • Use the “ 5 Whys” to identify causal relationships associated with the defined problem(s). • Brainstorm which causes can be removed to prevent recurrence. • Design solutions and associated measures to remedy the underlying causes. © 2011 Jones and Bartlett Publishers, LLC

• Pilot test these solutions and measures to evaluate the effects may help determine the priority for implementing each solution. Use the SMART criteria: – Simple – easy to design and put into service. – Measurable – capable of being measured to determine effectiveness – Attainable – achievable by the team and resources available. – Relevant – directed at the specific problem identified by the team. – Timely – achievable within the allotted timeframe. © 2011 Jones and Bartlett Publishers, LLC

RCA Procedure (cont. ) • Determine the sequence of implementation of the solutions, including the time for each improvement step to be applied. – Stage repairs to minimize costs – Implement stepwise to understand the effect of each solution – Serious errors may need rapid implementation of solutions • Measure the effects of the changes to ensure that the changes have produced the expected results. © 2011 Jones and Bartlett Publishers, LLC

The 5 Whys • Question-asking method used to ascertain the cause/effect relationships underlying a particular problem. • Based on the assumption that asking “why” up to five times usually gets to the root cause of a problem • Try it with a problem like “my car won’t run” © 2011 Jones and Bartlett Publishers, LLC

Pareto analysis • Narrow an extensive list of possibilities to those that have the greatest effect on the desired variable based on the Pareto principle (80 -20 rule – 80% of problems come from 20% of causes) • Procedure – Each underlying cause is assigned an estimate of its effects on the final outcome – Estimates are graphed in sequence until 80% of the effect is determined © 2011 Jones and Bartlett Publishers, LLC

Pareto Chart Example 2. 1 © 2011 Jones and Bartlett Publishers, LLC

Ishikawa Diagram • Root Cause Analysis – Cause and effect relationships – Many causes are related – Ishikawa allows aggregation of causes – Relationships are grouped in fishbone configuration • Procedure – Define problem – Have team work on list of root causes – Group causes – Create branching diagram – Continue analysis until all branches have been defined • Note – can be done in Visio © 2011 Jones and Bartlett Publishers, LLC

Fault tree analysis • Failure analysis using Boolean (ifthen-else) logic to determine the probability of a safety hazard • FTA diagrams are commonly used to illustrate events that might lead to a failure © 2011 Jones and Bartlett Publishers, LLC

• Targeted for prevention • Often applied during analysis phase of 6 s DMAIC • Analysis begins by defining top event (or failure), then using event and gate shapes to illustrate the process that might lead to the failure © 2011 Jones and Bartlett Publishers, LLC

Barrier analysis • Used to prevent harm to vulnerable or valuable objects (e. g. patients, staff, organizational reputation, or the wider community) • For RCA, the approach determines what barriers or controls should have been in place to prevent the incident, or that could be installed to increase system safety • Four types of barriers: – Physical – examples include bar coding for medications, keypad controlled doors for computer security, automated drug dispensing units. – Natural –barriers of distance, time, or location, e. g. spacing drug doses apart by several hours to prevent an adverse interaction, or surgical time out to ensure that all patient information is correct. – Human action – e. g. nurse checking the temperature of the water used to bathe a newborn in the nursery, physician using a checklist – Administrative – protocols and procedures for hospital processes, supervision requirements for new nurses, The Joint Commission’s Ongoing Professional Practice Evaluation (OPPE) program. © 2011 Jones and Bartlett Publishers, LLC

Change analysis • Compares an error free instance of a process with the situation in which the process created an error • Example: – RCA team might compare the process used during a surgical procedure that created an error with the process used for the same procedure at a different time that did not produce the error – Differences in the two situations can help identify the changes in the process that led to the nonconforming outcome © 2011 Jones and Bartlett Publishers, LLC

Automated methods • Example: Tap. Root® software • www. taproot. com © 2011 Jones

Is-Is Not (Kepner-Tregoe) • Associates reality with desire for problems in a process • Relates to four W’s and an H • Procedure – Characterize the problem in understandable terms – Formulate entries in matrix using idea generating techniques – Patterns usually emerge as matrix is completed © 2011 Jones and Bartlett Publishers, LLC

Is-Is Not Matrix Example IS - what actually happens now IS NOT - what should happen, but doesn't Variations - what seems unusual about the situation Who s involved in the i process or problem? What inputs or outputs are involved in the problem or process? When oes the problem d occur? In what portion of the process? Where does the problem occur? In what part of the organization or what location? How important is the problem to the process? How extensive is the problem? © 2011 Jones and Bartlett Publishers, LLC

Failure Mode and Effects Analysis “RCA in reverse” © 2011 Jones and Bartlett Publishers,

Widely used in health care • Preventive method used to investigate potential process failures prospectively • Also known as FMECA – Failure Mode and Effects Criticality Analysis • Veteran’s Health Administration was pioneer in applying FMECA in health care • Joint Commission began requiring use of FMEA as an accreditation standard (LD 3. 20) in 2002, caused wide adoption of the approach © 2011 Jones and Bartlett Publishers, LLC

FMECA - procedure • Choose a target process – Example: process associated with high risk of patient harm – Executive team input important – Tools - four quadrant importance/performance matrix that relates risk (importance) to performance metrics • Assemble Team – multidisciplinary teams, since failure modes often cross functional areas. Subject matter experts are often helpful, as is a senior executive who can ensure that the FMEA procedure has necessary resources. • Flowchart the process © 2011 Jones and Bartlett Publishers, LLC

FMECA – procedure (cont. ) • Perform a hazard analysis – Identify and number failure modes – Determine the cause and effect of each failure mode and record in a matrix – Score each failure mode on three factors using a 10 point scale: the likelihood of the failure mode, the likelihood that the failure mode will be detected by the process owners, and the severity of the effect – Calculate Risk Priority Number (RPN) from these three numbers - the higher the RPN, the greater the risk (equation in book) – Rank RPNs to determine priorities • Determine action steps and measures – Business case analysis © 2011 Jones and Bartlett Publishers, LLC