CHAPTER
229
USING IMPROVEMENT TEAMS AND TOOLS
Learning Objectives
After completing this chapter, you should be able to
• identify strategies for creating improvement project teams; • describe the role of managers in team decision making; • differentiate how, when, and why to use common improvement tools;
and• recognize what tools are best to use at each step of an improvement
project.
T he nursing shared leadership committee in a midsize hospital came up with a great idea for improving the work environment for bedside nurses, who spend time in face-to-face group meetings that take them
away from patient care duties. The committee proposed using electronic message boards to reduce the need for these meetings. The nurses could use this medium to complete some group work during their downtime rather than depart from units to attend formal meetings. This change would potentially help nurses be more productive at the bedside and improve the way they get their work done. The electronic message boards could also be used to update everyone on the work of various committees and share evidence-based practice recommendations.
The information technology department set up electronic message boards for each unit, and nurses were instructed on how to use the medium and its purpose. However, what seemed like a great idea did not catch on with the bedside nurses. Simply making this new communication tool available was not enough to get people to start accessing the board to interact with one another. The value of using the message boards for communication was unclear to people at the grassroots level, and face-to-face meetings had been their usual way of interacting for years. The committee chairs, charge nurses, and clinical leaders were not made responsible for regularly posting content on the message boards. The staff nurses quickly stopped logging into the message boards when they found very little to read.
12
Spath, Patrice, and Diane L. Kelly. Applying Quality Management in Healthcare : A Systems Approach, Fourth Edition, Health Administration Press, 2017. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/franklin-ebooks/detail.action?docID=5517324.Created from franklin-ebooks on 2023-02-08 00:23:25.
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Applying Qual i ty Management in Healthcare: A Systems Approach230
This change effort failed for several reasons. First, and most important, it was initiated with a top-down approach. The electronic message boards may have been a great idea; however, the frontline nurses were not engaged in the improvement project. The idea was pushed down from the upper levels of the nursing department, and the message boards were designed without any input from staff. Whether the frontline staff considered improved productivity and enhanced communication to be important goals was never fully explored before implementation.
Often, improvement projects result in people being asked to change the way they have always done things—thus, a bottom-up, team approach is more likely to be successful. This chapter describes how managers can reduce the likelihood of unsuccessful improvement projects. The first step is to charter the project, which involves clearly defining the project goals and scope. Next, the members of the improvement project team need to be carefully chosen. This chapter also discusses the various improvement tools that will be used by the team to understand the current process and select the best interventions for achieving the performance improvement goals.
Charter Improvement Projects
Before embarking on an improvement project, the manager or managers in the departments or units affected by an improvement project should establish clarity about the project scope (areas affected) and purpose (desired outcome). The more issues clarified up front, the less likely the team will be to experience false starts. A written project charter is essentially a contract between the organization’s management and the improvement team.
The project leader and the sponsoring manager(s) may jointly create the chapter, or it may be created at the first team meeting. Issues that should be addressed in creating the project charter include these (Rohe and Spath 2005):
• Purpose: In one or two sentences, describe the purpose of the project. The brief explanations should define, in specific terms, what the project is expected to achieve.
• Objectives: List some of the measurable outcomes of the project. The objectives should answer the questions, “How will we achieve our purpose?” and “What are the signs of success?”
• Deliverables: What are the tangible milestones anticipated along the way? What are the progress points that can be expected? When defining deliverables, include dates—they add commitment and urgency to the project completion.
Spath, Patrice, and Diane L. Kelly. Applying Quality Management in Healthcare : A Systems Approach, Fourth Edition, Health Administration Press, 2017. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/franklin-ebooks/detail.action?docID=5517324.Created from franklin-ebooks on 2023-02-08 00:23:25.
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Chapter 12: Using Improvement Teams and Tools 231
• Team and team resources: Identify the people and resources needed to analyze, create, and carry out the purpose.
• Success factors: These are the essential elements outside the team needed to make the project successful, such as buy-in from the staff or financial resources.
A typical charter consists of a one-page summary of critical details of the project, allowing all stakeholders to agree on the goals to be achieved, the scope, the time line, and the resources needed for the project to be successful. Exhibit 12.1 illustrates a project charter template.
Project Title
Purpose
What are we trying to achieve?
Objectives
What are we trying to achieve? How will we know we got there?
The new/redesigned process will (be specific):
• • •
Deliverables
What must be done to achieve the objectives?
The team is expected to complete the following:
By __/__:
By __/__: By __/__:
By __/__:
Team and Resources Core project team members:Leader:Other members:
People who have knowledge or skills that will be helpful for completing the project:
Success Factors
What leadership and resources are needed to make this improvement a success?
• • • •
Source: Adapted from Rohe and Spath (2005). Used with permission.
EXHIBIT 12.1Improvement Project Charter Template
Spath, Patrice, and Diane L. Kelly. Applying Quality Management in Healthcare : A Systems Approach, Fourth Edition, Health Administration Press, 2017. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/franklin-ebooks/detail.action?docID=5517324.Created from franklin-ebooks on 2023-02-08 00:23:25.
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Applying Qual i ty Management in Healthcare: A Systems Approach232
Once the initial project charter is drafted, its completeness can be evaluated using the following criteria:
• It specifies, in detail, the performance problem to be addressed.• It contains measurable objectives that include target goals to be
achieved.• It sets realistic deadlines and expectations.• It contains defined time lines for completion of the project.• It is relevant to the organization’s strategic quality goals.
If revisions are needed in the charter, the team should make them before the start of the project. Otherwise, the lack of clarity can eventually derail the improvement effort.
Performance Improvement Teams
Improvement methodologies such as Plan, Do, Check, Act and Six Sigma serve as critical thinking frameworks for managers studying any problems that may arise. Project teams also use these methodologies as they work to improve performance in a particular functional area. Regardless of the model used for an improvement project, assembling a team of people personally knowledgeable about the process to be improved is essential. Composition of the team (the number and identity of the members) and meeting frequency and duration are guided by the process purpose and scope. The questions that influence makeup of the team should include the following:
• What knowledge is required to understand the process and design the actual improvement intervention(s)?
• How should the team be designed to support the processes needed to accomplish implementation within the project constraints?
The number of team members needed to successfully achieve the project objective will vary. Managers need to take into account the number of staff members that can be taken away from their usual work without adversely affecting services. The optimal size of a team is between five and eight individuals. However, the size of the team is not as important as the diversity of its members. The team should include people who have different roles and perspectives on the process to be improved (Agency for Healthcare Research and Quality 2013). Individual contributions during a meeting tend to diminish as the size of the group grows beyond six members.
Spath, Patrice, and Diane L. Kelly. Applying Quality Management in Healthcare : A Systems Approach, Fourth Edition, Health Administration Press, 2017. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/franklin-ebooks/detail.action?docID=5517324.Created from franklin-ebooks on 2023-02-08 00:23:25.
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Chapter 12: Using Improvement Teams and Tools 233
Just as managers use human resources practices that promote matching an employee’s traits with the requirements of the job, managers may also match employees with the various roles and stages required in a change or improvement process. Problems in group processes tend to arise from a mismatch between a project stage and an individual rather than from problems inherent in the individuals themselves. Intentionally engaging individuals at the appropriate time, as well as offering support or requesting patience during other times, can enhance the effectiveness of both the team and the manager.
For instance, a team member favoring concrete thinking may get frustrated with creating a vision, though he will be essential in determining the logistics of implementing process changes. Someone with well-developed interpersonal or relational skills can be on the alert for any staff morale issues related to the changes. An employee who is good at seeing the big picture will be invaluable in identifying unintended consequences. A team member who is detail oriented can be an ideal choice for monitoring progress and ensuring follow-through; another member who is action oriented can make sure the project moves along on schedule.
Meeting Schedules and FrequencyTypically, team meetings are held weekly, biweekly, or monthly, and they generally last one to two hours. Some of the challenges associated with this approach in health services organizations include the time-consuming patient care duties required of clinical providers, the late arrival of team members because of other competing responsibilities, the need to devote portions of the meeting to updating team members, and dwindling interest as the project drags on.
Consider an alternative approach. If managers use a systematic method for approaching improvements, they will begin to get a sense for the total team time required for an improvement effort. For example, a team may take about 40 hours to complete the various phases of an improvement project. If the improvement effort is constrained by time or dollars, the team is faced with increasing its own productivity or reducing its own cycle time. With this limitation in mind, the 40 hours of time may be distributed in a variety of ways other than in one-to-two-hour segments. For example, ten four-hour meetings or five eight-hour meetings may better meet the needs of a particular project team. The meetings may occur once a week for ten weeks, twice a week for five weeks, or every day for one week. Based on the work environment, a strategy may be selected that balances project team productivity, daily operational capacity and requirements, the scope of the desired improvement, and project deadlines.
A concentrated team meeting schedule has several advantages:
Spath, Patrice, and Diane L. Kelly. Applying Quality Management in Healthcare : A Systems Approach, Fourth Edition, Health Administration Press, 2017. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/franklin-ebooks/detail.action?docID=5517324.Created from franklin-ebooks on 2023-02-08 00:23:25.
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Applying Qual i ty Management in Healthcare: A Systems Approach234
• It demonstrates the organization’s or management’s commitment to change.
• It saves duplication and repeated work associated with bringing everyone up to speed at each meeting.
• It establishes traction by contributing to the elements of creative tension.
• It reduces the cycle time from concept to implementation.• It forces managers and teams out of the “firefighting” mentality into
one of purposely fixing not just the symptoms of problems but also the underlying problems themselves.
Decision MakingConsensus is a commonly employed approach to decision making in which the team seeks to find a proposal acceptable enough that all members can support it (Scholtes, Joiner, and Streibel 2003). Seeking consensus may, however, reduce decisions to the lowest common denominator (Lencioni 2002). In a team comprising primarily concrete, practical, linearly thinking members, how likely is it that an idea posed by the one creative, conceptual team member will gain enough acceptance to be considered a possible solution to a problem? Conversely, on a team of creative, conceptual innovators who are quickly moving forward on an idea without regard for the practical considerations of implementation, how likely will it be that they embrace the input from the one concrete, practical, linearly thinking team member? In either case, the result will be less than optimal. The best result (i.e., improvement intervention) in these two circumstances may come from listening to the “outlier”; perhaps that team member’s perspective best matches the requirements of the decision at hand.
Using decision criteria is an alternative to consensus. For example, in one improvement effort, the criteria for pursuing an improvement idea include the following (Kelly 1998):
• Does it fit within the goal of the effort?• Does it meet customer requirements?• Does it meet regulatory or accreditation requirements?• Does it remain consistent with the department’s or organization’s
purpose?• Does it support the vision?• Does it demonstrate consistency with quality principles?
In this case, team members are expected to question and challenge each improvement idea. Those that meet the criteria are further evaluated by the team. All team members may not completely understand an idea the first time
Spath, Patrice, and Diane L. Kelly. Applying Quality Management in Healthcare : A Systems Approach, Fourth Edition, Health Administration Press, 2017. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/franklin-ebooks/detail.action?docID=5517324.Created from franklin-ebooks on 2023-02-08 00:23:25.
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Chapter 12: Using Improvement Teams and Tools 235
it is discussed, but the team can save time by quickly discarding ideas that do not meet criteria. Instead, they can then spend time on understanding and evaluating ideas that do meet criteria.
Managers can help support team decision making by staying informed about the progress of improvement projects. They can best keep up with events through periodic meetings with the team leaders. Unexpected “drop ins” by team managers in search of project updates can be disruptive to the team process. Some types of questions a project team leader would find helpful to discuss face-to-face with the manager or managers affected by the improvement project are listed in exhibit 12.2. These questions are especially useful during the action-planning stage of a project, when they can provide the team leader with a better understanding of leadership support, communication needs, and direction.
Improvement Tools and Techniques
In most improvement projects, regardless of the methodology followed, similar process improvement tools and techniques are used for understanding the performance problem and how to correct it. Appendix 12.1 provides descriptions of many frequently used tools and techniques. Some items in the list are described in greater detail in this chapter or covered in chapter 10.
• Does the manager have any preset expectations about what needs to be done to improve performance? Is the manager open to accepting the team’s recommendations, or does she have alternatives?
• Are the desired time frames for completing the improvement interventions realistic? Can the manager support these time frames?
• What resources (dollars, time, etc.) can be spent on the improvement interventions? What are the resource limitations?
• Is the manager willing to tolerate possible dips in productivity or service while the process changes are being implemented?
• Will the manager help prepare people to minimize disruptions during the implementation of improvement plans?
• What will make the manager anxious during the intervention design and implementation phase? How soon does he expect to see positive changes?
• If an individual or group resists making the needed changes, will the manager be willing to initiate appropriate pressure to correct the problem?
• Will the manager help dismantle the “old way” of doing things by holding fast to and reinforcing the redesigned way until it has had time to prove its effectiveness?
EXHIBIT 12.2Project Team Leader and Manager Discussion Questions
Source: Adapted from Rohe and Spath (2005). Used with permission.
Spath, Patrice, and Diane L. Kelly. Applying Quality Management in Healthcare : A Systems Approach, Fourth Edition, Health Administration Press, 2017. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/franklin-ebooks/detail.action?docID=5517324.Created from franklin-ebooks on 2023-02-08 00:23:25.
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Applying Qual i ty Management in Healthcare: A Systems Approach236
Readers are encouraged to learn more about tools not explained in depth here by using the resources found at the end of this chapter.
Document the ProcessSome of the most valuable improvement tools are those that help managers and teams better understand work processes. Often, a process is followed because “that’s how we’ve always done it” or because a certain way of doing things has simply evolved over time. Before a process can be improved, it must be understood. The tools described in this section help managers and teams understand processes by documenting the steps involved.
According to the American Society for Quality (ASQ), a process is “an organized group of related activities that work together to transform one or more kinds of input into outputs that are of value to the customer” (ASQ 2016a). This definition suggests the following key features of a process (ASQ 2016a; italics added):
• A process is a group of activities, not just one.• The activities that make up a process are not random or ad hoc; they are
related and organized.• All the activities in a process must work together toward a common goal.• Processes exist to create results your customers care about.
A process flowchart is a graphical representation of the steps in a process or project. Types of activities in the process are represented by variously shaped symbols. An oval indicates the start and end of the process, a rectangle indicates a process action step, and a diamond indicates a decision that must be made in the process. Depending on the decision, the process follows different paths. A simple process flowchart is illustrated in exhibit 12.3. Clinical providers may already be familiar with this tool, as many clinical algorithms and guidelines are communicated using process flowcharts. Professionals from other specialties, such as laboratory, radiology, and information systems, may also be familiar with this tool, as more complex versions of a process flowchart are used to document technical standard operating procedures or data and information flow.
At times, many individuals, departments, or organizations are involved in carrying out different steps of a single process. In such cases, a deployment flowchart (vertical flowchart) or “swim lanes” chart (horizontal flowchart) is used to indicate who is responsible for which steps of the process. Efforts to improve coordination of process steps may be enhanced by identifying, documenting, and understanding the essential handoffs that occur in a process.
process“an organized group of related activities that work together to transform one or more kinds of input into outputs that are of value to the customer” (ASQ 2016a)
process flowchartgraphical representation of the steps in a process or project
deployment flowchartprocess flowchart diagram that indicates who is responsible for which steps of the process
Spath, Patrice, and Diane L. Kelly. Applying Quality Management in Healthcare : A Systems Approach, Fourth Edition, Health Administration Press, 2017. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/franklin-ebooks/detail.action?docID=5517324.Created from franklin-ebooks on 2023-02-08 00:23:25.
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Chapter 12: Using Improvement Teams and Tools 237
Exhibit 12.4 shows simple deployment flowcharts illustrating coordination between an orthodontist and an oral surgeon in providing care for a teenage patient.
Using a flowchart to document a process allows managers and teams to see a picture of the process. Often, just seeing a picture leads to obvious ideas for improvement. Additional benefits include the opportunity to distinguish the distinct steps involved; identify unnecessary steps; understand vulnerabilities where breakdowns, mistakes, or delays are likely to occur; detect rework loops that contribute to inefficiency and quality waste; and define who carries out which step and when. The process of discussing, reviewing, and documenting a process using a flowchart provides the opportunity for clarifying operating assumptions, identifying variation in practice, and establishing agreement on how work should be done.
Uncover Improvement OpportunitiesA cause-and-effect diagram is a tool for organizing and documenting, in a structured format, the causes of a problem (Scholtes, Joiner, and Streibel 2003). The diagram may capture actual (observed) causes and possible (from brainstorming) causes. Kaoru Ishikawa, a Japanese quality management specialist, originally created this tool for use in product design and defect prevention.
cause-and-effect diagram (or fishbone or Ishikawa diagram)tool for organizing and documenting, in a structured format, the causes of a problem
Time to get up
Alarm goes off
Tootired?
Wake up
Get out of bed
Start andend ofprocess
Action step
Decision step
Hit snooze button
No
Yes
Connects process steps
EXHIBIT 12.3Simple Process Flowchart
Spath, Patrice, and Diane L. Kelly. Applying Quality Management in Healthcare : A Systems Approach, Fourth Edition, Health Administration Press, 2017. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/franklin-ebooks/detail.action?docID=5517324.Created from franklin-ebooks on 2023-02-08 00:23:25.
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Applying Qual i ty Management in Healthcare: A Systems Approach238
Because this diagram resembles a fish (the head represents the problem and the bones represent the causes), it is also referred to as a fishbone diagram (see exhibit 12.5). The problem is written on the far right of the diagram. Categories of causes are represented by the diagonal lines (bones) connected to the horizontal line (spine), which leads to the problem (head). The bones of the fish may be labeled in a variety of ways to represent categories of causes, including people, plant and equipment, policies, procedures, manpower, methods, and materials. Exhibit 12.6 is an example of a fishbone diagram.
Identifyneed for
oral surgery
Orthodontist
Makereferral
Assesspatient andplan surgery
Performsurgical
procedure
Continueorthodontia
treatment
Proceduresummary toorthodontist
Orthodontist
Oral Surgeon
Identifyneed for oral
surgery
Makereferral
Continueorthodontiatreatment
Assesspatient andplan surgery
Performsurgical
procedure
Proceduresummary toorthodontist
Oral SurgeonVertical Flowchart
Horizontal Flowchart
EXHIBIT 12.4Simple
Deployment Flowcharts
EXHIBIT 12.5How the
Fishbone Diagram Got Its
Name
Spath, Patrice, and Diane L. Kelly. Applying Quality Management in Healthcare : A Systems Approach, Fourth Edition, Health Administration Press, 2017. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/franklin-ebooks/detail.action?docID=5517324.Created from franklin-ebooks on 2023-02-08 00:23:25.
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Chapter 12: Using Improvement Teams and Tools 239
In exhibit 12.6, the problem is stated at the head of the fish (low hand-hygiene compliance) and the categories of causes are labeled as policies, procedure, people, and plant/equipment. Detailed causes are identified and represented by the small bones of the fish shown in the people category.
Stating the problem is the most important step in creating the fishbone diagram. Problem statements that are too narrow, vague, or poorly constructed can limit this tool’s effectiveness in the improvement process. Users may be tempted to begin generating solutions (rather than documenting causes) in a fishbone diagram. However, users should take care to focus on cause, because identifying solutions too soon also limits the tool’s usefulness and the opportunity to further investigate the problem.
A causal loop diagram is used to display the dynamic between cause and effect from a relational standpoint. While cause-and-effect diagrams elicit the categories of causes that affect a problem, causal loops show the interrelation between causes and their effects. When finished, a causal loop diagram provides an understanding of the positive and negative reinforcements that describe the system of behavior.
Exhibit 12.7 shows a simple causal loop diagram, including a problem statement: Maintaining qualified operating room (OR) staff during the nursing shortage is getting difficult. The causal loop diagram illustrates the behaviors that affect system outcomes. The cause-to-effect relationship is determined to be reinforcing (+) or negative (−). These designations do not indicate that the relationship is good or bad. They just mean that as the cause intensifies, effects do too, and as the cause diminishes, the effect does also.
An advantage of causal loops is that they depersonalize the process. People can point at the arrows in the loop that are reinforcing the problem
causal loop diagramvisual representa-tion that displays the dynamic between cause and effect from a rela-tional standpoint
Policies Plant/Equipment
Procedures People
Statement ofProblem:Low hand-hygienecompliance
Policy is outdatedNot enough hand sanitizerdispensers in patient care areas
Sinks not conveniently located
Staff perceive theyare doing a good job alreadyInadequate resources to monitor
hand-washing technique
Too busyLack offeedback
Not a managementpriority
Lack of knowledge
Poor attendance attraining sessions
EXHIBIT 12.6Fishbone Diagram Example
Spath, Patrice, and Diane L. Kelly. Applying Quality Management in Healthcare : A Systems Approach, Fourth Edition, Health Administration Press, 2017. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/franklin-ebooks/detail.action?docID=5517324.Created from franklin-ebooks on 2023-02-08 00:23:25.
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Applying Qual i ty Management in Healthcare: A Systems Approach240
instead of pointing at people. The causal loop diagram illustrates the behaviors that affect system outcomes.
Not all identified causes influence the problem equally. Data about how important causes are or how often causes occur aid managers in prioritizing and selecting improvement interventions. A Pareto chart is a helpful tool in this process. In appearance, it is like a histogram, but with the data sorted in order of decreasing frequency of events; it also includes other annotations to highlight the Pareto principle. The Pareto chart is named after nineteenth-century economist Vilfredo Pareto and refers to the Pareto principle, which suggests “most effects come from relatively few causes; that is, 80 percent of the effects come from 20 percent of the possible causes” (ASQ 2016b).
Exhibit 12.8 is an example of a Pareto chart based on data collected about the causes in exhibit 12.6. Prior to collecting and displaying the data, a nursing manager plans an educational session (e.g., how to wash hands). However, after systematically analyzing the problem, the manager realizes that the cause is the availability of supplies. He installs more hand sanitizer dispensers and provides small bottles for staff to carry in their pockets.
Select Improvement ActionsOnce the causes of a problem are understood and opportunities for improvement are clearly identified, actions intended to resolve the problems are selected. A team may have several ideas of what actions must be taken. However, a decision matrix that “evaluates and prioritizes a list of options” (ASQ 2016c) is an improvement tool that can help the team gain consensus.
To use a decision matrix, sometimes called a prioritization matrix, the team first comes up with criteria for judging the proposed actions (e.g., easy
Pareto chartimage similar to a histogram, but with the data sorted in order of decreasing frequency of events and with other annotations to highlight the Pareto principle
Pareto principletheory that “most effects come from relatively few causes; that is, 80 percent of the effects come from 20 percent of the possible causes” (ASQ 2016b)
decision matriximprovement tool that “evaluates and prioritizes a list of options” (ASQ 2016c)
Maintaining Qualified OR StaffDuring Nursing Shortage Is
Getting Difficult
+
+
+
++
+ +
+
Overtime isincurred
Staff burn out Staff arediscontented
Staff leave
Temps getpreferential treatment
Temps take time fromstaff to train to be
productive
Bring in temporary staff
Workload is greaterthan staff can
complete
EXHIBIT 12.7Causal Loop
Diagram Example
Source: Adapted from Rohe and Spath (2005). Used with permission.
Spath, Patrice, and Diane L. Kelly. Applying Quality Management in Healthcare : A Systems Approach, Fourth Edition, Health Administration Press, 2017. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/franklin-ebooks/detail.action?docID=5517324.Created from franklin-ebooks on 2023-02-08 00:23:25.
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Chapter 12: Using Improvement Teams and Tools 241
or hard to implement, low or high cost, low or high impact). The members then judge actions against the goal of the project using these criteria and a numeric rating system. For instance, if the goal of a nursing care center’s improvement project is to reduce resident falls by 20 percent, the criteria are applied individually by team members to each action being considered. An example of a simple decision matrix for the patient fall reduction project is illustrated in exhibit 12.9. Actions receiving higher scores are considered the best to implement. The team may ultimately implement all the actions being proposed, using the decision matrix to prioritize which actions to implement first.
If the criteria are not deemed by the team to be of equal importance, various statistical methods can be used to numerically weight each criterion (Minnesota Department of Health [MDH] 2016). For instance, “ease of implementation” may have a weight of 0.50, while “impact” might have a weight of 0.80.
An issue may come up during the action planning phase of an improvement project that relates to the expected success of the intervention. Force field analysis is “a technique for evaluating all the various forces for and against a proposed change” (McLaughlin and Olson 2012, 160). This technique can help the team determine whether a planned intervention can be successfully implemented. If the team has already chosen a particular intervention, a force field analysis can help in developing strategies for overcoming barriers to success.
Shown in exhibit 12.10 is a force field analysis developed by a hospital team involved in a project aimed at improving patient-centered care. The team had decided that moving the location of shift handoffs from the nurses’ station to the patient’s bedside would allow patients to be more involved in their care. The restraining forces were found to be significant; however, the team still chose to make this change. By using a force field analysis to identify
force field analysis“a technique for evaluating all of the various forces for and against a proposed change” (McLaughlin and Olson 2012, 160)
140
120
100
80
60
40
20
0
Not enoughhand rub
Sinks notconvenient
Staffperception
Too busy Lack ofknowledge
Inadequateresources
Outdatedpolicy
Number of observations Cumulative percentage
100908070605040302010
0
No.
of O
bser
vati
ons
% of Total O
bservations.
. ..
. .
.
.
EXHIBIT 12.8Pareto Chart Example
Spath, Patrice, and Diane L. Kelly. Applying Quality Management in Healthcare : A Systems Approach, Fourth Edition, Health Administration Press, 2017. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/franklin-ebooks/detail.action?docID=5517324.Created from franklin-ebooks on 2023-02-08 00:23:25.
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Applying Qual i ty Management in Healthcare: A Systems Approach242
Project Goal: Reduce resident falls by 20 percent in one year.
Proposed ActionEase of
Implementation Cost Impact Total
Hard = 1 →Easy = 5
High = 1 → Low = 5
Low = 1 → High = 5
“Ask for Help” signs in resident rooms
5 5 1 11
Bed alarms for high fall-risk residents
3 1 4 8
Change floor wax to a slip-resistant product
5 5 3 13
Add check that mobility devices are in the residents’ reach to hourly resident rounds
5 5 3 13
EXHIBIT 12.9Decision Matrix
Example
secroF gniniartseRsecroF gnivirD
Plan:Change to
bedside shifthandover
Critical incidentson the increase
Staff knowledgeable inchange management
Increase in dischargeagainst medical advice
Complaints from patientsand doctors increasing
Care given is predominantlybiomedical in orientation
Ritualism andtradition
Fear that this maylead to more work
Fear of increasedaccountability
Problems associatedwith late arrivals
Possible disclosure ofconfidential information
EXHIBIT 12.10Force Field
Analysis Example
Source: Adapted from McLaughlin and Olson (2012). Used with permission.
Spath, Patrice, and Diane L. Kelly. Applying Quality Management in Healthcare : A Systems Approach, Fourth Edition, Health Administration Press, 2017. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/franklin-ebooks/detail.action?docID=5517324.Created from franklin-ebooks on 2023-02-08 00:23:25.
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Chapter 12: Using Improvement Teams and Tools 243
the restraining forces prior to implementation, the team could then design the action plan in a way that would minimize these forces.
Monitor Progress and Hold the GainsFollowing an improvement project, there must be a control system that allows management to measure progress toward goal attainment and identify unacceptable variances requiring action. One of the hallmarks of a good control system is that corrective action is taken as soon as it is found to be needed. Why wait until the end of the year to discover that an improvement project has not changed performance as expected? However, at the other end of the scale, should a manager check performance every week? That may make no sense, either. Monthly checking is probably about right unless the organization’s leaders or healthcare regulators want more frequent checks.
A commonly used tool to monitor performance following an improvement project is a run chart, a graphic representation of data over time. This chart is described in chapter 10 and also discussed here because of its importance in monitoring the results of improvement projects. Run charts are useful for tracking progress after an improvement intervention and monitoring the performance of ongoing operations. On a run chart, the x axis represents the time interval (e.g., day, month, quarter, year) and the y axis represents the variable or attribute of interest. Displaying data on a run chart also enables a manager to more readily detect patterns or unusual occurrences in the data. Exhibit 12.11 shows a run chart tracking patient complaints about hospital noise at night. An intervention that involved some environmental changes—action that was taken as a result of an improvement project—is indicated with the arrow.
While managers should monitor performance following individual interventions, such as creating a quieter nighttime environment for hospitalized patients, changing system behavior often requires more than one intervention. Numerous factors contribute to consistent and successful practice, as illustrated in the simple cause-and-effect diagram in exhibit 12.6. Eliminating one of these causes can increase compliance a little; however, a problem with multiple causes requires a multifaceted improvement plan. For example, the World Health Organization (WHO) endorses a combination of interventions (exhibit 12.12) to improve the hand-hygiene compliance of health services workers.
Implementing the WHO guidelines involves improving multiple processes and engaging multiple stakeholders and departments throughout an organization on a continual basis.
Exhibit 12.13 provides an example of a control chart (sometimes called a process behavior chart). This graph provides a moving picture of the variation of key performance parameters. The control chart illustrates one organization’s experience with continuous attention to and improvement of its
variable number that “take[s] on different values on a continuous scale” (Carey and Lloyd 2001, 70)
attributetally of “events that can be aggregated into discrete categories” (Carey and Lloyd 2001, 70)
Spath, Patrice, and Diane L. Kelly. Applying Quality Management in Healthcare : A Systems Approach, Fourth Edition, Health Administration Press, 2017. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/franklin-ebooks/detail.action?docID=5517324.Created from franklin-ebooks on 2023-02-08 00:23:25.
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Applying Qual i ty Management in Healthcare: A Systems Approach244
Num
ber
of C
ompl
aint
s
Month
Changes Made in Environment
Average
21
2423
19
22
18
9
J F M A M J J A S O N D
108 9
67
29
24
19
14
9
4
EXHIBIT 12.11Run Chart of
Monthly Patient Complaints
About Hospital Noise at Night
Source: McLaughlin and Olson (2012). Used with permission.
System Change: ensuring that the necessary infrastructure is in place to allow healthcare workers to practice hand hygiene.
Training/Education: providing regular training on the importance of hand hygiene, based on the “My 5 Moments for Hand Hygiene” approach, and the correct procedures for hand rubbing and hand washing, to all healthcare workers.
Evaluation and Feedback: monitoring hand-hygiene practices and infrastructure, along with related perceptions and knowledge among healthcare workers, while providing performance and results feedback to staff.
Reminders in the Workplace: prompting and reminding healthcare workers about the importance of hand hygiene and about the appropriate indications and procedures for performing it.
Institutional Safety Climate: creating an environment and the perceptions that facilitate awareness-raising about patient safety issues while guaranteeing consideration of hand hygiene improvement as a high priority at all levels.
EXHIBIT 12.12WHO Hand-
Hygiene Recommendations
Source: Reprinted from WHO (2009). © World Health Organization 2009. All rights reserved.
Spath, Patrice, and Diane L. Kelly. Applying Quality Management in Healthcare : A Systems Approach, Fourth Edition, Health Administration Press, 2017. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/franklin-ebooks/detail.action?docID=5517324.Created from franklin-ebooks on 2023-02-08 00:23:25.
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Chapter 12: Using Improvement Teams and Tools 245
multifaceted hand-hygiene initiative. System behavior, as measured by hand-hygiene compliance rates, has been tracked each month for a three-year period. As various interventions were implemented, the graph allowed managers to see how the interventions affected system performance. Over the three-year period, one sees an improvement of the average compliance rate per year and a narrowing of the range, indicating more predictable and dependable behavior in the direction of 100 percent compliance.
If an improvement project fails to achieve desired results and the performance issue continues to be of strategic importance to the organization, another project should be initiated with the same or different team members. The first step for this team should be to conduct a postmortem on the failed project to determine what went wrong so the repeat project will not fall into the same traps. A survey of 167 frontline leaders from four Midwest community hospitals found the top reasons improvement projects are not successful (Longenecker and Longenecker 2014, 150):
1. Poor implementation planning and overly aggressive time lines2. Failure to create buy-in or ownership of the initiative3. Ineffective leadership and lack of trust in upper management4. Failure to create a realistic plan or improvement process5. Ineffective, unilateral communications6. A weak case for change, unclear focus, and unclear desired outcomes7. Little or no teamwork or cooperation
UCL
Avg
LCL
10090
80
70
60
50
40
30
20
10
0
Monthly observed complianceUpper control limit (UCL) (Avg + 3 St Dev)
Yearly averageLower control limit (LCL) (Ave – 3 St Dev)
raM
rpA
yaM
nuJuJ
l guA
peSt
cO
t oN
v ceD
naJ eFb a
Mr p
Ar ya
MnuJuJ
l guA
peSt
cO
t oN
v ceD
naJ eFb ra
Mp
Ar ya
MnuJluJ gu
ApeS
tc
Ot o
Nv ce
D
Year 1 Year 2
Per
cent
age
Com
plia
nce
Year 3
EXHIBIT 12.13Three-Year Hand-Hygiene Compliance Rates
Spath, Patrice, and Diane L. Kelly. Applying Quality Management in Healthcare : A Systems Approach, Fourth Edition, Health Administration Press, 2017. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/franklin-ebooks/detail.action?docID=5517324.Created from franklin-ebooks on 2023-02-08 00:23:25.
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Applying Qual i ty Management in Healthcare: A Systems Approach246
8. Failure to provide ongoing measurement, feedback, and accountability9. Unclear roles, goals, and performance expectations
10. Lack of time, resources, and support from upper management
Summary
Quality management is most successful when it is a bottom-up, team activity. The people personally involved in the process to be improved are best suited to identify the causes of performance problems and to propose and implement solutions. Involving frontline staff in improvement projects also reduces resistance to change. This chapter describes the role of managers throughout the life of an improvement project—from chartering the team to selecting the improvement strategies to monitoring the results.
Improvement tools and techniques are used during various steps of an improvement project. There are many different tools and techniques that can be used to document the process, uncover improvement opportunities, select improvement actions, monitor progress, and hold the gains. This chapter covers several of these tools and techniques, and students are encouraged to use the companion readings and web resources provided to learn more.
Exercise 12.1Objective: To practice creating a project charter.
Instructions: Read the case study. Assume you are one of the two directors in the case study, and you are writing a team charter jointly with the other director to address the problems identified in the case study. Use the template in exhibit 12.1 or a similar format to document the project charter.
Case Study: The directors of imaging services and surgical services in a hospital are discussing an improvement opportunity involving care provided to patients with breast cancer. The hospital is encountering delays for procedures involving surgical removal of breast tissue (lumpectomy) in the area where an image-guided core needle biopsy has been performed. During the surgery, the removed tissue is imaged to ensure that the biopsy clip and microcalcifications are present in the specimen. The imaging must be done with a mammographic unit to provide visualization of the microcalcifications. Because the mammography machines are in the Breast Center, which is only open regular business hours, scheduling for the lumpectomy procedures is restricted to when a mammography technologist is available. This limitation causes delays as late as 8:00 pm, and technologists must be paid overtime for these evening procedures. In addition, even during Breast Center operating hours, the breast tissue has to be packaged
Spath, Patrice, and Diane L. Kelly. Applying Quality Management in Healthcare : A Systems Approach, Fourth Edition, Health Administration Press, 2017. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/franklin-ebooks/detail.action?docID=5517324.Created from franklin-ebooks on 2023-02-08 00:23:25.
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Chapter 12: Using Improvement Teams and Tools 247
and delivered by hand from the operating suite to the imaging department—and after the specimen is imaged, it must be returned to surgery, all while the surgeon waits with the patient still under general anesthesia. The hospital is not able to meet the needs of the surgeon for late cases, and even the requirements for cases during the day are not being fully met.
Exercise 12.2Objective: To practice creating a process flowchart.
Instructions: Develop a flowchart for a healthcare process that you are familiar with. The flowchart should have a starting point and an end point. All key process steps should be included. Use the type of flowchart that will best display the steps in your chosen process. The flowchart can be hand drawn, or you can use software such as Microsoft Excel, Visio, or PowerPoint. Two examples of flowcharts are provided in this chapter, and the web resources included at the end of this chapter contain additional examples.
Companion Readings
Agency for Healthcare Research and Quality. 2013. Practice Facilitation Handbook. Published June. www.ahrq.gov/professionals/prevention-chronic-care/improve/system/pfhandbook/index.html.
Harel, Z., S. A. Silver, R. F. McQuillan, A. V. Weizman, A. Thomas, G. M. Chertow, G. Nesrallah, C. T. Chan, and C. M. Bell. 2016. “How to Diagnose Solutions to a Quality of Care Problem.” Clinical Journal of the American Society of Nephrology 11 (5): 901–7.
Health Resources and Services Administration. 2016. “Improvement Teams.” Accessed November 16. www.hrsa.gov/quality/toolbox/methodology/improvementteams/index.html.
Lenderman, H., H. Reffett, J. Moran, and M. Beaudry. 2014. “Selecting Quality Improvement Team Members.” Public Health Foundation. Published May 19. www.phf.org/resourcestools/Documents/Team_Member_Selection_Tool.pdf.
McQuillan, R. F., S. A. Silver, Z. Harel, A. V. Weizman, A. Thomas, C. M. Bell, G. M. Chertow, C. T. Chan, and G. Nesrallah. 2016. “How to Measure and Interpret Quality Improvement Data.” Clinical Journal of the American Society of Nephrology 11 (5): 908–14.
Minnesota Department of Health. 2016. “Public Health and Quality Improvement Resources and Tools.” Accessed November 16. www.health.state.mn.us/divs/opi/qi/toolbox.
Spath, Patrice, and Diane L. Kelly. Applying Quality Management in Healthcare : A Systems Approach, Fourth Edition, Health Administration Press, 2017. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/franklin-ebooks/detail.action?docID=5517324.Created from franklin-ebooks on 2023-02-08 00:23:25.
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Applying Qual i ty Management in Healthcare: A Systems Approach248
Public Health Foundation. 2011. Applications and Tools for Creating Healthy Teams. Published April. www.phf.org/resourcestools/Documents/Applications_and_Tools_for_Creating_and_Sustaining_Healthy_Teams.pdf.
Silver, S. A., Z. Harel, R. McQuillan, A. V. Weizman, A. Thomas, G. M. Chertow, G. Nesrallah, C. M. Bell, and C. T. Chan. 2016. “How to Begin a Quality Improvement Project.” Clinical Journal of the American Society of Nephrology 11 (5): 893–900.
Silver, S. A., R. McQuillan, Z. Harel, A. V. Weizman, A. Thomas, G. Nesrallah, C. M. Bell, C. T. Chan, and G. M. Chertow. 2016. “How to Sustain Change and Support Continuous Quality Improvement.” Clinical Journal of the American Society of Nephrology 11 (5): 916–24.
Weston, M., and D. Roberts. 2013. “The Influence of Quality Improvement Efforts on Patient Outcomes and Nursing Work: A Perspective from Chief Nursing Officers at Three Large Health Systems.” OJIN: The Online Journal of Issues in Nursing 18 (3). Published September. www.nursingworld.org/Quality-Improvement-on-Patient-Outcomes.html.
Web Resources
Agency for Healthcare Research and Quality flowcharts: https://healthit .ahrq.gov/health-it-tools-and-resources/workflow-assessment- health-it-toolkit/all-workflow-tools/flowchart
Institute for Healthcare Improvement: www.ihi.org
References
Agency for Healthcare Research and Quality. 2013. “Module 14: Creating Quality Improvement Teams and QI Plans.” Reviewed May. www.ahrq.gov/ professionals/prevention-chronic-care/improve/system/pfhandbook/mod14. html.
American Society for Quality (ASQ). 2016a. “Decision Matrix.” Accessed July 15. http://asq.org/learn-about-quality/decision-making-tools/overview/ decision-matrix.html.
———. 2016b. “Glossary—P.” Accessed July 15. http://asq.org/glossary/p.html.———. 2016c. “Process View of Work.” Accessed July 15. http://asq.org/
learn-about-quality/process-view-of-work/overview/overview.html.Carey, R. G., and R. C. Lloyd. 2001. Measuring Quality Improvement in Healthcare: A
Guide to Statistical Process Control Applications. Milwaukee, WI: Quality Press.
Spath, Patrice, and Diane L. Kelly. Applying Quality Management in Healthcare : A Systems Approach, Fourth Edition, Health Administration Press, 2017. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/franklin-ebooks/detail.action?docID=5517324.Created from franklin-ebooks on 2023-02-08 00:23:25.
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Chapter 12: Using Improvement Teams and Tools 249
Kelly, D. 1998. “Reframing Beliefs About Work and Change Processes in Redesigning Laboratory Services.” The Joint Commission Journal on Quality Improvement 24 (9): 154–67.
Lencioni, P. 2002. The Five Dysfunctions of a Team: A Leadership Fable. San Francisco: Jossey-Bass.
Longenecker, C. O., and P. D. Longenecker. 2014. “Why Hospital Improvement Efforts Fail: A View from the Front Line.” Journal of Healthcare Management 59 (2): 147–57.
McLaughlin, D. B., and J. R. Olson. 2012. Healthcare Operations Management, 2nd ed. Chicago: Health Administration Press.
Minnesota Department of Health (MDH). 2016. “Public Health and QI Tool Box: Prioritization Matrix.” Accessed July 15. www.health.state.mn.us/divs/opi/qi/toolbox/prioritizationmatrix.html.
Rohe, D., and P. L. Spath. 2005. 101 Tools for Improving Health Care Performance. Forest Grove, OR: Brown-Spath & Associates.
Scholtes, P. R., B. L. Joiner, and B. J. Streibel. 2003. The Team Handbook, 3rd ed. Madison, WI: Oriel.
Shiba, S., and D. Walden. 2002. “Quality Process Improvement Tools and Techniques.” Massachusetts Institute of Technology and Center for Quality of Management. Published July 30. www.walden-family.com/public/iaq-paper.pdf.
UK Department of Trade and Industry. 2016. “Tools and Techniques for Process Improvement.” Accessed July 15. www.businessballs.com/dtiresources/TQM_process_improvement_tools.pdf.
World Health Organization (WHO). 2009. A Guide to the Implementation of the WHO Multimodal Hand Hygiene Improvement Strategy. Accessed July 15, 2016. www.who.int/gpsc/5may/Guide_to_Implementation.pdf.
Spath, Patrice, and Diane L. Kelly. Applying Quality Management in Healthcare : A Systems Approach, Fourth Edition, Health Administration Press, 2017. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/franklin-ebooks/detail.action?docID=5517324.Created from franklin-ebooks on 2023-02-08 00:23:25.
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Applying Qual i ty Management in Healthcare: A Systems Approach250
Appendix 12.1
Frequently Used Improvement Tools
Tool Name Description
Affinity diagram Visualization that organizes ideas and issues to help in understanding the essence of a situation and possible actions
Arrow diagram Graphical representation showing the network of tasks and milestones required to implement a project
Bar chart (or bar graph) Display of data in which the height of the bars is used to show the relative size of the quantity measured
Benchmarking Comparison of a process with a “best practice” or “best in class” to learn how to improve that process
Brainstorming Process that allows a team to creatively generate ideas about a topic in a “judgment-free zone”
Capability measures Various measures of the natural variation of process outputs (e.g., a limit of three standard deviations on a control chart) and specification limits (e.g., six sigma)
Causal loop diagram Advanced type of relations diagram
Cause-and-effect diagram (or fishbone diagram or Ishikawa diagram)
Visualization that organizes and documents causes of a problem in a structured format
Check sheet (or tally sheet) Form used to record and compile data from archives or observations to detect trends or patterns
Control chart Display of data quantifying variation to monitor whether a process is continuing to operate reliably; also used to detect the effect of a process change
Decision matrix Diagram used to evaluate and prioritize a list of options
(continued)
Spath, Patrice, and Diane L. Kelly. Applying Quality Management in Healthcare : A Systems Approach, Fourth Edition, Health Administration Press, 2017. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/franklin-ebooks/detail.action?docID=5517324.Created from franklin-ebooks on 2023-02-08 00:23:25.
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Chapter 12: Using Improvement Teams and Tools 251
Tool Name Description
Design of experiments Systematic method that determines the relationship between factors affecting a process and the output of that process
Dot plot (or tally chart) Visualization showing how often a particular value has occurred (frequency), with the shape of the plot giving a picture of the variation and highlighting unusual values
5S methodology Philosophy and a five-step way of organizing and managing the workspace by eliminating waste
Five Whys Process in which, when a problem occurs, its nature and source are discovered by asking “Why?” several times
Force field analysis Examination that identifies forces that help or hinder change or improvement
Graphs and graphical methods
Many different techniques for showing data visually and analyzing the data
Histogram Display showing the centering, dispersion, and shape of the distribution of a collection of data
Matrix diagram Visualization showing multidimensional relationships
Pareto chart (or analysis diagram)
Visual representation similar to a histogram but with the data sorted in order of decreasing frequency of events and with other annotations to highlight the Pareto effect (i.e., the 20 percent of situations that account for 80 percent of results)
Poka-yoke (or mistake-proofing)
Methods for preventing mistakes
Process flowchart Graphical representation of the steps in a process or project
Queuing theory Analysis of delays and wait times
Regression analysis Analysis of the relationship between response (dependent) variables and influencing factors (independent variables)
Relations diagram Visualization showing a network of cause-and-effect relationships
Run chart (or line graph) Graphical representation of data over time
(continued)
Spath, Patrice, and Diane L. Kelly. Applying Quality Management in Healthcare : A Systems Approach, Fourth Edition, Health Administration Press, 2017. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/franklin-ebooks/detail.action?docID=5517324.Created from franklin-ebooks on 2023-02-08 00:23:25.
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Applying Qual i ty Management in Healthcare: A Systems Approach252
Tool Name Description
Sampling Statistical tool that selects a few instances from a set of events, from which characteristics of the entire set are inferred
Scatter diagram (or plot) Graphical method of showing correlation between two variables
Stratification of data Classification of data from multiple categories, such as what, where, when, and who
Tree diagram Visualization that organizes a list of events or tasks into a hierarchy
Value-stream mapping Graphical representation of the process of services or product delivery with use of inputs, throughputs, and outputs
Sources: Adapted from MDH (2016); Shiba and Walden (2002); UK Department of Trade and Industry (2016).
Spath, Patrice, and Diane L. Kelly. Applying Quality Management in Healthcare : A Systems Approach, Fourth Edition, Health Administration Press, 2017. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/franklin-ebooks/detail.action?docID=5517324.Created from franklin-ebooks on 2023-02-08 00:23:25.
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