SlideShare a Scribd company logo
1 of 124
Download to read offline
Acute Care Hospital Experience
                                              Quality
                                            Improvement
                                              Guide
                                          A resource designed to guide you through
                                          the 3 phases of an improvement project:
Improving the




                                              Planning
                                              Project management for QI: developing a blueprint for success


                                              Reflecting
                                              Analyzing current processes: where to begin and what you can
                                              do to make change


                                              Executing
                                              Strategies, tools, and tips for turning ideas into action
Atrium Building, Innovation Place
                                                    241-111 Research Drive
                                                    Saskatoon, SK S7N 3R2 Canada
                                                    P: 306-668-8810 F: 306-668-8820
                                                    E: info@hqc.sk.ca
                                                    W: www.hqc.sk.ca




ISBN 1-897155-17-4

Some of the material in this quality improvement guide was supplied by and is used with the kind permission
of other organizations, who retain copyright over their original work.

© 2006 Health Quality Council

Please contact the Health Quality Council for written permission to distribute or copy this document, in whole
or in part. Permissions do not extend to any materials within this document that are used with the permission
of a third party.

Please use the following citation style when referring to this document:
       N Wohlgemuth, S Oosman, S Furniss. Improving the Acute Care Hospital Experience: Quality
       Improvement Guide. Saskatoon: Health Quality Council. June 2006.

Health Quality Council also wishes to acknowledge the valuable contributions of other team members to the
development of this guide:
       • Catherine Delaney, Knowledge Exchange Consultant
       • Laurie Gander, Program Director
       • Mary Smillie, Senior Knowledge Exchange Consultant
       • Katherine Stevenson, Senior Knowledge Exchange Consultant
Project Checklist
                                       Are you ready to launch a quality improvement project?

                                    You may find this checklist a helpful reference in planning your improve-
                                    ment project. As you go through the list, check the box if you can answer
                                    “YES” to the statement. This will quickly identify areas where you might
                                    need some further planning before you get started.

                         We have a clear goal and scope of the project.
                         We have agreement in the senior clinical and management community that there is
                         a gap between where we are now and where we could be.
                         We have active support from senior clinical and managerial leaders.
                         We have completed the Blueprint for Success or project plan.
                         A leadership team is established and members are aware of their roles and respon-
                         sibilities. (LIST)




                         Our project sponsor(s) is confirmed.

                         We have explicitly described the necessary commitment required and specific roles
                         and responsibilities of front-line team members. As well, we have described our
                         expectations and the expected benefits for the organization and the front-line
                         team(s). (LIST)




                         We have measurement and reporting systems set up.
                         We know how and when we will involve patients, caregivers, and other users of the
                         system we want to improve.
                         We have a process for recruiting the front-line team(s).

                         We have recruited the required front-line team(s) with a designated team leader.
                         a. The front-line team(s) and the team leader(s) is:




                         b. The team(s) will be assembled by: (DATE)



Patient Experience Survey: Quality Improvement Guide
Health Quality Council 2006
Project Checklist
                           The team(s) is able to focus on the project and not get side tracked by other
                           demands.

                           We have secured the necessary budget and other resources required to support all
                           elements of the project.

                           We have completed a “quality improvement skills” training needs assessment for
                           front-line team(s) members.

                           We have support available for the front-line team(s) members to develop the neces-
                           sary quality improvement skills and to complete the project Improvement Charter.


                           We have the necessary support available to enable the front-line team(s) to analyze
                           current care processes. For example, using such tools as process mapping or
                           cause/effect diagram.


                           We know how we are going to launch the project.

                           We are already planning how we will acknowledge the quality improvement
                           achievements made by the front-line team(s).

                           We are already planning how to ensure that the improvements made are continued.

                           We are already planning how to spread the improvements to other parts of the
                           organization.




Used with permission by the NHS Modernisation Agency, subject to Crown copyright protection. Available from URL:
http://www.modern.nhs.uk/improvementguides/reading/collaborative.pdf

Patient Experience Survey: Quality Improvement Guide
Health Quality Council 2006
Phase One
                            Included in this section is information on:

                                   •   Key elements of an improvement project
                                   •   Creating a “blueprint for success”
                                   •   Developing effective teams




Patient Experience Survey: Quality Improvement Guide                            P—1
Health Quality Council 2006
Introduction to QI Planning
                                   Lloyd Provost (co-author of the Model of Improvement and the
                                   Improvement Guide) identifies three key elements to achieve significant
                                   improvement:
                                          • The will to do what it takes to change to a new system;
                                          • Ideas on which to base the design of the new system; and,
                                          • A clear plan of execution of the ideas.
                                          (L. Provost, Telehealth Presentation, October 5, 2005)

                                   While we often have a strong will to improve and many ideas (from the
                                   literature and our own experiences), execution—organizing, supporting,
                                   sustaining and spreading improvement—is a challenge we all share.

                                   This section of the QI Guide provides a blueprint for success: an out-
                                   line of the key elements needed to organize and support an improve-
                                   ment project in the acute care setting. This blueprint combines project
                                   management and improvement science principles.

                                   You may already have your own project planning tool; use the format
                                   you prefer. To better plan for success, you might want to ensure that
                                   your plan includes:
                                          • An explicit statement of what is expected from the improve-
                                               ment effort;
                                          • What supports the improvement team can expect from the
                                               organization;
                                          • Any limitations or constraints that must be taken into consid-
                                               eration; and,
                                          • An individual or team providing overall regional leadership for
                                               the improvement of patient experience.

                                   After completing this form, you should have a good start on your
                                   improvement journey. The next steps will be working with facility/unit
                                   level teams in analyzing current processes, identifying opportunities for
                                   improvement, and testing ideas on a small scale.




Patient Experience Survey: Quality Improvement Guide                                                 P—2
Health Quality Council 2006
Blueprint for Success
                                           Please see the Notes to the Blueprint on page P—5 for more informa-
                                           tion on completing this form.
1. Determine priority area (s). You may wish to look at survey results and your organizational goals.




2. Identify RHA leadership team members.

        Name:                                             Role:
                                           .

        Name:                                             Role:
                                   .

        Name:                                             Role:
                                               .

        Name:                                             Role:
                                       .

        Name:                                             Role:                                         .

3. Improvement aim(s) for region. Aim should be clear, specific, measurable, time-specific, and patient-centred.




4. Project deliverables. What will success look like?


        a. What numerical target are you striving for on repeat survey (patient perspective)?




        b. What changes in the system are you expecting (provider behavior perspective)?




Patient Experience Survey: Quality Improvement Guide                                                         P—3
Health Quality Council 2006
Blueprint cont’d
                                           Please see the Notes to the Blueprint on page P—5 for more informa-
                                           tion on completing this form.
5. Outline project scope. What are the project boundaries?

   a. Time frame of project:

        Start date:                                               End date:

   b. Number of teams necessary to achieve aim:


   c.   Number of facilities and units to be involved:


   d. Staff time limits for the duration of the project:

                 Hours per week

                 FTE per month


   e. Cost limits: $

6. Determine project sponsor(s).




7. Expectations for reporting between RHA leadership team and front-line team(s).




8. Project links to broader RHA goal(s).

Project linked to the following RHA goal(s):




Patient Experience Survey: Quality Improvement Guide                                                   P—4
Health Quality Council 2006
Notes to the Blueprint
                                   1. Determine priority area
                                         Consider your results from the Patient Experience Survey, as
                                         well as broader organizational/regional goals. Examples of prior-
                                         ity areas from the survey include discharge planning, provider-
                                         patient communications, pain management, etc.

                                   2. Identify RHA leadership team members
                                          Some key points to keep in mind when establishing your team:
                                                  • Ideal team size is 6-12 people
                                                  • Try to find a range of expertise
                                                  • Include both the “keen” and “not so keen”
                                          More information on teams is included in Additional Information,
                                          starting on page P—7.

                                   4. Project deliverables
                                          What will success look like? Consider both:
                                                 • An outcome goal, or numerical measure. For exam-
                                                     ple, if your improvement area is discharge planning
                                                     your goal might be: 100% of our patients will know
                                                     what side effects to watch for at home.

                                                 •     A process goal, something that will show you if
                                                       changes to process are resulting in more effective
                                                       care. For example, if your improvement area is pain
                                                       management, your goal might be: All patients will
                                                       have a pain management plan completed and at-
                                                       tached to their chart.

                                   5. Project scope
                                          Determine how many resources (money, time) can be devoted to
                                          the project to achieve your aim. Consider:
                                                  • Project timeframe—when does it start and end?
                                                  • How many front-line teams need to be established?
                                                  • How many facilities will be involved and which ones?
                                                  • Staff time limits—how many FTE hours?


                                   6. Project sponsor(s)
                                          The project sponsor can be an individual or a group. The role of
                                          the sponsor is to be the liaison between the front-line team and
                                          RHA leadership, and to help teams overcome obstacles.

Patient Experience Survey: Quality Improvement Guide                                                P—5
Health Quality Council 2006
Additional
   Information
Patient Experience Survey: Quality Improvement Guide   P—6
Health Quality Council 2006
Additional Information: Team Development
1. Team size

                                   It’s important to consider size when developing QI teams. A team that is
                                   too large may have difficulty coordinating schedules for meetings, and
                                   meetings may involve lengthy discussions and little consensus.

                                   On the other hand, a team that is too small may be missing representa-
                                   tion from key groups, and might feel overwhelmed by having to accom-
                                   plish so many tasks with so few resources.

                                   The optimal team size is between 6 and 12 members.




       Optimal team size: not too big, not too
                small—just right!
Patient Experience Survey: Quality Improvement Guide                                               P—7
Health Quality Council 2006
Additional Information: Team Development
2. Types of expertise

                                   Including the right people on the QI team is critical to successful im-
                                   provement efforts. Recruit staff and care providers from all aspects of
                                   the patient experience you are trying to improve. For example, if your
                                   improvement focus is on discharge planning, your team might include:
                                   nurses, physicians, occupational therapists, physiotherapists, social
                                   workers, and pharmacists. Each discipline will provide a unique perspec-
                                   tive on the processes of care involved in safely transitioning patients
                                   from hospital to home.

                                   There are three basic areas of expertise that should be part of any team.
                                   These include expertise in organizational authorization, clinical or techni-
                                   cal expertise, and someone with knowledge about the system of care.
                                   You may have one or more individuals with each kind of expertise, or an
                                   individual with expertise in more than one area. Regardless, try to en-
                                   sure that all three types are represented on your team.

                                   Team Sponsor
                                         The Team Sponsor should have enough authority in the organi-
                                         zation to implement suggested changes and overcome barriers.
                                         The Team Sponsor understands the implications of the proposed
                                         change on the various parts of the system, as well as the more
                                         remote consequences a change might trigger.

                                          It is important that the Team Sponsor have authority in all areas
                                          affected by the change, and the authority to allocate resources
                                          (time, people, money) needed to achieve the aim.

                                   Clinical/Technical Experts
                                          A Clinical or Technical Expert is someone who knows the subject
                                          matter intimately and who understand the processes of care. For
                                          Patient Experience, you may want to consider team members
                                          who are Technical Experts in your priority area (see page P—11
                                          for a provider-priority area chart). Brainstorming about the proc-
                                          ess should help you in selecting appropriate team members. Indi-
                                          vidualize your teams to ensure they represent your region/facility/
                                          unit and the variations in the processes of care.

                                          Patients should also be considered Technical Experts; your pro-

Patient Experience Survey: Quality Improvement Guide                                                  P—8
Health Quality Council 2006
Additional Information: Team Development
                                                 ject will be stronger if the patient voice is included on the team.
                                                 Please see page P—10 for more information on involving
                                                 patients.

                                         Day-to-Day Leaders
                                                The Day-to-Day Leader is the driver of the project; they ensure
                                                that tests are implemented and data are being collected. It is
                                                important that the Day-to-Day Leader understands not only the
                                                details of the system, but also the effect changes will have on the
                                                system. For Patient Experience, the Day-to-Day Leader may be
                                                someone within the unit who is knowledgeable about staff and
                                                care processes, but also has the authority to make decisions
                                                regarding care and staffing (for example, a nurse or unit
                                                manager).




                                                    Helpful Tool!
                                         Assess Your Team
                                               This team assessment tool can help your Regional Leadership
                                               team in brainstorming members for the facility/unit QI team. As
                                               each name is suggested, add them to the following matrix and
                                               determine their areas of expertise. This will show you at a glance
                                               if your team is well-rounded, and give you an idea of your team’s
                                               strengths and potential gaps.
Name                  Team Sponsor             Technical Expert         Day-to-Day Leader        Additional Strengths

Jane Doe                          √                                                 √

John Smith                                                 √


                                                 You may want to begin by suggesting a few names at the Re-
                                                 gional Leadership level, then ask these front-line people to select
                                                 the rest of the team.
Used with the permission of the Institute for Healthcare Improvement (IHI), c2005. Available from URL: http://
www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/HowToImprove/formingtheteam.htm




Patient Experience Survey: Quality Improvement Guide                                                             P—9
Health Quality Council 2006
Additional Information: Team Development
3. Involving patients

                                       Your efforts to improve the patient experience will be more successful if
                                       you include the patient voice on your team. The National Health
                                       Services (NHS), based in the United Kingdom, has done extensive work
                                       in the area of the “expert patient”.

                                       Some of their tips on approaching patients or caregivers to participate on
                                       a QI team:
                                                      • Have clear aims and objectives
                                                      • Explain project constraints and potential outcomes
                                                      • Involve more than one patient/caregiver on the team
                                                      • Be clear about the role of the patients/caregivers on
                                                          the team
                                                      • Be aware that involving current or recent patients may
                                                          present some difficulties
                                                      • Identify patients/caregivers who will help you meet
                                                          your aims
                                                      • Involve patients/caregivers early on in the project



Used with permission by the NHS Modernisation Agency, subject to Crown copyright protection. Available from URL:
http://www.cgsupport.nhs.uk/Patient_Experience/4@How_to_involve_people.asp




                                                     Web site resource
                      The NHS has resources and tips for working with patients on quality improvement.
                      Go to: www.cgsupport.nhs.uk and click on the Patient Experience hotlink.




Patient Experience Survey: Quality Improvement Guide                                                       P—10
Health Quality Council 2006
Additional Information: Team Development
4. Matching team members to priority areas

                                      When developing your QI teams, it may be helpful to consider your prior-
                                      ity area. The chart below shows health care providers who might be
                                      included on a team that is planning to focus on a specific priority area.

          Role                            Provider-Patient   Pain            Discharge         Hospital Food
                                          Communications     Management      Planning
          Patient                                 √                 √                √                √
          Physician                               √                 √                √
          Nurse Manager                           √                 √                √                √
          Front-line Nurse                        √                 √                √                √
          LPN                                     √                 √                √
          Pharmacist                              √                 √                √
          Unit Clerk                                                                 √                √
          Dietary Staff                                                                               √
          Director of Food Services                                                                   √
          Dietitian                                                                                   √
          Food Services Manager                                                                       √
          Others (e.g., physiothera-              √                 √                √                √
          pists, occupational thera-
          pists, social workers, etc.)–
          depending on priority areas
          and processes within spe-
          cific facilities




Patient Experience Survey: Quality Improvement Guide                                                   P—11
Health Quality Council 2006
Additional Information: Team Development
5. Stages of team development

                                       After members are selected, participants must move from being a group
                                       to becoming a team. The three stages of team development are forming,
                                       storming, and performing. Each stage is described in the table below.
   Stage                                               What it looks like

Forming            •   Members are concerned with inclusion and acceptance.
                   •   Interactions are polite and superficial—overt conflict is rare.
                   •   Conformity tends to be high.
                   •   Group struggles to define its boundaries; establish who is or isn’t part of this group.
                   •   Members rely on leader for direction and support.
                   •   Goals are not clear.
Storming*          •   Members are concerned with having their unique contributions recognized.
                   •   Participation increases; members want to exercise some influence in the group.
                   •   Conformity and compliance decrease.
                   •   Open conflict increases.
                   •   Members begin to take a critical look at the power structure in the group and question
                       how decisions are made.
                   •   Members may challenge the leader directly or indirectly.
                   •   Members begin to wonder if they can trust others to “pull their weight,” to make
                       meaningful contributions.
                   •   Clarification of roles and goals begins.
                   •   Ground rules are established.
Performing         •   Members have built a sense of trust and safety within the group.
                   •   Members are more friendly and supportive of one another.
                   •   All contributions are recognized and appreciated.
                   •   Members are clear about their roles and responsibilities.
                   •   Conflict is handled openly and constructively.
                   •   Members develop a sense of cohesiveness and group identity.
                   •   Leader’s role has become less directive and more supportive as members actively take
                       responsibility for setting and achieving group goals.
                                       * As uncomfortable as this stage may be, the conflict is a prerequisite to
                                       effective group functioning in the final stage. Groups unwilling to work
                                       through the storming phase remain dependent on their leader, maintain
                                       relatively superficial relationships, and are unable to work effectively be-
                                       cause no one is willing to voice differing opinions or points of view.

Adapted from: Renz, MA and Greg, JB (2000). Effective small group communication theory and practice. Toronto: Allyn
and Bacon Canada.

Patient Experience Survey: Quality Improvement Guide                                                        P—12
Health Quality Council 2006
Additional Information: Team Development
6. Effective meetings

                                   Team meetings are an important part of a quality improvement project.
                                   Holding both traditional and informal meetings (known as “huddles”) will
                                   help move your project forward. The tips listed below can help make
                                   your meetings more effective.

                                   Starting the meeting
                                   It is essential to start meetings with some type of Introduction Exercise
                                   or Icebreaker. When you have a large group, or you have a very full
                                   agenda, it may seem like a waste of time to conduct personal introduc-
                                   tions. But introductions are crucial to the overall comfort, trust, and risk-
                                   taking ability of the group. Introductions give group members a way to:
                                            • Get to know one another.
                                            • Gain a deeper appreciation of each other as individuals.
                                            • Understand the mindset of different group members on the
                                                meeting day.

                                   Some examples of introduction or icebreaker activities:
                                         • Have participants meet the person sitting next to them; they
                                           then introduce each other to the larger group.
                                         • Have each person take something out of his or her wallet,
                                           pocket or bag, and explain why it is important.
                                         • Have each person in the group identify themselves with a
                                           musical instrument, cartoon character, animal, etc (choose
                                           one) and explain why.
                                         • Ask people to identify themselves and then tell what they had
                                           for breakfast that morning.

                                   Getting organized
                                   It’s important to have an agenda, to make sure that all the necessary
                                   discussion takes place, and that the meeting stays on track. The agenda
                                   is usually set before the meeting—most often by the person who will
                                   lead the meeting. It helps meetings run more smoothly if the agenda is
                                   posted in a visible place.

                                   An agenda can be changed during the meeting. Sometimes items are
                                   added or deleted, or the order of discussion is changed. The chairperson
                                   should ask group members if they have additions or changes to the
                                   agenda at the beginning of the meeting. It’s also a good idea to assign

Patient Experience Survey: Quality Improvement Guide                                                   P—13
Health Quality Council 2006
Additional Information: Team Development
                                   times to each item so that you will know approximately how long the
                                   meeting will take.

                                   Agendas come in various formats and styles; choose the one that will
                                   work best for your meeting and group. For example, you might want to
                                   use a grid style that includes “person responsible” and “outcome
                                   needed” for each item.

                                   Roles and responsibilities
                                         • Chairperson. The chairperson takes responsibility for many
                                            tasks that keep the meeting running smoothly. The role may
                                            be assigned based on position in group or may be shared
                                            and rotated among the members. Responsibilities include:
                                                        • Arranging for the room and refreshments
                                                        • Setting and distributing the agenda
                                                        • Starting on time
                                                        • Leading the meeting
                                                        • Keeping the group on track
                                                        • Ending on time


                                          •   Note-taker. The note-taker records the important comments
                                              and decisions that the group makes during the meeting.
                                              Notes may be written discretely during the meeting, but many
                                              groups prefer to take notes on large flipcharts, so that notes
                                              are visible to everyone throughout the meeting. Members can
                                              repeat or reword statements for accuracy and better under-
                                              standing. It’s important for the notes to be distributed to the
                                              group before the next meeting.

                                          •   Timekeeper. The role of the timekeeper is to keep track of
                                              time during the meeting. If an item is taking longer than
                                              planned to discuss, the timekeeper would flag this so that the
                                              group can decide to defer an item, speed up discussion, or
                                              take another tack. Sometimes the chairperson functions as
                                              timekeeper, but often this is a separate role.

                                   Setting the stage
                                   Every meeting should have ground rules. Ground rules are the ex-
                                   pected rules of conduct that are important for the group’s full participa-
                                   tion and success. Involve the group members in setting the ground rules,

Patient Experience Survey: Quality Improvement Guide                                                P—14
Health Quality Council 2006
Additional Information: Team Development
                                   and then post them on a large piece of paper in the meeting room. This
                                   will serve as a visual reminder of what the group has agreed on for
                                   meeting conduct.

                                   It is not unusual for people to get side-tracked during a meeting. When
                                   people either talk about or have questions about something that is not
                                   on the agenda, you can write it down on a large piece of paper marked
                                   “Issues Bin” or “Parking Lot”. Later, when you have time, the group
                                   can return to the “parked” issues. It can be difficult to decide when is-
                                   sues belong to the Parking Lot or if they need to be discussed immedi-
                                   ately. The chairperson needs to exercise judgment, but can also ask the
                                   group for their opinion.

                                   It’s very important to include break time on the agenda. People lose
                                   interest if they sit too long, so set aside time to stretch and grab a snack
                                   or drink. If it’s a short meeting, people may choose not to take a break. It
                                   should always be up to the group to decide. You will also find that
                                   providing refreshments for the meeting fosters a caring, relaxed atmos-
                                   phere.

                                   Closing the meeting
                                   Renegotiating time and agenda
                                         It’s not unusual to find that there is not enough time to discuss all
                                         the items on the agenda, or that important items (not on the
                                         agenda) come up for discussion during the meeting. The group
                                         may decide to defer items to another meeting, meet for a longer
                                         time, eliminate items from the agenda, or take some other action.

                                   Next steps or action planning
                                          It’s a good idea to spend some time at the end of a meeting to
                                          clarify any action that needs to be taken, and who will be respon-
                                          sible for taking that action. Important decisions/action items can
                                          be recorded in the meeting notes.

                                   Evaluation techniques
                                         Meeting evaluation can be simple or complex. A very simple
                                         technique is to have a large piece of paper divided into two
                                         columns: “What Was Good About the Meeting” and “How To
                                         Improve the Meeting”. The chair elicits and records comments
                                         from the group.

Patient Experience Survey: Quality Improvement Guide                                                  P—15
Health Quality Council 2006
Additional Information: Team Development
                                               More formal techniques include a written set of questions with a
                                               rating scale, agree/disagree, or open-ended formats for mem-
                                               bers’ responses. Typical questions include: Do you think we met
                                               our objectives for meeting? Did we abide by our ground rules?

                                               Another option is to use imagery for creative and somewhat
                                               humorous evaluation. For example, ask participants to rate the
                                               meeting with reference to different cars:
                                                     • Did this meeting operate like a Cadillac DeVille—
                                                         smooth, easy perfection, purring right along?
                                                     • Or was it like a Ford Escort—predictable, dependable,
                                                         chugging but getting the job done?
                                                     • Or was it like the old Edsel—dysfunctional, poorly
                                                         planned, and unproductive?
      Was your meeting an Edsel? Ask the group!




Adapted from the System for Adult Basic Education Support (SABE) guide, Running Effective Meetings and Facilitating
Groups (July 2002). Available from URL: http://www.sabes.org/resources/facilitationguide.pdf

Patient Experience Survey: Quality Improvement Guide                                                        P—16
Health Quality Council 2006
Additional Information: Team Development
                                         Huddles
                                         Huddles are designed to keep teams informed about the project
                                         progress, review previous accomplishments, and make plans for the
                                         next steps. Because huddles are more informal than traditional meet-
                                         ings, they can occur more frequently. They allow for greater participation
                                         of front-line staff, who often can’t arrange schedules to attend longer
                                         meetings. They are great for keeping the momentum going. Many teams
                                         use them for reviewing and revising Plan-Do-Study-Act cycles.

                                         Keys to successful huddles:

                                                 •   Discuss the huddle concept with the team and explain how
                                                     huddles can be used as a tool to speed improvement.
                                                 •   Agree on a time and place where regular huddles will occur.
                                                 •   Choose a huddle location that is convenient for the team
                                                     members, particularly those who have the least time available
                                                     for meetings.
                                                 •   Have a clear set of objectives for every huddle.
                                                 •   Limit the duration of the huddle to 15 minutes or less.
                                                 •   Review the objective of the huddle for that day, then review
                                                     the work done since the last huddle. Act on the new informa-
                                                     tion and plan next steps.
                                                 •   Huddle frequently, even daily—particularly when many PDSA
                                                     cycles are being tested and the team needs to share informa-
                                                     tion regularly.




                                        If you want people to attend meetings, try to make them more convenient!


Used with the permission of the Institute for Healthcare Improvement (IHI), c2005. Available from URL: http://
www.ihi.org/NR/rdonlyres/74A9CD6C-B15A-45A1-87DE-FD7E6CE1F23C/654/Huddles1.pdf

Patient Experience Survey: Quality Improvement Guide                                                             P—17
Health Quality Council 2006
Additional Information: Team Development
7. Ten essential ingredients for successful teams

                                   Although conflict is to be expected in any team, some common group
                                   difficulties can be prevented when teams ensure they have the following
                                   essential ingredients:

                                       1. Clarity in team goals. A team works best when everyone under-
                                          stands its purpose and goals. If there is confusion or disagree-
                                          ment, effective teams work to resolve the issues rather than
                                          ignore or sidestep them.

                                       2. Established ground rules. Highly effective teams outline how
                                          they will work together and establish behavioural expectations for
                                          team members.

                                       3. A work plan. Successful teams outline who will do what and
                                          when. Clear action plans help the team identify what resources,
                                          materials or training are needed throughout the project so that
                                          they can plan accordingly. Work plans also flag uneven distribu-
                                          tion of tasks among team members.

                                       4. Clearly defined roles. Teams operate most efficiently if they tap
                                          everyone’s talents and all members understand their duties and
                                          know who is responsible for what issues and tasks. Roles may
                                          need to be re-visited periodically (e.g., as new tasks come to
                                          light, member workloads shift, etc.)

                                       5. Balanced participation. One or two members taking responsi-
                                          bility for the team’s efforts is neither effective nor sustainable. All
                                          members should participate in discussions and decisions, share
                                          commitment to the project’s success, and contribute their talents.

                                       6. Open communication. Effective teams share information,
                                          thoughts and ideas in an open and direct manner. Team mem-
                                          bers seek to understand one another’s perspectives.

                                       7. Beneficial team behaviours. Successful teams encourage all
                                          members to use behaviours that make discussions and meetings
                                          more effective, such as initiating discussion, listening to others,
                                          and working through conflict.

Patient Experience Survey: Quality Improvement Guide                                                    P—18
Health Quality Council 2006
Additional Information: Team Development
                                            8. Established decision-making methods. A team should always
                                               be aware of the different ways it reaches decisions, and the
                                               consequences of using those methods. For example, when the
                                               designated leader makes the decision, others may not fully
                                               understand the decision or feel committed to implementing it.

                                            9. Experimentation/creativity. An effective team experiments with
                                               different ways of doing things and is creative in its approach.

                                            10. Evaluation. Successful teams evaluate both their functioning
                                                and their accomplishments.




Portions of these materials are copyrighted by Oriel Incorporated, formerly Joiner Associates Inc and are used here with
permission. Further reproductions are prohibited without written consent of Oriel Incorporated. Call 1-800-669-8326.

Patient Experience Survey: Quality Improvement Guide                                                            P—19
Health Quality Council 2006
Reflecting
                                                       Phase Two
                            This section has information on analyzing current
                            processes, including:

                                   •   Process mapping
                                   •   Brainstorming
                                   •   Focus groups
                                   •   Fishbone diagrams




Patient Experience Survey: Quality Improvement Guide                            R- 1
Health Quality Council 2006
Introduction to Reflecting
                                   Understanding Systems
                                   To make effective changes, first we need to understand how our system
                                   currently works. We don’t intentionally design systems that are flawed,
                                   but a well-designed system can become unsatisfactory over time

                                   Anyone who has not kept up with the changes in telephones, for exam-
                                   ple, knows that a rotary dial telephone limits easy access to services
                                   within many organizations. As our culture and technology changes, our
                                   systems also need to change.

                                   What Is a System?
                                   Systems exist all around us: The cardiovascular system; the London
                                   underground subway system; the hockey draft system. Systems are
                                   defined as a collection of parts and processes organized around a
                                   purpose.

                                   All systems have three components:
                                           • Structures: Things you can touch and see, such as
                                              equipment, facilities, committees, roles.
                                           • Processes: Steps or actions to achieve the outcome, such
                                              as patient pathways.
                                           • Patterns: Repetitive features, often cultural, such as
                                              behaviours, conversations, and waiting times.

                                   Often we get caught up in the “do”; implementing changes without a
                                   complete understanding of where change will be most effective. Analyz-
                                   ing your current processes can help to make your improvements more
                                   meaningful and effective. Remember: All improvement involves change,
                                   but not all change will lead to improvement.

                                   This section has information on methods to analyze and understand
                                   your processes:
                                          • Process mapping
                                          • Brainstorming
                                          • Focus groups
                                          • Fishbone diagrams




Patient Experience Survey: Quality Improvement Guide                                               R- 2
Health Quality Council 2006
Process Mapping
                                   Overview
                                   Every process has a start and an end. In order to map a process, it is
                                   essential to clearly define each of these points. Processes can be simple
                                   and short, or complex and long. Processes are usually governed by
                                   rules, and they are usually linked with other processes.

                                   For example, a process might begin with the symptom and end with
                                   resumption of good health. Similarly, a process might begin with the
                                   request for an X-ray and end with the results.

                                   When examining a process, it is important to detail every point in the
                                   chain of action. Be sure to include everyone involved in that process, so
                                   that no point of action is missed. Often, no one person knows the entire
                                   process. By including everyone in the discussion, we may find that what
                                   we think is going on may not, in fact, be what is actually happening! By
                                   analyzing the process from start to finish, we identify all the opportunities
                                   to make improvements. We also avoid the pitfall of focusing on just one
                                   perspective.

                                   When mapping a process, it is important to consider the view of all
                                   stakeholders, including patients and caregivers:
                                          •   The only one who knows the whole process is the
                                              patient.
                                          •   Up to 50% of process steps involve a hand-off, leading to
                                              the possibility of error, duplication, or delay.
                                          •   30 to 70% of what we normally do does not add value for
                                              the patient.
                                                                                          (Dr. John Bibby)

                                   Start by gathering together representatives of all the stakeholders, i.e.,
                                   everyone who takes part in the process from start to finish. Using a white
                                   board or sticky notes, write down the task and the name of the person
                                   who carries out that task.


                                   Arrange the steps in order, but feel free to add new steps and move
                                   steps around at any point. Watch the patterns emerge that may indicate
                                   the root of a problem. You may be surprised!

                                   Please see the next page for a diagram of a process map.

Patient Experience Survey: Quality Improvement Guide                                                    R- 3
Health Quality Council 2006
Process Mapping
                                            Record each step of the process from
                                            start to finish. Write down the steps in
                                            the sequence they occur.



                                            Request         Complete          Results
                           START                                                                  FINISH
                                         for chest x-ray      X-ray         communicated

                                        Complete req.       Take films       X-rays to Dr.
                                           MD                 Tech              Patient

                                           Pt info         process films    Determine plan
                                         Receptionist          Tech              Dr
Begin by defining where
the process starts and
                                           Undress                          Bill Sask Health
ends.
                                            Patient                             Secretary

                                                                            Pay for services
                                                                              Sk Health
                                          Each step may have several
                                          sub-steps. Capture these and
                                          list them under the main step.


                                   Why Process Map?
                                   A map of the patient’s journey will give you:
                                         • Key starting point to any improvement project, large or small,
                                              which is tailored to suit your own organization or individual
                                              style.
                                         • The opportunity to bring together multi-disciplinary teams and
                                              bring together people from all roles and professions to create
                                              a culture of ownership, responsibility, and accountability.
                                         • An overview of the complete process, helping staff to under-
                                              stand, often for the first time, how complicated the system
                                              can be for patients. For example, how many times a patient
                                              has to wait (often unnecessarily), how many visits they make
                                              to hospital, and how many different people they meet.
                                         • An aid to effectively plan where to test ideas for improvement
                                              that will likely have the greatest impact on the improvement
                                              aims.


Patient Experience Survey: Quality Improvement Guide                                                 R- 4
Health Quality Council 2006
Process Mapping
                                               •   Brilliant ideas, especially from staff who don’t normally have
                                                   the opportunity to contribute to service organization, but who
                                                   really know how things work.
                                               •   An event that is interactive, that gets people involved and
                                                   talking.
                                               •   An end product, a process map which is easy to understand
                                                   and highly visual.

Used with permission by the NHS Modernisation Agency, subject to Crown copyright protection. Available from URL:
http://www.modern.nhs.uk/improvementguides/process/4.htm#


                                       How To Run A Process Mapping Session
                                       Setting up the meeting
                                           •   Identify the scope of the process you want to map, including pa-
                                               tient group, start point and end point.
                                           •   If you are unsure which part of the patient’s journey you want to
                                               map, start by mapping a high “macro” level process, to identify
                                               parts of the process that require more attention. For example –
                                               general patient journey from presentation in the ED to discharge
                                               from hospital. (You might then follow this up by looking more
                                               closely at the decision to admit general medicine patient to when
                                               patient arrives on ward.)
                                           •   Identify all stakeholders. It is essential that all the stakeholders
                                               involved in any part of the patient’s journey develop the process
                                               map. If the map is reflective of what actually happens, it will be
                                               easier to secure “buy-in” when it comes to improvements.
                                           •   Convene a workshop. Allow at least 3 hours for the workshop, in
                                               order to carry out both a high “macro” level map, and a low
                                               “micro” level map. You will need a suitable meeting room where
                                               the team can work free of interruptions.
                                           •   Send out invitations. In the invite, clearly explain the purpose of
                                               the meeting. Include contact information so invited participants
                                               can reply, but make sure the contact is someone who can an-
                                               swer questions or concerns prior to the event.
                                           •   Facilitation. You will need a facilitator for the session, ideally
                                               someone who is viewed as being independent. The facilitator’s
                                               role is to keep the session on time and to identify any issues or
                                               solutions as they arise. He or she does not directly provide input
                                               into the process map, but ensures everyone makes a contribu-



Patient Experience Survey: Quality Improvement Guide                                                         R- 5
Health Quality Council 2006
Process Mapping
                                              tion. It might also be useful to have another person on hand to
                                              take notes.
                                          •   Shortly before the meeting, follow up with people who have not
                                              yet responded.

                                      On the day
                                         • Gather your resources. You will need: post-it notes, pens,
                                             name labels, white board/large paper.
                                         • Group introductions.
                                         • Introduce the ground rules: No blame, respect diversity of opin-
                                             ion. Limit discussion on a particular issue to 5 minutes, then park
                                             it for follow up later. Focus on what happens 80% of the time.
                                             Focus on patient experience.
                                         • At the beginning of the session: gain agreement from the group
                                             on the scope of the map and record this on the paper.

                                      Map the process
                                        • Ask participants to individually record each step of the process
                                            from their own perspective – what they know happens 80% of
                                            the time. (See Pareto Principle, bottom of page.)
                                        • Participants should then stick the post-it notes on the wall.
                                            Duplicate steps should be placed under one another. Participants
                                            should move steps around until they are happy with order.
                                        • The facilitator should review each step with the group and trans-
                                            fer each step to the white board, to form an agreed upon map.

                                               Pareto Principle
The Pareto Principle describes the 80:20 relationship of cause and effect, efforts and rewards, inputs and out-
puts. It is a way to focus your improvement efforts:

•   Look at any complaints about your service. The Pareto Principle predicts that most of the complaints (80%)
    will be for a few causes (20%). So that is probably the place to start.
•   Look at the types of requests a department receives e.g. pathology and radiology. The Pareto Principle pre-
    dicts that most of the requests (80%) will be for relatively few of all the examinations or tests the department
    offers (20%). Again, showing you where you might start and have the most effect.

So the 80:20 rule, or Pareto Principle, will help you and your improvement aim focus on the areas that will have
the biggest impact when improved.




Patient Experience Survey: Quality Improvement Guide                                                      R- 6
Health Quality Council 2006
Process Mapping
                                          •   As a group, analyze each step in the process (either during or at
                                              the end of the mapping). Identify: Decision points and hand-offs;
                                              main bottlenecks and delays – how long does this process take?;
                                              gaps; necessary and unnecessary steps; problems for patients;
                                              problems for staff.

                                      Next steps—where to now?
                                             • Ask yourself: Is the map accurate? Or do you need more in-
                                                put from others? What issues were identified? What are the
                                                areas for improvement?
                                             • With your redesign team, look at the process map. Discuss
                                                how the process can be simplified, what steps can be modi-
                                                fied and deleted. Prioritize the issues and develop an action
                                                plan for how you are going to tackle them.

                                      Source: Clinical Excellence Commission website. Available from URL: http://
                                      www.health.nsw.gov.au/nursing/pdf/moc-cec-prcss_mpng_guide.pdf

                                      Handy Tip!
                                            Use different coloured post-it notes to differentiate the process
                                            (yellow) from problems/issues (purple) and solutions/ideas (blue).
                                            This will help keep the focus on the current process while captur-
                                            ing all the comments.


                                      Used with permission by the NHS Modernisation Agency, subject to Crown
                                      copyright protection. Available from URL: http://www.modern.nhs.uk/
                                      improvementguides/process/4.htm#




                                      Key Messages for Participants

•   Processes are all around us, but in healthcare our roles limit us to seeing only one small part of
    the whole patient process.
•   It’s not about blaming or criticizing anyone or any department.
•   It’s only the starting point and will lead to lots of other improvement tools and techniques.
•   It’s fun.

       Used with permission by the NHS Modernisation Agency, subject to Crown copyright protection. Available from
       URL: http://www.modern.nhs.uk/improvementguides/process/4.htm#


Patient Experience Survey: Quality Improvement Guide                                                         R- 7
Health Quality Council 2006
Process Mapping
                                       Analyzing the Process Map
                                       Once the process is mapped, analyze it. For each step, answer these
                                       questions:
                                              • Can it be eliminated?
                                              • Can it be done in some other way?
                                              • Can it be done in a different order?
                                              • Can someone else do it?
                                              • Can it be done somewhere else?
                                              • Can it be done in parallel?
                                              • Can any “bottlenecks” be removed?
                                              • Is the most appropriate person doing it?


                                       After you have mapped and analyzed the process, it is time to turn to the
                                       Model for Improvement and devise a plan to test ideas for positive
                                       change. It’s best to try a small change in one step of the process and
                                       see if it leads to an improvement. Several small PDSAs can be run con-
                                       currently, and each one should spark a hunch for a new PDSA.

                                       Other Process Analysis Questions
                                             • How many steps are there for the patient? This is often a real
                                                 revelation for staff.
                                             • How many times is the patient passed from one person to
                                                 another (handed-off)?
                                             • What is the approximate time taken for each step (task time)?
                                             • What is the approximate time between each step (wait time)?
                                             • What is the approximate time between the first and last step?
                                             • How many steps add no value for the patient? Imagine that
                                                 you, or your parent or child, is the patient. What steps add
                                                 nothing to the care being received?
                                             • Where are the problems for patients? What do patients
                                                 complain about?
                                             • Where are the problems for staff?
Used with permission by the NHS Modernisation Agency, subject to Crown copyright protection. Available from URL:
http://www.modern.nhs.uk/improvementguides/process/6.htm




Patient Experience Survey: Quality Improvement Guide                                                        R- 8
Health Quality Council 2006
Process Mapping
                                       Other Ideas for Process Mapping
                                       Activity and Role Lane Mapping
                                       For the parts of the process that are causing problems, consider activity
                                       and role lane mapping. To do this, take the role out of the activity so that
                                       “nurse records vital signs” becomes “record vital signs”. List the process
                                       activities and the roles involved and ask, “who does this now?” as in the
                                       diagram below. This could be followed by a discussion around who
                                       could do each activity if it were redesigned.

                   Activity and role lane mapping – current situation in outpatient clinic
                       Activity/role            Clerk              Nurse             Porter            Doctor
                   Move patient                                      X                 X
                   Record details                 X                                    X
                   Record vitals                                     X                                    X
                   Take history                                      X                                    X
                   Examine patient                                                                        X
                   Write imaging request                                                                  X

Used with permission by the NHS Modernisation Agency, subject to Crown copyright protection. Available from URL:
http://www.modern.nhs.uk/improvementguides/process/6.htm

                                       Tracking the Patient Journey
                                       Tracking the patient journey through the health care system is a simple
                                       way of understanding where problems are and how the service looks
                                       through the eyes of a patient. This exercise complements the process
                                       mapping exercise and allows you to identify waits and delays in real life.
                                       There are two ways of doing this:
                                       •   Physically walking through the patient’s journey with a patient.
                                              Determine with your team the start and end point of the journey
                                              you want to track. In order to gain a true picture of the journey, it
                                              is recommended to track patients who arrive both in and out of
                                              regular hours. It might also be beneficial to dress in the clothes
                                              you would wear as a patient so as not to draw attention. You will
                                              need to gain permission from the patient in order to accompany
                                              them. During the walk through, note both the positive and the
                                              negative experiences, as well as any surprises. What was frus-
                                              trating? What was confusing? (See sample tool, next page.)



Patient Experience Survey: Quality Improvement Guide                                                          R- 9
Health Quality Council 2006
Process Mapping
Sample Patient Tracking Tool
 Date/Time: 04/04/04, 11:00 am
 Start Point (location): ED Triage                          End Point (location): Patient leaves ED for home
 Patient Presenting Problem: Foreign body in eye
 Time             Activity              Where                   Who                    Additional Comments
             All time needs         Where was the        Who                     Positives/Negatives/Surprises/
             to be                  activity carried     undertook the           Frustrations
             accounted for          out                  activity
             e.g. waiting
 11:00       Patient sees           Triage office        ED nurse                Nurse friendly and cheerful but
   am        ED triage                                                           called away halfway through the
             nurse                                                               consultation as someone came in
                                                                                 by ambulance.
 11:30       Patient filled in      Standing at          Patient and
   am        info form              reception            clerk                                                               •


                                               •    Asking patients to keep a diary of their journey.
                                                       The patient diary allows patients to track their journey and
                                                       comment about their experiences along the way. It is particularly
                                                       useful for in-patients, where it is not possible for them to be
                                                       tracked by a staff member. We have included a sample patient
                                                       diary tool; patients can carry this form on a clipboard throughout
                                                       their visit. (See sample, below.)
Sample Patient Diary
    D a te             T im e                  A c tiv ity a n d L o c a tio n                    C o m m e n ts
  0 5 /0 4 /0 4        9 :15 a m      A d m itted to w a rd M , n u rse took           H a d a lrea d y g iv en
                                      m ed ica l history .                             m ed ica l history in E D la st
                                                                                       n ig h t d on ’t k n ow w hy sh e
                                                                                       cou ld n ’t rea d th a t
                       9 :2 5 a m     A t en d of h istory n u rse sa id I             I d on ’t k n ow w h en I w ill
                                      n eed ed ch est x-ra y , d octor w ou ld         h a v e th e chest x-ra y , n u rse
                                      refer m e.                                       sa id sh e w asn ’t su re
                      10 :0 0 a m     A sk ed for cu p of tea
                      11:3 0 a m      M y d a u g hter a rrives
                      12 :0 0 pm      M y d a u g h ter a sk ed th e n u rses          T h ey w ere v ery v a g u e th is
                                      w h en th e d octor w ou ld be com in g to       a ftern oon , bu t th is n u rse
                                      see m e.                                         w a s v ery polite a n d
                                                                                       frien d ly




Source: Clinical Excellence Commission. Available from URL: http://www.health.nsw.gov.au/nursing/pdf/moc-cec-
prcss_mpng_guide.pdf

Patient Experience Survey: Quality Improvement Guide                                                                             R- 10
Health Quality Council 2006
Process Mapping
                                   Some Final Tips and Questions
                                   Tips for Successful Process Mapping
                                                • DO analyze the current process, NOT your ideal
                                                    process.
                                                • DO focus on what happens to most of the patients
                                                    most of the time. OMIT the one-off cases that aren’t
                                                    normal. The faciliatator will need to pull people away
                                                    from drilling down into too much detail.
                                                • DO include every stakeholder in the process,
                                                    including patients and caregivers.
                                                • DO respect all contributions.
                                                • DO raise issues and questions. Debate is good.
                                                • DON’T assign blame.


                                   Frequently Asked Questions
                                   What happens if we can’t get everyone together at the same time?
                                         Consider any of the following variations on process mapping:
                                         • Process mapping can take place with very small groups or
                                            even getting one or two people to walk through and record
                                            the patient’s journey. Then take this map to other small
                                            groups or individuals for their comments.
                                         • Issue the instructions on how to map and set up the blank
                                            map in a place where people go for their coffee breaks. En-
                                            courage them to keep adding to the map over a two-week
                                            period and then produce a tidied up version for final amend-
                                            ments.
                                         • Organize a process mapping day, inviting all relevant staff to
                                            “drop in” at any point within a given timeframe. Cakes and
                                            chocolate are always a powerful way to draw people.

                                   How do I persuade colleagues of the value of spending time mapping
                                   the service?
                                          Explain that this is the best way to start making improvements
                                          and perhaps refer them to other services/colleagues who have
                                          done it. Stress the importance of understanding their contribution
                                          to the work of the service. Also consider if the team is ready for
                                          change and whether the problem with arranging a meeting is
                                          really a reluctance to be involved. In which case, engage your
                                          change agents, champions or sponsors.


Patient Experience Survey: Quality Improvement Guide                                                 R- 11
Health Quality Council 2006
Process Mapping
                                       How will all this really help us?
                                             The combination of process mapping and analysis, measurement
                                             for improvement, matching capacity and demand and improving
                                             flow will result in system improvements for patients. Seeing
                                             improvement is a great boost for the team and gets other people
                                             interested. All process steps needing improvement are identified.
                                             The results of your improvement activities may also provide the
                                             necessary information to support the business case for extra
                                             resources.

                                       What if the team can’t agree on the process map?
                                               • Check that you are mapping the current process, not the
                                                  ideal.
                                               • Check that you are mapping what happens 80% of the time.
                                               • Are there actually two different processes? Does the morning
                                                  team work differently than the evening shift? If so, capture
                                                  both of these processes.
                                               • Gather information on the current process. For example, use
                                                  the patient tracking tool (see page R—10) to see how
                                                  patients move through the system. You do not need to track a
                                                  significant number of patients—just enough to satisfy the
                                                  team they have accurately captured the process.
Used with permission by the NHS Modernisation Agency, subject to Crown copyright protection. Available from URL:
http://www.modern.nhs.uk/improvementguides/process/9.htm


                                       Case Studies
                                       Case Study #1
                                       An Example of a Patient Journey Map
                                       Who does what to the patient?
                                             • GP tells patient that they are being referred to the hospital
                                             • GP tells patient to go home and wait
                                             • Appointment letter is delivered via mail to patient
                                             • Patient arrives at the hospital for the appointment
                                             • Clinic Clerk receives the patient and checks their details
                                             • Nurse checks the patients details before they see a doctor
                                             • Doctor examines patient
                                             • Doctor refers the patient to the relevant department(s) for
                                                diagnostic tests
Used with permission by the NHS Modernisation Agency, subject to Crown copyright protection. Available from URL:
http://www.modern.nhs.uk/improvementguides/process/5_3.htm

Patient Experience Survey: Quality Improvement Guide                                                        R- 12
Health Quality Council 2006
Process Mapping
                                        Case Study #2
                                        Discharge Process – University Hospital Lewisham
                                        The University Hospital in Lewisham, England wanted to reduce the vari-
                                        ability of the discharge process for patients on the orthopedic ward. They
                                        began by measuring number of patients discharged each day from the
                                        ward, and the average length of stay for 80% of patients discharged
                                        each week. The measures helped them see two interesting things in
                                        their current process:
                                                 • There were very few patients discharged on Saturday and
                                                     Sunday – clearly there were two different processes in place
                                                     for weekdays versus weekends, but there was no real benefit
                                                     to having two systems.
                                                 • The current process did not ensure that patients waiting for
                                                     transport (hospital or relative) were transferred to the dis-
                                                     charge lounge by 10 AM. Since typically emergency patient
                                                     demand peaked after 2 PM, this meant that although patients
                                                     were leaving, there still weren’t any free beds.
Used with permission of the Institute for Healthcare Improvement (IHI), c2005. Available from URL: http://www.ihi.org/
IHI/Topics/Flow/PatientFlow/ImprovementStories/
ImprovingPatientFlowbyReducingVariabilityintheDischargeProcessatUniversityHospitalLewisham.htm


                                        Resources
                                        The web sites listed below have helpful resources for process mapping:
                                           • BOLO (Been On Look Out For). This is a list for analyzing the
                                              process map. http://www.isixsigma.com/library/content/
                                              c040301a.asp
                                           • Process Mapping Case Study. This article looks at the process
                                              Valley Baptist Medical Center in Harlingen, Texas went through
                                              to improve their discharge planning. http://
                                              healthcare.isixsigma.com/library/content/c040915a.asp
                                           • TeamFlow software - a free software download for creating an
                                              electronic process map. Great for putting together a final agreed
                                              up on version of the process map. http://www.teamflow.com/
                                              downloads.html
                                           • Running A Process Mapping Session Guide – includes patient
                                              diary and Patient Tracking Tool. http://www.health.nsw.gov.au/
                                              nursing/pdf/moc-cec-prcss_mpng_guide.pdf
                                           • Improvement Leaders Guide for Process Mapping, National
                                              Health Services. http://www.modern.nhs.uk/improvementguides/
                                              process/

Patient Experience Survey: Quality Improvement Guide                                                             R- 13
Health Quality Council 2006
Brainstorming
                                   Overview
                                   What Is Brainstorming and How Can It Help?
                                   Brainstorming is an idea-generation tool designed to produce a large
                                   number of ideas through the interaction of a group of people. Some of
                                   the positives to using this tool include:
                                          • It allows every member of the group to participate.
                                          • It encourages many people to contribute, instead of just one
                                               or two people.
                                          • It sparks creativity in group members as they listen to the
                                               ideas of others.
                                          • It generates a substantial list of ideas, rather than just the few
                                               things that first come to mind; categorizes ideas creatively;
                                               and allows a group of people to choose among ideas or
                                               options thoughtfully.


                                   Brainstorming Steps
                                   Step 1: Getting Started
                                          • The session leader should clearly state the purpose of the
                                             brainstorming session.
                                          • Participants call out one idea at a time, either going around
                                             the room in turn, which structures participation from every-
                                             one, or at random, which may favour greater creativity.
                                             Another option is to begin the brainstorming session by going
                                             in turn and after a few rounds, open it up to all to call out
                                             ideas as they occur.
                                          • Refrain from discussing, complimenting, or criticizing ideas as
                                             they are presented. Consider every idea to be a good one.
                                             The quantity of ideas is what matters; evaluation of the ideas
                                             and their relative merit comes later. This tool is designed to
                                             get as many ideas generated in a short period of time as
                                             possible. Discussing ideas may lead to premature judgment
                                             and slow down the process.
                                          • Record all ideas on a flipchart, or self-adhesive notes, so that
                                             all group members can see them.
                                          • Build on and expand the ideas of other group members.
                                             Encourage creative thinking.
                                          • Keeping going when the ideas slow down in order to create
                                             as long a list as possible and reach for less obvious ideas.
                                          • After all ideas are listed, clarify each one and eliminate exact
                                             duplicates.

Patient Experience Survey: Quality Improvement Guide                                                  R- 14
Health Quality Council 2006
Brainstorming
                                                       •   Resist the temptation to “lump” or group ideas. Combining
                                                           similar ideas will come next.

                                              Step 2: Affinity Grouping
                                              The next step in brainstorming is for participants to organize their ideas
                                              and identify common themes.
                                                     • Take the list of ideas from Step 1 and write each one on indi-
                                                          vidual cards or adhesive notes.
                                                     • Randomly place cards on the table or place notes on flip
                                                          chart paper taped to the wall.
                                                     • Without talking, each person looks for two cards or notes that
                                                          seem to be related and places these together, off to one side.
                                                          Others can add additional cards or notes to a group as it
                                                          forms, or re-form existing groups. Set aside any cards or
                                                          notes that become contentious.
                                                     • Continue until all items have been either grouped or set
                                                          aside. There should be fewer than 10 groupings.
                                                     • Now discuss the groupings as a team. Generate short,
                                                          descriptive sentences that describe each group and use
                                                          these as title cards or notes. Avoid one or two-word titles.
                                                     • Items can be moved from one group to another if a consen-
                                                          sus emerges during this discussion.
                                                     • Consider additional brainstorming to capture new ideas using
                                                          the group titles to stimulate thinking.

                                                 Step 3: Multivoting
                                                 The final step in brainstorming is multivoting. Multivoting is a structured
                                                 series of votes by a team, in order to narrow down a broad set of options
                                                 to a few actionable ones.
                                                           • Take the combined similar items (grouped in affinity group-
                                                                ing) and number each item.
                                                                            • Each person silently chooses one-third of the
Multivoting Table                                                             items. Tally votes.
Group size (number of people)      Eliminate items with less than “x” votes • Eliminate items with few votes. The table be-
            4 to 5                                    2                       side will help you determine how to eliminate
           6 to 10                                    3
                                                                              items. Repeat the multivoting process with
          10 to 15                                    4
                                                                              remaining items, if necessary.
         15 or more                                5



      Used with permission of the Institute for Healthcare Improvement (IHI), c2005. Available from URL: http://www.ihi.org/
      IHI/Topics/Improvement/ImprovementMethods/Tools/Brainstorming+Affinity+Grouping+Multivoting.htm

      Patient Experience Survey: Quality Improvement Guide                                                             R- 15
      Health Quality Council 2006
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide
Quality Improvement Project Guide

More Related Content

What's hot

Quality Health Occurence-Variance Report-Part 1.ppt
Quality Health Occurence-Variance Report-Part 1.pptQuality Health Occurence-Variance Report-Part 1.ppt
Quality Health Occurence-Variance Report-Part 1.pptGamal ElDin Soliman
 
Quality in hospital
Quality in hospitalQuality in hospital
Quality in hospitalMmedsc Hahm
 
PPT ON QUALITY IMPROVEMENT& PATIENT SAFETY
PPT ON QUALITY IMPROVEMENT& PATIENT SAFETYPPT ON QUALITY IMPROVEMENT& PATIENT SAFETY
PPT ON QUALITY IMPROVEMENT& PATIENT SAFETYsoumyareena
 
FOCUS PDCA Quality Imporvement Methodology
FOCUS PDCA  Quality Imporvement MethodologyFOCUS PDCA  Quality Imporvement Methodology
FOCUS PDCA Quality Imporvement MethodologyJoven Botin Bilbao
 
Health quality and management
Health quality and managementHealth quality and management
Health quality and managementDalia El-Shafei
 
Quality and Patient safety goals
Quality and Patient safety goalsQuality and Patient safety goals
Quality and Patient safety goalsrosebless
 
Quality health care
Quality health careQuality health care
Quality health carePS Deb
 
Quality Improvement Project
Quality Improvement ProjectQuality Improvement Project
Quality Improvement ProjectKristen Oxender
 
Quality Assurance in Hospitals
Quality Assurance in HospitalsQuality Assurance in Hospitals
Quality Assurance in HospitalsNc Das
 
developing performance indicators in healthcare
developing performance indicators in healthcare developing performance indicators in healthcare
developing performance indicators in healthcare Mohamed Elfaiomy
 
Healthcare operations management
Healthcare operations managementHealthcare operations management
Healthcare operations managementSABU VU
 
Quality orientation lecture (hospital orientation program)
Quality orientation lecture (hospital orientation program)Quality orientation lecture (hospital orientation program)
Quality orientation lecture (hospital orientation program)Nashwa Elsayed
 

What's hot (20)

Quality Health Occurence-Variance Report-Part 1.ppt
Quality Health Occurence-Variance Report-Part 1.pptQuality Health Occurence-Variance Report-Part 1.ppt
Quality Health Occurence-Variance Report-Part 1.ppt
 
Quality in hospital
Quality in hospitalQuality in hospital
Quality in hospital
 
FOCUS PDCA
FOCUS PDCAFOCUS PDCA
FOCUS PDCA
 
PPT ON QUALITY IMPROVEMENT& PATIENT SAFETY
PPT ON QUALITY IMPROVEMENT& PATIENT SAFETYPPT ON QUALITY IMPROVEMENT& PATIENT SAFETY
PPT ON QUALITY IMPROVEMENT& PATIENT SAFETY
 
FOCUS PDCA Quality Imporvement Methodology
FOCUS PDCA  Quality Imporvement MethodologyFOCUS PDCA  Quality Imporvement Methodology
FOCUS PDCA Quality Imporvement Methodology
 
Applying Lean Six Sigma in Healthcare
Applying Lean Six Sigma in HealthcareApplying Lean Six Sigma in Healthcare
Applying Lean Six Sigma in Healthcare
 
Health quality and management
Health quality and managementHealth quality and management
Health quality and management
 
Quality and Patient safety goals
Quality and Patient safety goalsQuality and Patient safety goals
Quality and Patient safety goals
 
Quality health care
Quality health careQuality health care
Quality health care
 
Risk management in healthcare
Risk management in healthcareRisk management in healthcare
Risk management in healthcare
 
Quality Improvement Project
Quality Improvement ProjectQuality Improvement Project
Quality Improvement Project
 
Quality manual
Quality manualQuality manual
Quality manual
 
Quality Assurance in Hospitals
Quality Assurance in HospitalsQuality Assurance in Hospitals
Quality Assurance in Hospitals
 
Qaulity improvement
Qaulity improvementQaulity improvement
Qaulity improvement
 
developing performance indicators in healthcare
developing performance indicators in healthcare developing performance indicators in healthcare
developing performance indicators in healthcare
 
Healthcare operations management
Healthcare operations managementHealthcare operations management
Healthcare operations management
 
Patient safety culture
Patient safety culturePatient safety culture
Patient safety culture
 
Root cause analysis
Root cause analysisRoot cause analysis
Root cause analysis
 
Quality orientation lecture (hospital orientation program)
Quality orientation lecture (hospital orientation program)Quality orientation lecture (hospital orientation program)
Quality orientation lecture (hospital orientation program)
 
Quality assurance in healthcare delivery
Quality assurance in healthcare deliveryQuality assurance in healthcare delivery
Quality assurance in healthcare delivery
 

Similar to Quality Improvement Project Guide

First steps towards quality improvement: a simple guide to improving services
First steps towards quality improvement: a simple guide to improving servicesFirst steps towards quality improvement: a simple guide to improving services
First steps towards quality improvement: a simple guide to improving servicesNHS Improvement
 
Let My Patients Flow-Streamlining the OR Suite
Let My Patients Flow-Streamlining the OR SuiteLet My Patients Flow-Streamlining the OR Suite
Let My Patients Flow-Streamlining the OR SuiteProModel Corporation
 
Qi step by step guide
Qi step by step guideQi step by step guide
Qi step by step guidedrrskhan
 
Implementing strategic planning getting the thing to work - robert l walker usc
Implementing strategic planning getting the thing to work -  robert l walker uscImplementing strategic planning getting the thing to work -  robert l walker usc
Implementing strategic planning getting the thing to work - robert l walker uscRobert L. Walker USC
 
Taney cqi plan docx
Taney cqi plan docxTaney cqi plan docx
Taney cqi plan docxPHABexchange
 
case_materials_tanzania_08_03.ppt
case_materials_tanzania_08_03.pptcase_materials_tanzania_08_03.ppt
case_materials_tanzania_08_03.pptIsseAwad
 
The 5 Critical Elements to Creating a Project Management Center of Excellence
The 5 Critical Elements to Creating a Project Management Center of ExcellenceThe 5 Critical Elements to Creating a Project Management Center of Excellence
The 5 Critical Elements to Creating a Project Management Center of ExcellenceFlevy.com Best Practices
 
Genesse, Julie Resume 2 10 09
Genesse, Julie Resume 2 10 09Genesse, Julie Resume 2 10 09
Genesse, Julie Resume 2 10 09juliegenesse
 
Bringing forth business value via proper test management process
Bringing forth business value via proper test management processBringing forth business value via proper test management process
Bringing forth business value via proper test management processPhanindra Kishore
 
Continuous improvement rahul (2)
Continuous improvement rahul (2)Continuous improvement rahul (2)
Continuous improvement rahul (2)Rahul Choudhary
 
L2 Strategic Operational Planning.pptx
L2 Strategic  Operational Planning.pptxL2 Strategic  Operational Planning.pptx
L2 Strategic Operational Planning.pptxssuserc89259
 
Implementing Change in the Capacity Planning Group
Implementing Change in the Capacity Planning GroupImplementing Change in the Capacity Planning Group
Implementing Change in the Capacity Planning GroupFrank Isham
 
SOFTWARE MEASUREMENT ESTABLISHING A SOFTWARE MEASUREMENT PROCESS
SOFTWARE MEASUREMENT ESTABLISHING A SOFTWARE MEASUREMENT PROCESSSOFTWARE MEASUREMENT ESTABLISHING A SOFTWARE MEASUREMENT PROCESS
SOFTWARE MEASUREMENT ESTABLISHING A SOFTWARE MEASUREMENT PROCESSAmin Bandeali
 
How to Engage the Workforce to Drive Operational Excellence
How to Engage the Workforce to Drive Operational ExcellenceHow to Engage the Workforce to Drive Operational Excellence
How to Engage the Workforce to Drive Operational ExcellenceJuran Global
 
Implementing Change at Iowa DOT - Path to Performance Management - TRB 01-11-16
Implementing Change at Iowa DOT - Path to Performance Management - TRB 01-11-16Implementing Change at Iowa DOT - Path to Performance Management - TRB 01-11-16
Implementing Change at Iowa DOT - Path to Performance Management - TRB 01-11-16DPutz
 
Performance Management - Herman Augnis
Performance Management - Herman Augnis Performance Management - Herman Augnis
Performance Management - Herman Augnis Preeti Bhaskar
 
Pyramid Healthcare Brochure
Pyramid Healthcare BrochurePyramid Healthcare Brochure
Pyramid Healthcare BrochureSherif Farghal
 
Dr.Rangappa. S. Ashi
Dr.Rangappa. S.  AshiDr.Rangappa. S.  Ashi
Dr.Rangappa. S. Ashirangappa
 

Similar to Quality Improvement Project Guide (20)

First steps towards quality improvement: a simple guide to improving services
First steps towards quality improvement: a simple guide to improving servicesFirst steps towards quality improvement: a simple guide to improving services
First steps towards quality improvement: a simple guide to improving services
 
Let My Patients Flow-Streamlining the OR Suite
Let My Patients Flow-Streamlining the OR SuiteLet My Patients Flow-Streamlining the OR Suite
Let My Patients Flow-Streamlining the OR Suite
 
Qi step by step guide
Qi step by step guideQi step by step guide
Qi step by step guide
 
Implementing strategic planning getting the thing to work - robert l walker usc
Implementing strategic planning getting the thing to work -  robert l walker uscImplementing strategic planning getting the thing to work -  robert l walker usc
Implementing strategic planning getting the thing to work - robert l walker usc
 
Ab cs of-pdca
Ab cs of-pdcaAb cs of-pdca
Ab cs of-pdca
 
Taney cqi plan docx
Taney cqi plan docxTaney cqi plan docx
Taney cqi plan docx
 
case_materials_tanzania_08_03.ppt
case_materials_tanzania_08_03.pptcase_materials_tanzania_08_03.ppt
case_materials_tanzania_08_03.ppt
 
The 5 Critical Elements to Creating a Project Management Center of Excellence
The 5 Critical Elements to Creating a Project Management Center of ExcellenceThe 5 Critical Elements to Creating a Project Management Center of Excellence
The 5 Critical Elements to Creating a Project Management Center of Excellence
 
Pm audit and assessment approach final
Pm audit and assessment approach   finalPm audit and assessment approach   final
Pm audit and assessment approach final
 
Genesse, Julie Resume 2 10 09
Genesse, Julie Resume 2 10 09Genesse, Julie Resume 2 10 09
Genesse, Julie Resume 2 10 09
 
Bringing forth business value via proper test management process
Bringing forth business value via proper test management processBringing forth business value via proper test management process
Bringing forth business value via proper test management process
 
Continuous improvement rahul (2)
Continuous improvement rahul (2)Continuous improvement rahul (2)
Continuous improvement rahul (2)
 
L2 Strategic Operational Planning.pptx
L2 Strategic  Operational Planning.pptxL2 Strategic  Operational Planning.pptx
L2 Strategic Operational Planning.pptx
 
Implementing Change in the Capacity Planning Group
Implementing Change in the Capacity Planning GroupImplementing Change in the Capacity Planning Group
Implementing Change in the Capacity Planning Group
 
SOFTWARE MEASUREMENT ESTABLISHING A SOFTWARE MEASUREMENT PROCESS
SOFTWARE MEASUREMENT ESTABLISHING A SOFTWARE MEASUREMENT PROCESSSOFTWARE MEASUREMENT ESTABLISHING A SOFTWARE MEASUREMENT PROCESS
SOFTWARE MEASUREMENT ESTABLISHING A SOFTWARE MEASUREMENT PROCESS
 
How to Engage the Workforce to Drive Operational Excellence
How to Engage the Workforce to Drive Operational ExcellenceHow to Engage the Workforce to Drive Operational Excellence
How to Engage the Workforce to Drive Operational Excellence
 
Implementing Change at Iowa DOT - Path to Performance Management - TRB 01-11-16
Implementing Change at Iowa DOT - Path to Performance Management - TRB 01-11-16Implementing Change at Iowa DOT - Path to Performance Management - TRB 01-11-16
Implementing Change at Iowa DOT - Path to Performance Management - TRB 01-11-16
 
Performance Management - Herman Augnis
Performance Management - Herman Augnis Performance Management - Herman Augnis
Performance Management - Herman Augnis
 
Pyramid Healthcare Brochure
Pyramid Healthcare BrochurePyramid Healthcare Brochure
Pyramid Healthcare Brochure
 
Dr.Rangappa. S. Ashi
Dr.Rangappa. S.  AshiDr.Rangappa. S.  Ashi
Dr.Rangappa. S. Ashi
 

More from primary

Waves Combined Fht By Size S Ont1
Waves Combined Fht By Size S Ont1Waves Combined Fht By Size S Ont1
Waves Combined Fht By Size S Ont1primary
 
Waves Combined Fht By Size N Ont1
Waves Combined Fht By Size N Ont1Waves Combined Fht By Size N Ont1
Waves Combined Fht By Size N Ont1primary
 
Waittimes
WaittimesWaittimes
Waittimesprimary
 
Usingstoriestoguideaction
UsingstoriestoguideactionUsingstoriestoguideaction
Usingstoriestoguideactionprimary
 
Tips Tools Reg Diet
Tips Tools Reg DietTips Tools Reg Diet
Tips Tools Reg Dietprimary
 
Tobacco,%20alcohol%20and%20abuse%20screening%20tool
Tobacco,%20alcohol%20and%20abuse%20screening%20toolTobacco,%20alcohol%20and%20abuse%20screening%20tool
Tobacco,%20alcohol%20and%20abuse%20screening%20toolprimary
 
The Sk Action Plan For Primary Health Care
The Sk Action Plan For Primary Health CareThe Sk Action Plan For Primary Health Care
The Sk Action Plan For Primary Health Careprimary
 
The Role And Value Of Primary Care Practice
The Role And Value Of Primary Care PracticeThe Role And Value Of Primary Care Practice
The Role And Value Of Primary Care Practiceprimary
 
The Nb Community Health Centers Framework
The Nb Community Health Centers FrameworkThe Nb Community Health Centers Framework
The Nb Community Health Centers Frameworkprimary
 
The Model For Improvement
The Model For ImprovementThe Model For Improvement
The Model For Improvementprimary
 
Teamworking
TeamworkingTeamworking
Teamworkingprimary
 
Strategies For Patient Flow
Strategies For Patient FlowStrategies For Patient Flow
Strategies For Patient Flowprimary
 
Snap%2 B Framework%2 Bfor%2 B General%2 B Practice
Snap%2 B Framework%2 Bfor%2 B General%2 B PracticeSnap%2 B Framework%2 Bfor%2 B General%2 B Practice
Snap%2 B Framework%2 Bfor%2 B General%2 B Practiceprimary
 
Smithermans Vision 2004
Smithermans Vision 2004Smithermans Vision 2004
Smithermans Vision 2004primary
 
Sept%20 Cdmc%20 Links%20 Update
Sept%20 Cdmc%20 Links%20 UpdateSept%20 Cdmc%20 Links%20 Update
Sept%20 Cdmc%20 Links%20 Updateprimary
 
Role Of Rd In Phc
Role Of Rd In PhcRole Of Rd In Phc
Role Of Rd In Phcprimary
 
Rg0035 A Guideto Service Improvement Nhs Scotland
Rg0035 A Guideto Service Improvement Nhs ScotlandRg0035 A Guideto Service Improvement Nhs Scotland
Rg0035 A Guideto Service Improvement Nhs Scotlandprimary
 
Role Of Dieticians
Role Of DieticiansRole Of Dieticians
Role Of Dieticiansprimary
 
Relationship%20 Breakdown
Relationship%20 BreakdownRelationship%20 Breakdown
Relationship%20 Breakdownprimary
 
Rethinking%20 Organizational%20 Change%202
Rethinking%20 Organizational%20 Change%202Rethinking%20 Organizational%20 Change%202
Rethinking%20 Organizational%20 Change%202primary
 

More from primary (20)

Waves Combined Fht By Size S Ont1
Waves Combined Fht By Size S Ont1Waves Combined Fht By Size S Ont1
Waves Combined Fht By Size S Ont1
 
Waves Combined Fht By Size N Ont1
Waves Combined Fht By Size N Ont1Waves Combined Fht By Size N Ont1
Waves Combined Fht By Size N Ont1
 
Waittimes
WaittimesWaittimes
Waittimes
 
Usingstoriestoguideaction
UsingstoriestoguideactionUsingstoriestoguideaction
Usingstoriestoguideaction
 
Tips Tools Reg Diet
Tips Tools Reg DietTips Tools Reg Diet
Tips Tools Reg Diet
 
Tobacco,%20alcohol%20and%20abuse%20screening%20tool
Tobacco,%20alcohol%20and%20abuse%20screening%20toolTobacco,%20alcohol%20and%20abuse%20screening%20tool
Tobacco,%20alcohol%20and%20abuse%20screening%20tool
 
The Sk Action Plan For Primary Health Care
The Sk Action Plan For Primary Health CareThe Sk Action Plan For Primary Health Care
The Sk Action Plan For Primary Health Care
 
The Role And Value Of Primary Care Practice
The Role And Value Of Primary Care PracticeThe Role And Value Of Primary Care Practice
The Role And Value Of Primary Care Practice
 
The Nb Community Health Centers Framework
The Nb Community Health Centers FrameworkThe Nb Community Health Centers Framework
The Nb Community Health Centers Framework
 
The Model For Improvement
The Model For ImprovementThe Model For Improvement
The Model For Improvement
 
Teamworking
TeamworkingTeamworking
Teamworking
 
Strategies For Patient Flow
Strategies For Patient FlowStrategies For Patient Flow
Strategies For Patient Flow
 
Snap%2 B Framework%2 Bfor%2 B General%2 B Practice
Snap%2 B Framework%2 Bfor%2 B General%2 B PracticeSnap%2 B Framework%2 Bfor%2 B General%2 B Practice
Snap%2 B Framework%2 Bfor%2 B General%2 B Practice
 
Smithermans Vision 2004
Smithermans Vision 2004Smithermans Vision 2004
Smithermans Vision 2004
 
Sept%20 Cdmc%20 Links%20 Update
Sept%20 Cdmc%20 Links%20 UpdateSept%20 Cdmc%20 Links%20 Update
Sept%20 Cdmc%20 Links%20 Update
 
Role Of Rd In Phc
Role Of Rd In PhcRole Of Rd In Phc
Role Of Rd In Phc
 
Rg0035 A Guideto Service Improvement Nhs Scotland
Rg0035 A Guideto Service Improvement Nhs ScotlandRg0035 A Guideto Service Improvement Nhs Scotland
Rg0035 A Guideto Service Improvement Nhs Scotland
 
Role Of Dieticians
Role Of DieticiansRole Of Dieticians
Role Of Dieticians
 
Relationship%20 Breakdown
Relationship%20 BreakdownRelationship%20 Breakdown
Relationship%20 Breakdown
 
Rethinking%20 Organizational%20 Change%202
Rethinking%20 Organizational%20 Change%202Rethinking%20 Organizational%20 Change%202
Rethinking%20 Organizational%20 Change%202
 

Recently uploaded

NewBase 14 March 2024 Energy News issue - 1707 by Khaled Al Awadi_compress...
NewBase  14 March  2024  Energy News issue - 1707 by Khaled Al Awadi_compress...NewBase  14 March  2024  Energy News issue - 1707 by Khaled Al Awadi_compress...
NewBase 14 March 2024 Energy News issue - 1707 by Khaled Al Awadi_compress...Khaled Al Awadi
 
AirOxi - Pioneering Aquaculture Advancements Through NFDB Empanelment.pptx
AirOxi -  Pioneering Aquaculture Advancements Through NFDB Empanelment.pptxAirOxi -  Pioneering Aquaculture Advancements Through NFDB Empanelment.pptx
AirOxi - Pioneering Aquaculture Advancements Through NFDB Empanelment.pptxAirOxi Tube
 
HOW TO START EARNING WITH AFFILIATE MARKETING
HOW TO START EARNING WITH AFFILIATE MARKETINGHOW TO START EARNING WITH AFFILIATE MARKETING
HOW TO START EARNING WITH AFFILIATE MARKETINGNATHAN SPEAKS
 
Digital Marketing Training Program skills s
Digital Marketing Training Program skills sDigital Marketing Training Program skills s
Digital Marketing Training Program skills sgodxzyrox
 
Streamlining Your Accounting A Guide to QuickBooks Migration Tools.pptx
Streamlining Your Accounting A Guide to QuickBooks Migration Tools.pptxStreamlining Your Accounting A Guide to QuickBooks Migration Tools.pptx
Streamlining Your Accounting A Guide to QuickBooks Migration Tools.pptxPaulBryant58
 
unfinished legacy it is a clothing brand
unfinished legacy it is a clothing brandunfinished legacy it is a clothing brand
unfinished legacy it is a clothing brandakashm530190
 
We are inviting you on board, to move forward together in the Right Direction
We are inviting you on board, to move forward together in the Right DirectionWe are inviting you on board, to move forward together in the Right Direction
We are inviting you on board, to move forward together in the Right DirectionRight Direction Aero
 
Olympus 38DL Plus Ultrasonic Thickness Gauge
Olympus 38DL Plus Ultrasonic Thickness GaugeOlympus 38DL Plus Ultrasonic Thickness Gauge
Olympus 38DL Plus Ultrasonic Thickness GaugeStephenKim86
 
Green Innovations: Wristbands Ireland's Eco-Friendly Products
Green Innovations: Wristbands Ireland's Eco-Friendly ProductsGreen Innovations: Wristbands Ireland's Eco-Friendly Products
Green Innovations: Wristbands Ireland's Eco-Friendly ProductsWristbands Ireland
 
CXO 2.0 Conference (Event Information Deck | Dec'24-Mar'25)
CXO 2.0 Conference (Event Information Deck | Dec'24-Mar'25)CXO 2.0 Conference (Event Information Deck | Dec'24-Mar'25)
CXO 2.0 Conference (Event Information Deck | Dec'24-Mar'25)CXO 2.0 Conference
 
Importance of Commercial Vehicle Insurance.pptx
Importance of Commercial Vehicle Insurance.pptxImportance of Commercial Vehicle Insurance.pptx
Importance of Commercial Vehicle Insurance.pptxBonano Insurance
 
Pitch Deck Teardown: SuperScale's $5.4M Series A deck
Pitch Deck Teardown: SuperScale's $5.4M Series A deckPitch Deck Teardown: SuperScale's $5.4M Series A deck
Pitch Deck Teardown: SuperScale's $5.4M Series A deckHajeJanKamps
 
Record of Module Forensic photography in
Record of Module Forensic photography inRecord of Module Forensic photography in
Record of Module Forensic photography inalexademileighpacal
 
Business Models and Business Model Innovation
Business Models and Business Model InnovationBusiness Models and Business Model Innovation
Business Models and Business Model InnovationMichal Hron
 
14 march 2024-capital-markets-update eni.pdf
14 march 2024-capital-markets-update eni.pdf14 march 2024-capital-markets-update eni.pdf
14 march 2024-capital-markets-update eni.pdfEni
 
L-1 VISA Business (Plan Sample) - Plan Writers
L-1 VISA Business (Plan Sample) - Plan WritersL-1 VISA Business (Plan Sample) - Plan Writers
L-1 VISA Business (Plan Sample) - Plan WritersPlan Writers
 
0311 National Accounts Online Giving Trends.pdf
0311 National Accounts Online Giving Trends.pdf0311 National Accounts Online Giving Trends.pdf
0311 National Accounts Online Giving Trends.pdfBloomerang
 
Presented by Sabri international .......
Presented by Sabri international .......Presented by Sabri international .......
Presented by Sabri international .......SABRI INTERNATIONAL
 
3BBE: THE FUTURE OF ECOMMERCE PRESENTATION - LOUIS MALAYBALAY
3BBE: THE FUTURE OF ECOMMERCE PRESENTATION - LOUIS MALAYBALAY3BBE: THE FUTURE OF ECOMMERCE PRESENTATION - LOUIS MALAYBALAY
3BBE: THE FUTURE OF ECOMMERCE PRESENTATION - LOUIS MALAYBALAYLouis Malaybalay
 
Mist Cooling & Fogging System Company in Saudi Arabia
Mist Cooling & Fogging System Company in Saudi ArabiaMist Cooling & Fogging System Company in Saudi Arabia
Mist Cooling & Fogging System Company in Saudi Arabiaopstechsanjanasingh
 

Recently uploaded (20)

NewBase 14 March 2024 Energy News issue - 1707 by Khaled Al Awadi_compress...
NewBase  14 March  2024  Energy News issue - 1707 by Khaled Al Awadi_compress...NewBase  14 March  2024  Energy News issue - 1707 by Khaled Al Awadi_compress...
NewBase 14 March 2024 Energy News issue - 1707 by Khaled Al Awadi_compress...
 
AirOxi - Pioneering Aquaculture Advancements Through NFDB Empanelment.pptx
AirOxi -  Pioneering Aquaculture Advancements Through NFDB Empanelment.pptxAirOxi -  Pioneering Aquaculture Advancements Through NFDB Empanelment.pptx
AirOxi - Pioneering Aquaculture Advancements Through NFDB Empanelment.pptx
 
HOW TO START EARNING WITH AFFILIATE MARKETING
HOW TO START EARNING WITH AFFILIATE MARKETINGHOW TO START EARNING WITH AFFILIATE MARKETING
HOW TO START EARNING WITH AFFILIATE MARKETING
 
Digital Marketing Training Program skills s
Digital Marketing Training Program skills sDigital Marketing Training Program skills s
Digital Marketing Training Program skills s
 
Streamlining Your Accounting A Guide to QuickBooks Migration Tools.pptx
Streamlining Your Accounting A Guide to QuickBooks Migration Tools.pptxStreamlining Your Accounting A Guide to QuickBooks Migration Tools.pptx
Streamlining Your Accounting A Guide to QuickBooks Migration Tools.pptx
 
unfinished legacy it is a clothing brand
unfinished legacy it is a clothing brandunfinished legacy it is a clothing brand
unfinished legacy it is a clothing brand
 
We are inviting you on board, to move forward together in the Right Direction
We are inviting you on board, to move forward together in the Right DirectionWe are inviting you on board, to move forward together in the Right Direction
We are inviting you on board, to move forward together in the Right Direction
 
Olympus 38DL Plus Ultrasonic Thickness Gauge
Olympus 38DL Plus Ultrasonic Thickness GaugeOlympus 38DL Plus Ultrasonic Thickness Gauge
Olympus 38DL Plus Ultrasonic Thickness Gauge
 
Green Innovations: Wristbands Ireland's Eco-Friendly Products
Green Innovations: Wristbands Ireland's Eco-Friendly ProductsGreen Innovations: Wristbands Ireland's Eco-Friendly Products
Green Innovations: Wristbands Ireland's Eco-Friendly Products
 
CXO 2.0 Conference (Event Information Deck | Dec'24-Mar'25)
CXO 2.0 Conference (Event Information Deck | Dec'24-Mar'25)CXO 2.0 Conference (Event Information Deck | Dec'24-Mar'25)
CXO 2.0 Conference (Event Information Deck | Dec'24-Mar'25)
 
Importance of Commercial Vehicle Insurance.pptx
Importance of Commercial Vehicle Insurance.pptxImportance of Commercial Vehicle Insurance.pptx
Importance of Commercial Vehicle Insurance.pptx
 
Pitch Deck Teardown: SuperScale's $5.4M Series A deck
Pitch Deck Teardown: SuperScale's $5.4M Series A deckPitch Deck Teardown: SuperScale's $5.4M Series A deck
Pitch Deck Teardown: SuperScale's $5.4M Series A deck
 
Record of Module Forensic photography in
Record of Module Forensic photography inRecord of Module Forensic photography in
Record of Module Forensic photography in
 
Business Models and Business Model Innovation
Business Models and Business Model InnovationBusiness Models and Business Model Innovation
Business Models and Business Model Innovation
 
14 march 2024-capital-markets-update eni.pdf
14 march 2024-capital-markets-update eni.pdf14 march 2024-capital-markets-update eni.pdf
14 march 2024-capital-markets-update eni.pdf
 
L-1 VISA Business (Plan Sample) - Plan Writers
L-1 VISA Business (Plan Sample) - Plan WritersL-1 VISA Business (Plan Sample) - Plan Writers
L-1 VISA Business (Plan Sample) - Plan Writers
 
0311 National Accounts Online Giving Trends.pdf
0311 National Accounts Online Giving Trends.pdf0311 National Accounts Online Giving Trends.pdf
0311 National Accounts Online Giving Trends.pdf
 
Presented by Sabri international .......
Presented by Sabri international .......Presented by Sabri international .......
Presented by Sabri international .......
 
3BBE: THE FUTURE OF ECOMMERCE PRESENTATION - LOUIS MALAYBALAY
3BBE: THE FUTURE OF ECOMMERCE PRESENTATION - LOUIS MALAYBALAY3BBE: THE FUTURE OF ECOMMERCE PRESENTATION - LOUIS MALAYBALAY
3BBE: THE FUTURE OF ECOMMERCE PRESENTATION - LOUIS MALAYBALAY
 
Mist Cooling & Fogging System Company in Saudi Arabia
Mist Cooling & Fogging System Company in Saudi ArabiaMist Cooling & Fogging System Company in Saudi Arabia
Mist Cooling & Fogging System Company in Saudi Arabia
 

Quality Improvement Project Guide

  • 1. Acute Care Hospital Experience Quality Improvement Guide A resource designed to guide you through the 3 phases of an improvement project: Improving the Planning Project management for QI: developing a blueprint for success Reflecting Analyzing current processes: where to begin and what you can do to make change Executing Strategies, tools, and tips for turning ideas into action
  • 2. Atrium Building, Innovation Place 241-111 Research Drive Saskatoon, SK S7N 3R2 Canada P: 306-668-8810 F: 306-668-8820 E: info@hqc.sk.ca W: www.hqc.sk.ca ISBN 1-897155-17-4 Some of the material in this quality improvement guide was supplied by and is used with the kind permission of other organizations, who retain copyright over their original work. © 2006 Health Quality Council Please contact the Health Quality Council for written permission to distribute or copy this document, in whole or in part. Permissions do not extend to any materials within this document that are used with the permission of a third party. Please use the following citation style when referring to this document: N Wohlgemuth, S Oosman, S Furniss. Improving the Acute Care Hospital Experience: Quality Improvement Guide. Saskatoon: Health Quality Council. June 2006. Health Quality Council also wishes to acknowledge the valuable contributions of other team members to the development of this guide: • Catherine Delaney, Knowledge Exchange Consultant • Laurie Gander, Program Director • Mary Smillie, Senior Knowledge Exchange Consultant • Katherine Stevenson, Senior Knowledge Exchange Consultant
  • 3. Project Checklist Are you ready to launch a quality improvement project? You may find this checklist a helpful reference in planning your improve- ment project. As you go through the list, check the box if you can answer “YES” to the statement. This will quickly identify areas where you might need some further planning before you get started. We have a clear goal and scope of the project. We have agreement in the senior clinical and management community that there is a gap between where we are now and where we could be. We have active support from senior clinical and managerial leaders. We have completed the Blueprint for Success or project plan. A leadership team is established and members are aware of their roles and respon- sibilities. (LIST) Our project sponsor(s) is confirmed. We have explicitly described the necessary commitment required and specific roles and responsibilities of front-line team members. As well, we have described our expectations and the expected benefits for the organization and the front-line team(s). (LIST) We have measurement and reporting systems set up. We know how and when we will involve patients, caregivers, and other users of the system we want to improve. We have a process for recruiting the front-line team(s). We have recruited the required front-line team(s) with a designated team leader. a. The front-line team(s) and the team leader(s) is: b. The team(s) will be assembled by: (DATE) Patient Experience Survey: Quality Improvement Guide Health Quality Council 2006
  • 4. Project Checklist The team(s) is able to focus on the project and not get side tracked by other demands. We have secured the necessary budget and other resources required to support all elements of the project. We have completed a “quality improvement skills” training needs assessment for front-line team(s) members. We have support available for the front-line team(s) members to develop the neces- sary quality improvement skills and to complete the project Improvement Charter. We have the necessary support available to enable the front-line team(s) to analyze current care processes. For example, using such tools as process mapping or cause/effect diagram. We know how we are going to launch the project. We are already planning how we will acknowledge the quality improvement achievements made by the front-line team(s). We are already planning how to ensure that the improvements made are continued. We are already planning how to spread the improvements to other parts of the organization. Used with permission by the NHS Modernisation Agency, subject to Crown copyright protection. Available from URL: http://www.modern.nhs.uk/improvementguides/reading/collaborative.pdf Patient Experience Survey: Quality Improvement Guide Health Quality Council 2006
  • 5. Phase One Included in this section is information on: • Key elements of an improvement project • Creating a “blueprint for success” • Developing effective teams Patient Experience Survey: Quality Improvement Guide P—1 Health Quality Council 2006
  • 6. Introduction to QI Planning Lloyd Provost (co-author of the Model of Improvement and the Improvement Guide) identifies three key elements to achieve significant improvement: • The will to do what it takes to change to a new system; • Ideas on which to base the design of the new system; and, • A clear plan of execution of the ideas. (L. Provost, Telehealth Presentation, October 5, 2005) While we often have a strong will to improve and many ideas (from the literature and our own experiences), execution—organizing, supporting, sustaining and spreading improvement—is a challenge we all share. This section of the QI Guide provides a blueprint for success: an out- line of the key elements needed to organize and support an improve- ment project in the acute care setting. This blueprint combines project management and improvement science principles. You may already have your own project planning tool; use the format you prefer. To better plan for success, you might want to ensure that your plan includes: • An explicit statement of what is expected from the improve- ment effort; • What supports the improvement team can expect from the organization; • Any limitations or constraints that must be taken into consid- eration; and, • An individual or team providing overall regional leadership for the improvement of patient experience. After completing this form, you should have a good start on your improvement journey. The next steps will be working with facility/unit level teams in analyzing current processes, identifying opportunities for improvement, and testing ideas on a small scale. Patient Experience Survey: Quality Improvement Guide P—2 Health Quality Council 2006
  • 7. Blueprint for Success Please see the Notes to the Blueprint on page P—5 for more informa- tion on completing this form. 1. Determine priority area (s). You may wish to look at survey results and your organizational goals. 2. Identify RHA leadership team members. Name: Role: . Name: Role: . Name: Role: . Name: Role: . Name: Role: . 3. Improvement aim(s) for region. Aim should be clear, specific, measurable, time-specific, and patient-centred. 4. Project deliverables. What will success look like? a. What numerical target are you striving for on repeat survey (patient perspective)? b. What changes in the system are you expecting (provider behavior perspective)? Patient Experience Survey: Quality Improvement Guide P—3 Health Quality Council 2006
  • 8. Blueprint cont’d Please see the Notes to the Blueprint on page P—5 for more informa- tion on completing this form. 5. Outline project scope. What are the project boundaries? a. Time frame of project: Start date: End date: b. Number of teams necessary to achieve aim: c. Number of facilities and units to be involved: d. Staff time limits for the duration of the project: Hours per week FTE per month e. Cost limits: $ 6. Determine project sponsor(s). 7. Expectations for reporting between RHA leadership team and front-line team(s). 8. Project links to broader RHA goal(s). Project linked to the following RHA goal(s): Patient Experience Survey: Quality Improvement Guide P—4 Health Quality Council 2006
  • 9. Notes to the Blueprint 1. Determine priority area Consider your results from the Patient Experience Survey, as well as broader organizational/regional goals. Examples of prior- ity areas from the survey include discharge planning, provider- patient communications, pain management, etc. 2. Identify RHA leadership team members Some key points to keep in mind when establishing your team: • Ideal team size is 6-12 people • Try to find a range of expertise • Include both the “keen” and “not so keen” More information on teams is included in Additional Information, starting on page P—7. 4. Project deliverables What will success look like? Consider both: • An outcome goal, or numerical measure. For exam- ple, if your improvement area is discharge planning your goal might be: 100% of our patients will know what side effects to watch for at home. • A process goal, something that will show you if changes to process are resulting in more effective care. For example, if your improvement area is pain management, your goal might be: All patients will have a pain management plan completed and at- tached to their chart. 5. Project scope Determine how many resources (money, time) can be devoted to the project to achieve your aim. Consider: • Project timeframe—when does it start and end? • How many front-line teams need to be established? • How many facilities will be involved and which ones? • Staff time limits—how many FTE hours? 6. Project sponsor(s) The project sponsor can be an individual or a group. The role of the sponsor is to be the liaison between the front-line team and RHA leadership, and to help teams overcome obstacles. Patient Experience Survey: Quality Improvement Guide P—5 Health Quality Council 2006
  • 10. Additional Information Patient Experience Survey: Quality Improvement Guide P—6 Health Quality Council 2006
  • 11. Additional Information: Team Development 1. Team size It’s important to consider size when developing QI teams. A team that is too large may have difficulty coordinating schedules for meetings, and meetings may involve lengthy discussions and little consensus. On the other hand, a team that is too small may be missing representa- tion from key groups, and might feel overwhelmed by having to accom- plish so many tasks with so few resources. The optimal team size is between 6 and 12 members. Optimal team size: not too big, not too small—just right! Patient Experience Survey: Quality Improvement Guide P—7 Health Quality Council 2006
  • 12. Additional Information: Team Development 2. Types of expertise Including the right people on the QI team is critical to successful im- provement efforts. Recruit staff and care providers from all aspects of the patient experience you are trying to improve. For example, if your improvement focus is on discharge planning, your team might include: nurses, physicians, occupational therapists, physiotherapists, social workers, and pharmacists. Each discipline will provide a unique perspec- tive on the processes of care involved in safely transitioning patients from hospital to home. There are three basic areas of expertise that should be part of any team. These include expertise in organizational authorization, clinical or techni- cal expertise, and someone with knowledge about the system of care. You may have one or more individuals with each kind of expertise, or an individual with expertise in more than one area. Regardless, try to en- sure that all three types are represented on your team. Team Sponsor The Team Sponsor should have enough authority in the organi- zation to implement suggested changes and overcome barriers. The Team Sponsor understands the implications of the proposed change on the various parts of the system, as well as the more remote consequences a change might trigger. It is important that the Team Sponsor have authority in all areas affected by the change, and the authority to allocate resources (time, people, money) needed to achieve the aim. Clinical/Technical Experts A Clinical or Technical Expert is someone who knows the subject matter intimately and who understand the processes of care. For Patient Experience, you may want to consider team members who are Technical Experts in your priority area (see page P—11 for a provider-priority area chart). Brainstorming about the proc- ess should help you in selecting appropriate team members. Indi- vidualize your teams to ensure they represent your region/facility/ unit and the variations in the processes of care. Patients should also be considered Technical Experts; your pro- Patient Experience Survey: Quality Improvement Guide P—8 Health Quality Council 2006
  • 13. Additional Information: Team Development ject will be stronger if the patient voice is included on the team. Please see page P—10 for more information on involving patients. Day-to-Day Leaders The Day-to-Day Leader is the driver of the project; they ensure that tests are implemented and data are being collected. It is important that the Day-to-Day Leader understands not only the details of the system, but also the effect changes will have on the system. For Patient Experience, the Day-to-Day Leader may be someone within the unit who is knowledgeable about staff and care processes, but also has the authority to make decisions regarding care and staffing (for example, a nurse or unit manager). Helpful Tool! Assess Your Team This team assessment tool can help your Regional Leadership team in brainstorming members for the facility/unit QI team. As each name is suggested, add them to the following matrix and determine their areas of expertise. This will show you at a glance if your team is well-rounded, and give you an idea of your team’s strengths and potential gaps. Name Team Sponsor Technical Expert Day-to-Day Leader Additional Strengths Jane Doe √ √ John Smith √ You may want to begin by suggesting a few names at the Re- gional Leadership level, then ask these front-line people to select the rest of the team. Used with the permission of the Institute for Healthcare Improvement (IHI), c2005. Available from URL: http:// www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/HowToImprove/formingtheteam.htm Patient Experience Survey: Quality Improvement Guide P—9 Health Quality Council 2006
  • 14. Additional Information: Team Development 3. Involving patients Your efforts to improve the patient experience will be more successful if you include the patient voice on your team. The National Health Services (NHS), based in the United Kingdom, has done extensive work in the area of the “expert patient”. Some of their tips on approaching patients or caregivers to participate on a QI team: • Have clear aims and objectives • Explain project constraints and potential outcomes • Involve more than one patient/caregiver on the team • Be clear about the role of the patients/caregivers on the team • Be aware that involving current or recent patients may present some difficulties • Identify patients/caregivers who will help you meet your aims • Involve patients/caregivers early on in the project Used with permission by the NHS Modernisation Agency, subject to Crown copyright protection. Available from URL: http://www.cgsupport.nhs.uk/Patient_Experience/4@How_to_involve_people.asp Web site resource The NHS has resources and tips for working with patients on quality improvement. Go to: www.cgsupport.nhs.uk and click on the Patient Experience hotlink. Patient Experience Survey: Quality Improvement Guide P—10 Health Quality Council 2006
  • 15. Additional Information: Team Development 4. Matching team members to priority areas When developing your QI teams, it may be helpful to consider your prior- ity area. The chart below shows health care providers who might be included on a team that is planning to focus on a specific priority area. Role Provider-Patient Pain Discharge Hospital Food Communications Management Planning Patient √ √ √ √ Physician √ √ √ Nurse Manager √ √ √ √ Front-line Nurse √ √ √ √ LPN √ √ √ Pharmacist √ √ √ Unit Clerk √ √ Dietary Staff √ Director of Food Services √ Dietitian √ Food Services Manager √ Others (e.g., physiothera- √ √ √ √ pists, occupational thera- pists, social workers, etc.)– depending on priority areas and processes within spe- cific facilities Patient Experience Survey: Quality Improvement Guide P—11 Health Quality Council 2006
  • 16. Additional Information: Team Development 5. Stages of team development After members are selected, participants must move from being a group to becoming a team. The three stages of team development are forming, storming, and performing. Each stage is described in the table below. Stage What it looks like Forming • Members are concerned with inclusion and acceptance. • Interactions are polite and superficial—overt conflict is rare. • Conformity tends to be high. • Group struggles to define its boundaries; establish who is or isn’t part of this group. • Members rely on leader for direction and support. • Goals are not clear. Storming* • Members are concerned with having their unique contributions recognized. • Participation increases; members want to exercise some influence in the group. • Conformity and compliance decrease. • Open conflict increases. • Members begin to take a critical look at the power structure in the group and question how decisions are made. • Members may challenge the leader directly or indirectly. • Members begin to wonder if they can trust others to “pull their weight,” to make meaningful contributions. • Clarification of roles and goals begins. • Ground rules are established. Performing • Members have built a sense of trust and safety within the group. • Members are more friendly and supportive of one another. • All contributions are recognized and appreciated. • Members are clear about their roles and responsibilities. • Conflict is handled openly and constructively. • Members develop a sense of cohesiveness and group identity. • Leader’s role has become less directive and more supportive as members actively take responsibility for setting and achieving group goals. * As uncomfortable as this stage may be, the conflict is a prerequisite to effective group functioning in the final stage. Groups unwilling to work through the storming phase remain dependent on their leader, maintain relatively superficial relationships, and are unable to work effectively be- cause no one is willing to voice differing opinions or points of view. Adapted from: Renz, MA and Greg, JB (2000). Effective small group communication theory and practice. Toronto: Allyn and Bacon Canada. Patient Experience Survey: Quality Improvement Guide P—12 Health Quality Council 2006
  • 17. Additional Information: Team Development 6. Effective meetings Team meetings are an important part of a quality improvement project. Holding both traditional and informal meetings (known as “huddles”) will help move your project forward. The tips listed below can help make your meetings more effective. Starting the meeting It is essential to start meetings with some type of Introduction Exercise or Icebreaker. When you have a large group, or you have a very full agenda, it may seem like a waste of time to conduct personal introduc- tions. But introductions are crucial to the overall comfort, trust, and risk- taking ability of the group. Introductions give group members a way to: • Get to know one another. • Gain a deeper appreciation of each other as individuals. • Understand the mindset of different group members on the meeting day. Some examples of introduction or icebreaker activities: • Have participants meet the person sitting next to them; they then introduce each other to the larger group. • Have each person take something out of his or her wallet, pocket or bag, and explain why it is important. • Have each person in the group identify themselves with a musical instrument, cartoon character, animal, etc (choose one) and explain why. • Ask people to identify themselves and then tell what they had for breakfast that morning. Getting organized It’s important to have an agenda, to make sure that all the necessary discussion takes place, and that the meeting stays on track. The agenda is usually set before the meeting—most often by the person who will lead the meeting. It helps meetings run more smoothly if the agenda is posted in a visible place. An agenda can be changed during the meeting. Sometimes items are added or deleted, or the order of discussion is changed. The chairperson should ask group members if they have additions or changes to the agenda at the beginning of the meeting. It’s also a good idea to assign Patient Experience Survey: Quality Improvement Guide P—13 Health Quality Council 2006
  • 18. Additional Information: Team Development times to each item so that you will know approximately how long the meeting will take. Agendas come in various formats and styles; choose the one that will work best for your meeting and group. For example, you might want to use a grid style that includes “person responsible” and “outcome needed” for each item. Roles and responsibilities • Chairperson. The chairperson takes responsibility for many tasks that keep the meeting running smoothly. The role may be assigned based on position in group or may be shared and rotated among the members. Responsibilities include: • Arranging for the room and refreshments • Setting and distributing the agenda • Starting on time • Leading the meeting • Keeping the group on track • Ending on time • Note-taker. The note-taker records the important comments and decisions that the group makes during the meeting. Notes may be written discretely during the meeting, but many groups prefer to take notes on large flipcharts, so that notes are visible to everyone throughout the meeting. Members can repeat or reword statements for accuracy and better under- standing. It’s important for the notes to be distributed to the group before the next meeting. • Timekeeper. The role of the timekeeper is to keep track of time during the meeting. If an item is taking longer than planned to discuss, the timekeeper would flag this so that the group can decide to defer an item, speed up discussion, or take another tack. Sometimes the chairperson functions as timekeeper, but often this is a separate role. Setting the stage Every meeting should have ground rules. Ground rules are the ex- pected rules of conduct that are important for the group’s full participa- tion and success. Involve the group members in setting the ground rules, Patient Experience Survey: Quality Improvement Guide P—14 Health Quality Council 2006
  • 19. Additional Information: Team Development and then post them on a large piece of paper in the meeting room. This will serve as a visual reminder of what the group has agreed on for meeting conduct. It is not unusual for people to get side-tracked during a meeting. When people either talk about or have questions about something that is not on the agenda, you can write it down on a large piece of paper marked “Issues Bin” or “Parking Lot”. Later, when you have time, the group can return to the “parked” issues. It can be difficult to decide when is- sues belong to the Parking Lot or if they need to be discussed immedi- ately. The chairperson needs to exercise judgment, but can also ask the group for their opinion. It’s very important to include break time on the agenda. People lose interest if they sit too long, so set aside time to stretch and grab a snack or drink. If it’s a short meeting, people may choose not to take a break. It should always be up to the group to decide. You will also find that providing refreshments for the meeting fosters a caring, relaxed atmos- phere. Closing the meeting Renegotiating time and agenda It’s not unusual to find that there is not enough time to discuss all the items on the agenda, or that important items (not on the agenda) come up for discussion during the meeting. The group may decide to defer items to another meeting, meet for a longer time, eliminate items from the agenda, or take some other action. Next steps or action planning It’s a good idea to spend some time at the end of a meeting to clarify any action that needs to be taken, and who will be respon- sible for taking that action. Important decisions/action items can be recorded in the meeting notes. Evaluation techniques Meeting evaluation can be simple or complex. A very simple technique is to have a large piece of paper divided into two columns: “What Was Good About the Meeting” and “How To Improve the Meeting”. The chair elicits and records comments from the group. Patient Experience Survey: Quality Improvement Guide P—15 Health Quality Council 2006
  • 20. Additional Information: Team Development More formal techniques include a written set of questions with a rating scale, agree/disagree, or open-ended formats for mem- bers’ responses. Typical questions include: Do you think we met our objectives for meeting? Did we abide by our ground rules? Another option is to use imagery for creative and somewhat humorous evaluation. For example, ask participants to rate the meeting with reference to different cars: • Did this meeting operate like a Cadillac DeVille— smooth, easy perfection, purring right along? • Or was it like a Ford Escort—predictable, dependable, chugging but getting the job done? • Or was it like the old Edsel—dysfunctional, poorly planned, and unproductive? Was your meeting an Edsel? Ask the group! Adapted from the System for Adult Basic Education Support (SABE) guide, Running Effective Meetings and Facilitating Groups (July 2002). Available from URL: http://www.sabes.org/resources/facilitationguide.pdf Patient Experience Survey: Quality Improvement Guide P—16 Health Quality Council 2006
  • 21. Additional Information: Team Development Huddles Huddles are designed to keep teams informed about the project progress, review previous accomplishments, and make plans for the next steps. Because huddles are more informal than traditional meet- ings, they can occur more frequently. They allow for greater participation of front-line staff, who often can’t arrange schedules to attend longer meetings. They are great for keeping the momentum going. Many teams use them for reviewing and revising Plan-Do-Study-Act cycles. Keys to successful huddles: • Discuss the huddle concept with the team and explain how huddles can be used as a tool to speed improvement. • Agree on a time and place where regular huddles will occur. • Choose a huddle location that is convenient for the team members, particularly those who have the least time available for meetings. • Have a clear set of objectives for every huddle. • Limit the duration of the huddle to 15 minutes or less. • Review the objective of the huddle for that day, then review the work done since the last huddle. Act on the new informa- tion and plan next steps. • Huddle frequently, even daily—particularly when many PDSA cycles are being tested and the team needs to share informa- tion regularly. If you want people to attend meetings, try to make them more convenient! Used with the permission of the Institute for Healthcare Improvement (IHI), c2005. Available from URL: http:// www.ihi.org/NR/rdonlyres/74A9CD6C-B15A-45A1-87DE-FD7E6CE1F23C/654/Huddles1.pdf Patient Experience Survey: Quality Improvement Guide P—17 Health Quality Council 2006
  • 22. Additional Information: Team Development 7. Ten essential ingredients for successful teams Although conflict is to be expected in any team, some common group difficulties can be prevented when teams ensure they have the following essential ingredients: 1. Clarity in team goals. A team works best when everyone under- stands its purpose and goals. If there is confusion or disagree- ment, effective teams work to resolve the issues rather than ignore or sidestep them. 2. Established ground rules. Highly effective teams outline how they will work together and establish behavioural expectations for team members. 3. A work plan. Successful teams outline who will do what and when. Clear action plans help the team identify what resources, materials or training are needed throughout the project so that they can plan accordingly. Work plans also flag uneven distribu- tion of tasks among team members. 4. Clearly defined roles. Teams operate most efficiently if they tap everyone’s talents and all members understand their duties and know who is responsible for what issues and tasks. Roles may need to be re-visited periodically (e.g., as new tasks come to light, member workloads shift, etc.) 5. Balanced participation. One or two members taking responsi- bility for the team’s efforts is neither effective nor sustainable. All members should participate in discussions and decisions, share commitment to the project’s success, and contribute their talents. 6. Open communication. Effective teams share information, thoughts and ideas in an open and direct manner. Team mem- bers seek to understand one another’s perspectives. 7. Beneficial team behaviours. Successful teams encourage all members to use behaviours that make discussions and meetings more effective, such as initiating discussion, listening to others, and working through conflict. Patient Experience Survey: Quality Improvement Guide P—18 Health Quality Council 2006
  • 23. Additional Information: Team Development 8. Established decision-making methods. A team should always be aware of the different ways it reaches decisions, and the consequences of using those methods. For example, when the designated leader makes the decision, others may not fully understand the decision or feel committed to implementing it. 9. Experimentation/creativity. An effective team experiments with different ways of doing things and is creative in its approach. 10. Evaluation. Successful teams evaluate both their functioning and their accomplishments. Portions of these materials are copyrighted by Oriel Incorporated, formerly Joiner Associates Inc and are used here with permission. Further reproductions are prohibited without written consent of Oriel Incorporated. Call 1-800-669-8326. Patient Experience Survey: Quality Improvement Guide P—19 Health Quality Council 2006
  • 24. Reflecting Phase Two This section has information on analyzing current processes, including: • Process mapping • Brainstorming • Focus groups • Fishbone diagrams Patient Experience Survey: Quality Improvement Guide R- 1 Health Quality Council 2006
  • 25. Introduction to Reflecting Understanding Systems To make effective changes, first we need to understand how our system currently works. We don’t intentionally design systems that are flawed, but a well-designed system can become unsatisfactory over time Anyone who has not kept up with the changes in telephones, for exam- ple, knows that a rotary dial telephone limits easy access to services within many organizations. As our culture and technology changes, our systems also need to change. What Is a System? Systems exist all around us: The cardiovascular system; the London underground subway system; the hockey draft system. Systems are defined as a collection of parts and processes organized around a purpose. All systems have three components: • Structures: Things you can touch and see, such as equipment, facilities, committees, roles. • Processes: Steps or actions to achieve the outcome, such as patient pathways. • Patterns: Repetitive features, often cultural, such as behaviours, conversations, and waiting times. Often we get caught up in the “do”; implementing changes without a complete understanding of where change will be most effective. Analyz- ing your current processes can help to make your improvements more meaningful and effective. Remember: All improvement involves change, but not all change will lead to improvement. This section has information on methods to analyze and understand your processes: • Process mapping • Brainstorming • Focus groups • Fishbone diagrams Patient Experience Survey: Quality Improvement Guide R- 2 Health Quality Council 2006
  • 26. Process Mapping Overview Every process has a start and an end. In order to map a process, it is essential to clearly define each of these points. Processes can be simple and short, or complex and long. Processes are usually governed by rules, and they are usually linked with other processes. For example, a process might begin with the symptom and end with resumption of good health. Similarly, a process might begin with the request for an X-ray and end with the results. When examining a process, it is important to detail every point in the chain of action. Be sure to include everyone involved in that process, so that no point of action is missed. Often, no one person knows the entire process. By including everyone in the discussion, we may find that what we think is going on may not, in fact, be what is actually happening! By analyzing the process from start to finish, we identify all the opportunities to make improvements. We also avoid the pitfall of focusing on just one perspective. When mapping a process, it is important to consider the view of all stakeholders, including patients and caregivers: • The only one who knows the whole process is the patient. • Up to 50% of process steps involve a hand-off, leading to the possibility of error, duplication, or delay. • 30 to 70% of what we normally do does not add value for the patient. (Dr. John Bibby) Start by gathering together representatives of all the stakeholders, i.e., everyone who takes part in the process from start to finish. Using a white board or sticky notes, write down the task and the name of the person who carries out that task. Arrange the steps in order, but feel free to add new steps and move steps around at any point. Watch the patterns emerge that may indicate the root of a problem. You may be surprised! Please see the next page for a diagram of a process map. Patient Experience Survey: Quality Improvement Guide R- 3 Health Quality Council 2006
  • 27. Process Mapping Record each step of the process from start to finish. Write down the steps in the sequence they occur. Request Complete Results START FINISH for chest x-ray X-ray communicated Complete req. Take films X-rays to Dr. MD Tech Patient Pt info process films Determine plan Receptionist Tech Dr Begin by defining where the process starts and Undress Bill Sask Health ends. Patient Secretary Pay for services Sk Health Each step may have several sub-steps. Capture these and list them under the main step. Why Process Map? A map of the patient’s journey will give you: • Key starting point to any improvement project, large or small, which is tailored to suit your own organization or individual style. • The opportunity to bring together multi-disciplinary teams and bring together people from all roles and professions to create a culture of ownership, responsibility, and accountability. • An overview of the complete process, helping staff to under- stand, often for the first time, how complicated the system can be for patients. For example, how many times a patient has to wait (often unnecessarily), how many visits they make to hospital, and how many different people they meet. • An aid to effectively plan where to test ideas for improvement that will likely have the greatest impact on the improvement aims. Patient Experience Survey: Quality Improvement Guide R- 4 Health Quality Council 2006
  • 28. Process Mapping • Brilliant ideas, especially from staff who don’t normally have the opportunity to contribute to service organization, but who really know how things work. • An event that is interactive, that gets people involved and talking. • An end product, a process map which is easy to understand and highly visual. Used with permission by the NHS Modernisation Agency, subject to Crown copyright protection. Available from URL: http://www.modern.nhs.uk/improvementguides/process/4.htm# How To Run A Process Mapping Session Setting up the meeting • Identify the scope of the process you want to map, including pa- tient group, start point and end point. • If you are unsure which part of the patient’s journey you want to map, start by mapping a high “macro” level process, to identify parts of the process that require more attention. For example – general patient journey from presentation in the ED to discharge from hospital. (You might then follow this up by looking more closely at the decision to admit general medicine patient to when patient arrives on ward.) • Identify all stakeholders. It is essential that all the stakeholders involved in any part of the patient’s journey develop the process map. If the map is reflective of what actually happens, it will be easier to secure “buy-in” when it comes to improvements. • Convene a workshop. Allow at least 3 hours for the workshop, in order to carry out both a high “macro” level map, and a low “micro” level map. You will need a suitable meeting room where the team can work free of interruptions. • Send out invitations. In the invite, clearly explain the purpose of the meeting. Include contact information so invited participants can reply, but make sure the contact is someone who can an- swer questions or concerns prior to the event. • Facilitation. You will need a facilitator for the session, ideally someone who is viewed as being independent. The facilitator’s role is to keep the session on time and to identify any issues or solutions as they arise. He or she does not directly provide input into the process map, but ensures everyone makes a contribu- Patient Experience Survey: Quality Improvement Guide R- 5 Health Quality Council 2006
  • 29. Process Mapping tion. It might also be useful to have another person on hand to take notes. • Shortly before the meeting, follow up with people who have not yet responded. On the day • Gather your resources. You will need: post-it notes, pens, name labels, white board/large paper. • Group introductions. • Introduce the ground rules: No blame, respect diversity of opin- ion. Limit discussion on a particular issue to 5 minutes, then park it for follow up later. Focus on what happens 80% of the time. Focus on patient experience. • At the beginning of the session: gain agreement from the group on the scope of the map and record this on the paper. Map the process • Ask participants to individually record each step of the process from their own perspective – what they know happens 80% of the time. (See Pareto Principle, bottom of page.) • Participants should then stick the post-it notes on the wall. Duplicate steps should be placed under one another. Participants should move steps around until they are happy with order. • The facilitator should review each step with the group and trans- fer each step to the white board, to form an agreed upon map. Pareto Principle The Pareto Principle describes the 80:20 relationship of cause and effect, efforts and rewards, inputs and out- puts. It is a way to focus your improvement efforts: • Look at any complaints about your service. The Pareto Principle predicts that most of the complaints (80%) will be for a few causes (20%). So that is probably the place to start. • Look at the types of requests a department receives e.g. pathology and radiology. The Pareto Principle pre- dicts that most of the requests (80%) will be for relatively few of all the examinations or tests the department offers (20%). Again, showing you where you might start and have the most effect. So the 80:20 rule, or Pareto Principle, will help you and your improvement aim focus on the areas that will have the biggest impact when improved. Patient Experience Survey: Quality Improvement Guide R- 6 Health Quality Council 2006
  • 30. Process Mapping • As a group, analyze each step in the process (either during or at the end of the mapping). Identify: Decision points and hand-offs; main bottlenecks and delays – how long does this process take?; gaps; necessary and unnecessary steps; problems for patients; problems for staff. Next steps—where to now? • Ask yourself: Is the map accurate? Or do you need more in- put from others? What issues were identified? What are the areas for improvement? • With your redesign team, look at the process map. Discuss how the process can be simplified, what steps can be modi- fied and deleted. Prioritize the issues and develop an action plan for how you are going to tackle them. Source: Clinical Excellence Commission website. Available from URL: http:// www.health.nsw.gov.au/nursing/pdf/moc-cec-prcss_mpng_guide.pdf Handy Tip! Use different coloured post-it notes to differentiate the process (yellow) from problems/issues (purple) and solutions/ideas (blue). This will help keep the focus on the current process while captur- ing all the comments. Used with permission by the NHS Modernisation Agency, subject to Crown copyright protection. Available from URL: http://www.modern.nhs.uk/ improvementguides/process/4.htm# Key Messages for Participants • Processes are all around us, but in healthcare our roles limit us to seeing only one small part of the whole patient process. • It’s not about blaming or criticizing anyone or any department. • It’s only the starting point and will lead to lots of other improvement tools and techniques. • It’s fun. Used with permission by the NHS Modernisation Agency, subject to Crown copyright protection. Available from URL: http://www.modern.nhs.uk/improvementguides/process/4.htm# Patient Experience Survey: Quality Improvement Guide R- 7 Health Quality Council 2006
  • 31. Process Mapping Analyzing the Process Map Once the process is mapped, analyze it. For each step, answer these questions: • Can it be eliminated? • Can it be done in some other way? • Can it be done in a different order? • Can someone else do it? • Can it be done somewhere else? • Can it be done in parallel? • Can any “bottlenecks” be removed? • Is the most appropriate person doing it? After you have mapped and analyzed the process, it is time to turn to the Model for Improvement and devise a plan to test ideas for positive change. It’s best to try a small change in one step of the process and see if it leads to an improvement. Several small PDSAs can be run con- currently, and each one should spark a hunch for a new PDSA. Other Process Analysis Questions • How many steps are there for the patient? This is often a real revelation for staff. • How many times is the patient passed from one person to another (handed-off)? • What is the approximate time taken for each step (task time)? • What is the approximate time between each step (wait time)? • What is the approximate time between the first and last step? • How many steps add no value for the patient? Imagine that you, or your parent or child, is the patient. What steps add nothing to the care being received? • Where are the problems for patients? What do patients complain about? • Where are the problems for staff? Used with permission by the NHS Modernisation Agency, subject to Crown copyright protection. Available from URL: http://www.modern.nhs.uk/improvementguides/process/6.htm Patient Experience Survey: Quality Improvement Guide R- 8 Health Quality Council 2006
  • 32. Process Mapping Other Ideas for Process Mapping Activity and Role Lane Mapping For the parts of the process that are causing problems, consider activity and role lane mapping. To do this, take the role out of the activity so that “nurse records vital signs” becomes “record vital signs”. List the process activities and the roles involved and ask, “who does this now?” as in the diagram below. This could be followed by a discussion around who could do each activity if it were redesigned. Activity and role lane mapping – current situation in outpatient clinic Activity/role Clerk Nurse Porter Doctor Move patient X X Record details X X Record vitals X X Take history X X Examine patient X Write imaging request X Used with permission by the NHS Modernisation Agency, subject to Crown copyright protection. Available from URL: http://www.modern.nhs.uk/improvementguides/process/6.htm Tracking the Patient Journey Tracking the patient journey through the health care system is a simple way of understanding where problems are and how the service looks through the eyes of a patient. This exercise complements the process mapping exercise and allows you to identify waits and delays in real life. There are two ways of doing this: • Physically walking through the patient’s journey with a patient. Determine with your team the start and end point of the journey you want to track. In order to gain a true picture of the journey, it is recommended to track patients who arrive both in and out of regular hours. It might also be beneficial to dress in the clothes you would wear as a patient so as not to draw attention. You will need to gain permission from the patient in order to accompany them. During the walk through, note both the positive and the negative experiences, as well as any surprises. What was frus- trating? What was confusing? (See sample tool, next page.) Patient Experience Survey: Quality Improvement Guide R- 9 Health Quality Council 2006
  • 33. Process Mapping Sample Patient Tracking Tool Date/Time: 04/04/04, 11:00 am Start Point (location): ED Triage End Point (location): Patient leaves ED for home Patient Presenting Problem: Foreign body in eye Time Activity Where Who Additional Comments All time needs Where was the Who Positives/Negatives/Surprises/ to be activity carried undertook the Frustrations accounted for out activity e.g. waiting 11:00 Patient sees Triage office ED nurse Nurse friendly and cheerful but am ED triage called away halfway through the nurse consultation as someone came in by ambulance. 11:30 Patient filled in Standing at Patient and am info form reception clerk • • Asking patients to keep a diary of their journey. The patient diary allows patients to track their journey and comment about their experiences along the way. It is particularly useful for in-patients, where it is not possible for them to be tracked by a staff member. We have included a sample patient diary tool; patients can carry this form on a clipboard throughout their visit. (See sample, below.) Sample Patient Diary D a te T im e A c tiv ity a n d L o c a tio n C o m m e n ts 0 5 /0 4 /0 4 9 :15 a m A d m itted to w a rd M , n u rse took H a d a lrea d y g iv en m ed ica l history . m ed ica l history in E D la st n ig h t d on ’t k n ow w hy sh e cou ld n ’t rea d th a t 9 :2 5 a m A t en d of h istory n u rse sa id I I d on ’t k n ow w h en I w ill n eed ed ch est x-ra y , d octor w ou ld h a v e th e chest x-ra y , n u rse refer m e. sa id sh e w asn ’t su re 10 :0 0 a m A sk ed for cu p of tea 11:3 0 a m M y d a u g hter a rrives 12 :0 0 pm M y d a u g h ter a sk ed th e n u rses T h ey w ere v ery v a g u e th is w h en th e d octor w ou ld be com in g to a ftern oon , bu t th is n u rse see m e. w a s v ery polite a n d frien d ly Source: Clinical Excellence Commission. Available from URL: http://www.health.nsw.gov.au/nursing/pdf/moc-cec- prcss_mpng_guide.pdf Patient Experience Survey: Quality Improvement Guide R- 10 Health Quality Council 2006
  • 34. Process Mapping Some Final Tips and Questions Tips for Successful Process Mapping • DO analyze the current process, NOT your ideal process. • DO focus on what happens to most of the patients most of the time. OMIT the one-off cases that aren’t normal. The faciliatator will need to pull people away from drilling down into too much detail. • DO include every stakeholder in the process, including patients and caregivers. • DO respect all contributions. • DO raise issues and questions. Debate is good. • DON’T assign blame. Frequently Asked Questions What happens if we can’t get everyone together at the same time? Consider any of the following variations on process mapping: • Process mapping can take place with very small groups or even getting one or two people to walk through and record the patient’s journey. Then take this map to other small groups or individuals for their comments. • Issue the instructions on how to map and set up the blank map in a place where people go for their coffee breaks. En- courage them to keep adding to the map over a two-week period and then produce a tidied up version for final amend- ments. • Organize a process mapping day, inviting all relevant staff to “drop in” at any point within a given timeframe. Cakes and chocolate are always a powerful way to draw people. How do I persuade colleagues of the value of spending time mapping the service? Explain that this is the best way to start making improvements and perhaps refer them to other services/colleagues who have done it. Stress the importance of understanding their contribution to the work of the service. Also consider if the team is ready for change and whether the problem with arranging a meeting is really a reluctance to be involved. In which case, engage your change agents, champions or sponsors. Patient Experience Survey: Quality Improvement Guide R- 11 Health Quality Council 2006
  • 35. Process Mapping How will all this really help us? The combination of process mapping and analysis, measurement for improvement, matching capacity and demand and improving flow will result in system improvements for patients. Seeing improvement is a great boost for the team and gets other people interested. All process steps needing improvement are identified. The results of your improvement activities may also provide the necessary information to support the business case for extra resources. What if the team can’t agree on the process map? • Check that you are mapping the current process, not the ideal. • Check that you are mapping what happens 80% of the time. • Are there actually two different processes? Does the morning team work differently than the evening shift? If so, capture both of these processes. • Gather information on the current process. For example, use the patient tracking tool (see page R—10) to see how patients move through the system. You do not need to track a significant number of patients—just enough to satisfy the team they have accurately captured the process. Used with permission by the NHS Modernisation Agency, subject to Crown copyright protection. Available from URL: http://www.modern.nhs.uk/improvementguides/process/9.htm Case Studies Case Study #1 An Example of a Patient Journey Map Who does what to the patient? • GP tells patient that they are being referred to the hospital • GP tells patient to go home and wait • Appointment letter is delivered via mail to patient • Patient arrives at the hospital for the appointment • Clinic Clerk receives the patient and checks their details • Nurse checks the patients details before they see a doctor • Doctor examines patient • Doctor refers the patient to the relevant department(s) for diagnostic tests Used with permission by the NHS Modernisation Agency, subject to Crown copyright protection. Available from URL: http://www.modern.nhs.uk/improvementguides/process/5_3.htm Patient Experience Survey: Quality Improvement Guide R- 12 Health Quality Council 2006
  • 36. Process Mapping Case Study #2 Discharge Process – University Hospital Lewisham The University Hospital in Lewisham, England wanted to reduce the vari- ability of the discharge process for patients on the orthopedic ward. They began by measuring number of patients discharged each day from the ward, and the average length of stay for 80% of patients discharged each week. The measures helped them see two interesting things in their current process: • There were very few patients discharged on Saturday and Sunday – clearly there were two different processes in place for weekdays versus weekends, but there was no real benefit to having two systems. • The current process did not ensure that patients waiting for transport (hospital or relative) were transferred to the dis- charge lounge by 10 AM. Since typically emergency patient demand peaked after 2 PM, this meant that although patients were leaving, there still weren’t any free beds. Used with permission of the Institute for Healthcare Improvement (IHI), c2005. Available from URL: http://www.ihi.org/ IHI/Topics/Flow/PatientFlow/ImprovementStories/ ImprovingPatientFlowbyReducingVariabilityintheDischargeProcessatUniversityHospitalLewisham.htm Resources The web sites listed below have helpful resources for process mapping: • BOLO (Been On Look Out For). This is a list for analyzing the process map. http://www.isixsigma.com/library/content/ c040301a.asp • Process Mapping Case Study. This article looks at the process Valley Baptist Medical Center in Harlingen, Texas went through to improve their discharge planning. http:// healthcare.isixsigma.com/library/content/c040915a.asp • TeamFlow software - a free software download for creating an electronic process map. Great for putting together a final agreed up on version of the process map. http://www.teamflow.com/ downloads.html • Running A Process Mapping Session Guide – includes patient diary and Patient Tracking Tool. http://www.health.nsw.gov.au/ nursing/pdf/moc-cec-prcss_mpng_guide.pdf • Improvement Leaders Guide for Process Mapping, National Health Services. http://www.modern.nhs.uk/improvementguides/ process/ Patient Experience Survey: Quality Improvement Guide R- 13 Health Quality Council 2006
  • 37. Brainstorming Overview What Is Brainstorming and How Can It Help? Brainstorming is an idea-generation tool designed to produce a large number of ideas through the interaction of a group of people. Some of the positives to using this tool include: • It allows every member of the group to participate. • It encourages many people to contribute, instead of just one or two people. • It sparks creativity in group members as they listen to the ideas of others. • It generates a substantial list of ideas, rather than just the few things that first come to mind; categorizes ideas creatively; and allows a group of people to choose among ideas or options thoughtfully. Brainstorming Steps Step 1: Getting Started • The session leader should clearly state the purpose of the brainstorming session. • Participants call out one idea at a time, either going around the room in turn, which structures participation from every- one, or at random, which may favour greater creativity. Another option is to begin the brainstorming session by going in turn and after a few rounds, open it up to all to call out ideas as they occur. • Refrain from discussing, complimenting, or criticizing ideas as they are presented. Consider every idea to be a good one. The quantity of ideas is what matters; evaluation of the ideas and their relative merit comes later. This tool is designed to get as many ideas generated in a short period of time as possible. Discussing ideas may lead to premature judgment and slow down the process. • Record all ideas on a flipchart, or self-adhesive notes, so that all group members can see them. • Build on and expand the ideas of other group members. Encourage creative thinking. • Keeping going when the ideas slow down in order to create as long a list as possible and reach for less obvious ideas. • After all ideas are listed, clarify each one and eliminate exact duplicates. Patient Experience Survey: Quality Improvement Guide R- 14 Health Quality Council 2006
  • 38. Brainstorming • Resist the temptation to “lump” or group ideas. Combining similar ideas will come next. Step 2: Affinity Grouping The next step in brainstorming is for participants to organize their ideas and identify common themes. • Take the list of ideas from Step 1 and write each one on indi- vidual cards or adhesive notes. • Randomly place cards on the table or place notes on flip chart paper taped to the wall. • Without talking, each person looks for two cards or notes that seem to be related and places these together, off to one side. Others can add additional cards or notes to a group as it forms, or re-form existing groups. Set aside any cards or notes that become contentious. • Continue until all items have been either grouped or set aside. There should be fewer than 10 groupings. • Now discuss the groupings as a team. Generate short, descriptive sentences that describe each group and use these as title cards or notes. Avoid one or two-word titles. • Items can be moved from one group to another if a consen- sus emerges during this discussion. • Consider additional brainstorming to capture new ideas using the group titles to stimulate thinking. Step 3: Multivoting The final step in brainstorming is multivoting. Multivoting is a structured series of votes by a team, in order to narrow down a broad set of options to a few actionable ones. • Take the combined similar items (grouped in affinity group- ing) and number each item. • Each person silently chooses one-third of the Multivoting Table items. Tally votes. Group size (number of people) Eliminate items with less than “x” votes • Eliminate items with few votes. The table be- 4 to 5 2 side will help you determine how to eliminate 6 to 10 3 items. Repeat the multivoting process with 10 to 15 4 remaining items, if necessary. 15 or more 5 Used with permission of the Institute for Healthcare Improvement (IHI), c2005. Available from URL: http://www.ihi.org/ IHI/Topics/Improvement/ImprovementMethods/Tools/Brainstorming+Affinity+Grouping+Multivoting.htm Patient Experience Survey: Quality Improvement Guide R- 15 Health Quality Council 2006