East Central Regional Hospital

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East Central Regional Hospital PERFORMANCE
IMPROVEMENT REFRESHER
LL Quality Management Department Revised 11/03
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This is a Typical Organizational Direction !
?
?
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This is the Preferred Organizational Direction !
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East Central Regional Hospital
Our Mission To provide quality mental
health/developmental disabilities care and
treatment to our consumers
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East Central Regional Hospital
Our Vision To use resources, creativity, and
innovation to become a CENTER OF EXCELLENCE.
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Performance Improvement is a continuous effort
of assessment, evaluation and adaptation by an
organization to improve the outcome of services,
processes and functions.
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Performance Improvement is every employees
concern! No matter what your job, you play an
important role in helping provide quality
patient care.
Performance Improvement is on-going! Being
committed to quality doesnt mean reaching a
goal, then quitting. Even when something is
working well, there is room for improvement.
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Performance Improvement Tools
Brainstorming Affinity Diagram Cause and Effect
Diagram (Fishbone) Flow Chart Checksheets Line
Graph Pareto Chart Histograms
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HOW DO WE KNOW WHICH TOOLS TO USE?
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Performance Improvement Tools
(These are Qualitative Tools which focus on data
describing consumers, occurrences conditions)
Tools for generating ideas, setting priorities,
providing direction, understanding root causes,
and helping to understand processes
Brainstorming Affinity Diagram Cause and
Effect Diagram (Fishbone) Flow Chart ,
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Brainstorming
What is Brainstorming ? A tool used by teams for
creative exploration of options in an environment
free of criticism.
Benefits of Brainstorming

• Creativity
• Large Number of Ideas
• All team members involved
• Sense of ownership in decisions
• Input to other Tools

Brainstorming Ground Rules

• Active participation by everyone
• No discussion
• Build on others ideas
• Display ideas as presented
• Set a time limit
• Clarify and combine

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What Is An Affinity Diagram?
A tool that gathers lots of language data, like
ideas and opinions and then sorts and groups the
related ideas.
LL- QM DEPT.
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What Is A Cause and Effect Diagram ? (Fishbone
Diagram)
A tool that helps identify, sort, and display
possible causes of a problem in a process.

• Benefits of Using a Cause and Effect Diagram
• Encourages group participation
• Uses an orderly, easy-to-read format
• Increases knowledge of what is happening in the
  process

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Cause Effect Diagram EXAMPLE Why are
employees late for work?
Methods
Environment
caught by train
Tried a new route
Raining hard
Late for Work
Forgot to set clock
Out of gas
Dog needed walking
car wouldnt start
Son misplaced books
People
Equipment
LL QM Dept.
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What Is A Flow Chart?
A diagram that uses graphic symbols to show the
nature and flow of steps in a process.

• Benefits of Using a Flow Chart
• Promote process understanding
• Provide a tool for training
• Identify problem areas and improvement
  opportunities

Symbols Used in Flowcharts
Start/End
Decision
No
Process Step
Yes
M
Connector
Measurement
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An example of a Flow Chart
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Performance Improvement Tools
(These are Quantitative Tools and focus on
specific measurement units)
Statistical Tools used for measuring performance,
collecting and displaying data, and monitoring
performance over time Check Sheets Line
Graph Pareto Chart Histograms
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CHECKSHEETS
Record data for further analysis, provide a
historical analysis and introduce data collection
methods.
Dwl 11/03
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(The chart above is an example only, not an
actual representation of restrictive procedures
used)
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What Is A Pareto Chart?
A graph using a set of bars to show how often a
problem occurs.

• Why use a Pareto Chart?
• Breaks big problems into smaller pieces
• Identifies most significant factors
• Shows where to focus efforts and improvement
  opportunities
• Allows better use of limited resources

(The chart above is an example only, not an
actual representation of reasons for
re-admissions)
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(The chart above is an example only, not an
actual representation of appointment wait times)
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What Is Data Collection?
Data Collection is obtaining useful
information. The issue is not How do we
collect data? It is How do we obtain useful
data?
Why Collect Data? To establish a factual basis
for making decisions I think the problem
is. becomes The data indicate the problem
is..
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FOCUS-PDCAPerformance Improvement Model
DO
CHECK

• Improvement
• Data Collection
• Data Analysis

• Data for process
• improvement

Examples of Quality in a Hospital Setting JCAHO
1992
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Find A Process to Improve
ThinK High Volume? High Risk? Problem Prone?
Externally mandated? Who will benefit from the
process improvement? How does it fit the mission?
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Organize a Team that knows the process
ThinK Does the team include members who do
the work know the process ?
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Clarify Current Knowledge of the Process
ThinK What are the things that contribute to
the process not working the way we expect it
will? Is this the actual flow of the process or
the perceived flow?
?
Perceived
Actual
?
?
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Understand Causes of Process Variation
ThinK Can we use the data collected to
determine specific, measurable and controllable
variations?
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Select the Process Improvement
ThinK What changes can be made to improve the
process? Can we test the changes in a pilot
project?
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Plan the improvement and continued data
collection.
ThinK How do we make the changes that were
selected as possible solutions and what are our
goals and targets and how can we reach
them?
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Do the improvement, data collection and analysis
ThinK As we begin the process improvement are
we getting the results/outcomes we expected? Are
there any surprises?
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Check and study the results
ThinK If there were surprises or unexpected
outcomes, can we do anything about them? Has the
process improvement been successful, or will it
be necessary to modify the change?
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Act to hold the gain and continue to improve the
process.
ThinK How will the improvement be implemented
beyond the pilot, if one was used, and can the
team find another potential improvement within
the process? Are we prepared to return to
Plan or earlier steps in the FOCUS-PDCA if
needed?
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FOCUS-PDCAPerformance Improvement Model
If necessary, you can start the FOCUS-PDCA again!
DO
CHECK

• Improvement
• Data Collection
• Data Analysis

• Data for process
• improvement

Examples of Quality in a Hospital Setting JCAHO
1992
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East Central Regional Hospital
Working together to improve Services, Safety and
Quality of Care for all our consumers!