Tools for Grantees: Quality Management Manual < Previous | Home | Next >  III. Step-By-Step Quality Management Guide: Nine Critical Steps   Study and Understand the Process   •  Analyze the root causes.    •  Utilize CQI tools and techniques to understand the process, such as flow charts, facilitated brainstorming, cause and effect diagrams, fishbone, etc.    •  Document and track progress by using activity logs, issue identification logs, meeting minutes, etc.    •  Report progress to senior leadership and staff on a regular, defined basis.

Analyze the root causes.  TOP

Once the team is in place and a clear team aim has been provided, the team will enter into the process of determining the root causes of the problem or opportunity for improvement. Skipping or short-cutting this point in the process may lead to changes and improvement strategies that do not address all of the key issues, and therefore, do not lead to the desired improvement. While the list of root causes may appear to be extensive, further analysis often identifies overlapping issues.

Utilize CQI tools and techniques to understand the process, such as flow charts, facilitated brainstorming, cause and effect diagrams, fishbone, etc.  TOP

Various quality improvement tools and techniques can be used to help understand the process, such as flow charts, facilitated brainstorming, cause and effect diagrams, fishbone, as well as others.

Flowchart: A flow chart is one of the most useful quality improvement tools as it depicts the sequence of steps performed in a specific process. By studying the process, a common understanding is gained by the team members and misconceptions of how the process works are reduced.

The purpose of the flowchart is to identify the actual path a process follows and to ultimately have a process that is predictable, consistent, and has minimal waste. By documenting a process in this manner, the team is be able to identify redundancies, inefficiencies, misunderstandings, and waiting loops. The flow chart also allows the team members to gain a better understanding of how a process should be performed. Because a single process often involves individuals from different disciplines, departments, and/or agencies, it is important to include representatives from all areas who touch the process at one or more points. In some cases, this will include individuals external to the program or department.

Once a flow chart is created that depicts the way a process currently works (Figure 4), a second flow chart should be created to document the ideal path the process should take (Figure 5).

Figure 4 (Current Process) & Figure 5 (Improved Process)

Developing the flowchart may take some time and may be confusing at first. If developing the flowchart around a process is confusing, it is likely that the process itself is confusing. In order to untangle the process, it must first be understood. Here are a couple of helpful hints to use as you are creating a flow chart:

• Decide on the starting and ending points of the process.
• Brainstorm to record all the activities and decision points involved in the process.
• Arrange activities and decision points in sequence.
• Using this information, create the flow chart.
• Analyze the flow chart.

Cause and Effect Diagram: Cause and Effect Diagram, sometimes called a “fishbone” diagram (because of its shape) or an “Ishikawa” diagram (after Kaoru Ishikawa, the diagram’s creator), focuses on causality (Figure 6). It is intended to illustrate the range of causes that lead to a particular outcome. The diagram helps a team visualize how the various components relate to one another and highlights specific conditions that require further attention.

The cause and effect diagram helps the team identify and define an outcome or a problem, determine causes of a given outcome or problem, and identify causes for variation in a process. Review of the cause and effect diagram can help lead the group to appropriate actions and provide ideas for data collection in order to measure performance.

Key steps in creating a cause-and-effect diagram include the following:

• Place the outcome (or problem statement) on the right side of the paper, halfway down: draw a horizontal line across the paper with an arrow pointing to the outcome.
• Determine major categories for the causes; connect them to the horizontal line with diagonal lines.
• Note the major causes and place them under the general categories. This step will take some time. To assure that no causes are missed the team should ask themselves why or how five times.
• Try to list sub-causes and place them under the main causes. Not every main cause has a sub-cause but the more detailed the diagram the easier it will be to determine an improvement strategy.
• Evaluate the diagram for obvious areas for improvement, causes that are readily solved or eliminated and areas needing further study or additional data collection to be better understood.

Figure 6. Cause and Effect Diagram (Fishbone)
Analysis of Performance of PAP Smears

A fishbone illustrates the range of causes that lead to a particular outcome. The diagram helps a team visualize how the various components relate to one another and highlights specific conditions that require further attention.

Source: HIVQual Group Learning Guide (2002). NY AIDS Institute http://www.hivguidelines.org

Document and track progress by using activity logs, issue identification logs, meeting minutes, etc.  TOP

Without proper documentation, it is easy to lose track of the progress made. Documenting the team’s work helps to assure focus and may minimize rework. By clearly documenting progress made from one meeting to the next, the team can become more efficient in the team meetings. The tracking method does not have to be complicated or cumbersome, but merely captures the key issues discussed, decisions made, and action steps to be taken.

To ensure accuracy and timeliness, tracking logs and meeting notes should be updated, generated, and distributed immediately after each meeting. This will reinforce the issues discussed, decisions made and inform any team members who were absent. The notes can also serve as a forum to communicate progress to senior leadership and/or the rest of the staff. Such documentation also provides a consolidated process for demonstrating agency compliance with CARE Act legislative requirements related to quality management.

Report progress to senior leadership and staff on a regular, defined basis.  TOP

Communication of the team’s progress on a regular basis will help to promote buyin from senior leadership, staff, and when appropriate, your clients/patients. Senior leaders may request a high-level summary, where as staff may benefit from the details of the team’s discussions. One strategy that has proven to be successful in various Ryan White funded agencies is the inclusion of QM activity reports at every staff, department, and/or program meetings.