4. Laying the Groundwork for Improvement

MODULE 10 | Section 4 of 11

Laying the Groundwork for Improvement

WHERE DO YOU START? DEFINING THE PROBLEM AND SETTING A GOAL

Lean, Six Sigma, and the IHI model all begin with the same step: identifying the problem that needs to be solved. Regardless of the improvement methodology used at your health care setting, you need to first succinctly identify and describe the problem. The following are steps to help guide the improvement implementation process.

1. CREATE A PROBLEM STATEMENT

A problem statement is a concise description of the problem you want to impact. It is used to focus your efforts and to keep you and your team on track for improvement. A problem statement should be specific and describe the nature and significance of the problem.

Here is an example of a problem statement:

 

Laboratory testing in the ED for acute coronary syndrome includes the use of tests that are no longer considered standard practice (e.g., CKMB), leading to unnecessary testing for the patient, wasted processing and review time by providers, and ultimately increased cost to the health care system and possibly also the patient.

Here is another example:

 

Internal Medicine discharges from General Hospital are delayed for hours after discharge orders are placed, leading to wasted time of clinicians and delays in getting patients home from the hospital in the afternoons. We will continue to explore process improvement using this example.

2. CREATE AN AIM STATEMENT

What do you aim to do with project to impact your problem statement? This goal should be specific and measurable. One way to help structure your aim statement is to make it a SMART goal. A SMART goal is Specific, Measurable, Attainable, Relevant, and Time-bound.

S
SPECIFIC
M
MEASURABLE
A
ATTAINABLE
R
RELEVANT
T
TIME BASED

Let’s go back to our one of our problem statements from before:

 

Internal Medicine discharges from General Hospital are delayed for hours after discharge orders are placed, leading to wasted time of clinicians and delays in getting patients home from the hospital in the afternoons.

Initial goal statement:

 

Increase the number of discharges from our hospital in the mornings.

IS THIS SPECIFIC?

IS IT MEASURABLE?

IS IT TIME BOUND?

SMART aim statement:

 

Increase the number of patients discharged and out of their hospital room by 1pm from the acute care floors of General Hospital by 20% (baseline: 10%) within the next four months.

3. CONDUCT A LITERATURE REVIEW

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What do we already know works to address the goal you have in mind? Could one of these approaches work in your clinical environment? Could an adapted version work? Is something new needed?

 

These are all important questions to ask before diving into implementation, something we all want to do! It is first worth your investment to truly understand the current state and frame a structured approach. While it may seem like busy work initially, you will not regret the investment of a literature search, and you’ll likely discover new information that will further refine your proposed intervention. You can also reference these materials with stakeholders and project members.

 

Though a common place to start your review is PubMed, remember that not all research is published by academic journals. Gray literature include reports, working papers, government documents, white papers, and evaluations. Check out UPenn’s curation of grey literature resources for the health sciences.

4. MAKE SURE YOU FULLY UNDERSTAND THE PROBLEM

Once you have a SMART aim set, it is tempting to move straight to implementation, meet your goal, and complete the project! But, it is important to first understand all of the possible reasons and factors contributing to the problem you want to solve. This not only helps to focus and prioritize your efforts, but may also help to identify components you had not previously seen that could lead to unexpected and unintended stalls and waste.

 

Below we will cover three different tools to use to help you to understand the problem you want to impact. Which one you choose to use will depend on the nature of your project and proposed intervention.

FISHBONE/ISHIKAWA DIAGRAMS

Also known as a cause and effect diagram, a fishbone diagram is a visual tool for identifying and categorizing the potential causes of a problem. It can help to identify root causes of the problem in different categories. Below is an example in which the overall problem is diagnostic error.
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USEFUL FOR:

      • Identifying possible causes of a problem
      • Brainstorming new approaches to a problem when others have not led to improvement

PARETO CHARTS

A Pareto chart is a visualization of the distribution of reasons contributing to a problem with both bars to represent frequency in descending order, and a line chart to represent the cumulative total of those reasons. When creating a Pareto chart you may observe what is known as the Pareto principle, or the 80/20 rule. The 80/20 rule states that often for a process, roughly 80% of the problem results from only 20% of the causes. It is therefore beneficial to focus your improvement efforts on this 20%.
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USEFUL FOR:

      • Focusing your efforts on top contributors to an outcome with many causes
      • Visualizing a problem that has many causes

PROCESS MAPPING

PROCESS MAPPING A process map, like the name suggests, is a visual representation of a process broken down into discrete steps. Each step is represented by a shape with lines connecting them in the order of the process. Different types of steps are indicated by different shapes—for example, square for a step, diamond for decision point. There are many different types of process maps, some detailed below.
HIGH-LEVEL

USEFUL FOR:

      • Simplifying complex processes
      • Estimating the amount of time needed for a process
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DETAILED

USEFUL FOR:

      • Understanding complex processes
      • Mapping processes to servicers and highlighting possible complications
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SWIMLANE

USEFUL FOR:

      • Visualizing how and when in a process different stakeholders contribute
      • Estimating amount of time needing per stakeholder for each process
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Whichever tool you decide to use, outlining the contributing causes of the problem you want to impact allows you to understand it and begin to develop a theory of change moving forward. This process sets the stage for the development of your improvement framework.

Learn More

ARTICLE

Read more about developing SMART Aims to make your initiatives implementable and successful.
ACT Academy – NHS Improvement Report. 2018, January.
WEBSITE

Visit this site for additional information about the DMAIC process and associated tools.

Process Improvement Tools and Templates. 2018.
WEBSITE

Want a free tool to make the process maps we’ve discussed? This Google application is handy and customizable for just that.

Flowchart maker and online diagram software
WEBSITE

This software is an add–in for Excel that makes creating the tools discussed here and more simple.

QI Macros website.

REFERENCES

  1. 1- Implementing Value-Based Initiatives: A New Challenge for Clinicians and Healthcare Systems. In: Moriates C, Arora V, Shah N. eds. Understanding Value-Based Healthcare New York, NY: McGraw-Hill. Accessed August 28, 2018.

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