Quality Improvement: Causes and EffectsMarch 18, 2009

Kathleen F. (Kay) Edwards, Ph.D.Quality Improvement Project LeadNational Network of Public Health Instituteskedwards@nnphi.org410-547-3050

Why is evaluation of public health work important?

• It shows others what is being done

• It should assist with resource allocation

• It can lead to improved methods

• It should lead to better decisions

• It can objectively suggest what is intuitively believed to be fact

Challenges for basing accountability on improving health

outcomes…• Interventions can take a long time before health

effects of them are seen/known• Evidence-based interventions may more likely

be geared to impacting behaviors, rather than health

• Data collection and surveillance systems may not exist to measure the desired change in health

Source: TFAH, 2008, p. 26

Performance management in public health….

Quality Concepts and Tools

POSSIBLE PROBLEMS

PROBLEM DEFINED

POSSIBLE CAUSES

ROOT CAUSE IDENTIFIED

POSSIBLE SOLUTIONS

SOLUTION CHOSEN TO TEST

EXPAND

FOCUS

“Expand-Focus Sequence,” p. 3, Nancy R. Tague, The Quality Toolbox, 2nd Edition. 2005. (American Society for Quality, Quality Press, 2005)

EXPAND

FOCUS

• Do we need to Expand or Focus our thinking?

• Are we working with ideas or numbers?

• What will be the easiest tool that will do the job?

EXPAND

FOCUS

Choosing the Right QI Tool

Getting to the Heart of Tough Problems

Why pause to examine “root causes” of public health performance or quality issues?

Successful Improvement EffortsAnalyze and Address “Root Causes”

Why can’t we make progress on ______________?

Is it because of:– Methods / procedures?– Motivation / incentives?– Materials / equipment– People (personnel, partners, providers, or

patients)?– Information / feedback?– Environment?– Policy?

Root Cause Checklist

• Make sure all possible causes of a problem are identified

• Use list as a prompt to expand thinking if needed

• May be substitute method

Fishbone Technique Cause & Effect Diagram

1. Agree on Problem Statement

2. Generate Causes

3. Construct Diagram

PROBLEM STATEMENT

Thank you…...Kay (Edwards)

Root Cause Analysis

Peter Tabbot & Mitchel Rosen

MLC Grantees Meeting

March 18, 2009

Why Root Cause Analysis?

• Planning process not routinely conducted

• Upfront planning to collect “baseline”

• Tool for finding and correcting…

…the most important reasons for performance problems

…the most basic causal factors

…underlying errors/failures

What did we do?

• Presented models of root cause analysis

• Presented many models

• Practice, practice, practice….

How to apply tool?

• Identifying causes of problems

• Identifying solutions

Examples

• Key stakeholders

• Barriers to vaccination

Lessons learned

• Practice, practice, practice

• Seems simple, but…takes a long time to get it right

• Time consuming process

• Stick with one or two models

• Involves deep analysis

5 Whys

• Helps a team focus on same problem• Trace chain of causality• 5 iterations is generally sufficient• Nature of problem & solution become clear• Leads to statement of cause• Team can take action

5 Whys – Issues

• Tendency to stop at symptoms• Inability to go beyond current knowledge• Are we asking the right ‘Why’ questions?• Results aren’t repeatable

(different people produce different causes)• If event is still occurring, you haven't gotten

to root cause

5 Whys

Problem (Effect)

Why?Why?Why?Why?Why?

5 Whys

Our influenza clinic was poorly attended• Why?Residents had many opportunities• Why?There was a lot of competition• Why?Pharmacies are in on the action• Why?It brings customers in• Why?They can ‘multi-task’ in one stop

5 Whys

Our influenza clinic was poorly attended• Why?Residents had many opportunities• Why?We didn’t advertise it well• Why?Inclement weather was a factor• Why?Our price wasn’t competitive• Why?The location wasn’t convenient

5 Whys

My off white carpeting must be replaced• Why?The carpeting has been stained• Why?My elder cat vomits periodically• Why?She is upset about something• Why?Her environment was compromised• Why?I introduced a new kitten a year ago

5 Whys – Expanding the Scope

My off white carpeting must be replaced• Why?The carpeting has been stained• Why?My elder cat vomits periodically• Why?She is upset about something• Why?She is not brushed frequently enough• Why?She is not hydrated• Why?Frequency, location & quantity of food• Why?Bowl has become a problem

5 Whys

I had to replace my car motor• Why?The motor seized while in transit• Why?There was insufficient oil• Why?I have not maintained my car• Why?I am an irresponsible boy

5 Whys – Expanding the Scope

I risk not affording my home construction• Why? I had to replace my car motor• Why?I had to install curtain drainage• Why?I had to pay for a pres. dose septic• Why?I changed the floor plan midstream• Why?I prefer granite countertops

5 Whys

• If event is still occurring, you haven't gotten to root cause

Getting to the Getting to the ““RootRoot”” of Root of Root Cause AnalysisCause Analysis

Cathy MontgomeryCathy MontgomeryFlorida Department of HealthFlorida Department of Health

March 19, 2009March 19, 2009

% of adolescents that are overweight (2006)% of adolescents that are overweight (2006)

FloridaFloridaTarget = 5%↓Target = 5%↓

Alachua

Martin

Okaloosa

BakerBay

Bradford

Brevard

Broward

Calhoun

Charlotte

Citrus

Clay

Collier

Columbia

De Soto

Dixie

Duval

Escambia

Flagler

Franklin

Gadsden

Gilchrist

Glades

Gulf

Hamilton

Hardee

Hendry

Hernando

Highlands

Hillsborough

Holmes

Indian River

Jackson

Jefferson

Lafayette

Lake

Lee

Leon

Levy

Liberty

Madison

Manatee

Marion

Miami-DadeMonroe

Nassau

Okeechobee

Orange

Osceola

Palm Beach

Pasco

PinellasPolk

Putnam

Santa Rosa

Sarasota

Seminole

St Johns

St Lucie

Sumter

SuwanneeTaylorUnion

Volusia

Wakulla

Walton Washington Target Met

NULL

NO

64 33 16 15

0%

20%

40%

60%

80%

100%

All S M L

Total No

Total Yes OpportunityOpportunity

N = 64N = 64

% of CHD programs conducting a customer satisfaction process (2008)

FloridaTarget = 80↑

Alachua

BakerBay

Bradford

Broward

Charlotte

Collier

De Soto

DixieFlagler

Franklin

Gadsden

Gilchrist

Glades

Gulf

Hamilton

Hardee

Hendry

Hernando

Hillsborough

Holmes

Indian River

Jackson

Jefferson

Lafayette

Lake

Lee

Leon

Levy

Madison

Manatee

Miami-Dade

Nassau

Orange

Osceola

Palm Beach

Pasco

Pinellas

Sarasota

St Johns

Sumter

SuwanneeTaylorUnion

Volusia

Wakulla

Walton Washington

Brevard

Calhoun

Citrus

Clay

ColumbiaDuval

Escambia

Highlands

Liberty

Marion

Martin

Monroe

Okaloosa

Okeechobee

Polk

Putnam

Santa Rosa

Seminole

St Lucie

Target MetYESNO

48 2711 10

19 6 8 5

0%

20%

40%

60%

80%

100%

All S M L

Total No

Total Yes N = 67

Baker (S)Baker (S)Clay (M)Clay (M)DeSoto (S)DeSoto (S)Duval (L)Duval (L)Glades (S)Glades (S)Martin (M)Martin (M)Monroe (S)Monroe (S)Nassau (S)Nassau (S)St. Johns (M)St. Johns (M)St. Lucie (M)St. Lucie (M)

Multi-County Learning CollaborativeMulti-County Learning Collaborative

Implementation – The ProjectImplementation – The Project

• Utilizing the QIC StoryUtilizing the QIC Story– PDCA model for PDCA model for

improvementimprovement– Incorporates quality tools Incorporates quality tools

and methodsand methods• Identifying root causesIdentifying root causes

– target populationtarget population– ““focus groups”focus groups”

• Selecting evidenced-based Selecting evidenced-based or model practicesor model practices

SuccessesSuccesses

• Collaborative completed multiple attempts Collaborative completed multiple attempts at root causeat root cause

• Eight (8) of ten (10) CHDs have completed Eight (8) of ten (10) CHDs have completed root cause analysisroot cause analysis

• CHDs utilized information to select CHDs utilized information to select workplan activitiesworkplan activities

ChallengesChallenges

• Face-to-face training is a MUST!Face-to-face training is a MUST!

• Lack of participation in focus groupsLack of participation in focus groups

• Insufficient data to validate root causeInsufficient data to validate root cause

• Participants “backing into” solutionsParticipants “backing into” solutions

• Frustration level of participantsFrustration level of participants

Lessons LearnedLessons Learned

• Assess audience knowledge of QI toolsAssess audience knowledge of QI tools

• Use multiple experts to provide technical Use multiple experts to provide technical assistanceassistance

• Don’t need to make the collaborative Don’t need to make the collaborative participants experts in root causeparticipants experts in root cause