Quality Improvement: Causes and EffectsMarch 18, 2009
Kathleen F. (Kay) Edwards, Ph.D.Quality Improvement Project LeadNational Network of Public Health [email protected]
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
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