Assignment

RADS 4633 CQI

Module V

Quality Management

Terminal Performance Objective  

Upon completion of this unit, the student should be able to recognize and utilize tools for quality management.

Enabling Objectives

Upon completion of this unit, the student should be able to:

• Discuss the importance of checks against bias in data collection.
• Identify the seven tools for collecting and displaying CQI data.
• Identify the nine tools for making CQI improvements.
• Give examples of uses of focus groups in CQI.
• Develop a CQI survey.
• Give examples of check sheet use.
• Cite examples of the uses of logs.
• Define the histogram as a CQI tool.
• State the Pareto principle and its application in chart form.
• Analyze control charts for run length, freaks, trends, sudden shifts, and cycling.

Introduction to the Tools of the Trade

This module will not only introduce you to the tools of the trade but will also give you some concrete ideas on how to use them. CQI cannot be effective if the appropriate tools are not utilized to gather, interpret, and apply your data. This unit will go through several tools for collecting and displaying data in detail. You should not skim through these; their importance will be evident in the module exam.

Checks against Bias in Data Collection

It is virtually impossible to absolutely ensure that gathered data is unbiased. All data collection depends on human input and even the best intentions can lend bias. The text lists seven types of data-collections bias. All of these types of bias can be damaging to your data, and influence the future of your CQI data collection.

Seven Types of Data-Collections Bias

1. Fear Bias

• Fear of repercussions from reporting things as they actually are.
• People will record what they think is desired rather than the reality.

• Distraction Bias

• People get busy and forget to record data, so they guess to avoid admitting the mistake.

• Sampling Error

• Sampling too little data may not represent what is really happening. 
• Include as much as will properly represent all process times and conditions.

• Intrusion Bias

• What you measure will influence the outcome.
• People will work faster if they think speed is an important outcome.

• Perception Bias

• People may gather information from sources they think are important and skip other important ones.
• They may throw out information they perceive as being unimportant.

• Operational Bias

• Lack of training, difficult procedures or lack of time may affect the way data is collected.

• Non-response Bias

• Data has to be complete in order to be valid.
• If people don't gather data, a complete analysis is not possible or valid.

The ideal situation might well be to perform data collection without anyone being aware of the collection. Because this is so rarely possible throughout an entire process, it is important that people are informed and that care is taken to involve and not intimidate people who take part in the process.

Five Steps to Counteract Data Collection Bias

The five steps for counteracting bias can help you gather data that is truthful and useful.

1. Data-collection devices must be "face valid"

• People close to the work have to be able to see how the device will work and how the information gathered is trustworthy and meaningful.

•  Data collectors must be unbiased

• Collectors must be chosen who have easy and immediate access to the process.
• Select collectors whom you believe can be unbiased and explain the importance of this to them.

• Forms must be simple

• Forms should be so clear that they are self-explanatory.

• Test and refine your forms and instructions

• Using the people who work with them, pinpoint problems and fix them.

• Audit the data-collection process

• Check up on data-collection in a non-threatening way.
• Use multiple collectors simultaneously to find out if there is collection variability.
• If there is, fix the process to eliminate it.

Tools of Continuous Quality Improvement

Now let's look at the tools that solve problems and make improvements.  Some can be used to collect data, others to display data, and still others to collect and display data at the same time.

There are seven tools for collecting and displaying data

1. Focus groups
2. Surveys
3. Check sheets
4. Logs
5. Histograms
6. Pareto charts
7. Trend and run charts

Also, there are nine tools for making improvements (which will be discussed in detail in Unit 6)

1. Flowcharts
2. Brainstorming
3. Affinity charts
4. Relationships diagrams
5. Cause-and-effect diagrams
6. Force-field analysis
7. Decision matrices
8. Tree diagrams
9. Tools for action-planning

These sixteen tools will allow you to organize, interpret, and analyze the mountains of information your hard work has reaped. Although there are a great many more tools than just these fourteen, we will focus on the ones listed. These tools have proven to be the most flexible and easy-to-use tools for collecting and displaying data, and for making improvements.

Tools for Collecting and Displaying Data

At this point, you have already determined that you have a process that has problems, and you know it needs to be fixed. You need to identify the customer, determine operational requirements, monitor performance, and then use your data to make improvements.

But which tools? When are they useful? The first step is to decide what questions need to be answered. In other words, what do you want to accomplish through the use of this process study? The second step is centered on the determination of the best way to display the answers you find to your questions in a way that is clear and easily communicated. The last step is to determine where, when, and how the data will be collected and who will provide the data.

Tool 1 - Focus Group

A focus group consists of people who have knowledge about the process you wish to study.   That knowledge may be as little as simple perception, so you shouldn't limit the group to persons who are only directly involved. Focus groups can be used to:

• Identify requirements and expectations (with customers and staff)
• Get perceptions of your area's performance in meeting requirements (with customers, staff, and knowledgeable observers)
• Clarify the dynamics, experience, or interaction with your area (with customers, staff, and knowledgeable observers)
• Generate improvement opportunities and ideas (with customers, staff, experts, and knowledgeable observers)
• Field-test changes, solutions, or options in order to refine or select among them (with customers, staff, and experts)
• Develop surveys based on customer expectations (with customers and staff)
• When forming a focus group, be sure that the members know why this group is necessary and what the goal is.

Procedure:

Before the Focus Group:

• Find a place conducive to the meeting that is free of distraction and has one large table and several chairs.
• Make your purpose clear to the participants ahead of time.
• Prepare a guide that includes open-ended questions that encourage a range of responses and that search for specifics such as who, what, when, why, and where.
• Test your questions on non-participants, and get reactions and suggestions.

During the Focus Group:

• Introduce the purpose.  Give a brief description and let everyone know that this is what the focus will be.
• Introduce everyone.
• Tell everyone the ground rules.  Let them know that no decisions or agreements are going to be made; this is an information gathering session.
• Conduct discussion.  Acting as facilitator takes some practice and patience.  Do not intervene in the discussion until enough people have contributed that a variety of opinions have been established.  Do not allow arguments or sidetracking.  A flip chart documenting the discussion can be very helpful. A predetermined chart that includes the key points for discussion can be handed out at the beginning.  This will help everyone stay within the proper discussion.
• End the session with appreciation.  If you want to meet with these participants again, let them know that, and make sure they understand how beneficial their input is.

After the Focus Group

• Summarize what was discussed as soon as possible, and be sure not to interpret the discussion; simply describe it.
• Make sure to note dominant themes and points.
• Present the results to others who can help you interpret, draw conclusions, and make decisions.

Tool 2 - Surveys

Surveys can be an effective way to gather perceptual and factual information which can be tallied easily. However, there are some pitfalls.  Be very careful when developing a survey not to ask biased questions. It's important to remember that the manner in which you design your questions will have a direct impact on how the questions are answered.

Asking questions about patient waiting times may affect the respondent's perception. For example, the answer to the question, "Do you feel that waiting 10 minutes in the waiting room is too long without a TV to watch?", not only may not have relevance to your problem but may spark respondents to complain that no TV is available in the waiting area.

A more appropriate question might be, "How long did you wait to be taken into a room for your examination?". This question allows you to limit response choices to specific times such as 5 minutes, 10 minutes, etc., or ranges of times such as 0-5 minutes, 5-10 minutes, etc. The first question allowed only a "yes" or "no" response, and since the respondents' actual waiting time and perceptual waiting time may not agree, what did the question really tell you?

You must also be careful not to ask questions that are sexually, ethnically, or socioeconomically biased. You don't want to make people mad; you just want to gather pertinent information.

Uses of Surveys

Surveys can be used in the following ways:

• To identify customer or staff expectations and needs.
• To monitor customer satisfaction.
• To identify the discrepancy between real and desired performance to target problems.
• To measure the effects of an improvement to see customer or staff perception improvement.
• To get reactions to hypothetical improvement alternatives.
• To tune your staff into their customers.
• To show your customers or staff that you care what they think.

How to Develop and Conduct a Survey

• Be clear about the purpose of the survey<
• What do you want to find out?
• Be clear about whom you want to survey
• Who are the respondents?  In-patients? Out-patients?  All of them?
• Design questions that line up with your purposes
• Brainstorm with others to ensure the questions solicit the information you need.
• Get a group together that represents the survey group
• Let them help you clarify and simplify your questions and survey.
• Determine how to survey people so that you have confidence in the results
• Standardize the survey introduction, the words to be used, and the conditions under which respondents complete the survey
• If you decide to distribute the surveys different ways, make sure the surveys are the same.
• Train the people involved in distributing the survey and collecting the data.

Types of Survey Instruments

• Service Report Card
• A short survey, usually on a relatively small card, often seen at store check-out counters.
• General Survey
• A comprehensive set of questions designed to collect data about the general satisfaction of many different services.
• Specific Survey
• A selection of questions designed to solicit perceptions and data about specific services.  Usually confined to a department or area within a department.

Tips for Developing Surveys

• Consult your customers
• Develop good questions that are clear, easy to read and easy to understand.
• Give the respondent a range of possible responses.
• Keep it unbiased.
• Avoid language such as horrible, so-so, wonderful, awesome.
• When using a scale for customers to rate services, the highest and lowest ends must be of equal intensity.
• If you use "Rarely" as the low end of the scale, then the high end needs to be "Often".
• Include only real possibilities.
• Avoid using any choice on a survey that you are not able to accommodate.
• Avoid using the words "Always" or "Never" as both are rare occurrences in daily life.
• Avoid survey overkill.
• If you perform surveys too often, customers will begin to tire of them and stop completing them.
• Use available resources.
• Marketing, risk management, and other areas within your organization may be able to provide you with surveys you can modify to fit your needs.
• Don't waste time reinventing the wheel.
• Involve the staff.

While it is important to keep the varied personal opinions of staff out of the surveys, it is also important to have their input.

When the staff collects data, it helps to raise their awareness of customer expectations.

Care must be taken to ensure that staff assistance is balanced against the possibility of impure data.

Tool 3: Check Sheets

A check sheet is a form designed to make recording data easier.  It is usually in the form of a table, and a check mark is placed to reflect an observation or action.  With a check sheet, you can count the frequency of an event or action within specified time periods.  Because things are recorded as they happen, analysis of results, patterns, and conclusion formation can be done later.

Check sheets can be used to:

• Trigger discussion of performance.
• Results will yield trends, frequencies of key events, and the distribution of data that may suggest theories about causes.
• Search for primary causes.
• Check sheets can show how people, equipment, methods, and materials affect a problem.
• Measure the results of a solution or improvement.
• Continuously monitor a process.
• Check sheets are an easy way to see the gains of your process and reveal reappearing problems.

Example:

Weekly Check Sheet of Information Missing from Radiology Requests

Collector:                                                    Week ending:
Information:	In-patient Floors
2-N	2-S	3-N	3-S	4-N	4-S	Nursery	ICU
Exam ordered
Pt. History
Patient complaint
Ordering physician
Diagnosis
Totals