Quality Views Newsletter

Volume 1, Issue 2

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Inside this Issue! 

The QI approach-analysis con't.1  

Putting ideas into action, 2  

The Follow-up: Q & A

The Quality Improvement approach Analysis of data (con't. from Issue 1) The previous edition of Quality Views reviewed the first three steps of continuous quality improvement: The Plan, Data Collection, and Data Analysis. This edition concludes the review of Data Analysis and wraps up with a discussion of Action & Follow up.

The results of data collection may be presented in a number of ways (e. g. line charts, bar graphs, and spreadsheets) to monitor, control and improve process performance over time:

These tools can help staff and managers observe problems and trends that are hidden when individual cases or results are reviewed. For example, when the results of a chart review project are displayed using a bar graph, staff might realize that the great majority of missing or incomplete records are those that require another department's' review or handling. Staff could then discuss ways to improve the coordination between the two departments and not focus on individual clinicians' documentation. A bar graph (or histogram) that contains data sorted in decreasing order is called a Pareto Chart. The use of this tool is based on the principle that 80% of problems are caused by 20% of the sources.

 A control chart is actually a line chart with statistically derived upper and lower limits for data and is useful in revealing when a process is experiencing variation.

Another powerful effect of collecting data over time is that staff can identify problems before they become bigger problems. Looking at the line chart on the left, one measurement is rising faster than the others. By monitoring this each month or quarter, staff can follow this data more closely.

Julie Poulson, RN, MN Interim Director, HCA

Douglas Barton Deputy Agency Director Behavioral Health Services

Published by: 

County of Orange Health Care Agency/ 

Behavioral Health Services 

Central Quality Improvement 

405 W. 5 th St 

Santa Ana, CA. 92701

(714) 834-5601

Inside the next Issue: Implementing our Performance Outcomes Measurement System

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Volume 1, Issue 2

Reviewing the 2000-2001 Quality Improvement Workplan 

A key element of Continuous Quality Improvement (CQI) is that the underlying processes of any activity must be explored. For example, a department that "digs deeper" into the process of how a clinical chart is developed and maintained might find that key steps are problematic. Ideas on how these steps affect the entire process can be generated in a number of ways. It is important for management staff to be involved in this step, so that decisions can be agreed upon. One person should be designated as the facilitator in the group so that the discussion stays on track. In addition, notes or minutes should be taken to document the discussion and any decisions( s). A group that meets to analyze a specific problem or activity is often called a "work group". Ground rules for workgroups include:

• Establishing and following an agenda
• Active participation by staff 
• Time limited meetings · 
• Answering the question (S)/ problem (S) presented

Cause and Effect Diagram This method allows a group to break down a process into its distinct parts. This is often done using a dry-erase board, using arrows and boxes to reflect the steps and points within the process and to identify and explore all of the possible causes relating to a problem or condition to discover its root causes. The main categories considered are:

• Equipment 
• Methods
• People  
• Materials

Affinity Diagram/ Brainstorming 

This approach encourages employees to be creative and develop a large number of ideas/ issues and then organize them.

Putting ideas into action

Once staff and managers have developed ideas to improve a process or activity, then the ideas need to be put into action. New forms might need to be developed, a new procedure established, or a different way to perform a task considered. Any changes that are established should be designed to directly improve the activity originally measured, but in a way so as not to adversely affect other operations or procedures. It is important to have different disciplines involved in the analysis phase of CQI so that different points of view are considered. This will help prevent the "cure being worse than the disease".

The follow up 

The last step in the CQI process consists of re-measuring the activity or process originally measured, to ensure that the changes made in procedure or process had the intended effect. We needn't worry if the improvements aren't as great as expected, since the original group evaluating the data can easily "go back to the drawing board" to review the data and reconsider its ideas. Many groups prefer to try changes using a "pilot project approach", so that changes are not set in stone, but rather remain flexible. After data is collected for a period of time, a decision can then be made to either stop collecting data or to collect data on a less frequent basis (compared to the original plan). Once an activity or process appears to have improved and remains "stable", then that department can forward its conclusions and results to management and quality improvement staff.

Remember to celebrate our successes!

Questions and Answers 

Q:If a site or department uses a CQI approach to improving quality, does this mean that quality assurance (QA) is no longer needed?

A:Not always. Although a CQI method will help uncover problems and help develop solutions, QA can be helpful after a process has been improved to help make sure it stays improved by notifying staff when results change for the worse.

Q: Won't a CQI approach just add more time and paperwork to a busy schedule?

A: Although initially the time investment to uncover the "root causes" of a problem and develop ways to improve it might take slightly longer, the results are more effective and longer lasting-i. e. there is less need to revisit the problem again!

Q: Are there required indicators each department must measure?

A: Each division, program, and clinic site is included in the Behavioral Health Services QI Plan, which outlines the quality framework as well as specific indicators. 2

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