Qaulity tools

Mr. Joven Botin Bilbao, RN, MAN
Deputy Chief Nurse Officer- Al Hayat National Hospital, Jizan Branch
Clinical and Accreditation Educator - Al Inma Medical Services

 Is a creative group process used to generate a large
volume of ideas in a minimum amount of time.
 When to Use Brainstorming
1. When a broad range of options (problems,
causes, solutions, actions…etc) is desired.
2. When creative, original ideas are desired.
3. When participation of the entire group is
desired.
4. At any stage of performance improvement.

1. Materials needed: flipchart, marking pens, tape and blank wall space.
2. Review the rules of brainstorming with the entire group:
 No criticism, no evaluation, no discussion of ideas.
 There are no stupid ideas.The wilder the better.
 All ideas are recorded.
 Piggybacking is encouraged: combining, modifying, expanding
others’ ideas.
3. Discuss the problem and better to be conducted using “why,” “how,”
or “what” question.
4. everyone should understand the subject of the brainstorm.
5. Allow a minute or two of silence for everyone to think about the
question.
6. Invite people to call out their ideas. Record all ideas, in words as
close as possible to those used by the contributor.
7. Continue to generate and record ideas until several minutes’ silence
produces no more.

 The affinity diagram organizes a large
number of ideas into their natural
relationships. This method taps a team’s
creativity and intuition. It was created in
the 1960s by Japanese anthropologist Jiro
Kawakita.
 •When to Use an Affinity Diagram:
 1.When you are confronted with many
facts or ideas in apparent confusion.
 2.When issues seem too large and
complex to grasp.
 3.When group consensus is necessary.
 •Typical situations are:
 1.After a brainstorming exercise.
 2.When analyzing verbal data, such as
survey results.

1. Record each idea with a marking pen on a separate
sticky note or card.
2. Randomly spread notes on a large work surface so
all notes are visible to everyone.
3. Look for ideas that seem to be related in some
way. Place them side by side. Repeat until all notes
are grouped.
4. When ideas are grouped, select a heading for each
group.

 The 5Whys Helps identify the root cause of a problem
and Determine the relationship between different root
causes of a problem.
 Developed by SakichiToyoda and was used within the
Toyota Motor Corporation.
 It is one of the simplest tools; easy to complete without
statistical analysis.
 When to use 5Whys ?
1. When problems involve human factors or
interactions.
2. Can be used within fishbone tool.
3. When you implement Root cause study of Major
incidents.

 Problem Statement:You are on your way home from
work and your car stops in the middle of the road.
1. Why did your car stop?- Because it ran out of gas.
2. Why did it run out of gas? – Because I didn’t buy
any gas on my way to work.
3. Why didn’t you buy any gas this morning? –
Because I didn’t have any money.
4. Why didn’t you have any money? – Because I lost it
all last night in a poker game.
5. Why did you lose your money in last night’s poker
game? – Because I’m not very good at “bluffing”
when I don’t have a good hand.

 The 5Whys can be used as a part of the
fishbone diagram.
 Once all inputs are established on the
fishbone, you can use the 5Whys technique
to drill down to the root causes.

 Also called: process flowchart, process flow
diagram.
 A flowchart is a picture of the separate steps of
a process in sequential order.
 Elements that may be included are: sequence of
actions, materials or services entering or leaving
the process (inputs and outputs), decisions that
must be made, people who become involved,
time involved at each step and/or process
measurements.
 The process described can be anything: a
manufacturing process, an administrative or
service process, a project plan.This is a generic
tool that can be adapted for a wide variety of
purposes.

1. To develop understanding of how a process is
done.
2. To study a process for improvement.
3. To communicate to others how a process is
done.
4. When better communication is needed
between people involved with the same
process.
5. To document a process.
6. When planning a project.

 Medication administration process.
 Patient transfer process to OR.
 Patient discharge process.

 Also Called: Cause–and–Effect Diagram,
Ishikawa Diagram
 The fishbone diagram:
1.Identifies many possible causes for an
effect or problem.
2.It can be used to structure a
brainstorming session.
3.It immediately sorts ideas into useful
categories.
 When to Use a Fishbone Diagram
1.When identifying possible causes for a
problem.
2.Especially when a team’s thinking tends
to fall into ruts.

Step 1: Materials needed: flipchart or whiteboard, marking pens.
Step 2: Agree on a problem statement (effect).
Step 3: Write it at the center right of the flipchart or whiteboard.
Draw a box around it and draw a horizontal arrow running to it.
Step 4: Brainstorm the major categories of causes of the problem. If
this is difficult use headings ofToyota Production System (5
Ms):
1. Methods
2. Machines (equipment)
3. People (manpower)
4. Materials
5. Measurement
6. Mother Nature(Environment) (added later and we want to
include)

Step 5: Write the categories of causes as branches from the
main arrow.
Step 6: Brainstorm all the possible causes of the problem.
Ask: “Why does this happen?” As each idea is given,
the facilitator writes it as a branch from the
appropriate category. Causes can be written in several
places if they relate to several categories.
Step 7: Again ask “why does this happen?” about each cause.
Write sub–causes branching off the causes. Continue
to ask “Why?” and generate deeper levels of causes.
Layers of branches indicate causal relationships.
Step 8: When the group runs out of ideas, focus attention to
places on the chart where ideas are few.

 High incidents of Medication error.
 Low documentation compliance.
 Low Hand hygiene compliance.
 High incidents of fall.
 Fishbone Diagram Exercise

 Also called: defect concentration diagram.
 A check sheet is a structured, prepared
form for collecting and analyzing data. This
is a generic tool that can be adapted for a
wide variety of purposes.
 When to Use a Check Sheet
1. When we need to identify the high
volume defect.
2. When data can be observed and
collected repeatedly by the same person
or at the same location.
3. When collecting data on the frequency
or patterns of events, problems, defects,
defect location, defect causes, etc.
4. When collecting data from a process.

1. Decide what event or problem will be observed.
Develop operational definitions.
2. Decide when data will be collected and for how long.
3. Design the form. Set it up so that data can be
recorded simply by making check marks or Xs or
similar symbols and so that data do not have to be
recopied for analysis.
4. Label all spaces on the form.
5. Test the check sheet for a short trial period to be sure
it collects the appropriate data and is easy to use.
6. Each time the targeted event or problem occurs,
record data on the check sheet.

 Patient identification defects.
 Hand hygiene five moments compliance.
 Patients’ discharge delay.
 Check Sheet Exercise

 A bar chart or bar graph is a chart that
presents Grouped data with rectangular
bars with lengths proportional to the values
that they represent.
 When to use Bar Graph:
1. Bar graphs/charts provide a visual
presentation of categorical data.
2. Categorical data is a grouping of data
into discrete groups, such as months of
the year, age group, causes, and defects.
3. These categories are usually qualitative.
4. In a column bar chart, the categories
appear along the horizontal axis; the
height of the bar corresponds to the
value of each category.
5. The easiest tool for judgment.

 Decide on a title for your graph.
 Draw the vertical and horizontal axes.
 Label the horizontal axes.
 Write the names of pets where the bars will be.
 Label the vertical axes.
 Decide on the scale. Explain that you should
consider the least and the greatest number
shown on the graph. Discuss what range of
numbers should be shown on this bar graph
(Begin at 0 and count by 5s to 25).
 Draw a bar to show the total for each item.

 Reasons of high Fall rate.
 Reasons of High HAPU percentage.
 Number of incidents per level.
 OR operation census.

 A line chart or line graph is a type
of chart which displays information
as a series of data points called
'markers' connected by straight
line segments.
 It is a basic type of chart common
in many fields.
 When to use a line graph:
1.to visualize a trend in data over
intervals of time – a time series –
thus the line is often drawn
chronologically.
2.To identify a target and monitor
performance based on it.

1. Create a table. Draw the x- and y-axes on the page.On the top of the
page, place a title that briefly describes the purpose of the chart.
2. Label each axis. If time is one of the factors, it should go along the
horizontal (x) axis.The other numeric values measured should be placed
along the vertical (y) axis. Each axis should be labeled with the name of
the numeric system as well as the measurements being used. For
example, you may label the x axis with "Time (Days)", indicating that
each number written on the axis is a number of days. Divide each axis
evenly into applicable increments.
3. Add data. Data for a line graph is usually contained in a two-column
table corresponding to the x- and y-axes.With SmartDraw you can also
import data from Excel. Once you've added your data, your line graph
will automatically reflect its values. If you want to call attention to any
particular value, you can add a label with an arrow pointing to it.
4. Create a key. If you are comparing multiple items, you'll want to create
a key that identifies what each line is by its color.

 Fall rate incidents per 1000 patient days
 HAPU percentage.
 Documentation compliance.

 Also called: Pareto diagram,
Pareto analysis
 A Pareto chart is a bar graph.The
lengths of the bars represent
frequency or cost (time or
money), and are arranged with
longest bars on the left and the
shortest to the right. In this way
the chart visually depicts which
situations are more significant.

1. When analyzing data about the frequency of
problems or causes in a process.
2. When there are many problems or causes
and you want to focus on the most
significant.
3. When analyzing broad causes by looking at
their specific components.
4. When communicating with others about
your data.

Step 1:Develop a list of problems, items or causes to be compared.
Step 2:Develop a standard measure for comparing the items.
 How often it occurs: frequency (e.g., utilization,
complications, errors)
 How long it takes: time
 How many resources it uses: cost
Step 3:Choose a timeframe for collecting the data.
Step 4: Tally, for each item, how often it occurred (or cost or total
time it took).Then, add these amounts to determine the
grand total for all items. Find the percent of each item in
the grand total by taking the sum of the item, dividing it by
the grand total and multiplying by 100.

 Nursing forms and time length of
documentation.
 Fall related incidents as per reasons.
 Staff turnover rate as per reasons.

 Also called: scatter plot, X–Y graph
 The scatter diagram graphs pairs of
numerical data, with one variable on each
axis, to look for a relationship between
them.
 If the variables are correlated, the points will
fall along a line or curve.
 The better the correlation, the tighter the
points will hug the line.
 When to use a scatter diagram:
1. To display the relationship between two
continuous variables (cause and effect)
(X,Y).
2. Helps to whether the cause is significant
and needs action or not.
3. If you have 50 and more of data pairs.

1. Collect pairs of data where a relationship is suspected.
2. Draw a graph with the independent variable on the horizontal axis and
the dependent variable on the vertical axis. For each pair of data, put a
dot or a symbol where the x-axis value intersects the y-axis value. (If
two dots fall together, put them side by side, touching, so that you can
see both.)
3. Look at the pattern of points to see if a relationship is obvious. If the
data clearly form a line or a curve, you may stop.The variables are
correlated.You may wish to use regression or correlation analysis now.
Otherwise, complete steps 4 through 7.
4. Divide points on the graph into four quadrants. If there are X points on
the graph,
• Count X/2 points from top to bottom and draw a horizontal line.
• Count X/2 points from left to right and draw a vertical line.
• If number of points is odd, draw the line through the middle point.
5. Count the points in each quadrant. Do not count points on a line.
6. Add the diagonally opposite quadrants. Find the smaller sum and the
total of points in all quadrants.
A = points in upper left + points in lower right
B = points in upper right + points in lower left
Q = the smaller of A and B
N =A + B
7. Look up the limit for N on the trend test table.
• If Q is less than the limit, the two variables are related.
• If Q is greater than or equal to the limit, the pattern could have occurred from
random chance.

 LOS and HAPU.
 Number of monthly patient census in a unit
and monthly medication administration
errors.
 Number of ventilator days andVAP.

• Also called: FOCUS-PDCA, Deming
cycle, Shewhart cycle .
• When to Use Plan–Do–Check–Act
1. As a model for continuous
improvement.
2. When starting a new improvement
project.
3. When developing a new or improved
design of a process, product or service.
4. When defining a repetitive work
process.
5. When planning data collection and
analysis in order to verify and prioritize
problems or root causes.
6. When implementing any change.

• Failure modes and effects analysis (FMEA) is a step-by-step
approach for identifying all possible failures in a design, a
manufacturing or assembly process, or a product or service.
• “Failure modes” means the ways, or modes, in which something
might fail. Failures are any errors or defects, especially ones that
affect the customer, and can be potential or actual.
• “Effects analysis” refers to studying the consequences of those
failures.

• Failures are prioritized according to how serious their
consequences are, how frequently they occur and how easily
they can be detected.The purpose of the FMEA is to take
actions to eliminate or reduce failures, starting with the
highest-priority ones.
• Failure modes and effects analysis also documents current
knowledge and actions about the risks of failures, for use in
continuous improvement. FMEA is used during design to
prevent failures. Later it’s used for control, before and during
ongoing operation of the process. Ideally, FMEA begins during
the earliest conceptual stages of design and continues
throughout the life of the product or service.

• When a process, product or service is being designed or redesigned,
after quality function deployment.
• When an existing process, product or service is being applied in a new
way.
• Before developing control plans for a new or modified process.
• When improvement goals are planned for an existing process, product or
service.
• When analyzing failures of an existing process, product or service.
• Periodically throughout the life of the process, product or service

1. Assemble a cross-functional team of people with diverse knowledge about the process,
product or service and customer needs. Functions often included are: design, manufacturing,
quality, testing, reliability, maintenance, purchasing (and suppliers), sales, marketing (and
customers) and customer service.
2. Identify the scope of the FMEA. Is it for concept, system, design, process or service?What are
the boundaries? How detailed should we be? Use flowcharts to identify the scope and to make
sure every team member understands it in detail. (From here on, we’ll use the word “scope” to
mean the system, design, process or service that is the subject of your FMEA.)
3. Fill in the identifying information at the top of your FMEA form. Figure 1 shows a typical
format.The remaining steps ask for information that will go into the columns of the form.

1. Identify the functions of your scope. Ask, “What is the purpose of this system, design, process or
service?What do our customers expect it to do?” Name it with a verb followed by a noun. Usually
you will break the scope into separate subsystems, items, parts, assemblies or process steps and
identify the function of each.
2. For each function, identify all the ways failure could happen.These are potential failure modes. If
necessary, go back and rewrite the function with more detail to be sure the failure modes show a
loss of that function.
3. For each failure mode, identify all the consequences on the system, related systems, process,
related processes, product, service, customer or regulations.These are potential effects of failure.
Ask, “What does the customer experience because of this failure?What happens when this failure
occurs?”
4. Determine how serious each effect is.This is the severity rating, or S. Severity is usually rated on a
scale from 1 to 10, where 1 is insignificant and 10 is catastrophic. If a failure mode has more than
one effect, write on the FMEA table only the highest severity rating for that failure mode.
5. For each failure mode, determine all the potential root causes. Use tools classified as cause
analysis tool, as well as the best knowledge and experience of the team. List all possible causes for
each failure mode on the FMEA form.
6. For each cause, determine the occurrence rating, or O.This rating estimates the probability of
failure occurring for that reason during the lifetime of your scope. Occurrence is usually rated on a
scale from 1 to 10, where 1 is extremely unlikely and 10 is inevitable. On the FMEA table, list the
occurrence rating for each cause.

7. For each cause, identify current process controls. These are tests, procedures or
mechanisms that you now have in place to keep failures from reaching the customer. These
controls might prevent the cause from happening, reduce the likelihood that it will happen
or detect failure after the cause has already happened but before the customer is affected.
8. For each control, determine the detection rating, or D. This rating estimates how well the
controls can detect either the cause or its failure mode after they have happened but
before the customer is affected. Detection is usually rated on a scale from 1 to 10, where 1
means the control is absolutely certain to detect the problem and 10 means the control is
certain not to detect the problem (or no control exists). On the FMEA table, list the
detection rating for each cause.
9. (Optional for most industries) Is this failure mode associated with a critical characteristic?
(Critical characteristics are measurements or indicators that reflect safety or compliance
with government regulations and need special controls.) If so, a column labeled
“Classification” receives a Y or N to show whether special controls are needed. Usually,
critical characteristics have a severity of 9 or 10 and occurrence and detection ratings
above 3.
10. Calculate the risk priority number, or RPN, which equals S × O × D. Also calculate Criticality
by multiplying severity by occurrence, S × O. These numbers provide guidance for ranking
potential failures in the order they should be addressed.
11. Identify recommended actions. These actions may be design or process changes to lower
severity or occurrence. They may be additional controls to improve detection. Also note
who is responsible for the actions and target completion dates.
12. As actions are completed, note results and the date on the FMEA form. Also, note new S, O
or D ratings and new RPNs.

 Use the learned tools to find an opportunity to
improve and implement performance improvement
project/actions.
 Cooperatively with your charge nurse and the staff in
your unit, conduct your improvement project/actions
within an identified time frame and submit to nursing
quality supervisor for competition enrollment.
 On a defined date using structured selection criteria,
the winners will be selected and then announced as
first, second and third best performance
improvement projects/actions.
 Celebration will be done for the winners and success
stories will be publicized.

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