Lecture 5:

Tools of Quality Improvement

• Adopted by Dr. Haitham Khatatbeh

• Jerash University- Faculty Of Nursing
Tools of Quality Improvement

A set of graphical techniques identified as being

most helpful in troubleshooting issues related to
quality.

These tools are suitable for troubleshooting

most quality-related problems and require little
formal training in statistics.
 1. Brain Storming
• 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. 2. When creative, original ideas are desired.
3. When participation of the entire group is desired.
 Brainstorming Procedure
1. Materials needed: flipchart, marking pens,
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.
 2. Affinity Diagram
• The affinity diagram organizes a large number of ideas into their natural
relationships. It is the organized output from a brainstorming session. Use it
to generate, organize, and consolidate information related to an outcome,
process, complex issue, or problem.
 Continue.. Affinity Diagram

• Affinity diagrams are a great way to organize a large volume of ideas that
might otherwise seem overwhelming.

• Affinity diagrams also allow a group to make connections between ideas,

or realize recurring themes, in ways that might not seem obvious at first.

• Affinity diagrams can also allow team members to complement each

other's knowledge in brainstorming; each member of a team or group can
contribute ideas to the best of their knowledge, even if they don't know or
understand the full scope of the problem.
 Affinity Diagram Process

1. Record each idea with a marking pen on a separate sticky note or card;
2. Look for ideas that seem to be related in some way and place them side
by side;
3. Begin a discussion with your team and attempt to define categories and
header cards for each grouping or category;
4. Combine groups into "supergroups," if appropriate.
3. Cause and effect diagram
• This tool is devised by Kaoru Ishikawa himself and is also known
as Ishikawa diagram and the fishbone diagram (for it’s shaped
like the skeleton of a fish).
• Identifies many possible causes for an effect or problem and
sorts ideas into useful categories.

Uses:
1. Problem-solving; finding root causes of a problem;
2. Uncovering the relationships between different causes leading
to a problem;
3. During group brainstorming sessions to gather different
perspectives on the matter.
Steps of making the cause and effect diagram
• Fishbone diagrams are typically made during a team meeting and
drawn on a flipchart or whiteboard. Once a problem that needs to be
studied further is identified, teams can take the following steps to
create the diagram:

1- Agree on a problem statement (effect). Write it at the center right of

the flipchart or whiteboard. Draw a box around it and draw a
horizontal arrow running to it.
Continue..
2- Brainstorm the major categories of causes of the problem. If this is
difficult use generic headings:
1. Methods
2. Machines (equipment)
3. People (manpower)
4. Materials
5. Measurement
6. Environment
Continue..
3- Write the categories of causes as branches from the main arrow.
4- 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.
5- 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.
6- When the group runs out of ideas, focus attention to places on the
chart where ideas are few.
Cause and effect diagram
-------------- Staff attitudes Complications
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Prolonged LOS
------------------ -------------------- --------------------
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------------ Procedure Post discharge support

4. Flow Chart
• Flowchart is one of the most popular quality tools. It is used to
visualize the sequence of steps in a process, event, workflow, system,
etc.
• In addition to showing the process as a whole, a flowchart also
highlights the relationship between steps and the process boundaries
(start and end).
Flow Chart Uses
1. To build a common understanding of a process
2. To analyze processes and discover areas of issues, inefficiencies, blockers, etc.
3. To standardize processes by leading everyone to follow the same steps
How to use flow chart?
• Gather a team of employees involved in carrying out the process for
analyzing it
• List down the steps involved in the process from its start to end
• If you are using an online tool, you can first write down the process
steps and rearrange them later on the canvas as you identify the
flow.
• Identify the sequence of steps; when representing the flow with your
flowchart, show it from left to write or from top to bottom
• Connect the shapes with arrows to indicate the flow.
 5. Check sheet
• Check sheet is a structured, prepared form for collecting and analyzing
data; a generic tool that can be adapted for a wide variety of purposes.
It was developed by Japanese quality control expert Dr. Kaoru Ishikawa.

• Check sheet is a form used to collect data in real time at the location
where the data is generated . The data it captures can be quantitative
or qualitative. When the information is quantitative, the check sheet is
sometimes called a tally sheet.
Advantages of Check Sheet

1. Keeps You Organized: A check sheet is a handy tool for keeping all your data
organized.

2. Can Be Used To Record Results: A check sheet is particularly useful for recording
or collecting data as the event happens.

3. Easy to Understand and Interpret it. It is straightforward to use and interpret the
results.

4. A Good Starting Point for the Process Improvement. You can use a check sheet to
collect data that can be used for further analysis using tools such as a Pareto
Chart.
How to create a check sheet?
• 1. Manual: Using a pen and paper: In most cases, this method will
work well unless the data volume is high.

• 2. Microsoft Excel: If the data volume is high and it is not practical to

collect it manually, you need some software support. If the data is
collected automatically in high volume, you can use a data analysis
tool (such as Excel) to compile or group the data into various
categories.
Example
6. Line graph
• A line graph, also known as a line chart or a line plot. It is made by joining
points using lines.

• A line graph is a graphical representation of information that changes over a

period of time.

• is commonly drawn to show information that changes over time.

Components of line graph
• Title: It tells us about the data for which the graph is drawn.
• X-axis: It tells us about the label on the x-axis, which is the time interval.
• Y-axis: It tells us about the label on the y-axis, which is the quantity.
• Points: It represents the (x, y) ordered pair.
• Trend: You need to connect the points to make the graph. The meeting point
of the label on the x-axis and y-axis reveals the movement.
Trends in observed inpatient mortality rate / 1,000 hospital admissions for four high-volume conditions, 2002-2012
 Pros and Cons of line graph
• Pros
• It helps to show small shifts that may be getting hard to spot in other graphs.
• It helps show trends for different periods.
• They are easy to understand.
• To compare data, more than one line can be plotted on the same axis.
• Cons
• If we plot too many lines on the same graph, it can become cluttered and hard
to read.
• When data sets have fractional or decimal values, it becomes difficult to plot it.
7. Control chart (Shewhart chart)
• The control chart is a graph used to study how a process changes over
time.
➢ Data are plotted in time order.
➢ A control chart always has a central line for the average, an upper
line for the upper control limit, and a lower line for the lower
control limit. These lines are determined from historical data.
➢ By comparing current data to these lines, you can draw conclusions
about whether the process variation is consistent (in control) or is
unpredictable (out of control, affected by special causes of
variation).
 Run chart

Average LOS (days) per month

60
50
40
days

30
20
10
0
1 2 3 4 5 6 7 8 9 10 11 12
m onth
How to create a Control
chart (Shewhart chart)?

1. Choose the appropriate control chart

for your data.
2. Determine the appropriate time
period for collecting and plotting data.
3. Collect data, construct your chart and
analyze the data.
4. Look for "out-of-control signals" on
the control chart. When one is
identified, mark it on the chart and
investigate the cause. Document how
you investigated, what you learned,
the cause and how it was corrected.
8. Histogram
• Histogram is a frequency distribution
shows how often each different value in
a set of data occurs.

• A histogram is the most commonly used

graph to show frequency distributions or
how often each different value in a set
of data occurs.

• It looks very much like a bar chart, but

there are important differences
between them.
 To easily interpret a large
amount of data and identify
patterns

Histogram To make predictions of process

performance
uses
To identify the different causes
of a quality problem
 HOW TO CREATE A HISTOGRAM?
• Collect at least 50 consecutive data points from
a process.
• Determine the number of bars, the range of
numbers that go into each bar, and the labels for
the bar edges.
• Draw x- and y-axes on graph paper. Mark and
label the y-axis for counting data values. Mark
and label the x-axis with the L values from the
worksheet. The spaces between these numbers
will be the bars of the histogram. Do not allow
for spaces between bars.
• For each data point, mark off one count above
the appropriate bar with an X or by shading that
portion of the bar.
Histogram analysis

1- Normal Distribution
• A common pattern is the bell-shaped
curve known as the "normal
distribution." In a normal or "typical"
distribution, points are as likely to
occur on one side of the average as on
the other. Note that other distributions
look similar to the normal distribution.
Statistical calculations must be used to
prove a normal distribution.
Continue..Histogram analysis
2- Skewed Distribution
The skewed distribution is asymmetrical because a
natural limit prevents outcomes on one side. The
distribution’s peak is off center toward the limit and
a tail stretches away from it. For example, a
distribution of analyses of a very pure product
would be skewed, because the product cannot be
more than 100 percent pure. Other examples of
natural limits are holes that cannot be smaller than
the diameter of the drill bit or call-handling times
that cannot be less than zero. These distributions
are called right- or left-skewed according to the
direction of the tail.
Continue.. Histogram analysis

3- Double-Peaked or Bimodal
The bimodal distribution looks like the
back of a two-humped camel. The
outcomes of two processes with different
distributions are combined in one set of
data. For example, a distribution of
production data from a two-shift
operation might be bimodal, if each shift
produces a different distribution of
results. Stratification often reveals this
problem.
A question..
• Have you ever seen a bar chart?
• What is the difference between the bar chart and the histogram?
9. Pareto chart
• Also called: Pareto diagram, Pareto analysis.
• It is a type of chart that contains both bars and a line graph, where
individual values are represented in descending order by bars, and the
cumulative total is represented by the line.
• It is useful When there are many problems or causes and you want to
focus on the most significant, and When communicating with others
about your data.
• Uses
1. To identify the relative importance of the causes of a problem
2. To help teams identify the causes that will have the highest impact
when solved
3. To easily calculate the impact of a defect on the production
 Pareto chart

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 How to make a Pareto chart?

1. Decide what categories you will use to group items.

2. Decide what measurement is appropriate. Common
measurements are frequency, quantity, cost and time.
3. Decide what period of time the Pareto chart will cover: One work
cycle? One full day? A week?
4. Collect the data, recording the category each time, or assemble
data that already exist.
5. Subtotal the measurements for each category.
 Continue.. How to make a Pareto chart?

6. Determine the appropriate scale for the measurements you have collected.
The maximum value will be the largest subtotal from step 5. (If you will do
optional steps 8 and 9 below, the maximum value will be the sum of all
subtotals from step 5.) Mark the scale on the left side of the chart.
7. Construct and label bars for each category. Place the tallest at the far left,
then the next tallest to its right, and so on. If there are many categories with
small measurements, they can be grouped as “other.”
 Continue.. How to make a Pareto chart?

• Note: Steps 8 and 9 are optional but are useful for analysis and
communication.
8. Calculate the percentage for each category: the subtotal for that category
divided by the total for all categories. Draw a right vertical axis and label it
with percentages. Be sure the two scales match. For example, the left
measurement that corresponds to one-half should be exactly opposite 50%
on the right scale.
9. Calculate and draw cumulative sums: add the subtotals for the first and
second categories, and place a dot above the second bar indicating that
sum. To that sum add the subtotal for the third category, and place a dot
above the third bar for that new sum. Continue the process for all the bars.
Connect the dots, starting at the top of the first bar. The last dot should
reach 100% on the right scale.
10. Scatter diagram

• Also called scatter plot, X-Y graph.

• It graphs pairs of numerical data,
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 validate the relationship between causes and effects
2. To understand the causes of poor performance
3. To understand the influence of the independent variable over the
dependent variable.

Examples: Number of monthly patient census in a unit and monthly

medication administration errors, Number of ventilator days and VAP.
See this link for example
• https://asq.org/quality-resources/scatter-
diagram#:~:text=a%20control%20chart-
,Scatter%20Diagram%20Procedure,intersects%20the%20y%2Daxis%2
0value.
Questions?
References

• https://asq.org
• Joint Commission International. International Library of Measures.
https://www.jointcommissioninternational.org
• Agency for Health Research and Quality. Resources for health care quality measurement.
https://www.ahrq.gov
• https://www.definitivehc.com/blog/history-of-quality-improvement-in-healthcare
• http://squire-statement.org/
• https://www.who.int
• https://www.cdc.gov
• https://www.ihi.org
• https://www.ahrq.gov/