Quality Improvement Tools

1. Using Quality Improvement Tools

Quality improvement (QI) tools are commonly used in continuous quality improvement (CQI) and process improvement (PI) throughout a CQI or PI project. By using QI tools, healthcare professionals can measure performance, identify inefficiencies, and make data-driven decisions to improve their services. These tools provide structured approaches that help teams address challenges, track progress, and ensure continuous improvement.

Common tools used by quality improvement (QI) teams are essential for planning, collecting, and displaying data because they assist with solving problems and making informed decisions. These tools help ensure that data is gathered systematically, accurately, and efficiently, which is crucial for identifying issues, measuring performance, and tracking improvements over time. They are also used extensively to communicate the data that is collected during the data collection stage and then toward the end of the project to communicate the results to stakeholders, especially other staff within the organization.

There are several major tools commonly used in quality improvement (QI) to help organizations identify problems, analyze data, and implement effective solutions.

2. Common Quality Improvement Tools

The process of quality improvement is typically a structured team project that is completed in stages. First, the identified issue (opportunity for improvement) is discussed, and the team tries to determine where the issues are. Next, data is collected to confirm where the issues are, backed by evidence. Then, the team sets out to determine how they will solve the problem. Next, the solution is put into place, and finally, data is collected again to show evidence that the solution worked (or not!). Remember Plan-Do-Check-Act? This process fits the PDCA model.

Following are some of the most commonly used QI tools and how they are used in each stage.

2a. Brainstorming

Brainstorming is a tool used to generate a wide variety of ideas and solutions to a problem. The rule is that no idea is too unrealistic or silly to share. Those crazy, out-of-the-box ideas may inspire another interesting idea from another teammate. Ideas should never be criticized, and there should be no discussion during brainstorming, only idea generation. One popular way that brainstorming is done is to go around the room and each team member throws out an idea while someone writes them all down. You keep going around the room until each person runs out of ideas. Next, all of the ideas are discussed, and the team determines which ideas make sense and which should be the focus. Brainstorming is often used to help answer two questions:

• What is causing the problem?
• How can we solve the problem?

EXAMPLE

A clinic QI/PI team might brainstorm ideas for solving the issue of long patient wait times prior to their appointment starting. The team brainstorms and comes up with possible solutions such as implementing a new appointment scheduling system, offering telemedicine options, optimizing nurse-patient ratios, hiring more staff, reducing scheduling options for each day, or adding a second clinic site.

2b. Flowchart

Once the opportunity for improvement is identified and brainstorming takes place, it is common to create a flowchart of the process that is in question. A flowchart visually represents the steps in a process and shows how they are interconnected. It helps to identify inefficiencies, bottlenecks, or redundant steps in workflows. In healthcare, a flowchart might be used to map out the patient admission process to see where delays occur. By visualizing the entire process, healthcare providers can make adjustments, such as simplifying forms or improving communication between departments, to streamline patient intake and reduce wait times.

2c. Fishbone Diagram

The fishbone diagram is a tool used to identify the root causes of a problem by mapping out potential contributing factors. The diagram looks like a fishbone, with the problem at the "head" and causes branching out in categories like people, processes, equipment, and environment. In a healthcare setting, this tool could be used to investigate the reasons behind frequent medication errors. A team might identify causes related to staff training, unclear communication protocols, or equipment malfunction, helping them pinpoint specific areas for improvement.

step by step

Here’s a step-by-step guide on how a team can create a fishbone diagram:

Step 1: Define the problem.

Start by clearly defining the problem you want to address. This will be the "head" of the fish. Write the problem statement at the far right of the diagram, inside a box or oval shape. For example, the problem might be "Increase in medication errors."

Step 2: Draw the backbone.

Draw a horizontal line (the “spine” of the fish) extending from the problem statement. This line will serve as the main structure of the diagram.

Step 3: Identify major categories of causes.

Identify the major categories that contribute to the problem. These categories will form the "bones" that branch off from the spine. Common categories include:

• People: Issues related to staff, training, or communication.
• Processes: Problems in workflows, procedures, or protocols.
• Equipment: Issues with tools, machinery, or technology.
• Materials: Problems with supplies or resources.
• Environment: External factors, such as workplace conditions or regulations.
• Management: Leadership or organizational issues. (These categories can vary depending on the problem and industry; in healthcare, you might also add categories like "Patients" or "Policies.")

Draw lines branching off the spine for each of these categories, forming the “ribs” of the fish.

Step 4: Identify potential causes.

Under each major category, the team should brainstorm potential causes of the problem. These causes are the smaller "bones" branching off the main ribs. For example, under the "People" category, potential causes might include "insufficient training," "lack of communication," or "staffing shortages." Continue this brainstorming for each category until you have listed all possible causes.

Step 5: Analyze and prioritize causes.

Once the fishbone diagram is complete, the team can analyze the potential causes. Discuss each cause, considering which ones are most likely contributing to the problem. You may use data or further investigation to prioritize the causes based on their impact or likelihood. This helps the team focus on the most important areas to address during the improvement process.

Step 6: Take action.

After identifying the root causes, the team can work on finding solutions to address the identified problems. This might involve revising procedures, improving training, fixing equipment, or addressing communication issues.

2d. Pareto Chart

The Pareto chart can also assist in visualizing data that has been collected to show evidence of what is causing an identified problem. A Pareto chart is a tool used to identify the most significant problems or issues in a process, based on the idea that a small number of causes often lead to the majority of problems. It is based on the "80/20 Rule," which states that about 80% of the problems come from 20% of the causes. The chart displays data in bars, with the largest bars representing the most common or impactful issues. By using a Pareto chart, teams can focus on fixing the biggest problems first, leading to the most significant improvements.

EXAMPLE

A Pareto chart could be used to identify the most common types of patient complaints or the most frequent causes of delays in patient care. For example, a hospital might use it to find that 80% of patient complaints are related to long wait times, prompting the team to focus on reducing delays in service.

2e. Control Chart

Control charts track the performance of a process over time, helping teams monitor stability and detect variations. By displaying data points within a range of acceptable limits, control charts make it easy to spot trends, anomalies, or problems. In a hospital, a control chart might be used to track infection rates after surgeries. If the rates exceed the established limits, the team can take corrective actions, such as revising sterilization procedures or enhancing staff training on hygiene protocols.

2f. Histogram

A histogram is a bar chart that shows the distribution of data, helping to visualize variations in a process. In healthcare, histograms can be used to analyze patient wait times or the time between diagnostic tests and treatment. By examining the distribution, healthcare providers can see whether the process is consistently efficient or if there are significant variations that need to be addressed, such as delays during certain hours of the day.

IN CONTEXT

A hospital is concerned about the rising number of medication errors and wants to track them more closely in order to improve patient safety. To analyze the situation, the hospital uses a histogram to display the data.

In this scenario, the hospital collects data on the number of medication errors that occur each day for a month. The data might be grouped into intervals (e.g., 0–5 errors, 6–10 errors, 11–15 errors, etc.). Each interval represents the number of days within that range of errors.

The histogram shows the frequency of days with different numbers of errors on the x-axis, while the y-axis shows how many days fall into each error range. For example, if most days fall into the "0–5 errors" range, it suggests that the majority of errors are relatively low in number. However, if the hospital sees many days with a higher number of errors (e.g., in the "11–15 errors" range), it indicates that there are particular days or times when medication errors occur more frequently, signaling the need for further investigation into the cause.

This histogram would allow the hospital to visually identify patterns or trends in the frequency of medication errors, helping them focus their efforts on addressing problem areas. For example, if the hospital finds that errors are higher during night shifts, they could investigate staff training, workload, or other factors specific to those shifts.

2g. Check Sheet

A check sheet is a simple tool used to collect data in real time. It allows teams to track the frequency of specific events, defects, or occurrences.

EXAMPLE

A check sheet might be used to monitor patient outcomes after specific treatments or track the occurrence of adverse events, such as falls or medication errors. This real-time data collection helps healthcare teams understand the scope of the issue and implement targeted interventions to reduce negative outcomes.

The check sheet could be used in the early stages of the project to track data about the issues, and then after the process improvement is put into place, the check sheet can be used again to collect the same data points. This will give you “before” and “after” data that can be graphed to show the change. The graph would be a great way to communicate the success, or failure, of the new procedure.

2h. Bar Graph or Column Chart

A bar graph or column chart is commonly used to show before-and-after data of a process improvement project. In this type of graph, you can display two sets of data side by side—one representing the data before the improvement (the baseline) and the other representing the data after the improvement was implemented. The bars for each set are typically placed next to each other for easy comparison.

EXAMPLE

In a healthcare setting, a bar graph might show patient wait times before and after implementing a new check-in process. This allows the team to visually compare the changes and assess the impact of the process improvement.

By using these tools, a healthcare manager can ensure that data is not only gathered but also analyzed and presented in a way that helps teams make informed, effective decisions, driving continuous improvements in processes and outcomes.