Continuous Improvement

Methodology- PDCA
Advocate Research and Innovation Forum 2012

October 2012

Operations Improvement Vision

All Advocate associates become passionate about
process improvement, embracing equality, excellence,
partnership, and stewardship.
Commitment to simplify our process

Learning to work more effectively

Learning to see things differently

Objectives
Introduce the PDCA cycle
Present tools and concepts to facilitate problem solving,
which can be applied to any problem in any setting
Illustrate the concepts with a healthcare application of
PDCA

Continuous Improvement
Continuous improvement is an ongoing effort to improve
products, services, or processes.
Continuous and incremental improvements remove
unnecessary activities and variations providing increased
capability, reduced costs, improved efficiency and quality
over time.
A complete transformation process takes time, but
continuous improvement allows teams to change the
organization one problem at a time.

A Method to Promote Continuous Improvement

The Plan-Do-Check-Act (PDCA) Cycle is an iterative
four-step problem solving model to promote continuous
improvement.
Brief History:
Walter A. Shewhart first discussed the concept of PDCA in 1939
when he introduced the notion that constant evaluation of
management practices is key to the evolution of a successful
enterprise.
In the 1950s, W. Edwards Deming promoted PDCA as a primary
means of achieving continuous process improvement. He also
referred to the PDCA cycle as the PDSA cycle ("S" for study).

PDCA
Standardize if it
worked, adjust if
it didnt work.

Progress, target
vs. actual

Alignment,
identify problem,
determine goal,
cause analysis.

Act

Plan

Check

Do
Action plan and
execution

PDCA - Template
Strategy:
Strategic Initiative:
Stakeholders (people involved/impacted by the initiative):
PLAN
Background Information:

DO
See Action Plan: (add action plan title here!)
CHECK

Problem Statement:

Goal (think SMART):

ACT
Cause Analysis:

Leader:
Department/Branch:

PDCA Is Not New: Clinical Thought Process

PLAN
Background Information:
Gather History and Physical information. Patient short
of breath and swelling of lower extremities over last
several weeks.

DO
Administer IV diuretics and electrolyte replacements
Administer O2 and monitor intake and output
Weigh patient daily
Perform Echocardiogram

CHECK
Problem Statement:
Patient is short of breath, elevated heart rate and Electrolytes in balance
Intake and Output balanced
swollen legs.
Weaning off O2
Goal:
Chest X-ray demonstrates improvement in patients
Upon confirmation of heart failure diagnosis, treat enlarged heart
patient until swelling in legs diminished and shortness
ACT
of breath subsides. Achieve over next ~4 days.
Ensure handoff to patients primary care physician
Cause Analysis:
CMP Lab test drawn identified electrolytes level.
Chest X-Ray showed enlarged heart, supporting
diagnosis of congestive heart failure.
7

Key Tools and Concepts to Help You Problem Solve

= Concept

= Tool

Go see visit the

Gemba

Strategy:
Leader:
Strategic Initiative:
Department/Branch:
Stakeholders (people involved/impacted by the initiative):
PLAN
Background Information:

DO
See Action Plan: (add action plan title here!)

Action Plan

CHECK

Process mapping

Brainstorming

Problem Statement:

Goal (think SMART):

Data analysis

ACT
Cause Analysis:

Problem Statement

Goals:
Specific
Measurable
Achievable
Relevant
Timely

Check
against
goal

Root cause
analysis:
5 whys

What worked/
what didnt work

Where do things stand today (current

state)?
What are the perceived symptoms that
makes us believe we need to act?

Act

Plan

Check

Do

Visit the Gemba (the real place)

What is it?
Gemba walk, is an activity
that takes management to
the front lines to look for
waste and opportunities.
How to do it?
While at the place where
the work is happening
(Gemba), ask the questions
to the right.
Results:
Understanding of what is
really happening
10

Work
Flow

What disrupts the work?

Errors

Where could mistakes be made?

What keeps those mistakes from being made?
Is it just vigilance?
Or is there some mechanism to prevent mistake?

Rework

Is there any backtracking, rework, looping around?

Are things where they are actually needed?
Do people have to look around for things?

Visual
Mgmt

How do they know what they should be doing?

What is their source of information?
Do they have to hunt it down, or worse, guess at
what should be done?
Or is the right thing and the right way crystal clear
to even the casual observer (that would be you).

Process Mapping Basics

What is it?
Visual step-by-step process flow
outlining how work is done
One Post-it note per process step
to depict main activities, information
flows, and interconnections
Apply 80/20 Rule 80% stays in
main path or flow
Overlay Data, Value Added, and
Waste Identification

Results:
Allows an observer to walkthrough the whole process and see
it in its entirety.

11

Process
Step

Decision
Point

Short, Simple, Specific

Noun-Verb

Yes, No

RN Gets
Gown for
Patient

Patient Yes
Available?

It Depends
No
Start & End Points = clearly
define scope of the process

Data Analysis
What is it:
Baseline data analysis provides a view of how big
the current problem is, where there is opportunity
to improve.
Re-measure data analysis demonstrates if the
solution has improved the problem and is sustained.

Results:
Data driven analysis that cannot be disputed to
quantify the problem and sustain results.
12

SURGICAL CARE IMPROVEMENT PROJECT (SCIP) BUNDLE

(January 2007-December 2008)
100
UCL=98.07
2

95
Performance %

How to do it:
Investigate various available reports, understand
definitions
Collect manual data if there is not electronic data
available
Analyze the data to quantify the problem

90
_
X=85.58

85
80

2
2

2008 Target: 79%

2007 Target: 77%

75
1

LCL=73.09

70
7 7 7 7 7 7 7 7 7 7 7 7 8 8 8 8 8 8 8 8 8 8 8 8
n /0 b /0 r /0 r/ 0 y /0 n/0 l/0 g /0 p /0 t/0 v /0 c/0 n/0 b /0 r/0 r /0 y / 0 n/0 l/0 g /0 p /0 t/0 v /0 c/ 0
J a F e M a Ap Ma Ju J u Au S e Oc N o De J a Fe M a Ap M a Ju Ju Au Se Oc N o De
2/9/09

PDCA Applied to Healthcare Processes

PLAN
DO
Background Information:
Chart Flow beginning in patient room
Inconsistent ED work practices create a chaotic and exhausting
RN, Tech, Physician assess patient together and
work environment.
share the plan of care
ED LOS metrics are too high, well above benchmark
Defined Roles and Standard Work
Identify a communication tool with All-Call
Pt Arrives
To Room
Greet
Triage
Register
feature to communicate a new patients arrival,
Initial
and patients discharge readiness.
Disp Plan
Discharge
Doctor
Treat
Care
CHECK
Problem Statement:
Inconsistent practices contribute to inefficiencies for our ED
Metric
discharged home patients with an average LOS of 181 minutes, well
LOSMap
Discharge
Process
above the national benchmark of 90 minutes.
Door to
Physician
Goal:
Door to Lab
Improve communication and optimize ED process, in order to
Received
provide timely quality care, with ED discharged home patient LOS
of 90min by January 2012.
ACT
Cause Analysis:
No Communication Tool to communicate patient readiness
No standard workflow
No Standard Patient Assignment process for Physicians
Chart is placed far away from care site
13

Baseline Remeasure Target

181min
136min
90min
55min
34min
30min
71min

61min

35min

Metrics trending positive, continue to implement.

What worked
Education before
implementation
Ownership of solution
Buy-In to try

What didnt work

Need more time to
trial process on
various patient days

Write a sentence that defines the problem you are

trying to solve.
The problem is the gap between the current state
and the goal.
Select one problem per PDCA

14

Act

Plan

Check

Do

Problem: understanding the gap

Goal

GAP

Process that is declining in

performance and currently not
achieving desired target.
15

OR

Patient Satisfaction

Patient Satisfaction

What is the gap that you are trying to close?

New Goal

GAP
Goal

Sustained performance compared

to initial goal. New level of
performance is identified.

Example Problem Statements

BEST
78% of outpatients have missing/incomplete testing on day of procedure which
results in 75% of the first cases to be delayed by more than 15 minutes.
38% of patients arriving at the Imaging Department Check-In desk wait longer than 15
minutes before being met by Liaison to take them to their CT scan.
AWV reimbursement is new from Medicare in 2011. The Clinic has approximately
44,000 patients that qualify for an AWV. This represents approximately $14.8M Gross
and $7.4M Net revenue opportunity.

GOOD
Average OR room turnover is 32 minutes which is higher than the national
average of 20 minutes.
There are 200-300 calls on average requesting information, distracting the desk
operators from their duties.
OR staff and surgeon frustration with process breakdowns leading to performance for
OR turn-around time, On-Time Starts, and associate satisfaction that does not meet
national best practice

BAD
Associate and physician satisfaction is low.
16

PDCA Applied to Healthcare Processes

PLAN
DO
Background Information:
Chart Flow beginning in patient room
Inconsistent ED work practices create a chaotic and exhausting
RN, Tech, Physician assess patient together and
work environment.
share the plan of care
ED LOS metrics are too high, well above benchmark
Defined Roles and Standard Work
Identify a communication tool with All-Call
Pt Arrives
To Room
Greet
Triage
Register
feature to communicate a new patients arrival,
Initial
and patients discharge readiness.
Disp Plan
Discharge
Doctor
Treat
Care
CHECK
Problem Statement:
Inconsistent practices contribute to inefficiencies for our ED
Metric
discharged home patients with an average LOS of 181 minutes, well
LOS Discharge
above the national benchmark of 90 minutes.
Door to
Physician
Goal:
Door to Lab
To achieve timely and quality care for our ED discharged home
Received
patient with a LOS of 90min by January 2012.
Cause Analysis:
No Communication Tool to communicate patient readiness
No standard workflow
No Standard Patient Assignment process for Physicians
Chart is placed far away from care site
17

Baseline Remeasure Target

181min
136min
90min
55min
34min
30min
71min

61min

35min

ACT
Metrics trending positive, continue to implement.
What worked
Education before
implementation
Ownership of solution
Buy-In to try

What didnt work

Need more time to
trial process on
various patient days

How will you measure success?

KRA goal or other goal that you are trying
to impact.

Think SMART!

18

Act

Plan

Check

Do

Goal
How will we know if we are achieving the
future state?
How will we know if we are successful?
Metrics must be SMART

19

Specific
Measurable
Achievable
Relevant
Timely

Example Metric Chart

Metric

Baseline

Goal

By When

Patient Wait
Time

50 minutes

30 minutes

12/31/2012

Room TurnAround Time

45 minutes

20 minutes

12/01/2012

Actual
Performance

PDCA Applied to Healthcare Processes

PLAN
DO
Background Information:
Chart Flow beginning in patient room
Inconsistent ED work practices create a chaotic and exhausting
RN, Tech, Physician assess patient together and
work environment.
share the plan of care
ED LOS metrics are too high, well above benchmark
Defined Roles and Standard Work
Identify a communication tool with All-Call
Pt Arrives
To Room
Greet
Triage
Register
feature to communicate a new patients arrival,
Initial
and patients discharge readiness.
Disp Plan
Discharge
Doctor
Treat
Care
CHECK
Problem Statement:
Inconsistent practices contribute to inefficiencies for our ED
Metric
discharged home patients with an average LOS of 181 minutes, well
LOS Discharge
above the national benchmark of 90 minutes.
Door to
Physician
Goal:
Door to Lab
To achieve timely and quality care for our ED discharged home
Received
patient with a LOS of 90min by January 2012.
Cause Analysis:
No Communication Tool to communicate patient readiness
No standard workflow
No Standard Patient Assignment process for Physicians
Chart is placed far away from care site
20

Baseline Remeasure Target

181min
136min
90min
55min
34min
30min
71min

61min

35min

ACT
Metrics trending positive, continue to implement.
What worked
Education before
implementation
Ownership of solution
Buy-In to try

What didnt work

Need more time to
trial process on
various patient days

What is causing the problem?

What prevents us from achieving the goal?
Why does the cause exist?
Is there a highest priority cause?

21

Act

Plan

Check

Do

Root Cause Analysis

What is it?
An identified reason for the
source or origin of an event
or defect.
How to do it?
An iterative, questionasking method used to
explore the cause/effect
relationships underlying a
particular problem.
Be sure to not stop at an
artificial reason.

Results:
Ultimate goal is to
determine a root cause of a
defect
or problem.
22

Five Whys - Example

Thomas Jefferson Memorial preservation:
The National Park Service noticed the Thomas
Jefferson Memorial in Washington, D.C., was
deteriorating faster than other monuments. Park
service rangers investigated the problem with
the five whys technique, which keeps asking
"Why?" for five or more times, and formed the
following chain of causation:

Five Whys - Example

Why does the memorial deteriorate faster?
Because it gets washed more frequently.
Why is it washed more frequently?
Because it receives more bird droppings.
Why are there more bird droppings?
Because more birds are attracted to the monument.
Why are more birds attracted to the monument?
Because there are more fat spiders in and around the
monument.
Why are there more spiders in and around the monument?
Because there are more tiny insects flying in and around
the monument during evening hours.
Why more insects?
Because the monument illumination attracts more insects.

PDCA Applied to Healthcare Processes

PLAN
DO
Background Information:
Chart Flow beginning in patient room
Inconsistent ED work practices create a chaotic and exhausting
RN, Tech, Physician assess patient together and
work environment.
share the plan of care
ED LOS metrics are too high, well above benchmark
Defined Roles and Standard Work
Identify a communication tool with All-Call
Pt Arrives
To Room
Greet
Triage
Register
feature to communicate a new patients arrival,
Initial
and patients discharge readiness.
Disp Plan
Discharge
Doctor
Treat
Care
CHECK
Problem Statement:
Inconsistent practices contribute to inefficiencies for our ED
Metric
Baseline Remeasure
discharged home patients with an average LOS of 181 minutes, well
LOS Discharge
181min
136min
above the national benchmark of 90 minutes.
Door to
55min
34min
Physician
Goal:
5 Whys: Door to Lab
71min
61min
To achieve timely and quality care for our ED dischargedWhy?
homeTime is wasted
looking for charts
Received
Why? Charts never in central designated location
patient with a LOS of 90min by January 2012.

Target
90min
30min
35min

Why? Care givers would take chart to see patients by bedside

ACTinformation is needed for patient care
Why? Chart
Metrics
trending
positive,
continue
Why? Chart
is placed
far away
from care
site to implement.

Cause Analysis:
No Communication Tool to communicate patient readiness
No standard workflow
No Standard Patient Assignment process for Physicians
Chart is placed far away from care site
25

What worked
Education before
implementation
Ownership of solution
Buy-In to try

What didnt work

Need more time to
trial process on
various patient days

What are the solutions to address

the root cause?
What activities need to take place?
Who will be responsible? When?
Document in the action plan!
Create the WIIFM

26

Act

Plan

Check

Do

Brainstorming
What is it:
Group technique for generating many ideas in a short period of time
An invitation to think outside of the box
How to do it:
Clearly state the topic and brainstorming guidelines
Give people plenty of time on their own at the start of the session to generate as
many ideas as possible.
Collect ideas on Post-Its or Flipchart.
Encourage people to develop other people's ideas.
Encourage an enthusiastic, uncritical attitude among members of the group.
Ensure that no one criticizes or evaluates ideas during the session and welcome
creativity!
Results:
A collection of ideas (no idea is too big or too small)
27

Brainstorming: Affinity Diagram

Group ideas and
create solution
categories/themes

28

Action Plan
What is it:
Tool that specifies the necessary tasks that
must be executed to implement the solution
to your problem. It contains the name(s) of
person(s) responsible and a time frame for
completing the task.

What (Tasks)

Who

When
Start

How to do it:
Define the key steps to implement the solution
Who will do each step
When the step should be completed
Identify plan to follow up and review the status of all assigned tasks
Results:
Critical to document and make visually available all action items
planned by the team.

End

Status

Action Plan - Example

#
1
2
3
4
5
6

What (Tasks)
Create new Standard Work to include
process change
Begin placing patient charts in ED
patients room
Teach ED associates the new process
Implement data tracking log
Obtain Walkie Talkies
Go-Live with new process

What (start
with verbs)

30

Who
Gloria

When
Start
End
11/1
11/7

Susan

11/1

11/7

Gloria 11/8
11/14
Susan 11/15 Ongoing
Steve 11/7
11/14
ALL 11/15 Ongoing

Who
(one
person)

When

Status Comments

PDCA Applied to Healthcare Processes

PLAN
DO
What (Tasks)
Who
When
Background Information:
Chart Flow beginning in patient room Start
End
Inconsistent ED work practices create a chaotic and exhausting Create
RN,
Tech,
Physician
assess
patient
together
new
Standard
Work to
include
Gloria
11/1 and
11/7
process change
work environment.
share the plan of care
Begin placing patient charts in ED
Susan 11/1
11/7
ED LOS metrics are too high, well above benchmark
Defined
patients
roomRoles and Standard Work
Teach ED associates the new process
11/8
11/14
Identify a communication tool Gloria
with All-Call
Pt Arrives
To Room
Implement data tracking log
Susan 11/15 Ongoing
Greet
Triage
Register
feature
communicate a newSteve
patients
Obtain
Walkieto
Talkies
11/7arrival,
11/14
Go-Live
with
new
process
ALL
11/15
Ongoing
Initial
and patients discharge readiness.
Disp Plan
Discharge
Doctor
Treat
Care
CHECK
Problem Statement:
Inconsistent practices contribute to inefficiencies for our ED
Metric
discharged home patients with an average LOS of 181 minutes, well
LOS Discharge
above the national benchmark of 90 minutes.
Door to
Physician
Goal:
Door to Lab
To achieve timely and quality care for our ED discharged home
Received
patient with a LOS of 90min by January 2012.
Cause Analysis:
No Communication Tool to communicate patient readiness
No standard workflow
No Standard Patient Assignment process for Physicians
Chart is placed far away from care site
31

Baseline Remeasure Target

181min
136min
90min
55min
34min
30min
71min

61min

35min

ACT
Metrics trending positive, continue to implement.
What worked
Education before
implementation
Ownership of solution
Buy-In to try

What didnt work

Need more time to
trial process on
various patient days

What is the progress/result in light

of your original goal?
Do the actual results match the
planned results?

32

Act

Plan

Check

Do

Check

Make sure you are making progress

Update action plan accordingly
Review metric chart
Did you achieve your goal?
Continue for 30/60/90-day sustainment
Metric
Patient Wait
Time
Room TurnAround Time

33

Baseline

Goal

By When

Actual
Monthly
Performance

50 minutes

30 minutes

12/31/2012

55 minutes

45 minutes

20 minutes

12/01/2012

19 minutes

PDCA Applied to Healthcare Processes

PLAN
DO
What (Tasks)
Who
When
Background Information:
Chart Flow beginning in patient room Start
End
Inconsistent ED work practices create a chaotic and exhausting Create
RN,
Tech,
Physician
assess
patient
together
new
Standard
Work to
include
Gloria
11/1 and
11/7
process change
work environment.
share the plan of care
Begin placing patient charts in ED
Susan 11/1
11/7
ED LOS metrics are too high, well above benchmark
Defined
patients
roomRoles and Standard Work
Teach ED associates the new process
11/8
11/14
Identify a communication tool Gloria
with All-Call
Pt Arrives
To Room
Implement data tracking log
Susan 11/15 Ongoing
Greet
Triage
Register
feature
communicate a newSteve
patients
Obtain
Walkieto
Talkies
11/7arrival,
11/14
Go-Live
with
new
process
ALL
11/15
Ongoing
Initial
and patients discharge readiness.
Disp Plan
Discharge
Doctor
Treat
Care
CHECK
Problem Statement:
Inconsistent practices contribute to inefficiencies for our ED
Metric
discharged home patients with an average LOS of 181 minutes, well
LOS Discharge
above the national benchmark of 90 minutes.
Door to
Physician
Goal:
Door to Lab
To achieve timely and quality care for our ED discharged home
Received
patient with a LOS of 90min by January 2012.
Cause Analysis:
No Communication Tool to communicate patient readiness
No standard workflow
No Standard Patient Assignment process for Physicians
Chart is placed far away from care site
34

Baseline Remeasure Target

181min
136min
90min
55min
34min
30min
71min

61min

35min

ACT
Metrics trending positive, continue to implement.
What worked
Education before
implementation
Ownership of solution
Buy-In to try

What didnt work

Need more time to
trial process on
various patient days

Adjust if it didnt work, reassess and

make changes.
Standardize if it worked, document
standard process if solution solved the
problem.
Expand implementation to other areas
as appropriate.
Ensure ongoing PDCA to sustain
results.
35
Celebrate
WINS!

Act

Plan

Check

Do

What Worked/What Didnt Work

What is it:
A simple tool to capture what
you learned.
Results:
A list of positive and
negative outcomes of your
attempt to solve the
problem.

36

What worked

What didnt work

PDCA Applied to Healthcare Processes

PLAN
DO
What (Tasks)
Who
When
Background Information:
Chart Flow beginning in patient room Start
End
Inconsistent ED work practices create a chaotic and exhausting Create
RN,
Tech,
Physician
assess
patient
together
new
Standard
Work to
include
Gloria
11/1 and
11/7
process change
work environment.
share the plan of care
Begin placing patient charts in ED
Susan 11/1
11/7
ED LOS metrics are too high, well above benchmark
Defined
patients
roomRoles and Standard Work
Teach ED associates the new process
11/8
11/14
Identify a communication tool Gloria
with All-Call
Pt Arrives
To Room
Implement data tracking log
Susan 11/15 Ongoing
Greet
Triage
Register
feature
communicate a newSteve
patients
Obtain
Walkieto
Talkies
11/7arrival,
11/14
Go-Live
with
new
process
ALL
11/15
Ongoing
Initial
and patients discharge readiness.
Disp Plan
Discharge
Doctor
Treat
Care
CHECK
Problem Statement:
Inconsistent practices contribute to inefficiencies for our ED
Metric
discharged home patients with an average LOS of 181 minutes, well
LOS Discharge
above the national benchmark of 90 minutes.
Door to
Physician
Goal:
Door to Lab
To achieve timely and quality care for our ED discharged home
Received
patient with a LOS of 90min by January 2012.
Cause Analysis:
No Communication Tool to communicate patient readiness
No standard workflow
No Standard Patient Assignment process for Physicians
Chart is placed far away from care site
37

Baseline Remeasure Target

181min
136min
90min
55min
34min
30min
71min

61min

35min

ACT
Metrics trending positive, continue to implement.
What worked
Education before
implementation
Ownership of solution
Buy-In to try

What didnt work

Need more time to
trial process on
various patient days

PDCA Applied to Key Result Areas

PLAN
Background Information:
In Press Ganey Q2 2012 report, Home Care Office identified that the
question Family informed regarding progress presents a low mean score
in the last two quarters. This question is rated as of high importance to
patients in the same report.

DO
See Action Plan:
Action plan attached.
CHECK

Awaiting further results to evaluate success.

Question: family informed regarding progress
Problem Statement:
Baseline (Q2)
Q3
Q4
Target
Patient satisfaction mean score for the question Family informed
87.5
91.7 (75th %ile)
th
regarding progress in Q2 2012 was 87.5. In order to achieve the 75
percentile goal, the mean score for this question should be 91.7.
ACT
Goal (think SMART):
What worked
What didnt work
Increase Press Ganey mean score for question Family informed regarding
Team based approach to
Team perceives
progress by 4.2 points by the end of 2012.
brainstorm issues and
communication
barriers
log as busy
Cause Analysis: (5 whys)
work, consider
Engaging team in the
Patients do not perceive that we keep family members informed of
revising the
action plan development.
progress
process.
Communication sheet
Families are complaining they are not adequately informed of progress
facilitates the
Staffs who care for patients are not informing the families of patients
communication of progress
progress
because it helps summarize
No standard process for how staff communicates patients progress
message.
with family/friends (root cause)
38

PDCA Applied to Key Result Areas

Action Plan
What (Tactics/Tasks)

Create draft of communication log.

Jenny

When
Start
End
8/20/12 8/24/12

Create draft of communication sheet.

Jenny

8/20/12

8/24/12

Completed

Review communication log and sheet with clinical

staff for feedback.

Jenny

8/20/12

8/31/12

Completed

Review with clinical managers and BSS how to

incorporate communication log/sheet into folders.

Jenny

8/27/12

9/6/12

Completed

Communicate new tools and how to use to field

staff.

Jenny

9/6/12

9/6/12

Completed

Educate field staff on communication tools for new

and existing patients.

Jenny

9/6/12

9/6/12

Completed

Survey field staff at September staff meeting to

inquire if communications tools are helpful.

Jenny

9/20/12

9/20/12

Started

39

Who

Status
Completed

PDCA Applied to Key Result Areas

PLAN
Background Information:
In Press Ganey Q2 2012 report, Home Care Office identified that the
question Family informed regarding progress presents a low mean score
in the last two quarters. This question is rated as of high importance to
patients in the same report.

DO
See Action Plan:
Action plan attached.
CHECK

Awaiting further results to evaluate success.

Question: family informed regarding progress
Problem Statement:
Baseline (Q2)
Q3
Q4
Target
Patient satisfaction mean score for the question Family informed
87.5
91.7 (75th %ile)
th
regarding progress in Q2 2012 was 87.5. In order to achieve the 75
percentile goal, the mean score for this question should be 91.7.
ACT
Goal (think SMART):
What worked
What didnt work
Increase Press Ganey mean score for question Family informed regarding
Team based approach to
Team perceives
progress by 4.2 points by the end of 2012.
brainstorm issues and
communication
barriers
log as busy
Cause Analysis: (5 whys)
work, consider
Engaging team in the
Patients do not perceive that we keep family members informed of
revising the
action plan development.
progress
process.
Communication sheet
Families are complaining they are not adequately informed of progress
facilitates the
Staffs who care for patients are not informing the families of patients
communication of progress
progress
because it helps summarize
No standard process for how staff communicates patients progress
message.
with family/friends (root cause)
40

Key Takeaways
Build confidence with the PDCA
tools by applying to small
problems.

Additional
Questions
Mariana Lipp Haussen,
Operations Improvement
Mariana.LippHaussen@advocatehealth.com
630.990.8114

Different problems require

different tools, you dont have to
use them all.
PDCA is to engage front line
associates.
Dont be afraid to experiment.
There is no failure if you learned
with your PDCA!
Continuous improvement is an
ongoing effort.
41

Rebecca Lechowicz,
Operations Improvement
Rebecca.Hattle@advocatehealth.com
630.990.8389

Mike Virgilio
Director Operations Improvement
Mike.Virgilio@advocatehealth.com
630.990.2649

Amy Herbst
Director Operations Improvement
Amy.Herbst@advocatehealth.com
630.990.8389

Additional Course Information

Change Acceleration Process (CAP)

Data Analysis (Excel Basic & Excel Intermediate)
WorkOut (WO)
Effective Meeting Facilitation
Statistical Process Control
Project Management 101
Six Sigma
Lean Fundamentals

Search words: Performance Enhancement in ALEX

AdvocateOnline > Divisions > Advocate Performance Enhancement >
42

Questions?

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