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U.S. Department of Health and Human Services
Health Resources and Services Administration
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Redesigning a System of Care to Promote QI

Part 1: Introduction

Part 2: Tools for System Redesign

Part 3: Sustain and Spread in Quality Improvement

Part 4: References

Part 5: Resources

Part 2: Tools for System Redesign  

Many quality improvement teams struggle with creating tests of change or deciding which of the choices that have worked for others are right for them. There are many tools for Quality Improvement, but a few have been extensively used by HRSA grantees and are worth mentioning here. This section will describe three tools in depth: process mapping (also known as flow charting), the 5 Why's for root cause analysis and the Cause Effect diagram (also known as the fishbone diagram.) A case story will illustrate how each of these tools could be used to augment their quality improvement efforts.

Case Story: The Problem

Process Mapping

Process Mapping or Flow Charting is one of the most powerful tools for process improvement. The map is optimally created by a team to assure that there is agreement in how the process currently works. Variation in how work is performed is a frequently encountered contributor to low performance.

Process mapping allows a visual depiction of processes and allows comparison of the current state to a more idealized process. Additional resources are available to learn how to do this and there are very sophisticated techniques and even software to process maps. But if we stick to the essentials, there are just a few basic steps:

  1. Clearly define where the process you are mapping begins and ends.
  2. Determine the steps in the process. For clinical QI teams, these are the tasks that a staff person would do for a patient. Avoid too much detail at first – in other words a step might "register the patient" instead of "greet the patient, ask the patient to sign in, give the patient the intake form to complete" etcetera.
  3. Sequence the steps. Using temporary adhesive notes are helpful so that you can move the steps around. Once they are ordered correctly, draw in arrows to show the direction of the process. 4. Label your process map by identifying the process and the date. That's it!

Teams use process maps in a variety of ways including a training tool to assure staff members do the process the same way, allow others external to the work to understand the process or as part of a training guide. But perhaps the most important role of process mapping is for quality improvement.

There are two important applications of process mapping for QI. First, process maps allow for a view of the process in its entirety. Unexpected complexity, redundancy, inconsistencies and inefficiencies often become apparent when you visualize a process in this way. Second, the map of how the process currently works can be compared to how an idealized process would work. The differences in the maps help organize the changes that need to be made to improve performance from how things are now to a more idealized state.

Case Story continued…

Case Story: Process Mapping in Action

A quick comparison of the process map presented in the above case story revealed the following observations:
Idealized StepKey difference(s) from our processQI Opportunities
1‘When patient presents" is not the same as "appropriate interval"Make sure A1c measured regardless of reason for visit when due; outreach to patients if they are due and have not come in
2No differenceNA
3Target level for patient not obviousFigure out how to communicate target a1c level among staff
4Treatment changed by provider but patient involvement varies depending on provider, improvement strategies implies ongoing support to patient ; providers differ in the response to an elevated A1cConsider how to involve patient in their care; how can we better support patient to achieve glycemic goals?; how do we address the variation in practice?
5Guidelines not currently shared; follow up provider dependentShare guidelines in patient-friendly format; consider options to improve rate of follow up.

By comparing the current map versus the idealized process map, the team had a good idea of where to focus their efforts. They decided to work on making sure that the A1c was drawn when it was due and started a two pronged approach including designing an outreach strategy and exploring how to assure patients who did come in had the A1c drawn on schedule.

Root Cause Analysis

At times during improvement work, teams may be confronted with a situation for which more information is needed. This is typically a situation where you see that something happens frequently but it is not entirely clear why it happens that way. The term Root Cause Analysis is used to describe the process of finding the real cause of the problem and dealing with it rather than simply continuing to deal with the symptoms.

5 Whys

Two techniques are commonly used to explore root cause analysis. One of the most popular techniques is call the "5 whys" – figure out something that went wrong and ask why, then in answer to that reason ask why again and so on. Coupled with some critical thinking questions, this can be a powerful tool to get to the bottom of issues that can be solved once and for all. These questions help keep you out of some of the traps you run into using the 5 Whys (1)to determine root cause:

  • What proof do I have that this cause exists? (Is it concrete? Is it measurable?)
  • What proof do I have that this cause could lead to the stated effect? (Am I merely asserting causation?)
  • What proof do I have that this cause actually contributed to the problem I'm looking at? (Even given that it exists and could lead to this problem, how do I know it wasn't actually something else?)
  • Is anything else needed, along with this cause, for the stated effect to occur? (Is it self-sufficient? Is something needed to help it along?)
  • Can anything else, besides this cause, lead to the stated effect? (Are there alternative explanations that fit better? What other risks are there?)

Case Story continued…

Case Story: Root Cause Analysis in Action

As is sometimes the case, teams think a process is working until they evaluate more closely. In the case of Windy Plains, the team determined that since the A1c was drawn on site, the process of getting the lab done and the results to the right people was working well. (see chart comparison of current care versus idealized care) When they started looking at patients to outreach however, it was discovered that up to 10% of patients who had A1cs ordered never had the test done. Since the processes were in place to ensure that the test was done, there was some negativity about where the process was failing and some finger pointing at Mas and lab personnel. The QI team lead recognized that a more objective evaluation of the problem was in order and suggested the construction of a Cause & Effect Diagram.

Cause & Effect (Fishbone Diagrams)

Cause Effect Diagrams (AKA Fishbone diagrams) allow a team to identify and display all of the possible causes of a problem. This pulls the discussion into a more objective realm and discourages focusing on the history of the problem or symptoms of the underlying issue. To construct the diagram, agree on a problem statement and place that on the right side of a large paper or white board. Draw major cause categories and connect them to the backbone of the chart as shown. Typical categories explored are equipment, people, methods, and materials but any categories that fit the problem should be used. This is exampled in the diagram below:

Cause Effect Diagrams.
Cause Effect Diagrams

Then brainstorm contributors to the problem under each category. Important "root" causes may appear in multiple categories or repeatedly or may be decided based on a nominal group process.

If we consider the case story as an example and determine the problem statement, "HbA1c was due for patient during visit but not did not occur we could then look at the root cause to determine categories which can be put into the format and the output of the brainstorm might be these:

Provider Procedure

  • Provider did not order
  • Provider did not use proper HER screen to order
  • Provider did not use alert that order ready
  • Provider did not discuss test with patient

MA procedure

  • MA cannot monitor orders in timely way
    • Short staffed
    • Overbooks
    • Variation in how test alerts used
  • MA does not have time to accompany patient to lab
    • Seniors and disabled are particularly challenging
    • Rooming patients higher priority
    • Short staffed
  • MA does not transmit order to lab
    • Why can't lab pick up order directly? HER access rules prohibit

Patient factors

  • Patient not aware test will be done
  • Patient time – has to leave
  • Patient disabled or sick and cannot navigate to lab
  • Patient not sure what to do next so leaves

Lab factors

  • Test order not received
  • Lab closed – hours of clinic and lab do not match
  • Out of reagent
  • Lab orders surpass staff capacity on Mon, Wed, Thursday mornings when all providers working.
Brain storm Results

From this brainstorm, the team was able to focus on two primary areas: how the order was communicated to all involved and the impact on staffing. They then can test strategies to improve within the parameters set out by leadership.

The case study illustrates that systems of care can be redesigned utilizing a variety of tools. In the case of the team from Windy Plains, a number of changes were tested and then implemented. These changes to the system of care for diabetes resulted in a substantial decrease in the number of patients with poor glycemic control. The changes that Windy Plains made included the following:

  • Patients with diabetes are now readily identified within the EMR. Mas check the last A1c date and order by protocol
  • Providers who order have agreed how to use the order entry feature on the EMR and have been trained to standardize this process
  • Laboratory hours have been adjusted to assure lab can be ordered while patients are being seen
  • Providers have agreed upon standards to take with elevated A1c, regardless of PCP. The clinic is also working hard to improve continuity of care for DM patients
  • The Mas have "adopted" patients who need more support and monitor their providers DM patients for visits due. They work with the front desk to outreach to patients to ensure they are retained in care.
  • As they implemented changes in their workflows, the mapped the new processes and looked at their redesigned systems with "Lean"thinking to optimize them. A few redundancies were eliminated and all members contributed to assure smooth handoffs for critical tasks.

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