NURSING QUALITY IMPROVEMENT

PROGRAMME

7 BASIC QUALITY TOOLS

 What are 7 QC tools?

7 QC tools are the means for –

 Collecting data
 Analyzing data
 Identifying root causes
 Identifying solutions through data stratification
 Measuring results
 Controlling improved state

Mr Kaoru Ishikawa – “As much as 95% of all quality related problems can be solved
with the 7 fundamental quality tools”.

2
Patient Waiting Time (Min) - OPD
46 38 36 26 28 17 11
48 38 36 30 26 16 19
47 36 40 27 23 14 13
50 40 37 29 28 18 11
58 45 40 28 24 11 13
60 45 38 27 24 12 12
51 46 35 25 24 17 14
57 42 35 23 30 18 12
60 42 35 28 29 12 11
53 41 33 21 21 20 19
56 49 35 28 23 30 11
54 45 36 29 26 24 15
55 49 36 28 26 28 17
58 44 32 30 25 30 20
57 44 40 35 22 23 20
51 47 36 32 29 28 19
58 46 33 40 23 30 18

3
Patient Waiting Time (Min) - OPD

Patient waiting time

40 38
35

30
27
No. of patients 25 24

20
17
15 13
10

0
0-20 21-30 31-40 41-50 51-60

Waiting time(min)

4
 Importance of Using Tools

1. Simple visual way of viewing data

2. For delivering effective presentation

3. Useful to establish facts about what is happening

4. Displays large amount of data at a time

5. Presents data accurately

5
 7 Basic Tools of Quality

1. Histograms
2. Pareto Charts
3. Cause and Effect Diagrams
4. Scatter Plot
5. Control Charts
6. Flow Charts
7. Check Sheet

6
 Basic Concepts

 Mean
It is a point of reference and also the central point for measuring variability. The only
disadvantage of the arithmetic mean is that it is greatly affected by extreme values.
 Median
It is the middle value in a series of numbers arranged in an increasing order.
 Series odd number - (n+1)/2.
 Series even- arithmetic mean of the two middle values.
 Mode
Most frequently occurring value.
 Standard Deviation
Average amount of variability in your data set. It is square root of the variance.
On average, how far each score lies from the mean.

7
 Histogram

 Introduced by Mr Karl Pearson

 Used for - Graphically summarizing large amount of data quickly
and easily , representing the distribution of numerical data
 Data should be quantitative and continuous like age, body
temperature, time, etc.
 Shows data in ranges, width is equal to the class interval
 Rectangles of a histogram touch each other to indicate that the
original variable is continuous (not categorical as in column
chart)
 Example of data – Age of OPD patients, drug dispensing TAT in
pharmacy, birthweight of babies, systolic BP, Time of patients
arrival in hospital, etc.

8
 Histogram

Time taken for discharge of IP patients

140
124
120

100
No. of patients 84
80
63
60

39 40
40

20
18

0
0-10 11-20 21-30 31-40 41-50 51-60

Time taken for discharge (min)

9
 Pareto Charts

 Used to - identify and prioritize problems to be solved.

 Mr Vilfredo Pareto, Italian economist noted “80% of wealth was
held by 20% of population”.
 Mr Juran applied the Pareto Principle, stating that 80%
variation in process is by 20% of the variables.
 80/20 rule. 80% of the effects come from 20% of causes.
 Need not be 80/20, could be 75/25 or 70/30 or even 65/35.
 The concept is to analyze broad causes, prioritize and address
the critical issues.

10
 Reasons for Medication Errors
Sr.No. Reasons for medication error Frequency
1 Wrong route 19
2 Wrong patient 20
3 Overdose 21
4 Under dose 7
5 Wrong time 89
6 Wrong IV rate 4
7 Dose missed 98
8 Wrong drug 86
9 Duplicated drugs 9
10 Wrong calculation 12

11
 Reasons for Medication Errors
Sr.No. Reasons for medication error Frequency
7 Dose missed 98
5 Wrong time 89
8 Wrong drug 86

Descending order
3 Overdose 21
2 Wrong patient 20
1 Wrong route 19
10 Wrong calculation 12
9 Duplicated drugs 9
4 Under dose 7
6 Wrong IV rate 4

12
 Reasons for Medication Errors

Sr.No. Reasons for medication error Frequency In %

(N=400)
7 Dose missed 98 27%
5 Wrong time 89 24.38%
8 Wrong drug 86 24%
3 Overdose 21 6%
2 Wrong patient 20 5%
1 Wrong route 19 5%
10 Wrong calculation 12 3%
9 Duplicated drugs 9 2%
4 Under dose 7 2%
6 Wrong IV rate 4 1%

13
 Reasons for Medication Errors

Sr.No. Reasons for medication error Frequency In % (N=400) Cumulative

frequency
7 Dose missed 98 27% 27%
5 Wrong time 89 24.38% 51%
8 Wrong drug 86 24% 75%
3 Overdose 21 6% 81%
2 Wrong patient 20 5% 86%
1 Wrong route 19 5% 91%
10 Wrong calculation 12 3% 95%
9 Duplicated drugs 9 2% 97%
4 Under dose 7 2% 99%
6 Wrong IV rate 4 1% 100%

14
 Reasons for Medication Errors

120 120%

100 97% 99% 100% 100%

91% 95%
86%
80 81% 80%
75%

60 60%
51%
40 40% Frequency
cumulative %
27%
20 20%

0 0%
ed m
e u g se nt te o n gs se te
si s dr o e
ro
u
al ti dr
u o ra
g ti g er
d a ti
er
d
I V
sem ro
n
ro
n
O v
ng
p
on
g
alc
u
ted d ng
D o W W ro W
r
g c
lic
a Un ro
W r on D up W
W

15
 Reasons for Medication Errors
Addressing these 3 issues out of 10, will solve 75% of the problems
120 120%

100 97% 99% 100% 100%

91% 95%
86%
80 81% 80%
75%

60 60%
51%
40 40% Frequency
cumulative %
27%
20 20%

0 0%
e ug se t te gs se te
ed m r en u o n
ra
si s
g ti
gd r do a ti ro al ti dr
u
r do V
I
sem ro
n
ro
n
O ve
ng
p
on
g
alc
u
te
d de n g
Do W W ro r c ic a Un ro
W W ng pl W
ro Du
W

16
 Cause and Effect Diagrams

 Introduced by Dr. Kaoru Ishikawa

 Also known as Fishbone or Ishikawa diagram
 It is a schematic way to understand the possible causes to a problem
 Problem (Effect) on the right side and the possible causes on the left side
 Causes are broadly classified into 5M’s and E -
Man (People)
Methods (Policies and Procedures)
Materials (Supplies)
Machine (Equipment)
Money
Environment (Mother nature)

17
 When is it used?

 When identifying possible causes for a problem.

 Identifies areas for collecting data.
 Good process knowledge from multiple stake holders.
 Useful for teams: focusing a discussion and organizing large
amounts of information coming from a brainstorming
session.
 Especially when a team’s thinking tends to fall apart, and
concentration is lacking.

18
 Schematic

Material People / Man Method

Effect

Environment Machine Money

19
 Cause and Effect Diagram
Material People /Man Policies

New staff
Policies not clear
No clock at nursing
counter Less manpower
Policies not available at
nursing counters
Lack of training Medication
administered
at wrong time
New EMR system Complicated IPD layout
No protocol on addressing queries of
patients at nursing station
Data loss Rounds interrupted

Second check by nurses not Inadequate signage /

performed Net bandwidth instructions
Procedures / Methods Machine Environment

20
Cause and Effect Diagram

21
 Scatter Plots

 Introduced by Mr René Descartes, a French Mathematician.

 Scatter diagram uses dots to show co-relation between two
numeric variables.
 Used to - observe relationship between two variables.
 If one variable can be predicted based on the value of the
other, then correlated.
 After brainstorming session and identifying causes and
effects using a fishbone diagram, to determine whether a
particular cause and effect are related.

22
 Dependent and Independent Variables

 X axis - Cause – Independent variable (age, height) - Input Y

axis
 Y axis - Effect – Dependent variable - Output
X axis

X axis - Input (Cause) Y axis - Output (Effect)

Waiting time Patient satisfaction

Study time Marks obtained
Number of staff available Compliance to case sheet documentation
Number of trainings provided Compliance to protocols
Age of patients Number of falls
Calories / quantity of sweets consumed Weight gain

23
 Scatter Plots - Correlation

 2 Dimensional X/Y plots

 Shows relationship between independent(x) and dependent(y) variable

Positive correlation Negative correlation Null / No correlation

Upward slope (as one variable Downward slope (as one variable No pattern. Both variables have
increases so does the other) increases the other decreases no effect on each other

24
 Curvilinear Relationship

A curvilinear relationship is a type

of relationship between two variables that has
a pattern of correspondence between the two
variables that change as the values of the
variables change (increase or decrease).

25
Strong and Weak Correlations

26
 Time Spent by Nurses and Patient Satisfaction
Patient hosp Time Spent by Patient hosp Time Spent by
Satisfaction Score Satisfaction Score
number nurses (In minutes) number nurses (In minutes)
1 24 5 12 12 3
2 8 1 13 12 2
3 9 1 14 14 3
4 22 4 15 11 2

5 10 3 16 16 3
17 20 4
6 19 4
18 18 3
7 10 2
19 14 2
8 16 4
20 14 4
9 13 4 21 17 3
10 15 3 22 17 4
11 23 4 23 13 3

27
 Scatter Plot

Satisfaction Score
5

Satisfaction score - 5 being the highest

4

0
6 8 10 12 14 16 18 20 22 24 26
Time spent by nurses (In minutes)

28
 Scatter Plot

Satisfaction Score
5

Satisfaction score - 5 being the highest

tion
4
e la
r
cor
e
3
si tiv
Po
2

0
6 8 10 12 14 16 18 20 22 24 26
Time spent by nurses (In minutes)

29
 Control Charts

 Introduced by Dr. Walter Andrew Shewhart

 Also known Shewhart charts
 Used to - determine if a process is in a state of control or not
 Monitor processes to show how the process is performing over time
 Post implementation, the mean and the control limits may vary depending on the
effectiveness of the implementation
 They are helpful for analyzing a process before and after an improvement

30
 Control Charts

 Following needs to be calculated -

 Mean
 Standard deviation
 Upper control limit (UCL)
 Lower Control limit (LCL)

 UCL and LCL can also be calculated based on:

 Data from scientific literature
 Historical data
 Statistical data like Standard deviation

31
Time Between Glucose Measurements (in Hours)

Date Hours Date Hours

01-12-21 5 12-12-21 5
13-12-21 6
02-12-21 5.5
14-12-21 6
03-12-21 5.5 15-12-21 5
04-12-21 5 16-12-21 4.5
05-12-21 7 17-12-21 5
06-12-21 5 18-12-21 6
07-12-21 5 19-12-21 5.5
20-12-21 6
08-12-21 6 21-12-21 5
09-12-21 6 22-12-21 5
10-12-21 10 23-12-21 5
11-12-21 11

32
 Time Between Glucose Measurements (in Hours)

Date Hours Date Hours

01-12-21 5 12-12-21 5
02-12-21 5.5 13-12-21 6
03-12-21 5.5 14-12-21 6
04-12-21 5 15-12-21 5 Calculate Mean and Standard
16-12-21 4.5 deviation
05-12-21 7
17-12-21 5
06-12-21 5
18-12-21 6 Mean = 5.869565
07-12-21 5 19-12-21 5.5 SD = 1.575
08-12-21 6 20-12-21 6
09-12-21 6 21-12-21 5
10-12-21 10 22-12-21 5
11-12-21 11 23-12-21 5

33
 Time Between Glucose Measurements (in Hours)

Date Hours Date Hours

01-12-21 5 12-12-21 5 Calculate UCL (upper control limit) and
13-12-21 6 LCL (Lower control limit)
02-12-21 5.5
14-12-21 6
03-12-21 5.5 15-12-21 5
04-12-21 5 Mean = 5.869565
16-12-21 4.5
05-12-21 7 17-12-21 5 SD = 1.575
06-12-21 5 18-12-21 6
19-12-21 5.5 UCL = Mean + 3 *(Standard Deviation)
07-12-21 5 UCL = 10.59
20-12-21 6
08-12-21 6 21-12-21 5
09-12-21 6 22-12-21 5 LCL = Mean -3 *(Standard Deviation)
10-12-21 10 23-12-21 5 LCL = 1.14
11-12-21 11

34
 Time Between Glucose Measurements (in Hours)

Date Hours Mean UCL LCL Date Hours Mean UCL LCL
01-12-21 5 5.86 10.59 1.14 12-12-21 5 5.86 10.59 1.14
02-12-21 5.5 5.86 10.59 1.14 13-12-21 6 5.86 10.59 1.14
03-12-21 5.5 14-12-21 6 5.86 10.59 1.14
5.86 10.59 1.14
04-12-21 5 15-12-21 5 5.86 10.59 1.14
5.86 10.59 1.14
16-12-21 4.5 5.86 10.59 1.14
05-12-21 7 5.86 10.59 1.14 17-12-21 5 5.86 10.59 1.14
06-12-21 5 5.86 10.59 1.14 18-12-21 6 5.86 10.59 1.14
07-12-21 5 5.86 10.59 1.14 19-12-21 5.5 5.86 10.59 1.14
08-12-21 6 5.86 10.59 1.14 20-12-21 6 5.86 10.59 1.14
09-12-21 6 5.86 10.59 1.14 21-12-21 5 5.86 10.59 1.14
10-12-21 10 5.86 10.59 1.14 22-12-21 5 5.86 10.59 1.14
11-12-21 11 5.86 10.59 1.14 23-12-21 5 5.86 10.59 1.14

35
 Control Chart

In this case, the variation was detected on Jun 11th because the corresponding data point
was above the upper control limit. Root cause for the variations needs to be investigated.

36
 Flow Chart

 Also known as Process flow diagram or flow diagram.

 Introduced by Mr Frank Gilbreth in 1921.
 A powerful improvement tool to define, describe, and
communicate clinical, administrative and operational
processes.
 Represents processes with the help of pictorial symbols.
 They trace the steps the ‘object’ of the process goes through
from start to finish.

37
 Uses of Flowcharts

 Explains how a process is performed.

 Helps to identify opportunities for improvement.
 Communicate to others how a process is done.
 When better communication is needed between people
involved with the same process.
 In order to document a process.
 While planning a project.
 Helps in identifying points or bottle necks where problems
might occur.

38
 Flow Chart - Symbols

Direction of One step in the Decision / Condition

Start and end points
flow process / based on a question
Processing/ activity

Link to another page

or flowchart / Delay or wait Input or
Document
Connectors output

39
The Process Flow Diagram (Flow Chart)
BEGIN

ACTIVITY

DECISION NO DELAY ACTIVITY

YES

ACTIVITY

DECISION NO ACTIVITY

YES

ACTIVITY DELAY

END

40
Simple Example

41
Flow Chart

42
43
 Check Sheet

 Introduced by Dr. Kaoru Ishikawa.

 Also known as Defect concentration diagram.
 A simple document used for collecting real time data at
the location where the data is generated.
 Helps in collecting and analysing data with ease.
 Identifies how often different problems occur /
Registers frequency of incidents that are believed to
cause problems.

44
 Check Sheet

When to be used ?
 When data can be observed and collected repeatedly by the same person
or at the same location
 To collect data on the frequency or patterns of events, problems, defects,
etc.

45
 Procedure for Check Sheet

i. Decide what problem will be observed.

ii. Decide when data will be collected and for how long.
iii. Decide the form.
iv. Label all spaces on the form.
v. Test check sheet for a short trial period to be sure it
collects appropriate data and is easy to use.
vi. Each time targeted problem occurs, record it.

46
 Check Sheet

Problems identified in the Wards

Staff not
punctual for
duty

Wrong diet

Missing CSSD
item

Late
Discharges

Wrong
admission

47
 Type of tool Used to

Histograms Categorize large amount of continuous,

quantitative data

Pareto Charts Prioritize problems to be addressed

Cause and Effect Find possible causes for a problem

Diagrams

See if 2 variables are related to each

Scatter Diagrams other or not

Control Charts To check if a process is in control or not

48
Thank You!