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QA Workbook

The Problem Solving

2nd Edition 2012

PROBLEM
IDENTIFICATION

MONITORING & PROBLEM
RE-EVALUATION PRIORITISATION

OF THE
PROBLEM

IMPLEMENTATION PROBLEM
OF REMEDIAL ANALYSIS
ACTION

IDENTIFICATION PROBLEM
OF STRATEGY VERIFICATION
FOR CHANGE
(REMEDIAL
ACTION)

QA STUDY

AUTHORS

DATO’ DR ABD JAMIL ABDULLAH
Hospital Sultanah Nur Zahirah,
Kuala Terengganu
SAMSIAH AWANG
Institute for Health Systems Research
DATIN DR SITI HANIZA MAHMUD
Institute for Health Systems Research
DR NOORHAIDA UJANG
Maharani Health Centre, Muar, Johore
DR RAMLI ZAINAL
Institute for Health Systems Research
DR NUR EZDIANI MOHAMED
Institute for Health Systems Research

COPYRIGHT

All rights reserved. No part of this publication
may be reproduced, stored in a retrieval
system, or transmitted, in any form or by any
means, electronic, mechanical, photocopying,
recording or otherwise, without the prior
permission from the authors.

First edition 2009
Second edition 2012

ISBN 978-967-5398-40-7

QA Workbook – The Problem Solving Approach – 2nd Edition Introduction

ACKNOWLEDGEMENT

The authors greatly appreciate the support of the following
persons in the development of this workbook:
• YBhg Dato’ Dr Maimunah A Hamid; Deputy Director General

(Research & Technical Support) as the Chairperson of the
National Committee for QAP MOH
• YBhg Dato’ Dr Azman Abu Bakar and YBhg To’ Puan Dr Hjh.
Rahmah Elias who were involved in the first edition of the
book.
• Dr Hjh Noorliza Mohamad Noordin as the Chairperson of the
National Technical Committee for QAP MOH.
We would also like to express our gratitude to the following
persons:
• Dr Tang Jyh Jong from Hospital Raja Permaisuri Bainun Ipoh
Perak for his permission to include the QA project entitled
Reducing wound infection rate for diagnostic skin biopsy in
Dermatology Clinic as one of the examples in this workbook.
• Mrs. Nur Faisza Mohd Isa for her continuous effort in assisting
to compile the discussion, arranging, typesetting & editing the
design of this workbook.
• Ms Zarifah Ahmad Zamri in assisting us to complete this
workbook.
• Ms Haniza Mohd Anuar for reviewing the language aspect of
this workbook.

iii

Introduction QA Workbook – The Problem Solving Approach – 2nd Edition

WHAT THIS BOOK IS ABOUT

This workbook consists of compilations of QA lecture notes, group
work assignments, the Health Systems Research Training modules
and other existing manuals. It is to be used in tandem with the
module for Implementing Quality and Improving Performance,
published by the Institute for Health Systems Research.

This edition was revised after taking into accounts valuable
comments, feedback and new ideas from various sources
including the previous users.

What is new in this edition?

• The topics are rearranged to follow the QA cycle in order to
guide the users to a step by step approach in conducting a QA
project

• A specific project was selected as an example and followed
through in all of the exercises to enhance users understanding

• Additional chapter on guidelines for oral and poster
presentation

• A sample of a QA project proposal, abstract and report and
other useful references

• Icons to facilitate user of this workbook including one which
indicate the need to refer to the main module i.e.
Implementing Quality and Improving Performance Module

We hope that this new edition will further simplify the training
components during QA workshops. We welcome any comments
and suggestions from the users to further improve this workbook.
Send us an email at [email protected]

The Authors
July 2012

iv

QA Workbook – The Problem Solving Approach – 2nd Edition Introduction

HOW TO USE THIS WORKBOOK

This workbook is to be used as a companion to the
Module “Measuring & Managing Quality of
Healthcare - Implementing Quality & Improving
Performance”.
This is NOT a textbook on quality.
The following icons were included to assist you in using this workbook:

This icon informs you about the OBJECTIVE of the
chapter.

This icon alerts you on important KEYWORDS,
SUGGESTIONS AND IDEAS.

This icon calls for ATTENTION to refer to the
Measuring & Managing Quality of Healthcare-
Implementing Quality & Improving Performance
module OR other chapter in this QA Workbook.

This icon indicates EXERCISE for you to carry out.

This icon signals you of an EXAMPLE that you can
refer to improve your understanding

v

QA Workbook – The Problem Solving Approach – 2nd Edition

ABBREVIATIONS & ACRONYMS

Introduction A = Achievable Benefit Not Achieved
Continuous Quality Improvement
ABNA Health Care Quality
Nominal Group Technique
C Model of Good Care
Standards for Quality Improvement Reporting Excellence
CQI = Total Quality Management

H

HCQ =

N

NGT =

M =

MOGC

S =

SQUIRE

T

TQM =

Q

QA = Quality Assurance
QC = Quality Control
QI = Quality Improvement
QIR = Quality Improvement Report
QM = Quality Management

vi

QA Workbook – The Problem Solving Approach – 2nd Edition Introduction

CONTENT

HOW TO USE THIS WORKBOOK ......................................................................................... V
LEARNING OBJECTIVES ......................................................................................................... 1
EXPECTED OUTCOME ........................................................................................................... 1
CHAPTER 1: OVERVIEW OF QUALITY ASSURANCE ............................................................. 7
1.1 UNDERSTANDING QA .................................................................................................. 8

1.1.1 DEFINITION OF QUALITY .................................................................................. 8
1.1.2 TERMINOLOGY IN QUALITY ............................................................................. 9
1.1.3 THE 4 TENETS OF QUALITY ASSURANCE ......................................................... 10
1.1.4 DIMENSIONS OF QUALITY ................................................................................ 10
1.1.5 ABNA CONCEPT ................................................................................................. 11
1.1.6 WHY WE NEED QUALITY ASSURANCE ............................................................. 11
1.1.7 STRUCTURE, PROCESS, OUTCOME APPROACH (DONABEDIAN) ................... 12
CHAPTER 2: THE QA CYCLE – A PROBLEM SOLVING APPROACH ..................................... 13
CHAPTER 3: IDENTIFICATION OF QUALITY PROBLEM ....................................................... 15
(OPPORTUNITY FOR IMPROVEMENT)
3.1 GUIDE IN IDENTIFYING RELEVANT PROBLEMS ........................................................... 16
3.2 EXERCISE ........................................................................................................................ 17
CHAPTER 4: PRIORITISATION OF QUALITY PROBLEM ........................................................ 19
4.1 THE NOMINAL GROUP TECHNIQUE (NGT) ................................................................ 20
4.1.1 USES OF NGT ....................................................................................................... 20
4.1.2 VOTE TO PRIORITISE PROBLEMS ........................................................................ 21
4.2 MULTIVOTING ............................................................................................................. 23
4.2.1 DEFINITION ....................................................................................................... 23
4.2.2 MULTIVOTING PROCEDURES ........................................................................... 23
4.3 CONSENSUS ................................................................................................................. 27
4.4 EXERCISE ........................................................................................................................ 28

vii

Introduction QA Workbook – The Problem Solving Approach – 2nd Edition

CHAPTER 5: PROBLEM ANALYSIS ......................................................................................... 31
5.1 PROBLEM ANALYSIS ..................................................................................................... 32
5.2 FORMULATING THE PROBLEM STATEMENT PURPOSE .............................................. 34
5.3 EXERCISE ....................................................................................................................... 35
CHAPTER 6: QA STUDY ....................................................................................................... 41
6.1 FORMULATING STUDY OBJECTIVES ........................................................................... 42

6.1.2 EXERCISE ............................................................................................................ 43
6.2 MEASURING QUALITY ................................................................................................... 44

6.2.1 IDENTIFY INDICATORS ...................................................................................... 44
6.2.2 IDENTIFY VARIABLES ......................................................................................... 46

6.2.2.1 CRITERIA OF VARIABLES ..................................................................... 46
6.2.2.2 OPERATIONALISING VARIABLES ........................................................ 47
6.2.3 IDENTIFY CRITERIA ........................................................................................... 47
6.2.4 SET STANDARDS ................................................................................................ 49
6.2.5 EXERCISE ............................................................................................................ 50
6.3 MODEL OF GOOD CARE (MOGC) .............................................................................. 53
6.3.1 EXERCISE ............................................................................................................ 54
6.4 DATA COLLECTION (PROCESS OF GATHERING INFORMATION) ............................. 55
6.4.1 VARIOUS DATA COLLECTION TECHNIQUES ................................................... 56
6.4.2 EXERCISE ............................................................................................................ 57
6.5 DATA ANALYSIS ............................................................................................................ 58
6.5.1 EXERCISE ............................................................................................................ 59

viii

QA Workbook – The Problem Solving Approach – 2nd Edition Introduction

CHAPTER 7: PLANNING FOR CHANGE ............................................................................... 63
7.1 STEPS IN RECOMMENDING REMEDIAL ACTIONS ...................................................... 64
7.2 GUIDE ON IMPLEMENTING CHANGE ....................................................................... 64
7.3 TYPE OF CHANGES THAT MAY REQUIRED ................................................................ 65
7.4 EXERCISE ...................................................................................................................... 66
CHAPTER 8: MONITORING CHANGE & RE-EVALUATION ................................................. 67
8.1 WHY EVALUATE? ......................................................................................................... 68
CHAPTER 9: WRITING A QA PROPOSAL ............................................................................. 69
CHAPTER 10: WRITING A QA REPORT ................................................................................ 70
CHAPTER 11: ORAL & POSTER PRESENTATION (THE DO’S & DON’TS) ............................. 75
11.1 ORAL PRESENTATION .................................................................................................. 76
11.2 POSTER PRESENTATION ............................................................................................... 79
APPENDICES ......................................................................................................................... 84
REFERENCES ......................................................................................................................... 102

LIST OF APPENDICES

APPENDIX 1 : JUDGING CRITERIA USED IN QA MOH CONVENTIONS ..................... 82
(ORAL & POSTER)

APPENDIX 2 : EXAMPLE OF A QA PROPOSAL .............................................................. 83
APPENDIX 3 : EXAMPLE OF A QA ABSTRACT ............................................................... 90
APPENDIX 4 : EXAMPLE OF A QA WRITE-UP ................................................................ 91
APPENDIX 5 : EXAMPLE OF QA PROJECTS PRESENTED AT THE NATIONAL ................ 99

QA CONVENTION
APPENDIX 6 : LIST OF POTENTIAL QUALITY JOURNAL FOR QUALITY ARTICLE ........ 101
APPENDIX 7 : QIR REPORTING FORMAT [BMJ] ............................................................ 101
APPENDIX 8 : SQUIRE GUIDELINE ................................................................................ 101

ix

QA Workbook – The Problem Solving Approach – 2nd Edition

LIST OF FIGURES

FIGURE 1 : ABNA CONCEPT ..................................................................................... 11

Introduction FIGURE 2 : APPROACH TO ASSESS QUALITY ........................................................... 12

FIGURE 3 : PROBLEM ANALYSIS CHART .................................................................. 34

FIGURE 4 : FISHBONE/ISHIKAWA DIAGRAM ............................................................ 34

x

QA Workbook – The Problem Solving Approach – 2nd Edition Introduction

LEARNING OBJECTIVES

At the end of the course, participants will be able to:
Understand the process of carrying out a QA project.
Identify quality problems (opportunities for improvement).
Identify key measures for improvement.
Identify process of gathering information.
Analyse and interpret finding(s).
Formulate appropriate strategies for change.

EXPECTED OUTCOME

[A proposal to improve quality using QA approach]

1

QA Workbook – The Problem Solving Approach – 2nd Edition

Notes

Introduction

2

QA Workbook – The Problem Solving Approach – 2nd Edition Introduction
Notes

3

QA Workbook – The Problem Solving Approach – 2nd Edition

Notes

Introduction

4

QA Workbook – The Problem Solving Approach – 2nd Edition Introduction
Notes

5

QA Workbook – The Problem Solving Approach – 2nd Edition

Notes

Introduction

6

CHAPTER 1: section 1
OVERVIEW OF QUALITY
ASSURANCE

Definition and
terminology of quality

ABNA concept
Quality dimensions

QA Workbook – The Problem Solving Approach – 2nd Edition

1.1 UNDERSTANDING QA

1.1.1 DEFINITION OF QUALITY
Quality is defined differently by different people. Some of which are:

section 1 Source Definition
Donabedian
Institute of Medicine Quality assurance means all actions taken to establish,
protect, promote and improve the quality of health care
Joseph Juran
Phillip Crosby Quality of care is the degree to which health services for
Deming individuals and population increase the likelihood of desired
ODI Consulting health outcomes and are consistent with current professional
Policy Makers knowledge

Health Care Fitness for use
Professionals
Zero defects, conformance to requirements
Patients
Reducing variations in practice, never ending cycle of
continuous improvement

Do the right thing right, the first time, every time

• Access to services

• Relevance of services

• Efficiency of services

• Acceptability & effectiveness of services

• Technically sound

• Outcome of treatment

• Professionally ethical

Responsiveness to perceived care needs; level of
communication, concern and courtesy; degree of symptom
relief, level of functional improvement

8

QA Workbook – The Problem Solving Approach – 2nd Edition

1.1.2 TERMINOLOGY IN QUALITY

Terms Definition

Quality Assurance (QA) QA refers to all of the processes and activities related to the
planning for quality, the setting and communicating of
standards, measuring and monitoring compliance to these
standards.

Quality Control (QC) QC refers to the processes of measuring the difference, if any,
between the current performance of an organization and the
desired levels of standards.

Quality Improvement (QI) QI refers to the process and activities to reduce variance in
performance from the desired standards, thus reducing the
gap between current performance threshold and the desired
thresholds.

Continuous Quality CQI is an incremental and continuous improvement for the
Improvement (CQI) whole organization.

Quality Management QM is the umbrella term that encompasses QA, QI and QC. section 1
(QM) It is the term applied to all of the process related to the
coordinating and facilitating of quality related activities and
tasks in an organization.

Total Quality TQM is a theory and a management method that was first
Management (TQM) introduced in Japan and involved 5 main principles: system
wide, leadership commitment, data driven decision-making,
customer focused and teamwork.

Healthcare Care Quality HCQ is another term that refers to an organization-wide

(HCQ) quality management program and processes.

The requirement of the customer is always a
consideration in defining quality

9

QA Workbook – The Problem Solving Approach – 2nd Edition

1.1.3 THE 4 TENETS OF QUALITY ASSURANCE

• QA is oriented toward meeting the needs and expectations of the patients/clients and
the community i.e stakeholders.

• QA focuses on systems and process.
• QA uses data to analyse service delivery process.
• QA encourages a team approach to problem solving and quality improvement.

According to Joint Commission on Accreditation of Healthcare
Organisations (JCAHO), quality is defined as “the degree to
which health services for consumers increase the likelihood of
the desired health outcomes and are consistent with the
current professional knowledge.”

1.1.4 DIMENSIONS OF QUALITY

section 1 Effectiveness It is the degree to which desired results are achieved.
Efficiency of service
delivery It relates to the effective use of resources to produce those
Accessibility services.

Safety It reflects a lack/presence of geographic, economic, social,
organisational or linguistic barriers to services.
Technical competence
It is the degree to which the risks of injury, infection and
Interpersonal relations harmful side effects are minimised.

Physical infrastructure It refers to the degree to which tasks are carried out by
and comfort health workers and facilities in accordance with standards
Choice of services and expectations.

Patient centredness It refers to effective listening and communication between
provider and client.

Also known as ‘amenities’ which includes a facility’s physical
appearance, cleanliness, comfort and privacy.

It refers to client’s right to choose and make an informed
choice of provider.

Consideration for human dignity, confidentiality and privacy

(Adopted from Al-Assaf et.al, 2007)

10

QA Workbook – The Problem Solving Approach – 2nd Edition section 1
1.1.5 ABNA CONCEPT
Refers to the difference between what could be optimally achieved with available resources
and what is presently achieved.

FIGURE 1: ABNA CONCEPT

1.1.6 WHY WE NEED QUALITY ASSURANCE

11

QA Workbook – The Problem Solving Approach – 2nd Edition

1.1.7 STRUCTURE, PROCESS, OUTCOME APPROACH (DONABEDIAN)
An approach to assess quality using structure, process and outcome model.
FIGURE 2: APPROACH TO ASSESS QUALITY

section 1

12 If you can’t do great things,
do small things in a great way.

CHAPTER 2: section 1
THE QA CYCLE – A PROBLEM
SOLVING APPROACH

Able to understand
the components of
the QA cycle.

Able to understand
the steps in
conducting QA
study.

section 1 QA Workbook – The Problem Solving Approach – 2nd Edition

14

CHAPTER 3: section 1

IDENTIFICATION OF QUALITY
PROBLEM (OPPORTUNITY FOR
IMPROVEMENT)

Able to identify
quality problems

QA Workbook – The Problem Solving Approach – 2nd Edition

3.1. GUIDE IN IDENTIFYING RELEVANT PROBLEMS

Problem should be related to your QUESTIONS TO ASK:
core business. What is your department?
What it does?
(What is your core business?) Who does it serve?
Where is the service given?
It has been brought up as issues at When?
meetings and discussions. Appeared Who else is involved in the service process?
in complaints and mentioned by staff. Which part of your business that is not doing
well?
Problem not solved.

section 1

16

QA Workbook – The Problem Solving Approach – 2nd Edition

3.2 EXERCISE

a. What is your core business? b. Who are your customers?

section 1

c. List down all problems at your workplace and decide whether it is a quality problem.
State the reason if it is not a quality problem.

Problems Is the problem a quality problem? Reasons if no
Yes No

Problems are not stop signs, they are opportunities. 17

QA Workbook – The Problem Solving Approach – 2nd Edition

Notes

section 1

18

CHAPTER 4: section 1

PRIORITISATION OF
QUALITY PROBLEM

Able to prioritise
quality problems
using appropriate
technique.

section 1 QA Workbook – The Problem Solving Approach – 2nd Edition

Prioritisation can be done using several methods which include/such as:
• Nominal Group Technique (NGT)
• Multivoting
• Consensus

4.1 THE NOMINAL GROUP TECHNIQUE

It is a weighted ranking technique that allows members of a team to prioritise a large number
of issues without creating any winners or losers. Everyone in the group will have input into
the problems, ideas which they feel have the most importance. The problems are ranked in
order of importance individually by members of the group. Then it is put to vote. The
problem which received the highest vote gets the priority.

The group must consist of people with a common interest. Example: quality
improvement and the subject matter related to them.
Number of group members: 7 – 12
• < 7 -- Inadequate expertise.
• > 12 -- Too many, creating unsatisfactory group dynamic - few loud-mouths,

many nodders & sleepy-heads.
Chairman should be a senior person with interest & authority. He is in the position to
lead the group into the study and solving the problem.
Final choice may need approval from people with financial & administrative authority.
4.1.1 USES OF NGT
NGT has a relatively low level of interaction. It is an effective technique when all or some
group members are new to each other.
NGT is used to find a common ground in face of disagreement to establish a starting point
for further discussion or negotiation.

20

QA Workbook – The Problem Solving Approach – 2nd Edition section 1

4.1.2 VOTE TO PRIORITISE PROBLEMS

4.1.2.1 Process of voting

1. Individuals need to prioritise and give highest point to the problem according
to priority. Individuals can use or develop criteria to prioritise which problems
they want to vote and give highest point.

2. Cumulative votes decide and prioritise the problem for the group.
3. SMART criteria can be used to decide if the problem is worth studying:

SMART stands for:

Seriousness

• How important is this problem in relation to the quality of patient care?
• Is life at stake? Does it cause permanent disability, pain?
• Does it cause distress to patient, relatives?
• Does it have an impact on patient, society and hospital image?
• Does it have an impact on cost and resources?
• Frequent occurrence though not very serious.
• Is there room for improvement?
• How large is the ABNA - Is it worth studying?

Measurable

• The process of care is clearly defined with easily identifiable starting and
ending points.

• The indicators are identifiable to the problems.
• Data related to the problem are available or can be obtained.

Appropriateness

• The process or project is related to core business and is consistent with the
organisation goals and values.

• The proposed opportunity for improvement has direct impact on the customers
and will likely result in an improvement in the quality of care.

• The cost of not solving this quality problem may be significant. This may be
financial, legal or related to image of the organization.

• Managers are concerned with this process, and agree that it is important to do
a study and improve this process.

21

QA Workbook – The Problem Solving Approach – 2nd Edition

Remediable

• ARE solution available? Availability of resources and expertise to do the study
or correct the situation

• OR solution is too obvious? If the solution is very obvious, just solve it without
doing a study.

Timeliness

• There are no current operational, financial or political issues which might
affect the success of the project.

• Social, political, ethically acceptable.
• This process is not being studied by any other group.
• The problem has not been solved.
• The study and remedial measures can be carried out within a reasonable

period by the group.

section 1 4.1.2.2 Prioritisation by giving weightage according to the
`SMART’ criteria

Proposed Topic Serious or Relevant / Timely Total
Measurable Appropriate 3 14
Specific Remediable
11
1. Unnecessary 2 3 3 3

CXRs in Surgical

in-patients

2. Unnecessary 3 3 2 2 1

catheterisation

for Medical

patients

Rating scale: 1 = low, 2 = medium, 3 = high

This prioritisation by weightage can be done as a group or individual. Once a problem to be
studied has been identified and prioritised by whichever technique, the whole committee
must work together towards solving this problem. Other members can be co-opted at this
point according to the nature and area of problem to be studied.

22

QA Workbook – The Problem Solving Approach – 2nd Edition section 1

4.2 MULTIVOTING

4.2.1 DEFINITION

Multivoting is a group decision-making techniques
used to reduce a long list of items to a manageable

number by means of a structured series of votes.

Brainstorming, generates a long list of ideas which many are not realistic or feasible. The
multivoting activity allows a group to narrow their list or options into a manageable size for
consideration or study. It will not help the group make a single decision but can help the
group narrow a long list of ideas into a manageable number that can be discussed and
explored. It allows all members of the group to be involved in the process and ultimately
saves the group a lot of time by allowing them to focus energy on the ideas with the greatest
potential. The result is a short list identifying what is important to the team.

4.2.2 MULTIVOTING PROCEDURES

1. Brainstorm for a list of options.
2. Review the list from the Brainstorming activity.
3. Participants vote for the ideas that are worthy of further discussion.
4. Indentify items for next round of voting.
5. Vote again.

23

section 1 QA Workbook – The Problem Solving Approach – 2nd Edition

1. Brainstorm for a list of options.
Conduct the Brainstorming activity to generate a list of ideas or options.

2. Review the list from the Brainstorming activity.
Once you have completed the list, clarify ideas, merge similar ideas, and
make sure everyone understands the options.

3. Participants vote for the ideas that are worthy of further discussion.
Each participant may vote for as many as they wish. Voting may be by show
of hands or physically going to the list and marking their choices or placing
a dot by their choices. If they so desire, participants may vote for every item.

4. Identify items for next round of voting.
Count the votes for each items. Any item receiving votes from half the people
voting is identified for the next round of voting. For example, if there are 12
people voting, any item receiving at least six votes is included in the next
round. Signify the items for the next vote by circling or marking them with a
symbol, i.e., all items with a star by the number will be voted on the next
round.

5. Vote again
Participants vote again, however this time they may only cast votes for half
the items remaining on the list. In other words, if there are 20 items from the
last round that are being voted on, a participant may only vote for ten items.

6. Repeat steps 4 and 5
Participants continuing voting and narrowing the options as outlined in steps
4 and 5 until there is an appropriate number of ideas for the group to analyze
as a part of the decision-making or problem solving process. Generally
groups need to have three to five options for further analysis.

7. Discuss the remaining ideas.
At this time the group engages in discussing the pros and cons of the
remaining ideas. This may be done in small groups or the group as a whole.

8. Proceed with appropriate actions
At this point the group goes to the next step. This might be making a choice
of the best options or identifying the top priorities.

24

QA Workbook – The Problem Solving Approach – 2nd Edition

4.2.3 EXAMPLES

Members of a command’s Planning Board for Training conducted meetings which were not
always as productive as they might have seen. The XO called a meeting to identify the
reasons for the lack of meeting productivity and to determine which reasons the team thought
most important. The XO led a Brainstorming session which produced the following list :

Lack of Meeting Productivity I. Problems not mentioned section 1
A. No Agenda J. Interrupted by phone calls
B. No clear objectives K. Few meaningful metrics
C. Going off on targets L. Interrupted by visitors
D. Extraneous topics M. No administrative support
E. Too many “sea stories” N. Meetings extended beyond allotted time
F. Vital members missing from meeting O. Members distracted by pressing operations
G. Not enough preparation for meetings P. Unclear charts
H. Too much “dog and pony”

The team used Multivoting to reduce this list to a manageable size:

• Each of the 6 members of the team was allowed 8 votes (half the number of items).

• The votes were tallied, as shown in Viewgraph 1, and the top 8 items were carried
forward to the second round.

• The items that had 4 or more votes in the first round were reduced to 4 in a second
round of voting. The group chose to focus on problems F, G, H, and J, as shown in
Viewgraph 2.

25

QA Workbook – The Problem Solving Approach – 2nd Edition

FIRST VOTE TALLY

Vote : 1 A. No Agenda Vote : 1 I. Problems not mentioned

Vote : 4 B. No clear objectives Vote : 5 J. Interrupted by phone calls

Vote : 2 C. Going off on targets Vote : 2 K. Few meaningful metrics

Vote : 1 D. Extraneous topics Vote : 4 L. Interrupted by visitors

Vote : 2 E. Too many “sea stories” Vote : 3 M. No administrative support

Vote : 6 F. Vital members missing from Vote : 2 N. Meetings extended beyond
meeting allotted time

Vote : 5 G. Not enough preparation for Vote : 4 O. Members distracted by
meetings pressing operations

Vote : 4 H. Too much “dog and pony” Vote : 4 P. Unclear charts

section 1 Multivoting Example Viewgraph 1

Vote : 0 SECOND VOTE TALLY
Vote : 5 B. No clear objectives
Vote : 5 F. Vital members missing from meeting
Vote : 5 G. Not enough preparation for meetings
Vote : 4 H. Too much “dog and pony”
Vote : 0 J. Interrupted by phone calls
Vote : 2 L. Interrupted by visitors
Vote : 3 N. Meetings extended beyond allotted time
O. Members distracted by pressing operations

Multivoting Example Viewgraph 2

26

QA Workbook – The Problem Solving Approach – 2nd Edition

4.3 CONSENSUS section 1

4.3.1 DEFINITION

Consensus decision making is a process used by groups seeking to generate widespread
levels of participation and agreement. There are variations among different groups regarding
the degree of agreement necessary to finalize a group decision. The process of group
deliberation, however, has many common elements that are definitive of consensus decision
making. These include:

• Inclusive
As many stakeholders as possible are involved in group discussions.

• Participatory
All participants are allowed a chance to contribute to the discussion.

• Collaborative
The group constructs proposals with input from all interested group members. Any
individual authorship of a proposal is subsumed as the group modifies it to include the
concerns of all group members.

• Agreement Seeking
The goal is to generate as much agreement as possible. Regardless of how much
agreement is required to finalize a decision, a group using a consensus process makes
a concerted attempt to reach full agreement.

• Cooperative
Participants are encouraged to keep the good of the whole group in mind. Each
individual’s preferences should be voiced so that the group can incorporate all
concerns into an emerging proposal. Individual preferences should not, however,
obstructively impede the progress of the group.

4.3.2 Process of consensus
There are multiple stepwise models of how to make decisions by consensus.

Step 1 Step 2 Step 3 Step 4 Step 5 Step 6
Discussion
Identify Identify any Collabo- Assess the Finalize the
emerging unsatisfied ratively degree of decision
proposal concerns modify the support OR
proposal
circle back
to

step 1 or 3

27

QA Workbook – The Problem Solving Approach – 2nd Edition

4.4 EXERCISE

a. The prioritisation can be done in many ways:

Option 1
Step 1: Individuals place appropriate weightage for each
problem according to the criteria (SMART).
Step 2: Vote.

Option 2
Place appropriate weightage as a group using the criteria (SMART).

Based on the list in exercise 3.2, prioritise your problems using the NGT.

No. Problems S M A R T Total

section 1

Weightage: 1 = Low, 2 = Medium, 3 = High

28 It takes courage to grow up and turn
out to be who you really are.

QA Workbook – The Problem Solving Approach – 2nd Edition

Example for individual weightage

No. Problems SMA R T Total
13
1 High wound infection rate for diagnostic 3 22 3 3
skin biopsy 10
2 22 2 2 9
2 Delay in tracing blood result for outpatient 2 12 22 9
2 22 1 2
3 Long patient waiting time to see doctor 11
2 32 31
4 Poor understanding among patients
regarding topical treatment

5 High default rate among patients
undergoing phototherapy

Weightage: 1 = Low, 2 = Medium, 3 = High

Example for group weightage

No. Problems SMA R T Total section 1
33
1 High wound infection rate for diagnostic 9 88 99
skin biopsy 30
6 65 76 25
2 Delay in tracing blood result for outpatient 4 55 65 29
6 66 56
3 Long patient waiting time to see doctor 27
4 66 56
4 Poor understanding among patients
regarding topical treatment

5 High default rate among patients
undergoing phototherapy

Weightage: 1 = Low, 2 = Medium, 3 = High

29

QA Workbook – The Problem Solving Approach – 2nd Edition

Notes

section 1

30

CHAPTER 5: section 1

PROBLEM ANALYSIS

Able to analyse
the selected QA
problem using
1H + 4W.

Able to formulate
a problem statement.

QA Workbook – The Problem Solving Approach – 2nd Edition

After identifying a problem, we need to analyse it and identify factors contributing to it. It
should result in a statement that describes the problem (Problem statement).

5.1 PROBLEM ANALYSIS

In this stage, problem should be clarified by using (1 Husband + 5 Wives) technique;

What is the actual problem?
Where does it occur?
When does it happen?
Who are those involved with the process?
Who are those affected?
How does it happen?

The wording of the problem should illustrate between what it is now and what it should be.
The steps involved are as follow:

List the problems in the area of concern as they perceived them. 1
Care of diabetic patients needs review.
section 1 Insufficient awareness of diabetes and self care measures
among diabetic patients and their relatives.
Insufficient peripheral facilities for long term follow-up care.
Excessive admission rates among diabetics.
High diabetic complication rate.
Poor compliance of diabetics with insulin therapy.

Specify and describe the core problem and quantify it. 2
From the example it may be decided that:

The high rate of admission among diabetics; a discrepancy
between what it should be and what is in services.
The high rate of diabetic complications; a discrepancy
between what it should be and what is in diabetic patients.
Attempt to describe more elaborately: In terms of re-
admissions and/or complication rates.

32

QA Workbook – The Problem Solving Approach – 2nd Edition 3

The distribution of the problem (with regards to where the
project is to be carried out).

Who -– Diabetics with diabetic foot complications.
When - All the time/now.
Where - Orthopaedic wards

The size and intensity of the problem. 4
All diabetics admitted have other complications.
All have neuropathies.
What are the consequences (disability, death, waste of resources).
50% required amputation, 10% mortality.
75% stayed more than 1 month.

Analyse the possible causes of the problem and its effects using Problem Analysis Chart or section 1
Fishbone Diagramme (Ishikawa Chart).

Steps:
Identify the factors that may have contributed to the problem.
Clarify relationship between the problem and contributing factors.
There can be 1st, 2nd and 3rd generation bubbles leading to the problem.
For Ishikawa Chart, causes can be grouped under:

4Ms - Manpower, Machines, Methods and Materials or
4Ps - Policies, Procedures, People and Plant

33

section 1 QA Workbook – The Problem Solving Approach – 2nd Edition
FIGURE 3: PROBLEM ANALYSIS CHART

FIGURE 4: FISHBONE/ISHIKAWA DIAGRAM

5.2 FORMULATING THE PROBLEM STATEMENT

PURPOSE
To justify why the study needs to be carried out. This will be the foundation for further
development of the research proposal and help in defining the scope of study. In addition,
by formulating problem statement it should tell us why this study should be carried out and
what is expected from the results.

PROBLEM STATEMENT & OPPORTUNITY PROBLEM
Problem Statement

Brief statement about the process of care where the problem occurred
Explaining what the problem is – Supported by evidence, if any
What are the consequences?
What are the possible causes?
Why we want to do the study?

34

QA Workbook – The Problem Solving Approach – 2nd Edition section 1

5.3 EXERCISE

a. Develop a flowchart of the current process of care related to the
problem. Concentrate on the steps that could have led to the
problem.

35

section 1 QA Workbook – The Problem Solving Approach – 2nd Edition
Example of flowchart: Process of care for skin biopsy

36

QA Workbook – The Problem Solving Approach – 2nd Edition section 1
b. Illustrate relationship between problem and contributing factors using either a

Problem Analysis Chart or Cause & Effect Diagram (Ishikawa Diagram).

37

section 1 QA Workbook – The Problem Solving Approach – 2nd Edition
Example of relationship between problem and contributing factors:

38


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