Mechanical Ventilation Weaning

Paper details

Project Topic: Readiness to wean patients from mechanical ventilation

Create a quality improvement project based on the following information.

Readiness to wean compliance
53 mechanically ventilated patients in the 2 months in icu
Count of sbt’s:
Total ventilated days 283
Charted sbt 199
Terminal 15
Short term vent 9
Coded 9
Missing sbt 51
The issue is some staff members don’t do the SBT trials
Some forget to chart
Some lack the proper education

1 create a why why chart for spontaneous breathing trials that were not done, and explain
2. Create a spontaneous breathing flow chart as to how It’s supposed to be done. And explain what this is.
3.Create a fishbone diagram of common issues found that may act as barriers to charting SBTs. And explain what it means.
Create a run chart for:reason sbts are not charted.
Ex.Unknow, terminal,codes, md order hold, or accidental extuabtion.
Research the rest of information.
QI Final Project
Module 02 – QI References (40 points): Due by deadline in Course Schedule. Use the template provided and include the following information:

I. References:
All of your references must be cited and discussed or quoted in your paper – no exceptions
• You must review at least five (5) peer-reviewed journal articles and discuss or include applicable quotes that support the points you will make in your QI project. These must be included in your QI Final Project and be cited in-text using APA format.
• Provide Five Reference Peer-Reviewed Articles from the Current Literature – additional books or websites are allowed in addition to the five (5) peer-reviewed journal articles
• You must obtain the FULL TEXT article online via Albertson Library or another online source that can be accessed by the instructor for verification – no sites requiring username/password
• Must put references in APA format
• References heading must be centered
• References must be double-spaced (use Microsoft Word Paragraph Spacing)
• Indent 5 spaces for 2nd and remaining lines
• Alphabetize references A-Z (Community, Harbrecht, Kallam, Kollef, Kress, The College of William & Mary, Venes)
• Italicize Journal Name and Volume information
• Volume (Italicized)/Issue/Pages. For example: Volume(Issue), Page-Page
• Date retrieved and web address where accessed must be provided – do not use doi in this course
• Put cursor at the end of the web address and hit backspace once to remove hyperlink

Examples: In 431, you provide the web address where the article is found and date accessed. All articles must be found online.

Community Hospital of the Monterey Peninsula. (2012). Respiratory care policy: Assess and treat protocol. Monterey, CA. Retrieved August 10, 2017 from http://www.chomp.org/policy/assess_and_treat
Harbrecht, B., Delgado, E., Tuttle, R., Cohen-Melamed, M., Saul, M., & Valenta, C. (2009). Improved outcomes with routine respiratory therapist evaluation of non-intensive-care-unit surgery patients. Respiratory Care, 54(7), 861-867. Retrieved July 13, 2017, from http://rc.rcjournal.com/content/54/7/861.full.pdf+html
Kallam, A., Meyerink, K., & Modrykamie, A. (2012). Physician-ordered aerosol therapy vs. respiratory therapist-driven aerosol protocol: the effect on resource utilization. Respiratory Care, 58(3), 431-437. Retrieved July 10, 2017, from http://rc.rcjournal.com/content/58/3/431.full.pdf+html
Kollef, M., Shapiro, S., Clinkscale, D., Cracchiolo, L., Clayton, D., … Willner, R. (2000). The effect of respiratory therapist initiated treatment protocols on patient outcomes and resource utilization. Chest, 117(2), 467-475. Retrieved July 10, 2017, from http://journal.publications.chestnet.org/article.aspx?articleid=1078573
Kress, J., Pohlman, A., O’Connor, M., Hall, J. (2000). Daily Interruption of Sedative Infusions in Critically Ill Patients Undergoing Mechanical Ventilation. The New England Journal of Medicine 342(20), 1471-1477. Retrieved July 6, 2017 from http://www.sciencedirect.com.libproxy.boisestate.edu
The College of William & Mary. (n.d.). The William & Mary mission statement. Retrieved August 1, 2017 from http://www.wm.edu/about/administration/provost/about/mission/
Venes, D. (2001). Taber’s Cyclopedic Medical Dictionary (19th ed.). Philadelphia: F.A. Davis Company.
QI Final Project Outline
Module 03 – QI Outline (50 points): Due by deadline in Course Schedule. This is part of the Define step of DMAIC. Use the template provided and include the following information:

D. Problem Description:
• What is the Problem identified that was being evaluated in the QI Project, or
• What is the Thesis Statement – what are you attempting to prove (or disprove) based upon your evaluation of the process identified (do not use bullet points – these are for you to make sure to address each element)
• Describe your Problem Statement and/or Thesis
• Make sure to provide at least one reference or quote in this section (See References, Module 02)

E. Project Process:
• Be specific – you must include at least one paragraph on each of the QI Tools and Indicator listed below in your QI Project and do the following:
o Demonstrate an understanding of the QI tool and how it is used
o Discuss specifics on how you intend to use the QI tool in your project and what you expect to find (do not use bullet points – these are for you to make sure to address each element)
• DMAIC Process
o Define
o Measure
o Analyze
o Improve
o Control
• Quality Indicators
• Why-Why Chart
• Fishbone Diagram
• Flowchart
• Run Chart

For example: You might create a flowchart, which shows the correct steps in a procedure or process. You could use a fishbone diagram or other RCA tool to “dissect” an event and then make recommendations based on your findings.

Module 05 – QI Data (100 points): Due by deadline in Course Schedule. This is the Measure step of DMAIC. Use the template provided and include the following information:

E. Measure:
Provide the data measurements (Summarized Checklists or worksheet(s) used to obtain data for your project (do not use bullet points – these are for you to make sure to address each element).
• Provide a complete description of the process (4 paragraphs minimum)
• Copy the worksheet(s) into your Word document, only one document can be submitted
• Make certain to remove all Protected Health Information (PHI)
• Provide headers so that the information is readily understandable
• Include necessary QI Tool Charts and Figures in your narrative at the exact point where you discuss them (Why-Why, Fishbone should be here, 2 paragraphs minimum for each)
• Provide appropriate markings and a summary for every Chart or Figure used. For example: Chart 1: This chart details the…blah, blah, blah (keep to one sentence).
• Discuss the contents of the Chart or Figure in your narrative. Do not simply refer to the Chart – I want to know your findings and do not want to have to figure out the information on my own.
• Make sure to provide at least one reference or quote in this section (See References, Module 02)

Module 06 – QI Analysis (100 points): Due by deadline in Course Schedule. This includes the Analysis, Improve and Control steps of DMAIC. Use the template provided and include the following information:

E. Analysis:
Discuss the results of your findings and analyze the information based upon your Problem Statement or Thesis Statement (do not use bullet points – these are for you to make sure to address each element)
• Discuss findings from your data measurements in detail (Run Chart should be here, 2 paragraphs minimum)
• Analyze the data – What does the data tell you? Support your comments with statistics from your results (4 paragraphs minimum)
o Compare your analysis with your Problem Statement or Thesis Statement
• Evaluate your findings with your original Purpose Statement – were results achieved or not?
o If results were achieved, what does this tell about the process and people?
o If results were not achieved, what does this tell about the process and people?
• What actions will be implemented as a result of the findings to Improve the process? Be specific (Flow Chart should be here, 2 paragraphs minimum)
o If check sheets or other tools will be used, provide them
o If a change in process will be implemented, provide it – maintain privacy
• What actions will be implemented to ensure that actions taken are Controlled in the future? (2 paragraphs minimum)
o If check sheets or other tools will be used, provide and discuss them
o If a change in process will be implemented, provide and discuss it – maintain privacy
• Make sure to provide at least three references or quotes in this section (See References, Module 02)
• The Analysis, Improve and Control sections are critical to a successful QI Project and must have sufficient detail

QI Final Project

A. Project Title: Replace with your Title – use Title Case

B. Purpose Statement: The purpose of this project is (finish statement here, should be one sentence – remove this section and parentheses)

C. Problem Description
• What is the Problem identified that was being evaluated in the QI Project, or
• What is the Thesis Statement – what are you attempting to prove (or disprove) based upon your evaluation of the process identified
• Describe your Problem Statement and/or Thesis
• Make sure to provide at least one reference or quote in this section (See References, Module 02)

D. Project Process:
Begin your introductory paragraph here before discussing your project’s Indicators
• Using DMAIC, discuss your project and include evidence of QI Tool use and results, including charts, graphs. Be specific! You must identify how you used each of the QI Tools in your project, including the raw data on surveys and observations (summarized).
• This part of your presentation should be very detailed and include comparisons, including applicable quotes and proper in-text citations per APA. See the APA Writing Style Guide, p.4 for details on how to cite in-text.
• Your graphs and charts should be included and appropriately indexed (Figure 1, etc.) and discussed. Do not make your reader figure out the results of a figure or chart – you discuss the results.
• Neatness counts. Your presentation should be detailed and of good quality.
1. Indicators: Begin your Indicators here
2. Define: Begin your Define section here
• This should be your outline for the entire project. Use each of the tools within this structure where they are most appropriate (in the Measure, Analyze or Improve sections). Also, make sure to put your charts and graphs in your paper at the point where they are discussed. Charts and Graphs should be the full-width of the paper so that they can be seen. If I can’t review your data due to size, they are of little value.
• All QI Tools must be included in your paper: Why-Why Diagram, Fishbone Diagram, Flowchart, Run Chart
3. Measure: Begin your Measure section here
• This section should have your data measurement data – if possible, provide summarized data in any checklists, observation sheets or survey tools. Details count!
4. Analyze: Begin your Analyze section here
• What did you find? What does the data tell you? Your analysis should be detailed and must be based upon facts – statistics help here. Do not make a statement unless you are able to back it up with your data.
5. Improve: Begin your Improve section here
• I cannot stress the importance of this element enough. You proposed a problem statement/thesis, did some research, applied some tools, came up with some findings – what are you going to do with this data?
6. Control: Begin your Control section here
• It’s one thing to recommend improvements – what steps need to be implemented to make sure that your improvement steps, what are you going to do with this data?

E. Project Outcomes:
1. Project Outcomes: Begin your Project Outcomes section here
• What outcomes were initially desired, then obtained as you reported findings to them at the conclusion of your research? Discuss this fully.
2. Next Steps: Begin your Next Steps here
• What are next steps as a result of your research? (Additional projects, training, monitoring, new processes?). Do not restate your Improve section here. One QI project usually uncovers others – what is next?
• The goal of QI, Quality Improvement, is to improve processes and procedures. This section should be forward-thinking and should be performed, ideally, with your QI Supervisor and/or other members of your QI or management team.

F. Personal Outcomes:
1. What I Learned: Begin your What I Learned section here
• What did you learn about QI through this project and the course?
2. Future QI Tool Use: Begin your Future QI tool Use here
• State how will you use one or more of these tools in your personal and professional life in the future
3. Takeaways: Begin your Takeaways section here
• What is one (or more) takeaway(s), that is, positive and/or negative – something you did well or could do better the next time you tackle a QI Project?

Why this Supervisor?: Your manager
• Why was this individual your project supervisor?
1. Assistance Provided:
• What did they do to assist you in the project? Tell what actually happened (be discreet if not a great situation), don’t tell me what you think I want to hear. Good and not-so-good situations can bring benefits in future projects or working situations.
2. Supervisor Reporting:
• How did you report to them during the course of your research? (Department meeting, One-on-one discussion, etc.). Tell what actually happened (be discreet if not a great situation), don’t tell me what you think I want to hear. Good and not-so-good situations can bring benefits in future projects or working situations.

J. References:
All of your references must be cited and discussed or quoted in your paper – no exceptions
• You must review at least five (5) peer-reviewed journal articles and discuss or include applicable quotes that support the points you will make in your QI project. These must be included in your QI Final Project and be cited in-text using APA format.
• Provide Five Reference Peer-Reviewed Articles from the Current Literature – additional books or websites are allowed in addition to the five (5) peer-reviewed journal articles
• You must obtain the FULL TEXT article online via Albertson Library or another online source that can be accessed by the instructor for verification – no sites requiring username/password
• Must put references in APA format
• References heading must be centered
• References must be double-spaced (use Microsoft Word Paragraph Spacing)
• Indent 5 spaces for 2nd and remaining lines
• Alphabetize references A-Z (Community, Harbrecht, Kallam, Kollef, Kress, The College of William & Mary, Venes)
• Italicize Journal Name and Volume information
• Volume (Italicized)/Issue/Pages. For example: Volume(Issue), Page-Page
• Date retrieved and web address where accessed must be provided – do not use doi in this course
• Put cursor at the end of the web address and hit backspace once to remove hyperlink

Examples: In 431, you provide the web address where the article is found and date accessed. All articles must be found online.

Community Hospital of the Monterey Peninsula. (2012). Respiratory care policy: Assess and treat protocol. Monterey, CA. Retrieved August 10, 2017 from http://www.chomp.org/policy/assess_and_treat
Harbrecht, B., Delgado, E., Tuttle, R., Cohen-Melamed, M., Saul, M., & Valenta, C. (2009). Improved outcomes with routine respiratory therapist evaluation of non-intensive-care-unit surgery patients. Respiratory Care, 54(7), 861-867. Retrieved July 13, 2017, from http://rc.rcjournal.com/content/54/7/861.full.pdf+html
Kallam, A., Meyerink, K., & Modrykamie, A. (2012). Physician-ordered aerosol therapy vs. respiratory therapist-driven aerosol protocol: the effect on resource utilization. Respiratory Care, 58(3), 431-437. Retrieved July 10, 2017, from http://rc.rcjournal.com/content/58/3/431.full.pdf+html
Kollef, M., Shapiro, S., Clinkscale, D., Cracchiolo, L., Clayton, D., … Willner, R. (2000). The effect of respiratory therapist initiated treatment protocols on patient outcomes and resource utilization. Chest, 117(2), 467-475. Retrieved July 10, 2017, from http://journal.publications.chestnet.org/article.aspx?articleid=1078573
Kress, J., Pohlman, A., O’Connor, M., Hall, J. (2000). Daily Interruption of Sedative Infusions in Critically Ill Patients Undergoing Mechanical Ventilation. The New England Journal of Medicine 342(20), 1471-1477. Retrieved July 6, 2017 from http://www.sciencedirect.com.libproxy.boisestate.edu
The College of William & Mary. (n.d.). The William & Mary mission statement. Retrieved August 1,

This overview should help you as you put together the QI Project Outline:

• Tree Diagram
• Fishbone Diagram
• Flowchart
• Run Chart
• DMAIC Process

Tree Diagram / Fishbone Diagram
Tools and Methods for Root Cause Analysis
Root cause analysis generates and sorts hypotheses about possible causes of problems within a process by asking participants to list all of the possible causes and effects for the identified problem. This analysis tool organizes a large amount of information by showing links between events and their potential or actual causes and provides a means of generating ideas about why the problem is occurring and possible effects of that cause. Root cause analyses allow problem solvers to broaden their thinking and look at the overall picture of a problem. Root cause diagrams can reflect either causes that block the way to the desired state or helpful factors needed to reach the desired state.
When to Use It
A graphic presentation, with major branches reflecting categories of causes, a cause-and-effect analysis stimulates and broadens thinking about potential or real causes and facilitates further examination of individual causes. Because everyone’s ideas can find a place on the diagram, a cause-and-effect analysis helps to generate consensus about causes. It can help to focus attention on the process where a problem is occurring and to allow for constructive use of facts revealed by reported events. However, it is important to remember that a cause-and-effect diagram is a structured way of expressing hypotheses about the causes of a problem or about why something is not happening as desired. It cannot replace empirical testing of these hypotheses: it does not tell which is the root cause, but rather possible causes.
Types of Root Cause Analysis
The slide presentation you watched introduced you to two of the most common RCA tools, Fishbone Analysis and Why questions.
There are two ways to graphically organize ideas for root cause analysis. They vary in how potential causes are organized:
1. by category: called a fishbone diagram (for its shape) or Ishikawa diagram (for the man who invented it). It ties in nicely with the artichoke model from chapter one in our textbook, and
2. as a chain of causes: called a tree diagram or “Why, Why chart”. Both fishbone diagrams and Why charts are used in the Six Sigma’s DMIAC model and TQM’s PDCA model.

The choice of method depends on the QI teams’ need. If the team tends to think of causes only in terms of people, the fishbone diagram, organized around categories of cause, will help to broaden their thinking. A tree diagram, however, will encourage team members to explore the chain of events or causes.
Causes by Categories (Fishbone Diagram)
The fishbone diagram helps teams to brainstorm about possible causes of a problem, accumulate existing knowledge about the causal system surrounding that problem, and group causes into general categories.

When using a fishbone diagram, several categories of cause can be applied. Some often-used categories are:
• Human resources, methods, materials, measurements, and equipment
• Clients, workers, supplies, environment, and procedures
• What, how, when, where

Categories for this type of cause-and-effect diagram vary widely, depending on the context. The group should choose those categories that are most relevant to them and feel free to add or drop categories as needed. A quality improvement team at San Carlos Hospital in Bolivia developed the fishbone diagram to improve the attention given to women in delivery and prenatal care.

Tree Diagram/Why, Why Charts: A second type of cause-and-effect analysis is a tree diagram, which highlights the chain of causes. It starts with the effect and the major groups of causes and then asks for each branch, “Why is this happening? What is causing this?” The tree diagram is a graphic display of a simpler method known as the Five Why’s. It displays the layers of causes, looking in-depth for the root cause. This tool can be used alone or with any of the cause-and-effect diagrams.

Example
Question 1: Why did the patient get the incorrect medicine?
Answer 1: Because the prescription was wrong.
Question 2: Why was the prescription wrong?
Answer 2: Because the doctor made the wrong decision.
Question 3: Why did the doctor make the wrong decision?
Answer 3: Because he did not have complete information in the patient’s chart.
Question 4: Why wasn’t the patient’s chart complete?
Answer 4: Because the doctor’s assistant had not entered the latest laboratory report.
Question 5: Why hadn’t the doctor’s assistant charted the latest laboratory report?
Answer 5: Because the lab technician telephoned the results to the receptionist, who forgot to tell the assistant.
Solution: Develop a system for tracking lab reports.
When using this method it is critical that one question naturally leads to the next. If more than one cause of the problem might be to blame each would need it’s own set of “why” questions or the questions might merge at some common point.

Here is another example of “Why, Why’s”

How to Use Root Cause Analysis

Although there are several ways to construct root cause, the steps of construction are essentially the same:

Step 1. Agree on the problem or the desired state and write it in the effect box. Try to be specific. Problems that are too large or too vague can bog the team down.

Step 2. If using a tree or fishbone diagram, define six to eight major categories of causes. Or the team can brainstorm first about likely causes and then sort them into major branches. The team should add or drop categories as needed when generating causes. Each category should be written into the box.

Step 3. Identify specific causes and fill them in on the correct branches or sub-branches. Use simple brainstorming to generate a list of ideas before classifying them on the diagram, or use the development of the branches of the diagram first to help stimulate ideas. Either way will achieve the same end: use the method that feels most comfortable for the group. If an idea fits on more than one branch, place it on both. Be sure that the causes as phrased have a direct, logical relationship to the problem or effect stated at the head of the fishbone. Each major branch (category or step) should include three or four possible causes. If a branch has fewer, lead the group in finding some way to explain this lack, or ask others who have some knowledge in that area to help.

Step 4. Keep asking “Why?” and “Why else?” for each cause until a potential root cause has been identified. A root cause is one that: (a) can explain the “effect,” either directly or through a series of events, and (b) if removed, would eliminate or reduce the problem. Try to ensure that the answers to the “Why” questions are plausible explanations and that; if possible, they are amenable to action. Check the logic of the chain of causes: read the diagram from the root cause to the effect to see if the flow is logical. Make needed changes.

Step 5. Have the team choose several areas they feel are most likely causes. These choices can be made by voting to capture the team’s best collective judgment. Use the reduced list of likely causes to develop simple data collection tools to prove the group’s theory. If the data confirm none of the likely causes, go back to the cause-and-effect diagram and choose other causes for testing.

Caution
Remember that cause-and-effect diagrams represent hypotheses about causes, not facts. Failure to test these hypotheses—treating them as if they were facts—often leads to implementing the wrong solutions and wasting time. To determine the root cause(s), the team must collect data to test these hypotheses. The “effect” or problem should be clearly articulated to produce the most relevant hypotheses about cause. If the “effect” or problem is too general or ill defined, the team will have difficulty focusing on the effect, and the diagram will be large and complex. It is best to develop as many hypotheses as possible so that no potentially important root cause is overlooked. Be sure to develop each branch fully. If this is not possible, then the team may need more information or help from others for full development of all the branches.

The purpose of a Fishbone Diagram is to categorize and identify potential problems, NOT to offer solutions to problems. The next step would be for a QI committee to select one or more causes and use PDCA or DMAIC cycles to identify solutions to correct the cause.
More information on Fishbone or Cause and Effect Diagrams
A Cause & Effect Diagram is used to categorize and organize ideas about contributing factors and their relationships within a process.

Use a Cause & Effect Diagram to:
• Define and understand the causes of an outcome
• Graphically display the relationship of causes to the outcome
• Help identify improvement opportunities

1. Start by drawing a central horizontal line with a box at one end. Write the specific process or outcome being studied in the box. Do not forget this step.
2. Next, draw four to six vertical lines from the horizontal line; these will identify categories of contributors (sources) to the central issue. Frequent categories include People, Equipment, Policies and Procedures, Patients, and Environment. These may be supplemented by other sources identified by the QI team.
3. Next, brainstorm to generate a list of factors or situations that ‘cause’ a problem and assign them to one of the identified sources. The Cause & Effect Diagram can be completed by either working entirely through all of the causes in one source before moving on to the next or moving randomly from source to source as items are identified.
4. Look for multiple causes within a single source. Ask questions such as:
• What is being done?
• Why (cause) is it done at all?
• What else could be done in its place to accomplish the same result?
• When is it done?
• Why (cause) is it done at that time?
• Is there another time it could be done?
• Who does it?
• Why (cause) these specific individuals?
• Could someone else do it?
• Where is it done?
• Why (cause) is it done there?
• Where else could it be done?
• How is it done?
• Why (cause) is it done that way?
• Are there other ways it could be accomplished?

Flowchart
Flowcharting is another method which can be used for RCA. Here is some information on this method.
A Flowchart is a graphic diagram or map that illustrates the steps and decision points that make up a work process. It represents a common understanding of the process and enables the team to examine individual steps in order to identify problems and improvement opportunities.
Use a Flow chart to:
• Clarify the steps and decision points in the process
• Identify the complexity or variability of the process, as well as its management
• Clarify outcome vs. process steps
• Establish measures for procedures within a process
How to Create a Flowchart
Flowcharts can depict a process at two or more levels – a high-level diagram that describes the overall process from the beginning to the ending point. The actual diagram for a high-level flow chart can be a series of phrases in sequential boxes. A low-level flow diagram contains more detail about the major steps in a process and can be constructed once the specific start and end points are defined. For lengthy, time-dependent processes, it may be helpful to create a mid-level flow chart.

For example:
• High-level – Wake up ⇒ Take a shower ⇒ Get dressed ⇒ Have Breakfast ⇒ Drive to work
• Mid-level – Get the milk out ⇒ Make a pot of tea ⇒ Eat cereal ⇒ Clean up dishes
• Low-level – Take cereal box out of cupboard ⇒ Pour into bowl ⇒ Pour milk over cereal ⇒ Get Spoon ⇒ Eat

How to Create a Flowchart
1. Define start and end points to the selected process, as well as where it interfaces with a larger process and/or support processes.
2. Identify the individual steps within the current process, not how the team thinks it should happen. Identify the decision points in the process, as these may highlight the potential for roadblocks, errors, or miscommunication in the systems. Questions that may help in flow charting a process are:
• What is being done?
• When is it done?
• Who does it?
• Where is it done?
• How it is done?

3. Create the initial flow chart using post-it notes or notepaper and a pencil. Place the notes on a flip chart pad or blank wall. Keep the flow chart simple and use arrows to show the direction of all the steps in the process. Make sure each step is placed in the order that it occurs in the current process.

4. Allow time for the team to study the flow chart–it may have to be left up for several days. This will allow the team time to observe the current process and make adjustments and additions to the flow chart as needed. Finalize the flow chart at a second meeting.

5. Keep the flowchart. The QI team will need to refer to it several times throughout the course of the project.

Basic Flowcharting Shapes and Symbols
Formal flow charts use special shapes to represent different types of actions or steps in a process. Lines and arrows show the sequence of the steps, and the relationships among them. Some of the more frequently used shapes are described below. It is not necessary to use these symbols and shapes to create an effective flow chart.
The vast majority of flow charts rely on just four 4 of the symbols: oval (End point), rectangle (Process), diamond (Decision), and circle (Connector). In fact, if you use other flow charting shapes, many people will not know what they are for, so add a shape symbol key to your flow chart.

Things to keep in mind when creating Flowcharts
At decision points (diamonds), use a down arrow to show a positive workflow, and an arrow, typically going right from the shape for an alternative workflow or stop.
• Only one arrow for ‘Yes’ and one arrow for ‘No’ should flow from each decision. If more than one arrow is needed for multiple yes and no responses, it usually suggests that the decision question is unclear or that two decisions are stacked and requires separation.
• Draw lines after all the steps and decisions are identified.
• At any time during the creation of the flow chart, it may become evident that the starting and ending points are farther apart than initially thought. It is acceptable to adjust the starting and ending points to make the quality improvement project more manageable.
• Use the flow chart during a Cause and Effect analysis to facilitate identification of process factors or issues.
Example of a Flowchart

A quality improvement team reviews the data they have collected from the users to identify the problem. There are many issues that affect the users, yet through the brainstorming, prioritization matrix, and user survey, one major problem is revealed. Users wait too long when they come to the health center for services. Since they feel that they waste time by waiting too long, most of them decide to use the health center services less regularly, or not at all.
The team decides to use a flow chart to analyze the process the users go through in using the health center’s services, and to visualize when the waiting time occurs.
The team decides to observe the process of a user who comes to get health care from the health center. They will observe the user from his or her arrival in the center to his or her departure. Through a direct observation technique, they observe all the steps taken by the users in the health center.
The team draws the process that users follow from their arrival at the health center to their departure by putting each activity in a rectangle and each decision point in a diamond, and connecting all these rectangles and diamonds in order. The flow chart allows the team to replicate the steps each patient goes through.
User Flowchart, Registration Process, Santa Rosa Health Center

The flowchart allows the manager and the team to visualize the process as it actually occurs in their health center and helps them to understand where and when they should make changes to reduce the users’ waiting time.
RUN CHART

Run charts (often known as line graphs outside the quality management field) display process performance over time. Upward and downward trends, cycles, and large aberrations may be spotted and investigated further. In a run chart, events, shown on the y axis, are graphed against a time period on the x axis. For example, a run chart in a hospital might plot the number of patient transfer delays against the time of day or day of the week. The results might show that there are more delays at noon than at 3 p.m. Investigating this phenomenon could unearth potential for improvement. Run charts can also be used to track improvements that have been put into place, checking to determine their success. Also, an average line can be added to a run chart to clarify movement of the data away from the average.
Alternatives with run charts:
1. An average line, representing the average of all the y values recorded, can easily be added to a run chart to clarify movement of the data away from the average. An average line runs parallel to the x axis.
2. Several variables may be tracked on a single chart, with each variable having its own line. The chart is then called a multiple run chart.
3. Run charts can also be used to track improvements that have been put into place, checking their success.
Questions to ask about a run chart:
1. Is the average line where it should be to meet customer requirements?
2. Is there a significant trend or pattern that should be investigated?
Two ways to misinterpret run charts:
1. You conclude that some trend or cycle exists, when in fact you are just seeing normal process variation (and every process will show some variation).
2. You do not recognize a trend or cycle when it does exist.
Both of these mistakes are common, but people are generally less aware that they are making the first type, and are tampering with a process which is really behaving normally. To avoid mistakes, use the following rules of thumb for run chart interpretation:
1. Look at data for a long enough period of time, so that a “usual” range of variation is evident.
2. Is the recent data within the usual range of variation?
3. Is there a daily pattern? Weekly? Monthly? Yearly?
Using run charts to detect “special causes” of variation:
If you have 25 points or more in your data series, you can use run charts to detect special causes – something beyond the usual variability of the process -acting on the process.
1. Shifts: If you see eight or more consecutive points on one side of the center line, that indicates that a special cause has influenced the process. Points on the center line don’t count; they neither break the string, nor add to it.
2. Trends: Six consecutive jumps in the same direction indicate that a special cause is acting on the process to cause a trend. Flat line segments don’t count, either to break a trend, or to count towards it.
3. Pattern: If you see a pattern that recurs eight or more times in a row, it is a good idea to look for a special cause.
For more robust monitoring of a process, and better information about when your process is showing variation beyond what is expected, try using a control chart. It will detect special causes more quickly, and with more accuracy.

DMAIC

Review of DMAIC cycles – Define, Measure, Analyze, Improve, Control. Incremental process improvement
using Six Sigma methodology. Pronounced (Duh-May-Ick).

Each step in the cyclical DMAIC Process is required to ensure the best possible results. The process
steps:

Define the Customer, their Critical to Quality (CTQ) issues, and the Core Business Process involved.
• Define who customers are, what their requirements are for products and services, and what their
expectations are
• Define project boundaries the stop and start of the process
• Define the process to be improved by mapping the process flow

Measure the performance of the Core Business Process involved.
• Develop a data collection plan for the process
• Collect data from many sources to determine types of defects and metrics
• Compare to customer survey results to determine shortfall

Analyze the data collected and process map to determine root causes of defects and opportunities for
improvement.
• Identify gaps between current performance and goal performance
• Prioritize opportunities to improve
• Identify sources of variation

Improve the target process by designing creative solutions to fix and prevent problems.
• Create innovate solutions using technology and discipline
• Develop and deploy implementation plan

Control the improvements to keep the process on the new course.
• Prevent reverting back to the “old way”
• Require the development, documentation and implementation of an ongoing monitoring plan
• Institutionalize the improvements through the modification of systems and structures (staffing, training,
incentives)

From Six Sigma Dictionary: http://www.isixsigma.com/dictionary