Participant's Guide - Process Improvement

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PARTICIPANT WORKBOOK

Process Improvement
For Public Health Professionals
Sustainable Management Development Program

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Sustainable Management Development Program

Division of Public Health Systems and Workforce Development

Center for Global Health

U.S. Centers for Disease Control and Prevention

http://www.cdc.gov/globalhealth/SMDP/

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Process Improvement

CONTENTS

Introduction

Sustainable Management Development Program viii

Acknowledgements iii

Process Improvement for Public Health Professionals

About this Course viii

Target Audience viii

Learning Objectives viii

Typical Schedule ix

Icon Glossary ix

Overview of Process Improvement

Definitions 1

The Seven Step Approach 1

Case Example 3

Step 1: Define Process

Introduction 5

Identify Processes 6

Process Levels and Boundaries 8

Select Process 10

Define Customers 12

Products and Services 14

Definition of Quality 15

Understand Customer Wants and Needs 16

Identify Other Stakeholders 17

Flowchart 21

Summary Step 1: Define Process 26

Step 2: Measure Process Performance

Introduction 27

Measurement Good Practice 28

The Performance Gap 30

Definitions 30

Sources of Measures 30

Case Example: ART Measures 32

Selecting Measures 34

Collect Data 35

Check Sheet 35

Stratification 38

Pareto Chart 39

Variation 42

Problem Statement 49

Improvement Objective 50

Summary Step 2: Measure Process Performance 52

Step 3: Analyze Causes of Variation

Introduction 53

Cause and Effect 54

Example of Creating a Fishbone Diagram 56

Multivote 64

Verify Cause 66

Summary Step 3: Analyze Causes of Variation 67

Step 4: Generate & Plan Improvement Ideas

Introduction 68

Plan, Do, Study, Act 70

Breaking Down the Task 71

Summary Step 4: GENERATE & PLAN IMPROVEMENT IDEAS 77

Step 5: Implement Change

Introduction 79

Summary Step 5: Implement Change 80

Step 6: Study Results of Change

Introduction 82

Case Example: Implementing the New Educational Material 83

Summary Step 6: Study Results of Change 85

Step 7: Act Accordingly

Introduction 87

Summary Step 7: Act Accordingly 89

Applied Learning Project

About This Section 91

My Project 91

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Process Improvement Checklists

Define Process 93

Measure Process Performance 94

Analyze Causes of Variation 95

Generate & Plan Improvement Ideas 96

Implement Change 97

Study Results of Change 98

Act Accordingly 99

Course Conclusion 100

Resources

Web Sites 101

Introduction

Sustainable Management Development Program

SMDP works with ministries of health, educational institutions, nongovernmental organizations, and other partners to strengthen leadership and management skills and systems to improve public health in low resource countries.
Program Strategy
SMDP strengthens leadership and management skills and systems through—
· Integration with country public health priorities.
· Strategic partnerships.
· Technical assistance and training.
· Policy and systems development.
· Advocacy and education.
· Evaluation.
For more information, visit http://www.cdc.gov/globalhealth/SMDP/.

Acknowledgements

Dr. Hailu Negassa, CDC Ethiopia
Dr. Tekeste Kebede, CDC Ethiopia
Donald M. Berwick, MD, MPP, FRCP,
President and CEO Institute for Healthcare Improvement
Lloyd Provost, Associates in Process Improvement
Dr. Elliot Raizes, Medical Officer, Care & Treatment, GAP

SUSTAINABLE MANAGEMENT DEVELOPMENT PROGRAM | vii

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Process Improvement for Public Health Professionals

About this Course

The goal of this course is to enable you to implement the seven steps of process improvement in your own work environment and to deal with problems efficiently and effectively.

Target Audience

This course is designed for supervisors and managers in public health services, typically at district-level. You will probably manage a small team of staff. You are responsible for delivering essential public health services. You and your staff always want to do a better job. Sometimes your manager will define a problem that you have to resolve.

Learning Objectives

This workshop will introduce tools and techniques to complete seven steps to improve work processes in a public health organization.
When participants complete this workshop they will be able to:
1. Define a process.
2. Measure process performance.
3. Analyze causes of variation.
4. Generate and plan improvement ideas.
5. Implement changes.
6. Study the results of changes.
7. Act according to the results of the study.
· / Apply at least five process improvement tools to achieve objectives 1 to 7.

Schedule

Day 1
· / Define a process.
Day 2
· / Define a process (continued).
· / Measure process performance.
Day 3
· / Analyze causes of variation.
· / Generate and plan improvement.
· / Implement, study and act accordingly.

Icon Glossary

The following icons are used in this workbook:
/ TIP: SUPPLEMENTAL INFORMATION TO HELP PERFORM A TASK MORE EASILY
/ SMALL GROUP EXERCISE

SCHEDULE | ix

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Icon Glossary | vii

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Overview of Process Improvement

Definitions

Process improvement is a systematic, data-based method for improving the quality of work processes. It uses team decision-making to improve processes that affect the quality of services or products for a customer.
The operational definition of quality used in this process improvement training is satisfying the customers’ wants and needs for service, while at the same time achieving the technical standards for public health practice.

The Seven Step Approach

Process improvement comprises a seven-step method.
/ Step
1. / Define Process.
2. / Measure Process Performance.
3. / Analyze Causes of Variation.
4. / Generate & Plan Improvement Ideas.
5. / Implement Change (Do).
6. / Study Results of Change.
7. / Act Accordingly.
This workbook takes you through the seven-step method using 11 tools applied to a case example of an antiretroviral therapy process for HIV infection.
Use this notes section for jotting down Guiding Principles:
Notes

DEFINITIONS | 1

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Case Example

To learn how to apply the process improvement steps and tools, and to understand how they link together, we will use one case example throughout.
We will work through the seven-step method using the example of the delivery of Antiretroviral Therapy (ART) for Human Immunodeficiency Virus (HIV) infection in a community health center.
Acquired Immunodeficiency Syndrome (AIDS) is a disease of the body’s immune system caused by the human immunodeficiency virus (HIV). The death of infection-fighting white blood cells leaves the body vulnerable to life-threatening conditions such as infections and cancers.
Voluntary Counseling and Testing (VCT) for HIV usually involves two counseling sessions: one before taking the HIV test, known as pre-test counseling, and one following the test, when the results are given, often referred to as post-test counseling.
VCT centers and counselors often use rapid HIV tests that only require a drop of blood or some cells from the inside of one’s cheek.
CD4 cells are one type of infection-fighting white blood cells. The CD4 cell count is a measure of the number of CD4 cells in a sample of blood. The CD4 cell count is one of the most useful indicators of the health of the immune system and the progression of HIV/AIDS.
ART is a treatment with drugs that inhibit the ability of retroviruses, such as HIV, to multiply in the body.
The case example deals with the process of customers attending VCT clinics and receiving counseling and testing.
If their test is positive, patients may be eligible for ART based on the CD4 count and other criteria defined in the guidelines for ART from the World Health Organization. If eligible for ART, patients will receive regular supplies of ARV drugs and counseling to ensure adherence.

CASE EXAMPLE | 3

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OVERVIEW OF PROCESS IMPROVEMENT | 5

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Step 1: Define Process

Introduction

Define Process Check List
£ / Processes identified.
£ / A process selected.
£ / Customer defined.
£ / Products and services identified.
£ / Customers’ wants and needs understood.
£ / Other Stakeholders identified.
£ / Existing process is understood.
You will begin by identifying all the processes for which you are totally or partially responsible.
Within your group you will then work to identify the most important work processes using a list of criteria.
Now you can define your customers and the products and services they receive from your selected process.
Finally you can show in detail how you organize your work process to deliver products and services to the customers of the process.
The questions you will answer in step one are as follows.
1. / “What do I do?”
2. / “For whom do I do it?”
3. / “What products and services do I provide?”
4. / “What do they want and need from me?”
5. / “In detail, how do I create the products and services?”

Identify Processes

/ Exercise 1: The Tennis Ball Game
1. / As one group you will play the Tennis Ball Game.
2. / Your trainer will guide you through the instructions.
3. / Reflect on the experience as a group.
In the game you experienced creating a process and then you improved it several times.
/ We define a process as a repetitive sequence of activities leading to desired outcomes for the benefit of customers. The inputs to the process are transformed to achieve products or services.
A customer is any person who receives a product or service. The term is used broadly—no financial transaction need occur.
VCT Example of Process
1. / Person arrives at clinic.
2. / Person registers.
3. / Counselor provides pre-test counseling.
4. / Counselor takes blood sample.
5. / Laboratory staff conducts rapid HIV test.

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What is the process in the scenarios listed below?
In a district hospital people are experiencing long wait times at the pharmacy.
The process is:
In a clinic pregnant women are not being tested for HIV.
The process is:

Process Levels and Boundaries

Whatever we do, our processes can always be improved. Process improvement is a systematic, data-based method for improving the quality of work processes. It enables staff to identify opportunities and creates a culture of continuous improvement. It also improves communication, reduces departmental barriers, increases pride in work, and leads to more efficient and effective services.
When describing a process, it is important to set limits and boundaries. Frequently your process is, in fact, a component of a larger process. Define and communicate the boundaries of the process you are working on to better focus your efforts.
ART Levels and Boundaries

Identify processes | 7

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/ Exercise 2: List Processes
As a team, list the common processes for which you are responsible.
Our Processes:

Select Process

Which process should you improve?
In some cases it might be very obvious. Your team may already know where in your organization you fail to meet customers’ needs and reasonable expectations. Perhaps other stakeholders’ requirements or technical standards are not being met. There may also be excessive waste that you know about. If the priority is not shared then a selection process should be completed.
You can now evaluate the potential impact of improving your processes on the following four criteria:
1 / Customer satisfaction.
2 / Satisfaction of other stakeholders.
3 / Reduction of wasted time, money and materials.
4 / Compliance with technical standards.
Other important questions to consider when choosing a process to improve are:
· / Does the team have the authority to make improvements?
· / Are resources available to achieve improvement?
· / Can significant improvements be achieved quickly and easily?
· / Do the key stakeholders support the improvement activity?
/ If the answer to any of these questions is “no,” the process improvement work might not be successful.

exercise 2 | 9

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/ Exercise 3: Select Process to Improve
1. / Review your list of processes from Exercise 2 (page 9).
2. / Consider each one’s potential impact on the four criteria
(previous page).
3. / Decide which process is going to be the group’s focus for the rest of the training.
Our Chosen Process:

Define Customers

A customer is any person who receives a product or service from a process. The term is used broadly—no financial transaction need occur.
As public health workers, we serve the people who receive our services or products; they are considered our customers.
The people we serve can be external to the organization, such as clients and families, or they can be internal, such as work colleagues.
ART Customers
· / People living with HIV/AIDS,
· / Friends, family, relatives, and
· / The local community.

exercise 3 | 11

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/ Exercise 4: Define Customers
1. / As a group, list the customers of your chosen process.
Customers

Products and Services

Products and services can be tangible or intangible—a thing, information, knowledge, a procedure, or a function.
Examples of ART Products and Services:
· / ART medications
· / CD4 count test results
· / Condoms
· / ART treatment information
· / On-going counseling

exercise 4 | 13

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/ Exercise 5: Identify Products and Services
1. / What are the products and services generated by your chosen process for your customers?
2. / List them below.
Product and Services

Definition of Quality