If you can't describe what you're doing as a process, you don't know what you're doing.
—W. Edwards Deming
"...you don't know what you're doing"? Although somewhat harsh, this quote gets at the heart of quality improvement (QI). QI is about improving the process that supports a product, service, or outcome. The lack of a standardized process is often the root of a team’s difficulties, resulting in fluctuations that can affect the quality of the process output. For health departments beginning the journey to accreditation, a culture of quality, or a quest to document policies and procedures, it is not at all uncommon to discover that many processes are not known, much less used as standard practice. This type of deficiency could be identified in any number of scenarios, including when a health department embarks on a QI effort.
Developing a flowchart is one of the first steps in a QI effort, and if a team discovers that no standardized process exists, the best decision at this juncture is to suspend the QI work and establish a new process. An established process must be in place before any improvements can be identified and tested. Too often, however, teams that find themselves in this position move ahead and spend time completing a Plan, Do, Study, Act (PDSA) cycle. For example, they might quickly develop a process, complete a root cause analysis and determine that the problem is that a process did not exist, identify potential solutions focused on implementing the new process, train staff on the process and implement it, and wrap up by testing whether staff knowledge of the process is at an acceptable level or whether the process was followed correctly. The result of this scenario is a new standardized process, which is good; however, a PDSA cycle is not the most efficient or effective way to develop a new process. Enter quality planning.
Quality planning refers to establishing a process that is specifically designed to meet its customers’ needs. A quality planning approach enables a team to deliberately incorporate process features that will help them achieve their goals. As described previously, quality planning can be used when work is already under way but when no agreed-upon process is in place. Quality planning also can be used when a new process is needed. One example is when the health department receives a grant and offers a new service. Another example is when an existing service is offered in a different place, such as when immunization clinics are established at various community sites.
As with any flowchart or process mapping, quality planning begins with identifying the beginning and end points of the process. Once this has been done, complete the following steps to identify customer needs and how they will be met through the process:
- Identify customers. Your customers are everyone who is affected by the process you are defining. Customers include staff who are engaged in the process, those receiving the service or product or who otherwise will be affected by the outcome, and those who pay for the process. Remember that the general public and elected officials are the ultimate customers of a public health department (although they will not always be a relevant customer for your quality planning purposes). When you list your clients, be as specific as possible.
Identify customers' requirements. Be specific about what your customers need. This could come from customer satisfaction surveys, internal discussions, or another source that provides this kind of information. The team may also decide to gather input from customers at this point and/or engage in a robust brainstorming session if they feel they have the right people at the table. During this step, the team might find that different customers may have some of the same needs. Some general examples of customer needs are as follows:
- Staff may want to ensure that they achieve their program goals, which could entail completing a certain number of client encounters; minimizing paperwork; streamlining approval processes; or having access to specific materials, expertise, facilities, training, and so on.
- Clients’ needs are likely to be focused on quality and efficiency (i.e., wanting the “best” service for the lowest possible cost in the shortest amount of time).
- Funders might want to see results or proof that the process is working well and should continue to be funded.
- Prioritize customers' requirements. The point of this step is to help you identify those needs, if met, that are most likely to have a meaningful impact on customer satisfaction. The team’s determination might be based on the number of times a need was cited in a survey, how strongly a need was expressed during discussions, or the team’s own best judgment.
- Identify process steps to meet prioritized customers’ requirements. For each priority need, determine what process step(s) will address that need. This may be a step that would be in your process regardless of the customer need, or it might be an additional step.
- Identify which customer requirements will be sufficiently met by the identified process steps. Will each step make a difference? If not, and if it is an extra step (i.e., not otherwise needed in your process), you should not include it in your process.
- Determine performance measures. Whether or not you include them in your organization’s performance management system, carefully consider what can be measured, how frequently it should be measured, and by whom. The measure(s) should reflect high-priority requirements. It is not necessary to have a measure associated with each requirement; that said, it is necessary to consider what measure(s) will help you ensure customer satisfaction. This part of quality planning includes determining any additional process steps needed to obtain data for performance measurement purposes.
At this point, the team is ready to develop the flowchart or process map. As the flowchart is being constructed, insert the process steps generated through quality planning where appropriate. After the process has been documented, pilot-test the process and make any changes needed to ensure that the measures are met. Once you are satisfied that the process works, it is time to train all staff and monitor the process measure(s) over time. If the measures are not being met, then it could be time to engage in a PDSA cycle or other QI method.
The following is an example involving a county health department:
A new strain of the influenza virus, J1M1, has been spreading around the globe and has come to the United States. Fortunately, a vaccine is available. Many in your community are clamoring for the vaccine, so your department decides to hold its first-ever mass immunization clinic. (Although this type of eventuality has been addressed in your emergency management plan, for the sake of this example, we will assume that this is the first time your staff has planned the process.) The health department decides to take a quality planning approach to establish a process for the mass immunization clinic. The process begins when the determination to hold the clinic has been made and ends with the last client leaving the clinic. The health department takes the following steps for quality planning:
Identify customers and their needs
Staff begin by identifying four major customers and brainstorming their respective requirements.
They know where and when the flu clinics will be held.
They know whether they are eligible to receive the flu vaccine, so they do not make an unnecessary trip.
They have all the necessary documentation and payment method with them.
They do not have to spend too much time at the flu clinic.
The clinic is well used (the health department vaccinates the highest number of people it can handle).
The process in the clinic is smooth and efficient (everyone knows and follows the process, and people are immunized in the most efficient way possible).
The clinic has a sufficient number of all needed supplies (vaccines, forms, etc.).
The flu clinic site has sufficient space.
Staff are prepared to do their job at the clinic (everyone understands the process and their specific roles with respect to paperwork, vaccine administration, and medical emergencies).
Media coverage is accurate and positive (i.e., encourages people to get the vaccine).
County emergency managers
The entrance(s) and exit(s) to the clinic site are clearly marked.
The process of getting into and out of the clinic is safe and orderly.
They have the information they need to help spread the word to encourage people to use the clinic and let them know the logistical information.
They have space on site that is sufficient for their reporting purposes.
Different customers often have the same, similar, or related requirements. Therefore, it is important to identify themes that emerge, as well as overlapping requirements, and reframe them as appropriate (by completing an affinity diagram or engaging in a group discussion). The staff members generate the following list of requirements:
- A communication plan that encourages people to be vaccinated, provides clear and easy-to-digest information about the flu clinic logistics (date, time, location), necessary documentation, and contraindications to the vaccine
- A site that can accommodate the process (several sites have been identified in the past through emergency planning efforts) with a designated area for media
- Sufficient supplies at the clinic
- An on-site process that is safe and efficient (i.e., people move efficiently from the time they are on the clinic site grounds through the time they leave); all who are registered receive a vaccine (i.e., no one begins this part of the process and is then told there are no vaccines or the clinic needs to close before the vaccines are administered)
- Staff members who are prepared to do their job at the clinic
As you can see, this list captures and summarizes all the requirements that were listed.
Prioritize customers’ requirements
At this point, it is important to prioritize the requirements. This task is especially important if many requirements have been identified. Even when only a few needs are identified, it is important to complete this task because processes ultimately should include only steps that add value.
Prioritization can be done using the nominal group technique method or through a discussion. Factors to keep in mind are as follows:
- Is the requirement critical for that customer’s satisfaction?
- Does a single requirement meet several customers’ needs?
- Does the requirement meet a need of your most important customers?
In our example, staff agree that all these requirements should be met. Staff make this determination because the five requirements are all felt to be important, and they collectively meet all the identified needs.
Identify process steps to meet prioritized requirements
The next task is to identify process steps to meet the requirements. A list of requirements and their associated steps follows:
- Ensure that messages are compelling regarding the need to be vaccinated, that they include all the information identified previously, and that they provide accurate information in a clear and simple way.
- Develop an extensive outreach plan to disseminate the information.
- Secure the first site that best aligns with optimal days and times to hold the clinic.
- Immediately notify the county emergency managers (so they can begin their planning process).
- Identify the designated area for media.
- Determine the maximum number of clients that can be seen per clinic.
- Develop a checklist of all needed supplies (items and quantity).
Safe and efficient process
- Develop a process map for the clinic, including a process to track the number of vaccines being administered and to halt the registration process for any new patients once it is known when supplies will be exhausted, so no one has to wait in line unnecessarily.
- Pilot-test the on-site process with all on-site workers (from beginning to end), and make any needed refinements.
- Train staff regarding how to address security concerns.
- Review the entire final process with all on-site workers (so that all are prepared to answer questions regarding the process).
- Develop and provide just-in-time training and job aids (e.g., “cheat sheets,” forms).
Identify which customer requirements will be well met by the identified process steps
As noted previously, it is important to add only steps that provide value to a process. Therefore, at this juncture, staff carefully consider the degree to which each process step will meet the associated customer requirement(s). Any steps that will not make a meaningful contribution to customer satisfaction should not be included in the final process. In our example, staff determine that each of the identified steps is a value-add.
Determine performance measures
The final step in a quality planning process is to determine how to measure whether the process is working as it should. This is the time to consider customer requirements and whether any items related to customer requirements should be measured.
With that in mind, staff in our example identify the following measures:
- The flu clinic uses 100% of its vaccines during established clinic hours. Staff decide that this measure is the best way to assess the on-site process. Staff surmise that if the goal is reached, and the clinic was well used, the communication plan was effective. In addition, the process flow was smooth because the staff decided on the clinic hours ahead of time, and this measure accounts for not going over the established hours. Moreover, this measure suggests that no major disruptions occurred because of security issues. Staff discuss other measures as well (e.g., patient encounter time, customer satisfaction), but for the purposes of a mass immunization clinic, they agree that this measure will provide good information and will not necessitate any additional process steps.
- All on-site workers report a high level of confidence and comfort with their tasks. Given the importance of having well-prepared workers and the reality of a relatively short time to prepare them, staff felt that this was an important measure. They decide to capture this information with a post-clinic survey that includes requests for feedback on how to improve. This approach will not necessitate any additional steps in the on-site process.
- Media coverage is timely and accurate. Staff plan to review various forms of media coverage to assess this measure and discuss the results among each other. Staff will consider whether the information was factually accurate and determine whether any additional access (beyond the established staging area) would be beneficial. This measure will help reflect the effectiveness of the health department communication plan and will help them assess the adequacy of media access—a significant factor for an important health department partner. Finally, because media events will occur outside of the on-site clinic process, this measurement activity will not interfere with the flu clinic.
Staff are now ready to develop the process map or flowchart, incorporating the aforementioned steps where appropriate.
In Conclusion . . .
The next time you hear “I don’t do it that way” or “We have a process? Where is it?” give yourself permission to stop everything, pivot, and do some quality planning!
Gorenflo, G. Quality Planning: A Quick “How-To” Guide. Tues, 06/05/2018. Available at https://www.phqix.org/content/quality-planning-quick-how-guide. Accessed 12/03/2020.