6051 Continuous Quality Improvement Plan | ADMINISTRATION-5600-MANUAL

The first stage in the PDCS cycle is PLAN.

Step 1: Identify Opportunities for Improvement (OFI)

Identify the specific problem or specific process that needs to be addressed or changed. This can be improving a current process or developing a new process to meet a current or future need.

Use data, including information from the DAS Data System (DDS) and/or HAR reports, to determine the problem. Examples include targeting improvement related to the number of clients served, reduction in error rates, or improved timeliness.

Consider using other data sources such as customer satisfaction reports or handwritten data tallies to target improving quality of client services.

Opportunities for improvement can be identified or required through:

If more than one opportunity for improvement is identified, use a tool such as a Fish Bone Diagram or Pareto Chart to assist in determining which OFI takes priority.

The Fish Bone Diagram is explained at:
www.reliableplant.com/fishbone-diagram-31877

The Pareto Chart is explained at:
www.jmp.com/en_us/statistics-knowledge-portal/exploratory-data-analysis/pareto-chart.html

Step 2: Determine Whether the Project Should be Carried Out by a Team or if it is a ‘Just Do It'

Every improvement effort will not need a team. Some efforts are “just do its” that are accomplished individually or with the help of just a few others.

There are no clear rules to follow to determine whether an item is a “just do it” or should be carried out by a team. However, the information below can be used as a guide:

‘Just Do It':

Team Needed:

If a team is needed, include DAS staff members who have knowledge in the area. External customers and stakeholders must also be included, when appropriate. If possible, only include team members who want to participate; they tend to add the most value.

Individuals and teams working on improvement projects should use the steps outlined in the remainder of the Plan. While some of the language specifically uses “team” terminology, individuals may tailor the steps to meet their needs.

Refer to Section 6055, Teams and Chartered Teams in this manual for further information on teams.

Step 3: Examine the Approach

When the goal is to improve a current process, examine the process in this stage. Start by asking the team these basic questions:

This list of questions is not all inclusive, but can be used as a starting point. Creating a process flow or reviewing an existing process flow chart can also be helpful. Both Microsoft Word and PowerPoint are good tools to use when developing flowcharts; Visio is not the only option. All have auto shapes, connectors, and definitions that inform when to use each shape.

If establishing a new process, determine if other states/agencies have developed processes to address similar problems or reach similar goals. Narrow potential solutions to those within the team’s control or influence.

Step 4: Identify the Desired Outcome

After the OFI is selected and the approach is examined, identify the desired outcome of the new process or what changes will be made in the current process. The desired outcome can be very simple or quite complex.

Record the desired outcome in an Outcome Statement. An Outcome Statement template is in Appendix D. The Outcome Statement describes the desired outcome and outlines the steps that must be taken to accomplish the desired outcome. The Outcome Statement can change after more information is obtained. While drafting the Outcome Statement, specify how it will be determined that a change in the process or the development of a new process will actually equal an improvement.

Step 5: Establish Completion Date

DAS teams will often be given a completion date by the Management Team (MT). If a completion date is not received, establish one. The best way to determine a realistic completion date is to research how long it took to complete similar projects. This may not be completely reliable especially if the older project(s) did not have similar resources (i.e. number and knowledge base of team members, more leadership involvement, departmental or governor’s office deadlines associated with previous project). If there are no similar projects, breakdown the project into small sections of work and estimate how long it will take to complete each section; the total time can be used to set the completion date.

If necessary, an extension to the completion date may be requested of DAS' Management Team.

The second stage in the PDCA cycle is DO.

During this step, perform the work outlined in the Outcome Statement.

When working on a larger process/project, consider testing on a small scale (i.e. in one PSA region or in one DAS program or section). Collect, chart, and display data to determine the effectiveness or lack thereof of the changes to the process or implementation of the new process. Document problems, unexpected observations, and unintended side effects.

If the work in this stage is successful, proceed to “CHECK”.

The third stage in the PDCA cycle is CHECK.

The primary focus of this part of the cycle is to determine if the items accomplished in the “Do” phase were successful. Use Data collected during the “Do” phase to determine if implementation was successful. Review actual results against goals established in the Outcome Statement.

Ask these questions:

Explain and document what was learned through the improvement process.

The fourth stage in the PDCA cycle is ACT. Fully implement actions taken in the “Do” phase and document processes.

If the likelihood of continued success is promising, then fully implement and document the process. Refer to MAN 5600, Section 1050.

Consider training needs regarding changes to the revised policy or training on the new policy.

Review the new policy and steps in the process frequently. Do this by going back through the PDCA cycle.

If the work in the “Do” phase was not successful, use the tools provided in the “Plan” section above to develop strategies to improve the process, then continue testing. Test until the changes result in an acceptable level of improvement.

Consider these possibilities when going back to the drawing board:

acl.gov/programs/strengthening-aging-and-disability-networks/improving-quality-services

Various Forms and Content
American Society for Quality
www.asq.org

asq.org/learn-about-quality/seven-basic-quality-tools/overview/overview.html

MAN 5600, Section 6055, Teams and Chartered Teams

MAN 5600, Section 1050, DAS Process for Developing or Changing Policy, Procedures, Program Standards.