The Seven New Quality Tools used in Healthcare Project Management

The Seven New Quality Tools used in Healthcare Project Management

The affinity diagram is an effective technique used to handle large numbers of ideas, typically during a brainstorming session. It helps with organizing, prioritizing, and categorizing diverse views and opinions based on each team member’s knowledge of a particular subject. The team should consist of people with different backgrounds, knowledge, and skills. Diversifying the team members helps present new, out-of-the-box ideas and facilitates in melding opinions and perspectives. It also allows discovery of root causes, common themes, and unseen connections between ideas and information.

After choosing the appropriate team members and inviting them to the meeting, the key steps for hosting the group discussion using the affinity diagram are as follows:

  • Introduction of self, team members, topic of discussion, and objectives.
  • Invite all to participate in contributing ideas and opinions and write them down on large individual Post-It notes (or equivalent).
  • Place the notes in the middle of the table and ask the members to re-arrange and organize the ideas into related groups silently. If an idea falls into more than one category, place another Post-It with the same idea in both groups.
  • Participants can now discuss on the different grouping patterns and focus on controversial ideas. If a conflict arises, try and reach a general consensus and make any necessary changes in grouping.
  • After the ideas have been arranged, select a short heading to categorize each group.
  • Finally, move groups under each heading to view the affinity diagram.

Once the affinity diagram is complete, the prioritized ideas are now ready for further management decisions and approvals. A simplified example of the affinity diagram process is shown below in Figures (A) and (B)

Figure (A) – Example listing of all team members’ ideas to be categorized

Figure (B) – Example of a completed affinity diagram.

The affinity diagram could be used in reforming a specific area of a health care system that needs to become more efficient in terms of process flow and organization.  For example, the CEO of a hospital discovers that the most coding and billing errors are made in the outpatient center, specifically in the laboratory-draw station (aka blood testing center). Because of these coding errors, the hospital is not getting reimbursed for performing the tests and patients have to come back to have their blood drawn for a second time, which now has to be funded by the hospital since they are responsible for the mistake. The CEO has also been informed that many patients have been complaining about the excessive waiting time at the outpatient lab center. Upon first impression of the situation, the CEO concludes that the lab workers must be performing at a slow pace, don’t understand how to properly code, or they don’t realize the importance of coding and the severity of mistakes.

If the CEO decided to conduct a meeting using the process described for an affinity diagram, he would invite several key individuals from different departments to participate in resolving the issue. Key individuals would include one or two of the phlebotomists, receptionists, and medical laboratory technicians who work during the busiest hours at the lab as well as the outpatient lab supervisor. As they take the steps to create an affinity diagram, the CEO would discover that the true reasons for the problems at the outpatient lab center are described from each of the individuals as:

  • Phlebotomists 
    • Constantly short staffed with high volumes of patients
    • Insufficient training on how to properly code
    • Doing the same type of coding as medical assistants 
    • Not paid to perform the level of coding required
    • Lack of communication when a code/procedure changes
    • Unfairness in scheduling/problems and favoritism among co-workers
    • Lack of proper supplies
    • STAT lab work from physicians 
    • Lengthy process to perform, label, and code specialized tests
    • Called from the outpatient center to fill in at the hospital when the hospital is short staffed
    • When requesting additional help during extremely busy hours, relief doesn’t actually arrive until hours after it was requested, if it comes at all.
  • Receptionists 
    • High volume of paperwork associated with each patient
    • Must send patients ordered as STAT or who need special tests to be drawn first, even if another patient was waiting fifteen minutes before the STAT patient arrived. 
  • Supervisor 
    • Not enough employees to staff
    • Do not want to over-staff
    • Scheduling conflicts, no one to work if employee calls in sick
    • Does not have control over certain policies or procedures
  • Medical Lab Tech
    • Under staffed
    • Receiving blood work from both the outpatient center and the hospital, both of which use different codes
    • Certain tests need to be conducted before others
    • Contaminated blood samples
    • Lost, broken, or missing information on a test tube
    • Must perform all the blood testing, send away certain tests in proper packaging, lengthy coding and labeling processes
    • Sometimes called to draw a patient’s blood when the hospital is understaffed  

The team members would also suggest and write down solutions to all of these issues and then arrange them into groups of related areas under a common heading. These groups allow the CEO to be able to prioritize and organize the situation and make decisions based on the affinity diagram. The most re-occurring issue is lack of adequate staffing. The CEO can weigh the cost of hiring additional employees for the outpatient lab versus the total cost of the coding errors being made as well as the growing dissatisfaction among patients and employees.

The relations diagram is best used to illustrate cause-and-effect relationships and identifying an area of greatest need for improvement. It is also helpful in analyzing the links between different aspects of a complex situation, especially after generating an affinity diagram, tree diagram, or fishbone diagram.

After introducing the topic and setting the objectives of the discussion, the following steps should be taken to create an accurate relations diagram.

  • Use ideas created from an affinity diagram, the most detailed row of a tree diagram, or the final branches on a fishbone diagram as starting points.
  • Place one idea at a time on the table and ask the question “Is this idea related to any others?” If so, place that card near the group most relevant making sure to leave enough space for drawing arrows in step 3.
  • Once the ideas are grouped together, take each individual card and ask “Does this idea cause or influence any other idea?” Then draw arrows from each idea to the ones that it causes or influences. After all cause-and-effect relationships are identified, the final product is known as the relations diagram.
  • To analyze the relations diagram, count the arrows in and out of each idea and write the number in the bottom of each box. Those with the highest number of arrows are usually key issues.
  • Draw bold boxes around ideas flagged as key issues.
  • Ideas that have primarily outgoing arrows are basic causes. Similarly, ideas having primarily incoming arrows are final effects. Both cause and effect ideas with high numbers of arrows are typically the most critical issues needing to be addressed.
    • Note: Sometimes ideas with fewer arrows can also be key ideas.

Figure (C) illustrates an example relations diagram.

Figure (C) – Example of a Relations Diagram

The relations diagram would be an ideal tool for reducing ER wait times. For example, if the ER supervisor wanted to reduce patient wait times by 10 minutes, the diagram would be able to illustrate key issues currently affecting the wait times and which areas should be addressed first to achieve the largest reduction of waiting time. It can also highlight independent and dependent variables as well as expose previously unseen links and flaws in the system. The relations diagram can reveal each step that needs to be taken in order to implement a specific change.

The Tree Diagram is used to break down broad categories into smaller, more detailed, sub-categories. It begins as one general item which branches into two or more sections. Each section branches into two or more sub-sections, and so forth, ultimately resembling a tree-like shape. The purpose of this type of diagram is to help break down a large category and think about it step by step from generalities to specifics. The tree diagram is best used when analyzing the detail of a process, evaluating implementation issues for several possible solutions, developing actions to carry out a specific solution, or as a communication tool for explaining details to others.

Steps for developing a tree diagram are as follows.

  • Develop an objective, goal, or problem and write it at the top (vertical tree) or far left (horizontal tree) of the designated work area.
  • Ask a question for each branch that will lead you to the next level of detail.                Examples include: “How can this be accomplished?” “Why does this happen?” “What causes this?” “What are the components to this?”
  • Perform a “necessary and sufficient” check, which indicates whether the items in the completed row are necessary for preceding level.
  • Every new branch in the tree now becomes the subject. For each new branch, ask the question again to obtain the next level of detail.
  • Repeat step 4 until the fundamental elements of the issue have been reached (a branch cannot be broken down any further, specific actions can actually be performed, root cause was discovered, etc.)
  • Repeat step 3 for the entire diagram and determine if all the items are necessary and sufficient for the objective.

Figure (D) – Example of a Tree Diagram

The tree diagram would be ideal to use for breaking down complex health care problems and deciding on solutions for implementation. For example, say a hospital is making budget cuts and has to reduce the cost of employee wages on the clinical floor. The Safety and Occupational  may use a tree diagram to visualize, organize, and compare the benefits and risks of two feasible solutions. When looking solely at the nursing department in the hospital, the CEO could use “Reduction of Staff” as the main focus, or “tree trunk”, for this specific diagram. From this trunk, two possible solutions he is considering implementing are “Reduce number of LPNs” and “

A fourth component of the “Seven New Quality Tools” is the Process Decision Program Chart (PDPC). This chart identifies potential flaws or problems in a plan and helps develop countermeasures to prevent or offset them. The PDPC allows the plan to be revised to avoid an identified problem or at least anticipate and prepare for a problem if it should occur. It is extremely valuable before implementing a plan, especially if the plan is large and complex. It is also useful when the plan must be completed on a schedule or when the price of failure is high.

In order to use a PDPC, a tree diagram of the proposed plan must be obtained. It should contain a high-level diagram that indicates the objective, a second-level composed of the main activities, and a third level with broadly-defined tasks to accomplish the main activities. After obtaining a detailed tree-diagram, the following steps should be taken.

  • Each task listed in the third level of the tree diagram should be analyzed for all possible errors, conflicts, and flaws.
  • Review all the problems associated with each branch and eliminate any that are improbable or have consequences that are insignificant. Re-list the eliminated problems as a fourth level linked to the tasks.
  • For each potential problem, brainstorm possible countermeasures. For example, actions or changes that would prevent the problem or remedy it once it has occurred. These countermeasures should be listed as a fifth level, outlined in clouds or jagged lines.
  • Decide how practical each countermeasure is based on cost, time, and ease of implementation and effectiveness. Mark impractical ones with an X and practical ones with an O.
  • Some questions that can be used to identify potential problems include: “Are there any undesirable consequences directly linked to good inputs?” “Is there something else that might happen instead or in addition to?” “Does this depend on any extraneous actions, conditions, or events?” “What is the margin for error?” “What assumptions have been made that could be wrong?” “How is this different than before?” “If we wanted this to fail, how could we accomplish that?”

Figure (E) – Example of a Process Decision Program Chart

Another component of the “Seven New Quality Tools” is the arrow diagram. This diagram illustrates the required order of tasks in a project or process. It highlights potential scheduling and resource problems as well as their possible solutions. It is helpful when calculating the critical path of a project, which is the flow of critical steps where delays will affect the timing and completion of the entire project and where additional resources can facilitate the project.

The arrow diagram is a valuable resource when scheduling and monitoring tasks in a complex project. It helps to demonstrate the sequence of steps in a process and the length of time each step may take to complete. The arrow diagram should be used whenever a project schedule is critical and has consequences for completing the task late.

The following steps are used to create a typical arrow diagram.

  • Make a list of all necessary tasks in the project.
  • Determine the correct sequencing of the tasks. Three questions that can assist is sequencing include “Which tasks must happen before this one can begin?” “Which can be performed at the same time as this one?” and “Which tasks should happen immediately after this one?”
  • Diagram the tasks by arranging them in order from left to right.
  • Between each task, draw a circle for “events”, which marks the beginning or end of a task. Look for three common-problem situations and draw them as “dummies”. A dummy is an arrow drawn with dotted lines which separates tasks that would otherwise start and stop with the same event.
  • Determine task, critical path, and slack times and incorporate them into the diagram.

Figure (F) – Example of an Arrow Diagram

The final two components of the “Seven New Quality Tools” are Matrix Diagrams and Matrix Data Analysis. A Matrix Diagram is another useful diagramming tool which shows the relationship between two, three, or four groups of information. It can also provide information about the relationship of different groups to each other, such as the strength of the relationship and the roles played by various individuals or measurements. Matrix Data Analysis refers to a complex math technique used to analyzing matrices. The most challenging, careful, and time-consuming of the decision-making tools is a prioritization matrix. A prioritization matrix is an L-shaped matrix that makes comparisons of one set of options to a set of criteria in order to find the best option.

There are six different types of matrix shapes that are possible. These include L, T, Y, X, C, and “roof-shaped”. The American Society for Quality website describes which matrix is best suited for a particular situation:

  • An L-shaped matrix relates two groups of items to each other (or one group to itself).
  • A T-shaped matrix relates three groups of items: groups B and C are each related to A. Groups B and C are not related to each other.
  • A Y-shaped matrix relates three groups of items. Each group is related to the other two in a circular fashion.
  • A C-shaped matrix relates three groups of items all together simultaneously, in 3-D.
  • An X-shaped matrix relates four groups of items. Each group is related to two others in a circular fashion.
  • A roof-shaped matrix relates one group of items to itself. It is usually used along with an L- or T-shaped matrix.
L-shaped 2 groups A B (or A A)
T-shaped 3 groups B A C but not B C
Y-shaped 3 groups A B C A
C-shaped 3 groups All three simultaneously (3-D)
X-shaped 4 groups A B C D A but not A C or B D
Roof-shaped 1 group A A when also A B in L or T

. Table 1: When to use differently-shaped matrices


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