Using the Tree Diagram to Improve Complex Projects

Earlier in the chapter we discussed the use of the tree diagram for planning (see Figure 213). In this section we will discuss using the tree diagram for breaking down complex improvement projects. The first tree diagrams presented will employ the questions from the Model for Improvement for guidance in breaking down the project from the aim of the project to questions that can lead to possible improvement cycles. We will then conclude this discussion with a healthcare example that employs the use of the Planning type tree diagram over the time of the project. This example will show how improvement concepts can be developed into potential changes that will lead to a desired vision developed by an improvement team. Examples of the Tree Diagram Integrating the Model for Improvement to Address Complex Projects Figure 21-7 has been borrowed from the Improvement Guide to show the complexity of various types of improvement efforts from the very simple to the most complex. For the next example of using the Tree Diagram we will focus on an example that is aimed at improving a process to gather data from sales within an organization. Figure 21-7: Complexity of Level of Various Improvement Projects Focus is on Improving a Process in an Organization

The tree diagram depicted in Figure 21-8 generally follows the flow of the Three Questions in the Model for Improvement: 1. What are we trying to Accomplish? General Description Project Objectives describe objectives to support the overall general description and the answer to question one. In this example we are trying to Improve the process by which we gather data from the product sales force

Using the Tree Diagram to Improve Complex Projects

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2. How will we know that a change is an improvement For each objective, a measure(s) is selected to answer question two in the Model for Improvement. Identifying measures related to the objectives usually provides some intermediate measures for the project (see Improvement Guide p.55). 3. What changes do we need to make? For this question, questions are posed that need to be answered by the people leading the project. These questions can lead to appropriate PDSA cycle. Also added are appropriate Change Concepts (Reference: Improvement Guide, p. 295) that can lead to changes and ideas that can be tested immediately. Figure 21-8: Tree Diagram Using the Three Questions to Improve a Sales Process
1 .What are we trying to accomplish?
2 .How will we know a change is an improvement?
Improvement Objectives / Measures Describe Project:
(check one)

3. What changes can we make that will lead to improvement?

Change Concept/ Ideas
B14 / Implement a request form and web link D28 / Implement a measurement process & report

Questions to Answer
How do we make it easy for people to engage the team to deliver surveys? How do we measure the resources needed to support the process? How do we assess whether a survey is needed or not with the existing Time Analysis survey in place & other data collected?

Create request process & measures M - Process utilization rate (Collect data)

_ X_ Redesign existing Process(es), product or service ___ Design new process(es), Product or service ___ Improve the system as a Whole (mainstay, drivers & support processes)

A9, D34, D27, G53 / Engagement guidelines to assess survey needs Engagement guidelines to advise partners

Brief Description: (include

description above)

Improve the process by which we gather data from the Product Sales Force & increase knowledge retention of key sales performance indicators (time spent, satisfaction, etc) consistently through a single point of capture.

Improving sales data collection & usage M - # of Surveys Received by Sales, & Time Spent on Surveys (Collect data)

What alternate methods can we advise the internal partner to use? How is the outcome tracked, monitored and used for questions asked? Sales: Have the decision makers heard the sales feedback?

B18, E38 / Communicate responses E42 / Communicate change based on feedback

Standardize the survey launch process M Client satisfaction (Collect data)

To create cadence in the sales work week how do we create consistency? How do we draw new clients into the process? How do we ensure consistent delivery of the survey process?

A5, B20, G51, I68 / Widespread executive sponsorship for a single process

Items in Green

answer the question What can we do right now?

H59, F46 / Develop a checklist for survey launch

Using the Tree Diagram to Improve Complex Projects

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Figure 21-9: Planning Chart Using Action Items from the Tree Diagram
PDSA Cycles & Activities Implement Request Form Implement Measures Develop Guidelines Test Guidelines Implement Guidelines Develop Process for Responses Test Response process Implement Response Process Survey Decision Makers Standardize Survey Process Test Survey Implement New Survey Process Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8

Once the tree diagram is detailed to a useful state, the actions associated with Question Three of the Model for Improvement can be placed in time order. Figure 21-9 describes the flow of the various action items and PDSA cycles developed from the questions that need to be answered in the project and potential changes developed by consideration of the Change Concepts (Reference: Improvement Guide, p. 295). The tree diagram can also be used to scope large complex projects that would have multiple application of the Model for Improvement. Figure 21-10 shows the relative position of our next example as improvement of a subsystem for sales support within a large international corporation. As we focus on the tree diagram in Figure 21-11, we see that each of the objectives is large enough to incorporate an improvement effort for each objective. In this organization, the term Charter is reserved for a document that will guide the deployment of several Improvement Plans. Figure 21-12 describes this breakdown of individual improvement objectives at the Charter level to four individual Improvement Plans. All efforts are being guided by the Model for Improvement. Figure 21-10: Complexity of Level - Focus is on Improving a Subsystem

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Figure 21-11: Tree Diagram Using the Three Questions to Improve the Sub-system for Technical Support within a Large Technology Company
1. What are we trying to accomplish?
General Description of Project

2. How will we know a change is an improvement?

Project Objectives

3. What changes can we make that will lead to improvement?

Questions to Answer (Potential Cycles)
What knowledge is most useful ? How does it affect resolution of customer case (should be 2x faster, if not a defect)? Does customer has better experience ? What system(s) are most useful for capturing customer knowledge ? How should the process and system use be deployed ? What are measures of effectiveness of this process relative to the overall system ? What gaps in current KM are most needed to improve the customers self -solve usage? What process changes are needed to ensure we fulfill those knowledge gaps initially and on going ? What costs are involved in the fulfillment of the knowledge gaps and how does this impact the overall delivery of service to customers ? What measures are needed to ensure we maintain an effective system of delivery for both assisted and self-solve processes ? What are the variations in supplier costs /case and what are some of the main reasons for these? What opportunities do we have for improving the system by which suppliers provide service / support on our behalf , esp. to reduce average costs?
Which older product versions (>n-2) have the greatest impact on support delivery cost call today? / What are the reasons? Which accounts have the greatest impact on cost/ call and overall costs (GM), and what are the reasons? What products currently have high defect rates that are impacting costs, and what steps are needed to reduce the impact of these?

Possible Change Concepts to Apply

16. Find & remove bottlenecks 27. Give people access to information 40. Focus on outcome for a customer 7. Reduce classifications 9. Match amount to the need 11. Change tgts / set points (SLO)

M: CSI/top 20 in region M: CSI for non-top in reg.

Describe Project:
(check one )

1.

___ Redesign existing Process(es), product or service ___ Design new process (es), Product or service _X_ Improve the system as a Whole (mainstay , drivers & support processes )

Provide a differentiated customer experience for strategic customers , and a more basic experience for non-strategic . (reduce over-delivery )

M: cost/incident, vol. self-solve vs. assisted solve

Brief Description: (include

description above )

2.

Improve the system for technical support, reducing costs while maintaining customer satisfaction. FY06 Strategic objectives specifically target $15M in cost reduction to improve GM% by 11%. The majority of the cost reduction is targeting in the mainstay of the system.

Improve the self -solve web capabilities (greater coverage across products for knowledge , patches, upgrades , defect management ) shifting away from resources for assisted solve

40. Focus on the outcome for a customer 39. Coach customer to use product / service 43. Outsource for free suppliers provide knowledge 51. Standardization of processes

3.

M: reduced cost/case , reduced variation per supplier

Reduce supplier cost /case for assisted solve from partners , contractors and 3 rd parties .

45. Work with Suppliers 16. Find & remove bottlenecks

4.

M: reduced cost/case, cost attribute per classification

Reduce support costs for older versions of products , low GM% accounts, cost of supporting products with high defects

45. Work with suppliers (CPE partners) 39. Coach customer to use product/service (training, KP, NRCE)

Figure 21-12 describes how the project was managed using a Charter to guide four Improvement Plans. The project measures were connected to the overall charter. For each of the four objectives it was deemed appropriate to have a separate Improvement Plan to guide the effort. The Model for Improvement was then used to manage and coordinate the overall project.

Using the Tree Diagram to Improve Complex Projects

API/September 2006

Figure 21-12: Tree Diagram Using the Three Questions to Improve the Sub-system for Technical Support within a Large Technology Company
General Description of Project Project Objectives Questions to Answer (Potential Cycles ) W hat knowledge is most useful ? H ow does it affect resolution of customer c ase
(should be 2x fas ter if not a defect? , ) D oes customer has better experience ?

Possible Change Concepts to Apply

16. Find & remove bottlenecks 27. Give people access to information 40. Focus on outcome for a customer 7. Reduce classifications 9. Match amount to the need 11. Change tgts set points / (SLO)

Improvement Plan 1
Model for Improvement
accomplish? Improvementwe know that2 Plan a How will What are we trying to

M: CSI/top 20 in region M: C SI for nontop in reg .

Describe Project :
(check one )

___ Redes ign existing Process (es), product or servic e ___ Design new proc ess (es), Product or service _X_ Improve the system as a Whole (mainstay, driv ers & support processes )

1.

Provide a differentiated cus tomer experience for s trategic c ustomers and a , more basic experience for non-strategic. (reduce over-delivery)

W hat system are mos t useful for capturing (s)

cus tomer knowledge ? H ow should the process and system use be deployed? W hat are measures of effectiveness of this proces s relative to the overall system ?

Model for Improvement

change is an improvement?

Improvement Plan 3 a How will we know that

40. Focus on the outcome for a customer 39. Coach customer to use product/ service 43. Outsource for free suppliers provide know ledge 51. Standardization of processes

What change can we make that What willwe tryingimprovement? are result in to accomplish?

M: cost/incident, vol. self-solve vs. assisted solve

W hat gaps in c urrent KM are mos t needed to

improv e the customers self -solve usage ? W hat process changes are needed to ensure w e fulfill those know ledge gaps initially and on going? W hat costs are involved in the fulfillment of the knowledge gaps and how does this impact the overall deliv ery of service to customers ? W hat measures are needed to ensure w e maintain an effec tive system of deliv ery for both ass isted and self -solve processes ?

Model for Improvement What change can we make that Act Plan

change is an improvement?

Brief Description (include :

description above )

Improve the system for technical support , reducing costs while maintaining customer satisfaction. FY06 Strategic objectives specifically target$15M in cost reduction to improve GM% by 11%. The majority of the cost reduction is targeting in the mainstay of the system.

2.

Improve the selfsolv e web capabilities(greater coverage acros s products for knowledge patches, , upgrades, defect management) shifting aw ay from resources for assis ted solve

Improvementwe know that4 Plan Study How will a

change is an improvement? What willwe tryingimprovement? are result in to accomplish?

What are willtrying to improvement? we result in accomplish?

Do

Model for Improvement What change can we make thatPlan Act

MI LLI O N S $

3. 4.

M: reduced cost /case, reduced variation per supplier

W hat are the variations in s upplier costs /case W hat opportunities do we have for improving
the system by which suppliers provide service / support on our behalf esp. to reduce av erage , cos ts? and what are some of the main reasons for these?

R educe supplier cos/case t for assisted solve from partners, contractors and rd 3 parties.

45. Work w ith Suppliers 16. Find & remove bottlenecks

230 210 190 J M M

System Measures willan improvement? How we know that Study a change is

TOTA L SALES

Do

What change can we make that Act Plan will result in improvement?
S N J M M J
1995

J
1993

J
1994

M: reduced cost /case, cost attribute per classification

Which older p roduct versions (>n-2) have the greate st impact on support delivery cost today /call ? What are the reasons ? Which accounts have the greatest impact on co st / call and overall costs (GM), and what are the reasons ? What products currently have high d efect rates that are impa cting costsand w hat steps a re needed to , reduce the impa ct of these ?

C E N T S/ P O U N D

UNIT COST S

R educe support c osts for older versions of products , low GM% acc ounts cost of , supporting products with high defects

INJ U R IES / M ONTH

45. Work w ith suppliers (CPE partners J M M J S ) 39. Coach customer to use productservice (training KP, / , NR CE ) 15
1993

95 90 85 80 75

Study
S N

Do

J
1994

1995

Act

Plan Do

T OT AL INJ URIES

C YC LE T I ME IN D A YS

Overall System Charter

J M M
1993 J

10 5 0

1994 J

M 1995 J

Study
N

P E R C E N T A B SE N T

A BSENTEEISM OF 16 0 EMPLOYEES

15 10 5 0

1993

1994

1995

Before C hange

CYCLE TIME After C hange

35 25 15 5 J M M J
1993

J
1994

1995

Using the Planning Type Tree Diagram to Guide a Complex Project in Healthcare The tree diagram in Figure 21-13 describes the use of planning type tree diagram to guide a project towards accomplishing a desired vision. In this diagram we have four concepts that are driving the current changes. From these current changes, potential changes have been identified that will be necessary to move the overall effort to the desired vision. Figure 21-14 describes a project in a Healthcare system where changes are being developed, tested and implemented to improve the relationships between healthcare professionals and patients. The team started off with several guiding principles: You Know Me; Changes to establish the relationship with the patient The Care Team; Changes to be made by key contacts in the care team Collaboration; Changes to better understand and work with the patient Options and Tools; Methods and Tools to enhance communication and the relationship.

Using the Tree Diagram to Improve Complex Projects

API/September 2006

From these concepts, changes known to the team were identified that could be tested now. As the team developed and tested and these changes, other potential changes were identified. In addition to this thought process, the team used the overall vision to develop other potential changes that would be required to move the team to accomplishing their vision. As the team developed the plan for these changes they also included a timeline to forecast when the changes could be integrated into the system. Figure 21-13: Using the Planning Type Tree for Planning Changes Over Time Directed to a Desired Vision in Healthcare Conceptual Example

Current Change

t pec no C

Planned Change Current Change Potential Change Planned Change Current Change

Potential Change

t pec no C

Potential Change

t pec no C

Potential Change Planned Change

Team Vision The teams vision/ personali zation of the concept design

Current Change

t pec no C

TODAY

Mar. 2006 3 Mos.

June 2006 6 Mos.

PROJECT TIMELINE

Sept. 2006 9 Mos.

Dec. 2006 12 Mos.

Using the Tree Diagram to Improve Complex Projects

API/September 2006

Figure 21-14: Using the Planning Type Tree for Planning Changes Over Time Directed to a Desired Vision in Healthcare Detailed Example
Kp.org sign-up kiosks & info Patient contact preferences Nickname in Receptionist header co-located with team CA reviews after visit summary with patient RN prescreening Proactively charts identifying patient needs Reaching out to patient and subsequent follow-up Telephone visits Group visits Health Assessments

m e T er a C a

Pre-visit prep with patients to elicit what matters New roles for members of the care team based on the work Ask patients to do collaborative Build Care plan goal setting into chart during visit consistent place Virtual visits with agreeable members

New members Action plans of the care based on team based evidenceon the care based work developed with patients e-visits as the standard mechanism for follow-up

What matters to patient addressed by care team Collaborative care plan guides all interactions Panel View tool to manage patients

e M won K uo Y

s ooT s not p O l / i

not ar obal o C i l

The care team, supported by optimizing the relationshi p-based care of a population of patients

TODAY

Mar. 2006 3 Mos.

June 2006 6 Mos.

PROJECT TIMELINE

Sept. 2006 9 Mos.

Dec. 2006 12 Mos.

Summary This paper has discussed several key points related to using tree diagrams to breakdown complex improvement projects: 1. The Model for Improvement and use of the Three Questions can be used in conjunction with the Tree Diagram to break down improvement projects. 2. Obvious PDSA cycles can be identified and testing started on changes that can lead to improvement. 3. Time lines can be constructed to give guidance to the team. 4. Larger projects can be scoped down using the Tree Diagram. Charters can be used to manage these larger projects with sub-charters or improvement plans.

Using the Tree Diagram to Improve Complex Projects

API/September 2006

References Bowles, John. The Society of Automotive Engineerings Failure Modes and Effects Analysis (Proposed Document) 1996. Juran, J.M., Gryna, Frank. Jurans Quality Control Handbook Fourth Edition McGraw-Hill Book Company. 1988. Mizuno, S., ed. Management for Quality Improvement: The 7 New QC Tools. MA: Productivity Press, Inc. 1988. Shiba, Shoji, Alan Graham, David Walden. A New American TQM: Four Practical Revolutions in Management. Portland, OR: Productivity Press. 1993. Wilson, Paul F., Larry D. Dell, Gaylord F. Anderson. Root Cause Analysis: A Total Quality Management. Milwaukee: ASQC Quality Press. 1993. Exercises 1. Consider a recent problem in your organization and develop a problem tree diagram. 2. Select a work objective that is currently a challenge and develop a planning type tree diagram. Tool for New York: Cambridge,

Using the Tree Diagram to Improve Complex Projects

API/September 2006

Appendix: Healthcare Examples of the Tree Diagram Care of Heart Failure Patients at XYZ Hospital Describe Project:
(check one)

Improvement Objectives / Measures

Questions to Answer
How can we automate this with Excellian (computerized documentation system) How do we get this on the chart for every patient? How do we ensure providers use it and fill it in on each patient?

Change Concept/ Ideas

B17: Develop computerized order set for HF patients E41/H59/B18:Work with Care Coordinators to put paper order set on chart and follow up to ensure it is completed

100% of patients will have standardized order set used

_X_ Redesign existing Process(es), product or service ___ Design new process(es), Product or service ___ Improve the system as a Whole (mainstay, drivers & support processes)

99% of pts will receive LVF assessment and ACEI/ARBs as appropriate

How can we assess if LVF assessment is planned for after DC or done prior to adm? How will we know if ACEI/ARB was considered but contraindicated?

H59/B18/B19: Include check boxes on order set that indicate these elements

Brief Description: (include

description above)

99% of pts will receive smoking cessation advice

Is smoking history getting consistently assessed on admission? How do we ensure all providers know what elements need to be included in dc instructions? How do providers document instructions given?

To improve the care provided to heart failure patients by including evidenced based interventions thereby decreasing readmission rates

B17: Make this a required field on admission profile and/or on order set

99% of pts will receive comprehensive dc instructions

H59/B18/B19: Include check boxes on order set that indicate these elements

Decrease ALOS

What other factors influence ALOS beyond 4 core measure?

G51: Create a standard HF pathway

Do these pts follow a typical path? Prepared by: Martha Frederickson

Are there commonalities among pts with targeted LOS? E41/E40: Have Case managers follow HF patients while hospitalized

Using the Tree Diagram to Improve Complex Projects

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Improvement Objectives Measures

Describe Project:
(check one) Develop a standardized pre-op pulmonary rehab referral form and process to begin use in physician office through Pulm Rehab to Pre-Surgical Screening (PSS). Include ICD9 codes for insurance coverage. Develop Rehab Express program to accommodate elective general and vascular surgery patients with pre-op chronic respiratory risks (optimal length of time for conditioning is projected at 2 weeks)

Questions to Answer
Can Pulm onary Rehab handle added volum Do they e? have a programalready or one that could be adapted to this? Are there form that could be used/m s odifiedfor this program ? Will surgeons agree with the need for pre pulm -op onary conditioning and refer in adv ance of boarded elective surgery? W hats the degree of belief that this programis needed bysurgeons, anesthesiologists &pulm onologists? Will busy and different office staffs and PSS cooperate and support this newinitiative? Teach office staff, PulmRehab and PSS the process. Teach office staff, PulmRehab and PSS the process. Will this programbe cost effective? What happens if a patients insurance w not cover or the ill patient does not have insurance? What if there is less than 2 w eeks before surgery?

Change Concept/ Ideas Develop alliance/cooperat ive relationships (37) Coach customers to use product / service (39) Standardization (51) Use a coordinator (41) Conduct training (31) Enable access to information

PDSA (gant) 1. Pulm Rehab capacity/program evaluation PDSA 2. 4/12/2006 Surgery QA Committeesurgeon buy-in PDSA 3. 4/28/06 first patient referral (elective AAA) 5/2 assessment completed, 5/5 PR Express began PDSA 4. PDSA

___ Redesign existing Process(es), product or service __Design new process(es), product or service ___ Improve the system as a Whole (mainstay, drivers & support processes)

Brief Description: (include

description above)

To decrease the risk and occurrence of post-op respiratory complications after elective general and vascular surgery in at-risk patients by initiating a preop pulmonary assessment and conditioning/rehabilitation program. This will be achieved by: Physician engagement identify patient candidates well in advance of surgery date Development of a Pulmonary Rehab Express program for preop patients Availability of documentation of rehab parameters upon arrival on day of surgery

Develop procedure and educate surgeons, Anesth., Pulmonologists, office staff, PSS and patients (develop educational materials). Develop a process and provide pre- and post-rehab conditioning parameters for Anesthesiology at time of patient admission for surgery. Decrease post-op pulmonary complications including dyspnea, prolonged ventilator dependency and pneumonia. Potential additional measures: decrease post-op length of stay, cost per case and readmission for respiratory conditions. Category and continuous data on patients referred, rehab program completed and pulmonary status measure improvement. Engage/use the physicians and office staff in ongoing evaluation/process im provem ent.

Standardization create a formal process (51) Develop operational definitions (53)

5. PDSA

Will Anesthesia utilize pulm onary rehab inform tion, find it a of value? What if there is less than 2 w eeks before the surgery?

Will patients agree to the program stick w it once it is , ith started?

Howw w attribute com ill e plications to pre pulm -op onary risk? Will office, PulmRehab and PSS staff support ongoing evaluation &im provem of the process? Pilot the w ent hole process on one or tw patients to w out the bugs. o ork Include office, Pulm onary Rehab and PSS stgff in evaluation and revision of process. Will tim of NSQIP data be tim enough to m ing ely onitor the process?

Conduct training (31)

Will there be enough patients referred in order to ev aluate and do statistical analysis?

9/8/2006
Use proper

Prepared by: Laura DeSantis

Using the Tree Diagram to Improve Complex Projects

API/September 2006

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