Pilot Plan As part of the Define and Measure phases of the DMAIC model, you identified areas for improvement in the emergency care process at Shelbyville Medical Center

Introduction, click
to open section

Pilot Plan

As part
of the Define and Measure phases of the DMAIC model, you identified areas for
improvement in the emergency care process at Shelbyville Medical Center. The
next step is to determine the causal factors for the deficiencies in quality
and formulate improvements. As part of the Analyze and Improve phases, you will
prepare a pilot plan to address the causal factors of declining patient
satisfaction at the Shelbyville Medical Center.

The pilot plan is the second task of the
assessment. As part of the pilot plan, you will evaluate the following:

• the tools
  necessary to perform a causal analysis
• the common
  mistakes made in implementing a 5 Whys Analysis
• the elements of
  a successful pilot plan

Follow these three steps to help you complete
the pilot plan:

Discover: Discover
the importance of a causal analysis and assess the successful implementation of
a causal analysis in a case study.

Engage: Critique
two 5 Whys Analyses conducted by the CQI team at Shelbyville Medical Center.

Review: Apply
what you have learned to complete Task 2 of the Quality Improvement in
Healthcare assessment. For more detailed requirements, visit the Assessment area
on the Course of Study landing page.

Essential Materials

Use the
following resources to complete the Pilot Plan.

Healthcare
Performance Improvement: A Lean Six Sigma Approach prepares
healthcare administrators to meet the challenges of a changing marketplace through
the Lean Six Sigma method of quality improvement.

Miller’s
Impact Assessment Framework provides an in-depth guide to assessing
the potential impact of quality improvement on the multiple dimensions of the
organization.

Task 2:
Pilot Plan Template

Complete and Close Introduction

With
the Define and Measure phases of the DMAIC model now completed, the CQI team at
Shelbyville Medical Center needs to identify the root causes of low patient
satisfaction at the facility as part of the Analyze and Improve phases. To
identify root causes, CQI teams must perform what is known as a causal
analysis. There are several tools available to do this.

How can a
causal analysis determine root causes?

How can
pilot plans be used to test solutions?

Now
that you have reviewed and explored the tools involved in the Analyze and
Improve phases of DMAIC, you can begin applying those tools to quality
improvement at Shelbyville Medical Center. As a health leader, you will collaborate
with a CQI team to perform a causal analysis to identify root causes of quality
deficiencies.

How Is Causal Analysis Performed?

The
outcomes of patient care result from a complex interconnection of process and
system failures. CQI teams often use what is known as the 5 Whys Analysis
method to analyze performance, process, and system gaps specific to the
problem. Asking the “five why” questions is not limited to seeking insights
only five times, but rather a method to elicit relevant facts to a point when
continuing to ask why does not further inform the investigation process.

Review Chapter 4 of Basics of Health
Care Performance Improvement and complete the following scenario to
identify the common mistakes made in conducting a 5 Whys Analysis. This
activity will prepare you for the pilot plan, in which you will be required to
analyze a 5 Whys Analysis and explain how this process could have been used
more effectively.

5 Whys
Analysis Critique, click to open activity

The
complex relationship between cause and effect makes a causal analysis a
difficult task. But a quality improvement initiative can only be successful if
it is targeting the actual source of quality deficiencies. In the next
assignment, you will perform a thorough critique of a 5 Whys Analysis and then,
based on information from the analysis, identify areas for improvement and
create a future state process flowchart.

Complete and Close Engage

Pilot Plan

Complete
the Analyze and Improve phases of DMAIC by preparing a pilot plan for the
quality improvement initiative.

For this part of the assessment, you will
complete Task 2, the Pilot Plan.
This task will provide opportunities to analyze and critique a 5 Whys Analysis.
The task will also provide opportunities to outline goals for future processes
and assess the impact that the quality improvement will have on different
dimensions of Shelbyville Medical Center.

For the pilot plan, do the following:

• Use the pilot
  plan to review and critique a 5 Whys Analysis conducted by the CQI team. ​
• Produce an
  Ishikawa (fishbone) diagram.
• Identify
  opportunities for improvement.
• Outline a future
  state process.
• Prepare an
  implementation plan.
• Assess the
  impact that quality improvement will have on various dimensions of the
  organization’s care.

Complete and Close Review

References

Lighter,
D. E. (2013). Basics of health care performance improvement: A Lean Six
Sigma approach. Jones and Bartlett Learning.
https://eds.b.ebscohost.com/eds/ebookviewer/ebook?sid=c94f2d6a-baae-40b1-950b-12abffc53c90%40sessionmgr103&ppid=pp_Cover&vid=0&format=EB

Miller, C. (n.d.) Impact
assessment framework. Master of Healthcare Administration Program. Western
Governors University, 1-33.