Project Leader Facilitation Guide
Project RED (Re-Engineered Discharge) Training Program
To approach solutions systematically, it is important for performance improvement (PI) teams to create an organized approach to problem solving through the use of planned facilitation. Instead of seeing a problem and fixing it, a planned facilitated approach to problem solving enables:
- In-depth analysis of potential root causes to problems.
- Appropriately scoped projects.
- Generation of sustainable solutions.
This guide will assist project leaders in organizing their PI teams and designing and analyzing processes.
A team charter is a good tool to communicate PI team intent and its progress to the senior leaders who sponsor your project. A charter, at a minimum, can help you identify:
- Problem focus.
- Patient benefit.
- Team members, including the team leader.
- Stakeholders (i.e., those impacted by the process from start to finish).
Other items that should also be addressed in the early stages of a PI project include:
- Time requirements.
- Requirements for PI team visits to the area to validate process mapping.
- Acquisition of current State data and sources of information.
Specific facilitation techniques are highlighted below to provide an overview of the foundational components of running effective meetings through the use of clearly defined ground rules, role designation, a parking lot, flexible supplies, and brainstorming techniques.
Team ground rules promote functional team meetings and focused work time. Traditional ground rules for PI team meetings include:
- Start and end meetings on time.
- Remain issue focused. You can use a flip chart to record off-topic issues that arise so they can be addressed if time permits. See the Parking Lot section, below.
- Ensure only one person speaks at a time.
- Be open to hearing each member's perspective.
- Be brief so everyone can participate.
- Avoid side conversations.
- Place mobile devices on vibrate or turn them off. Members should arrange for coverage as needed.
Designation of roles is often helpful in structuring the PI team's work. PI team roles may include but are not limited to:
- Facilitator – Creates the agenda, leads the meeting, and documents the team's work. The facilitator should be an objective team member. If he or she is knowledgeable of the process, the facilitator should ask the group questions instead of dictating actual process steps.
- Recorder – Assists the facilitator in synthesizing the team's work documents for the final report.
- Time Keeper – Reminds the group where they are in relation to the agenda times.
- Team Member – Understands the process at the point of service. Team members may include physicians, nurses, case managers, and pharmacists.
- Ad Hoc Team Member – Joins the team by request because of expertise in areas such as information technology, education, or finance.
- Team Champion – Supports the work of the team and carries the process forward.
Meeting time is a valuable resource. A parking lot let facilitators to take the issue that is being discussed, but is not the issue of concern, and park it on a flip chart so it can be discussed if time permits. The parking lot enables PI team members to keep their meeting on track but also have confidence that their issue will be discussed eventually.
The process of creating a map is dynamic and requires tools that enable flexibility. For example, sticky notes can be easily placed and moved on flip charts as the group discusses and decides on their proper placement. After the PI team meeting, the recorder or another team member can translate the flip chart and sticky notes into a more formal document for those team members who enjoy structure, neatness, and legibility.
Brainstorming is a technique that enables the generation of bigger and better ideas, capturing all of the PI team information quickly. It allows the PI team to put a full range of ideas on the table before team members take positions. Brainstorming may include some or all of the following:
- Structured brainstorming allows each PI team members to generate individual ideas before sharing them in a larger group discussion.
- Nominal group technique involves stating all ideas that were generated in structured brainstorming and listening without judgment until all ideas are documented and heard.
- Informal brainstorming involves idea generation within the group without any structured process. Ideas are generated in a free-flow manner without formal structure to the process.
General ground rules for brainstorming include the following:
- All ideas are welcome. There are no bad ideas.
- Everyone should participate.
- Ideas should flow freely.
- Keep the discussion moving.
- Evaluation and debate are not permitted.
- Feel free to build on others' ideas.
- Break out of what you know.
- Be creative.
Designing the Process
The actual designing process may include the following steps:
- Mapping the high-level process steps by determining the start and end points first.
- Discussing each step in the process from the point of view of those individuals who are closest to the work.
- Reviewing current problems or potential errors that can occur within each step.
- Documenting the work of the PI team by using brainstorming techniques and individual sticky note ideas.
- Synthesizing the work of the PI team into a Process Map or Swim Lane Diagram.
- Reviewing current data and metrics.
- Verifying the map by witnessing the process in action.
- Discussing and analyzing lessons learned.
- Creating a plan for next steps in the Plan-Do-Study-Act (PDSA) or Define-Measure-Analyze-Improve-Control cycle.
- Documenting and communicating your work.
Process Analysis: Beyond the Map
Once a process map is completed, the PI team will analyze it. The analysis includes considering the process activities and flow by:
- Looking at each process step for:
- Bottlenecks here does the process breakdown? Where are the waiting periods and why?
- Sources of delay.
- Errors being fixed instead of prevented (i.e., rework).
- Role ambiguity.
- Duplications. Where are steps repeated and why?
- Unnecessary steps. Is this step actually needed for a successful outcome?
- Cycle time (i.e., the total time that it takes to start and end a process). What is the lab cycle time from physician order to the time results are obtained? The process time will actually document the time it takes for each step in the process.
- Looking at each decision to determine the following:
- Role ambiguity (i.e., responsibility, authority, and accountability issues).
- Whether decisions are immediately necessary.
- Using the customer's point of view, consider value-added versus non-value-added steps. Value-added activities are those that would be seen as valuable to the patient and that the patient would be willing to pay for. For example, if a patient went to his or her physician for an annual checkup, value-added activities may be perceived to be vital signs; initial assessment; and physician assessment, care, and treatment. Non-value-added activities might include registration, co-payment collection, waiting in the waiting room, and checking out. PI teams should review which activities within an appointment are perceived as value added and non-value added. Typically, in health care, non-value-added activities account for 40 to 60 percent of the time spent in the process.
As the PI team members review the process map, they can ask which steps the customer or patient would perceive to be value added and why. For those non-value-added steps, the PI team can begin to look at whether or not the steps can be eliminated or replaced to improve efficiency within the process.
Process Map Completion
After the PI team completes the process map, they should complete the following steps to systematically move forward, not only as a PI team but also as a department and an organization:
- Label the map. Include the map type, if it is a current or future map, date, name of map, and name of the team champion or team leader.
- List potential root causes for defects at each step of the map.
- Determine potential failure modes:
- Omission of accurate name and address.
- Failure to administer right drug, dose, etc.
- Miscommunication of patient assignment to attending physician.
- Incorrect selection of lab test ordered.
- Misunderstanding of physician order.
- Failure to communicate open and clean bed for patient admission.
- Use the five “whys,” as needed, for additional depth in analysis. Asking why five times is a technique to get to a problem's root cause.
- Determine which data and metrics are available within the mapped process.
- Discuss potential solutions and the types of solutions that may be studied in the next phases of PDSA.
- Discuss lessons learned.
- Identify next steps or next potential projects.
- Communicate results to department, medical staff, and key stakeholders in the organization.
- Recognize the PI team.
Not only is it important to recognize the PI team's work, but it is also important to document the team's work in a way that disseminates the lessons learned across the organization. Newsletters, staff articles, and public story boards are all helpful means of communicating the PI team's work and the sustainable improvements that were made.
Applying Process Analysis in PDSA
The Deming Cycle, or PDSA Cycle (also known as the Plan-Do-Check-Act, or PDCA Cycle), is a continuous quality improvement model consisting of a sequence of four repetitive steps for continuous improvement and learning Plan, Do, Study (Check) and Act. Its origin can be traced back the 1920s with the work of statistics expert Walter A. Shewart, who introduced the concept of Plan, Do and See. Edward W. Deming, founder of Total Quality Management, modified Shewart's concept to Plan, Do, Study, and Act:
Plan. Plan ahead for change. Analyze and predict the results.
Do. Execute the plan, taking small steps in controlled circumstances.
Study. Check, study the results.
Act: Take action to standardize or improve the process.
Applying Process Mapping to PDSA
To create a plan for continuous improvement changes, the PI team should define the process that is error prone. Process mapping is a critical tool that PI teams can use in PDSA's Plan phase. Without using a Process Map or a Swim Lane Diagram, PI teams tend to define root causes based on their perceptions and move to problem solving without accurately determining the root causes.
After analyzing the process map, the PI team can move into PDSA's Do phase to make small, controlled changes for improvement that can then be studied and fully executed within the department and across the organization.
- Keep it simple when mapping processes. Focus on the high-level steps that occur 80 percent of the time.
- Map the current process, not what the process should be.
- Verify the process map by going and seeing what actually happens.
- Determine whether the process occurs the way it should be.
- Discuss the obvious complexities and redundancies that can be reduced or eliminated.
- Identify other discrepancies and ideas for improvement.
- Determine the ideal state through the customer's point of view.
- Prioritize next steps and determine a plan of action within PDSA.
- Celebrate the PI team's work and communicate findings to key stakeholders.