2. Learning outcomes
Identify and select theme/problem
Grasp current status and set goal
Establish activity plan
Analyze causes of a problem
Examine countermeasures and their
implementation
Assess effectiveness of the solution
Standardize and sustain operation
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3. Introduction cont ….
What is problem ?
Anything that deviates from the standard
or target.
A gap between actual and desired
conditions .
12/28/2022 3
Desire /ideal
situation
Current
Gap =problem
4. Introduction cont …
12/28/2022 4
What is Problem Solving
Problem solving is a process to identify a
challenge or barrier to high quality care and
implement and evaluate measurable solutions
to the identified problem.
It is a systematic way to break down complex
issues into tangible solutions.
5. Problem solving ….
Problem solving is the act of
◦ defining a problem;
◦ determining the cause of the problem;
◦ identifying, prioritizing, and selecting
alternatives for a solution; and
◦ implementing a solution.
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7. Define problem
Differentiate fact from opinion
Specify underlying causes
Consult each faction involved for
information
State the problem specifically
Identify what standard or expectation is
violated
Determine in which process the problem
lies
Avoid trying to solve the problem without
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8. Generate alternative solutions
Postpone evaluating alternatives initially
Include all involved individuals in the
generating of alternatives
Specify alternatives consistent with
organizational goals
Specify short- and long-term alternatives
Brainstorm on others' ideas
Seek alternatives that may solve the
problem
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9. Evaluate and select an
alternative
Evaluate alternatives relative to a target
standard
Evaluate all alternatives without bias
Evaluate alternatives relative to
established goals
Evaluate both proven and possible
outcomes
State the selected alternative explicitly
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10. Implement and follow up on the
solution
Plan and implement a pilot test of the
chosen alternative
Gather feedback from all affected
parties
Seek acceptance or consensus by all
those affected
Establish ongoing measures and
monitoring
Evaluate long-term results based on
12/28/2022 10
11. Benefits of Structured Problem
Solving process
Remove time lost in debate
Identify weak points in processes
Discover systemic causes
Explain with reasons why an incident
occurred
Gives a real representation of the incident
Compare what actually happened against
what should have happened, at any point
during the incident.
12/28/2022 11
12. Importance of problem selection
Many problems happen everyday in
working place
All problems cannot be solved at once
Identification, prioritization and focus
is necessary
Resources are limited
12/28/2022 12
21. How to solve problems?
-The Problem Solving process is based upon
PDCA CYCLE
- Plan, Do, Check & Act
Where to Identify the Problem ?
Problems you are facing in your workplace
Things you want to improve to make your
work effective and efficient
Issues raised or claimed from your internal
and external client
12/28/2022 21
22. Who should select theme?
Who knows what is happening on the ground?
The staff working in the section.
Process for theme selection.
1.Staff meet to brainstorm about problems in
their current working place (Clarify problem
statement)
◦Issues and problems in their working
environment
◦Complicated work processes/procedures
◦Clams from internal and external clients
◦ Accident, errors often happening
12/28/2022 22
23. Process for theme selection conti…..
2. List up all raised issues and problems
Note :
- Do not seek contributing factors and causes
of the problems
- Do not blame and deny others’ opinions
3. Categorize listed issues and problems into
two
categories;
1) Possible to solve immediately
2) Impossible to solve immediately
12/28/2022 23
24. Process for theme selection cont…
4. Action should be taken immediately for the
issues Possible to solve immediately
5. Check feasibility of all the problems for those
which are Impossible to be solved immediately
Possible themes need to be checked its
feasibility by impact, urgency, possibility,
resource availability.
12/28/2022 24
25. Process for theme selection cont…
Impact
What is the impact, when it is
implemented?
Is it possible to get impact with little
inputs?
Urgency
Do we have to do it immediately?
Possibility
Is it possible to complete whole process
within 6 months?
Is it possible to carry out this process
within your department?
12/28/2022 25
26. Process for theme selection cont…
Resources
Possible to implement with existing
resource?
Require involvement of many sections?
Is data and information available for
situation analysis?
If not available, is it possible to
collect?
Who and how many staff are going be
involved?
12/28/2022 26
28. Case 1: Overcrowding-Surgery ward
• Surgical Ward of Y hospital has 87 beds.
Staff complain to management that there is
overcrowding and that the 87 beds are
always occupied which forces them to use
beds from other wards.
• After receiving the complaint, hospital
management immediately decided to get
more beds for the surgical ward.
What would you do?
12/28/2022 28
29. Case 2: Long Waiting Time
• X health Center received complaint from
the community that there is long waiting
time at OPD.
• Health center management conducted a
meeting to review complaints and decided
to write a letter to the Woreda requesting
financial support to build two additional
consultation rooms to alleviate the problem
of long waiting time.
What would you do?
12/28/2022 29
30. What Is Problem Solving?
12/28/2022 30
Current State
(Problem)
Future State
(Vision/Objective)
STRATEGY
31. Problem statement
A problem statement is a statement of a current
issue or problem that requires timely action to
improve the situation.
A problem statement is a concise description
of the issues that needs to be addressed
Good problem statement should:
1. Focus on a single problem
2. Do not state the cause or the solution; focus
on the problem
3. Be brief
4. Address problems that are feasibly solved
5. Ensure the problem is shared widely by key
12/28/2022 31
32. Examples of good problem
statements
• There is a high rate of neonatal mortality at
the health center.
• Medical records cannot be located in the
health center.
• The waiting time for outpatient clinic is long.
• There is no ambulance service in the
Woreda.
12/28/2022 32
33. Exercise 1 problem statement
12/28/2022 33
“Lack of budget support from the woreda to
maintain water supply in the emergency room”
Single problem
No cause/solution
Brief
Feasible to solve
Agreed by others
Suggestion:
“emergency room does not
have water supply”
34. Exercise 2 problem
statement
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“Our budgets are too small and we run out of HIV
test kits in the middle of the year, and our health
officer has left, along with 3 other workers, and
clients are not very happy with our service”
Single problem
No cause/solution
Brief
Feasible to solve
Agreed by others
Suggestion: correction
1. We have a poor supply chain for
HIV test kits.
2. Staff turnover is too high.
3. Clients are dissatisfied with our
services.
35. Exercise 3 problem statement
12/28/2022 35
“Our referral system is vertical. We receive from
the health centre (referral in) and refer out to
secondary hospital if beyond our hospital capacity.
So the weakness is our hospital is not giving the
feedback to the referred facility and not receiving
/collecting /feedback from the referred hospital.”
Single problem
No cause/solution
Brief
Feasible to solve
Agreed by others
Suggestion:
“Feedback documentations
are not provided to referring
facility”
36. Exercise 4 problem statement
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“HEWs are not motivated to work. We need
to increase supervision to improve the
number of graduating model households in
the woreda”
Single problem
No cause/solution
Brief
Feasible to solve
Agreed by others
Suggestion: the correct
“Low number of model
households graduating by
HEWs”
37. Exercise 5 problem statement
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“Spare parts are not available in Ethiopia, so a lot
of medical equipment at the health center are not
functioning”
Single problem
No cause/solution
Brief
Feasible to solve
Agreed by others
Suggestion:
“High rate of non functional
medical equipment in the health
center” or
“Broken medical equipment's in
the health center are not being
repaired”
38. Magnitude of the problem
Why we need to measure the magnitude?
1. To know if the problem is really a problem
2. To have baseline measure to set objective
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39. Measuring Magnitude
• There is a high rate of neonatal mortality
at the health center.
What is the neonatal mortality rate?
• Medical records cannot be located in the
health center
Percent of medical records not located?
• The waiting time for outpatient clinic is
long
What is the waiting time at the outpatient clinic?
• There is low ANC coverage in the woreda
12/28/2022 39
41. Cont..
The above images in order are
1. Line graph
- Visualization of measurements
- Upper & lower specification limits +
mean
-Location of measurements helps
analysis
2. Brain storming
- No judgment or criticism
- Quantity over quality
- Keep using previous ideas as stimuli
for new ideas 12/28/2022 41
42. ROOT CAUSE ANALYSIS
- Then we add headers for: “Man”, “Method”, “Material”,
“Machine”,
“Measurement”, and “Mother Nature” (Environment)
3. Fish bone
12/28/2022 42
Effect
Environmental
Man
measurement Mother nature
Material
Machine
43. 4. The Tree Diagram
12/28/2022 43
Effect
Why?
Why?
Why?
Why?
Why?
Why?
46. Step 2. Set Objectives
12/28/2022 46
Current state
(problem)
Desired state
(objective)
47. Cont..
Once the problem has been clearly defined, the
problem statement can be translated into an
overall objective, or main goal.
This is the goal that your team will focus all of
your efforts on, so it is important that it is clearly
defined.
Good overall objectives
◦ Address the problem statement
◦ SMART
12/28/2022 47
48. SMART objectives
12/28/2022 48
SPECIFIC– What exactly are we
going to do?
MEASURABLE– Can we measure
it?
ACHIEVABLE– Can we get it done
in time? With available resources?
RELEVANT – is it inline with the
vision and priorities of the MOH?
TIME-BOUND – When will we
achieve our goal?
Problem: Long
waiting time in
OPD
Objective:
Reduce OPD
wait time by 30%
in 6 months
49. Cont…
GOOD or BAD
= We will improve the way we handle
complaints
= We will reduce the number of
complaints by 10% by next FY
= We will increase our service
coverage from 75% to 85% in next FY
by end of Q3
= We will increase our sales next FY
12/28/2022 49
50. Exercise 2 – Objective Statement (30
minutes)
1. Review background information and
problem statements
2. Propose a SMART Objective
12/28/2022 50
51. Exercise 2. Suggest an objective for:
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Background Information: Alem woreda often
reports in accurate HMIS data. The woreda has the
high mortality rate in emergency room at 55%.
HMIS department claims that this is due to skill gap
of staff.
Problem statement: Alem woreda frequently faces
inaccurate case management .
Objective: To decrease the emergency case
mortality in emergency room of Alem woreda from
55% to 30% by the end of 2016.
52. Exercise 2. Suggest an objective for:
12/28/2022 52
Background Information: Tena Health Center
reported that only 10% of pregnant women in its
catchment area have completed the required 4
ANC visit (ANC+4). MOH has set a national goal
of reaching 50% ANC+4 coverage by July 2016.
Problem statement: Low coverage rate of four
ANC visits in Tena Health Center.
Objective: To increase the percentage of
pregnant women completing 4 ANC visit from 10%
to 50% by July 2016.
53. Exercise 2. Suggest an objective
for:
12/28/2022 53
Background Information: Woreda official have
realized that Tena Health Center refers patients to
Beza primary hospital but never receives feedback.
The Woreda plans for this to change and feedback
after referral to at least reach 70%
Problem statement: Feedback is not provided to
Tena Health Center following referral.
Objective: To increase the percent of referral-
feedback received by Tena health center from
Beza hospital from 0% to 70% by July 2016.
54. Session=THREE
Analyze causes of a problem
Objectives of the session :-
Listing all possible causes of problem
Analyzing cause relationships using4M1E
Identifying causes of the problems
Selecting root causes
Listing all possible ways using creative
idea generation
Testing and evaluating suggested
solutions
Preparing detail summaries of the action
12/28/2022 54
55. Determine Root Cause
Why Root Cause Analysis?
To solve problems on structural basis
To ensure problems do not return
To ensure sustainable improvements
12/28/2022 55
56. Step 3: Root Cause Analysis
12/28/2022 56
It is a step by step process that:
• answers the question, “why is this problem
happening?”
• finds the true origin of the problem
It is important to ensure we:
• solve the problem permanently
– treat more than just the symptoms of the
problem
What is a root cause analysis and why should
we conduct one?
58. Steps for successful RCA
1. Assemble a knowledgeable team
2. Start with a descriptive statement of the
incident/near miss
3. Use Root Cause Analysis techniques
4. Determine what conditions, events,
and/or factors might have caused the
incident
5.Prevent skipping levels or jumping to
conclusions
12/28/2022 58
59. How do you do root cause
analysis?
12/28/2022 59
Collecting possible root
causes
A
Verify
B
Identify real root cause
C
60. First, collecting possible root causes & opinions
(brainstorm, interview, focus group…)
• Discuss with involved staff
• Ask them about the causes to the problem
• Allow them to provide their opinion
• Record the “suggested” root causes using
“Fishbone”
A
How do you do root cause
analysis?
12/28/2022 60
61. Root……
Several tools could be used in the process
of root cause analysis, such as " 5 Ms &
E" the abbreviation stands for "Manpower,
Machine, Measurement, Material,
Methods and Environment“
it is a technique where you ask questions
about the 5Ms & E till you find the root
cause of the problem
12/28/2022 61
63. Environment
Measurement
Material
Not motivated
Small space
MR misplaced
No filing system
Loss of MR
man
Patient don’t remember
MRN
No training in
filing system
No method to find MRN
Bad shelves, difficult to
locate file
Fishbone diagram
12/28/2022 63
66. How do you do root cause analysis?
12/28/2022 66
-Next, verify each “suggested” root cause.
-Collecting evidence using different tools
Verify and prioritize
-This verification step is the most analytical
part of the root cause analysis. Which tools
should you use?
-A robust root cause analysis usually requires
the use of a few tools together.
B
67. Tools to collect evidence
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Flow chart
Pareto diagram
Mapping
Time study
Questionnaire
Tally
Others
Many methods/tools can help to collect evidence to
identify the real root cause(s)
Data
68. When to use which?
12/28/2022 68
• To collect initial perspectives
Fishbone
- Flow chart
- Mapping
-Pareto diagram
-Tally
Line graph
Time study
Questionnaire
• To understand the work process
• To present frequency data for
comparison
• To compare trend
• To understand the time required to move
through a process
• To organize opinion into quantifiable data
72. Advantage of Pareto Diagram
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• Quantifies information
• Provides data so you can prioritize
focus on biggest issues first
• Useful tool for showing progress
74. Time Study
Measure times of a process
Eg. Time study can be used to study waiting
time & process time of a given event
• Wait time
From time the patient arrived to the time
service was provided
• Process time
Time used to provide the service
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76. Advantage of time study
12/28/2022 76
Value
• Provide quantified data
• Extremely useful in problems
related to “time”
• Useful tool for showing progress
77. Advantage Tally sheet
12/28/2022 77
• Quantifies information
• An easy, simple form used to “count”
occurrence
in real time for simple situations
78. Questionnaires
12/28/2022 78
A tool consisting of a series of questions for
gathering information from respondents.
Advantage
• Able to quantify qualitative data
• Collect and gather “opinion”
79. D. To find out which staff has taken
the most day off
Fishbone
Flow chart
Pareto diagram
Mapping
Time study
Questionnaire
Tally
B. To understand the IP
admission process
E. To initiate an investigation
G. To understand how the cashier
location affects OP traffic
F. To find out waiting time for
surgical clinic consultation
C. To investigate patient
satisfaction
A. To calculate the % of HIV
patients completed ART course
Exercise 3 -When to use which?
12/28/2022 79
80. Session -4.
Establish activity plan
Objectives of the session :-
Develop different alternative interventions
Compare each strategy standard .
Select your best intervention
12/28/2022 80
81. Steps 4-6
12/28/2022 81
4: Develop different alternative interventions
5a: Set criteria for comparison
5b: Create table for comparison (matrix)
5c: Compare each strategy criterion by criterion
6: Select your best intervention
82. List ALL the possible solutions you might
use to address the root cause(s)
Good interventions:
Address the most important and feasible
root causes
Use existing resources if possible
Have some degree of flexibility
Think about possible unintended
consequences
12/28/2022 82
4: Develop different alternative
interventions
83. - Avoid the temptation to do
everything
12/28/2022 83
84. The common criteria's are
Effectiveness (Impact): What is the probability
that it will work?
Time to effect: How long will it take to work?
Feasibility: Is there capacity and stakeholder
support?
Annual Cost: How expensive is it to carry out?
12/28/2022 84
5a: Set criteria for comparison
85. 5b: Create table for comparison
(matrix)
Strategie
s
Criteria Impact Cost Time Feasibilit
y
Strategy
1
Strategy
2
Strategy
3
12/28/2022 85
86. 12/28/2022 86
5c: Compare each strategy criterion
by criterion
Evaluate with qualitative and quantitative
data
Listen to reason and intuition
Impact Cost Time Feasibilit
y
Strategy
1
Strategy
2
Strategy
3
5- most ideal; 1 – least ideal
87. 12/28/2022 87
6: Select your best strategy
Impact Cost Time Feasibilit
y
Total
Strategy
1
5 3 4 3 15
Strategy
2
4 4 2 3 13
Strategy
3
1 2 1 2 6
Be clear on choice and communicate it
88. Short comings of decision matrix
Estimates are not precise typically,
so judgment is required.
The matrix gives guidance only.
There is always uncertainty.
12/28/2022 88
89. Example
Problem: Toilets are always dirty
Objective: Ensure all toilets are always clean in the
coming 6 month.
Root cause: toilets are cleaned only 3 times a day and is
not sufficient for the high patient volume usage
Alternative Interventions
1. Increase # of cleaning staff
2. Increase frequency of cleaning
3. Lock toilet and supervisor keeps the key
4. Adjust frequency of cleaning according to
patient volume
5. Supervisor station in toilet to supervise usage
12/28/2022 89
90. Key Summary
Create good interventions that address the most
important and feasible root causes
Set clear criteria that are important to
implementation
Create matrix to compare criteria by criteria
Compare objectively as well as using common
sense
Select and communicate the best strategy to
stakeholders 12/28/2022 90
91. Session .5.
Develop implementation plan and
implement
Objectives
Implementing action plan
Monitoring Implementation and
checking activities
12/28/2022 91
92. Strategic Problem Solving
12/28/2022 92
8-Step Method
1. Define the problem
2. Set the overall objective
3. Conduct a root cause analysis
4. Generate alternative interventions
5. Perform comparative analysis of
alternatives
6. Select the best intervention
7. Develop implementation plan and
implement
8. Develop evaluation plan and
93. Implementation Plan
Why do we need an implementation
plan?
What should be included in the plan?
How do you communicate the plan to
other people?
What if other people do not want to
engage (resist your proposed change)?
12/28/2022 93
94. Step 7 Implementation Plan
12/28/2022 94
Step 7a: Create a detailed list of tasks/activities
Step 7b: Estimate the time required for each task
Step 7c: Sequence the tasks/activities
Step 7d: Identify a person(s) responsible, Resources
required
Step 7e: Use Gantt chart format for the project plan
95. Step 7 Implementation Plan
12/28/2022 95
In order to complete a project, there are many
tasks/activities/steps to do, what are they?
Step 7a: Create a detailed list of tasks/activities
96. Step 7 Implementation Plan
How much time does each task need?
12/28/2022 96
Step 7b: Estimate the time required for each task
97. Step 7 Implementation Plan
Why is sequencing important?
◦ Some tasks need to be done before others can happen
12/28/2022 97
Step 7c: Sequence the tasks/activities
98. Step 7 Implementation Plan
Who is the person responsible to do the
task
Match the tasks and skills and
convenience
Identify resource requirements
(materials, people budget)
12/28/2022 98
Step 7d: Identify a person(s) responsible,
resources required
99. Step 7 Implementation Plan
• Use the plan to monitor progress
• Change the plan regularly to keep it
realistic
• Use it to update and communicate to
others
12/28/2022 99
Step 7e: Use Gantt chart format for the project
plan
101. Strategic Problem Solving
12/28/2022 101
8-Step Method
1. Define the problem
2. Set the overall objective
3. Conduct a root cause analysis
4. Generate alternative interventions
5. Perform comparative analysis of
alternatives
6. Select the best intervention
7. Develop implementation plan and
implement
8. Develop evaluation plan and evaluate
102. Step 8: Evaluation & monitoring
12/28/2022 102
Why evaluate?
How will you know if your problem has been
solved?
How will you know if your implementation is
working?
How will you know if the implementation is not
creating negative effect?
103. Continuous monitoring
Indicators help to measure results
Good indicators should be:
◦ Reliable
Regardless who is measuring it, the result
should be the same
◦ Feasible
Possible to measure with the available
systems and resources
12/28/2022 103
104. Are these indicators appropriate?
12/28/2022 104
1. Objective: To increase completeness of nurse
care plan
Indicator: # nurses trained in documentation
2. Objective: To increase number of functioning
toilets
Indicator: Percentage of functioning toilets
3. Objective: To decrease OPD wait time
Indicator: # physician started clinic on time
Are these process or outcome indicators?
105. Example
Problem: high hospital acquired infection rate
Objective: To reduce HAI from 55% to 25% by
Aug 2016
Indicators Pre
intervention
Post
intervention
Existance of policy on
infection control
No Yes
Staff trained on infection
control
35% 65%
HAI Rate 55% 25%
12/28/2022 105
When is the use of each method most applicable?
Fishbone Diagram is applicable for problems that are generally very complicated, and all the various root causes cannot be determined by one person.
Flow Charting is more helpful in the case where there is a work process with many handoffs along the process
Example: Ordering and attaining medication for a patient. This involves the physician ordering the medication, the order being taken to the pharmacy, the order being filled at the pharmacy, and the medication being brought back to the patient. It involves several staff members and several handoffs of responsibility.
Address the most important and feasible root causes
Take an ecological approach
Use leverage already in the system to accomplish more with the existing resources (water flows downhill)
Have some degree of flexibility and
create safety nets for unintended consequences
As a manager, you have a higher interest in process indicators than any other members of the staff.