 It's probably within five minutes, I would already have forgotten the names and I apologize in advance, but if you're more of a worker who let me know who you are, when you will raise your hand and participate in the discussion of today. I am Luca, my name is somewhat easy to remember, and I am one of the volume engineers at Wonka University of Utah now. For volume engineers we are the people that we collaborate, partner if you will, with the providers, administration, and other roles within the system to help improve the delivery of healthcare. Me, I'm just special, especially in many different ways, and I also am lucky because I get to work with more than just a clinical mission, the academic medical center, I also work with academic research. So I participate and learn how to use quality improvement principles in how to submit a grant, how to start a clinical study, how to teach and better the process of learning for students in the various colleges and as well, of course, residents. So this is my fourth iteration of how to share quality improvement, problem solving principles for QI projects for the Moran Institute residents. Oh, I think that I'm getting to the point where I'm hoping to provide something of value to you, rather than just telling you all the whole history of quality improvement. I'm getting to a much more succinct discussion on what the title of this presentation should have actually said, improving value. At the end of the day, what we're trying to do, whether you are a doctor, whether you're a nurse, whether you are a volume engineer, whether you are a mechanic, whether you are somebody else, even an older teacher, we are always trying to deliver something to whoever the recipient of our actions are. With the hope that in this exchange, value is built. At the person receiving our care, what our learning or our car being fixed, they're saying, you know what, this was done right. That's why, but this value is never stagnant. Expectations are always changing or new ways of doing things are always found. That's why value improving, improving value is always somewhat a moving target as well. What we're gonna be talking about today are what I call value principles and then value added versus non-value added activities, continuous improvement versus problem solving, and then getting started on your QI project. General question, you don't need to have any specific background on any of the terms I just talked about. What makes healthcare encounter exceptional? We've all been to the doctor, there are doctors, I've been to the doctors, and I think we all have some, what an example in our mind of what makes an encounter exceptional. Not just okay, it's just something that's stuck with you, so what makes it exceptional? Doctor answers your questions. A doctor answers your question, of course you go to the doctor's too with some questions and your questions have been answered, okay? What else? It's time like this. Honey? No exception for the shop on time. Yes? Personalized, so like know who you are and they remember you. I hear that one a lot. Why do we go to the doctor, we feel like we're just a number, okay? No challenge in that, I just, it always comes up. We feel special, we feel like something went well, exceptionally well, if we feel like we're being cared for as an individual, rather than just a next in line. Anything else? That person on the other end is listening. But only your questions are being asked to her, but also you feel like you're being listened, so it's not a mechanic transfer of knowledge. Correct diagnosis. Correct diagnosis? Okay. Then you get home and take. It's, I'm chuckling because it's, I said exceptional, not baseline. You can fix the problem. You fix the problem, but this is where it gets funny. Everything you said is very consistent with everything else I've heard from different groups. And yet, I think the baseline is just so low, but. Right, so we just show up to the doctor and we don't know what to expect anymore. We're just glad we got an appointment. We have questions they answer to us. They call us by name, we're like, man, that's awesome. He knows my name, he just looked up at the chart. He like, does me correctly. Wow, I feel special today. Well, having, getting this experience, and by the way, I am glad that no, well, not glad. It's not that we're being glad. Nobody here has mentioned anything about being treated nicely, being given cookies or the drink or comfortable chairs or the rooms were beautifully lit with wonderful piano players. No, you focused on, I have a, I went in there with some problems and I was treated nicely sure, but my problem was solved. And you go to that exceptional. And that's fair because what we are talking about in here is improving processes to deliver consistently that level of care. So to do that, and this is what we often fail to do, this conversation here is valid whether you are a clinical provider or if you are an administrator that never seen a patient. This is something that gets often missed and it's always fascinating to me that no matter how simple these principles are, they get forgotten. So you build a process to deliver value, which in your case is your process to see a patient or do a clinical research or teach other residents, but you start by identifying your customer's requirements, not what they want, what they actually need. And you do that by asking questions. And these questions are asked whether it's our surveys or just asking questions during your interview, you're doing your diagnostic meetings, et cetera, et cetera, but you ask questions so you can understand the requirements. Then you see where value is created in the work, the work meaning the steps, the processes that you take to deliver these patient's requirements to them. Then you learn how to recognize and eliminate waste in the process, because unfortunately we don't come to work and everything just falls in line like that. There are many bottlenecks, many issues, many things that don't go always right. I call that waste. So you have to learn to recognize it and eliminate it. And then some problems are just so complex that you will use a problem solving method to address them instead of jumping to solutions, otherwise the problems keep coming back. And then the next step is many problems arise in our organizations because there is variation. This variation can be fixed through standard work. Sometimes we hear the term protocols, standard operating procedures, guidelines, same thing in here. Understanding this principle starting from what does my customer want, how am I going to deliver value to them, how can I make the processes better so I'm always delivering value to them without variation. And if there is a problem, how do I solve it? It's how you build this concept of value. Any thoughts, questions so far? This is a very general, very specific flow of patient intake to going to inpatient. But it's just my way of showing that the concept of value added. An activity is value added when it adds or transforms the product or service in some manner. That's the broad general everywhere description. Whether it adds or transforms to the product or service in some manner. For healthcare, we also coined the term an activity is value added whether it adds to patient's care provision or information. Patient usually comes to you for two reasons. One is care provision or information. So as long as what you're doing is adding to that, they're good. And then there is you in your process and there are people that do something upstream and people that do something downstream. When you're looking at the concept of value as those five principles as defined before, you need to take into consideration the work that everybody's doing. We don't work into seamless silence. So we have to be able to collaborate and cooperate in adding value to our patient. Sometimes things don't go well and you have to fix them. For example, you go to operate on a patient that consistently you're finding that the instrument sets is missing something or the supplies or the medication and anesthesia is delivered incorrectly. And so you have to address it. What that happens, it's a problem. A problem to me is nothing is not bad. It's just a gap in performance which means that you have the expectation was here and the process delivered this. So now you have this gap and you have to address it. And it is mostly what you do when you have a quote improvement project. You address this gap in performance. So the goal then is to, oops. If we're trying to create a process where all the activities are value added, the goal should be to minimize non-value added activities. I don't, did I actually talk about what non-value added activities is? Okay, back up for a second Luca, I'm going too fast. What do I mean for value added activities? I kind of mentioned in there, but I'm very excited. What's value added activity? You're changing the service that you're delivering to add some. Fantastic, thank you, you were paying attention. More, for example, in your case, what's an example as doctors, what's an example of a value added encounter to your patient, value added to your patient? What is one thing that you do that adds value to your, for the people that kind of see you? Describe something. What? Give a prescription. A prescription, sure. Okay. Anything else? The diagnostic test. The diagnostic test, yes, that's also value added. So if that's value added because it's giving something to the patient that they want, what is a non-value added activity? Something that doesn't, that the patient isn't asking, but it's in the process you have to do it. Add extra information, sure. Could be, why didn't I say sure? I don't know, maybe it could be. It doesn't add value to you, to your introduction to the patient. Checking a man at the front desk and it doesn't help them really, it just helps us with our flow. Correct. So there are some times, there are times where activities may help with the flow, are in there just a part of the work that you have to do but they still don't add value to the patient, which is ultimately our customer. That's why I talk about minimizing non-value added activities because I'm not sure you can completely eliminate them in the healthcare industry. We do that three ways really. Continuous improvement. I throw it in there because this is important to me. I'd be happy, I will be happy, if I can have residents or medical students or doctors, yeah, everybody's got a doctor or attendings, to be able to go to the workplace and have this common understanding that quality improvement or improving patient care or finding better ways to do something isn't always happening in the clinical research or a quality improvement project with 20 people in there. There is more to that. Sometimes it just falls around coming to work one day and thinking about I can do this better, I can do this differently. And you just do it. You don't ask permission because there is not need for permission. You just make a change. And so incremental improvement is accomplished when you understand the process, meaning all the various steps that take place in delivering values to your customer. You're able to eliminate waste, reduce variation or you simplify this process. That's when you have incremental improvement. All this takes place every day. You're always finding new ways of doing something better. You're always finding a process or a new procedure or a new supply or a new something that helps eliminate waste, reduce variation or simplify the process. Which can only be done if you truly understand how the work has been done. Not just yours, but in general, the bigger process. So that's what I mean with continuous improvement. Waste. When I talked about the non-value added activities or waste in our processes, there are seven type, which is helpful to go through them for a moment. And they are defect, overproduction, waiting, transportation, inventory, motion and over-processing. I will send you this presentation so you can have a list from it and you can go over it. It's always interesting. People know what they are intuitively, but then if you have this list with you, I'm not saying that now your job is going to be looking for ways to continue doing what you're doing, but it helps have an awareness that if you are there in your operating room or in the patient room or in the queue in the charging station and you're waiting for your patients to show up, you are waiting, that's waste. Now the process is being unproductive or you go looking for, there is too much inventory on hands. So now there's no room to store it and we have to build new buildings because we have too much inventory. It costs money, it costs time to look for it, et cetera. Defects, the deck dosage was incorrect or the patient information was wrong or patient came here and got an infection. That's also defect and it should be eliminated over production. We order too many tests that we don't need to and we do it because it's part of the way we do things. I am new here. I'm just going to order everything. All of the processing. I need one test, but just to be sure I'm going to order all of them. We do that a lot. And then motion and transportation that go hand on hand, so much walking around in the hospital for both the patients and the providers. I'm trying to be eliminated. Any other examples that you can think of of this waste that you are clearing your mind is what I'm talking about them. Point is, this is a list. You don't have to be perfect in categorizing. I really don't know if performing the incorrect procedure is a defect or it's over-processing. I'm really confused. I don't care. It doesn't matter. What it matters to me that you're paying attention to the fact that some things, they take some actions, some steps, some work in our process, doesn't add value and it's waste. And as long as you're aware of what type of waste are, you can then have proper conversations between each other, leaders, et cetera, and attendings on how to eliminate them. That's what matters. Structure problem solving. Sometimes eliminating waste is as simple as, hey, you know what, do you really need 200 type of guards to care for the patients or two type would just be sufficient? Do you really need 10 different type of gloves or only two types would be sufficient? Sure, two would be fine, okay, great. It's a simple, quick, simple change. Sometimes it's more complex than that. We keep having this type of infection to this type of these patients and we don't know what's causing it. That's when you use a framework for improvement, which is very simply based on the scientific method which you use for caring for patients. You identify a problem, you do some tests, collect some information. You research a baseline analysis, then you start asking questions of what may be causing it, investigation, and then you suggest a standard of care or a treatment. Improvement design and the patient carries through, improve implementation, then you monitor for results. Then in our case, I'm hoping that as you have completed your problem solving project, you can then share and standardize your best practices. By the way, when you're doing a quality improvement project, these are the steps that you follow. You don't go from, hey, I have a solution. Let me see what problem can I solve. That's annoying to me. I've never, that's not annoying. That's actually quite entertaining because in the end, I always look at people, like, mm-hmm, mm-hmm, mm-hmm. You tell me what you want to do. Now, what do you think what your problem is? My problem is that I want to implement it, that, that, that, that. Stop telling me what you want to do. What you want to do is try to address what problem. And eventually, people get it. And it's important because if you can reverse engineer what problem you're trying to, what problem you're trying to address and why it's a problem, people are more likely to listen to you and work with you in addressing it. More to that in a second. And then there is innovation. Of course, sometimes looking for ways it's helpful doing a problem is helpful, doing a project is helpful, but sometimes something has never been done before. So you also have to find, you have to do something different. I talked about problem and problem solving and problem solving from framework. Let me take a step back because it's important we understand how simple this actually is. What is problem solving? What may look a possibly mean about problem solving? We do problem solving every day. We apply problem solving principles every day. You get in the car, you're driving to work and you notice that the orange light indicator showing that you're running out of gas. No, sorry, forgot that, Pete. You got the little orange light indicator but your gauge for the fuel is blinking to you. What does it mean? What could possibly be happening? You're running out of gas. So, you just continue driving. Probably. Then you go to the car out of gas to respond, man, who called you to say that? Why are you out of gas? You're driving. So you're there, so now you have an indicator and it's telling you you're running out of gas. Why could you possibly be running out of gas? Yes. Why don't you put gas into fuel for three weeks because I'm a rednessy? Why a rednessy? Because I want to help people. No, okay. This is not complicated and I'm having fun with this but we do problem solving every day. My tie looks like this. Why does my tie look like this? Because I did the not wrong. So what do I do? I just do my not right. Asking why like this is my very simple, very basic root cause to understand what's causing my problem. Sometimes it's not that simple though but the principle still applies. You have a problem, if my knot is like this and I'm like, dang it, my tie looks weird, I'm gonna get a different tie. The problem is not a tie, the problem is a knot. And yet we do that all the time. We try to address the wrong problem. That's why we, without understanding, without following proper problem solving steps, asking questions, we always are just having a solution in mind. If you have a solution in mind, if there's something you want to do, just do it but don't pretend it's a quality improvement project. I finally said it, that's what I'm gonna say. I keep spinning around this wheel with people, like if you come to me and you're like, I really want to implement a new charting system. What problem can I possibly be? It's because we don't have standards in how we're charting, okay. Why don't you just implement your new system and stop bothering me with finding data, supporting that you want a new system. I have so many examples, one more costly than the other. My favorite example was, and I gotta stop venting that when I get back to the presentation. When I was asked to shadow a bunch of cardiologists in a cardiology clinic because the administration wanted to justify a $250 million remodel of the clinic because they wanted to add a room. They didn't have enough rooms, patients waiting. And I'm there and I'm working and I'm shadowing and I'm watching the process because that's what you do. You have to understand how the work is being done and I'm noticing five rooms are never being used. I'm like, why are these rooms being used? Because they belong to so-and-so doctor. But he's not here. No, he's not, that's all these days. So why are they being used? Because they're his. You're not answering my questions. Why are their rooms being used? We don't want them to be used. They're his rooms. How can their rooms be his rooms? Why are you, you see where I'm going with that? They were addressing the wrong problem. Why are we spending money of building more space if you have the space, change the policy? What have been, understanding why does the doctor wants those rooms being used? It would have been a better use of time. This is one of the costly examples that I have. I have some other ones and of course I was blamed because Luca doesn't want us to have a nicer building. Like, I never said that. I just said you were addressing the wrong problem. So are you solving problems at work? And its simplest answer is yes. Every time you see a patient, you are addressing a problem. The thing is, even without seeing patients, you are addressing problems. You're doing problems solving at work. So my question is to you, and that's what I wanted to do for the rest of the class session, is ask these questions. Do you use problem solving to improve processes or do you just jump to solutions? What barriers and process improvement have you encountered? And do you use any format to do that? And then when do you start actually solving a problem? And how do you share improvements in your organization? How do you use problem solving to improve process? Any questions or thoughts so far, by the way? We're good on time. This is back to what I was saying earlier. I'm not going to spend too much time on this slide. There are various level of application of problem solving. On one end is what I refer to continuous improvement over here. These are those simple changes to a process that trying something new that is just do it. Don't go and assemble a team if you want to pilot something that is low stake, basically. That's what I'm saying. But it may be a high impact, so just try it out. On the other hand, we have research studies or innovations. That requires a lot more time, data analysis, probably more complicated statistics to make sure everything is being done right and publishable, et cetera, et cetera. In the middle, in terms of complexity, are those continuous improvement or quality improvement projects, that's how you may be calling them in here, where you can identify the problem, maybe has to do with diagnosing a patient or intaking a patient or how you teach each other or how do you reduce infection rates, et cetera, et cetera. And you need to assemble a team. You have to ask better questions. You have to collect some data, and so on. So that, to me, requires a structural problem solving approach. All I'm doing with this slide is to help you remember that, depending where you are in a complexity scale of problem solving, you have to be more aware of the support you're going to need and the impact that this project is going to have, which is, at the University of Utah Health, I've had the privilege of working in two different organizations here in Utah in improving health care. And when I say that we just are so slow in improving things here, it's fascinating. I'm not being mean. It's just a reality. A project that used to take me eight weeks at different organizations here takes months. And it's just the way it is. People are generally busier, and they have more hats. So more hats. So be aware. If you are selecting a quality improvement project and your attending has only given you six months to do so, don't go there and try to change a whole. We're going, I want to address that and take the creation of a new protocol to deliver care to this patient because they've done before. And there is no data, so I'm going to find data. And just finding data here takes two years. I'm just joking. I don't know how long it takes, but it does take some time. So pay attention to that. Then ask these questions to have an interested team, to have sponsorship, how it is to collect data, how it is to commit time or resource access. One of the things that can do for you is to help you align with the right people that you can ask questions in terms of data and support here at the university. So notice I am not giving you specific examples about projects here because I'm much trying to do that on our individual time. If you have questions, you should shoot many mails in the past that are taking place. If you actually have a project, I'm more than welcome to go with you in helping you fine tune what your challenges are, your problem statement, and help you find the resources, et cetera, et cetera. So just be aware that not every project starts or is created equal. So again, pay attention to support and the impact. What I am here, though, is any of you working on a quite improvement project right now? And how is that going? Give me some examples of processes or things that you have been working on to improve or that you have been hearing about being improved on here at the institution. So the medical to make you, I was working up there and we had a patient that had a corneal transplant and had a really bad corneal abrasion because he was intubated and they don't have any protocol for eye lubrication at all with their patients. And so basically, I have done a literature review at this point and pulled out like 20 papers. And so I'm just in the process of going back and reading them and figuring out what information I want to get and how to develop a protocol. What was the problem? Problem is that nobody assesses for eyelid closure. There's a protocol whenever patients get admitted where there's a couple. Nobody assesses for eyelid closure. In the admission orders, there's lubrication in Q4 hours and Q4 hours PRN. And no one thinks about if the patient's intubated or if you put in an intubation order. It's not tied to anything like that. Thank you. I like that. Be prepared, of course, when you come to me again, I will always be asked, I will listen and I will love to listen to all these stories and then I will ask you the question, what's your problem? And thank you for answering that. Let go, that's a very valid problem. So we're not keeping track of this. Sometimes somebody's improvements are born because we realize that this is something we didn't realize before. So now we should address it with a protocol. What you call protocol to me is it is standard work. It is something that eventually creates, if this happens, this is what you do. And if you follow this, the most optical outcome should happen. Yeah. So here is the opportunity for the other use to tell me about your project. What barriers and process improvement have you encountered? If you have gone to somebody with, hey, I have an idea on how to make things better, what barriers have you encountered? No barriers whatsoever. People are unwilling to change what they do. People are unwilling to change what they do, okay? Cost. Okay. What do you think is that? Expand to what you're saying. People are set in their way of doing things. It takes effort to do something new. It takes effort to get everyone on board to change people's habits. Sometimes you've invested in the system that you're working in right now. So to do something different would be another expenditure that, you know, you've already put sunk money into something that you're doing already. And so I think it's a barrier sometimes for people to change their minds about that also. I heard the term sunk money last week actually was an interesting conversation. Yes. Anything else? It's funny to me that I am, the person that is, one of the person that is paid to, that is brought into this discussion on how to get people to change or how to reverse their action. And I'm not doing anything special. I don't have this million dollars idea on how to make people, how to make people change their mind. I don't do that. Yet, I have seen people change their ways and be willing to take a different approach over and over and over. These things do happen. And I am not minimizing your comments because, yep, it does happen. And yes, they do frustrate me when people are guessing that that's the, I just like the way that things are working for me. And this is how I was trained. And so that's great. But, in my perfect world, and these are some of the examples that I've seen, by the way, I forgot what I'm like. This PowerPoint slide is somewhat new to me so I'm not sure what I put next. I'm learning with you. Then I'm like, oh, that's what I was trying to say. Okay, good. These are some of the examples that I've seen. Like sponsorship, communicating between team members, dog improvement cycles. All these things do frustrate people. Should you use a template during your problem solving? That I stopped using all this framework. I used to teach what different documents or take you to the University of Utah Health Sciences in Pulse, the Value Summary page. And I showed you how to create a project, your Value Summary, which I will do if we meet individually because I still value that. But for the purpose of the training today, what I care about is that you remember that. How do I overcome this unwillingness to change or understanding that you need to approach costing and change your methods? How do I get people's attention? How do I keep people on track? How do I help speed up a problem solving project? I do this. I stick to a framework. And there are many frameworks at University of Utah. I counted about 20 that we like to use. I don't care how many are there. I don't care what you call them. As long as you are there ready to prepare to talk about, do you have a problem? Why is it a problem? What is causing the problem? How are you going to solve the problem? And how will you know if it worked? That's what you need to do. You come to your meetings with your pretty papers and your pretty documents. Let's answer these questions. And that is your template. Now, every organization has their own versions of these templates. We do, we have it too. Our is online. It's going, right now it's found on Pulse. Eventually it's going to be a different place. So that's why I don't have it with me today. But it's still going to be online. So for all those people to say, yeah, but we're never in the same place. Good, because our template is found online. So no matter where you are, you can still talk about it. And that's all this is. These are more than just questions to me. This is my pattern. This is my agenda for my problem solving. Which is, by the way, what I'm trying to say, I'm not being very clear right now. If we're meeting for the first time and we're trying to talk about whether I have a problem, don't you come to me and tell me how are you going to solve it? I don't want to know that. I don't want to know your solutions. I want to talk about your problem. I want to talk about your problem for the first two discussions or until we're good to understanding what is causing it. And by the way, the difference between just do it kind of problem solving and complex problem solving is this part here. Your investigation, that what's causing it. Because if I'm doing something as simple as I run out of gas, it's probably because I forgot to put gas or because I'm in residency and I didn't put gas for three weeks. I'm not going to do a root cause analysis on that. I'm just going to put gas in it. So, but these are the steps of problem solving. Do you have a problem? Why is it a problem? What is causing the problem? How are you going to solve it? And how do you know if it worked? I spent time repeating them because it's important enough. Every variation, there is a variation how those questions are asked in these templates. As University of Utah, we call them problem statement based on analysis, investigation, improvement design, implementation and monitoring. So then, somebody asked me this question once. They can't talk. You kind of put me off guard because that was a very valid question. So, how do you have a problem? How soon do you start solving the problem then? How do I know when it's time to start solving the problem? You're here, you're telling me we're going to talk about this thing, we're going to do all this process mapping, collecting data, do exhausting literature review. I had this resident once, she was like, Luca, I have, there are 1,100 charts I have to read through, I have to audit. What's the minimum number can I go by to make it statistically significant? I don't know, 220, that's still a lot. How do I audit less charts? This is just, okay. Yes, so there's all these things. You have to do all this prep work. Then people get freaked out and they get confused when do you start solving your problem? It's not a trick question, but I'm really curious. I made some points, when you start solving, my question wasn't as clear as I made it. That's why I was confused when the person asked me the question, too. Because I'm not the only confused person I'm not the only confused. You're tired this morning. When you haven't got a point to it. What's the first, what are the steps before actually solving the problem? Identify the problem. Identify the problem, then... Designing a solution. Sorry? Designing a solution. Designing a solution, yeah. Before you get to designing a solution, you study what's causing it. But how do you know if you got there? How do you know if you identify the true cause of your problem? I'm comfortable with that answer. We know the answer you were looking for. I'm comfortable with that, because this is continuous improvement. Yes, we can teach you methods to be very specific in selecting the right root cause of the problem, but that's not the point. For the most part, a lot of the things we're working on in here is scientific problem solving. We're going to try to find the correct root cause, but hopefully we've addressed the right one. It wasn't a trick question, as though it feels like it. You start solving the problem when it's time to. All I'm asking is, don't put the cart before the horse. When you're unsure of what is causing the problem, push for based on analysis and investigation first, which is what you said. Jumping solutions to soon may work, may not. You may just go lucky and solve the problem right the first time, or sometimes, which is usually what happens, you've missed the right cause and the problem persists. That should answer the question. The root cause of the problem is people. The buggy. This is probably my old time favorite strip. I don't go through much in details on what the based on analysis is or should be done. Again, when you actually have a quote improvement project in mind, shoot me an email, I'll give you my opinion on how you could get started. If you wanna talk about, after you have literature research, different things, different methods, or even how you do your track, how do you share what you learn, we're more than happy to do so. To me, and I'm being very careful how I say this, because not every process improvement project will have a process map, but it's commonly done, so I talk about it. You process map after you are, what's the process map? Have you ever seen a process map? Have you seen algorithm protocols? Okay, that's the process map. The various steps that are followed with arrows that tells you patient checking, patient resource information, take a patient, take patient to the room, nurse visit, doctor visit, check out, that's the process map. What I'm drawing in the air is actually being built in my mind. So you start with a beginning and an end, identify stakeholders who is doing the process, you write down the steps, and then you complete the map with the information useful to tell the story. Goes hand on hand with GENBA, which is the funny Japanese, I'm Italian. I'm sure every language has funny words, and now I'm gonna start thinking about all the funny Italian words in my mind I can think of, which most of them are swear words actually, but that's okay. Let's ignore that for a moment. So GENBA means go and see. I can't just tell you to use the term go and see because in here for some reason, we like to word GENBA. So if somebody say, hey, did you go to the GENBA? Or did you go GENBING? I don't know what people are saying here. Go GENBA. What they really mean is, did you actually go and see how the process is being done? So you get an idea. Did you ask questions? Did you walk the process? Did you pay attention? Did you take pictures? Did you take notes? And this is important because when you are in your pretty conference room with your nice stickies and your papers and you're talking and everybody think they know what's going on out there, they don't. Everybody has an idea of how the work is being done and so you think your process map is perfect and it's correct, it's not. You have to go out there and look how the work is being done. And then you verify and you collect your information. Then after you do these two steps and there are more, you have all this information, you have mapped out your process, you've collected your data, you've done your chart reviews, you've talked to people and the experts, you start asking a question. All right, what is causing the problem? And you do two things. Fishbone diagram and the five Ys. Technique. So for a cycle of time, I'm not gonna, I'm not like, you're not going through anything. No, I'm not. I know, I'm just giving you a taste of what I'm talking about. It's like a preview, like a sampler of continuous improvement. When they tell me, look, can you teach one hour, one hour lesson on quality improvement? That's not much time. So I'm gonna give you a sample. This is a sampler of the tools we can use to capture the knowledge of the process. So Fishbone diagram is done when most likely you have reasons, multiple reasons, multiple causes of what's causing the problem. Why does the patient arrive late? Why didn't we intimate the patient? Why did we misdiagnose the patient? All those things may have multiple reasons. So we do a categorical brainstorming type thing called Fishbone diagram. It helps. And then from here, you prioritize your, you can reach a consensus of where you want to start. Sometimes there is just one cause. Why did you run out of gas? There are not probably not many causes about that, but you still ask questions, why did that happen? And the technique, which you're gonna call it this way, that came from Taiichi Ono from Toyota back in the 50s and 60s, is you ask why five times about every matter? So basically this is saying, don't stop at the first problem, dig deeper, to get to the cause of it. Either way, the goal is you're going to come up with more than one causes of the problem. Ask it, this is again, very basic matrix. None of these tools are complicated. Anybody can use them. It's a four quadrant matrix where you look at low effort and a high impact. It's your quick wins or high effort and high impact major projects. Anything else below that is either low impact. It is, if you wanna do it, do it, but it's not necessarily gonna address your problem or please don't do that. Don't go by expensive equipment just because somebody else has it and you think you're losing patience so you need a robot to do surgery that then the poor sex robot goes part in the corner about the users and because nobody knows how to use it. I know I'm venting, I'm rambling. But there are quick wins and major projects. Between those two, it's difficult to know where to start because sometimes that project is complex enough and there are no quick wins. So prioritize your major projects. How do you share your learning? I am greatly invested in the fact that I want people to hear the stories of your project. So of course, when we meet individually, if you have any questions or even on your own, I will send you the link after this presentation with a value summary because I like to share organizational knowledge. That's how people grow, that's how people learn. And there is a way that you share your project. We do it to accelerate, which is our portal. I will send you the link to the value summary so you can create your own. I will send you the link to accelerate page. There is a lot of knowledge being shared there, including from your institution. And your QI project. Ultimately, anything you're gonna be working on is going to fall under variance or cost reduction, unnecessary care, clinical restructuring, system optimization, patient safety, or patient experience. There are methods and tools that you use for each one of these type of improvements. This is, I don't know, it kind of helps to categorize. It helps to know what you're trying to do. If you can't pass this around, these are just some handouts that I think can help you get started on your QI project. My goal in here is to teach you how to write the form statement. So I can find parking when I come to work. That's the beginning of an idea, but how is that a problem? Why is it a problem? How does it impact, et cetera, et cetera? So that's your, how do you write a form statement? And then from there, how do you do a fishbone diagram? And then from there, how do you select which route cause you should be addressing? First, within your project that you may be choosing to, you may choose to work on, they may fall between process, quality improvement projects. Some of you may choose to work on research type, clinical research type projects. These frameworks may not always work, but the concepts still apply. So yes, I am cheating the one hour timeframe. Instead of talking to you about each one of these methods, these things, I'm just giving you a handout straight on your own. That's the best I can do. The next step is to pick up projects, pick up probably you're working on with the team, create a value summary, contact me if you have any questions.