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The following is the car repair shop data: attached in pdf,
Prepare a check sheet for the above car repair shop data.
Prepare a Pareto diagram with cumulative % as explained in Supplemental Reading PDF

Interpret your Pareto diagram and the cumulative %.Performance Improvement
Supplemental Reading
Improvement Tools
• Diagrams, charts, techniques, and
methods used during an
improvement project (also called
analytic tools)
• Quantitative: Used to measure
performance, collect and display data,
and monitor performance
• Qualitative: Used to generate ideas,
set priorities, maintain direction,
determine causes of problems, and
clarify processes
During an improvement project, various analytic tools
are used to discover the causes of undesirable
performance and plan solutions.
Analytic tools are either qualitative or quantitative.
Qualitative tools are used to generate ideas, set
priorities, maintain direction, determine problem
causes, and clarify processes. Quantitative tools are
used to measure performance, collect and display
data, and monitor performance.
The quantitative tools should look familiar; they were
discussed in the prior week lesson of performance
assessment. Qualitative tools are used to present ideas
in a manageable and useful form. In other words, they
give structure to a set of ideas. Qualitative tools are
used throughout an improvement project. Together
with quantitative tools, qualitative tools help the
improvement team define the goal, understand how
the process works, identify improvement Brainstorming
opportunities, and create solutions.
Guide to
Quantitative Tools
Qualitative Tools
• Used in performance
assessment and performance
• Bar graph
• Check sheet
• Control chart
• Histogram
• Line graph
• Pareto chart
• Scatter diagram
• Brainstorming
• Used for creative
exploration of options in an
environment free of
• Multi-voting
• Used to pare down a broad
list of ideas and establish
• Nominal group technique
• A structured form of multivoting
It is a technique used to
quickly generate lots of ideas
about a problem or topic. It
encourages creative thinking
and incites enthusiasm. The
most common brainstorming
techniques are structured,
unstructured, and silent
brainstorming. In structured
brainstorming, a group leader
solicits ideas from group
members one at a time.
Participants may skip their turn
if they don’t have an idea.
Structured brainstorming is
advantageous in that each
person has an equal chance to
participate, but it is
disadvantageous in that it
discourages spontaneity and is
somewhat restrictive.
Unstructured brainstorming
is free-form; participants
contribute ideas as they
come to mind. Unstructured
brainstorming is
advantageous in that
participants can build on
each other’s ideas in a
relaxed atmosphere. It is
disadvantageous in that less
assertive or lower-ranking
participants (such as nonleadership staff) may not
speak up. A few rounds of
structured brainstorming
followed by unstructured
brainstorming may help
reticent participants open up.
In silent brainstorming,
participants write their ideas on
small slips of paper, which are
collected and posted for everyone
to see. Silent brainstorming is
advantageous in that everyone’s
ideas are captured. In
brainstorming sessions where
ideas are voiced aloud, ill feelings
among team members or fear of
disruptive comments may make
people reluctant to share their
ideas. Silent brainstorming is
disadvantageous in that the group
does not build the synergy of an
open session. Silent
brainstorming is often used in
combination with other
brainstorming techniques.
The result of a
brainstorming session is
a list of ideas. If this list
is too long, the group can
narrow it down using
another qualitative tool,
such as multi-voting or
nominal group technique.
It often follows a
brainstorming session. It
is used to pare down a
broad list of ideas and
establish priorities. Multivoting is a simple and quick
method for setting
priorities. Which task is
most important? What do
we need to do first? Which
solution will work best?
Which improvement goals
are most important?
Suppose an improvement team charged with
reducing patient wait times in an outpatient
clinic has identified several problems that
contribute to service delays. They know they
can’t fix all of these problems at once, so they
use multi-voting to determine which problems
they should address first. The problems are listed
on a flipchart in random order. Team members
are given ten self-stick dots (color is irrelevant)
and told to place them next to the problems they
feel are most urgent. They are instructed to use
all ten dots but to place no more than four dots
on one problem. When everyone is done, the
number of dots next to each problem is tallied.
The problems with the highest number of dots
are addressed first.
A few clear winners usually stand
out. Before finalizing the list of
high-priority problems, the team
may discuss the results to ensure
everyone agrees with the
Nominal group technique
It is a more structured form of multivoting, involves five steps. The
following example illustrates the use
of nominal group technique to select
solutions for a performance problem. In
the first step, the discussion leader
states the problem and clarifies it if
necessary, to ensure everyone
understands. In the second step, each
team member silently records potential
solutions to the problem and does not
discuss them with other team members
(as in silent brainstorming). In the third
step, each person shares one idea with
the group, and the discussion leader
records the idea on a flip chart. The
process is repeated until all solution
ideas have been recorded. As in step
two, the ideas are not discussed.
In the fourth step, the team clarifies the ideas
listed on the flip chart. The discussion leader
may ask some team members to explain their
ideas. Comments from other members are
not allowed during the explanation. The goal
in this step is to ensure everyone
understands the suggested solutions. In the
final step, the team votes on the ideas
silently. Team members are asked to select
five ideas they think are most effective,
record them on separate index cards, and
rank them in order of importance. They mark
a “5” on the card for most important, “4” for
second most important, and so on.
When team members have finished ranking
their ideas, the discussion leader collects
the cards and tallies the votes. Items that
received one or no votes are removed from
the list. Items with the highest total point
values are most important to the group and
should be addressed first. The primary
difference between the results of multi-voting
and the results of nominal group technique
is that the improvement team considers the
total point count for each item (adding up the
values of each vote) as well as the number
of votes each item received.
Affinity diagrams are used to organize
large amounts of language data
(ideas, issues, opinions) generated by
brainstorming into groupings based on
the relationships be-tween data items.
This process helps improvement
teams sift through large volumes of
information and encourages new
patterns of thinking. Affinity diagrams
also help improvement teams identify
difficult, confusing, unknown, or
disorganized performance concerns.
To create an affinity diagram, team
members write their ideas, issues, or
opinions on separate pieces of paper or
index cards and scatter them on a large
table. Together, and without speaking,
the team then sorts related ideas into no
more than eight groups. Sorting the ideas
into an affinity diagram should be a
creative process, so the groups should not
be named until later. This categorization
process takes from 10 to 20 minutes,
depending on the number of ideas.
Once the ideas are sorted, the team names the groups by creating header cards
and placing one at the top of each. The name should describe the thread or topic
that ties the cards in the group together. The figure s a partially completed affinity
diagram created by an improvement team in a hospital’s business office. The team
brainstormed the problems associated with billing errors and grouped these
problems into categories.
Cause and effect diagrams
are used to identify all possible
causes of an effect (a problem
or an objective). They are
sometimes called Ishikawa
diagrams after Kaoru Ishikawa,
a quality pioneer who created
and first used them in the
1960s for quality control
purposes (Best and
Neuhauser 2008). They are
also called fishbone diagrams
because the lines connecting
major cause categories
resemble the backbone of a
fish. The figure is a cause-andeffect diagram created by an
improvement team charged with
reducing patient wait times in a
DECISION MATRIX Improvement teams can use a
decision matrix (sometimes called a selection or
prioritization matrix) to systematically identify,
analyze, and rate the strength of relationships
between sets of information. This type of matrix is
especially useful for looking at large numbers of
decision factors and assessing each factor’s relative
importance. Teams frequently use this tool to select
improvement priorities and evaluate alternative
solutions. In the case study involving Sunrise Home
Health Agency in the previous chapter, the manager
conducted a brainstorming session to solicit ideas
on how to make monthly staff meetings more
valuable to staff. Suppose the manager used a
decision matrix (Table) to evaluate the suggested
solutions more systematically. The staff’s
recommendations are listed in the first column. The
criteria for evaluating each solution are listed across
the top of the remaining columns. The manager asks
each staff member to score the solutions according
to the ranking key. The scores are then tallied, and a
group average is calculated for each solution.
Solutions with the highest group average are
selected for implementation.
Before developing solutions,
teams need to confirm they have
found the underlying causes of a
performance problem. The Five
Whys tool helps an improvement
team dig deeper into the causes
of problems by successively
asking what and why until all
aspects of the situation are
reviewed and the underlying
contributing factors are
considered. Usually by the time
the team has asked and
answered five why questions, it
will have reached the core
problem. Teams often uncover
multiple, underlying root causes
during this exercise.
The following figure is an illustration of the Five Whys process for a common
problem—water in a sink is draining too slowly. The root cause is eventually
discovered by asking why repeatedly.
It sometimes referred to as process maps, are used to identify and
document the flow or sequence of events in a process or to develop an
optimal new process during the solution stage. They can be used to detect
unexpected complexity, problem areas, redundancies, unnecessary steps, and
opportunities for simplification. They also help teams agree on process steps and
examine activities that most influence performance. Standard flowchart symbols
are shown in the following Table. When developing a flowchart, especially in a
group environment, the goal is to illustrate the process. After identifying the
process adversely affecting performance, the improvement team defines the
beginning and end of the process and the steps between these two points. It then
sequences the steps in the order they are executed. The flowchart should
illustrate the process in its current state—the way it is operating at that moment.
When the team is satisfied that the chart represents the process accurately, it
asks questions to locate improvement opportunities:

Can any steps be eliminated?
Can any steps be combined with others?
Can any steps be simplified?
Can delays in the process be eliminated?
Can rework loops be eliminated?
Can buildup of paperwork be minimized?
Can handoffs between people or departments be streamlined?
Detailed Flowchart
A detailed flowchart maps all the steps and activities that occur in the
process and includes decision points, waiting periods, tasks frequently
redone, and feedback loops. The Figure is a detailed flowchart of the
patient X-ray process. his type of flowchart is particularly useful for
looking for problems or inefficiencies. For example, the flowchart in
Figure shows that delays occur when physician orders are not readily
available to the X-ray technician. Delays also occur when X-rays have to
be retaken for technical reasons. This flowchart was taken from a Lean
project that was implemented to reduce inefficiencies in the process.
From this flowchart, the team identified delays that could be eliminated
by shifting some tasks to the radiology department’s receptionists. The
receptionists could confirm the availability of physician orders before
patients enter the X-ray area. The receptionists also could retrieve
missing orders and escort patients to and from the dressing room,
freeing up even more time for the technician. These changes would
streamline the technician’s job, increasing productivity
Deployment Flowchart
A deployment flowchart, shows detailed process steps and the
people involved in each step. A deployment flowchart is
particularly useful for map- ping processes in which information or
services are passed between people and groups. They also may
reveal unclear responsibilities, missing information, and unshared
expectations that contribute to performance problems. Figure
shown is a deployment flowchart of an employee training
process. To create this flowchart, the improvement team listed the
departments involved across the top of the chart. Next, it
arranged the process steps in sequence and positioned each
step in the column of the department that executes the step. The
process steps are connected with arrows to show where the flow
lines cross from one column to the next. A handoff occurs each
time the flow line crosses from one column to another. The
project team focused improvement solutions on the handoffs in
the process because these transitions are prone to errors and
miscommunication. Delays can happen at handoff points
because people may not know when they can expect to receive
something or that another group is waiting for them to complete a
Top-down Flowchart
Top-down flowchart, the major steps in a
process are arranged sequentially across the
top and the detailed steps are listed under each
major step (Figure shown). Unlike a detailed
flowchart, a top-down flowchart does not
include decision points or other steps that might
be causing inefficiencies. A top-down flowchart
is useful for viewing the process in a systematic
manner to better understand the activities
involved and their interconnectedness. Each
type of flowchart has its strengths and
weaknesses. To choose the best format for the
project, the improvement team needs to
understand the reason for creating the
flowchart. If the team is unsure about the substeps in the process, it should create a highlevel flow- chart. When the team understands
the process sub-steps and wants to better
understand how the steps are carried out, it
should create a detailed, deployment, or topdown flowchart.
A workflow diagram is a visual representation of the
movement of people, materials, paperwork, or
information during a process. The diagram can also
illustrate general relationships or patterns of activity
among interrelated processes (such as all processes
occur- ring in the radiology department). Workflow
diagrams are used to document how work is
executed and to identify opportunities for
improvement. A common type of workflow diagram is
a floor plan of the work site. Lines are drawn on the
floor plan to trace the movement of people, paper,
data, etc., to identify redundant travel and
inefficiencies. Figure shown is a floor plan of a
hospital pharmacy department. The lines on the floor
plan trace the movements of a pharmacy technician
during the process of filling a prescription. To create
this workflow diagram, staff from the quality
department observed traffic flow in the pharmacy at
12:30 p.m. on a typical day.
The technician’s movements are chaotic because of
the layout of the department. The central medication
supply is located in the middle of the pharmacy, and
medications that are infrequently prescribed line the
back wall of the department. The narrow walkway
between the two sections causes delay and
congestion because it comfortably accommodates
only one person at a time. The resources needed to fill prescriptions are not easily
accessible. Two printers in the lower left corner of the department, approximately 26
feet from the medication area, print prescription enclosures. The technicians must
travel to this area through a narrow doorway. After studying the workflow in the
pharmacy department, several changes were made to the department layout and the
prescription receiving process.
Surveys (also considered a quantitative tool)
• Used to gather quantitative and qualitative information
Types of surveys
• Questionnaires: Paper or electronic instruments that
the respondent completes independently
• Interviews: Conducted with the respondent face-toface or over the phone
The purpose of force field analysis is to determine the potential
support for and against a particular plan or idea. Once these
“forces” are identified, plans can be devised to strengthen
support for the idea and reduce resistance against it. Teams
typically use force field analysis during the solution phase of an
improvement project but may also use it to prioritize their
improvement goals. Figure shown is a force field analysis
completed by an improvement project team in a children’s
hospital. The goal of the project is to increase parents’
participation in the hospital’s quality improvement efforts. To
achieve this goal, the team suggested that the hospital host
quarterly focus groups with the parents of former patients to
solicit ways to improve parent satisfaction. The improvement
team uses the force field analysis to clarify current and desired
participation and identify obstacles that could impede
implementation of their proposal. The vertical line at the center
of the diagram represents the status quo. Teams brainstorm to
identify the driving and restraining forces and then decide which
will most influence the outcome. They develop strategies to
minimize the forces against, and strengthen the forces for, the
desired outcome. Teams should focus on reducing or
eliminating the restraining forces because they are usually
more powerful and can prevent the change from being
People usually resist change. If the improvement project team does not
deal with this resistance, desired performance improvements may not
materialize. Teams can use a stakeholder analysis to identify the individuals
or groups that would be affected by a proposed process change. Each
stakeholder is considered to deter- mine who would readily accept and
who would resist the process changes. Stakeholders can be grouped into
four main categories: allies, associates, enemies, and opponents. Not all
will be affected by all stakeholders are equal; some have more influence on
the outcome of the improvement plan than others. All of these factors are
considered in a stakeholder analysis. A stakeholder analysis matrix (Table)
helped the team predict each group’s influence on project outcomes and
its level of support. The individuals and groups that would be affected by
the proposed changes to the process are listed in the first column. The
team determines the specific interests these stakeholders have in the new
process. The team considers such issues as

benefits to the stakeholder,
benefits to the stakeholder’s patients,
changes the stakeholder will have to make, and
activities that might cause conflict for the stakeholder.
These issues are recorded in the “Stakeholder Incentives” column.
Next, the team uses the following five-category ranking system to
judge each stake- holder’s support of the process change:
++ strongly in favor
+ weakly in favor o indifferent
− weakly opposed
−− strongly opposed
After ranking the stakeholders, the improvement team develops strategies for
gaining stakeholder support, plans for all possible barriers to success, and
decides how each stakeholder should be approached about the proposed
change. What kind of information does the stakeholder need? Should the
team involve the stakeholder in the project? Could any other groups or
individuals influence those opposed to the change? The team records these
ideas and actions it must take to further the project in the last column of the
Planning matrix
• Shows the tasks needed to complete an
improvement activity, the people or groups
responsible for completing the tasks, and the
deadlines for completion
Gantt Chart: Graphic representation of a planning matrix
Table shown is a planning matrix for an improvement
project involving changes to the patient registration
process at Redwood Health Center. In hopes of reducing
patient wait times, the team decides to implement a
change to the registration process for new patients. The
clinic will mail a registration form to all new patients who
schedule appointments. Patients will be asked to bring the
completed form on the day of their appointment. The
project seems simple and straightforward, but the
planning matrix reveals that the team must complete a
number of tasks to implement the change successfully.
Quality storyboard
• Summarizes the major elements of a completed improvement project
Recap: Two Types of Tools
• Quantitative tools
• Used for measuring performance, collecting and
displaying data, and monitoring performance
• Qualitative tools
• Used for generating ideas, setting priorities,
maintaining direction, determining causes of problems,
and clarifying processes
Improvement Tools
How are we
Are we meeting
How can we improve
Help to answer these questions:
• How does the process work
• What can we improve?
• How do we improve it?
• How should we measure and
track performance?

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