Getting Started

If you are just getting started, you can help build momentum and support for the project by choosing to remedy an easy-to-solve problem first before moving onto more complex causes, even if addressing the more complex cause will probably have a greater impact on the problem.

Steps to Quality Improvement > Planning > Planning Steps

Prioritize

A problem can arise from many different related—or unrelated—contributing causes. For this reason, it is important to determine and prioritize which cause or causes have the greatest effect. Some may be beyond the control of the organization or impossible to solve. In the example, the QI team will recognize that the organization cannot change the economic situation of its members, and will need to choose a different cause to address. Answering these questions will help.

Which causes affect the target population most?
Which causes have the greatest effect on the problem? Which are most likely to be successful?
Which causes have the greatest effect on the organization’s income or expenses?
Which causes are most important to the organization?
Which causes are most important to the organization’s stakeholders (e.g., members, patients, employers)?
Which causes are most important to the organization’s leaders?
Which causes are most important to the organization’s mission?
Which causes are most easily addressed?

One way to identify causes to address first is with a Pareto diagram (Figure 2), which displays the relative importance of each factor in contributing to the problem. In the absence of data, a group of people who have experience with a problem but may have differing viewpoints about it can brainstorm and negotiate priorities. Including members of the targeted population on the team will guard against bias.

To construct a Pareto diagram, the QI team can segment data into different categories according to the causes or issues it has identified. After determining how often each occurs, the team can chart them in order of decreasing frequency to visibly depict which causes are most significant and where to focus its efforts. Click here for an example of a Pareto diagram. The Pareto diagram shows that the first three categories account for 80% of all of the physician concerns identified; therefore the QI team may choose to focus its efforts there.

Identify a Solution

After identifying the problem and root causes, the QI team must identify specific changes necessary to solve or mitigate the problem, and consider all possible solutions. There could be several possible interventions for each high-priority root cause identified, depending on the resources available in the organization or the community. The team should consult all stakeholders who could be affected by projects developed to solve the problem. Stakeholders include patients, family members, patient advocates, health care practitioners, staff members, administrators, community service organizations and others who can contribute information from a unique point of view.

The health plan has identified these solutions.

Educate families or parents about obesity risk/prevention through culturally and linguistically appropriate mailings.
Create incentives for members to achieve and maintain a healthy weight.
Develop and conduct culturally effective outreach to Latino members with children.
Create a DM program for overweight and at-risk children and their families.
Develop and disseminate tools for physicians to use when counseling children and their families on obesity and weight loss.
Provide training for practitioners to effectively counsel children and their families on obesity and weight loss.

All possible solutions should be evaluated for feasibility, cost and probable effect so the organization can compare and choose the most effective interventions. A good solution will solve a problem by attacking individual rool causes. Although it might be tempting to look for a solution that will target all causes and solve the problem in its entirety, the project must be realistic and achievable.

L.A. Care Health Plan decided to focus on helping practitioners combat pediatric obesity in their practices. The goal was to help practitioners screen, counsel and manage children at risk or already overweight. The health plan provided a toolkit with clinical resources and materials for practitioners to give to patients and use in exam rooms to facilitate counseling sessions. To address physician demand for training, L.A. Care provided a series of continuing medical education conferences that offered strategies for health care practitioners to manage overweight and obese patients in a culturally and linguistically appropriate manner.