Module 1
Discover Quality Improvement Tools
What it does: A simple brainstorming exercise that helps teams identify barriers and facilitators before planning improvement efforts.
When to use it: This activity helps teams understand the current system, surface different perspectives, identify strengths and challenges, and build a shared understanding before developing solutions.
How to use it:
- Choose one challenge.
- Spend five minutes listing as many barriers and facilitators as possible.
- Discuss common themes and identify opportunities to build on strengths or address challenges.
- Save your notes for use in later QI activities.
What it does: Organizes ideas from brainstorming sessions into clusters of related themes, helping reveal patterns across staff input that may not be obvious in open discussion.
When to use it: During team brainstorming sessions when you have many ideas, observations, or barriers to organize. Especially effective when gathering input from diverse team members who may see the problem differently.
How it works: Each team member writes ideas on sticky notes (one idea per note). Notes are posted on a wall and silently grouped into clusters by theme. The team labels each cluster and discusses the patterns that emerge.
Example Resource: Affinity Diagrams from American Society for Quality (ASQ)
What it does: Visualizes the steps in a current workflow to identify redundancies, gaps, bottlenecks, and handoff failures. Shows the process as it actually happens (not as it’s supposed to happen).
When to use it: When the problem involves a multi-step workflow with handoffs between people, departments, or systems. Essential for understanding where breakdowns occur in referral pathways, screening processes, and care transitions.
How it works: Walk the actual process with the people who do the work. Map each step, decision point, and handoff. Use symbols to distinguish steps, decisions, waits, and handoffs. Compare the “as-is” map with the “desired state” to identify where redesign is needed.
Example Resource: Process Mapping Template
(Note: Process mapping is typically NOT linear, and you might find loops, cut-throughs, and dead ends.)
What it does: Looks at what’s already working well and builds on it. This is especially powerful in teams that feel demoralized by problems or overwhelmed by what’s not working.
When to use it: When team morale is low, when the QI project needs to build momentum from strengths, or when you want to identify bright spots that can be replicated.
How it works: Ask staff to describe a time when the process worked exceptionally well. What was different about that situation? What conditions, behaviors, or resources made it successful? Extract the principles and design your intervention to reproduce those conditions more reliably.
Example Resource: Generic Process of Appreciative Inquiry from The Center for Appreciative Inquiry
What it does: Traces the root causes of a problem across categories such as People, Process, Equipment, Environment, and Policy. Creates a visual map of contributing factors.
When to use it: When you need to understand why a problem is occurring. The fishbone diagram works best after you’ve defined the problem clearly and want to dig into root causes before designing interventions.
How it works: Write the problem statement at the “head” of the fish. Draw “bones” for each category. Under each bone, list specific contributing factors. For each factor, ask “Why?” to drill deeper. The completed diagram reveals the web of causes that your intervention needs to address.
Example Resource: Fishbone Diagram Template
What it does: Anticipates potential failures in a process and evaluates their severity, probability, and detectability before they occur. Particularly useful for high-stakes processes like suicide risk screening, medication handoffs, and care transitions.
When to use it: Before implementing a new process or when redesigning a high-risk workflow. Also valuable after a near-miss or adverse event to prevent recurrence.
How it works: The team walks through each step of a process and asks: What could go wrong here? How severe would the impact be? How likely is it to occur? How easy is it to detect before it reaches the patient? Each failure mode is scored and prioritized for intervention.
Example Resource: SFMEA Template
Audience-Specific Examples
Applying QI Tools
| Audience | Scenario / Application | Key Takeaway |
|---|---|---|
Emergency Physician |
Uses a fishbone diagram with the care team to identify why follow-up rates after ED discharge for mental health visits are low. The team identifies root causes across multiple categories: Process (no standardized discharge checklist), People (inconsistent provider communication about follow-up), Environment (noisy, chaotic discharge area), and Policy (no requirement for documented follow-up plan). Two root causes emerge as highest priority: unclear documentation handoffs and limited outpatient appointment availability. |
The fishbone reveals that the problem has multiple contributing factors — not just one fix. The team targets both causes in subsequent PDSA cycles. |
EMS Team / EMS Medical Director |
Applies SFMEA to the pediatric behavioral health transport protocol. The team walks through the process from dispatch to ED arrival and identifies that the lack of a decision tool for transport destination is a high-severity, high-probability failure mode. They also identify that crews have no way to contact a behavioral health clinician in the field for guidance — another high-severity gap. |
SFMEA prioritizes the development of a transport decision aid and a field consultation pathway. Both become change ideas on the Key Driver Diagram. |
PECC |
Facilitates an affinity diagramming session with triage nurses around barriers to suicide screening. Nurses write individual barriers on sticky notes. After grouping, three clusters emerge: lack of time during busy shifts, uncertainty about what to do with a positive screen, and fear of escalating a situation. The PECC uses these clusters to design targeted interventions for each barrier. |
Affinity diagramming reveals barriers that might not surface in an open discussion. The structured format ensures all voices are heard. |
School Clinician |
Uses process mapping to chart the current referral workflow from identification of a student in need through connection to a first behavioral health appointment. The map reveals that 3 handoffs occur with no documentation trail: teacher to counselor, counselor to nurse, and nurse to family. Each handoff is a point where information — and the student — can be lost. |
Process mapping makes invisible handoff failures visible. The team introduces a shared tracking log to close the loop at each handoff. |
Primary Care Team |
Uses brainstorming with the care team to generate ideas for reducing referral wait times. In 15 minutes, the team generates 22 ideas ranging from co-located behavioral health visits to group therapy models to a “same-day warm handoff” protocol. After voting, the team selects three ideas to test in PDSA cycles. |
Brainstorming generates breadth quickly. The key is separating generation from evaluation — no judging ideas during the brainstorm itself. |
Behavioral Health Staff |
Applies positive inquiry: asks staff to describe a time when a family left the ED feeling genuinely supported during a mental health crisis. Staff describe a case where the social worker personally walked the family to the car, reviewed the safety plan, and made a follow-up call the next day. The team extracts the key elements — personal connection, clear safety plan, and proactive follow-up — and designs an intervention to make these practices standard. |
Positive inquiry builds on existing strengths rather than focusing only on deficits. It’s especially effective for demoralized teams. |
Hospital Leadership / CMO / CNO |
The CMO convenes a multidisciplinary task force after the Board flags a 14-hour average boarding time for pediatric behavioral health patients. The task force uses a fishbone diagram to trace root causes across People (limited psychiatric staff coverage on evenings and weekends), Process (no standardized criteria for inpatient admission vs. discharge), Equipment (EMR lacks a real-time behavioral health census), and Environment (no designated behavioral health holding space in the ED). Two high-priority drivers emerge: psychiatric coverage gaps and inconsistent disposition criteria. |
Executive-led fishbone analysis creates organizational alignment around root causes. Leadership sponsorship ensures the QI project has the cross-departmental authority needed to address the highest-priority drivers. |