Hello. We're now going to talk about scope and the importance of scope in project selection. Let's think about scope as a fence. There are two purposes of a fence. One is to keep things on the inside from going out, and the other is to keep things on the outside from coming in. That's about the best thing I can explain the work of scope in our project and how it impacts. First, what shall we improve and or not improve? We want to be very specific about that. Which locations, procedures, departments? Think about that in terms of the work that you're doing. So for example, we have two emergency departments where I work. One is the pediatric department, and one is the adult department. We could choose to do both departments or perhaps just one. So for example, if we chose to do the peds department, we want to put that inside the fence. So our pediatric emergency department is what we want to work on and we might specifically say for clarity, excluding the adult emergency department. We have to be very very specific to the degree we can, about what we're working on. The steps of the process come into play too. So if we're thinking about an improvement effort within the emergency department, are we talking about from the time the patient presents to the time they're dispositioned, or are we talking about perhaps triage or registration? Sometimes, in many cases actually, we don't know what we don't know and we want to cast that wider net and maybe temporarily say, okay, it's going to be the entire emergency department. We don't know which steps yet. Later on we'll collect data, and that'll lead us to get to the steps and limit that scope. What improvement methods are off limits? So, we have to be a little bit careful about that because any time you're doing an improvement project, the staff always wants to know how will this impact me. So, you might want to say, right from the get go, that there will be no staff reductions as a result of the work we're doing. Money is always an interesting thing to too. So for the most part we've been very fortunate. We've done a lot of our improvement efforts, low cost or no cost. But one of the most devastating things that can happen down the line, is you select a project, or you select the area of work focus, and basically nothing is said about the money. And then you go through the phases and at some point you have this great improvement idea, it's only going to cost $25,000 and you're so excited and your team's jazzed about the whole thing. You go to your champion say, wow look at this, we can fix this problem for only $25,000. Your champion gives you a funny look and say, we don't have $25,000. Then you have to slump your shoulders and go back to your team and explain to them why that idea is no good. So if you can get that up front in terms of, is there a budget or isn't there, it can eliminate a lot of problems down the line. What shall not be harmed? First do no harm. A lot of times we can sacrifice efficiency but the alternative is, we sacrifice some safety element. So you need to understand and need to articulate upfront that this effort will not sacrifice or harm patients in any manner or their families or staff. So, let's look at the fence if you will. In this fence we're going to show our QI initiative, our QI effort in the middle, and that's the fence surrounding it. And we're going to put it in the form of an equilateral triangle and for those of you who need a little tutoring in geometry, that means all three sides of the triangle are equal. At the bottom, that's the scope. That's the work we're doing. What's in the fence what's out? On one of the legs, we have time, the element of time. So a certain scope of work is going to take a certain time to complete it. On the last side, we have resources or cost. It can be the number of people that are going be involved in the effort. So for example, if we were working with two emergency departments, we'd need resources both from the adult and the pediatric side versus if we were working on one the resources would be limited. In some cases, if you do have a budget, the larger it is typically the cost goes higher. Now what happens? If we increase that scope, it could be due to just your champion pushing you to do something bigger or it's a situation where we just picked something too big. The time is going to take longer and alternatively the resources and cost are going to be more. So it's okay again, as I said earlier, to scope it a little large upfront with the understanding that you're going to make this smaller over time. There's an old saying, bunts and singles win baseball games. The truth is here too that you can get something and do it much faster with your resources if you scope it down a little bit smaller. You don't need to hit the home runs every time. So let's look at some examples. In terms of trying to scope and you may not get there immediately, but this would show you the evolution of a scope. You might start out with, we're going to focus on patient and family centered care. That's our priority. That's the organizational priority. There might be a goal behind that, in terms of partnering with families and others to eliminate preventable harm and optimize patient outcomes and experience. So that's the next tier down from that the wording, and then getting a little more granular, how do we measure that? We measure that through our HCAHP scores, patient experience measures. And maybe it's the aggregate score we're going after for all of HCAHPs. Next, we could trickle that down. What's the next level down? It might be the domain with an HCAHP, so physician communication. So we've determined that our physician communications stores are largely driving those patient experience measures and aggregate. Then we get down to what's another level that we could see here and it's the question, during your hospital stay how often did doctors explain things in a way you could understand? Now, we're getting to the part where that's where we want to focus on. That's the piece that we can scope to and probably get a reasonable result in a reasonable period of time. A great tool to try to hone the scope down a little bit it's called the SIPOC. It stands for Supplier Inputs Process Outputs and Customers. And each one has a little bit of a lane here. For example the suppliers. There are people or entities that provide inputs or things to the process. So these are people, suppliers are people. The inputs are the things the process needs to function. The processes are always very high level. Four to eight process steps. We're not getting into minutia we're not getting into a detailed process maps, it's a 500 foot level of the process. The outputs are similar to the inputs but this is the things that the process produces. And likewise, the customers are the people or entities who are receiving, the things if you will, the outputs from the process. Let's see how this plays out. Pharmacy example. So we here we have the pharmacy and the first thing you want to do is you want to articulate what are those high level process steps? And we have those indicated here. It's the time from the time a doctor submits the script to the time the patient picks up the script and the high level steps in between. What are the outputs? And I'm not going in any particular order here. The only first mandatory step is listing the processes. The outputs are those. It could be anything from prescription instructions, a filled order, what's in queue. The customers who receives those, whether patients, the providers, the pharmacy techs, the pharmacists they would be customers. This by the way is not a detailed list as a high level list. You can get a little more granular. What are the things that these processes need? Well they need patient information scripts, physician order entry system, patient insurance. Who supplies those? Patients, providers, pharmaceutical companies and insurance companies. So at the end, now we have a detailed listing of what the suppliers are, what the customers are, so the people in the process you might want to think about that later on for the people in your team. The inputs where possibly things could go wrong and the outputs might be measurable factors. So looking at all that we might decide collectively, and this is a little bit of a subjective tool, we might decide collectively as a team that, hey our biggest area of problems are where the pharmacist checks for conflicts. This is only example. So in that case, we want to identify the inputs that possibly produce the most defects or possibly the most severe defects. We want to focus on the biggest problem area and now we've taken the whole pharmacy scrip process, and we've broken it down to the area where we can focus. The next tool we'll talk about is the Pareto chart. So it identifies the most important categories using that Pareto principle, routinely known as that 80-20 rule, where the 80 percent of what we're seeing involves 20 percent of the things, the inputs to the process. So we're trying to focus down on what could go wrong where and when. It's basically a glorified bar chart, just sorted high to low, where it's counting the number of times, we're seeing each one of these things happening. In this case it's reasons why we're delayed for surgery. And you're sorting from high to low. It's used for data they've been categorized into distinct groups. So it's what we call attribute data. I'll give you an example this momentarily. It includes possibly a cumulative percentage. That's that red line that you see across the top. And what we're looking for is, we're looking to see when that line hits 80 percent, because that's that Pareto rule at work that 80 percent of what we're seeing is caused by those 20 percent. So, let's use an example, I'll articulate a little bit more on that one. So the problem is, late first case starts. We want to identify those reasons for those late starts and sum, add up those occurrences, and then last but not least, we're using that Pareto tool to isolate, identify those higher frequency issues. The reasons where we can get the most effectuation. And then you see one filled out completely here and sometimes we have the other category, the other category is that check all, catchall category. You have to be a little bit careful for this one because if you wind up getting the vast majority of responses are other, that means you have to detail into what's driving that other. So we're looking for the contributing factors that are driving the results we're seeing. So in this particular case, the first three categories add up to over 80 percent and we might choose to work on one or perhaps all three of those and limit the scope to those.
