The Quality Improvement Challenge. Richard J. Banchs
best to get the VOC in person; talking to patients, staff, or providers at the time and location where they receive the end product of the process, whether that be receiving care (patients), or what they need to perform their work (staff and providers). If this is not possible, try to fund other alternatives that get you as close as possible.
One type of interview is a focus group. A focus group is a gathering of a selected number of people from the population of interest who participate in a facilitated discussion intended to elicit their opinions and perceptions about a particular issue or service. A focus group allows guests to interact. The format is flexible and follows a loose structure. It allows different groups to be invited around a single area of interest.
Surveys
A survey provides quantitative and qualitative information about a large population of customers. A survey can also be used as preliminary tool to gather information and identify a target population, and subsequently conduct an interview. When preparing a survey, we recommend these steps:
1 Develop the objectives.
2 Calculate the sample size. Use standard formulas as needed (you can easily find them online).
3 Draft each question and determine the measurement scale. Numeric scales are often easier to work with but qualitative scales are sometimes needed. If necessary, include a “not applicable” category.
4 Determine how you are going to code the survey to maintain anonymity.
5 Make sure you conduct a pilot to assure the questions probe the correct issues and the answers are appropriate to the questions. Nothing is more disappointing than to find the survey you worked hard to design and administer is not fulfilling its purpose.
6 Decide how you will send the survey (email, mail, fax, download from web page, etc.).
7 Decide on the timeline and how you are going to get the surveys back.
Questionnaires designed in the United States may not be valid when applied to patients from other countries, as there may be disparities in patient expectations and cultural biases .
When direct methods for soliciting feedback are not available, indirect ways such as emails, phone interviews, or letters can be used to ensure that the needs and expectations of the customers are known.
CRITICAL‐TO‐QUALITY (CTQ)
What are the CTQs?
Patients, providers, and staff are customers in our healthcare processes. They expect an outcome:
The outcome must have certain attributes and must be delivered within certain requirements (VOC).
The customer also defines the specifications for both the attributes and requirements of the final outcome.
Patients know what they mean when they say that something is “good.” Our job is to help translate their statement into specific attributes and requirement that can be measured, tracked, and improved.
The customer (patient, staff, or provider) defines quality by identifying the outcome, the attributes of the outcome, and the requirements that characterize the outcome. The customer also defines the specifications for both the attributes and the requirements.
Patients’ needs and expectations are at times vague and nondescriptive. Specificity is needed to address the identified gaps between our current performance and the needs of our customers. A method designed to focus on the critical issues needed to achieve customers’ satisfaction with the outcome involves developing Critical‐to‐Quality (CTQ) requirements, or CTQs.
The CTQs are key measurable characteristics of service or care whose performance standards or specifications must be met in order to satisfy the customer (see Figure 8‐3).
FIGURE 8‐3 The CTQs are the specifications of the Voice of the Customer
The CTQs translate general and difficult‐to‐measure customer needs or desires into very specific and measurable attributes and requirements of customer satisfaction. The CTQs are the quantifiable expectations of the customer.
Patient or customer needs and expectations come in all forms, shapes, and length of detail. Before we can move forward, these expectations need to be identified, organized, and understood. The CTQs help with this important task. The CTQs translate the broad needs and requirements of the customer (patients, staff, and providers), the VOC, into specific, actionable, and measurable performance attributes and requirements that provide direction for the project’s goals and activities.
Remember, improving a process and achieving patient or customer satisfaction are the underlying targets of the QI project. Developing CTQ requirements allows us to define the expectations of the customer (i.e. quality from the customer’s perspective), and set the goal and aims of the project. Once we understand what is critical for the customer, we can
Define our current performance.
Define the gap in performance and understand the magnitude of the problem.
Set the scope for the project.
Define the goals of the improvement initiative.
Set the targets we need to achieve.
Because patients, providers, and staff are the customers of our healthcare processes, CTQs are the critical patients’ requirements, critical physicians’ requirements, or the critical staff’s requirements whose performance standards or specifications must be met in order to meet their expectations.
THE CRITICAL‐TO‐QUALITY TREE
From the Voice of the Customer, the CTQs can be developed using a tree diagram. The CTQ tree is a diagram‐based tool used to organize identified specifications of an outcome’s attributes and requirements that the customer expects.
A tree diagram provides the clarity and structure needed to develop CTQs and focus our improvement efforts. To create a CTQ tree, follow these six steps:
1 Define the customer. First, find the customer of your process.
2 Get the Voice of the Customer. Use interviews, surveys, or any other means to get the customer’s needs and expectations. Record the VOC statements. Make sure you write down the attributes and requirements of each outcome they expect.
3 Aggregate the VOC statements into families with similar meaning. Combine the statements from the VOC according to categories or topics. Group ideas or statements with similar meaning. Topic categories could be: “expectations of the clinic environment”; “quality of clinical care”; “staff and physician interaction”; “the registration process” and so on. You may want to repeat these steps for each customer segment.
4 For each family, create the drivers. For each family or group of statements, create the “drivers” or single word or short sentence that defines the group. Ask yourself, “What do all these statements have in common? What attributes or requirements of the outcome are customers referring to?” Use the word or sentence that best describes the idea.
5 Develop the specifications or CTQs. For each driver or group of statements, drill down to the specifics. What does the driver mean to the customer (patient, staff, provider)? What are the technical characteristics? How can it be measured? What