What do you do when a problem seems too big to know where to start? We worked recently with a clinical service that had tens of thousands of out-patient appointments a year. The clinical team identified many wastes in the existing systems, and had a lot of ideas on how to tackle some of them. With a colleague, I had undertaken observations in the service, and it looked as if some clinics ran very well, while others had backlogs with harassed staff and bored patients.
As part of the preparation for a Rapid Process Improvement Workshop (RPIW), we produced Pareto charts of the volume of activity by clinic type. We also looked at trends in clinics over time. It became clear that a relatively small number of clinics accounted for a large proportion of the attendances. One particular clinic had increased rapidly over time. This related to a new treatment becoming available, and which needed regular administration in a clinic setting. This clinic was also the clinic which, during observation, had some of the longest delays.
Pareto charts are named after Vilfredo Pareto, an Italian economist. Its use in quality is associated with Joseph Juran. Juran is an important name in quality work for several reasons, including his ideas the core concepts of quality (the ‘Juran trilogy’) and his work to popularise quality circles. In relation to Pareto, however, Joseph Juran noticed that most production problems came from a small set of causes, which he described as separating ‘the vital few from the useful many’.
In drawing a Pareto chart, the categories are put in order of size from largest to smallest, and then a line is drawn showing the cumulative proportion of the total contributed by the categories. This blog post describes how to create a Pareto chart, and there is an (oddly cheerful) video from the Juran institute outlining the main idea on You Tube. There is an example of a Pareto chart here, used to identify sources of problems, rather than to graph activity.
At the RPIW, when the data, the observations and the staff views and experience came together at the beginning of the RPIW, the clinic staff decided to focus their activity on three areas, one of which was the high volume activity clinic. There were no unique issues about the clinic, but the increase in volume, the size of activity and the complexity of the interventions seemed to have come together to emphasise issues with flow that existed to some extent in other clinics as well.
As usual, Pareto charts are not always the right tool for every job. Mike Rother points out, in an interesting Blog post, that spending too long on analysis can interfere with people getting on with sorting out the problems. This is true, but in the case of our RPIW the data, the observations and most importantly staff knowledge and experience, came together to support one another in identifying the issues that needed work.
Portrait from Wikimedia Commons