Identify Change Ideas (Answers the question: What changes can we make that will result in an improvement?)

Understand the Current Condition

Before you can make an improvement it is important to understand how your current process works.   A great way to accomplish this is to conduct an observational walk by going to where the work is done (also referred to as the Gemba Walk).  It is important to observe the process (and flow) firsthand so that you can see how the process is actually performed versus how you think it is performed.  It is best to schedule a time when your entire QI team can conduct the Gemba walk together.  As you observe the process you should:

  • Document each step of the process
  • Record the time it takes to complete each process step (cycle time)
  • Record the time it takes to complete the entire process from start to end (lead time)
  • Record any wait times between each process step or during the process step
  • Document any "waste" you see in the process—remember to view the process from your customer's point of view.   (Use the 8-Wastes Form to help identify the wastes--Defects, Overproduction, Waiting, Non Value-Added Processing, Transportation, Inventory, Motion, and Employee Underutilization)

After the Gemba Walk, the team should discuss the "waste" identified and create a list.  Additionally, the team should use the data collected to create a value stream map.    This visual depiction of your process greatly helps the team analyze the process, see where the flow is interrupted or stopped, and highlight opportunities to reduce waste and improve the process.  Depending on your aim statement and goals, some additional tools may be used to enhance your team's understanding of the current process, including focus groups, surveys,  spaghetti diagrams, swim lane chart, focus groups, and interviews with staff and customers. 

Once you have analyzed the process, it is time to identify opportunities for improvement.   Review your current process through the eyes of your client and begin to categorize each activity within the process based upon Lean thinking: 

  • What activities are value added? (i.e., activities that the client/community deems necessary and are at the right time and cost)
  • What activities are non-value added but necessary? (i.e., activities that have to be performed but are not considered of value to the client/community)
  • What activities are non-value added?  (i.e., activities that the client/community does not see as necessary and are unwilling to pay for, such as waiting to see a nurse

You want to focus your improvement efforts on eliminating non-value added activities and reducingnon-value addedbut necessary activities.  In addition, for projects aimed at improving health outcomes or improving the process' effectiveness, you want to identify changes that will increase the value added nature of the process (e.g., adding an evidence-based component to your current process, such as incorporating a referral to an evidence-based smoking cessation program in a project aimed at improving care for diabetic patients).  Do not put a "Band-Aid" on the problems, make sure to drill down to the root cause of the problem using the 5 Whys or Fishbone Diagram.   

Identify and Prioritize Change Ideas

As your team reviews the current state of your process, team members will begin to have improvement ideas (also referred to as starbursts).  If your team has difficulty identifying improvement ideas, use the following tools to help generate ideas:    

  • Use the general change concepts list to help your team "think outside of the box" and generate specific ideas
  • Brainstorm or brainwrite ideas and use an affinity diagrams to organize ideas
  • Refer to the 8-Wastes Form to identify potential change ideas for your process
  • Identify evidence-based and promising practices (e.g., the open access scheduling change package from the Clinical Microsystems website, Bright Futures, 5As for smoking cessation, and ideas that other local health department and Division of Public Health teams have used)
  • Collect feedback from staff and clients on ideas for improvement --usually those who are part of the process can identify innovative ways to improve

Many times your team will develop a long list of change ideas.  Work with your team to prioritize the change ideas to work on first (e.g. changes that are easiest to implement and will have the largest benefits to the organization.  You want to get "the biggest bang for your buck" and the "easy wins"! Use the Impact Matrix(e.g., PACE chart) or Pareto Chart to help prioritize your changes ideas.



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8 Wastes

Value Stream Map

5 Whys

Fishbone Diagram

General Change Concepts

Impact Matrix

Pareto Chart Maker


Programs supported by:

BlueCross BlueShield of NC FoundatoinThe Duke Endowment

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