Quality Management in Healthcare Services

Unit 4

Unit 4

Quality Tools and Techniques

Structure:
4.1 Introduction
Objectives
4.2 Overview of Quality Tools and Techniques
4.3 Seven Quality Tools
Flowchart
Cause and effect diagram
Pareto analysis
Check sheet
Control chart
Histogram
Scatter diagram
4.4 Seven Management Tools
Affinity diagram
Relations diagram
Tree diagram
Matrix diagram
Matrix data analysis chart
Arrow diagram
Process decision program chart
4.5 Statistical and Design Tools
Statistical process control
4.6 Benefits of Quality Tools and Techniques
4.7 Summary
4.8 Glossary
4.9 Terminal Questions
4.10 Answers
4.11 Case-Let

4.1 Introduction
In the previous unit we dealt with quality management in healthcare. We
have also learnt the dimensions, principles and objectives of quality in
healthcare. This unit explains the seven tools of quality and management. It
also describes the statistical and design tools of quality in healthcare. This
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unit also discusses the benefits of quality tools and techniques in

healthcare.
Objectives:
After studying this unit, you should be able to:
explain seven quality tools
explain seven management tools
describe statistical and design tools
discuss the benefits of quality tools and techniques

4.2 Overview of Quality Tools and Techniques

Quality tools and techniques are used by organisations to monitor and
manage quality initiatives. The tools and techniques are the fundamental
instruments used to improve the quality of products. They are used to
analyse the production process, recognise the major problems, control the
fluctuations of product quality and also give solutions to avoid any future
defects. The tools use the statistical techniques and knowledge to
accumulate data and analyse them which help to organise the collected
information in an understandable way. Different tools and techniques are
used for different problem solving opportunities and many of the tools can
be used in different ways. The quality tools and techniques are the problem
solving tools which can be used to recognise and prioritise the problems
quickly and more effectively.
The quality tools are flowchart, cause-and-effect diagram, Pareto analysis,
check sheet, control chart, histogram and scatter diagram. The quality
techniques are brainstorming, nominal group technique, affinity diagrams
and structured discussions. The tools and techniques help in the decisionmaking process. It gives a simple but powerful tool for use in the continuous
improvement activity. It helps in communicating the problems and the
resolutions throughout the business. Information can be extracted from the
data collected using these tools. The data can be collected by asking the
following questions:
What are the questions to be answered to collect the data?
How to recognise and communicate the answers collected?
What data analysis tools should be used and how should the results be
communicated?
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What is the type of data required to answer the question?

Where in the process can the required data be obtained?
Who in the process will give the data?
How can the data be collected from the individuals with minimum effort
and error?
When should the data be given?
How much is the cost to collect the data?
What additional information is required for future analysis?

Self
1.
2.
3.

Assessment Questions
What is the use of quality tools and techniques?
Brainstorming is a quality technique. (True/False)
Check sheet is a quality tool. (True/False)

4.3 Seven Quality Tools

After World War II, the Japanese adopted Quality as the philosophy for
economic recovery. They sought seven tools to accomplish the economic
rejuvenation. The seven tools that they chose were Histogram, Cause and
Effect diagram, Check sheets, Pareto diagrams, Graphs, Control charts and
Scatter diagrams. Each quality tool is described below.
4.3.1 Flowchart
Flowcharts give a visual illustration of the sequence of the operations
needed to complete a task. To understand a process, the first step is to
draw a flowchart of the process. Every process will need input to finish the
individual tasks and will give an output when the tasks are completed. For
example, there might be some activities which may be repeated while others
may be unnecessary. The activities might be performed in a sequence,
when they can be conducted at the same time to minimise the overall time
for the process.
There are some guidelines to be followed while constructing a flowchart
which are as follows:
Right people should be involved in making the flowchart. This might
include people who can actually do the work of the process, supervisors,
suppliers to the process and the customers of the process.
Enough time should be allotted to the group members to finish the
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flowchart construction as it needs more time than expected.

Key to flowchart process is to ask questions. The more the questions
asked the better. The following questions can be asked while
constructing the flowchart:
o What happens first?
o What happens next?
o Where does the operations output go?
o Where does the processes input come from?
o How does the process get its input?

The following flowchart explains the procedure of services provided to the

patient in a hospital:

Figure 4.1: Flowchart

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The advantage of using flowchart is that the people involved in constructing

the flow chart can understand the process better, recognise the areas for
improving the process and also realise how the process and the people
involved can fit into the overall process or business.
4.3.2 Cause and effect diagram
Cause-and-effect diagram, also known as the fishbone diagram, helps to
obtain more information about the process and its output. It will also help to
obtain the root cause of problem.
In 1943, Kaoru Ishikawa developed the cause-and-effect diagram at the
University of Tokyo. The cause-and-effect diagram relates the symptom or
the problem to the factors or causes driving it. It achieves this through the
hierarchical relationship between the effect, the reasons for the effect and
the subsequent relationship to the sub-causes. A cause-and-effect diagram
usually consists of two sides. The right side is the effect list which lists the
problem or the quality concern. While the left side is the cause side and lists
the primary causes of the problem. The right hand side can include the
desired effect which the user wishes to achieve.
The following must be considered while constructing a cause-and-effect
diagram:
1. Choosing the team members. It is preferable to have team members
knowledgeable about the quality concern under question. In this, one of
the team members has to be selected as the team leader (Facilitator)
whose responsibility is to listen to ideas presented by the other team
members, capture the thoughts and write them on charts.
2. Assuming that the quality concern has to be recognised. The concern
should be written as the problem statement on the right hand side of
the page and box should be drawn around it with the arrow running to
it. The quality effect is the main cause.
3. Brainstorming. The team members will generate ideas as to what is the
reason for the effect. The main causes as well as the sub causes
should be recognised. As indicated before, the team should choose
generic or particular headings for describing the main causes.

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4. Recognising the quality concern or problem for each main cause and
its related sub-causes .Also the factors contributing to the problem will
have to be recognised. Brainstorming can be used here.
5. Focusing on one or two causes for which the improvement action can
be developed using the quality tools like the Pareto charts, check
sheets and other gathering and analysis tools. This depends on the
team members on where and how to start. The agreement between the
team members should be based on consensus. The figure 4.2
represents the cause-and-effect diagram where the problem is on the
right side and the process, people, material and equipment are on
either side.

Figure 4.2: Cause-and-Effect Diagram

Source:
http://www.thethrivingsmallbusiness.com/articles/wpcontent/uploads/2010/0
2/clip_image0044.gi
In healthcare industry, the cause-and-effect diagram can be used explain a
hospital. In hospital, people will include the secretary, physician, lab
technician, process will include the process followed by the hospital like the
transcription error, the way treatment is given, materials include lab supplies
and specimen vials and equipment will include lab equipment, pager
malfunction and phone system.
4.3.3 Pareto analysis
Pareto chart is used to prioritise the problems, to decide what problems
should be addressed. No company will have enough resources to handle
every problem so they should prioritise them.
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In 1906, Vilfredo Pareto, an Italian economist, developed the concept of

Pareto. The Pareto chart helps in describing the frequency distribution of
any given characteristic of the population. It is also called the 20-80 rule,
where a small percentage of any given group (20%) account is determined
for a high amount of a certain characteristic (80%). The Pareto chart is
particularly helpful in improving the manufacturing processes. The Pareto
diagram can be constructed as follows:
1. Deciding the problem, type of data required and the cause categories.
2. Collecting or obtaining the data.
3. Ordering the causes or categories.
4. Calculating the cumulative total and the percentage of the total for each
cause in the cumulative percent table.
5. Drawing and labelling the horizontal x-axis including the interval.
6. Drawing the scale and labelling the vertical y-axis on the left side of the
diagram.
7. Drawing the vertical bars for each cause in the order of the highest to
lowest frequency.
8. Plotting a point at the centre of each bar equal to the cumulative totals.
The following example shows the Pareto graph for surgical setup. It is
plotted based on the cumulative data on the type of errors caused during
surgical setup. The table lists the error types and cumulative percentage for
surgical setup:

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Table 4.1: Sample Data on Types of Errors Caused During Surgical Setup.

Figure 4.3: Pareto Graph for Errors Caused During Surgical Setup

Source: QP-ParetoDiagram-IHI.pdf
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4.3.4 Check sheet

Check sheets will allow the user to collect data from the process in an easy,
systematic, and organised manner which shows the history and pattern of
the variations. At the beginning of the change process this tool is used to
recognise the problems and collect the data easily.
The process improvement actions are usually based on the information
obtained from the data collected from the actual process. The collected data
has to be accurate and related to the quality problem which is being
analysed if the information about the problem has to be accurate. There are
three key steps to be taken before any data can be collected:
1. Set up the purpose for collecting the data which will be based on the
quality problem which will be investigated.
2. Type of data that is going to be collected has to be defined. The type of
data to be used depends on the quality of problem being investigated.
This data can be collected in two ways:
Measurable data like length, size, weight and time.
Countable data like the number of defects.
3. Determine who is going to collect the data and also when it should be
collected.
Usually, one can use the statistical guides to take the samples or the data
points from the process. The person collecting the data should understand
the purpose of collecting the data and what will be his role in the data
collecting process.
The following figure shows the check sheet shows the august 2007 data for
central sterile supply department:

Figure 4.4: Check Sheet for Central Sterile Supplies Department

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Check sheets is the most common tool used for collecting the data. There
are four main types of check sheets used for data collection and they are as
follows:
Defective item check sheet
This type of check sheet is used to recognise the types of problems or
defects which are going to occur in the process. Usually, the check sheets
will have a list of defects or problems which might occur in the process.
When each sample is taken, a mark will be placed in the appropriate column
whenever a defect or a problem is recognised. The type of data that can be
used in the defective item check sheets is the countable data.
Defective location check sheet
This type of check sheet is used to recognise the location of the defect on
the product. It is used when the external appearance of the product is vital.
Usually, this type of check sheet consists of the picture of the product and
the marks can be created to indicate where the defects are occurring on the
surface of the product.
Defective cause check sheet
This type of check sheet will try to recognise the causes of the problem or
the defect. More than one variable is monitored while collecting the data for
this type of check sheets. For example, we can collect data about the type
of machine, the operator, the date, and the time on the same check sheet.
Check-up confirmation check sheet
This type of check sheet is used to make sure that proper procedures are
followed. These check sheets will usually have a list of the tasks which have
to be accomplished before the action can be taken. Examples of the checkup confirmation check sheets are the final inspection, machine
maintenance, operation checks and service performance sheets.
4.3.5 Control chart
Control charts are used to make sure that the process is in control. It is also
used to monitor the process variation on a continuous basis. It was
developed in mid-1920 by Walter Shewhart of Bell labs. This tool has
become a main contributor to the quality improvement process. This allows
the user to monitor and control the process variation. It also allows the user
to take proper corrective actions to eliminate the sources of variation. Even
though they need the user to have some statistical background, they are
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relatively easy to construct. There are two types of control charts - the
average and the range control charts. The average control chart deals with
how close the process is related to the nominal design value and the range
chart indicates the amount of spread or the variability around the nominal
design value. A control chart mostly has three lines:
The Upper Control Limits (UCL)
The Centre Line (CL) or the average line
The Lower Control Limits (LCL)

Figure 4.5: Control Chart

These lines are computed from the samples taken from the production line.
Each of the samples will represent the point on the control chart. A minimum
of 25 points is needed for the control chart to be accurate.
Variation reveals itself through the recognisable patterns on the control
charts. A process is said to be under the influence of the common causes
only if all the data points will lie within the upper and lower control limits. If
the point falls outside the control limits then the process will be out of control
or under the influence of the special causes. Process improvement can
begin only when the process is under control. Control charts can detect
many basic patterns which can occur in the process. These patterns are:
Runs It is a series of consecutive points on the control chart which fall
on one side of the central Line. This will indicate that the mean or the
average of the process has shifted.
Trends It is a series of points which continues to rise or fall in one
direction. This indicates that an abnormal condition will be operating
within the process. Example of causes of the trends is the tool or the
equipment wear.
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Cycles It is a series of the points displaying a similar or a repeated

pattern.
Jumps It occurs when any large shift has occurred between the
consecutive points.
Hugging - It is a series of points which are very close to the central line
or the control limits.

4.3.6 Histogram
Histogram is the tool used for summarising, analysing and displaying the
data. It gives the user a graphical representation of the amount of variation
found in the set of data. Histograms sort the observations or the data points
into categories and then describes the frequency of the data which are
found in each category. Histograms show a visual summary of the data,
which will be simple to understand. This tool is used when the data given is
of various varieties and is difficult to understand. In addition the visual
summary shows whether the method is centred on a desired value. It is
used to determine the spread or the variation of the set of data points in the
graphical form. There is always the desire to produce things which are equal
to the design values. It is easy to know the amount of deviation and whether
the data matches the requirement. Hence histograms help in recognising
process capacity, which is necessary to meet customer needs. Histograms
are of five types. They are:
Bell shaped
Double peaked
Plateau distribution
Comb type distribution
Skewed distribution

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Figure 4.6 shows a pictorial representation of different types of histograms.

Figure 4.6: Types of Histogram

For example, if the number of cylindrical objects having a certain diameter

value is being produced then every produced should have the same
diameter value.
There is variation everywhere. It has been found that the output of any
process can be manufacturing, service or administrative. One characteristic
of the variation is that it will always display the pattern and distribution.
Histograms help to recognise and interpret the patterns.
4.3.7 Scatter diagram
Scatter diagram is used to recognise the correlations which might exist
between the quality characteristic and the factor which might be driving it. A
scatter diagram is the nonmathematical or graphical approach for
recognising relationships between the performance measure and the factors
which might be driving it. The scatter diagram can be used when the
assumed variation of two items is connected in some way. It can also be
used when it is assumed that one item might be causing another to build the
evidence for connection between the two. The following figure 4.2 is a string
diagram used in problem solving where the problem should be recognised
along with the possible casual relationships. It should be implemented and
then reviewed.

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Figure 4.7: String Diagram to Represent Problem

The graphical approach can be used to communicate with others in an easy

and quick means. It is also easy to interpret. The data required to construct
the scatter diagram should be collected in pairs (X, Y).
Always the performance characteristic, Y, is plotted on the vertical axis,
while the suspected correlated factor, X, is plotted on the horizontal axis.
The point of intersection between the two axes is the average of each of the
sets of data. The collected data is not for just observing the quality
characteristics under examination but also for observing other factors or
causes which might affect the quality characteristics.
The Scatter diagram can be constructed in the following way:
Select the two items which should is under study. The results of the
cause-and-effect diagram can be very helpful in determining the item to
be selected. For example, the two items can be affected and a related
cause.
Collect the data. When the data is more the conclusions are more
accurate. The data required to construct the scatter diagram is always
paired.
The axis of the scatter diagram should be drawn. The performance
characteristic is on the Y axis and the suspected correlated factor on the
X-axis. The point where the two axes interest is the average of each of
the sets of data.
Plot each set of the paired data onto the graph that is (X0,Y0), (X1,Y1),
(X2,Y2),..,(Xn,Yn) where n is the number of samples.
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Once all the data points have been plotted on the scatter diagram, then
the relation between the two selected items, if any, can be determined. If
a strong relation exists, the change in one item can automatically cause
a change in the other. If the relationship cannot be detected then the
change in the one item will not affect the other item. Figure 4.8 depicts a
scatter diagram.

Figure 4.8: Scatter Diagram

Activity: 1
Using a flowchart, represent the procedure of admitting a patient to the
hospital.
(Hint: Refer to section 4.3.1 Flowchart)
Self Assessment Questions
4. Pareto chart is also known as ____________.
5. Cause-and-effect diagram is also known as _____________.
6. Histograms are of six types. (True/False)

4.4 Seven Management Tools

The Japanese Union of Scientists and Engineers (JUSE) define the seven
management tools as the seven most useful tools after the seven quality
control tools. The seven Management tools are concerned with the Plan
step of Plan-Do-Check-Act (PDCA) cycle. It helps in understanding complex
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situations, recognising opportunities for improvement and developing

detailed implementation plans. The seven management tools are affinity
diagram, relations diagram, tree diagram, matrix diagram, matrix data
analysis chart, arrow diagram and program decision chart. The following
sections explain these management tools.
4.4.1 Affinity diagram
Affinity diagram is a tool which is used to classify the ideas and the data.
This tool is usually used in project management. It is used to allocate
information which can be arranged into groups for evaluation and analysis.
This is basically a brain-storming method. It is based on the group work in
which every participant will write down the ideas which can then be grouped
and realigned by the subject matter.
It is used when chaos exists and the team has large volume of ideas. A
break through thinking is necessary where the broad issues or themes can
be recognised. The items which are naturally related can be grouped
together so that one concept which ties each other together can be
recognised. This is a creative rather than a logical process which produces
consensus by sorting the cards rather than by discussion.
The steps involved in creating an Affinity diagram are as follows:
1. Write down each thought on a note pad and display it to other
members.
2. The entire team assembles around the notes and takes part in the
further steps.
3. Look for ideas and thoughts that are related to the process.
4. It is preferable to move a note that someone else has already moved. If
a note seems to belong in two groups, make a second note.
5. Observe note in each grouping that explains the meaning of the group.
Keep it at the top of the group.
6. Often it is useful to write or highlight this note in a different colour.
7. Merge groups into super groups.

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Figure 4.9: Affinity Diagram

4.4.2 Relations diagram

Relations Diagram is also known as the Interrelationship Diagram or
Digraph or Network Diagram. This diagram shows the cause-and-effect
relationships and helps to evaluate the links between different phases of a
complex situation. The relations diagram after generating the affinity
diagram or the cause-and-effect diagram or the tree diagram recognises the
primary issues based on the root causes to explore the relations of ideas
more completely. A large number of inter-related issues will have to be
defined and the scarce resources will need focused effort. The tool
addresses these situations by presenting relationships between objects with
an arrangement of boxes and arrows. The following are the steps to be
followed for relations diagram:
1. Find the factors that have to be analysed for possible relationships and
label them.
2. Plot the factors on a chart on whiteboard.
3. Assess the impacts of every factor.
4. After the relationships have been assessed, count the number of
arrows pointing towards and away from each factor and denote the
information in the diagram.
5. Direction of the number of arrows pointing in each direction for a factor
will decide whether it is driver or indicator.
6. When doing the root cause analysis, the drivers will form the starting
point.
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Items are
identified
chunks of the
problem

Unit 4

Arrows show a direct

relationship between
individual items
Item 2

Item 1
Item 3

Item 5

Item 4

Figure 4.10: Relations Diagram

4.4.3 Tree diagram

The Tree diagram tool refers to the particular kind of diagram which has the
distinctive network topology. It can be seen as a special kind of cluster
diagram. It simplifies the large categories into simpler levels of detail. This
tool in turn helps in the step by step analysis which is more precise and
understandable. The broad objectives should be broken down into specific
implementation details. All the implementation options should be explored
and the assignable tasks should be created. The full range of paths and
tasks can be accomplished by systematically mapping to achieve a primary
goal and each related to a sub-goal. The tree diagram can be represented
as shown in figure 4.12. According to figure 4.12, the problem is divided into
a number of causes where each cause will have tasks. The task and cause
can then be analysed to create assignable task.

Figure 4.11: Tree Diagram

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4.4.4 Matrix diagram

Matrix Diagram is the graphical tool which shows the relationship between
ideas in the form of a table. It provides the information on the relationship
between different groups and provides details about the strength, the roles
played by different persons and measurements. It is used when the
definable and assignable tasks have to be deployed within the organisation.
The chosen activities will have to be tested against other current activities. It
is also necessary to prioritise the current activities against the new
objectives. Two or more sets of ideas, issues have to be organised by
graphically connecting the points between the items. The matrix will show
the presence and strength of the relationship shown in the matrix. There are
six types of matrices that are available. They are L, T, Y, X, C and roofshaped matrices. These types depend on how many groups must be
evaluated. Figure 4.12 shows the matrix diagram for one-to-one and manyto-many relationship.

Figure 4.12: Matrix Diagram

Matrix diagram can be created using the following steps:

1. Defining the objective of using the Matrix Diagram.
2. Arranging a team who has knowledge to work on attaining the purpose.
3. Deciding what has to be compared to achieve the objective. Identify the
appropriate matrix to use.
4. Choosing how to compare list items.
5. Measuring the final matrix and look for items which are important that
result in specific actions which will be carried on.
4.4.5 Matrix data analysis chart
Matrix Data Analysis chart is used to recognise clusters of the related items
within the larger group. This is a composite mathematical method for
analysing matrices. It is used when the investigating factors which affect the
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number of different items to determine the common relationships. It can be

used to determine whether or not the logically similar items have similar
factor effects. It helps to find the groups of logically different items which
have same factor effects. L-shaped matrix is one of the most precise,
cautious, and prolonged decision-making tools. It also uses pair wise
assessments of a list of options to a set of standards in order to select the
better choices. The following steps are used to create a Matrix Data
Analysis Chart:
1. Recognise the items which are to be matched up, and choose the
primary goal of using the Matrix Data Analysis Chart.
2. Recognise the measurement units for the horizontal and vertical axes
of the chart. These should be two aspects which are the most
significant illustrations of the purpose recognised in the previous step.
3. Measure the factors identified in the previous step, aiming to get
practical and balanced values.
4. Illustrate a chart and draw each point on it.
5. Look for considerable clusters of points on the chart, and connect them
jointly into a ring.
6. Understand the chart and proceed on the results.
4.4.6 Arrow diagram
Arrow diagram is also known as the activity network diagram or the network
diagram or the activity chart or the node diagram or the Critical Path
Diagram (CPM) chart. The arrow diagram shows the essential order of
responsibilities in a project or a process. It also identifies the best schedule
for the whole project, identifies problems, and finds better solutions. The
arrow diagram shows the necessary order of tasks in the project or process,
best schedule for the whole project and potential scheduling and resource
problems along with the solutions. The arrow diagram can be used for
scheduling and monitoring the tasks within the complex project or process
with the interrelated tasks and resources. This diagram will be useful when
the step to the project or process, their sequence and how long each task
will take is known. Figure 4.14 describes an arrow diagram.

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Figure 4.13: Arrow Diagram Process

Creating an arrow diagram involves the following steps:

1. List out the essential tasks of a process.
2. Establish the proper order of the tasks.
3. Plot the network of tasks.
4. Illustrate circles for events between two tasks; an event marks the
start or ending of a task.
5. Choose three general problem conditions and rewrite them using
replica.
This is often used in Program Evaluation and Review Technique (PERT)
and Critical Path Method (CPM). It uses a network representation to show
the steps necessary to implement a plan.
4.4.7 Process decision program chart
The Process Decision Program Chart (PDPC) is an application which is
used in operations research. This is a method developed to organise the
contingency plans in a proper way. The importance of the PDPC is to
recognise the significant impact of the failure on different process plans. The
PDPC is used when the task is new, unique or substantially revised. It is
also used when the task is complex and the stakes of failure are very high.
PDPC will generate proper contingency plans to avoid risks because the
implementation programs to achieve specific goals do not always go
according to plan and unexpected developments might have serious
consequences. The PDPC has been developed not only to arrive at the
conclusion but also to avoid surprises. For example, consider a medical
group is planning to improve the medical care given to the patients with
chronic illnesses like diabetes and asthma through a new chronic illness
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management program. They can define the four main elements and for each
elements the key components. Figure 4.15 represents the Process Decision
Program Chart.

Figure 4.14: Process Decision Program Chart

Process Decision Program Chart can be created as mentioned in the below

steps:
1. Obtain or develop a tree diagram of the projected plan.
2. For every task in the third level, think what could go incorrect.
3. Reassess all the possible problems and remove any that are unlikely or
whose consequences are not important.
4. For each possible problem, suggest possible countermeasures.
Self Assessment Questions
7. Affinity diagram is a tool which is used to classify the ________ and the
data.
8. PDPC stands for ________________.
9. Activity network diagram is also known as ______________.

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4.5 Statistical and Design Tools

The statistical and design tools can be divided into three main areas such as
Statistical Process Control (SPC), Design of Experiments (DOE) and
Acceptance Sampling. The Statistical Process Control is used for process
monitoring and variability reduction. It is an online quality control tool. The
Design of Experiments is an approach to systematically vary the controllable
factors in the process of determining the effect which these factors will have
on the output responses. The experimental designs are off-line quality tools
and are important for variability reduction. The acceptance sampling is the
inspection and classification of the sample product selected at random from
the larger batch or lot and the ultimate decision about the disposition of the
lot. There are two types of inspection and they are outgoing inspection
which follows production and incoming inspection which is used before
production.
4.5.1 Statistical Process Control (SPC)
The SPC involves using statistical techniques to measure and analyse the
variation in the processes. Most often used for manufacturing processes,
the intent of the SPC is to monitor the product quality and maintain the
processes to the fixed target. The statistical quality control refers to the use
of statistical techniques for measuring and improving the quality of
processes and also includes SPC in addition to other techniques like
sampling plans, experimental design, variation reduction, process capability
analysis and process improvement plans.
The SPC is used to monitor the consistency of the processes which is used
to manufacture the product as designed. It is targeted to get and keep the
processes under control. No matter how good or bad the design, SPC can
make sure that the product is being manufactured as designed and
intended. Thus, the SPC may not improve a poorly designed products
reliability but can be used to maintain the consistency of how the product is
made.
Control chart is a primary tool which is used in SPC. It is the graphical
representation of descriptive statistics for the specific quantitative
measurements of manufacturing process. The descriptive statistics have to
be displayed in the control chart in comparison to the in-control sampling
distributions. This comparison will detect any unusual variation in the
manufacturing process. Many different descriptive statistics may be used in
the control charts and there are many different types of control charts which
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can test for many causes like how quickly major and minor shifts in the
process can be detected. The control charts can be used with product
measurements to analyse the process capability for continuous process
improvement efforts. The advantages of SPC are as follows:
Gives surveillance and feedback for keeping the processes in control.
Signals when some problem in the process has occurred.
Detects the assignable causes of variation.
Accomplishes the process characterisation.
Minimises the need for inspection.
Monitors the process quality.
Gives the mechanism to make process changes and track the effects of
those changes.
Once the process is stable the assignable causes of variation can be
eliminated by giving process capability analysis in comparison to the
product tolerance.
The capabilities of the SPC chart are as follows:
All forms of the SPC control charts.
Selection of the measures for the SPC.
Process and machine capability analysis.
Process characterisation.
Variation minimisation.
Experimental design.
Quality problem solving.

4.6 Benefits of Quality Tools and Techniques

There are many benefits of quality tools and techniques. Some of the
benefits are listed below:
It helps to find out the root cause of the problem.
It helps to find a solution to the problem immediately.
It helps to meet the customer requirements.
It helps to make sure the process of statistical control chart is statistically
stable and capable.
It helps in continuous improvement.
It helps to give awareness on the quality status.
It gives visibility of the problem.
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It gives traceability of the problem.

It helps to support smooth regular quality activity.
It helps to eliminate previous problem.
It helps to improve the existing product or process.
Activity: 2
A Government Hospital is using SPC for their data. List the benefits of
SPC.
(Hint: Refer to section 4.5.1 Statistical process control)

Self
10.
11.
12.

Assessment Questions
SPC stands for ____________________.
DOE stands for ____________________.
The statistical and design tools can be divided into three main areas.
(True/False)

4.7 Summary
Quality tools and techniques can be summarised as follows:
As the statistician, Taguchi, defines quality as loss of function which will
help assess the loss to society for not having a high quality product.
Higher the quality of the product or the service, the lower is the loss.
The simple idea is that the variables which influence the product can be
changed to find the performance of the product in different situations.
The tools and techniques is the practical means of determining exactly
how the product will work and what kind of variation it will present.
The quality management tool like the affinity diagram can be used to
organise the abstract thinking about a problem.
The relations diagram is used to determine the casualties among the
parts of the problem.
The PDPC can be used to find out the processes used to evaluate the
events and the prospective outcomes.

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4.8 Glossary
Facilitator:

It is someone who is can help everyone in the group and

express their leadership qualities

Cumulative:

It is formed by addition of successive parts or elements

Statistics:

It is the numerical data

Charts:

It is a sheet representing data in the form of graphs

Illustration:

It makes a comparison which is intended to clear or remove

the obscurity

4.9 Terminal Questions

1.
2.
3.
4.
5.

Explain quality tools and techniques.

Describe flowchart.
Explain cause-and-effect diagram.
Describe matrix diagram.
Explain Statistical Process Control (SPC).

4.10 Answers
Self
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.

Assessment Questions
Decision Making Process
True
True
20-80 rule
Fishbone diagram
False
Ideas
Process Decision Program Chart
Arrow diagram
Statistical Process Control
Design of Experiments
True

Terminal Questions
1. The quality tools and techniques are used by the organisations to
monitor and also manage the quality initiatives. Refer to section 4.2 for
the same.
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2. The flowcharts give the visual illustration of the sequence of the

operations needed to complete a task. Refer to section 4.3.1 for the
same.
3. The cause-and-effect diagram is used to obtain more information about
the process and its output. Refer to section 4.3.2 for the same.
4. The matrix diagram is the graphical tool which shows the relationship
between ideas in the form of a table. Refer to section 4.4.4 for the
same.
5. The Statistical Process Control (SPC) is used for process monitoring
and variability reduction. Refer to section 4.5.1 for the same.

4.11 Case-Let
Control Charts to Track the Productivity of Physicians
In a Government Hospital, the control chart is used to track the
productivity of physicians. The hospital provides healthcare services at
low cost to patients and thus has the name of being patient centred.
Dr. Sham, the head surgeon of the hospital, is responsible for managing
the medical staff, clinical research, resident education and clinical quality
improvement. During his tenure, he encouraged the physicians and staff
members to become more productive. He developed a strategy for
performance improvement, based on his nine years of service, using the
control charts. The use of clinical data to monitor and improve
performance is an old concept, but the traditional approach involved the
observation of clinical measure from month to month by reacting to the
individual practitioner's volume statistics at the end of each time period.
He used the productivity data from month to month and found a lot of
variation in the survey. On the other hand, in March 2001, the clinical
activity had almost tripled between September and December of that
year. Then, the clinical activity performance had decreased, which lead to
a dilemma regarding the variation in performance. He wanted to know if
there were any underlying special circumstances that lead to the variation
or was it within the range that could be considered as normal variance?
One method which the doctor could use to make sense of the variation in
the clinical activity performance is to add a trend line using traditional
linear regression. The trend line would show an increasing trend during
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the 12-month period that would have been difficult to detect through
simple analysis of the data.
Using control charts for evaluating the physician activity had a number of
advantages. Firstly, the importance of the variation in the clinical activity
measurement was readily apparent. Control limits, which are used to
establish the bounds, can be used for determining if the variation can be
treated as a special cause or if it is related to expected variability in the
physician's practice patterns. Secondly, it will give information about the
trend of the physician's activity. Finally, combining the trend and control
chart analyses will give more complete representation of the doctor's
clinical activity. The physician's evaluation can utilise all of these
measures to identify opportunities for improvement, which will comprise
the discussion topics for the half-yearly physicians reviews.
Discussion Questions
1. Briefly describe how control charts were used by the government
hospital and how they benefited from using control charts. (Hint:
Refer to section 4.3.5 Control chart)
References
Nash, D. B and Goldfarb, N., The Quality Solution: The Stakeholder's
Guide to Improving Health Care, USA, Jones and Bartlett Publishers.
Lighter, D E. and Fair, D C., Quality Management in Health Care:
Principles And Methods, USA, Jones and Bartlett Publishers.
Committee on Quality of Health Care in America and Institute of
Medicine, Crossing the Quality Chasm: A New Health System for the
21st Century
E-References
http://www.balancedscorecard.org/Portals/0/PDF/control.pdf.
http://www.syque.com/quality_tools/toolbook/MDAC/do.htm.

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