How To Decide Which Quality Project To Do First

By:  David M. Kashmer, MD MBA (@DavidKashmer.  Linked profile here.)


Once you start down the pathway of quality improvement, you may start to see potential projects everywhere.  Problems with prolonged patient times in the Emergency Department?  Maybe you’ll start with that project first.  Trouble with supplying or re-setting the trauma bay?  There’s another potential project.  And what about operating room turnover time?  There’s another.  Hmmm…each of these seems very different and very important.  Which one do we address first?


Read on, because this blog entry is about a useful tool to help prioritize each potential issue in order to decide where to turn first.


It’s Not Just About Which Feels Worse


Sometimes, there may be that one project that we just really want to do.  It could be because we are mostly in the operating room, and an issue with turnover time affects us each day.  Or, perhaps, it’s because we are in the Emergency Department a great deal and that project with patient time in the department is so obvious to us that it just has to be done right this minute.


Well, this is a situation where spending some time thinking about which project to do first may help you a lot later on.  Let’s look in on a useful tool to help decide where to go first.


Look At The FMEA


The FMEA, or Failure Mode Effects Analysis, is a tool designed to prioritize potential projects–and it does so based on some interesting criteria.  For example, the FMEA ranks potential failure modes of a system according to severity.


That criterion is clear enough:  the worse the outcome could be, the higher the severity score from 1-10.  That criterion seems fairly obvious.  If a situation could give a worse outcome, that situation (or the project to repair it) receives a higher severity score.


The FMEA also ranks failure modes using their probability of occurrence.  More common occurrences receive a higher score on the 1-10 scale.  We tend to think of the typical failure rate in service industries, with 1 defect in 1000 opportunities (1 sigma), as approximately a 5 on the 10 point scale.  That said, it is the next criterion that the FMEA uses which interests me most.


If A Defect Happens In The Forest, And There’s No One There…


What if you had a system that made a defect that it was impossible to find before it made it to the patient?  Think about it for a moment.  You may have met someone at the quality meeting who says “Well it’s just very difficult to detect this particular issue before it gets to the patient.  And even if it does they do ok.  I see no bad outcomes.  In other words, there’s no way to know.” The implication may be that the defect just doesn’t matter.


Well, in terms of ability to detect a defect, if it’s difficult to detect the defect then the defect matters even more.  Said differently, if there’s no known way to figure out that there’s a defect before it gets to the patient it is more important to prioritize that failure mode on the FMEA.  Impossible to find the defect before it gets to the patient?  That, my friend, is a 10 on the FMEA’s detection scale parameter.


Here’s The Most Useful Part


The next useful step is to multiply the severity (S) index by the probability of occurrence (O) and the probability of detection (D).  This S x O x D gives the Risk Priority Number, or RPN.  Find the failure mode with the highest RPN, and the project associated with that failure mode is often the one to address first.


In the end, the FMEA allows us to rank each potential failure (usually named as the project that would repair it) on the FMEA grid.  Just as importantly, it allows us to bring the team onto the same page about which issue to address first.  It even highlights how events that are more difficult to detect may be the more important ones to address earlier.


Hope you find this quality tool as useful as I do!  For more information on the FMEA process, click here.


And here is an Excel workbook, tabs at the bottom for each step, for your very own next FMEA:




Questions or comments?  Let me know.