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Class Six Agenda & Objectives
HA 4315
I. Objectives and logistics A. Flow chart assignment due B. Overview of what radiation therapy is. C. Introduction to the exercise on brainstorming one or more of the problem areas from the radiation therapy report as to what caused the problem and as to what could be done to solve the problem. 1. Groups then use affinity diagrams to organize the output. 2. Groups then use multi weighted voting to rank either the causes or the solutions. D. Memory Jogger II, pp. 91-94, nominal group technique, multi-voting, and one half plus one. E. Memory Jogger II, pp. 12-18, affinity diagrams.
II. What is radiation therapy? A. Overview of radiation therapy People who need radiation therapy are not going to be particularly happy about having to get the treatment. These people have cancer. The cancer is sufficiently serious that they may be at risk of death or disfigurement from surgical removal of the cancer. There are three basic ways to treat cancer: Surgery, where you cut out the cancerous tissue. Chemotherapy, where the person is given drugs that kill the cancer cells and a lot of other cells too. These people often go bald. When they get radiation therapy of the scalp they may go bald and the hair is not likely to grow back.1 Those undergoing chemotherapy
Figure 1: Chemo and radiation: now deceased.
Figure 2: Radiation therapy baldness
Image of radiation therapy-induced baldness and the info following are from http://www.hairtherapyforwomen.com/causes.html, retrieved January 13, 2009. Drugs designed to kill cancer cells also poison the hair follicles and often result in total hair loss. Hair on the head is most commonly affected. The scalp may become tender; and hair that is still growing may become dry and brittle. Usually hair loss starts approximately 2-3 weeks after the first dose of chemotherapy, with total hair loss generally occurring 1-2 months later. Hair often grows back 3-4 months after the last chemotherapy treatment. As hair may grows back, it may
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usually get their hair back. Radiation therapy does not affect hair unless the radiation is of the scalp. Radiation therapy2 (also called radiotherapy, x-ray therapy, or irradiation is the use of ionizing radiation to kill cancer cells and shrink tumors. Radiation therapy injures or destroys cells in the area being treated (the target tissue) by damaging their genetic material, making it impossible for these cells to continue to grow and divide. Although radiation damages both cancer cells and normal cells, most normal cells can recover from the effects of radiation and function properly. The goal of radiation therapy is to damage as many cancer cells as possible, while limiting harm to nearby healthy tissue.
People getting any of these three therapies are usually desperate, choosing between a set of very unpleasant options. It is not uncommon for a person to be getting radiation and chemotherapy at the same time and then perhaps to undergo surgery. Or, the person may have already had surgery and it did not work. Cancer is the second leading cause of death in the U.S. and 52% of hospice patients in 2000 had cancer as the diagnosis.3 The side effects of these therapies can be grim, so persons treating them have to be especially careful to manage the experience of care in not only a professional and competent manner, but to exhibit kindness and compassion. Many people recover and lead full lives. However, many bear substantial scars. Wayne Sorensen lost an eye due to brain cancer. My mothers boss lost an ear and the radiation therapy so damaged his ribs that they were brittle and would break if he sneezed. A friend of my wife lost both breasts and is unable to work. My mother lost her colon and later had to undergo an ileostomy,4 but she is alive and otherwise pretty well at age 89. Imagine losing one or both breasts, becoming impotent or infertile. These are not pleasant side effects. Since many students in this class are radiation therapy majors and we shall analyze a case involving data from a radiation therapy clinic, it is very important to understand just what takes place in the radiation therapy part of the treatment. Even if the class has no radiation therapy
be thinner and a different color, which may be gray or white, due to the absence or alteration of pigment. In most cases hair eventually returns to its original texture and color. Radiation therapy destroys the ability of all cells within its reach to grow and reproduce. If radiation is applied around the head or neck, hair loss will occur as alopecia, and may not grow back. 2 Information on radiation therapy here is taken from http://www.cancer.gov/CANCERTOPICS/FACTSHEET/THERAPY/RADIATION, retrieved January 12, 2009. 3 Statistics taken from NCHS at http://www.cdc.gov/nchs/FASTATS/cancer.htm, retrieved January 13, 2009. An ileostomy is procedure in which your normal excretory functions are terminated and you excrete into a bag on your thigh. See http://www.cancer.org/docroot/CRI/content/CRI_2_6x_Ileostomy.asp, retrieved January 13, 2009. Needless to say, emptying and periodically attaching a new bag are not on anyones list of fun things to do.
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majors in it, health administration majors will likely work in the supervision of clinical areas. This can serve as an example of collecting information so you can understand what is taking place. I have never been in a radiation therapy clinic and hope not to be. But I can still learn about what is taking place in one. Health administration majors gain considerable credibility if they understand the processes in the departments they supervise. In the descriptions below, when a term occurs that is part of the data set we are using and I consider it would be unfamiliar, I have bolded it. Radiation therapy5 may be used to treat almost every type of solid tumor, including cancers of the brain, breast, cervix, larynx, lung, pancreas, prostate, skin, spine, stomach, uterus, or soft tissue sarcomas and lymphoma (cancers of the blood-forming cells and lymphatic system. respectively). The amount of the radiation dose delivered to each site depends on a number of factors, including the type of cancer and whether there are tissues and organs nearby that may be damaged by radiation. Radiation therapy also can be given to help reduce symptoms such as pain from cancer that has spread to the bones or other parts of the body. This is called palliative radiation therapy. External radiation therapy usually is given on an outpatient basis; most patients do not need to stay in the hospital. External radiation therapy is used to treat most types of cancer, including cancer of the bladder, brain, breast, cervix, larynx, lung, prostate, and vagina. In addition, external radiation may be used to relieve pain or ease other problems when cancer spreads to other parts of the body from the primary site. Note that in our case, the data are from a hospital. However, I think we can assume that most of the patients are seen at a clinic and are treated as outpatients. Nonetheless, there are inpatient stays for some types of radiation therapy. Radiation therapy that involves a hospital overnight stay is usually done in conjunction with a surgical procedure. The doctor works with a figure called the therapeutic ratio. This ratio compares the damage to the cancer cells with the damage to healthy cells. Several types of machines are used to produce the radiation and others are used in the diagnosis and treatment planning. Linear accelerators Gamma knives CT MRI PET SPECT
There are likely others I did not list.
The material in the next several paragraphs is taken from http://www.cancer.gov/CANCERTOPICS/FACTSHEET/THERAPY/RADIATION, retrieved January 12, 2009, and edited.
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B. Planning for the treatment and diagnosis and the role of the team members As you can imagine, the planning of the amount of the dose, the duration, the frequency, the depth, and how to protect the healthy issue are all major issues in planning a radiation therapy regimen. Traditionally, the planning of radiation treatments has been done in two dimensions (width and height). Three-dimensional (3D) conformal radiation therapy uses computer technology to allow doctors to more precisely target a tumor with radiation beams (using width, height, and depth). Many radiation oncologists use this technique. A 3D image of a tumor can be obtained using computed tomography (CT), magnetic resonance imaging (MRI), positron emission tomography (PET), or single photon emission computed tomography (SPECT). Using information from the image, special computer programs design radiation beams that conform to the shape of the tumor. Learning to use these programs to simulate the therapy is a major part of the training for radiation therapists. Radiation therapists do not plan the therapy, but carry out the instructions of other, more highly trained medical professionals. Many health care providers help to plan and deliver radiation treatment to the patient. The radiation therapy team includes the radiation oncologist, a doctor who specializes in using radiation to treat cancer; the dosimetrist, who determines the proper radiation dose; the radiation physicist, who makes sure that the machine delivers the right amount of radiation to the correct site in the body; and the radiation therapist, who gives the radiation treatment. Often, radiation treatment is only one part of the patient's total therapy. Combined modality therapy, the use of radiation with drug therapy, is commonly used. The radiation oncologist also works with the medical or pediatric oncologist, surgeon, radiologist (a doctor who specializes in creating and interpreting pictures of areas inside the body), pathologist (a doctor who identifies diseases by studying cells and tissues under a microscope), and others to plan the patient's total course of therapy. A close working relationship between the radiation oncologist, medical or pediatric oncologist, surgeon, radiologist, and pathologist is important in planning the total therapy. Before radiation therapy is given, the patient's radiation therapy team determines the amount and type of radiation the patient will receive. If the patient will have external radiation, the radiation oncologist uses a process called simulation to define where to aim the radiation. During simulation, the patient lies very still on an examining table while the radiation therapist uses a special x-ray machine to define the treatment port or fieldthe exact place on the body where the radiation will be aimed. Most patients have more than one treatment port. The team uses a special X-ray machine called a "simulator" that can duplicate the position of potential treatment beams. Devices such as molds or masks may be made to immobilize the patient and aid in subsequent repositioning for daily treatment. These are called blocks in our data set. Using fluoroscopy and X-rays, the doctor decides what treatment fields will be used. Radiation therapists assist in this process. Simulation may also involve CT scans or other imaging studies to help the radiation therapist plan how to direct the radiation. The simulation may result in some changes to the treatment plan so that the greatest possible amount of healthy tissue can be spared from receiving radiation.
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The areas to receive radiation are marked with either a temporary or permanent marker, tiny dots or a tattoo showing where the radiation should be aimed. These marks are also used to determine the exact site of the initial treatments if the patient should need radiation treatment later. Depending on the type of radiation treatment, the radiation therapist may make body molds or other devices that keep the patient from moving during treatment. [I think these are blocks too.] These are usually made from foam, plastic, or plaster. In some cases, the therapist will also make shields [blocks] that cannot be penetrated by radiation to protect organs and tissues near the treatment field. When the simulation is complete, the radiation therapy team meets to decide how much radiation is needed (the dose of radiation), how it should be delivered, and how many treatments the patient should have. After the physician evaluates and approves the final plan, a physicist checks all the computations and details. The settings for each beam are also entered into a special computer system that will automatically check and verify that every subsequent treatment exactly matches the intended plan. All this preparatory work takes time, therefore, treatments usually begin approximately 5-10 days after simulation. C. Treatment Radiation therapy usually requires 5 treatments per week, Monday-Friday, for 2-7 weeks, although other schedules are sometimes employed. Radiation therapists place the patient on the treatment table in the same position as was used in simulation. They adjust the treatment machine, called a linear accelerator ("linac"), according to the plan. The accelerator produces high energy radiation beams that are suitable for cancer treatment. The therapists leave the room during the actual treatment, but maintain contact with the patient with closed-circuit TV and intercom. Before the first treatment and periodically thereafter, the therapists take films using the treatment beams to verify the accuracy. The treatment itself lasts only a few minutes, is not painful, and does not make the patient radioactive. It is similar to getting a long X-ray. The treatment planning involves only the radiation oncologist, physics staff, and dosimetrists.6 The radiation oncologist, using the x-rays obtained during the simulation, designs the treatment field. The physics staff designs special shielding blocks or plans that shape the radiation beam to the treatment field and help shield normal tissue from the radiation beam. In addition, special computer plans are developed by the dosimetrist that help the radiation oncologist develop a treatment plan that gives the best radiation dose distribution to the treatment field selected. Depending on the treatment plan, some patients return for a second simulation appointment. During this appointment the shielding blocks are placed at the top of
6
http://www.21stcenturyoncology.com/treatments/radiation-process.asp, retrieved January 12, 2009.
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the machine, and an x-ray is taken. The radiation oncologist compares this x-ray with the simulation film (or planning films) to ensure accuracy. During this visit, additional lines are drawn on the skin to outline the exact treatment field for the radiation therapists use. The lines remain on the skin throughout the course of treatment. Below are images from a PowerPoint developed for Mayo Clinic patients. I simply show them
to give a sense of the equipment and the processes involved.7 If you prefer to see a virtual tour of photon therapy, a form of radiation therapy, Loma Linda University Medical Center in California has a decent tour. I shall not show it here, but you can access it at http://www.protons.com/about-us/photo-tour/proton-treatment-center-entrance.html. The images below are from the Mayo Clinic slide show noted above.
7
Slide show: Radiation therapy treatment planning - MayoClinic.com, retrieved January 12. 2009.
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III. Introduction to the four projects for the radiation therapy exercise. The data set we shall use for all the remaining projects in the class is given below. It is a list of problems for which the number of incidents is being kept on a monthly basis at the facility. The facility is the East Texas Medical Foundation hospital in Tyler, TX. Ronnie Lozano, Program Director of the Radiation Therapy Program, provided the data, taken from a conference he attended on how to use the problem solving tools you are learning in this class. This case is as real world as it gets: real problems from a real place, chosen by someone from the field. Please note that this list is modified from the original as to the number of entries per problem and the dates of the problems.
These capitalization inconsistencies in the table below are from the original document from the health care facility. They would count as G&S errors owing to the inconsistent capitalization. Just because your source writes poorly will not excuse you to copy their poor work and not correct it. The same goes for the affinity diagram in Figure 13, page 15. This table of data is in TRACS so you can use it in your projects, correcting G&S as needed. It is found at TRACS/HA 4315/resources/group project assignment instructions/RT projects data set.xls.
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2008 records Radiation therapy patients
680 685 713 647 762 726 675 720 5608 JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC Sums
CT / Simulation delays/Problems CT/SIm delays: Imaging studies not available on time CT/Sims delays: Physician not available at appt time CT/Sims delays: Insufficient time allotted for procedure CT/Sims delays: Contrast not given
0 0 0 0
0 0 0 0 0 1 1 1 2 3 8
0 0 0 0 0 0 1 3 2 1 7
0 0 0 0 0 0 1 4 1 1 7
0 0 0 0 0 0 1 1 1 2 5
0 0 0 0 0 1 1 1 1 2 6
0 0 0 0 1 0 1 3 1 3 9
0 0 0 0 0 1 2 1 4 5 13 0 0 0 0
0 0 0 0 1 3 9 16 13 20 62
CT/Sims delays: BUN/Creat. not taken 0 CT/Sims delays: Delay in registration 0 CT/Sims delays: Nursing not Available 1 CT/Sims delays: Delay in IV 2 placement CT/Sims delays: Patient Schedule 1 Conflicts C T/ S i m s d e la ys : S c h e d u le 3 inaccuracies TOTAL 7 Treatment delay problems Treatment delays: Chart removed and not tracked Treatment delays: Blocks incorrect Treatment delays: Blocks not ready Treatment delays: Incorrect/Incomplete information inchart or Impac. Treatment delays: Delay caused by machine fault Treatment delays: Chart Not Tracked Treatment delays: Films Not Run On Time Treatment delays: Sim Films Misplaced Treatment delays: Presc. Not Complete Treatment delays: Comp. plan not ready TOTAL
3 9 2 3 3 1 1 2 1 1
4 4 2 7 5 1 1 1 1 3
7 1 3 6 6 1 1 2 1 1
3 1 2 7 5 3 1 1 1 3
7 4 1 7 5 1 1 1 1 3
4 4 0 7 5 2 1 1 0 3
4 4 4 7 10 1 1 3 2 3
8 4 1 7 5 4 1 1 0 3 0 0 0 0
40 31 15 51 44 14 8 12 7 20 242
26 29 29
27 31 27 39 34
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2008 records Radiation therapy patients
CT Film Rejects CT film rejects: Treatment Planning CT film rejects: Diagnostic CT film rejects: Therapy TOTAL Causes of Repeats: Cause of rpts: Cause of rpts: Cause of rpts: Cause of rpts: Cause of rpts: Cause of rpts: blank, black TOTAL Equipment Equip prob: Equip prob: Equip prob: TOTAL
680 685 713 647 762 726 675 720 5608 JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC Sums
3 1 1 5
1 2 1 4
1 0 1 2
1 1 1 3
1 0 1 2
1 1 1 3
1 0 0 1
1 1 1 3
0
0
0
0
10 6 7 23
Positioning Error Difficulty due to size Too Light Too Dark Motion Wasted film: green,
3 0 1 0 0 0 4
4 0 0 0 0 0 4
5 0 0 0 0 0 5
7 0 1 0 0 0 8
7 0 1 0 0 1 9
7 0 0 0 1 0 8
5 0 0 0 0 0 5
7 0 0 0 0 1 8 0 0 0 0
45 0 3 0 1 2 51
Malfunction: Phototimer Generator Processing Problem
0 0 0 0
0 0 0 0 1 1
0 0 0 0 1 0
0 0 0 0 0 1
0 0 0 0 0 0
0 0 0 0 0 1
0 0 0 0 0 1
0 0 0 0 0 1
0
0
0
0
0 0 0 0 3 5
Ports not checked by Dr. within 24 1 hours Calculations not checked by physicist 0 within 3 days
Grand Total
43 47 44
46 47 45 55 59
0
0
0
0
386 6.9
Proportion of quality problems per 100 6.3 6.9 6.2 7.1 6.2 6.2 8.1 8.2 ## ## ## ## patients
Some terminology not already provided may prove helpful. Contrast not given: the contrast is something you take orally or by injection that helps make the images easier to read on X-rays and other modalities. BUN/creatine not given: this is something given to the patient to determine if they will have an allergic reaction to the contrast medium. Patient schedule conflict:: the patient is scheduled to be at two places at one time by the organization. Schedule inaccuracies: the schedule says one time in one place and another time in
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another place. Charts removed and not tracked: the patients chart has been taken from where it was expected to be. It is not tracked if no one knows where it is, meaning it was not signed out. Incorrect information in the chart or Impac: I assume Impac was a computer program in place at the time the data were provided by ETMF. You cannot develop a plan if the data are not correct. Prescription not complete means the treatment plan is not done. Computer plan not ready means the treatment plan has not been loaded into the computer and the parameters prescribed set up.
CT film rejects in three categories. I do not know the differences in the categories, but in any case, the films taken are not useful and will have to be taken again. Remember that the table of data is in If any of the other items are unclear to you, TRACS so you can use it in your projects, ask me. correcting G&S as needed. It is found at TRACS/HA 4315/resources/group project assignment instructions/RT projects data Now that you have seen the data, the flow set.xls. chart below, Figure 11, the shows tasks required for the remaining four projects in the class.
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Overview of all four radiation therapy projects
Get motivated to improve the patient care experience.
Examine the data to get a sense of the nature of the problems and the extent of the problems.
Identify the major problems and prioritize them.
Perform a root cause analysis to detect problems that are generalized.
Develop a plan to address one or more of the major problems.
Develop standards of performance & measure the organization against those standards.
Write a memo explaining what you did, how the tools worked, and what your assessment of the RT department is.
Take a ten minute break.
Figure 11
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Now we turn to the first of the four projects taking up this data. This will first involve the use of brainstorming to create an affinity diagram that organizes the results of the checksheet ETMF provided. Second, once the data are organized, you will use weighted multi-voting to rank the categories in terms of importance and then vote again to rank the items listed under the most important category.
IV. Memory Jogger II, pp. 12-18, affinity diagrams.
The affinity diagram is a means of organizing the output from the brainstorming technique. The basic idea is similar to that of an outline, except you are using cards instead of a piece of paper. This concept was developed to make it easier for a team to reorganize the brainstorming output several times without having to rewrite an outline. Using cards, the team members can simply rearrange the cards until they get the ideas organized to their liking. Then an affinity diagram can be drawn that is based on the cards.
A. Examples of affinity diagrams
The Memory Jogger II uses a rather simplistic example of progressing from brainstorming to an affinity diagram by using the problem or opportunity of planning a family vacation. I have replaced that affinity diagrams brainstorming results with Figure 12, which shows a few
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Figure 12
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ideas/cards which came up in brainstorming the topic of issues involved in radiation therapy treatment delays. Figure 12 is NOT an affinity diagram, but simply a pile of cards resulting from brainstorming.
Figure 13, below and to the right, shows the ideas from the note cards organized under headers. This is the format of an affinity diagram.
Figure 13
Notice in Figure 13 that the header elements have different shaped boxes. The issue
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statement includes the major headers as part of the sentence. The middle header topic, key items are misplaced or wrong, is further subdivided into two subtopics, patient information is misplaced, and materials are prepared incorrectly or data is input incorrectly. All of these headers are in complete sentences. These subheaders are also distinguished by having different box shapes. Given that I have said the affinity diagram is nothing more than outlining using cards in a group setting, the actual outline version of the affinity diagram is shown below. I converted the headers to complete sentences to correspond to the assignment requirements.
Treatment delays in radiation therapy are due to failure to follow schedules, misplacing items, incorrectly prepared items, inadequately performing people, and machine failures.
I.
Schedules are not followed A. Films Not Run On Time B. Comp. plan not ready C. Presc. Not Complete D. Blocks not ready Note, again, that the diagrams above and the outline to the left are reproduced as it was given to me from the facility. You will observe many capitalization inconsistencies. If you copy material from the tables, I expect you to correct their errors. I left them there so you would have something to do.
II. Key items are misplaced or wrong A. Charts and films are misplaced 1. Chart Not Tracked 2. Patient chart removed and not tracked 3. Sim Films Misplaced
B. Blocks are done incorrectly and computer info is input wrong 1. Blocks incorrect 2. Incorrect /Incomplete information in chart or Impac. III. Other problems observed include poor management, machine problems, and poorly trained or supervised employees A. Radiation therapy manager is disorganized B. Delay caused by machine fault C. Employees do not know what to do
While we have not had the tool yet, this outline or the affinity diagram could serve as the major elements to build a cause and effect or fishbone diagram. A rudimentary version is shown to the right in Figure 14. Figure 14
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D. How to use the affinity diagram
1. Specify the issue under consideration in a full sentence which the team will agree upon.
2. Brainstorm until 20 or more ideas are generated.
Affinity diagrams may have many more than 20 ideas. Record the ideas on note cards, each idea should have at least a noun and a verb, not one word only. Phrases or sentences are allowed.
3. Once the brainstorming portion is completed, group members move the cards into categories they think make sense.
The text says to do this silently. The main reason is that it allows any team member to move a card without having to justify the move. However, any other team member can move the card again. Im not sure how important the silence rule is. Decide upon it yourself in your ground rules and change the rule if you find it is not working.
a. Sort individually, not in subgroups
b. If one card belongs in several categories, make copies of it and have it in multiple groups.
c. All notes do not have to be in groups.
d. Six to ten groupings are common, with a usual maximum of 15-17.
e. Stop the sorting process when it appears that little additional sorting is wanted by any team member.
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4. For each group, create a header card which summarizes the central idea or theme of the grouping.
Optimally, the header cards should look different--different ink color, bigger print, a pattern marked on the card, etc.--so that they are not confused with the ideas they are supposed to summarize. It may be that different group members have different ideas about what the header card should be. In this case, make multiple draft header cards. Draft header cards can be phrases. W hen the final version of the header card for each group is agreed upon, the header should be a complete sentence. All members should be involved in the development of the headers, just as with the development of the ideas on the cards.
A full sentence header card is required for each item which has subsidiary items under it. Consider the outline analogy. If you had major points I. and II. and major point II. had an A. and a B under it and A had no items under it and B had three items under it, the complete sentences would be required for I. and II. and B, but not for A. This is shown below.
I II
This is a header and needs to be a complete sentence. This is a header and needs to be a complete sentence. A. This is NOT a header since it has no subsidiary idea under it. It could be in complete sentences, but it is not required. B. This is a header and needs to be a complete sentence because there is a subsidiary idea under it. 1. Topic idea one. 2. Topic idea two. 3. Topic idea three.
The diagram below, Figure 15, shows the process.
E. Diagram of the affinity diagram process
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Figure 15 As you can see, affinity diagrams are nothing more than a way to create an outline of sorts, using cards in a group process, rather than using an actual outline as an individual. The main purpose of affinity diagrams is to clarify and organize the nature of the problem.
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II. Memory Jogger II, pp. 91-94, nominal group technique, weighted multi-voting, and one half plus one.
The nominal group technique and weighted multi-voting are ranking techniques. These particular versions of ranking do not develop weighted criteria, but simply have the team members rank their choices as if each item was of the same importance or value. Different team members may well have very different criteria in mind when ranking the options. If this becomes a problem within the group, then more complex ranking methods must be used. The more complex methods require development of specific criteria for the team to use. These methods are found in prioritization matrices. I had to remove the exercise that used that tool owing to time constraints.
A. The nominal group technique
The nominal group technique occurs after brainstorming. You rank the brainstorming output according to the team members evaluation of the usefulness of the ideas. Thus, to use the technique, you first develop ideas using brainstorming. With simple problems or solutions, instead of going from brainstorming to an affinity diagram which organizes the output, the text says the next step is to rank the importance of the ideas. If there are a large number of ideas, using the affinity diagram may help. My view is that most problems that require use of problem solving techniques would need to be outlined or put into an affinity diagram.
The Memory Jogger II suggests giving a letter to the choices you are going to rank or rate to represent them. In my opinion a short descriptive phrase is a lot better than an utterly uninformative representational letter. Next, provide a numerical scale to rank the importance of the causes, problems, ideas, solutions, whatever. This scale is determined by the number of items. Ten items would have a scale of one to ten. Five items you would scale one to five. As noted before, development of explicit criteria for the ranking is never done. There is no requirement to avoid development of criteria. It simply does not appear to occur in the nominal group technique.
We would choose to have as many things to rank as we have causes, problems, solutions, ideas, etc. Lets assume we are looking at a problem with five categories of causes. This gives us five letters or short descriptive phrases. The Memory Jogger II says the process simply requires each person to put an A-E (for the five items to rank) down one column on a piece of paper and a ranking next to them, 1-5. The outcome might look as seen below:
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While we have no idea what the criterion or criteria each team member used, we see that cause category B scored significantly higher than the other cause categories. Cause category D was least important, with the other categories not much more important.
Nominal Group Technique for ranking cause categories
Cause category Group
Torrie R. Kraig S.
Members
Sandra T. Monique S. Jennifer J.
Total
A B C
4 5 3 1 2 15
5 4 1 2 3 15
2 5 3 1 4 15
2 3 4 5 1 15
1 5 4 2 3 15
14 22 15 11 13
These finding suggest that the team should focus on cause category B. No member rated B less than a three.
D E
Totals
For purposes of group cohesiveness I would want to know why Monique S. thought cause category D had such great importance. Conceivably, the group may wish to reassess their votes if Monique S. has reasons that were both important and overlooked by other team members.
The biggest problem for me in the nominal group technique is how it forces you to vote. No matter what your opinion of the various items, if there are only five, the lowest score you can give is a 1, which would mean you voted 20% for it. W hy should I have to give any value to an option I do not like? For these sorts of reasons, I prefer the weighted multi-voting method, shown next.
B. Weighted multi-voting
The Memory Jogger II tells us that we can rate (not rank) our choices by allocating 100 total votes among the choices as we see fit. The idea of multi-voting is to help break ties by letting the group vote again. The advantage of the weighted multi-voting is that no scores need be given to choices the team member does not favor at all. The nominal group method forces a vote for each cause. The weighted multi-voting method allows voters to concentrate their votes on the categories they value the most. However, the negative to the weighted multivoting is that one person may succeed in skewing the entire process. Some examples are given below.
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In the example to the right, one person, April P, forces a cause category no one else favors very much at all to come in second in the ratings.
Weighted multi-voting
As can be seen, the members have 100 votes and the high vote went to solution idea B again. However, note what could occur when all of the votes can go to one cause category. April P. put all her votes on cause category D, leading it to be quite high relative to the other cause categories. However, all the other group members either failed to vote for D at all or gave it a low score. Even had April P. been the only person to vote for D, by giving it the entire weight of 100, it would still have been number 2.
One solution to this circumstance is to agree that idea #1 will be taken up first in priority. Then remove idea #1 from the matrix and vote again. This keeps one person from dominating the vote. This method should remedy the problem. The reason this will work is that the other team members have already set aside their first preference. Category C is the one most favored as second for the other group members. If they believe that category D will get a 100 from April again, and they do not want this choice to prevail, you can bet some of the team members will vote very highly in favor of what was their second preference to offset the 100 given by one member to category D. Weighted multi-voting when one persons vote skews the entire group process
However, this rule is not going to work in all circumstances where a skewed vote could occur. A similar situation with dysfunctional results is shown to the right. The main difference from the prior example is that there are eight categories.
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In the situation depicted above, one extremely adamant person again gave all their votes to one idea. This made that idea come in first, even though no one else voted for it at all.
My view is that this is not a tolerable outcome--and is probably unlikely to occur. Nonetheless, for the group process to work, it should not even be possible for one person to dominate. Knowing the egos and the tendency to protect turf, it is a contingency to prepare against.
In this situation, the group needs to consider what rules to follow--before they vote--so they can be clear on them up front.
Before voting, I would have a rule that no Take Steps to Avoid One Person idea can be considered the top idea unless Dominating the Voting a majority of the group at least voted some Before voting, I would have a rule that specified percentage for it. In this case, if no idea can be considered the top idea the rule was At least three members have to unless a majority of the group at least give at least a 10% or higher vote for it to voted some specified percentage for it. receive top rank then only A, B, and E would be in the consideration. In this case, idea #1 would win. When developing these rules it is important to keep the integrity of the voting process sacrosanct. No rule should restrict how anyone can vote. Everyone has 100 points and they should be able to vote them as they wish. Make sure you know how to write an appropriate rule without restricting anyones voting. Simply quoting what it says in the box will not suffice as having developed a complete voting rule. The box is the theory, the test will ask you how to apply it.
C. Ranking ideas when using affinity diagram
Sometimes, it is necessary to rank the ideas in an affinity diagram. Since the affinity diagram has organized the ideas into categories you could then use the nominal group technique or some other ranking technique to rank the ideas in each header category. If it is necessary to organize the output of brainstorming into categories by rank, then you would rank the header cards or header statements. Once those are ranked, you would then rank the ideas within the headers. The next stage is to develop means and ends to solution of the problem.
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Figure 18, to the right, shows a possible ranking of the problems leading to delays, using the three major header statements from the radiation affinity in Figure Figure 18 13, page 15. Item #2, key items are misplaced or wrong, scored the highest as contributing to the problem.
The next step is to rate the items within that category. That is seen in Figure 19, to the right. We see that chart removed and not tracked is the leading cause of delays Figure 19 within the category of key items are misplaced or wrong. This lets us know that it is the first thing to concentrate upon when trying to solve the problem of delays, since it is the largest problem in the largest category of problems. Note too that the problem chart not tracked appears to duplicate a portion of chart removed and not tracked. The better procedure, if this is true, is to either have two categories, 1) chart removed and 2) chart not tracked, or get rid of the duplication and only vote on chart removed and not tracked. Any decent team would make these clarifications before voting or vote again after clarification.
Part of what another group and I shall be looking for when you turn in the assignment is whether you used the spreadsheet effectively. Thus, besides getting a printed copy, the other group and I need to see the formulas. An easy way to print showing the formulas is to first make them show by pressing Ctrl and ~ at the same time. Then what you print shows the formulas. However, then you have print two copies. One has the formulas and one has the output of them. What I am looking for is the following.
The totals for the rows and the columns are calculated using the =sum(list) formula, where list is the cell addresses of the items being added. As an example, Figure 20, on page 25, below,
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is what the cells look like in formula format for one row of cells being added up properly. I made the formulas appear by pressing ctrl and ~ at the same time. To get rid of the formulas press the combination again. The expected printed version of the same would look as in Figure 21. When you create the correct formula for the first column you can simply dragcopy it to the right and fill in the others.
Figure 20
Figure 21 For the final column, H in the example below, where you compute the percentage each item is of the denominator I want you to show good technique by locking the cell address for the denominator. The formula is simply created by going to the cell where you want the answer. Press = and then move the cursor to the denominator. Press / to signal division and then move the cursor to the denominator. When the cursor is over the cell you want to lock you press the F4 key. Or, you can simply put dollar signs around the parts of the cell you want to lock manually. In formula form the outcome would look like column H in Figure 21. When you copy from the top on down the denominator remains the same.
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V. Exercise using affinity diagrams and multi weighted voting
Your group will brainstorm one or more of the problem areas from the radiation therapy report as to what caused the problem and as to what could be done to solve the problem. Groups then develop an affinity diagram to organize the output. Groups then use multi-weighted voting to rank either the causes or the solutions. The list of problems is below.
My examples of these tools that are in these notes can be used as models of the format and process, but I expect something different than copying what I have put in the notes. To accomplish this, take one task and work out the causes of the problem and some solutions or take two or three closely related problems and work out the causes and the solutions. Grading criteria for the exercises are given below and are also found in TRACS/resources/Project grading criteria/Project Two gradingSpg08.xls.I have also put the grading criteria below. They are in three parts. There is one sheet for the affinity diagram (Figure 22, below) and one sheet for the multi-weighted voting (Figure 23, page 27).
A third sheet (Figure 24, page 27) assembles all of the information on the first two, shows the weights for each component, and shows the grades for the group evaluating how well these things were done. This sheet is very similar to the single sheet you saw in the flow chart grading criteria spreadsheet.
Figure 22
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Figure 23
Figure 24
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