How many times have you been part of a discussion about what health care workers, patients, or people in your community want and need and wondered whether you have identified the most urgent needs of the whole?
Imagine using a tool to uncover issues of the most importance to a group of health care workers as you seek to address the pain points that cause them to burn out so much that they no longer love their job or even treat others kindly. Imagine using a tool to sort through similar questions asked of community members you seek to engage, families who support their sick loved ones, or people who need the care you are seeking to improve. And imagine doing this work with their active engagement rather than for them. Picture the “aha!” moment your team may have when you name the vital few areas that, if addressed first, will matter most to and make the biggest impact on a wider swath of your community.
I have to admit: I love Pareto charts! A few years ago, this tool empowered our IHI team to identify the “vital few” areas to concentrate on to plan for the future. A Pareto chart is a type of bar chart that helps teams home in on the most important factors of a problem they are trying to improve or an effect they want to understand more fully. The Pareto principle, otherwise known as the 80/20 rule, tells us that 80 percent of the effect comes from 20 percent of the causes. (For further background, see this fabulous video demonstration or IHI’s QI Essentials Toolkit.)
At the start of a large-scale project to reduce maternal and newborn mortality, with many moving parts, new territory, and new team members converging from four different countries to support the efforts, both excitement and anxiety were going through the roof! I helped to facilitate a retreat for this group, the first time all team members would gather together to work on this initiative. Success would mean countless mothers’ and babies’ lives would be saved; failure wasn’t an option. I talked with individual team members in advance to discover what issues each person most wanted to address so we could draft an agenda and plan activities for our three days together. Pressing concerns included strategy, operations and logistics, roles and responsibilities, and mapping out activities for the year.
On the first day we prioritized topics to discuss during the retreat, but we needed a way to bring to the surface the positive and negative emotions that were quietly bubbling up. Enter: the Pareto chart. I realized this was the perfect time to use a rapid, modified version of the tool to get a sense of the team’s feelings and home in on a few key concepts to discuss together.
On note cards, team members wrote down what made them most excited and what made them most nervous for this new initiative. During the break, we categorized and tallied these responses. We drew bar charts with factors causing these emotions plotted on the x-axis and the frequency of responses plotted on the y-axis, ordered with the most common responses starting on the left (see photo).
Pareto charts showcased causes of the team’s nervousness (left) and excitement (right). The circled bar indicates the factor that most concerned the group: managing all the moving parts.
Those makeshift, hand-drawn Pareto charts (admittedly missing some components*) and the process behind them allowed the team to unpack the areas they needed to address first to succeed, while showing what else was on everyone’s mind. The excitement chart showcased what brought us joy. It added urgency, motivated us, and reminded us that the potential impact of this work outweighed the challenges.
The nervousness chart allowed us to acknowledge these feelings and validated our decision to focus on one factor that was screaming out to us: managing all the moving parts. This was by far the most frequently noted concern due to the immense scale of the project; it was the first time IHI would have an office in-country, and managing the operations and the implementation support would be a big task with ambitious goals.
During the retreat, we did exercises to get to know each other better and emphasized planning, including creating a project timeline on a giant calendar of the year ahead. Finally, we returned to our charts and re-assessed our feelings. We saw a clear reduction in the number of people nervous about the management piece, and one more category of excitement was added: everyone was excited about the team!
The Pareto chart is so versatile and can be a life saver when it comes to empowering teams to sift through the “useful many” to find the “vital few.” It combines the head and heart as you collect stories, feelings, insights, and ideas and sort them to create a visual depiction and count of what matters most to those who matter most. It creates a north star for improvers, leading them to the right place(s) to spend time, energy and effort. And it can free up countless hours from areas that may need improvement but are not going to move you toward your goals quickly enough.
*We didn’t have time to fully utilize all the components of a true Pareto chart. For example, we omitted the right-hand vertical axis that lists the percentage of the total that each factor represents. For more details about complete Pareto charts, review IHI’s QI Essentials Toolkit.
Patty Webster is an Improvement Advisor and Faculty at the Institute for Healthcare Improvement.