Quality Assurance

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Quality assurance

 Course Number:
 Credit Hours: 1
 Pre-Requisites: Management
 Location of Classroom: to be determined
 Time Slot: 15 Hours
 Course Dates/Times: First trimester

Facilitator’s Information

 Emmanuel BIKORIMANA, Lecturer

 General Staff Office
 Email: emmanuelbikori@gmail.com
 Phone number: 0788571508

Course Information

Course Description:

The course of quality assurance teaches the tools and procedures which prepare learners to
improve the quality of care delivery

Purpose of the Course:

The main purpose is to raise awareness about the importance of quality assurance in
everyday work situations. It focuses on essential knowledge needed to plan and
establish quality assurance in the health facility. It gives concept, principles and
processes of quality assurance. The course is also a useful guide for supervision the
implementation of quality assurance programmes

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Course Goals/Objectives:

• General objective:

At the end of the course the 3rd year student will be able to participate in quality improvement
projects of care and services offered to the clients/patients.

 Specific objectives
At the end of the course, the student will be able to:

Declarative Knowledge

The students will be able to:

1. Define the key concept

2. Explain the quality dimension
3. Describe the stage of the quality improvement process
4. Describe the types of measurement of quality care and services

Cognitive Skills

In a concrete situation, the students will be able to:

1. Illustrate with concrete examples, the 4 basic principles of quality assurance

2. Select an appropriate tool relevant to a stage of quality process
3. Use an appropriate approach to the improvement of quality care and services according to
the identified problem

Teaching and Learning Strategies:

Lecturing, Group discussions, assignment, group Presentations, Case studies

Course Policies and Expectations:

 The attendance is compulsory

 Students are expected to submit all assignments on time .Those who are late to submit
their assignments will lose 10% per day, up to a total of 5 days, at which point the
student will receive a mark of zero.
 Students are expected to actively participate in all sessions.
 Recommended language : English (Refer to the Academic regulations
 Student should refer to the facilitator any problem she/he meets within the course

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Exam and Grading Criteria:

The exam will be worth a total of 50% of the student’s final grade. The exam will test students
on all topics covered in class and on the information discussed with each weekly assignment.
The format for the exam will consist of a combination of multiple choices; fill in the blank
questions, short answer questions, and a case study.

Grading Criteria:

Assignments……………………………………………………………...25%
CAT………………………………………………………………………25%

Final Exam…………………………………………………………….....50%
Total……………………………..…….…………………..……………..100%

Required Texts, Readings, and Resources:

Ashton, J. 2001. Monitoring the quality of hospital care. Health Manager’s Guide. Bethesda,
MD: Published for the U.S. Agency for International Development (USAID) by the Quality
Assurance Project.

Batalden, P., and P. Gillem. 1989. Hospital-wide quality improvement storytelling. Quality
Resource Group. Nashville, TN: Hospital Corporation of American.

Bouchet, B. 2000. Monitoring the quality of primary care. Health Manager’s Guide. Bethesda,
MD: Published for the U.S. Agency for International Development (USAID) by the Quality As
surance Project.

Donabedian, A. 1980. Explorations in Quality Assessment and Monitoring. 3 vols. Ann Arbor,
MI: Health Administration Press.

Massoud, R., and K. Kuznetsova. 1998. Iaania.aiea ea.anoaa o.aaiia .oeiaianoai. Bethesda, MD:
Published for the United States Agency for International Development (USAID) by the
Quality Assurance Project.

Miller Franco, L., J. Newman, G. Murphy, and E. Mariani. 1997. Achieving Quality through
Problem-Solving and Process Improvement (Second Edition). Quality Assurance Methodology
Refinement Series. Bethesda, MD: Published for the U.S. Agency for International Development
(USAID) by the Quality Assurance Project. NHS (National Health

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COURSE CONTENT

CHAPTER I: GENERAL INFORMATION

1.1 Definition of concept

1.2 Quality dimension
1.2.1 Professional competence
1.2.2 Performance of service providers and health care institutions
1.2.3 Accessibility
1.2.4 Effectiveness
1.2.5 Continuity
1.2.6 Equity
1.2.7 Efficiency
1.2.8 Interpersonal relationships
1.2.9 Innocuousness
1.2.10 Coverage/utilization of service
1.2.11 Choice of service
1.3 Quality standards
1.3.1 Interest of standards
1.3.2 Types of standards

CHAPTER II: QUALITY ASSURANCE PRINCIPLES

2.1 Emphasis on the client/patient

2.2. Systemic approach
2.3. Teamwork
2.4 Utilization of data and scientific method
2.5 Effective Communication

CHAPTER III: QUALITY IMPROVEMENT TOOLS

3.1 Data Collection

3.2 Brainstorming
3.3 Affinity Analysis
3.4 Creative Thinking Techniques
3.5 Prioritization Tools: Making Decisions among Options
3.6 Expert Decision Making
3.7 System Modeling
3.8 Flowchart
3.9 Causes-and-Effect Analysis
3.10 Forces-Field Analysis
3.11 Statistical/Data Presentation Tools
3.12 Benchmarking
3.13 Gantt Chart
3.14 Quality Assurance Storytelling

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CHAPTER IV: QUALITY IMPROVEMENT STEPS

4.1 Step One: Identify

4. 2 Step Two: Analyze
4.3 Step Three: Develop
4.4 Step Four: Test and Implement
4.4.1 The Cycle for Learning and Improvement

CHAPTER V: QUALITY CARE AND SERVICES IMPROVEMENT APPROACHES

5.1. Individual Problem Solving

5.2 Rapid Team Problem Solving
5.3 Systematic Team Problem Solving
5.4 Process Improvement

CHAPTER VI: QUALITY MEASURES:

6.1. Goals and purpose of measurement

6.2. Types of measurement
6.2.1. Supervision
6.2.2 Monitoring
6.2.3 Evaluation
6.2.4 Self evaluation
6.2.5 Evaluation by pairs
6.2.6 Investigations
6.2.7 Audit

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CHAPTER I: GENERAL INFORMATION

1.1 Definition of concept

1.1.1 Quality:
To the ordinary person, quality is how good something is. This may be a service e.g. canteen
service or a product eg. wrist watch. A person's judgment about a service or product depends on
what he expects of it or from it. Some of the words used to describe quality are:
 Beautiful or attractive
 Durable
 Meeting standards
 Healthy
 Value for money
Although different words are used to explain quality, we would define it as the extent to which
a product or service satisfies a person or a group i.e. how much satisfaction the person gets
from the service.

1.1.2 Quality assurance:

The quality of technical care consists in the application of medical science and technology in a
way that maximizes its benefits to health without correspondingly increasing its risks. The
degree of quality is, therefore, the extent to which the care provided is expected to achieve the
most favorable balance of risks and benefits. (Avedis Donabedian, M.D., 1980)

...proper performance (according to standards) of interventions that are known to be safe, that are
affordable to the society in question, and that have the ability to produce an impact on mortality,
morbidity, disability, and malnutrition. (M.I. Roemer and C. Montoya Aguilar, WHO, 1988)

The most comprehensive and perhaps the simplest definition of quality is that used by advocates
of total quality management: .Doing the right thing right, right away..

1.1.3 Quality control:

1. Quality control is the process through which we measure the actual quality performance,
compare it in with the standard and take corrective action if there is deviation
2. It is a systemic control of various factors that affect the quality of the product. It depends on
material, tools, machines, types of labor, working condition, measuring instruments ,etc
3. It is a system, plan, method or approach to the solution of quality problem

1.1.4 Quality management:

1. (in health care) any evaluation of services provided and the results achieved as compared with
accepted standards. In one form of quality assurance, various attributes of health care, such as
cost, place, accessibility, treatment, and benefits, are scored in a two-part process. First, the
actual results are compared with standard results; then, any deficiencies noted or identified serve
to prompt recommendations for improvement.

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2. a system of review of selected hospital medical and/or nursing records by medical and/or
nursing staff members, performed for the purposes of evaluating the quality and effectiveness of
medical and/or nursing care in relation to accepted standards.

1.1.5 Total quality:

A total quality can be defined as a sequence of activities aimed to increase the global quality
levels of all operations that are carried out within an organization. A total quality programme is
not a simple campaign. A first step of the programme involves the development of organisation
and planning activities which have to be carried out just once, but the activities of analysis,
prevention, improvement and tracking of the total quality must be embodied in the management
system of the organization in a permanent manner, and have to be concreted in annual
programmes to keep the awareness and spirit on organization quality in the highest levels.

1.1.6 Quality circle:

Quality Circle is a small group formed to perform voluntarily Quality Control activities leading
to self development within the work place/workshop utilizing Quality Control techniques with all
members’ participation

1.1.7 Standards:

The term standard is used very often but its meaning is not understood by most people.
A Standard is a statement of expected level of quality. It states clearly the inputs required to
deliver a service, how things should be done (process) and what the output or outcome should be.
When we compare what is expected in the standards to what we do, we shall be able to identify
any quality gaps and then make plans to improve upon it.
Standards can be set for any level of the healthcare system i.e. national, regional, district, sub
district. They can be developed for use in public health, clinical care and support services.
There are also international standards e.g. those developed by the World Health Organization
that can be adapted to that of the country.

1.1.8 Quality dimension:

In order to develop a more complete definition of quality, we must consider some of the key
dimensions of a quality product or service. Dimensions of quality are a useful frame- work that
helps health teams to define and analyze their problems and to measure the extent to which they
are meeting program standards. These dimensions of quality are as appropriate for clinical care
as for management services that support service delivery.

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1.2 Quality dimension

1.2.1 Professional competence

Professional competence as an indicator of quality assurance implies that we should have
adequate knowledge and skills to carry out our functions in order to provide quality service. E.g.
one must go to a nursing school and pass the nursing examinations before she can work as a
nurse.
Even though we are no longer in school, we have to continue to update our knowledge by
reading health books and attending in-service training workshops etc.
As health professionals, we should also know our limits, that is, know what we can do and what
we cannot do. With respect to what we cannot do, we are expected to refer them to other centres
or personnel who are more competent to handle them. Our practice should also be guided by laid
down standards and guidelines e.g. Standard Treatment Guideline.

1.2.2 Professional Performance

The degree to which the tasks carried out by health workers and facilities meet expectations
of technical quality (i.e., comply with standards)

1.2.3 Accessibility
Everyone should have access to quality health care. Access refers to the ability of the
individual to obtain health services. Some of the factors that can affect access are:
a) Distance: e.g. where health facility is sited far away or it is difficult to get transport to
the facility access to quality health care becomes a problem.
b) Financial: e.g. where people cannot pay for the services provided.
c) Culture, beliefs and values: The services provided may not be in line with the culture,
beliefs and values of some people.

1.2.4 Effectiveness

We are interested in the type of care that produces positive change in the patient's health or
quality of life. We therefore use treatments that are known to be effective, for example, giving a
child with diarrhea Oral Rehydration Salt (ORS)

1.2.5. Continuity

Continuity means that the client gets the full range of health services he/she needs, and that when
the case is beyond us, we refer him/her to the right level for further care. Continuity may be
achieved by the patient seeing the same primary health care worker or by keeping accurate health
records so that another staff can have adequate information to follow up the patient.

1.2.6 Equity

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Quality services should be provided to all people who need them, be they poor, children, adults,
old people, pregnant women, disabled etc. Quality services should be available in all parts of the
country, in villages, towns and cities.
1.2.7 Efficiency
Efficiency is the provision of high quality care at the lowest possible cost. We are
expected to make the best use of resources and avoid waste of our scarce resources. We
waste resources by :
 prescribing unnecessary drugs
 stocking more drugs than is required and making them expire
 buying supplies and equipment we do not use

1.2.8 Interpersonal relationships

It refers to the relationship between us and our clients and communities, between
health mangers and their staff. We should:
 show respect to our clients;
 feel for our patients;
 not be rude or shout at them;
 not disclose information we get from patients to other people.
These will bring about good relations and trust between the clients/communities and
us. Clients consider good interpersonal relationship as an important component of
quality of care.

1.2.9 Innocuousness
Innocuousness/ Safety means that when providing health services, we reduce to the barest
minimum injuries, infections, harmful side effects and other dangers to clients and to staff. In
providing quality care, we should not put the patient's life at risk. For example, we should not
give unsafe blood to patients and thereby infect them with HIV/AIDS.

1.2.10 Coverage/utilization of service

The extent to which people are using services health. The health service utilization rates are
measured by the frequencies of visits to service providers, such as doctors, dentists, and
hospitals, and by whether or not people are taking prescription medicine.

1.2.11 Physical infrastructure and comfort:

The physical appearance of the facility, cleanliness, comfort, privacy, and other aspects those are
important to clients

1.2.12. Amenities
These are features that can be provided by our health facilities to make life comfortable and
pleasant for clients. They contribute to clients' satisfaction and make clients willing to use our
services. For example, comfortable seats, television set, music, educational materials, educative
video films, etc. at the OPD and wards.

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1.2.13 Choice of service:
When appropriate, client choice of provider, insurance plan, or treatment

Quality Assurance in Healthcare

QUALITY assurance (QA) includes all the actions taken to make healthcare better. These
activities build on the principles of quality management, “a systematic managerial transformation
designed to address the needs and opportunities of all organizations as they try to cope with the
increasing change, complexity and tension within their environments” (Berwick 1991).
The QA Project has used and adapted concepts of quality management to healthcare
environments worldwide, particularly in lower- and middle-income countries.
This document summarizes QA Project knowledge in one area of QA activities: quality
improvement. Quality improvement (QI) identifies where gaps exist between services actually
provided and expectations for services. It then lessens these gaps not only to meet customer
needs and expectations, but to exceed them and attain unprecedented levels of performance. QI is
based on principles of quality management that focus on the client, systems and processes,
teamwork, and the use of data. QI has evolved over the years to arrive at the ideas presented in
this document. Originally, improvements were thought to depend on adding new or more things,
such as a new machine, procedure, training, or supplies. It was believed that more of these
resources or inputs would improve quality. People working to improve quality learned that
increasing resources does not always ensure their efficient use and consequently may not lead to
improvements in quality. For example, the purchase of a new machine in a hospital does not
alone improve the quality of care. In order to benefit from the machine’s advancement in
technology, employees need training to learn to use the machine, patients need access to the
services that the machine provides, and the system of healthcare delivery must be changed in
ways that permit the use of this new technology. In other words, improvement involves not only
adding new resources to a system, but also making changes to an organization in order to make
the best use of resources.

In fact, a key lesson is that in many cases quality can be improved by making changes to
healthcare systems without necessarily increasing resources. Interestingly, improving the
processes of healthcare not only creates better outcomes, but also reduces the cost of delivering
healthcare: it eliminates waste, unnecessary work, and rework. Inspecting main activities or
processes is another way that management has attempted to identify and solve problems. This
method tried to increase control over staff and often blamed people for mistakes.
This philosophy of improving quality showed limited success because it did not necessarily
identify barriers to improvement or generate the support of workers who felt resistant to being
evaluated. Current QI approaches examine how activities can be changed so employees can do
their work better. For example, poor employee performance may stem from a lack of supplies,
inefficient processes, or the lack of training or coaching rather than worker performance.
The philosophy behind the QI approaches presented in this document recognizes that both the
resources (inputs) and activities carried out (processes) must be addressed together to ensure or

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improve the quality of care (output/outcome). Based on the ideas of Dr. Avedis Donabedian
(1980), shows how the quality of care can be considered as inputs, processes, and
outputs/outcomes. This figure demonstrates how both inputs and processes are linked to the
desired output and outcome: quality care. For example, it is evident that improvements result
from advances in technology, such as new pharmaceuticals or diagnostic techniques.
Improvements also result, however, from an organization’s ability to incorporate inputs, such as
technology, effectively and efficiently into the delivery of care.
Figure: 1 Input, Processes, and Outputs/Outcomes
Inputs, Processes, and Outputs/Outcomes

Activities contain two major components: what is done (content) and how it is done (process of
care). Improvement can be achieved by addressing either of these components.
The most powerful impact, however, occurs by addressing both content and process of care at
the same time. This paradigm for QI makes organizations more efficient and able to provide
quality care with increased access and decreased waste, often at less cost. In looking at the
content of care, we review and update the clinical management of patients for improvements that
address clinical care. In doing so, we use evidence-based medicine literature and the highest
level of evidence available in order to update clinical practices. In looking at the process of care,
the objective is to enhance the capacity in healthcare delivery such that it will allow the
implementation of the updated content.

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Figure 2: Quality Improvement Integrates Content of Care and the Process of Providing
Care

Figure 3: Integrating Changes in the Content and Process of Care

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Evidence-Based Medicine

The use of evidence is critical to improving the quality of healthcare. Evidence based medicine is
“the conscientious, explicit, and judicious use of current best evidence in making decisions about
the care of individual patients” (Gardner and Altman 1986). The practice of evidence-based
medicine integrates individual clinical expertise with the best available external clinical evidence
from systematic research (Sackett et al. 1996). Individual clinical expertise refers to expertise
acquired by clinicians. This expertise is seen in their thorough proficiency and judgment, such as
effective and efficient diagnosis. External clinical evidence refers to clinically relevant research
that invalidates previously accepted diagnostic tests and treatments, and replaces them with new
ones that are more powerful, accurate, efficacious, and/or safer. Clinical expertise combined with
external clinical evidence allows providers to decide between current best practices, using
discretion as to which will be appropriate and meet the needs of the individual patients.
Evidence-based medicine led to changes in the clinical care provided for women with
pregnancy-induced

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CHAPTER II: QUALITY ASSURANCE PRINCIPLES

2.1 Meeting the Needs of Our Clients

The people we provide health services for are very important to us. Without them, we
will not be in employment. Therefore we must do our best to satisfy them. In the past,
we worked as if the clients did not matter so we did not involve them in healthcare,
neither were their needs in service delivery addressed. With QA, the situation is now
changing. All over the world, patients concerns regarding their rights to participate in
healthcare delivery are becoming important. The clients are the main focus in quality
assurance programmes.
There are two types of clients:These are internal and external clients.

 The external clients include people who directly use our services and those who
have special
interest in our services. They are made up of patients, relatives and friends and the
community as well as other organizations: Non-Governmental Organisations (NGO's),
District Assemblies, Ministries, Development partners (Donors) etc

 The internal clients are the workers in the health facility. Their needs must also be
catered for
so that they can provide quality care. We can assess our client's needs either through
surveys (interviews) or discussions with individuals and groups within the community
who use our services. The clients are in the best position to say what constitutes quality
to them. They tell us whether we are meeting their expectations through client surveys,
community meetings, focus group discussions etc.

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2.2 Focusing On Systems
Systems are the various aspects or components of service delivery that have to operate
together as a unit in a facility to deliver quality health care. The three components of
service delivery; namely; inputs, processes and outcomes have already been explained
When things go wrong with health services we often blame the staff. Whilst this may be
true to some extent, in most cases, the problems lie in all the areas of service delivery.
In QA also, we address problems by looking at all the three areas - inputs, processes,
and outcomes at the same time.

2.3 Use of Data to Improve Quality

We collect a lot of information (data) in our health facilities but we just send them on to
the District level without making use of them. Some of the data we collect include the
number of people who attend the OPD, their age and sex. We also collect information
on the number of cases of malaria, diarrhoea, mothers dying from pregnancy, delivery
and after delivery.
These data are very useful. They can tell us where there are problems in service
delivery. We can use the information in planning services and for monitoring. Data can
also be used in identifying resources (people, drugs and supplies as well as the amount
of money) required for health services. We must analyze data and use it locally to
improve services; some of these data can be
shared with community members.

2.4 Improving Quality through Team Work

A team is a group of people who work together to achieve a common goal. In health
service delivery we have different kinds of health workers working together. Let's use
the outpatient services as an example of teamwork. There are laborers to clean the unit,
records officers to register the patient, nurses to take the temperature and weight, the
medical assistants to examine and prescribe the drugs, laboratory technicians to do the
investigations and the dispensary technicians to give the drugs. All these people are
playing important roles and if they work well in the team, the outcome is always good
Quality assurance uses teams in problem solving and quality improvement. A team can
do analysis problems, determine the best solution(s) and develop plans implement
them. In starting and sustaining quality assurance programme we need strong
leadership support and commitment.

2.5 Effective Communication

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Communication is a process by which messages are passed from a sender to a receiver
with feedback to the sender. In health delivery there is communication between:
 Health worker and Patient;
 Health worker and Community;
 Health worker and Health worker.
a) Health worker and Patient
Good communication between health worker and the patient increases compliance to
treatment and contributes to client satisfaction.
b) Health worker and Community
Health workers should have regular interactions with their communities to share
information on service delivery and their role in healthcare. We need special skills to be
able to effectively communicate with our communities
c) Health worker and health worker:
There should be good communication between health workers to ensure effective
dissemination of information, understanding among staff and effective teamwork.

B e n e f i t s o f Q u a l i t y Assurance

Quality assurance is beneficial to everybody - the client, community, health workers,

health managers and the health institution. Benefits of quality assurance are varied in
nature. We have benefits to the clients, to the health worker and to the health
institution.

a) Benefits to the Clients

Some of the benefits of quality assurance to the clients are:
 Good health outcomes.
 Client satisfaction
 Value for money.
 Less frustration.

b) Benefits to Health Providers

Health providers also benefit from quality assurance in the following ways.
 Health staff become more satisfied with their work.
 Health workers understand patients better.
 Information flow among staff is improved.
 Health staff who perform well are rewarded.

c) Benefits to the Health Institution

Quality assurance brings some benefits to the health facility and they include:
 Patients become more satisfied with the services.

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 More patients may use our services.
 The environment will become clean and beautiful.
 The facility will have a good reputation.

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CHAPTER III: QUALITY IMPROVEMENT TOOLS

This section provides information on several tools and activities to facilitate the work of teams
and individuals in quality improvement. These tools and activities can be used alone, or in
combination with one another, to identify and analyze problems as well as to develop, test, and
implement solutions to those problems. Although these tools and activities can be used by teams
and individuals at any time, the table below indicates when each tool or activity is most often
useful during quality improvement efforts.
Table 1: Quality Improvement Tools and Activities

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 1. Data Collection
Data collection is an important often necessary part of quality improvement. It becomes
necessary when existing data are not sufficient for identifying or analyzing problems or for
developing, testing, or implementing solutions to those problems. It also helps maximize the
usefulness of QI tools. Both qualitative and quantitative data help us understand the situation
where a problem exists, test hypotheses of causes, and demonstrate the effectiveness of
interventions. Qualitative data use words to describe a situation and can provide in-depth
information about why a problem may occur. This type of data is collected through a variety of
techniques, such as focus group discussions, unstructured interviews, observation, and role-play.
Quantitative data describe the problem through numbers to provide information such as averages
and variability. Quantitative data collection involves a wide range of methods, including formal
survey sampling and the review of existing data. When to Use Existing Data The most efficient
and economical means of using data is often to analyze existing data. For instance, data collected
on a regular basis may indicate the characteristics of external clients or the percentage that return
for follow-up visits.
Examples of existing data include the data from patient medical records, facility logbooks, and
health information system reports (see Bouchet 2000 for a detailed presentation of data sources
and uses). The review of existing data reduces the denial that organizational members might
experience when addressing needs for quality improvement.
Data can also be used to switch the focus of improvement from blaming people to improving the
overall process or system. Use existing data reviews when: (a) relevant existing data are
available, (b) there is not enough time or funding to collect data, and/or (c) there is a need for
proof or credibility. How to Collect Data If existing data are not accurate or do not provide
enough or the right kind of information, then actual data collection may be necessary. Common
data collection methods include, but are not limited to, the following: Direct observation
involves watching and noting the behavior of and/or interactions between service providers and
external customers. One way to observe these interactions is through client simulation, where
trained observers enter a health facility under the guise of being a customer seeking services.
This technique allows an observer to assess the actual services provided and how patients are
treated. Customer feedback can be gathered in a number of ways, such as comment cards and
exit interviews. Information about how customers perceive health services or how these services
could better meet their needs helps to identify opportunities for improvement.
Interviews with healthcare providers are a way to get information through questions designed for
short (“yes,” “no,” “somewhat”) answers and/or lengthy, detailed ones. It is important to
remember, however, that while interviews may provide information about a provider’s
knowledge, they do not actually measure provider performance. Data collection helps to focus
our understanding of the causes of a problem as well as test theories. Therefore, it is important to
ask the right questions to capture accurate and precise data. The process for collecting
information should be (IHI 1995):
 Focused and specific
 Process oriented
 Avoiding blame and fear
 Clearly stating what the data intends to collect
 Implying that decisions will be made

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Caution
The collection of accurate data also depends on minimizing biases. Bias is a “systematic error or
change that makes the data you have collected not representative of the natural state of the
process” (IHI 1995). Basic precautions can minimize the risk of introducing bias into the data
collection: testing data collection instruments, training interviewers, auditing the collection
process, and an impartial data collector. In addition to biases, common problems in data
collection include:
 Failure to use existing data
 Misunderstanding
 Lacking needed information
 Complicated data forms that result in incomplete forms
 Incomplete information due to fear or bias (IHI 1995) Precautions that help prevent these
problems in data collection are presented in Table below

Table 2: Precautions for Avoiding Data Collection Problems

2. Brainstorming
Brainstorming is a way for a group to generate as many ideas as possible in a very short time by
tapping into group knowledge and individual creativity. Brainstorming produces ideas by
encouraging the participation of all group members through structured and unstructured thought
processes on a given subject. It requires participants to be willing to express their ideas without
evaluating them, remain open to new ideas, and refrain from criticizing suggestions.
Brainstorming works best in an uninhibited environment where ideas are freely generated and
built upon.

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When to Brainstorm
Brainstorming is particularly useful when trying to generate ideas about problems, areas for
improvement, possible causes, other solutions, and resistance to change. By bringing out many
creative ideas quickly and encouraging all group members to participate, this activity opens up
people’s thinking and broadens their perspectives. It allows ideas to build on one another, which
would not occur if each team member were interviewed separately.
Use Brainstorming When:
 You need to generate ideas and insights
 You want to draw out the experiences of each participant
 Creative ideas have been suppressed in the group

How to Brainstorm
Write the question or issue to be explored through brainstorming on a flip chart, blackboard, or
any place where everyone can see. Make sure that everyone is clear about the topic.
Review the rules of brainstorming:
 Do not discuss ideas during the brainstorming
 Do not criticize any idea
 Be unconventional: every idea is acceptable
 Build on the ideas of others
 Quantity of ideas counts
Brainstorming can be unstructured or structured. In brainstorming, each person voices ideas as
they come to mind. This method works well if participants are outgoing and feel comfortable
with each other. In structured brainstorming, each person gives an idea in rotation (a person can
pass if he or she doesn’t have one at the moment). Structured brainstorming works well when
the structure encourages everyone to speak. Give people a few minutes to think of some ideas
before starting.
Write all ideas on a flip chart. After all the ideas have been generated (usually after about 30–45
minutes), review each one to make it clear and combine related ideas.
Agree on ways to judge ideas, and use data collection, voting, matrices, or a Pareto chart to
choose among options.
Groups often use voting techniques first to reduce the list to about six to 10 top ideas. Then they
use other techniques to choose among this shorter list.

Caution
Brainstorming is a technique for generating ideas, but each idea will need elaboration.
Discussing or judging ideas while brainstorming impedes the exercise and limits the flow of
ideas. Save discussion until the end. If one or a few individuals dominate the discussion in an
unstructured brainstorming session, shift to a structured brainstorming format.

3. Affinity Analysis
Affinity analysis is a process that helps groups gather a large amount of information and
organize it on the basis of affinities (natural relationships). This technique lets the ideas
determine the categories, rather than letting predetermined categories determine or constrain the
generation of ideas. The affinity technique consists of two components individuals’ first
brainstorm on ideas and then organize them into natural categories. This process generates a lot
of ideas and also organizes the overall picture of the issue (such as a problem) to understand its

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relationship to other areas. Like many other aspects of QI, this process inspires feelings of
ownership and participation for group members.

When to Use It
An affinity analysis can help a team or group organize many different ideas or items in a short
period of time. Groups often use affinity analysis to generate ideas about problems or areas for
improvement, causes, alternative solutions, and resistance to change. It is chiefly useful when
issues appear too large or complex, when consensus is desired, or when creative ideas are
needed. Because everyone’s idea is included and groupings of ideas are done by the team, it
helps develop consensus. It is also useful for making sure that no ideas are lost.
Use Affinity Analysis When:
 The problem or area for improvement is large and complex
 The group feels overwhelmed by the complexity and size of the problem
 You need a lot of ideas in a short time

How to Use It
State the issue or question to be considered and assure that all participants are clear on what is
being asked. Generate and record ideas on slips of paper. Each idea or item should be recorded
on its own slip. Post-it Notes® or notecards, if available, make this exercise easier. Generate
ideas through group brainstorming. Have one person take charge of writing down each idea, or
have each person record his or her own ideas. Having each person record his or her own ideas
works best when it is important to capture everyone’s individual contribution or to draw on
everyone’s expertise. Place the slips of paper in any order in a manner that allows everyone to
see them (e.g., on a table or wall). Ask team members to sort the ideas on the slips of paper into
categories by moving the slips of paper around; members should keep the discussion brief. After
a while, the team members will stop moving items around. If the group is large, have the
members work in groups of three or four to arrange the slips. Allow each group to work for a few
minutes then call the next group of three or four. Let the groups continue in turns until they are
no longer moving items around.
Do not force an item into a category; it is fine to have categories with only a single item. If an
item is constantly being moved back and forth between two categories, either clarify its meaning
or make a copy and put it in both categories. Develop a name for each category that captures the
essential meaning of all the items in the category. When doing this, look first among the items in
the category. If no single item captures the idea clearly, create one that does. Write it on a slip of
paper. Transfer the category titles and lists from all the slips of paper onto a sheet of paper; use
lines to separate the categories.
Use prioritization tools to select from among categories.
Caution
Sorting should be done as silently as possible. Discuss the items on the slips of paper only for
clarification.

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4 .Creative Thinking Techniques

Tools and methods like brainstorming and affinity analysis allow us to collect our thoughts;
creative thinking techniques provide new ideas and ways to look at things, including needs for
improvement. We tend to think in terms of our individual belief systems and the context in
which we operate. Creative thinking techniques help us to break out of our own ideas and see
things, such as problems, from a different perspective. Creativity is a means to “connecting,
rearranging, and transforming knowledge to generate new, surprising, and useful ideas” (Plesk,
1997). There are many methods to encourage creative thinking, including element modification
and random word provocation.
When to Use Element Modification and Random Word Provocation
Element modification lists elements in a common scene and varies them one by one. This
method helps us to examine our daily reality in a different way to see which elements can be
improved. Random word provocation records free-flow thought associated with the area of
improvement. Some of the ideas generated seem outrageous or impractical but may be adapted to
show problems in a new way. The application of concepts foreign to your organization can also
create new ideas for quality improvement. For example, a group could think about the attributes
of a library and how they could be applied to improve a hospital. By listing library services such
as reference materials, library cards, or database systems, groups generate

5. Prioritization Tools: Making Decisions among Options

Group methods for narrowing down and ranking a list of ideas include voting and prioritization
matrices. Both methods allow individuals to express their opinions or choices in reaching a
group decision. Voting is a relatively unstructured technique where group members make a
choice, using either implicit or explicit criteria. Prioritization matrices allow the team to review
the options against a standard set of explicit criteria.
Voting
When to Use It
Voting is most useful when the options are fairly straightforward or time is limited. It encourages
equal participation of all team members by equalizing decision making between dominant and
quiet participants.
How to Use It
Teams can structure voting in several ways, but they all have the purpose of letting each
individual state his or her preferences. Regardless of the type of voting used, all group members
must understand the various options being voted on.
Use Voting When:
 You need a quick and efficient way to make a decision
 There are quiet and dominant group members
 There is an opportunity to follow up with team-building exercises

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Table 3: Straight Voting

Straight voting: List all options and give each person in the group one vote. Weight all votes
equally. This is the easiest method for a group to select an activity, as the activity with the
highest total is selected.
Multivoting
When to Use It
This method is useful when the group wants to pick more than one item or the list of items is
very long and needs to be reduced to two or more. (To reduce a list to one item, use straight
voting.) Multivoting can be repeated several times until the list is short enough to work with or a
single priority stands out. This voting method increases the likelihood that everyone will have at
least one of the items for which they voted on the reduced list.
How to Use It
List all options and allow each person to vote for a limited number of items (e.g., three or five).
A general rule to determine the number of votes is:
 Up to 10 options = 2 votes
 10–20 options = 3 votes
 20–30 options = 5 votes
Add up the votes for each item; the one with the highest score is the group’s top priority

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Table 4: Multivoting

Weighted Voting
When to Use It
Weighted voting allows a group to select an item or items on the basis of not only how important
it is to the group but also how strongly the group feels about their options. Use it when your
team expresses strong but divergent ideas about how to proceed.
How to Use It
List all options. Give each person a way to give more weight to some choices than to others. For
example, give participants a fixed amount of hypothetical money, allowing each person to
distribute it any way he or she wishes among the alternatives. If given $10, one could spend all
$10 on a single item that he/she felt very strongly about, or he/she could distribute it evenly over
five items, or any other combination. This method allows the voting to reflect each individual’s
conviction about the various choices.
Caution
While equal participation in the process can contribute to the group spirit, a minority may feel
disenfranchised by the result. That is, they may feel that they lost out. This can diminish the
coherency of the group dynamics. To prevent this, engage in team-building exercises after voting
activities.

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Table 5: Weighted Voting

Criteria (Prioritization) Matrix

In each of the above voting options, each individual uses his or her own internal criteria to make
a decision. A criterion is a measure, guideline, principle, or other basis for making a decision.
Examples of criteria that are often used in healthcare settings are that activities must be
affordable and safe. In working groups, it is an agreed-upon basis for making a group decision.
Often in making decisions, more than one criterion is used at the same time. Sometimes the
group may want to discuss and agree upon the criteria by which each participant should base his
or her vote or selection. A criteria or prioritization matrix is a tool for evaluating options based
on a set of explicit criteria the group has determined is important for making an appropriate,
acceptable decision.
Criteria for improvement can be weighted and ranked to help in the decision making process.
Although the prioritization matrix is the method most likely to result in consensus, at times it can
be time-consuming and complex. Different versions of the matrix adapt this method for use in
small or larger groups and with few or many criteria.
Use the Criteria (Prioritization) Matrix When:
 The core area of improvement has been identified but requires further focus
 The group agrees that a solution is needed, but disagrees about where to start
 Resources for testing and implementation are scarce
 A strong link between areas necessitates a need to sequence options

When to Use It
Matrices work best when options are more complex or when multiple criteria must be considered
in determining priorities or making a decision. The matrix presented below displays the options
to be prioritized in the rows (horizontal) and the criteria for making the decision in the columns
(vertical). Each option is then rated according to the various criteria.

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Table 6: Criteria Matrix

How to Use It
Step 1: List the options or choices to be evaluated. Make sure that all team members understand
what each option means.
Step 2: Set the criteria for making the decision. The group can choose these criteria using
brainstorming and then voting to determine the most important/relevant ones.11 Be sure that
everyone understands what the chosen criteria mean.
Criteria commonly used for choosing problems to work on include importance, support for
change, visibility of problem, risks if nothing is done, and feasibility of making changes in this
area. For choosing solutions, the following criteria are often applied: cost, potential resistance,
feasibility, management support, community support, efficiency, timeliness, impact on other
activities. These are not the only possible criteria; the group should develop a list that is
appropriate for its situation.
No minimum or maximum number of criteria exists, but three or four is optimal. More than four
criteria would make the matrix cumbersome. One way to reduce the number of criteria is to
determine if there are any criteria that all options must meet. Use this criterion first to eliminate
some options. Then, list the other criteria to prioritize the remaining options.
Another way to make the matrix less cumbersome is to limit the number of options being
considered. If the list of options is long (greater than six items), it may be easier to first shorten
the list by eliminating some options. Commonly used criteria for eliminating potential problems
from consideration include: (a) the problem is too big or complex, (b) it is not feasible to make
changes in this area (beyond the team’s control or authority), and (c) lack of interest among staff
to work on the problem.
Step 3: Draw the matrix and fill in the options and criteria.
Step 4: Determine the scale to use in rating the options against each criterion. Ways to rate
options range from simple to complex. A simple rating scale sets a score based on whether the
option meets a given criterion, e.g., Are trained staff already available? The answer (vote) “yes”
would gain one point, while “no” would gain zero points. Another common rating scale scores
options according to how well one option meets the criterion, e.g., How much management
support is there for this option? The answer of “high” would garner three points, “medium” two
points, and “low” one point (see note in box for another example).

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Step 5: Taking one option at a time, review each criterion and determine the appropriate rating,
using the simple, common, or complex rating scale. This ranking can be done individually and
then added up. Or, if the rating method is simple, it can be done by group discussion.
Step 6: Total the value for each option by adding the ranking for each criterion.
Step 7: Evaluate the results by considering the following questions:
 Does one option clearly meet all criteria?
 Can any options be eliminated?
 If an option meets some but not all criteria, is it still
 Worth considering?
Caution
Make sure that everyone clearly understands the options under consideration and the definitions
of the criteria.

Table 7: Complex Rating Scale

Case Example: Using Outside Experts

A quality improvement expert was called upon to analyze an average waiting time of three hours
for an outpatient clinic. Having addressed issues of waiting time in other facilities, the expert,
was able to work with a team to quickly focus attention on standardizing work regulations and
developing outpatient cards. These interventions, along with others, reduced the waiting time
from three hours to 20 minutes.

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6. Expert Decision Making
Sometimes outside experts can expedite the decision making process through their objectivity
and past experience. Organizations often experience similar needs for improvement, and outside
experts that specialize in quality improvement can apply extensive experience in problem solving
to adapt strategies from other organizations to an organization’s specific situation.

7. System Modeling

System modeling shows how the system should be working. Use this technique to examine how
various components work together to produce a particular outcome. These components make up
a system, which is comprised of resources processed in various ways (counseling, diagnosis,
treatment) to generate direct outputs (products or services), which in turn can produce both direct
effects (e.g., immunity, rehydration) on those using them and longer term, more indirect results
(e.g., reduced measles prevalence or reduced mortality rates) on users and the community at
large.

When to Use It
By diagramming the linkages between each system activity, system modeling makes it easier to
understand the relationships among various activities and the impact of each on the others. It
shows the processes as part of a larger system whose objective is to serve a specific client need.
System modeling is valuable when an overall picture is needed. System modeling shows how
direct and support services interact, where critical inputs come from, and how products or
services are expected to meet the needs in the community. When teams do not know where to
start, system modeling can help in locating problem areas or in analyzing the problem by
showing the various parts of the system and the linkages among them. It can pinpoint other
potential problem areas. System modeling can also reveal data collection needs: indicators of
inputs, process, and outcomes (direct outputs, effects on clients, and/or impacts). Finally, system
modeling can be helpful in monitoring performance.
Use System Modeling to:
 Understand the process or problem as a part of a system
 Identify where to begin in the analysis of a problem
 Discover potential needs for data

Elements of System Modeling

System modeling uses three elements: inputs, processes, and outcomes.
Inputs are the resources used to carry out the activities (processes). Inputs can be raw materials,
or products or services produced by other parts of the system. For example, in the malaria
treatment system, inputs include anti-malarial drugs and skilled health workers. Other parts of
the system provide both of these inputs: the drugs by the logistics subsystem and the skilled
human resources by the training subsystem.
Processes are the activities and tasks that turn the inputs into products and services. For malaria
treatment, this process would include the tasks of taking a history and conducting a physical
examination of patients complaining of fever, making a diagnosis, providing treatment, and
counseling the patient.

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Outcomes are the results of processes. Outcomes generally refer to the direct outputs generated
by a process, and may sometimes refer to the more indirect effects on the clients themselves and
the still more indirect impacts on the wider community.
Outputs are the direct products or services produced by the process. The outputs of the malaria
treatment system are patients receiving therapy and counseling.
Effects are the changes in client knowledge, attitude, behavior, and/or physiology that result
from the outputs. For the malaria treatment system, this would be reduced case fatality from
malaria (patients getting better) and patients or caretakers who know what to do if the fever
returns.
These are indirect results of the process because other factors may intervene between the output
(e.g., correct treatment with an anti-malarial) and the effect (e.g., the patient’s recovery).

Impacts are the long-term and still more indirect effects of the outputs on users and the
community at large. For malaria treatment, the impacts would be improved health status in the
community and reduced infant and child mortality rates.
The utility of system modeling is its ability to depict how parts relate. The system model displays
the system’s strengths or weaknesses at the junctions.

How to Use It
Step 1. Identify the major process or “system” to be modeled and the need that system should be
serving (desired impact). This can be done by starting with the PROCESS or IMPACT. If
starting with the PROCESS of interest, identify the part of the system to be modeled: a
healthcare intervention (such as immunizations, malaria treatment, or hospital emergency
services). It is also possible to focus system modeling on a support service, such as supervision
or logistics. Next, identify the needs in the community that this PROCESS should be addressing
(remember that support services meet the needs of internal clients). If starting with the IMPA
identify what the system is supposed to affect, e.g., what need in the community should the
system meet? Then, identify what PROCESS is carried out to create the services or products
(OUTPUTS) that would be expected to have an appropriate EFFECT on clients, which could in
turn be expected to result in the desired IMPACT (meet that need).
Step 2. Draw and label the IMPACT and the PROCESS boxes.
Step 3. Work backwards through the OUTCOMES, beginning with the need (DESIRED
IMPACT), and determine what EFFECTS the product or services (OUTPUTS) must produce in
the clients to achieve that desired IMPACT. Think about the various groups affected by the
products and services. Draw and label the OUTCOME box.
Step 4. Identify other factors that can affect the IMPACT: e.g., the economy or cultural factors,
and add them to the model. No system operates in a vacuum, and the IMPACT will always be
influenced by factors outside the system.
Step 5. Identify the specific OUTPUTS produced by the process that lead to the OUTCOMES
just identified. In many instances, there will be more than one kind of OUTPUT. For example, a
vaccination system should produce vaccinated children and “knowledge-able” mothers.
Step 6. Identify the major task categories in the PROCESS: e.g., taking the history, giving the
physical, making a diagnosis, giving a treatment, and counseling. Write these in the PROCESS
box. Review the OUTPUTS (e.g., patient history recorded, patient diagnosed, patient treated)
and make sure that there is an OUTPUT identified for each beneficiary of the major tasks.

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Step 7. Identify the various INPUTS needed to carry out the process. These INPUTS should
include manpower, material, information, and financial resources. Draw boxes for the various
INPUTS and label them. Determine which support systems (such as logistics, training,
supervision) produce each of these INPUTS and write the sources in the boxes.

Using the System Model for Problem Analysis

Review the various elements of the system. Determine what data are needed to know whether the
system is sufficiently productive or adequately functioning to achieve the outcome and impact
desired. Use these data to assess whether the system is performing the way it should be
according to the system model you have drawn. Identify weak or missing components of the
system by seeing where in the process quality falls short.

Caution
Involve people who know the system being modeled, either while developing the model or as
reviewers after it has been drafted. Be sure that the system model really addresses the identified
problem.

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Figure 2 : System Model for Malaria Treatment

9. Cause-and-Effect Analysis
A cause-and-effect analysis generates and sorts hypotheses about possible causes of problems
within a process by asking participants to list all of the possible causes and effects for the
identified problem. This analysis tool organizes a large amount of information by showing links
between events and their potential or actual causes and provides a means of generating ideas
about why the problem is occurring and possible effects of that cause. Cause and- effect analyses
allow problem solvers to broaden their thinking and look at the overall picture of a problem.
Cause-and-effect diagrams can reflect either causes that block the way to the desired state or
helpful factors needed to reach the desired state.
When to Use It
A graphic presentation, with major branches reflecting categories of causes, a cause-and-effect
analysis stimulates and broadens thinking about potential or real causes and facilitates further
examination of individual causes.
Because everyone’s ideas can find a place on the diagram, a cause-and-effect analysis helps to
generate consensus about causes. It can help to focus attention on the process where a problem is
occurring and to allow for constructive use of facts revealed by reported events. However, it is
important to remember that a cause-and-effect diagram is a structured way of expressing
hypotheses about the causes of a problem or about why something is not happening as desired. It
cannot replace empirical testing of these hypotheses: it does not tell which is the root cause, but
rather possible causes.
Use the Cause-and-Effect Analysis:
 At the beginning of the analysis stage
 To broaden thinking about the possible reasons for a problem; this tool helps groups to think
beyond people responsible for a problem and looking at deeper causes
 To develop hypotheses about the causes of the situation: some ideas will not prove to be
correct, but at this stage you just want to capture ideas

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Types of Cause-and-Effect Analyses
There are two ways to graphically organize ideas for a cause-and-effect analysis. They vary in
how potential causes are organized: (a) by category: called a fishbone diagram (for its shape) or
Ishikawa diagram (for the man who invented it), and (b) as a chain of causes: called a tree
diagram. The choice of method depends on the team’s need. If the team tends to think of causes
only in terms of people, the fishbone diagram, organized around categories of cause, will help to
broaden their thinking.
A tree diagram, however, will encourage team members to explore the chain of events or causes.
Causes by Categories (Fishbone Diagram) The fishbone diagram helps teams to brainstorm about
possible causes of a problem, accumulate existing knowledge about the causal system
surrounding that problem, and group causes into general categories.
Causes by Categories (Fishbone Diagram)
The fishbone diagram helps teams to brainstorm about possible causes of a problem, accumulate
existing knowledge about the causal system surrounding that problem, and group causes into
general categories.
When using a fishbone diagram, several categories of cause can be applied. Some often-used
categories are:
 Human resources, methods, materials, measurements, and equipment
 Clients, workers, supplies, environment, and procedures
 What, how, when, where

Figure 3: Fishbone Diagram Structure

Categories for this type of cause-and-effect diagram vary widely, depending on the context. The
group should choose those categories that are most relevant to them and feel free to add or drop
categories as needed.

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Figure 4: Fishbone Diagram used at x hospital

Example
Question 1: Why did the patient get the incorrect medicine?
Answer 1: Because the prescription was wrong.
Question 2: Why was the prescription wrong?
Answer 2: Because the doctor made the wrong decision.
Question 3: Why did the doctor make the wrong decision?
Answer 3: Because he did not have complete information in the patient.s chart.
Question 4: Why wasn.t the patient.s chart complete?
Answer 4: Because the doctor.s assistant had not entered the latest laboratory report.
Question 5: Why hadn.t the doctor.s assistant charted the latest laboratory report?
Answer 5: Because the lab technician telephoned the results to the receptionist, who forgot to tell
the assistant.
Solution: Develop a system for tracking lab reports.

Figure 5: Three diagram

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A Chain of Causes (Tree Diagram) and the Five Why.s
A second type of cause-and-effect analysis is a tree diagram, which highlights the chain of
causes. It starts with the effect and the major groups of causes and then asks for each branch,
“Why is this happening? What is causing this?” The tree diagram is a graphic display of a
simpler method known as the Five Why’s. It displays the layers of causes, looking in-depth for
the root cause. This tool can be used alone or with any of the cause-and-effect diagrams.
How to Use Cause-and-Effect Analysis Although several ways to construct a cause-and-effect
analysis exist, the steps of construction are essentially the same.
Step 1. Agree on the problem or the desired state and write it in the effect box. Try to be specific.
Problems that are too large or too vague can bog the team down.
Step 2. If using a tree or fishbone diagram, define six to eight major categories of causes. Or the
team can brainstorm first about likely causes and then sort them into major branches. The team
should add or drop categories as needed when generating causes. Each category should be
written into the box.
Step 3. Identify specific causes and fill them in on the correct branches or sub-branches. Use
simple brainstorming to generate a list of ideas before classifying them on the diagram, or use
the development of the branches of the diagram first to help stimulate ideas. Either way will
achieve the same end: use the method that feels most comfortable for the group. If an idea fits on
more than one branch, place it on both. Be sure that the causes as phrased have a direct, logical
relationship to the problem or effect stated at the head of the fishbone.
Each major branch (category or step) should include three or four possible causes. If a branch
has fewer, lead the group in finding some way to explain this lack, or ask others who have some
knowledge in that area to help.
Step 4. Keep asking “Why?” and “Why else?” for each cause until a potential root cause has
been identified. A root cause is one that: (a) can explain the “effect,” either directly or through a
series of events, and (b) if removed, would eliminate or reduce the problem. Try to ensure that
the answers to the “Why” questions are plausible explanations and that, if possible, they are
amenable to action.
Check the logic of the chain of causes: read the diagram from the root cause to the effect to see if
the flow is logical. Make needed changes.
Step 5. Have the team choose several areas they feel are most likely causes. These choices can
be made by voting to capture the team’s best collective judgment. Use the reduced list of likely
causes to develop simple data collection tools to prove the group’s theory. If the data confirm
none of the likely causes, go back to the cause-andeffect diagram and choose other causes for
testing.
Caution
Remember that cause-and-effect diagrams represent hypotheses about causes, not facts. Failure
to test these hypotheses—treating them as if they were facts—often leads to implementing the
wrong solutions and wasting time. To determine the root cause(s), the team must collect data to
test these hypotheses. The “effect” or problem should be clearly articulated to produce the most
relevant hypotheses about cause. If the “effect” or problem is too general or ill defined, the team
will have difficulty focusing on the effect, and the diagram will be large and complex.
It is best to develop as many hypotheses as possible so that no potentially important root cause is
overlooked. Be sure to develop each branch fully. If this is not possible, then the team may need
more information or help from others for full development of all the branches.

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10 .Force-Fields Analysis

Force-field analysis was developed by Kurt Lewin. It identifies forces that help and those that
hinder reaching the desired outcome. It depicts a situation as a balance between two sets of
forces: one that tries to change the status quo and one that tries to maintain it. Force-field
analysis focuses our attention on ways of reducing the hindering forces and encouraging the
positive ones. Force-field analysis encourages agreement and reflection in a group through
discussion of the underlying causes of a problem.

When to Use It
Because force-field analysis causes people to think together about what works for and against the
status quo, it helps team members to view each case as two sets of offsetting factors. It can be
used to study existing problems, or to anticipate and plan more effectively for implementing
change. When used in problem analysis, force-field analysis is especially helpful in defining
more subjective issues, such as morale, management, effectiveness, and work climate.
Force-field analysis also helps keep team members grounded in reality when they start planning
a change by making them systematically anticipate what kind of resistance they could meet.
Conducting a force-field analysis can help build consensus by making it easy to discuss people’s
objections and by examining how to address these concerns.

Use Force-Field Analysis to:

 Plan for the implementation of change
 Keep group members realistic about change and the obstacles that may be encountered
 Arrive at a consensus and address concerns

How to Use It
Step 1. State the problem or desired state and make sure that all team members understand. You
can construct the statement in terms of factors working for and against a desired state or in terms
of factors working for and against the status quo or problem state.
Step 2. Brainstorm the positive and negative forces.
Step 3. Review and clarify each force or factor. What is behind each factor? What works to
balance the situation?
Step 4. Determine how strong the hindering forces are (high, medium, low) in achieving the
desired state or from improving the problem state. When the force-field is used for problem
analysis, the forces with the biggest impact should be tested as likely causes. If the force-field is
used to develop solutions, those factors with the biggest impact may become the focus of plans
to reduce resistance to change.
Step 5. Develop an action plan to address the largest hindering forces.

Caution
If a significant force is omitted, then its impact can negatively affect a plan of action. All
significant forces or factors must be included and considered.

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 11 .Statistical/Data Presentation Tools
Descriptive statistics enable us to understand data through summary values and graphical
presentations. Summary values not only include the average, but also the spread, median, mode,
range, and standard deviation. It is important to look at summary statistics along with the data set
to understand the entire picture, as the same summary statistics may describe very different data
sets. Descriptive statistics can be illustrated in an understandable fashion by presenting them
graphically using statistical and data presentation tools. When creating graphic displays, keep in
mind the following questions (IHI 1995):
 What am I trying to communicate?
 Who is my audience?
 What might prevent them from understanding this display?
 Does the display tell the entire story?
Several types of statistical/data presentation tools exist, including: (a) charts displaying
frequencies (bar, pie, and Pareto charts, (b) charts displaying trends (run and control charts), (c)
charts displaying distributions (histograms), and (d) charts displaying associations (scatter
diagrams). Different types of data require different kinds of statistical tools. There are two types
of data. Attribute data are countable data or data that can be put into categories: e.g., the number
of people willing to pay, the number of complaints, percentage who want blue/percentage who
want red/percentage who want yellow. Variable data are measurement data, based on some
continuous scale: e.g., length and cost.

Bar and Pie Charts

Bar and pie charts use pictures to compare the sizes, amounts, quantities, or proportions of
various items or groupings of items.

When to Use Them

Bar and pie charts can be used in defining or choosing problems to work on, analyzing problems,
verifying causes, or judging solutions. They make it easier to understand data because they
present the data as a picture, highlighting the results. This is particularly helpful in presenting
results to team members, managers, and other interested parties. Bar and pie charts present
results that compare different groups. They can also be used with variable data that have been
grouped. Bar charts work best when showing comparisons among categories, while pie charts are
used for showing relative proportions of various items in making up the whole (how the “pie” is
divided up).
Selecting a Type of Bar Chart
Teams may choose from three types of bar charts, depending on the type of data they have and
what they want to stress:
Simple bar charts sort data into simple categories.
Grouped bar charts divide data into groups within each category and show comparisons between
individual groups as well as between categories. (It gives more useful information than a simple
total of all the components.)
Stacked bar charts, which, like grouped bar charts, use grouped data within categories. (They
make clear both the sum of the parts and each group’s contribution to that total.)

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Table 8: Choosing data display tools

How to Use a Bar Chart

Step 1. Choose the type of bar chart that stresses the results to be focused on. Grouped and
stacked bar charts will require at least two classification variables. For a stacked bar chart, tally
the data within each category into combined totals before drawing the chart.
Step 2. Draw the vertical axis to represent the values of the variable of comparison (e.g.,
number, cost, time). Establish the range for the data by subtracting the smallest value from the
largest. Determine the scale for the vertical axis at approximately 1.5 times the range and label
the axis with the scale and unit of measure.

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Figure 6: Bar chart

Step 3. Determine the number of bars needed. The number of bars will equal the number of
categories for simple or stacked bar charts. For a grouped bar chart, the number of bars will
equal the number of categories multiplied by the number of groups. This number is important for
determining the length of the horizontal axis.
Step 4. Draw bars of equal width for each item and label the categories and the groups. Provide a
title for the graph that indicates the sample and the time period covered by the data; label each
bar.
How to Use a Pie Chart
Step 1. Taking the data to be charted, calculate the percentage contribution for each category.
First, total all the values. Next, divide the value of each category by the total. Then, multiply the
product by 100 to create a percentage for each value.
Step 2. Draw a circle. Using the percentages, determine what portion of the circle will be
represented by each category. This can be done by eye or by calculating the number of degrees
and using a compass. By eye, divide the circle into four quadrants, each representing 25 percent.

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Figure 7: Pie Chart

Do not draw conclusions not justified by the data. For example, determining whether a trend
exists may require more statistical tests and probably cannot be determined by the chart alone.
Differences among groups also may require more statistical testing to determine if they are
significant. Whenever possible, use bar or pie charts to support data interpretation. Do not
assume that results or points are so clear and obvious that a chart is not needed for clarity.
A chart must not lie or mislead! To ensure that this does not happen, follow these guidelines:
 Scales must be in regular intervals
 Charts that are to be compared must have the same scale and symbols
 Charts should be easy to read

Run and control chart

Run charts give a picture of a variation in some process over time and help detect special
(external) causes of that variation. They make trends or other non-random variation in the
process easier to see and understand.
With the understanding of patterns and trends of the past, groups can then use run charts to help
predict future performance.

When to Use a Run Chart

If data analysis focuses on statistics that give only the big picture (such as average, range, and
variation), trends over time can often be lost. Changes could be hidden from view and problems
left unresolved. Run charts graphically display shifts, trends, cycles, or other non-random
patterns over time. They can be used to identify problems (by showing a trend away from the
desired results) and to monitor progress when solutions are carried out.

How to Use a Run Chart

A run is the consecutive points running either above or below the center line (mean or median).
The points in a run chart mark the single events (how much occurred at a certain point in time).
A run is broken once it crosses the center line. Values on the center line are ignored: they do not
break the run, nor are they counted as points in the run. The basic steps in creating a run chart
follow

Step 1. Collect at least 25 data points (number, time, cost), recording when each measurement
was taken. Arrange the data in chronological order.
Step 2. Determine the scale for the vertical axis as 1.5 times the range. Label the axis with the
scale and unit of measure.

41
Step 3. Draw the horizontal axis and mark the measure of time (minute, hour, day, shift, week,
month, year, etc.) and label the axis.
Step 4. Plot the points and connect them with a straight line between each point. Draw the center
line (the average of all the data points).
The following provide some guidance in interpreting a run chart:
 Eight consecutive points above (or below) the center line (mean or median) suggest a shift in
the process
 Six successive increasing (or decreasing) points suggest a trend
 Fourteen successive points alternating up and down suggest a cyclical process

Figure 8: Run Chart of Arterial Hypertension Patients under Observation

When and How to Use a Control Chart

If the run chart provides sufficient data, it is possible to calculate “control limits” for a process;
the addition of these control limits creates a control chart. Control limits indicate the normal
level of variation that can be expected; this type of variation is referred to as common cause
variation. Points falling outside the control limits, however, indicate unusual variation for the
process; this type of variation is referred to as special cause variation. This analytical tool helps
to distinguish between common and special causes of variation, allowing teams and individuals to
focus quality improvement efforts on eliminating special causes of variation (e.g., unplanned
events).

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Figure 9: Control Chart of Average Wait Time before and after a Redesign

Caution
Be careful not to use too many notations on a run chart. Keep it as simple as possible and include
only the information necessary to interpret the chart. Do not draw conclusions that are not
justified by the data. Certain trends and interpretations may require more statistical testing to
determine if they are significant. Whenever possible, use a run chart to show the variation in the
process. Do not assume that the variation is so clear and obvious that a run chart is unnecessary.
A run chart must not lie or mislead! To ensure that this does not happen, follow these guidelines:
 Scales must be in regular intervals
 Charts that are to be compared must also use the same scale and symbols
 Charts should be easy to read

Histogram
The histogram displays a single variable in a bar form to indicate how often some event is likely
to occur by showing the pattern of variation (distribution) of data. A pattern of variation has
three aspects: the center (average), the shape of the curve, and the width of the curve. Histograms
are constructed with variables such as time, weight, temperature and are not appropriate for
attribute data.

When to Use It
All data show variation; histograms help interpret this variation by making the patterns clear.
They tell a visual story about a specific case in a way that a table of numbers (data points)
cannot. Histograms can be used to identify and verify causes of problems. They can also be used
to judge a solution, by checking whether it has removed the cause of the problem.

How to Use It
Step 1. From the raw numbers (the data), find the highest and lowest values. This is the range.
Step 2. Determine the number of bars to be used in the histogram. If too many bars are used, the
pattern may become lost in the detail; if too few are used, the pattern may be lost within the bars.

43
Step 3. Determine the width of each bar by dividing the range by the number of bars. Then,
starting with the lowest value, determine the grouping of values to be contained or represented
by each bar.
Step 4. Create a compilation table like and fill in the boundaries for each grouping.

Table 9: Compilation Table for Constructing a Histogram

Step 5. Fill in the compilation table by counting the number of data points for each bar and
calculating the total number of data points in each bar.
Step 6. Draw the horizontal and vertical axes, and label them
Step 7. Draw in the bars to correspond with the totals from the frequency table
Step 8. Identify and classify the pattern of variation.

When to Use the Histogram

 The data are continuous, such as temperature, time, or numbers

 There are large amounts of data that are difficult to understand in tables
 You want to show where the data for the variable clusters and what the end points are

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Figure 10: Types of histogram

Caution
Simple daily observations often do not tell enough about a process, and averages or ranges are
not adequate summaries of the data. The potential pitfall of a histogram is not using one: it is a
useful, necessary tool. If variation is small, the histogram may not be sensitive enough to detect
significant differences in variability or in the peaks of the distribution, especially if using a small
sample data set. There are advanced statistical tools that can be used in such situations.

Scatter Diagram
The scatter diagram is another visual display of data. It shows the association between two
variables acting continuously on the same item. The scatter diagram illustrates the strength of the
correlation between the variables through the slope of a line. This correlation can point to, but
does not prove, a causal relationship. Therefore, it is important not to rush to conclusions about
the relationship between variables as there may be another variable that modifies the
relationship. For example, analyzing a scatter diagram of the relationship between weight and
height would lead one to believe that the two variables are related. This relationship, however,
does not mean causality; for instance, while growing taller may cause one to weigh more,
gaining weight does not necessarily indicate that one is growing taller. The scatter diagram is
easy to use, but should be interpreted with caution as the scale may be too small to see the
relationship between variables, or confounding factors may be involved.

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When to Use It
Scatter diagrams make the relationship between two continuous variables stand out visually on
the page in a way that the raw data cannot. Scatter diagrams may be used in examining a cause-
and-effect relationship between variable data (continuous measurement data). They can also
show relationships between two effects to see if they might stem from a common cause or serve
as surrogates for each other. They can also be used to examine the relationship between two
causes.
Use the Scatter Diagram When:
 You suspect there is a relationship between two variables
 The data is continuous, such as temperature, time, or numbers
 You need a fast and easy way to test relationships between variables

How to Use It
Scatter diagrams are easy to construct.
Step 1. Collect at least 40 paired data points: “paired” data are measures of both the cause being
tested and its supposed effect at one point in time.
Step 2. Draw a grid, with the “cause” on the horizontal axis and the “effect” on the vertical axis.
Step 3. Determine the lowest and highest value of each variable and mark the axes accordingly.
Step 4. Plot the paired points on the diagram. If there are multiple pairs with the same value,
draw as many circles around the point as there are additional pairs with those same values.
Step 5. Identify and classify the pattern of association using the graphs below of possible shapes
and interpretations.

Caution
Stratifying the data in different ways can make patterns appear or disappear. When
experimenting with different stratifications and their effects on the scatter diagram, label how the
data are stratified so the team can discuss the implications. Interpretation can be limited by the
scale used. If the scale is too small and the points are compressed, then a pattern of correlation
may appear differently. Determine the scale so that the points cover most of the range of both
axes and both axes are about the same length.
Be careful of the effects of confounding factors. Sometimes the correlation observed is due to
some cause other than the one being studied. If a confounding factor is suspected, then stratify
the data by it. If it is truly a confounding factor, then the relationship in the diagram will change
significantly. Avoid the temptation to draw a line roughly through the middle of the points. This
can be misleading. A true regression line is determined mathematically. Consult a statistical
expert or text prior to using a regression line. Scatter diagrams show relationships, but do not
prove that one variable causes the other.

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Figure 11: Scatter Diagram Interpretation

Pareto Chart
In QI a Pareto chart provides facts needed for setting priorities. It organizes and displays
information to show the relative importance of various problems or causes of problems.
It is essentially a special form of a vertical bar chart that puts items in order (from the highest to
the lowest) relative to some measurable effect of interest: frequency, cost, time. The chart is
based on the Pareto principle, which states that when several factors affect a situation, a few
factors will account for most of the impact. The Pareto principle describes a phenomenon in
which 80 percent of variation observed in everyday processes can be explained by a mere 20
percent of the causes of that variation.

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Figure 12: Pareto Chart

Placing the items in descending order of frequency makes it easy to discern those problems that
are of greatest importance or those causes that appear to account for most of the variation. Thus,
a Pareto chart helps teams to focus their efforts where they can have the greatest potential
impact.
When to Use It
Pareto charts help teams focus on the small number of really important problems or causes of
problems. Pareto charts are useful in establishing priorities by showing which are the most
critical problems to be tackled or causes to be addressed.
Comparing Pareto charts of a given situation over time can also determine whether an
implemented solution reduced the relative frequency or cost of that problem or cause.

Use the Pareto Chart to:

 Focus on areas of priority
 Prioritize factors and put them in graphical form in a simple and quick manner
How to Use It
Step 1. Develop a list of problems, items, or causes to be compared.
Step 2. Develop a standard measure for comparing the items.
 How often it occurs: frequency (e.g., utilization, complications, errors)
 How long it takes: time
 How many resources it uses: cost

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Table 10: Arranging Items in compilation tables

Step 3. Choose a time frame for collecting the data.

Step 4. Tally, for each item, how often it occurred (or cost or total time it took). Then add these
amounts to determine the grand total for all items. Find the percent of each item in the grand
total by taking the sum of the item, dividing it by the grand total, and multiplying by 100.

Table 11: Tallying items in a compilation tables

Step 5. List the items being compared in decreasing order of the measure of comparison: e.g., the
most frequent to the least frequent. The cumulative percent for an item is the sum of that item’s
percent of the total and that of all the other items that come before it in the ordering by rank.
Step 6. List the items on the horizontal axis of a graph from highest to lowest. Label the left
vertical axis with the numbers (frequency, time, or cost), then label the right vertical axis with
the cumulative percentages (the cumulative total should equal 100 percent). Draw in the bars for
each item.
Step 7. Draw a line graph of the cumulative percentages. The first point on the line graph should
line up with the top of the first bar.
Step 8. Analyze the diagram by identifying those items that appear to account for most of the
difficulty. Do this by looking for a clear breakpoint in the line graph, where it starts to level off
quickly. If there is not a breakpoint, identify those items that account for 50 percent or more of

49
the effect. If there appears to be no pattern (the bars are essentially all of the same height), think
of some factors that may affect the outcome, such as day of week, shift, age group of patients,
home village. Then, subdivide the data and draw separate Pareto charts for each subgroup to see
if a pattern emerges.

Table 12: Client Window Framework

Caution
Try to use objective data instead of opinions and votes.

Client Window
A client window is a tool for gaining feedback from clients about the products and services they
use. It differs from a client survey in that a survey asks clients about product or service
performance, based on the survey designer’s ideas about what clients want and need. A client
window asks questions in very broad terms, letting the clients express what they need, expect,
like, and dislike in their own terms and from their point of view.

When to Use It
A client window can be used to get information from clients, in their own terms, about what they
want or what they like about the current service. However, this is really only one step in
understanding what is most important to clients. Not all things listed will be of equal weight, and
further discussion with clients may be needed to find which areas are true priorities. A client
window can be used by itself, or as groundwork for more formal data collection through surveys;
using it in this way can help design more relevant survey questions. Client windows can also be
used when designing solutions, getting information that will make it easier to avoid repeating
past mistakes in planning.

How to Use It
Step 1. Determine the product, area, or service for which feedback is desired. Frame what kind
of feedback is being sought. Is feedback desired on the whole range of products and services
provided? Is the team more interested in specific areas? For example, clients could be asked to
provide feedback on all health services they receive, or the team may want to focus on specific
health activities, such as immunizations and curative care.
Step 2. Gather information from clients by asking them to respond to the following questions:
 What are you getting that you want? What are you getting that is meeting your needs and
expectations?
 What are you getting that you really don’t want or need?
 What do you wish you were getting that you are not?

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 What needs do you expect in the future?
 What suggestions do you have for how we can improve our products or services for you?
There are two ways to administer the client window: to a group of clients or to clients
individually.
Group: Prepare a large client window framework. When the clients are gathered, explain that the
goal of this activity is to get honest feedback about how their needs and expectations are being
met. Write the areas of focus on a flip chart or blackboard. Ask them to write individually the
answers to the above questions on the client window. (It is best to leave the room at this point so
that the clients have privacy to answer as honestly as possible.)
Individual: In this mode, ask each client to fill out the client window and return the responses (no
names required). Prepare instructions, including how their feedback will be used, the areas of
focus, how to fill out the client window, and where and when to return it. Clients write their
responses to the above questions directly on the client window form.
Step 3. Compile the information. If the client window was administered in a group, record the
answers on a separate sheet of paper as they were written for each section of the window.
Review the answers and count how often the same feelings were expressed by several people.
Step 4. If the client window was administered individually, place all individual responses on a
master sheet, and then count how frequently similar responses were given.

Caution
Be sure to have the correct people (the clients) present when completing the window.

12. Benchmarking
Best practices benchmarking is a systematic approach for gathering information about process or
product performance and then analyzing why and how performance differs between business
units. In other words, benchmarking is a technique for learning from others’ successes in an area
where the team is trying to make improvements. The term benchmarking means using someone
else’s successful process as a measure of desired achievement for the activity at hand. Some
sources of information for benchmarking include: literature reviews, databases, unions, standard-
setting organizations, local organizations, universities, the government, staff or customer
interviews, and questionnaires.

Use Benchmarking to:

 Develop plans to address needs for improvement
 Borrow and adapt successful ideas from others
 Understand what has already been tried

When to Use It
Benchmarking is most useful when trying to develop options for potential solutions. When trying
to develop solutions, teams often have difficulty generating new ideas.
People frequently do not know what others nearby are doing. Benchmarking helps stimulate
creativity by gaining knowledge of what has been tried. It can also be used to identify areas for
improvement by seeing what level of quality is possible.

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How to Use It
Identify other groups, organizations, or health facilities that serve a similar purpose and that
appear to work well. They do not need to be doing exactly what the team does, as long as it can
be compared. For example, if the team is dealing with problems in hospital laundry services, the
team could learn from hotels and dormitories that provide similar services, although they are not
in the same field and/or do not provide exactly the same service. Visit these sites and talk to
managers and workers, asking them what they are doing, if they have similar problems, what
they have done about it, and what levels of performance they have achieved. Ask as well what
obstacles they have run into and how they have dealt with them.
Review how the situation and constraints for the process in question are similar to or different
from theirs and determine if changes are needed in carrying out their plan.

Caution
Be sure to understand fully how the process in question works before looking at others’
processes. Be sure that the other facility’s process is fully understood before adapting or
adopting it to the process in question.

13.Gantt Chart

A Gantt chart aids planning by showing all activities that must take place and when they are
scheduled to occur. This tool helps planners to visualize the work that needs to be completed, the
activities that can be overlapped, and deadlines for completion.

When to Use It
Gantt charts provide a graphic guide for carrying out a series of activities, showing the start date,
duration, and overlap of activities. Gantt charts are most useful in the planning stages, to mark
when each activity should start and to draw the linkages in timing between activities. Gantt
charts are also useful for keeping track of progress and rescheduling activities if progress is
slowed.

Timelines and Gantt Charts Are Best to:

 Plan a quality improvement project according to activities and time

 Understand the overlap and sequence of activities
 Monitor progress and re-evaluate deadlines if the project is behind schedule

How to Use It
Step 1. List all the activities that need to be carried out to implement a solution.
Step 2. Determine when each activity must start and list them in chronological order.
Step 3. Draw the framework for the Gantt chart by listing the months of implementation across
the top of a sheet of paper. List the activities down the side.
Step 4. For each activity, mark its starting date. Determine the duration for each activity and,
using a horizontal bar, mark the duration on the graph. Continue this process for each activity.
Step 5. Review the chart and determine if it is possible to carry out all the activities that are to be
conducted simultaneously.

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14. Quality Assurance Storytelling
Quality assurance storytelling is an organized way of documenting the quality improvement
process of a team that is working systematically to resolve a specific problem and/ or improve a
given process. QA “stories” are described in detail as they unfold in QA storybooks and
presented publicly through QA storyboards. Initially developed as Quality Improvement
Storytelling for industrial programs, the technique has more recently been adapted and applied to
quality improvement efforts in the health sector. Initially this was carried out by the Hospital It
is increasingly used by others in health as an effective way of documenting the activities of QI
teams in various of settings. The QA storybook is a complete and permanent record of the
improvement process, usually kept in notebook format.
The QA storyboard is a large display area (section of a wall, or a board or poster) that allows a
team to display its work publicly in an ongoing, structured, and visually understandable way. It
has been described by HCA’s Batalden and Gillem (1989) as the team’s “working minutes.”

When to Use It
By systematically documenting the quality improvement progress made by a team, QA
storytelling helps to keep everyone focused on the task at hand and allows team members to
describe their work to others in a clear and comprehensible way. It is normally begun as soon as
a problem has been identified and continues throughout the QI process. When used routinely,
QA storytelling can help make QA part of the ongoing life of the organization.

How to Use the QA Storybook

One team member is usually designated as recorder to maintain a complete and detailed record
of the team’s activities. The record should include minutes of team meetings as well as such
items as lists of persons contacted, presentations made, indicators monitored, sampling designs
and analytical methods employed, data collected, etc. From time to time the recorder may use the
information in this record to prepare brief summaries of the team’s progress in resolving the
problem in question. Items are selected from this record for posting on the QA storyboard.

How to Use the QA Storyboard

The QA storyboard serves as an ongoing visual record of the team’s progress, helping to keep
team members focused on the task while sharing their progress with others. Storyboards use
simple, clear statements as well as pictures and graphs to describe a problem, summarize the
analysis process while it is under way, describe the solution and its implementation, and display
the results. Steps in creating and maintaining a QA storyboard follow.
Step 1. Reserve a section of the wall or secure a large board or poster board (measuring at least
one and a half meters high by two meters in length) to serve as the QA storyboard.
Step 2. Mark off and label different areas of the storyboard for displaying the team’s progress
during each of the quality improvement steps. Include areas for the problem statement, names of
team members, the work plan, activities undertaken during problem analysis (e.g., root cause
analysis, graphs, etc.) and the results, solution(s) selected, solution implemented, the results, and
any other information that seems interesting or relevant.
Step 3. Post a copy of the initial statement of the problem and the names of the team members. A
picture of the team may be added.
Step 4. Keep these up-to-date as the problem statement is refined and/or as team membership
changes.

53
Step 5. Post a copy of the team’s work plan and schedule, and modify it as changes are made
during the problem solving process.
Step 6. As work progresses, display the progress made in analyzing the problem. If analytical
tools were used (e.g., flowcharts, cause-and-effect diagrams), include these items on the
storyboard. It is also useful to include (if they were used) the list of indicators to be monitored,
the data collection forms, and graphs displaying the results.
Step 7. Post the findings of the problem analysis and the solution(s) proposed and selected for
implementation.
Step 8. Add any other aspects of the process of solution identification and selection (e.g.,
selection criteria or selection method) to be displayed for ready reference.
Step 9. Maintain an ongoing display of the progress of solution implementation. Show as much
(or as little) detail as team members find helpful, either to focus their own work or to
communicate their work to others.
Step 10. When the solution has been implemented and evaluated, post the results for all to see.

Caution
The storyboard is a helpful tool to show the progress of a quality improvement team; it will also
stimulate other to initiate or participate in Quality Improvement efforts. Be sure to use it.

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CHAPTER IV: QUALITY IMPROVEMENT STEPS

Although the four QI approaches differ in complexity, each follows the same basic four-step
sequence.
This section discusses each step in detail and addresses how steps may vary for each approach.
QI is not limited to carrying out these four steps, but rather is continuously looking for ways to
further improve quality. When improvements in quality are achieved, teams can continue to
strive for further improvements with the same problem and/or address other opportunities for
improvement that have been identified. This concept , frequently referred to as continuous QI,
encourages teams to work towards achieving unprecedented levels in the quality of care.

Figure 13: Four Steps to Quality Improvement

Figure 14: Continuous Quality Improvement

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Step One: Identify
The goal of the first step, identify, is to determine what to improve. This may involve a problem
that needs a solution, an opportunity for improvement that requires definition, or a process or
system that needs to be improved. This first step involves recognizing an opportunity for
improvement and then setting a goal to improve it. QI starts by asking these questions:
 What is the problem?
 How do you know that it is a problem?
 How frequently does it occur, and/or how long has it existed?
 What are the effects of this problem?
 How will you know when it is resolved?

Table 13: Common Problems/Quality Dimensions

Creating a problem statement is not always necessary, but helps to clarify and communicate the
area identified for improvement. A problem statement is a concise description of a process in
need of improvement, its boundaries, the general area of concern where QI should begin, and
why work on the improvement is a priority. In creating a problem statement, it is important to
avoid listing potential causes or solutions, and to focus energies on describing the problem. It is
also important to note that problem statements should be carefully constructed to not assign
blame to a particular person or department. The assignment of blame not only makes
assumptions about the cause of a problem, but also alienates key people from the design and
implementation of solutions. The case examples of problem statements illustrate how they can be
worded to simply describe the identified problem. Problems are identified in a variety of ways.
An adverse event or a customer complaint may call attention to a gap between client
expectations and the actual services provided. Alternatively, organizations can intentionally

56
assess quality through on-going monitoring, service statistics, and/ or planning and prioritizing.
Political or professional agendas may also evoke interest in QI. The impetus for improvement
differs in each situation, as does the amount of data that support the decision. Sometimes
problems are intuitive or obvious and can be addressed without collecting additional data or
information. Individual Problem Solving and Rapid Team Problem Solving approaches often
identify problems based on existing data, observation, and intuition; as a result, these approaches
tend to require less time and fewer resources. Systematic Team Problem Solving and Process
Improvement require a deeper analysis of the problem, there by necessitating data collection and
team work. Although the identification process varies according to which approach is
appropriate, this step remains crucial for all approaches in order to define the problem or
opportunity for improvement.

Case Example: Problem Statement

In areas without electricity, refrigerators are powered by gas in bottles, which need regular
refills. Deficiencies in the transportation and refill of the bottles, however, disrupted the
refrigeration of vaccines. Health workers wrote the following problem statement to identify the
problem and to aim for improvement:
“Interruptions in the supply of butane to most health centers in the district have become
increasingly frequent and long-lasting. An improvement in this situation would reduce the
number of interruptions of the cold chain.”

Case Example: Constructing a Problem Statement

The following problem statement was revised to avoid blame and assumption of causes:
First Version: Waiting times for pregnant women are long because the midwives take too long
for tea breaks. This discourages women from coming for prenatal care.
Final Version: Waiting times for pregnant women have been shown to take up to three hours.
This has been stated as a reason that women do not make the desired four prenatal visits before
delivery.

Case Example: Problem Identification through an Adverse Event

A quality assurance team at a hospital x noted a shortage in medication for Acute Respiratory
Infections (ARI) for children under five.
What is the problem? A shortage of ARI drugs for children under five exists.
How do you know it is a problem? Drugs run out by the third week of the month.
How frequently does it occur? This shortage has occurred every month for the past nine months.
What are the effects of this problem? Patients develop complications and increased referrals to a
first-level facility.
How will you know when it is resolved? The problem will be resolved when ARI drugs last until
the end of the month.

Case Example: Problem Identification through On-Going Monitoring

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A quality assurance team at a rural health center reviewed vaccination data and found low
coverage rates for the measles vaccine.
What is the problem? The coverage of the measles vaccine (children 0.11 months) is low.
How do you know it is a problem? The vaccine data from the previous year revealed the low
coverage rate.
How frequently does it occur? Approximately 8 out of 10 children (0.11 months) do not receive
the measles vaccine.
What are the effects of this problem? There are measles epidemics causing children to suffer.
How will you know when it is resolved? Increased coverage of children with the measles
vaccine.

Step Two: Analyze

Once a problem or opportunity for improvement has been identified, the second step analyzes
what must be known or
understood before changes are considered. The objectives of the analysis can be any combination
of the following:
 Clarify why the process or system produces the effect that we aim to improve
 Measure the performance of the process or system that produces the effect
 Formulate research questions, such as:
 Who is involved or affected?
 Where does the problem occur?
 When does the problem occur?
 What happens when the problem occurs?
 Why does the problem occur?
 Learn about internal and external clients, such as their involvement in the process being
analyzed and needs and opinions about the problem
To reach these goals, the analysis stage uses existing data or requires data collection. The extent
to which data are used depends on the QI approach chosen. Data are an important part of
problem analysis in that they help to:
 Document the problem
 Provide credibility regarding the need for improvement
 Help to identify possible solutions
A few techniques for analyzing problems include:
 Clarifying the processes through flowcharts or cause-and-effect analyses
 Reviewing existing data
 Collecting additional data

Data can also be used to conduct a root cause analysis of the problem to discover the underlying
causes for the occurrence of a problem. This in-depth analysis is useful when the causes of a
complex and/or recurring problem are unclear, or require more definition. A root cause is defined
by the following criteria (IHI 1995):
 Directly and economically controllable
 A fixed part of the area in need of improvement
 If the root cause is eliminated, the problem is drastically reduced Possible causes are first
identified through tools such ascause-and-effect diagrams (Section 9) and then screened
to determine which are most likely to cause the problem.

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Causes are then ruled in or out as a root cause through further investigation. If resources and time
allow, data collection can be used to narrow down the list of hypothesized causes as well as test
and quantify the most likely causes of the problem. Intuition and team consensus are also
valuable in determining root causes, especially when time and resources are limited. Although a
root cause analysis could be conducted in the problem analysis of any of the quality
improvement approaches, it is most commonly used by Systematic Team Problem Solving teams
that are addressing complex and recurring problems with unclear causes.
Like the identification stage, the analysis step is an essential element of each approach, but varies
in its depth depending on which QI approach is being used. Individual Problem Solving could
rely on one individual’s analysis or intuition of a problem and does not normally require
extensive additional data in order to understand the problem.
Rapid Team Problem Solving uses as much existing data as possible to analyze the problem,
saving time and money by collecting only minimal additional data. Systematic Team Problem
Solving uses existing data and data collection to conduct an in-depth analysis of the problem and
often requires extensive time and resources. Finally, Process Improvement requires detailed
knowledge of the area identified for improvement and necessitates ongoing data collection to
monitor the process over time.

Step Three: Develop

The first two steps helped us to: (a) identify what we want to improve, and (b) analyze the
information we need to understand to make the improvement. The third step, “develop,” uses the
information from the previous steps to ask what changes will yield improvement. The answer
provides a hypothesis about what changes, would solve the problem and in turn improve the
quality of care. A hypothesis is an educated guess; in Step 3, a hypothesis is an educated guess
about what would solve the problem. It is crucial to remember that at this point the hypothesis
remains a theory, as it has not yet been tested. Hypotheses are developed in a variety of ways,
depending on the QI approach being used. Using the Individual Problem Solving, individuals
develop specific minor changes in the system. These small changes effect few people and require
less planning and time. This method generally does not require teams or outside experts for the
development of hypotheses for improvements.
The other three approaches generally require hypotheses development:
 Rapid Team Problem Solving involves the development of a series of small changes to be
sequentially tested and possibly implemented.
 Systematic Team Problem Solving develops solutions directed towards the root cause of a
problem and therefore these changes are generally large.
 Process Improvement involves the permanent monitoring and improvement of a key process
and therefore encounters a variety of improvement needs over-time.
Changes may affect different processes and impact a lot of people, so they require significant
planning. Although the change may result in improved quality, people often feel apprehensive
about change and resist it, especially if they did not participate in developing the change.
Therefore, changes at this level require time for organizational members to grow accustomed to
the new ideas and learn the new methods. Resistance to change can be prevented through group
participation and time for adjustment.
Step Four: Test and Implement
This stage of quality improvement builds upon the previous steps where an improvement area
was identified, analyzed, and then hypothetical interventions4 or solutions were posed. This final

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step in the process tests the hypothesis to see if the proposed intervention yields the expected
improvement. It is important to remember that large changes should be tested extensively and
modified to reduce the risk of the intervention not working and that interventions may not yield
immediate results even if they are effective. Allowing time for change to occur is important in
the testing process.
Each of the QI approaches requires different intensity levels of testing before implementation.
The Individual Problem Solving approach does not require extensive testing before
implementation and generally works on a level of “trial and error.” If the change is small enough
to justify the use of this approach, the decision maker can try the change and modify it as
necessary. Because Rapid Team Problem Solving entails many small to medium size tests of
individual changes in similar systems, less risk is involved than in the QI approaches where one
large test of all of the changes is made. Rapid Team Problem Solving members build on the
knowledge generated from these multiple tests.
Because Systematic Team Problem Solving often poses and tests theories for the underlying
causes of problems, it involves substantial testing and modification of a proposed intervention.
Finally, Process Improvement makes changes to a key process in the delivery of care through
any of the approaches to quality improvement.

The Cycle for Learning and Improvement

The scientific method generally involves planning a test, doing the test, and studying the results.
Quality management, however, has expanded the scientific method to act upon what is learned:
essentially plan, do, study, and act (PDSA). PDSA, otherwise referred to as Shewhart’s Cycle for
Learning and Improvement (Shewhart 1931), is a fourstep process included in the testing and
implementation stage of every QI approach.
The PDSA cycle allows for continuous improvement as hypotheses are regularly created, tested,
revised, implemented, and then adapted further. This continual process allows us to make
constant changes and deepen our understanding of organizational improvement needs and
solutions. The PDSA cycle for learning and improvement applies to each of the four approaches
to QI and is discussed in the next four sections.

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61
62
In summary, following the four-step process to QI is important for all QI approaches.
1. Identify: Determine what to improve
2. Analyze: Understand what must be known or understood about the problem in order to make
improvements
3. Develop: Use the information accumulated in the previous steps to determine what changes
will yield improvement
4. Test and Implement: Check to see if the proposed intervention or solution yielded the
expected improvement
The next four sections detail the application of these steps for each of the four quality
improvement approaches. Quality improvement tools are covered in the final section.

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CHAPTER V: QUALITY CARE AND SERVICES IMPROVEMENT APPROACHES

The need for QI varies widely, depending on the health setting and circumstances: from rural
health posts, to urban hospitals, to entire systems (such as ministries of health), and from a
simple process in a small system to a complex process in a large system. Although the principles
of QI apply in all circumstances, different QI approaches work better under certain
circumstances. In response to the wide variety of settings and circumstances it has encountered
in over 30 developing countries, the QA Project has identified many approaches to QI. Some
problems are simple in nature and can be resolved rapidly, while others involve core processes
and require extensive data collection and analysis. QA Project experience has demonstrated that
a wide range of QI approaches exists and that they range from simple to complex. These
approaches can be visualized along a continuum of complexity, with greater time, resource
allocation, and group participation required along the progression of complexity. Along this
continuum, the QA Project has identified
four points, each representing a QI approach (see Figure 3.1). These four approaches are not the
only points along
this continuum of complexity, but they are an illustration of how QI approaches may differ
depending on the setting
and circumstances.

1. Individual Problem Solving

Individual Problem Solving is the simplest approach to QI. Any organizational member can use
this approach when it is possible to solve a problem without a team. The approach is found in
everyday work when individuals identify apparent problems, recognize their ability to fix it, and
feel empowered to make necessary changes. Although teamwork is an essential part of QI, the
QA Project has learned that simpler or urgent improvement needs do not necessitate lengthy
team-based approaches. The hallmark of this approach is that it is used to address problems that
are not interdependent with other people. This means that one person can make and implement
the decisions necessary to address that problem. Individual Problem Solving tends to require
little time or data and is methodologically the least complex. This approach occurs in

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organizations where each individual recognizes the overall goal of delivering quality care and
acts accordingly when needs arise that he or she can address individually. Organizations and
individuals familiar with the QI process can use this method quickly and inexpensively to
address minor needs for improvement. For example, a nurse who regularly administers vaccines
notices that the storage refrigerator is full; in order to store more vials, the nurse takes the
initiative to reorganize the refrigerator (Population Information Program 1998). This minor
change is important because it allows for the refrigeration of more vials. Since it does not
seriously affect the actions of others and probably will not be met with resistance to change, the
Individual Problem Solving approach is appropriate.

2. Rapid Team Problem Solving

Rapid Team Problem Solving is an approach in which a series of small incremental changes in a
system is tested and possibly implemented for improvements in quality. This approach entails
many small to medium size tests of individual changes in similar systems.Like Individual
Problem Solving, this approach could be used in any setting or circumstances, although it
generally requires that teams have some experience in problem solving and/or seek a mentor to
help implement this approach quickly.
This approach to Quality Improvement is less rigorous in the time and resources required than
the next two approaches because it largely relies on existing data and group intuition, thereby
minimizing lengthy data collection procedures. Teams are ad hoc (temporary) and disband once
the desired level of improvement has been achieved.
3. Systematic Team Problem Solving

Systematic Team Problem Solving is often used for complex or recurring problems that require a
detailed analysis; it frequently results in significant changes to a system or process. The mainstay
of this approach is a detailed study of the causes of problems and then developing solutions
accordingly. This detailed analysis often involves data collection and therefore often requires
considerable time and resources. While Systematic Team Problem Solving can be used in any
setting, due to its depth in nature, it is most appropriate when the ad hoc team can work together
over a period of time, but it typically disbands once sufficient improvement objectives are
reached.

4. Process Improvement
Process Improvement is the most complex of the four approaches as it involves a permanent
team that continuously collects, monitors, and analyzes data to improve a key process over time.
Therefore, Process Improvement generally occurs in organizations where permanent resources
are allocated to quality improvement. This team can use any of the other three QI approaches, for
example forming ad hoc teams to solve specific problems. This approach is often used to assure
the quality of important services in a health facility or organization. Since this approach is often
used to respond to core processes of a system, various stakeholders contribute to the analysis
stage. Choosing a QI approach: Once a problem has been identified for improvement, the next
step is determining which QI approach will best address the problem. Criteria such as the
problem existing within a core process, being interdependent with other people, or being
complex or recurring can help to determine which QI approach to use.

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Choosing a QI approach:
Once a problem has been identified for improvement, the next step is determining which QI
approach will best address the problem. Criteria such as the problem existing within a core
process, being interdependent with other people, or being complex or recurring can help to
determine which QI approach to use.

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 Figure 15: Choosing a QI Approach

Table 14: Comparison of QI Approaches

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Approach 1: INDIVIDUAL PROBLEM SOLVING

Along the continuum of complexity and resource investment, Individual Problem Solving is
often the quickest of the four quality improvement approaches. This approach differs from the
other three in that it is not team based and essentially relies on individual decision making. This
approach is appropriate when the issue is not interdependent; in other words, the single person
upon whom the change depends can make the change happen without affecting processes outside
his/her understanding and control. The Individual Problem Solving approach focuses on
improvement needs that are apparent and do not require teamwork to analyze, develop, test, or
implement a solution. Therefore, this approach is generally faster than the others. However, it is
not necessarily rapid; individual problem solvers may use many of the quality improvement tools
and carry out problem solving over time if necessary.
Individual Problem Solving is successful in organizations where each individual understands his
or her contribution to the overarching goal of quality care and is empowered to make the
necessary decisions within his or her jurisdiction. In short, Individual Problem Solving is
founded on the philosophy that quality is everyone’s responsibility. Individual Problem Solving
may be appropriate when some or all of the following circumstances surround the need for
improvement:
 The problem is not interdependent
 The problem is apparent
 The problem necessitates a rapid response
 Improvements can be achieved by one person

Step One: Identify

The Individual Problem Solving approach is appropriate when an individual recognizes and
makes small changes to correct a problem that is apparent and/or must be fixed immediately.
Once it is noted that a discrepancy exists between the real situation and the ideal situation, the
problem solver investigates further to confirm that the problem exists. Because the problem and
solution are apparent, problem identification tools generally are not necessary, but may be used
as needed. The person who perceives the problem would proceed to fix it.
Step Two: Analyze
The analysis stage of Individual Problem Solving may rely on intuition, observation, the past
experience of the decision maker, and/or analysis of existing data. Based on this knowledge, the
individual considers what he or she needs to know in order to change the problem. Although the
problem is apparent, occasionally some brief investigation or consultation with others may be
necessary. The following activities are completed to analyze the problem:
 Consider the possible causes
 Confirm information through dialogue (if necessary) or readily available data

Step Three: Develop

The decision maker at this point has identified something that needs to be fixed and has analyzed
possible causes of the problem. The development stage of Individual Problem Solving generates
possible solutions in order to resolve the problem through simple, obvious solutions. Based on

68
the analysis of possible causes for the problem, the decision maker generates a list of solutions to
address this need (often mentally). Depending on the nature of the problem, the following
activities support the development of solutions:
 Generating simple, obvious, and feasible solutions
 Validating solutions through dialogue (if necessary) or readily available data to make sure
that the solution will not negatively affect the work of others

Step Four: Test and Implement

The previous step developed what appeared to be the most viable and feasible solution to address
the problem. As in the other three approaches, possible solutions must be tested for effectiveness
before being declared successful.
This approach tests each solution individually. Interventions are tested, modified, and re-tested
until the problem has been resolved. Although hypothesized solutions tend to be obvious and
simple, decision makers still develop, test, and modify the hypotheses as necessary.
In this QI approach, the PDSA cycle is largely intuitive imagining and trying out the solution and
can be completed rapidly to resolve the problem at hand.
Nevertheless, the thought process behind testing and implementing solutions still follows the
PDSA cycle and may require some data and/or dialogue with others.
Individual Problem Solving often presents an opportunity to prevent the problem from recurring.
Once the immediate problem is resolved, the person who identified it can form a team to begin
planning to prevent the problem from recurring. Any of the other QI approaches can be used to
follow up on the problem.

Table 15: PDSA for Individual Problem Solving

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Figure 16: Summary of the Individual Problem-Solving Approach

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Case Example of an Individual Problem Solving

Step One: Identify

A receptionist at a district hospital saw that a patient appeared to be confused about where to go
for her appointment. The receptionist asked the patient if she needed any help and discovered
that the patient had become lost while looking for the place to have blood drawn.

Step Two: Analyze

The receptionist thought about the problem for a moment. Although there were signs in the
hospital to direct patients, she realized that the patient may not have been able to read or the
signs may have been unclear. The receptionist recognized that the patient may have needed some
assistance in finding the clinic where blood was dawn.

Step Three: Develop

The receptionist quickly thought of a couple solutions. At first she considered giving the woman
directions, but then realized that she could become lost again. Another idea was to call someone
over to assist, but she realized that this could take too much time. Finally, she decided that the
best solution was to walk with the patient to the clinic, as it was nearby and another receptionist
was in the office.

Step Four: Test and Implement

The receptionist offered to accompany the woman to the clinic so that she would not get lost
again. She was pleasantly surprised by the courtesy and friendliness of the receptionist. After
they walked to the clinic together, the receptionist verified that this was where the patient needed
to be and then returned to her station. Because it does not make sense that the receptionist always
accompany patients to areas in the hospital, the receptionist decided to form a team to address
this issue and prevent its recurrence. The team studied the problem and decided to code each
clinical area with a color. Lines of the corresponding color were then painted along the wall to
lead patients to the different clinic areas. If patients could not read or became lost, they could
follow the line.

Approach 2: Rapid Team Problem Solving

Rapid Team Problem Solving is different from theother team-based approaches because it can be
accomplished quickly while still using a team. Two factors make Rapid Team Problem Solving
the fastest of the team-based approaches. First, it tailors the problem-solving process to the
situation at hand and minimizes activities just to those necessary to make improvements. Since
this approach requires decisions about doing only the essential parts, it is advisable that someone
experienced in this methodology assist the team: teams lacking experience in problem solving
need mentors to foster the learning process in applying this approach. Experience or assistance in
problem solving enables teams to move quickly through the improvement steps. Secondly, Rapid
Team Problem Solving builds on available data as much as possible and attempts to minimize
new data collection.

71
Another feature of this approach that distinguishes it from others is that small interventions are
introduced sequentially to improve a situation in a very controlled way that prevents or quickly
corrects—any adverse result.
Rapid Team Problem Solving is most successful when:
 Teams have experience in Systematic Team ProblemSolving and/or a mentor to guide them
through this approach
 Team members are familiar with quality improvement tools, especially in knowing when and
where not to apply a tool
 Teams express intuitive ideas for solutions and use benchmarking
 The team can generate solutions or has access to known interventions for improvement
Step One: Identify
The Rapid Team Problem Solving approach functions in a series of cycles to sequentially
introduce small, new interventions and continuously improve quality. Usually leaders and/or
team members identify and define an opportunity for improvement through the following sub-
steps:
Define a specific goal for improvement. Rapid Team Problem Solving generally addresses
problems that have been identified by leaders or team members as opportunities for
improvement. If a goal for quality improvement has not been established, the team can review
existing data and assess group intuition to set realistic goals. QI goals should be clearly defined,
such as the following examples:
 Reduced waiting time
 Reduced infection rates
 Reduced complication rates

Once a specific aim for improvement has been defined, the identification process proceeds to
define teams and achieve consensus for the aim.
Decide who needs to be on the problem-solving team. The team must be chosen carefully to
ensure that key players who can provide insight into the problem are represented. For example, a
hospital QI team that wants to address medicine shortages should recognize the need to include
pharmacists so that their knowledge of the processes of ordering supplies and prescribing
medication is represented.
Achieve consensus for the aim. It is crucial that a team re-clarify the problem that they wish to
address and goals for improvement so that all members understand what they are working
toward. Problem-solving teams should consider constraints in time, money, and feasibility in
addressing aims for improvement. If an improvement need does not seem self-evident, teams
may use tools such as the priority matrix to prioritize improvement needs. Agreement regarding
which improvement need to address can be achieved by voting.

Step Two: Analyze

Activities in the analysis stage allow the team to explore what it needs to know or understand in
order to make an improvement. To reach this understanding, teams:
Analyze available and readily accessible data and information. Rapid Team Problem Solving
attempts to achieve rapid improvement and therefore minimizes the use of data. Only what a
team needs to know about an area of improvement is studied, so data analysis mostly relies on
existing data and the intuition of the group. Process description tools, such as flowcharts and
cause and-effect diagrams, aid teams in drawing out group experience and analyzing the

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information available; however, these tools are used only if they are critical to the problem
solving process.
Identify indicators to measure achievements. Indicators are variables or characteristics that
can be measured and monitored to test the achievement of quality improvement goals. Indicators
are critical in understanding the impact of an intervention or solution and in determining whether
implementation should continue. Teams need to know how to determine if a change results in
improvement. Therefore, teams must tie the aim to an indicator to be able to test for the change’s
impact. When using limited data, run charts help to track trends or patterns in the indicators. This
tool improves a team’s ability to monitor and predict the performance of processes.

Table 16: Sample Indicators for Improvement Goals

Collect data prior to an intervention if available data are not sufficient. Baseline data (data
collected before implementing an intervention) are needed for comparison with post-intervention
data to assess the intervention’s effectiveness. If this information is not readily available, some
data collection may be necessary.
Rapid Team Problem Solving uses only the data necessary to understand the area of
improvement and therefore limits data collection to critical information only. Teams collect a
minimal set of data that provides enough information about the area of improvement and does
not require large amounts of time or money. For example, a team may collect data on a sample (a
representative subgroup) of patients, such as five to ten per day for two weeks. Although the
sample size is small, if the data are collected correctly, they will provide basic information to
understand the opportunity for improvement and to make decisions.

Step Three: Develop

Once the improvement goal has been set and the relevant data have been analyzed to clarify the
current process, teams begin to consider what changes could yield improvement. These ideas are
based on the information provided through the data and group intuition. The development of
interventions has three main stages:
Generate possible changes/interventions. Team members are a valuable resource in the
generation of possible changes or interventions. Rapid Team Problem Solving largely relies on
group intuition to develop ideas for changes to address the identified area of improvement.
Group activities such as brainstorming, affinity analyses, and creative thinking tap the
knowledge of group members and generate lists of possible changes. Benchmarking also
provides ideas for the development of interventions by studying the changes that other

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organizations or departments have tried in similar situations. These ideas are then adapted for the
specific situation and improvement needs.
Rank the order of possible changes according to criteria. When a team has generated a list of
possible interventions, the ideas must then be ranked according to criteria, such as urgency or
feasibility, so that the team can choose one intervention to develop and test. Tools such as the
prioritization matrix help groups to rank interventions and decide which one to develop.
Select one intervention to test. Interventions are developed together and tested separately.
Teams use judgment to select and prioritize the interventions to continue to the next step of
testing and implementation. Interventions are then implemented into the system either together
or separately, creating a sequence of small changes over time. This process helps to prevent
unexpected consequences if the intervention should fail or need to be modified considerably.
Interventions may be studied, adapted, and re-tested individually and then eventually
implemented into the system once they have proven to be successful.

Step Four: Test and Implement

The first three steps identified the aim for improvement, analyzed the situation, and developed
and ranked possible interventions. The final stage, testing and implementation, reveals whether
the intervention is effective. In the Rapid Team Problem Solving approach, the testing and
implementation of interventions are generally conducted on a small scale with only a few people.
These small changes usually meet little resistance because they are introduced incrementally.
Interventions can also be tested in parallel (e.g. in different departments or units) and, with
judgement, implemented together once each has proven to be effective.
This approach uses the PDSA cycle in the following way:
Plan: In planning for a test, one should also prepare for the possibility that the intervention may
fail or produce adverse effects. Teams should try to foresee unexpected impact or results that
may occur. Communication and pre-planning are critical to the successful testing of an
intervention or change.
 Verify that all baseline data are complete
 Make a plan of action for the test
 Communicate the intervention to others: make sure all involved parties understand the
change clearly
Do: The team tests each change separately. The individual testing of each intervention allows the
team to modify them separately before integrating effective changes.
 Test the intervention
 Document modifications made to the intervention or solution
 Check that the data are complete and accurate
Study: As mentioned previously, data collection and analysis are limited to information that is
necessary to determine whether an intervention is effective. Teams compare the baseline data
and the follow-up data (data collected after implementing an intervention) to assess the
effectiveness of an intervention.
 Verify that the intervention was tested according to the original plan
 Compare baseline and follow-up data to measure the impact of the intervention
 Compare results with the expected or desired results
Act: Once the intervention has been planned, tested, and studied, the team summarizes and
communicates what was learned from the previous steps. This summary helps the team decide
whether to implement, modify, or discard the intervention. This decision is based on the data that

74
measure the impact of the intervention. Two questions help to determine a route of action: (a)
Did the intervention yield improvement, and if so, (b) Was the improvement sufficient?
Improvements are deemed sufficient when they achieve a benchmark level or the level of
performance is satisfactory to the team or leadership. If the intervention leads to improvement
and the improvement is sufficient, implement the intervention as a permanent part of the system
and return to Step Three to develop another intervention. (The Rapid Team Problem Solving
approach functions in a series of cycles to sequentially introduce small, new interventions and
continuously improve quality.) If the intervention leads to improvement but the improvement is
not sufficient, adapt the intervention and repeat Step Four to test the revised intervention. If the
intervention does not lead to improvement, return to Step Three to select a different intervention
to develop and implement.
Teams then continue to test one intervention at a time, keeping successful interventions until the
team is satisfied with the improvement achieved.
Prevention planning. Each intervention by itself may or may not yield improvement.
Interventions may also interact with each other when implemented together, possibly enhancing
each other’s effects and yielding even greater improvement than expected, or possibly reacting
adversely to each other. Try to predict these outcomes to plan for all possibilities and prevent any
unexpected reaction when interventions are implemented together.

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Figure 17: Summary of the Rapid Team Problem-Solving Approach

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Case Example of a Rapid Team Problem Solving

Dr. Maged Awadalla, a pediatrician x Hospital in, noted that neonates with physiological
jaundice were spending more time than expected in phototherapy.
Jaundice occurs in neonates when bilirubin levels are too high; it is caused by a variety of
factors, such as prematurity or an incompatibility in blood type. Phototherapy exposes the skin to
ultraviolet light, causing the breakdown of bilirubin and its excretion, ultimately reducing the
body’s bilirubin level. Although the length of therapy varies among infants, depending on weight
and bilirubin level, Dr. Awadalla sensed that phototherapy treatment lasted on average longer at
x Hospital than at other hospitals.

Trained in quality improvement by the Ministry of Health Quality Improvement Project, Dr.
Awadalla recognized that this long treatment presented a possible opportunity for improvement.
Through the development, testing, and implementation of three simple changes, he and his team
developed an intervention to reduce treatment time and achieved dramatic results within one
month. Ms. KAMANA, the quality improvement project coordinator for provided technical
assistance to the team. This case study shows the improvement process and demonstrates the
powerful applications of the Rapid Team Problem Solving approach.

Step One: Identify

1. Identify a specific aim. Dr. Awadalla noted that neonates with jaundice received longer
phototherapy treatment than he would have expected; this resulted in long hospital stays for the
neonates. Long treatment times not only affected the neonates and burdened their families, but
also created a chronic shortage of phototherapy incubators countrywide and increased the
workload of intensive care staff. The shortage of incubators led to overcrowding in the intensive
care unit, increasing the risk of cross-infection among neonates.
The following goals for improvement associated with the long phototherapy treatment were
identified:
Primary aim for improvement:
 Reduce the amount of time in phototherapy for neonates with jaundice.
Additional goals for improvement included:
 Reduce the overcrowding in the intensive care unit
 Reduce the workload of staff
 Reduce cross-infection of neonates
 Reduce the risk of possible adverse effects due to phototherapy
 Reduce the burden on families from the lengthy hospitalization

2. Decide who should be on the problem-solving team.

After identifying the aim for improvement, Dr. Awadalla and his colleagues thought carefully
about who should participate in the problem-solving team. They wanted to form a team of people
involved in providing neonatal phototherapy to incorporate their knowledge in the problem-
solving process and to prevent feelings of resistance or resentment in introducing any
interventions. Two nurses and two doctors from the neonatal intensive care unit were asked to
form a problem-solving team to work towards this aim for improvement under the guidance of
Dr. Awadalla. Team members included: Dr. Charles, John, Abidan , and Emmanuel.

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3. Achieve consensus for the goals for improvement.
Based on their experience working in the neonatal intensive care unit, the team agreed that
reduction of time in phototherapy treatment would benefit both internal and external customers.
The possible implications for reducing the time in phototherapy convinced the group members to
proceed to the analysis of the issue.

Step Two: Analyze

1. Analyze available and readily accessible data and information. The team of experienced
nurses and physicians knew that phototherapy functions by exposing the neonate’s skin surface
to light. With this in mind, they began to question how care was provided and made
observations. First, they discussed the fact that the diapers were often too large, covering a lot of
skin. Secondly, the neonates were not on a schedule to be turned to ensure that the entire body
received light. Finally, the team considered that some of the neonates were not on a regular
breastfeeding schedule, affecting their nutrition and health.
2. Identify indicators. The team identified the length of treatment as the indicator for the amount
of phototherapy treatment needed. The length of phototherapy treatment was measured as the
number of hours necessary to reduce the bilirubin level enough to allow for a neonate’s
discharge (6.5 milligrams percent).
3. Collect data prior to an intervention if none exists. The problem-solving team recognized a
lack of data on the length of treatment for neonates receiving phototherapy, so they collected a
small sample of data from eight neonates prior to the intervention. They checked the neonates
bilirubin levels daily as part of standard procedure to determine if any could be discharged. The
sample required an average of 49 phototherapy hours each to achieve the bilirubin discharge
level.

Step Three: Develop

1. Generate possible changes/interventions. Based on the analysis of the phototherapy treatment
procedure, the team generated a possible intervention to reduce the number of hours of treatment
needed. Team members agreed to test the effect of completing the following regimen every three
hours:
 Make sure that the diaper fits properly; for example, check that the diaper is not oversized
 Change the neonate’s position
 Ensure that the neonate has been breast fed
2. Rank their order according to priority. Team members felt that the regimen was necessary
and could improve the care of neonates by reducing the length of treatment. As a result, the team
decided to test it.
3. Select one intervention at a time. Because these interventions seemed self-evident, it was
logical that they be tested and implemented together. If the interventions had been more difficult
or questionable, the team probably would have tested them separately. The team chose to
proceed to the testing and implementation stage to assess the impact of this procedure.

Step Four: Test and Implement

1. Plan: Plan the test. The problem-solving team chose to test the intervention on eight neonates
in the intensive care unit. The team verified that the baseline data were complete to compare
against post-intervention data. The problem- solving team also communicated the change among

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nurses and physicians to ensure that the regimen would be carried out on these neonates
throughout all work shifts.9
2. Do: Conduct the test. The regimen of care was tested on eight neonates receiving
phototherapy in the intensive care unit.
3. Study: Collect and analyze data. The regimen was not modified from the original plan and
was tested accordingly. Data regarding the hours of phototherapy were collected and checked for
accuracy and completeness. Post-intervention data revealed a dramatic decrease in the length of
phototherapy required. While neonates prior to the intervention required an average of 49 hours
of treatment, neonates who received the new regimen needed an average of 24.
4. Act: Decide how to act upon the information. This change, charted in Figure 6.3, proved to
reduce the average number of hours of phototherapy by nearly 50 percent. The problem-solving
team felt that the reduction of treatment by half was sufficient evidence of the regimen’s success.
This information led to the decision to implement the regimen into the standard of care for
neonates being treated for jaundice.
Although these three changes appear to be small and simple in nature, they proved to be critical
to assuring the proper exposure of the neonates to the treatment and the effectiveness of the
phototherapy. This demonstrates that simple interventions can yield powerful improvements.
The team felt satisfied with the improvements made in the treatment of physiological jaundice in
neonates. These improvements not only validated the success of the intervention itself, but also
demonstrated the powerful effects of Rapid Team Problem Solving. The team used these results
to communicate with colleagues about the importance of maintaining the new standards of care.
Although the team disbanded after improvements were achieved, each member developed
experience in and enthusiasm for quality improvement, providing a strong foundation for future
endeavors.

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Figure 18: Duration of Phototherapy before and after the Improvement

Approach 3: Systematic Team Problem Solving

Systemic Team Problem Solving responds to recurring, chronic, or difficult problems that may
require the identification of the real, root cause of the problem and the development of solutions
accordingly. Root cause analysis methods were introduced into Systematic Team Problem
Solving to address the need for better solutions through increased understanding of the
underlying causes of problems. Systematic Team Problem Solving poses and tests possible
theories of cause for problems; solutions are then developed to address the theories proven to be
causes of a problem. Due to its heavy use of analytic techniques, Systematic Team Problem
Solving often requires significant time and data to develop, test, and implement solutions and to
observe any improvements. The payoff for this investment in time is in-depth understanding of a
problem and its causes. Systematic Team Problem Solving also requires a certain skill level,
made possible by coaching, team training, and/or experience in analytic techniques. Systematic
Team Problem Solving is appropriate when the problem:
 Is chronic, recurs, or is complex
 Does not have an obvious solution
 Is not an emergency or safety issue
 Need not be solved in a short period
 Allows for a team to work together on the analysis over time

Step One: Identify

The “Identify” step for Systematic Team Problem Solving, much like the other approaches,
involves identifying what problem the team will work on and who will be on the team.

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Choose a problem or opportunity for improvement: An area for improvement to be addressed
through Systematic Team Problem Solving does not necessarily have to be a problem, but could
reflect a difference between current and desired performance. It is essential that this area for
improvement be something that managers, clients, and staff are enthusiastic about and feel is
important. Anyone quality assurance committees, department managers, a group of workers,
individual staff members, clients, etc. can identify areas for improvement. Routine monitoring of
management health information systems provides data about health indicators and may reveal
needs for improvement.
Other useful data sources include health records, management records, direct observation, and
interviews. Data may point to several areas in need of improvement, for example immunizations,
in-patient care, or maternal care. In prioritizing which area to address, it is helpful to consider
which is:
 High risk: Could have the most negative effect if the quality is poor
 High volume: Takes place often and affects a large number of people
 Problem prone: An activity susceptible to errors
Define the problem: Once the area for improvement has been identified, the issue to be
addressed must be clearly defined. Defining the problem (writing a problem statement) does not
search for causes or remedies, but rather tries to describe the situation. It is important that the
problem be clearly described to focus Systematic Team Problem Solving efforts in the “analyze,”
“develop,” and “test and implement” stages. Clearly defining a problem articulates what the
problem is and how it affects the quality of care. In addition to measuring the problem,
boundaries also must be established so that problem-solving activities do not escalate to address
a larger issue or wander into related issues. It is advisable to set boundaries limiting problem-
solving activities to specific processes or activities, facilities or services, or measures of quality
(such as timeliness or effectiveness). A problem statement is one way to clearly synthesize,
establish, and record boundaries and goals.
Identify who should work on the problem: Once the problem is clearly defined, key people
should be identified to work on the team. Answers to questions like the following can help in
determining who should take part: Where (what departments/sections) is the problem occurring?
What tasks are involved? Who carries out these tasks? Who determines how the tasks should be
done? Who provides inputs to these tasks? Who uses the outputs of these tasks?
The people chosen provide special knowledge, insights, and services during the problem-solving
journey. It is important to note that each person selected should have direct, detailed, personal
knowledge of some part of the problem. They also must have time for meetings and assignments
between meetings. As needed, the team may call upon others outside the team who have
specialized knowledge or experience about the problem. These “part-time” members can be
external consultants or others within the organization. When all those who will work on the
problem agree to the problem statement, the team may proceed to the analysis step.

Step Two: Analyze

This is the step where the team will attempt to understand more about the problem or quality
deficiency: Why does it happen? People often identify a problem, decide they already know
everything about it (including the cause), and jump to a solution already in mind. When they do
this, they often find that the problem does not go away after the solution has been implemented.
Why? They did not broaden their thinking and verify their assumptions with data. The causes of
a problem are not always obvious.

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Good problem solving means resisting the temptation to jump to conclusions. The objective of
this step in Systematic Team Problem Solving is to identify the problem’s major causes in order
to choose an appropriate solution. This can be done very quickly if the problem is simple and the
cause obvious; it takes longer when the problem is more complex and there are several possible
causes. Problem analysis can be like peeling an onion: there are many layers to be removed
before reaching the core, i.e., the major cause. It can also be thought of as a series of
investigations to dig down to the cause of the problem. By exposing the problem’s components,
it is possible to reach the root or underlying cause. Given the diverse nature of problems, there is
no single method for analyzing them.
Describe and understand the process in which the problem exists: Most problems or quality
deficiencies relate to the way work is conducted (the process). Yet people do not always have a
clear picture of the process, especially the links between their work and the work of others. Thus,
one important step in the analysis of the problem is to gain an understanding of the process itself
and to develop consensus among the team members about how the process actually operates. The
latter is distinct from how it is “supposed” to operate. This is where “peeling of the onion” starts:
with identifying where the problem is located within the process.
Team members must have a common understanding of the process to save time and energy while
working through the remaining steps. One way to do this is to visualize the actual flow of the
process where the problem occurs. There are two tools that can be applied: system modeling and
flowcharting. While examining the process, the team may discover that it is missing facts needed
to understand what is happening: data collection may be necessary. It is possible that the cause(s)
will be revealed while flowcharting the actual process as it currently operates. Flowcharting the
actual process, as opposed to the ideal process, may reveal where a step in the process is missing,
a part where there is confusion about what to do, or the presence of unnecessary steps. It may be
that in drawing a flowchart the team will discover that no single, clear process exists. In this
case, the solution may lie in designing a standardized process.
Conduct cause-and-effect analysis: In medicine diseases are cured in so far as possible by
treating their causes, not their symptoms. This principle applies to problem solving as well if a
chronic problem recurs because its causes have not been addressed. Once the problem has been
located more specifically, it is time to develop hypotheses about the causes. The term
“hypotheses” is used because it is unknown whether the true causes, the core of the problem,
have been uncovered. The validity of the cause will be verified later by data.
Because the root cause is often not obvious, it is best to start by generating a list of as many
possible causes as possible. A cause-and-effect analysis helps to look beyond the symptoms of
the problem. It pushes one to ask, “What causes that?” and “What is behind that?” This broadens
thinking about causes and explores other areas that might be contributing to the problem.
Alternatively, other methods, such as asking the “five why’s,” using a tree diagram, or
conducting a force-field analysis, can be used. A fishbone diagram may be used to document this
thinking
Reduce the possible root causes: When all possible causes have been suggested, it is common
to have more causes than could possibly be investigated. The expertise of the team helps to
narrow down the possible causes to the most probable. Several decision-making methods (such
as expert opinion and voting) can lead to some hypotheses about the root cause(s). The point is to
produce a few possibilities from the many possible causes identified. It is advisable to start
testing hypotheses about those possible causes that are easiest to collect data on: doing so may
eliminate certain hypotheses quickly. When collecting data to verify cause, try using information

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sources that are different from the ones used to identify the problem.
Define data needed to test theories of cause: Again, the causes at this point are hypotheses.
Now it is time to collect and interpret data to prove or disprove the hypotheses. Determining
causes should be based on facts, not opinions or assumptions. A few key points about data
collection are reviewed here. It is easy to fall into the trap of collecting more data than needed or
data that do not provide any real information. The key message here is that data collection should
be designed to provide the information needed to answer the question: What is (are) the major
cause(s)? Some questions that help teams to verify possible root causes include:
 Does this hypothesized cause really exist? (Do we experience it?)
 Is this hypothesized cause frequent and/or widespread enough to explain the extent of the
problem?
 How many times does the hypothesized cause occur?
 Is the hypothesized cause associated with the problem? (For example, do the causes and
problem happen at the same time or to the same client?)
The answers to these questions must be based on facts (data), but the data in and of themselves
do not necessarily provide answers. Data must be analyzed and the results presented in a way
that translates them from mere facts into information.
Collect and analyze data; identify root cause: A good place to start in collecting data is
making a plan; it should address the following questions:
 What data would answer the question?
 How should the data be collected? By whom and how often? With what tools?
 How will the data be analyzed? With what tools? By whom and how often?
Determine efficient ways to collect the data. When possible, use existing data sources. If needed,
collect data as needed to investigate root causes and to determine the actual root cause; this data
collection should not become a long-term monitoring system.
After data are collected, they need to be displayed and analyzed to draw conclusions about root
causes and key improvements. Data analysis tools (e.g., bar charts, run charts, pareto diagrams)
can identify and display information. First, the team should be prepared to display data inmany
ways to gain the most knowledge possible. For example, data originally displayed in a histogram
can be plotted by each data point on a run chart to show patterns of variation over time.
Secondly, data may also be divided into sub-groups or strata based on individual characteristics.
For instance, data about whether mothers understood instructions about giving medicine to their
children can be stratified by the mother’s language. This would help to determine if mothers do
not understand instructions due to language differences
Case Example: Hypothesis and Questions to Investigate Root Causes
Hypothesis: Pharmaceutical supplies are not in stock.
Questions: How many days a month are pharmaceutical supplies out of stock? How many
patients do not receive medication as a result? What is the reason that pharmaceuticals are not in
stock?
Three: Develop
The objective of this step in Systematic Team Problem Solving is to develop a solution that
solves the problem by eliminating its cause(s). Developing solutions is not always a
straightforward task, and many solutions fail because they were not carefully thought through
before implementation. This is not the time to rush to a solution, given all the effort that has been
invested in selecting and analyzing the problem. The best approach is to be open and think
creatively, first to develop a list of potential solutions, then to review each carefully before

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selecting one. These solutions must address the root causes identified. Choosing sound solutions
requires a good list of options. This is where creativity is important. All too often, groups
become stuck in their thinking (“This is how we have always done it”), or they let themselves be
swayed by one person’s ideas without exploring other options. Consider inviting others to join
with the team in suggesting possible solutions. The additional members should be those who
have been working on similar problems within the organization. Begin by reviewing previous
successes and, more importantly, previous failures. Why did these occur? What lessons can be
learned from these? It can also be useful to examine the experience of others.
Benchmarking combined with brainstorming can stimulate creativity. Benchmarking involves ex
ploring a similar process that works well, or considering solutions others have tried when they
had similar problems or situations with a similar root cause and examining closely what
succeeded. However, it is essential to have a thorough understanding of one’s own process
before attempting any benchmarking and to understand fully the other process before using it as
a benchmark. If this is not done, it may create more problems than are solved. Clearly stated
criteria can help teams to choose a solution from a list of several. Examples of criteria include:
 Affordable to implement
 Free from negative affect on other processes or activities
 Feasible to implement
 Management support
 Community support
 Efficient
 Timely
Try to limit the number of criteria to three or four, since too many would make this step
unwieldy. Identify which criteria any solution must meet to be considered seriously, as this will
quickly eliminate certain choices.

Step Four: Test and Implement

Like the other quality improvement approaches, Systematic Team Problem Solving depends on
effectively testing and implementing the appropriate solution. Even a well-chosen solution will
not resolve the problem if it is poorly planned, implemented, and/or monitored. The PDSA
applies to Systematic Team Problem Solving as follows:
Plan (to test the solution): Planning for any activity, including quality improvement, involves
determining who, what, where, when, and how. Planning for solution implementation should
include the following tasks:
 Review the objective of the solution. What are we trying to achieve? What is “success”?
 Review the solution’s design. What are the steps in the proposed process? Who will be doing
what, where, and when?
Review or develop a simple flowchart of the process. The flowchart can help the team to
determine if what it has in mind will work. Can the solution be simplified?
 Identify potential resistance. The team must think about who may be affected by each step or
change in the process.
Such individuals may be sources of potential resistance. Could resistance be reduced by
including these individuals in the planning process? How else can resistance be avoided?
 Determine the prerequisites to implementation. What needs to be done or prepared before
this process can be carried out? Think about what kind of training might be required, what

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 kind of communication is necessary and what kind of support (material, supervisory,
managerial) needs to be organized.
The team members should think about everything that could go wrong and, after brainstorming,
use an affinity analysis to group these for preventive action.
 Develop a step-by-step list to lay the groundwork. What must be done first? How long will it
take? How will we know when that activity is completed? What is the product?
A Gantt chart (see Section 9) can help to plan the order of activities.
 Assign responsibility for each activity. Who will see that each activity is carried out?
He/she/they may not have to carry out the activity, but will be responsible for seeing that it
happens. Who will be testing it? Who will be supervising it?
 Determine what information is needed to follow up the solution. What data are required to
determine whether the solution was actually tested, whether it was tested well (according to
the plan), and whether it had the intended results? Where are the data available? Who can
collect the data? When and how will it be collected?
 Prevention planning: solutions created by Systematic Team Problem Solving teams often
affect a number of people and processes, and therefore present a risk that something may go
wrong.
Several prevention planning measures help to reduce this risk. For example, test the solution on
a small scale first. If the solution requires major changes, affects many people, or has never been
tried, testing the solution on a small scale first will help:
 Work out the kinks before large scale implementation
 Generate support by showing that the solution actually works
 Save resources if the solution was not as successful as anticipated
Do (test the solution): Testing the solution involves carrying out the steps of the Gantt chart or
action plan and collecting the information that indicates how well it went.
Teams should check periodically to verify that testing is going as planned and to communicate
progress to all those involved. Teams should also be ready to provide encouragement to
everyone involved and assistance as needed.
Document successes and obstacles that occur while conducting the test. These bits of information
can help later in assessing the solution. Every problem or error is an opportunity for
improvement, and this is as true for the testing and implementation of solutions as for the
identification of problems.
Study (follow up to determine if the solution has had the intended results): At this point the
team should pause to determine what can be learned from testing the solution. Using the data
collected and any other information (formal or informal) obtained during the testing phase, the
team should answer the following questions:
 Did we meet our criteria for success? Did the solution have the desired results? What did
people think of the change?
 What aspects of the test went well? What aspects were difficult?
 Did the solution create unforeseen problems for others or other processes?
 What kind of resistance did we encounter?
Act (make decisions about the implementation): Based on what was learned from evaluating
the test of the solution, the team now must decide what action to take. Just because a solution
was chosen and tested does not mean that it must be adopted. Referring to the results obtained in
the follow-up, determine whether it was successful, whether it merits modifications, or whether it

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should be abandoned altogether and another solution tried. If modifications are to be made, they
should be tested using the PDSA. To ensure that improvements are sustainable, the team will
need to look for opportunities to standardize the improvement and make it permanent through
activities such as developing/changing job aids and manuals, inserting new material into pre- and
in-service training, and getting official policy statements. Additionally, sustainability requires
vigilance: the team should think about what indicators should be monitored and by whom to
assess whether the solution continues to be successful and to verify that the problem does not
recur. The Systematic Team Problem Solving team usually disbands after completing the four
steps and therefore generally does not continue to monitor the progress of the solution. Although
quality can always be improved, individuals and teams must be able to say, “That was a job well
done.” The team can consider the quality improvement effort a success when it has evidence that
the problem has been resolved: the data show that the problem no longer exists and the changes
(solution) have been incorporated into routine procedures. The quality improvement efforts are
complete when the team feels happy about its efforts and their effectiveness.

Case Example of a Systematic Team Problem Solving

The staff at a health center in Africa noticed that a high number of children who had been treated
for malaria returned to the clinic after initial treatment without improvement. Failure to be fully
cured put the children at risk for untreated or partially treated malaria; it also and causes parents
to think their children are not treated properly. Some staff suspected that parents were not giving
Coartem to the children, but were selling it in the market. Other staff thought that perhaps
parents were not administering the medication properly: perhaps the patients did not understand
the instructions, had not been instructed by the staff, or preferred shots and refused to give pills.
Some staff were upset, thinking that some of their co-workers were not following treatment
protocols—perhaps some children who should have been getting Coartem were not being given
the medication.
Furthermore, the health center director knew that Coartem supplies were a chronic problem, as
the ministry routinely provided only a set amount of Coartem at irregular intervals, never enough
to cover all the cases. The ministry claimed that the health center was getting the proper amount
of Coartem, based on its population and past usage rates. The availability of Coartem was a long-
standing problem that could not be solved by the health center.
The director had observed health workers while they were treating patients and discovered that
some health workers were not following treatment guidelines. The health workers individually
claimed to follow the guidelines, but said perhaps their co-workers did not.
Step One: Identify
1. Identify a specific aim. The staff generated the following list of the different components of
this complex problem:
 Need to improve the administration of medication to children with malaria
 Staff may not follow treatment protocols
 Staff may not be honest in saying they follow guidelines
 Children return with continued symptoms
To decide which component of this problem to address, the team made a prioritization matrix,
using these criteria:
 Problem is clear
 Risk of not addressing the problem
 Visibility of the problem

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They rated the problems on a scale from 1 to 5, with 5 being the clearest, having the most risk,
and having the highest visibility, as seen in Table.

Table 17: Prioritization of Problems

2. Define the problem: The team finally chose medication administration as the best problem to
address. The team continued to clarify the problem by writing the following problem statement:
“An opportunity exists to improve the management of medication administration for children
with malaria, starting with the health worker deciding the child needs medicine and ending with
the child well at a return visit to the health center. The current process results in a high number of
children who are not recovered after initial treatment. An improvement would ensure that
children actually take their complete oral dose of medicine and improve.”
3. Identify who should work on the problem: A high-level flowchart of the process of
administering malaria medication to children helped to identify who should work on the
Systematic Team Problem Solving team. It was determined that a clerk, a nurse, a physician, a
health worker, a pharmacist/technician, and a mother should be included in the team.

Step Two: Analyze

1. Describe and understand the process in which the problem exists: To further understand the
situation, the team drew a process flowchart to look for any repetitive, missing, or incongruent
steps. This helped them understand the existing process and to see what problems may exist.
2. Conduct a cause-and-effect analysis: The team conducted a cause-and-effect analysis of all
of the possible causes that the team members could imagine that would lead a child to not take
the proper dose of medicine and, as a result, fail to show improvement when he or she returned
to the health center. The team drew a fishbone diagram to come up with the possible root causes
of the problem in the administration of malaria medication.
3. Suggest possible root causes (hypotheses of cause) based on the process and cause-and-
effect analysis: The problem-solving team was able to use the information from the flowchart
and the cause-and-effect analysis to begin hypothesizing about root causes to explain why
children were not improving. The team stated their theories about the root cause of the problem
and then posed questions that would help define what information was needed. For example:
Hypothesis: Health workers are not prescribing Coartem for malaria patients.
Questions: How many times is a diagnosis of malaria listed on the health card but Coartem not
prescribed?
Hypothesis: Mothers do not understand instructions for malaria administration.
Questions: How many mothers know how and when to give Coartem? If they do not understand,
is language a barrier?

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4. Define data needed to test the theories of cause: The team now had several theories that they
wanted to test. They wanted to collect data for a short time on all malaria patients who were
treated to see which theories could be proven. Their data sources would be patient health cards,
interviews with mothers and health workers, and observations of health workers. They used a
data collection plan that would specify exactly what data they would collect, who would collect
data, and when. They also suggested ways to analyze the data, since they could predict what data
displays would help answer the questions. For example, if they wanted to know parts of a whole,
such as how many of the children that returned to the clinic were improved and how many were
not, they could display this ratio with a pie chart.
5. Collect and analyze data; identify the root cause: The team then designed check sheets to
specify details about collecting data. There was one check sheet that the registration clerk kept to
track the patients who had a diagnosis of malaria. This sheet not only tracked the number that
had Coartem prescribed, but also the number of mothers who could correctly state the
instructions, said that they were not told the instructions, or did not understand the instructions
because of language differences. The clerk also developed another check sheet to track, by
patient name, the number of children who had a diagnosis of malaria, whether they returned, and
their condition when they returned (improved or not). Additional check sheets included: a
follow-up on how many patients took all of the three doses, how many did not, and reasons for
not completing the doses (whether Coartem was in stock, the number of patients who came to
the dispensary for Coartem and the number who received it). Finally, the health workers were
interviewed to see if they could correctly state directions for taking Coartem. Because only 43
percent of the children improved, data were also collected on whether or not the children
completed the prescribed regimen of Coartem . Even when Coartem was available, 48 percent
(10 of 21) of the children that returned for follow-up did not complete their dose. The primary
reason was the taste of the pill; recovering and simply forgetting were other reasons cited. When
asked, however, 79 percent of mothers could correctly state how to administer the medicine even
though only 38 percent claimed to have heard these instructions from the health workers.
The team concluded that the root cause of the problem was the unclear or incomplete
information given to mothers about administering Coartem , in spite of its bad taste or the child’s
improvement.

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Table 18: Data Collected with the Check Sheet

Figure 19: Reason why children did not take medication

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Figure 20: High-Level Flowchart of the Process of Administering Malaria Medication

Figure 21: Fishbone Diagram of Possible Root Causes of nosocomial pneumonia

Step Three: Develop

The team recognized that the mothers needed information that was more specific about taking
Coartem with food or some flavoring to try to change the taste and to continue for the full three
doses. The team brainstormed possible solutions, and, using criteria, chose from a list of options
to make a poster to inform mothers of foods that cut the taste of the medication. Specific
responsibilities were assigned: the clerk and the nurse would make the poster, and all nurses and
the clinical officer would review its content. Mothers were asked which foods cut the bad taste of

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Coatem best. The poster was then developed to communicate (with drawings that would were
easily understood by mothers) how the taste of the Coartem could be disguised. The team set
the goal of completing the poster in two weeks.

Step Four: Test and Implement

The team followed the four steps to testing and implementation: plan, do, study, and act.
1. Plan: Plan the implementation of the solution: The team identified potential sources of
resistance, such as being too busy with work to carry out the plan or not agreeing on foods. To
address the former issue, work was reassigned to allow staff in charge of making the poster the
time to do so. To address the latter issue, staff asked mothers which foods their children liked
that would likely hide the taste. The in-charge verified with the hospital pharmacist that Coartem
could be given with any food.
2. Do: Implement the solution:The poster was completed and displayed on a wall within ten
days. It was placed where all mothers would see it and could take time to study it
3. Study: Follow up to determine if the solution has the intended results: One month after the
poster was hung, the staff began the data collection. They were both happy and surprised to have
this be a time when Coartem had just been delivered from the ministry of health, so supplies
would last throughout the time of the data gathering. It took a week and a half to measure results
from 20 children with malaria who returned for follow up: 14 of the 20 children (70 percent) had
completed the medicine, as compared to 48 percent before.
4. Act: Make decisions about the implementation: The team attributed this remarkable
improvement to the poster. Due to the success in influencing the completion of all three doses of
the malaria medication, the team decided that the poster was effective and that the clinic should
continue to use it.

Approach 4: Process Improvement

The most complex of the four approaches, Process Improvement falls at the end of the
continuum. It usually involves permanent teams that feel ownership of and take responsibility for
key processes and continuously work for their improvement. Process Improvement teams
monitor processes over time and make long term improvements suggested by the monitoring
data. That is, while other Quality Improvement teams disband after completing the improvement
steps, Process Improvement teams remain together to monitor the improvement or begin
improving another aspect of the process. This continuity distinguishes Process Improvement
from the other QI approaches. Because it is an approach to QI with permanent teams, Process
Improvement is also a way to manage a service or process. Process Improvement teams not only
carry out improvement activities, but also manage other teams that were chartered by the original
team. In addition to the Process Improvement approach, permanent teams can apply any of the
other QI approaches to adapt to the wide variety of improvement needs that it will likely confront
over time, and/or to address a specific process within a bigger process or system. A team can do
this by addressing the specific process itself, or by forming sub-teams to study the identified
area. These sub-teams may be ad hoc (i.e., temporary) that are chartered especially for this
particular improvement need. For example, a Process Improvement team could charter a
Systematic Team Problem Solving team to research a chronic, recurring problem within a key
process or an ad hoc Rapid Team Problem Solving team to introduce a sequence of small
changes into the key process. Process Improvement closely resembles models from

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manufacturers that worked to improve core processes in the production of a product. While this
classical theory focused on production lines in factories, the Process Improvement approach
described in this paper has been adapted to address a core process (a key service line, such as
maternal care) within health facilities or organizations. Teams are set up to represent, monitor,
and improve the various elements in these service lines. Within the context of this document,
Process Improvement refers to changes that are made while keeping the existing process.
Although this includes taking out parts of a process, adding new parts, reducing waste, or
standardizing the process, the major parts of the process remain the same. Process Improvement
should be a proactive approach that puts activities in place to prevent problems and not just react
to them. This prevention of costly problems can result in savings over time. In sum, this
approach should be used to continuously improve and monitor a process, plan for the future, and
fix problems as they arise. Process Improvement is not used as an approach for a problem that
requires quick attention, such as an emergency or safety issue. Process Improvement teams
usually work across functions or departments to improve complex processes that effect the
greatest number of internal and external customers. Process Improvement teams, usually
consisting of five to seven members, should represent everyone who works on the various
aspects within these processes. This is important because when patients receive care, they
receive services from a variety of departments: healthcare providers, administrative staff,
cleaning staff, etc. For example, a Process Improvement team examining surgical procedure
could include a combination of the following: nurses to represent preparation for surgery,
administrative staff to contribute on admitting and billing, surgeons who carry out the
procedures, and cleaning staff who sterilize the surgical room. The most important point is that a
team should reflect the various elements of a process through its members. Process Improvement
can also address a process within a single department as long as outside departments are
consulted in developing and implementing any changes. Process Improvement also emphasizes
the need to understand the expectations of external customers. The participation of external
customers in Process Improvement teams contributes to an understanding of how the process can
be improved to meet their needs. This and other aspects of the nature of the Process
Improvement approach mean that it is not appropriate when quick attention is required, for
instance, when an emergency or safety is involved.
In summary, use Process Improvement when:
 Teams can be permanent
 There is a monitoring system or the capacity to establish one
 A proactive, preventive approach is needed
 The key process does not require quick attention (e.g., not an emergency or safety issue)

Step One: Identify

Process Improvement focuses its improvement efforts based on the requirements of customers.
Often the first step in identifying a process for Process Improvement is to examine the
organizational mission or vision to assess the extent to which services support the mission or
vision. Processes that are not achieving the organizational mission are candidates for Process
Improvement. A management team usually identifies and decides which core process will be the
focus of Process Improvement efforts. Criteria for selecting a process are whether it:
(a) is key to the delivery of care, (b) effects a high volume of internal and external customers, (c)
presents potential to be of high-risk if neglected, (d) is problem prone, and (e) is apparent to the
customer and management.

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The Process Improvement approach to quality improvement emphasizes the importance of
monitoring the process over time. Just a couple of indicators that measure outcome, effect, and
impact can indicate whether the process is functioning correctly. In order to determine which
indicators are most useful, teams must have a thorough understanding of the process. For
example, a Process Improvement team addressing immunization would need team members or
sub-teams that understand the various elements of this process, such as the refrigeration of the
vaccines, the transportation of vaccines, and the community outreach program. Representatives
of each of the areas then help to establish and track indicators (such as refrigerator temperature
checks, stock outs of vaccines, and coverage rates) to monitor the quality of the overall
vaccination process. When possible, indicators should be designed to use existing data to avoid
setting up data collection systems.

Table 19: Sample Indicators for Key Processes in a Vaccination Program

If a data system does not exist or is insufficient, a monitoring system must be set up to measure
relevant indicators over time. This system does not necessarily have to collect data throughout
the entire institution or facility, but can focus on the areas pertinent to the Process Improvement
target. Once a monitoring system has been established, it is critical that the initial data be
analyzed to determine a baseline of information. The baseline data help Process Improvement
teams to understand the current status of the process; consider what the process is capable of
performing; and, later, compare post-intervention data to detect any change.
In summary, the “identify” step for Process Improvement establishes: (a) What to work on based
on the requirements of customers, (b) Who is on the team and the criteria for being on the team,
and (c) What the indicators should be. It also requires that a monitoring system be set up if data
are not sufficient.

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Step Two: Analyze
The Process Improvement approach is different from the other QI approaches because it involves
the regular monitoring of key indicators over time. Data routinely analyzed include information
about the performance of key processes and about customers. Run are commonly used to
illustrate this information and observe performance over time.
The routine analysis of this information stems not only from Process Improvement, but also from
a management philosophy that concerns itself with performance and values the opinion of
customers. Therefore, the data are actively sought out and not exclusively drawn from existing
data. For example, data about customers would not be derived exclusively from their feedback,
but also would be actively sought through the inclusion of customers in Process Improvement
teams. In addition to analyzing the data, Process Improvement teams also measure the outputs of
a system and assess the progress of chartered ad hoc teams.
Process Improvement teams then use data to determine where the problems exist within the
identified process. The established monitoring system may provide enough information for
decision making. Sometimes, however, even an elaborate monitoring system may not provide all
of the necessary information. For example, if a weak spot in the system is targeted for further
analysis, it may be necessary to create a sub-set of data to study this area further. In this instance
a new indicator may be established either temporarily or permanently to monitor improvements
in the area under study.
If a weak spot within the process is identified and analyzed, the Process Improvement team may
chose to continue to work on it as a team or charter another team to do so. This decision is based
on two issues: whether the weak area should be monitored permanently (Process Improvement
team) or temporarily (ad hoc team) and whether the key people for the particular area are
represented on the Process Improvement team. If the second criterion is not met and temporary
monitoring is sufficient, a separate sub-team must be created to provide information for the
Process Improvement team to use in decision making.

Case Example: Process Improvement Team

A Process Improvement team formed to improve the quality of care for neonates suffering from
Respiratory Distress Syndrome (RDS). In reviewing existing data, the team discovered that care
delivered in the 42 hospitals was not adequate-demonstrated by the fact that 67 percent of early
neonatal deaths were attributed to RDS.
The Process Improvement team reviewed evidenced-based literature to develop guidelines for
care and discovered that it would probably be impossible to provide the interventions necessary
to ensure adequate care in all 42 centers. Even if it were possible, there were not enough
neonates for providers to practice and maintain their skills. The team agreed to develop one
system of care, redesigning the existing system of care into one system with three levels:
resuscitation of newborns, transportation, and then care at the center. The same team continued
to work on the redesign and, having improved the system, it continues to monitor the progress on
an on-going basis and makes necessary changes. This experience exemplifies how Process
Improvement endeavors can evolve into the re-design of a system, introducing radical changes.

The “Analyze” step of Process Improvement emphasizes the need to understand the current
process. As mentioned previously, a number of tools exist that allow teams to further analyze
areas that have been identified through the on-going monitoring system or an adverse event.
First, the flowchart lays out each step in a process to see where delays or redundancy may exist.

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This knowledge is important in understanding how the process can be improved to better meet
the needs of customers. Another tool that helps in analyzing processes is the cause-and-effect
analysis. This analysis helps teams to generate possible causes for the identified problem;
although the causes listed are hypotheses and may later prove to be incorrect, at this point the
cause-and-effect is useful to illustrate a broader picture of the problem. The root cause analysis
can then determine which of these hypothesized causes the main contributor to the problem at
hand is.
Finally, systems modeling examines what resources are required to go into a process (inputs), the
activities that will make these resources products (processes), and the effect of this process on
clients (outcomes). Systems modeling helps teams to comprehend the relationship between these
parts of a system and to generate ideas about where further analysis and data are necessary.
Tools such as the flowchart, cause-and-effect analysis, and systems modeling help teams to
understand what data are required to proceed in the Process Improvement approach. A reliable
monitoring system is critical to this approach so teams can track key indicators over time to
make continuous improvements to a process. Therefore, if a data system currently exists, teams
must assess its content, validity, and reliability to determine if it needs to be refined to meet the
monitoring needs. Data collected in the past can be analyzed retrospectively to determine if and
where processes are out of control; this information can them help teams to compare the
performance of their process with other, similar processes to find deficiencies.

Step Three: Develop

Interventions developed in Process Improvement are based on the findings of either the Process
Improvement teams or the ad hoc QI teams during the “analysis” step. If an ad hoc team was
chartered to study a particular part of a process, it can either proceed to the development of
interventions or provide recommendations for the Process Improvement team to do so.
Interventions are developed separately but with the idea that effective changes will be
implemented together to change and improve the process. Within Process Improvement, the
problems addressed range in complexity. The level of complexity determines how drastic the
changes made to the process will be. Complex problems may involve developing solutions that
completely change the original process; this radical change could be evidenced by a change in a
high-level flowchart after an intervention. This level of change within a process is not discussed
within this text; please refer to materials on the redesign of processes for more information about
the development of solutions of this. The solutions developed by Process Improvement teams
introduce changes to a process without significantly altering the existing process. While
solutions would aim to add or take out parts of a process, reduce waste, or standardize the
process, the major parts of the process remain the same. In other words, while a high-level
flowchart would remain the same, a detailed flowchart could change considerably. These
changes would address problems within parts of a process or the hand-offs between parts.
A common example is lost patient files. Patient files usually are not lost while someone is using
them, but rather are lost either in the process of handing them off from one healthcare provider to
the next or in the process of returning them to storage. A Process Improvement team trying to
reduce lost files would not aim to help doctors and nurses in not losing them during use, but
instead would establish a clear system to coordinate hand-offs and ensure proper storage. People
vary in the way they do things and therefore achieve different results. Therefore, standardizing
processes gives people implicit (not formally written down) and explicit (formally written)
guidelines to follow, making the output—the quality of care—more predictable and consistent.

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Step Four: Test and Implement
Plan: Plan the test:If there is more than one intervention, Process Improvement teams can plan
to test them together or separately in a process. Either way, it is always important to (a) make
sure all involved people understand the change(s) clearly, and (b) verify that the baseline data are
complete.
Do: Conduct the test: If the team decides to test the interventions together, the interventions
would be combined and tested all at once. Interventions tested separately, however, are added to
the process one by one to measure the individual ability of each intervention to improve the
process. Similar to the other QI approaches, it is necessary to follow the following steps: (a) test
the intervention(s), (b) document modifications made to the intervention(s), and (c) check that
the data are complete and accurate.
Study: Collect and analyze the data: Data from the monitoring system or additional data
collected indicate whether the interventions were effective. The comparison of data from before
and after the trial demonstrates the intervention’s impact on the performance of the process.
In studying an intervention’s impact for Process Improvement, one should: (a) verify that the
intervention was tested according to the original plan, (b) compare baseline and follow-up data to
measure the impact of the intervention, and (c) compare results with the predicted or desired
results.
Act: Decide on a route of action based on the results of the previous steps: At this point,
Process Improvement teams or chartered ad hoc teams review what was learned from the
previous steps and decide how to proceed. Based on the results of the previous test, the team
decides to implement, modify, or discard the intervention. Again, this depends on whether the
team decided to test the interventions together or separately. If the interventions were tested
together, the team would decide how to proceed with the entire set of interventions.
If the interventions were tested separately, however, the team decides which interventions to
keep, modify, or discard, and then acts accordingly. This decision is guided by two questions: (a)
Did the intervention yield improvement? and (b) If so, was the improvement sufficient?
Improvements are deemed sufficient when they achieve a benchmark level or the level of
performance is satisfactory to the team or leadership. Based on the answers to these questions,
teams proceed as follows:
1. If the intervention leads to sufficient improvement: (a) implement the intervention(s) as a
permanent part of the system; (b) continue to monitor the performance of the process as a part of
ongoing data collection, or charter an ad hoc team to do so; and (c) continue with improvements
as warranted by that monitoring.
2. If the intervention leads to improvement but the improvement is not sufficient: (a) adapt the
intervention(s) and repeat Step 4 to test any modified intervention(s), (b) use a known change
strategy, and/or (c) understand that the problem may have multiple causes and it may be
necessary to consider a strategy to uncover the root causes of the problem.
If the intervention does not lead to improvement: develop a new intervention to test and
implement. Once the PDSA cycle has been completed and the improvement has been deemed
sufficient, the Process Improvement team does not disband, but continues to monitor the process,
manage any ad hoc teams chartered, and may also proceed to another aspect of the process to
improve. Process improvement can dramatically change a process through its interventions.
Therefore, Process Improvement teams should take into account the possibility that the
intervention may not work or create an unforeseen side effect. As a result, prevention planning is
a critical part of developing interventions in Process Improvement. Because interventions can

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dramatically effect different aspects of people’s work, the changes must be communicated
clearly in advance of their implementation. An alternative plan should also be devised in case the
testing of the intervention is unsuccessful. On-going monitoring of implemented interventions
and the key process should also reveal if any unexpected problems arise and need to be
addressed.
Case Example of a Process Improvement
This example illustrates how a Process Improvement team monitored and improved maternal
care delivery. A provincial hospital in an urban area has OB/GYN and outpatient departments to
serve the many referrals from district and primary care facilities that they receive. The labor
ward has some resources to meet these demands, such as a physician with skills in obstetrics,
trained nurses, and midwives that assist in routine deliveries. A Process Improvement team
monitors the maternal care in the hospital to track the delivery of antenatal, delivery, and
postpartum care. The team consists of the physician, a physician’s assistant, two midwives, a
nurse from prenatal care, and a representative from the operating room. Additionally, the Process
Improvement team includes the leader of a women’s group to represent the opinions of external
customers.
Step One: Identify.
The Process Improvement team reviewed the information collected from routine monitoring of
maternal care services. In analyzing data on postpartum care, the team noted a low return rate of
20 percent for appointments six weeks after delivery. This finding concerned the Process
Improvement team as postpartum care allows providers to verify that the uterus and cervix have
returned to normal size, as well as provide contraceptive counseling for birth spacing options.
Given the risks of not receiving postpartum care, the Process Improvement team determined that
postpartum care is key to maternal care and that neglecting this area would pose a threat to the
health of their patients. Therefore, the team decided to continue studying this issue and continued
to the analysis step.

Step Two: Analyze.

At first some team members thought that the nurse and midwives may have been forgetting to
inform women of the importance of postpartum care, but the nurse and midwives assured the rest
of the team that they regularly stressed this point. The Process Improvement team came up with
a simple and fast way to discover why women were not returning for the postpartum
appointments. They randomly chose 10 women who had been scheduled for and missed their
six-week postpartum appointments. A couple of team members went out into the communities to
ask the women why they did not return. Reasons included not knowing that is was important to
return, a lack of transportation, and that their husband would not allow them. They developed a
graph to illustrate the frequency of each reason and the fact that most women did not understand
the importance of the postpartum appointment.

Figure 22: Reasons Cited for Not Attending Postpartum Appointments

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Step Three: Develop.
Based on this information, the Process Improvement team decided to develop an intervention
that would not just tell women to come to their postpartum appointments, but also explain why it
is important. Working together, the team decided that an Information, Education, and
Communication (IEC) campaign could provide the critical information about postpartum care to
women consistently throughout pregnancy and after delivery. The IEC campaign would start
during prenatal counseling and be reinforced again during postpartum counseling with the
midwife. The goal of this intervention was to communicate a consistent message to women about
the importance of postpartum care with the objective of increasing attendance at postpartum
appointments.

Figure 23: Percentage of Women Who Return for Appointments

Step Four: Test and Implement.

The Process Improvement team added providing the IEC materials to the standard procedure for
prenatal and postpartum counseling. The midwives were trained to use the new IEC materials
and asked to try them with each patient. The team then monitored the attendance of postpartum
appointments over the next three months and was pleased to see a gradual increase. The team
attributed the improvement to the use of the IEC materials. The Process Improvement team
continued to monitor the entire maternal care process, including postpartum care. The team noted
that while attendance of postpartum appointments rose from 20 percent to 60 percent, they
leveled off after a few months. The team did not think that the 60 percent attendance of

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postpartum care was satisfactory and consequently decided to revisit the issue and begin the
Process Improvement steps again.

Step One: Identify: The team identified the low attendance of women for postpartum
appointments through the routine monitoring of the indicator that they had implemented six
months earlier.

Step Two: Analyze: The team repeated the analysis completed previously to discover the
reasons why women were still not returning for postpartum appointments at an acceptable rate.
Interviews with 10 women revealed that the majority were not returning because the scheduling
of afternoon appointments was inconvenient for them. Other women indicated that poor
transportation and their husbands kept them from returning.
Figure 24: Reasons Cited for Not Attending Postpartum Appointments: Round 2

This information indicated that the time scheduled for postpartum appointments was
inconvenient for the women and therefore prevented them from coming.

Step Three: Develop: The Process Improvement team, deciding that scheduling could be
addressed by an ad hoc QI team, chartered one to develop, test, and implement a solution. The
physician and midwife who conduct postpartum appointments formed this team with
administrative staff to develop a solution. They decided to try permitting postpartum
appointments one morning a week to make postpartum hours more convenient for the women.

Step Four: Test and Implement: The ad hoc team tested the solution of morning hours by
providing patients with a choice of afternoon or morning appointments for postpartum care. They
then continued to monitor the attendance by the time of day that this service was available.
Attendance rose from 60 percent to 75 percent within just a few months. Because this new
schedule appeared to improve attendance of postpartum women, the ad hoc team advised
the Process Improvement team to implement this schedule as a part of the regular process.

CHAPTER IV: QUALITY MEASURES:

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5.1. Goals and purpose of Quality measurement
Quality measurement is the ongoing monitoring and reporting of program accomplishments,
particularly progress towards reestablished goals. It is typically conducted by program or agency
management. Performance measures may address the type or level of program activities
conducted (process), the direct products and services delivered by a program (outputs), and/or
the results of those products and services (outcomes).
A “program” may be any activity, project, function, or policy that has an identifiable
purpose or set of objectives. Measurement enables:
 trends and characteristics to be quantified
 performance towards the achievement of health service goals (particularly
those elements to which nursing contributes) to be monitored and managed
 the identification of aspects of care requiring improvement.
 informed choices - based on published quality data - by patients, clients and others.

5.2. Types of measurement

Supervision
Supervision is a way of stimulating, guiding, improving, refreshing and encouraging and
overseeing certain group with the hope of seeking their cooperation in order for the supervisors
to be successful in their task of supervision.

Types of supervision
Educational Supervision: assessment of skills, evaluation of needs, provision of learning
experiences, upgrading of knowledge and skills. The supervisor assures that workers know what
constitutes substance abuse and assists them in working effectively and efficiently with
families involved in substance abuse issues.
Administrative Supervision: monitoring work and workload, assuring work completion, quality
and quantity control, appropriate implementation of agency policies and procedures. The
supervisor assures that the purpose, vision, and policies of the agency in terms of working with
families involved in substance abuse are met.
Supportive Supervision: providing support, understanding and assistance, understanding
emotional needs. The supervisor provides employees with a supportive environment where they
can enjoy high morale and job satisfaction as they assist families involved in substance abuse
issues.

Monitoring
Monitoring is the routine tracking of the key elements of programme/project performance,
usually inputs and outputs, through record-keeping, regular reporting and surveillance systems as
well as health facility observation and client surveys. It focuses on Indicator: a measurable
characteristic or variable, which represent project progress.

Evaluation
Evaluation is the episodic assessment of the change in targeted results that can be attributed to
the programme or project/project intervention.

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Evaluation attempts to link a particular output or outcome directly to an intervention after a
period of time has passed.
It focuses on Target: an objective, which is time-limited and can be measured. Targets are set for
a baseline and successive measurement over 5 years.

Self evaluation
A self-assessment is an employee's evaluation of his or her own performance during the specified
performance period. The purpose of the Self-Assessment is to have the employee think about
and give serious consideration to how he or she has performed in meeting expectations.
It's where a person gets to take a good, long look at herself and write down what he or she sees.
A self-evaluation measures a person's likes, dislikes, aptitudes and more. In self-evaluation, there
are the concerned persons who look at their own work, at their impersonal performance, results,
interactions, processes in which their take part. The evaluated and the evaluator are identical.
What we question is our own domain of responsibility, within a given implicit or explicit frame.
In an SE, the persons who are the subject of an evaluation and the ones who do evaluate are the
same.

Peer (review) evaluation

Peer review is a process used for checking the work performed by one's equals (peers) to ensure
it meets specific criteria. Peer review is used in working groups for many professional
occupations because it is thought that peers can identify each other's errors quickly and easily,
speeding up the time that it takes for mistakes to be identified and corrected.

In Health, as in other professions, peer review applies professional control to practice, and is
used by professionals to hold themselves accountable for their services to the public and the
organization.
Peer review plays a role in affecting the quality of outcomes, fostering practice development, and
maintaining professional autonomy. So define peer review is defined as the process by which
practitioners of the same rank, profession, or setting critically appraise each other’s work
performance against established standards. Professionals, who are best acquainted with the
requirements and demands of the role, are the givers and receivers of the feedback review.

Investigations
Investigation is the process of trying to find out all the details or facts about something in order
to discover who or what caused or how it happened

Investigations are processes, as is quality control. The process of investigation help define the
desired outputs of the investigation process, and what it takes to produce those outputs, by
forcing orderly examination of the investigation process elements.

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Audit

The general definition of an audit is an evaluation of a person, organization, system, process,

enterprise, project or product. The term most commonly refers to audits in accounting, but
similar concepts also exist in project management, quality management, water management, and
energy conservation.
Clinical audit is a process that has been defined as "a quality improvement process that seeks to
improve patient care and outcomes through systematic review of care against explicit and the
implementation of change".
The key component of clinical audit is that performance is reviewed (or audited) to ensure that
what should be done is being done, and if not it provides a framework to enable improvements to
be made.
Audit in health in can be described as a cycle or a spiral within the cycle there are stages that
follow the systematic process of: establishing best practice; measuring against criteria; taking
action to improve care; and monitoring to sustain improvement. As the process continues, each
cycle aspires to a higher level of quality.

Figure 25; Clinical audit- the process

The clinical audit process seeks to identify areas
for service improvement, develop and carry out
action plans to rectify or improve service
provision and then to re-audit to ensure that
these changes have an effect

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