Achieving Quality Through Problem Solving and Process Improvement

Transcription

1 Quality Aurance Methodology Refinement Serie Achieving Quality Through Problem Solving and Proce Improvement Second Edition By Lynne Miller Franco Jeanne Newman Gaël Murphy Elizabeth Mariani Quality Aurance Project 7200 Wiconin Avenue, Suite 600 Betheda, MD USA 301/ , FAX 301/

2 1997 Center for Human Service

3 Acknowledgement Achieving Quality Through Problem Solving and Proce Improvement The author wih to acknowledge the many colleague who have contributed to the development of thi monograph. Thank are due to thoe who erved on the Project problem olving methodology refinement tak force who helped clarify each of the tep in problem olving and developed the initial idea for the monograph. We are indebted a well to all who hared their experience in adapting quality improvement tool for ue in primary health care etting, and to all whoe comment on earlier draft helped to hape the current verion. Special thank are due Denni Zaenger for help in developing the guideline in the Tool Section (Section 2), to Maria Francico who kept u mindful of the importance of grounding proce improvement and problem olving on data, to Vincent DeSomma and Therea Hatzell for killful editing, to Nadwa Rafeh who wa invaluable to the conceptualization of thi Monograph, to Véronique Autphenne who twice aw the document through the production proce, to Chinwe Madubuike and Lani Marquez who aw the document through the reviion proce, and to Dan Garver, Maureen Berg, Kurt Mulholland and their media team for alway accommodating our production need with a mile. Although thi monograph would not exit without their help, the error are thoe of the author alone. The Quality Aurance Project i funded by the U.S. Agency for International Development, Office of Health, Bureau for Science and Technology under Cooperative Agreement Number DPE-5992-A with the Center for Human Service. Collaborating with the Center for Human Service on thi project are the John Hopkin Univerity School of Hygiene and Public Health and the Academy for Educational Development.

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5 Content Introduction... vii I. The Six Step To Solving Quality Problem and Improving Procee II. Tool for Quality Improvement Gloary... G-1 Selected Reference... R-1

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7 Solving Quality Problem and Improving Procee I. Introduction Quality deficiencie can be found in any health care etting, from the mot ophiticated urban hopital to the village clinic. Poor quality reduce the benefit to client, frutrate health care provider, and wate carce health reource. A ytematic, ongoing proce of enuring and improving quality i therefore an eential component of an effective, efficient, and reponive health care ytem. Thi monograph preent a tep-by-tep approach for improving procee and for olving problem related to health care quality. A uch, the approach applie to any level of the health ytem. A quality-related problem ha been decribed a the gap between what i and what i deired. Situation do exit in which the current ervice delivery proce work well and there are no major gap between performance and expectation, i.e., there are no problem. However, concientiou health profeional recognize that it i normally poible to improve the quality of ervice by making them more efficient, more reponive to client need, and le likely to run into problem. Current State Deired State Gap = Problem or opportunity for improvement Opportunitie for improvement can be found at every level of the health ytem. Individual or team may find them in their own work, in the work of uperviee, or in the ditrict, region, or country a a whole. Solving problem and improving procee require more than intuition and judgment. The method preented in thi monograph follow logical tep developed from practical problem-olving experience in health care and other etting. While peronnel olve problem every day without mapping out a tated plan, the tep preented here provide concrete meaure for improving quality efficiently and effectively. They are deigned to help to avoid common pitfall. Problem olving and proce improvement work bet when conducted a part of a quality aurance (QA) program in which tandard are developed and quality indicator are monitored. Neverthele, the problem-olving tep preented herein can be applied whenever and however an opportunity for improving quality arie. vii

8 A. The Approach to Quality Aurance Four main principle define the approach preented in thi monograph for enuring and improving quality and for reolving quality problem a they arie. Thee are ummarized below: A Focu on Client Need: Client need and deire hould drive the planning and performance of any activity. The term client refer to both: External client: the final recipient and beneficiarie of health ervice and the reaon the ervice exit, i.e., the patient and community erved. Internal client: thoe within the organization who rely on fellow worker for product and ervice that help them to fulfill their part in providing quality health care to the external client. Internal client include front-line health worker, upervior, and other health team member. Enuring quality begin with knowing who the client are and undertanding their need and expectation. Within thi idea of client, every worker play the complementary role of erving client and of being a client. A Focu on Sytem and Proce: The quality of health ervice i uually judged by outcome, pecifically, the immediate and long-term effect on the health of the individual and communitie they erve. When the outcome fail to meet expectation, people often point to poor worker motivation and inadequate effort a caue. But all productive work reult from procee. A proce i a erie of tep or tak that turn people, method, and material into product and ervice, e.g., adminitering a vaccine or monitoring a child growth. Procee operate within ytem: a ytem i a et of procee that function together. For example, a vaccination ytem include procee for the delivery of vaccine, their torage and ditribution, vaccine adminitration, and program evaluation. Quality problem in one proce are often due to a deficiency in one or more of the ytem related procee or to a failure in coordination of the interrelated procee. If the procee are deficient, the outcome will likely be deficient a well. Poor quality i often the reult of poor job deign (procee that do not work or take too long) or the failure of leaderhip to provide a clear purpoe for activitie. Quality improvement require an undertanding of the relevant procee and their acceptable level of variation. A Focu on Data-baed Deciion: Improving procee require information about how they function. Deciion about problem area and improvement hould be baed on accurate and timely data, not on aumption. Often, all the fact may not be immediately available, and data need to be collected. Inight hould be verified by data whenever poible, although informed judgment about problematic procee i a valuable tarting point. For example, intead of auming what the client think, feel, and need, the quality aurance team collect information on client need and level of atifaction. Data are needed throughout the problem-olving proce to 1) help to detect and define problem, 2) identify the root caue of problem or error-prone procee, and 3) monitor effect of viii

9 implemented olution to enure they are working. Care need to be taken to enure both that ufficient data are collected to have the eential fact and that too much time not be pent collecting more data than are really needed. A Focu on Participation and Teamwork in Quality Improvement: For quality improvement to ucceed, worker mut participate in making change in the organization ytem and procee. Empowering worker to carry out quality improvement ha two advantage. Firt, thoe conducting the daily work often have a better ene of where thing go wrong and which corrective action may be feaible. Second, people are more likely to carry out change when they feel they have had a part in developing the olution. B. The Quality Aurance Proce The four principle decribed above form the baic philoophy behind the Quality Aurance Project (QAP) 1 10-tep quality aurance (QA) proce. The QA proce combine quality management approache ued in the United State, Europe, Canada, and ome Latin American and Aian countrie, with leon derived from working with health ervice in a variety of developing countrie. QAP 10-tep proce i not a linear tep-by-tep approach with, for example, planning alway occurring firt. Rather, the approach Deigning 1. Planning 2. Setting Standard 3. Communicating Standard Problem Solving 5. Identifying Problem 6. Defining Problem 7. Chooing Team 8. Analyzing Problem 9. Chooing Solution 10.Implementing Solution 4. Monitoring 1 The Quality Aurance Project i funded by the United State Agency for International Development to ait Minitrie of Health and other group to develop and implement mechanim for monitoring and improving the quality of health ervice. For a more detailed dicuion of the project 10-tep QA proce, ee: Brown, Lori D. et al., Quality Aurance of Health Care in Developing Countrie, Quality Aurance Methodology Refinement Serie, Center for Human Service, Betheda, MD, ix

10 i cyclical and iterative, with each tep depending on information provided by the other. Where to begin in the cycle depend upon the organization prioritie and need. The QA cycle encompae three et of activitie: 1) deigning for quality aurance, 2) monitoring quality, and 3) olving quality problem and improving procee. The following are the 10 tep of the QA proce: Deigning for Quality 1. Planning for Quality Aurance: Develop a viion and trategy for QA activitie, aign dutie, and allocate reource. 2. Developing Guideline and Setting Standard: Define expectation for quality health ervice. 3. Communicating Guideline and Standard: Enure that thoe who mut apply the tandard are aware of them, undertand them, and believe in them. Monitoring 4. Monitoring Quality: Develop indicator and collect data to meaure performance and to identify current or impending problem. Problem Solving and Improving Procee 5. Identifying Problem and Selecting Opportunitie for Improvement: Examine information through monitoring, talking to people, conducting pecial urvey in order to identify exiting or emerging problem. Then elect the mot important problem() or problematic proce(e) to tackle. 6. Defining the Problem Operationally: Develop a clear tatement of the problem in term of it meaurable effect on health ervice procee. 7. Identifying Who Need to Work on the Problem: Determine which peron or group hould take part in the problem-olving proce to help in analyzing the problem and in developing and implementing olution. 8. Analyzing and Studying the Problem to Identify Major Caue: Gather and analyze data to undertand the nature of the problem and it principal or root caue. 9. Developing Solution and Action for Quality Improvement: Generate a lit of likely olution, chooe the one() which bet addre the principal caue, and deign a practical, feaible olution. 10. Implementing and Evaluating Quality Improvement Effort: Plan the implementation of the olution (who, what, where, when, how), execute the tet, and determine x

11 whether to expand implementation, modify the olution to make it more feaible or effective, or drop the olution in favor of another. Step 5-10 make up the problem-olving/proce-improvement methodology decribed in detail in thi monograph. Although integral to the comprehenive 10-tep QA proce, tep 5 through 10 can be applied independently for rectifying any health care quality problem. C. Who can olve problem and improve procee? Quality aurance, problem olving, and proce improvement are not olely the domain of the central minitry of health: quality aurance i everyone buine. QA can be applied by an individual to hi or her own work, by a ditrict team to the ervice it provide, or by a deignated body within the minitry of health. The four QA principle (focu on client need, ytem and procee, data-baed deciion, and participation) and the problem olving proce (Step 5-10) apply to problem of varying complexity at all level of the health care ytem. The context determine which particular QA tep or principle hould be applied. Many individual and team heitate tackling quality problem becaue they feel they do not have the reource to make improvement. Yet improving quality may not require additional reource; progre can often be accomplihed imply by adjuting exiting procee. The problem-olving proce may ait in improving quality even in the face of eriou reource contraint. If problem olving i carried out effectively, it can even heighten the efficiency of health ervice delivery, making better ue of exiting reource. D. How To Ue Thi Monograph Thi monograph i divided into two cro-reference part. Part One decribe in detail how to conduct each tep and ugget appropriate tool. Part Two preent the tool in detail, explaining how and when to apply each and providing tep-by tep intruction. Table 2-1 lit the tool that might apply during variou tage of the problem-olving proce. Throughout the monograph, two example of health ervice area are developed to illutrate the problem-olving proce and tool. Example 1 deal with the effort of a upervior and hi uperviee to improve client compliance with acute repiratory infection (ARI) treatment regimen. Example 2 deal with the effort of a team of ditrict upervior to reduce exceive waiting time for prenatal ervice. Boxed idebar demontrate how the QA tep or problem-olving tool being dicued on that page can be applied either to Example 1 or Example 2. Thi monograph i not intended to provide a cookbook approach to all problem olving and quality improvement. Some problem may be relatively uncomplicated and, once clearly defined, may lend themelve to traightforward olution. The problem-olving proce may be imple, with ome of the 10 eparate QA tep more dicernible than other. Some problem can be reolved by an individual; other require colleague participation (Step 7: chooing a team). Some ituation will demand more concentration on xi

12 the initial tep (Step 5-6: identifying and defining the problem) while other will require more focu on undertanding the root caue() (Step 8: analyzing the problem). For ome problem, once properly analyzed, the olution may be obviou. For other, many different change in the proce may be required to produce meaurable improvement (Step 9: develop the olution()). Some olution require pilot teting prior to full implementation (Step 10: implementing and evaluating the olution); other will not. Depending on the problem itelf, more than one tool may be ueful at a given tep. Thi monograph provide information to make it eaier to judge when enough time and energy have been pent on any ingle tep and which tool are mot appropriate. A in mot human endeavor, flexibility, imagination, and common ene are indipenable. A Few Hint To Getting Started on Problem Solving and Quality Improvement Here are three hint that may help in applying thi monograph content to your own problem-olving effort. 1. After reading Part One on the ix tep to problem olving, think about the logic of the tep. Think about a problem you recently encountered and ee how well you applied the principle in thee ix tep. 2. Try out ome of the tool at firt for ome problem that are outide your work ituation. Apply them to a imple problem you have at home, or to a problem omeone ele i having. Thi way, you can become comfortable with the tool and what they can do for you before you embark on a problem that you may feel preured to olve quickly. The learning proce and quick reult do not alway go hand-in-hand. 3. We recommend tarting with the impler tool firt, and if they do not eem to help your effort, try the more complex. Think of problem olving not a a chore or a hopele tak, but rather a a challenge, a the unraveling of a mytery. xii

13 Part One The Six Step to Solving Quality Problem and Improving Procee STEP 5 Identify Problem and Select Opportunitie for Improvement STEP 6 Define the Problem Operationally STEP 10 STEP 7 Identify Who Need To Work on the Problem Implement and Evaluate Quality Improvement Effort STEP 8 Analyze and Study the Problem To Identify Major Caue STEP 9 Develop Solution and Action for Quality Improvement 1-1

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15 TOOLS Page Step 5 Identify Problem and Select Opportunitie for Improvement 1-5 Step 6 Define the Problem Operationally 1-12 Step 7 Identify Who Need To Work on the Problem 1-16 Step 8 Analyze the Problem and Identify Major Caue 1-21 Step 9 Develop Solution and Action for Quality Improvement 1-35 Step 10 Implement and Evaluate Quality Improvement Effort 1-41

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17 I. STEP 5. Identify Problem and Select Opportunitie for Improvement Improving the quality of health ervice begin with identifying quality problem and finding opportunitie for improvement. Although ome argue that thi tep lie outide the improvement proce, it i the only way to tart. Quality improvement look beyond problem : it applie to improvement opportunitie in ituation which have not become crie but could be improved. For example, a recent increae in clinic ue ha been accompanied by a gradual increae in client waiting time. Early attention to monitoring patient flow and to identifying and redeigning potential bottleneck could prevent a crii. Quality can alway be improved. STEP 5 Identify Problem and Select Opportunitie for Improvement identify problem agree on criteria elect area to work on Define the Problem Operationally Identify Who Need To Work on the Problem Implement and Evaluate Quality Improvement Effort Analyze and Study the Problem To Identify Major Caue Develop Solution and Action for Quality Improvement The objective of thi firt tep i to elect a pecific problem or proce on which to focu. It i important to elect carefully where to focu quality improvement effort. Quality improvement i mot attainable when thoe involved are enthuiatic about it and when it ha a poitive effect on patient and their community. Accordingly, manager, client, and taff hould elect a problem which i important. What contitute a quality-related problem or area for improvement? A tated earlier, it i the gap between what i and what i deired. An opportunity for improvement need not tem from a major deficiency. It may repreent imply a deire to improve a proce that i operating in a atifactory manner in order to reach a higher level of acceptable quality. When identifying area of focu, individual and team often fall into the trap of extreme, believing that there are either no problem or a multitude of them. In our dicuion of thi tep (Step 5), we will preent ome guideline for conidering poible focu area and for narrowing down the choice. 1-5

18 Identifying and electing problem area or opportunitie for improvement can be thought of a a two- (or more) tage cyclical proce, each tage compriing three ubtep: Stage One Select a ervice, care proce or area on which to concentrate, e.g., outpatient care, urgical ervice, patient aement, medication precribing, and billing: review the area/ervice that you are preently providing, agree on criteria for electing an area on which to work and the proce for making thi choice, elect an area on which to concentrate. Stage Two Within the area of concern, elect a pecific problem or opportunity for improvement, e.g., potoperative infection and outpatient waiting time: identify pecific problem or improvement opportunitie, agree on criteria for electing an area on which to work and the proce for making thi choice, elect a problem or pecific proce on which to work. A. Identify Potential Area for Improvement Any taff member of a hopital or clinic can identify a potential area for improvement. For example: The Quality Aurance Committee may identify a potential area baed upon it impact on the organization overall quality. Thee area for improvement uually require the participation of everal department in the organization. A department manager may identify a problem becaue of hi or her team inability to meet it goal and objective. A group of worker may identify a project to increae their ability to work more efficiently. To identify potential area for improvement, it i eential to conider ource of information that can explain the current ituation. Several ource can be ued to identify pecific area for improvement. Information ource and appropriate data collection method are lited in Table 1-1; the data collection method are lited in order of eae in obtaining information. However, it hould be noted that eae and reliability are not alway compatible. One need not be retricted to a ingle ource or method for finding a potential area for 1-6

19 improvement: a combination of ource can be ued to lit potential area for improvement or problem on which to work. An effective, ongoing quality improvement ytem depend upon a management and health information ytem that routinely monitor important ervice quality indicator. Such a monitoring ytem provide timely data that can point to exiting or emerging problem and potential area for improvement. Beide the routine monitoring ytem, everal other ource can provide information about quality deficiencie. Thee can be formal ource, uch a urvey or ampling of exiting record, or more informal method, uch a interviewing taff or client. Flow charting a proce that need improvement can alo reveal pecific problem (ee page 2-20). Table 1 Source of information to identify problem and/or opportunitie for improvement Data from monitoring or ad hoc tudie: uing exiting ource of data, or rapid aement technique. Staff concern: aking worker about their concern regarding quality and the procee they carry out. Impreion or data from peronal obervation: going to health facilitie to look around. Feedback from client: aking thoe who receive or ue ervice how atified they are with them and what problem they feel are important. Data collection method Reviewing clinic record, ervice tatitic, report; conducting obervation uing checklit; uing urvey quetionnaire. Braintorming (ee page 2-7) at a meeting, interviewing, flow charting (ee page 2-20) a proce. Oberving informally, or formally through obervation checklit. Conducting informal converation, compiling complaint, uing client window (ee page 2-42), conducting urvey or focu group dicuion. B. Agree on Criteria When electing ervice on which to focu, begin by liting the activitie carried out, e.g., immunization, curative care, maternal care, inpatient care, well-baby care. Thee activitie or procee can then be ranked uing the criteria of high rik (activitie that could have the mot negative effect if quality i poor), high volume (activitie conducted mot often), and problem prone (activitie that are uceptible to error). A matrix (ee page 2-14) which rate activitie and procee in term of thee criteria can be ued to elect the focu area. Once an activity ha been deemed a priority, it pecific procee can be lited and the ranking proce repeated until a reaonably narrow area for improvement ha been elected. Manager often find that they can work on only a few problem at a time. When everal problem have been identified, choice mut be made baed on clear reaoning. People 1-7

20 alway apply criteria when making deciion, although the criteria are uually untated. However, it i eential that the election criteria in the quality improvement proce be clearly tated. All involved mut recognize the importance of the elected problem and agree that the time pent i worth the effort. Quality improvement take time and i mot effective when focued on the vital few, e.g., what people conider to be important and effective. EXAMPLE 1 A ditrict-level upervior, while conducting a uperviion viit to one of hi health center, entered into a dicuion about quality of care with hi uperviee. They developed a lit of area in which the uperviee encountered profeional frutration. They produced the following lit: not enough antibiotic, children do not come for their meale immunization, the community doe not liten to the health worker. Each group or team hould develop it own election criteria, but the following lit of commonly applied criteria can be ued a a guide: The problem i important: It ha been a problem for ome time and i widepread. The benefit of olving it i obviou. Support for change exit in thi area: People recognize the need for change. Management want thi to be worked on. The project ha emotional appeal/viibility: People are motivated to work on thi area. There are rik aociated with not addreing thi area: If omething i not done about thi, it may create other problem. The project i within your phere of influence: Thoe who are intereted in problem olving hould have ome control over the ituation and the authority to make change. For initial quality improvement effort, we ugget ome additional criteria: The effort hould addre a mall problem and one that can be dealt with quickly. If quality improvement i focued on a pecific proce, that proce hould be a permanent one: there i no need to work on a proce that will eventually be eliminated. C. Select the Targeted Area for Improvement Once people have reached agreement on the criteria and their meaning, the pecific problem area can be choen. Whenever the particular deciion can have a major impact on the group, the choice hould be made by conenu, with everyone upporting the propoal. It doe not mean that everyone get hi or her firt choice, nor doe it mean a majority deciion (in which a minority get omething it doe not want). Conenu mean that the final choice i acceptable to all partie. Although developing conenu can be a timeconuming proce, it i a wie invetment a it help to prevent future reitance. 1-8

21 EXAMPLE 2 A team of ditrict upervior met to determine where they wanted to tart improving quality in their ditrict. They followed a two-tage proce to identify the improvement opportunity to work on. Firt they elected a broad program area, then they choe a pecific problem within that area. To elect the program area, they reviewed the type of ervice they provided: maternal care, wellbaby care, curative treatment, immunization, and communicable dieae. They ranked thee activitie according to the health rik for the population, the volume of activitie, and how problematic thee activitie eemed to be (the quality tatu). Uing a ytem of multivoting, they aigned a value of 1 through 5 to each of thee activitie for the three criteria. They determined that maternal care wa the priority area becaue monitoring data had hown that many children were born with low birth weight (cauing health rik later on, therefore a high volume health rik) and they felt that the quality of maternal care wa not what they wanted it to be (quality tatu). Next they reviewed the characteritic of quality (i.e., acce, technical competence, etc.), to determine which were mot important. They then held a meeting with their taff to dicu quality iue and interviewed ome client to learn of any complaint they had regarding the ervice they received. For each problem identified, they identified the characteritic of quality aociated with that deficiency. In the end, the ditrict team developed a lit of four major area for improvement: waiting time for pregnant women were very long and eemed to dicourage women from coming for prenatal care (acce), couneling of pregnant women appeared to be uele a women did not eem to undertand the importance of good nutrition and malaria prophylaxi (technical competence, interperonal relation), health center were often out of tock of malaria prophylactic drug and iron upplementation (acce), tandard for the content of prenatal viit were not alway followed (technical competence). The following are ome method for making deciion baed on criteria (tated or untated), a well a ome of their advantage and diadvantage: Expert make deciion: The expert in the proce intuitively know which problem meet mot of the criteria and chooe which problem hould be olved. Thi method i fat, but there i danger that the expert could be wrong or that ome will be unhappy with the expert deciion. Voting (ee page 2-11): In thi commonly ued method, individual conider deciion criteria themelve. It can be quick and efficient, but a minority can be left unhappy. The group may loe it team pirit, although ome form of voting can help to maintain teamwork. 1-9

22 Matrice (ee page 2-14): A tool for guiding deciion making baed on previouly agreed upon criteria. The group applie clearly tated criteria in an open dicuion. Thi method can take time and rik adding complexity to the deciion making proce. However it i the mot likely method for achieving conenu becaue the criteria are applied by the group. D. Some Guideline for Knowing When to Move on to the Next Step One critical iue in applying thee tep to problem olving i knowing when one tep i completed and it i time to move on to the next. The following quetion erve a a guide for when to Define the Problem Operationally: Do you (or the team) feel that the elected problem i important? Do you (or the team) want to work on it? Could you explain to omeone ele why thi area for improvement ha been choen? Can you explain how thi problem affect the quality of ervice and the population erved? If problem have not become elf-evident (through monitoring or more informal mean), two additional method for identifying quality deficiencie include: Looking at procee and chooing meaure of quality. Chooing the characteritic of quality that mean the mot to the context/ituation: Quality ha many face, and reviewing the variou characteritic of quality can help to focu attention. Thee include: effectivene, efficiency, technical competence, interperonal relation, afety, continuity, acceibility, and amenitie. The team can decide (uing voting technique, ee page 2-11) which of thee are relevant to their ituation and which caue the mot problem. Both method for identifying opportunitie for improvement may, however, require the ue of data to verify that thee are problem area or to provide more information about the problem area itelf. 1-10

23 EXAMPLE 1 The upervior uggeted uing a criteria matrix to chooe the problem becaue he did not want to influence hi uperviee too much, yet he wanted the uperviee to think clearly about what to chooe. They agreed upon the following criteria: importance, rik, phere of influence. They developed the following matrix (uing a cale of 1 to 3, i.e., from leat to mot), with the upervior and the uperviee each getting a vote of equal weight: Criteria/Problem Antibiotic Immunization Community doe not liten Important = = = 4 Rik = = = 5 Sphere of influence = = = 5 Total The matrix reult led to chooing the litening iue, even though the upervior wa not too ure thi wa a good problem. However, he decided to go on to the next tep to ee how the problem would become defined a they worked on it. EXAMPLE 2 The ditrict team dicued election criteria and choe emotional appeal/viibility and importance a the criterion. They alo felt it hould be omething that could be dealt with quickly. They then decided to conduct multivoting to elect the problem to work on. Each of the four team member would be given a hypothetical $5.00 to pend and they could ditribute thi amount in any way they wanted, a long a they each applied the agreed upon criteria. The following reult were obtained: Team Member Problem Total Waiting time $4.50 $3.00 $4.00 $2.00 $13.50 Couneling $0.00 $0.00 $0.00 $2.00 $2.00 Drug hortage $0.00 $2.00 $1.00 $0.00 $3.00 Not following Standard $0.50 $0.00 $0.00 $1.00 $1.50 Total $5.00 $5.00 $5.00 $5.00 $20.00 Accordingly, they choe to work on waiting time for prenatal care. 1-11

24 II. STEP 6. Define the Problem Operationally The purpoe of Step 6 i to tate clearly the targeted problem. An operational definition of a problem or quality deficiency expree the difference, in pecific and obervable term, between the current and deired tate of affair. A clear problem tatement help to focu problem-olving effort throughout the remaining tep. If the problem i poorly defined, it will become apparent later in the proce that each team member ha been thinking of a different problem. The lack of a clear problem tatement can lead to internal conflict and to a lo of focu and motivation. STEP 6 Identify Problem and Select Opportunitie for Improvement Define the Problem Operationally decribe the problem determine boundarie verify no blame or olution Identify Who Need To Work on the Problem Implement and Evaluate Quality Improvement Effort Analyze and Study the Problem To Identify Major Caue Develop Solution and Action for Quality Improvement In identifying and electing a problem or a deficient proce on which to focu, it i natural to think about caue and remedial action. However, it i important not to allow thee idea to limit thinking or creativity. At thi tep in the improvement proce, it i neceary to keep an open mind about both the caue() and potential remedie. Identifying the root caue() and generating effective olution() are the tak of Step 8 and 9 repectively. One way of maintaining an open mind, therefore, i to formulate the problem tatement o that it doe not include any hint of it caue or potential olution, and o that it doe not implicitly blame omeone for the difficulty. A problem tatement hould clarify the exact target of quality improvement, indicating clearly what i deficient, not why or how to fix it. 1-12

25 There are three tep to defining the problem operationally: Decribe what the problem i and how you know it i a problem. Determine the boundarie of the problem: where the problem begin and end. Check to ee that the tatement doe not aign any blame or include an implied caue or olution. A. Decribe What the Problem I and How You Know The problem hould be decribed in meaurable, operational term: if the problem i not meaurable, it will be difficult to know when the problem ha been olved. The following quetion are deigned to help to decribe the problem: 1. What i the problem (not the caue or the olution)? What i not functioning a we deire? 2. How do we know it i a problem? What information do we have to upport or confirm the exitence of the problem or deficiency? 3. What are the effect of thi problem on quality and on the population we erve? 4. How long ha thi been a problem? How frequently doe it occur? 5. How will we know the problem i olved? What doe the deired tate look like? What data will we need to anwer thee quetion? Hint: If it i difficult to define the problem operationally, think about the effect of the problem, on the population being erved. Think about how you would know that the problem had been olved: what would be different? B. Determine the Boundarie of the Problem One common difficulty encountered in quality improvement i that an effort which tart by focuing on a mall problem grow into tackling an enormou problem, beyond the capability of the individual or team. Thu, it i important to et ome limit or boundarie around the problem; it i important to determine not only what i to be worked on, but alo what i not to be worked on. Thee boundarie of the problem could be tated in term of: Proce or activity itelf: where doe it tart and where doe it end? Scope: which pecific facilitie, clinical ervice, geographic location? Specific meaure of quality: timeline, effectivene, etc. It i not neceary to try to improve everything imultaneouly. Team are encouraged to tart with a problem that can be handled comfortably; there will be time later to deal with other quality deficiencie. 1-13

26 C. Verify That the Problem Statement Doe Not Aign Blame or Imply Caue or Solution Stay open-minded about caue() and potential olution when formulating the problem tatement. If the operational definition of the problem or deficiency already include caue or olution, then creativity ha already been limited. If it already ay who i to blame, not only doe thi imply a caue which may be incorrect, but it often alienate the very people who mut be involved in deigning and implementing any olution. Check to ee that the problem tatement decribe the deficiency, not why it occur or how to correct it. There will be plenty of opportunity to analyze the proce and to collect data upporting hypothee about caue in later tep. EXAMPLE 1 The upervior and hi uperviee worked to develop an operational definition of the problem. They ran into a few difficultie a they tried to anwer the guideline quetion: Supervior: Superviee: 1. What i the problem? The community doen t liten. That i fixing blame. 2. How do we know it i a problem? They do not follow our advice. That till tate the problem a omeone ele fault. The couneling we provide doe not eem to change their behavior with repect to treatment regimen we precribe. But thi tate a caue. Patient do not repect the treatment regimen we precribe. 3. I thi true for all illnee? Mainly for repiratory infection. 4. How do you know thi? People have aid o. 5. What are the effect on the population we erve? They do not get better when we try to treat them. 6. How long ha thi been a problem? A long a I have worked here. 7. How will we know when the problem i olved? When the population take the entire coure of drug that we precribe. By going through the quetion, the team developed the following problem tatement: Patient do not finih their treatment for repiratory infection. Thi problem, which can caue lingering health problem and reitance to antibiotic, ha exited for a long time. 1-14

27 EXAMPLE 2 The Ditrict team wrote three verion of their problem tatement before they arrived at one that had all the neceary element: 1t attempt: Waiting time for pregnant women are long becaue there are not enough midwive to ee them all. Thi dicourage women from coming for prenatal care. 2nd attempt: Waiting time for pregnant women are long becaue the midwive take too long for tea break. Thi dicourage women from coming for prenatal care. Final tatement: Waiting time (elaped time from when they arrive at the health center to when they are een by the midwife) for pregnant women have been hown to take up to three hour. Thi ha been tated a a reaon that women do not make the deired four prenatal viit before delivery. D. Enure that the Problem Statement i Clear Review the problem tatement to enure that it i clear and undertandable. If an individual i working alone on a problem, he will find it i ueful to ak colleague to read the problem tatement and expre in their own word what problem they think i being worked on. If a team ha developed the problem tatement, have everyone in the group decribe what he or he think the term or word ued in the tatement mean. It i common to find that different undertanding till exit. One ueful method i to ak everyone: How will we know when the problem i olved? How will thing be different? Hint: Even if a good problem tatement ha been developed at thi point, it may need to be refined later on, ince information obtained during the analyi phae may lead to change in perpective about where to focu problem olving effort. E. How to Know When To Go on to the Next Step Finally, when the problem tatement i clear and undertandable to all concerned, it i time to progre to the next tep, identification of the memberhip of the problem-olving team. Thi tep focue on conidering who hould be involved in the earch for a olution to the problem or a way to improve the proce in quetion, whether a informant, conultant, team member, or in another way. 1-15

28 III. STEP 7. Identify Who Need To Work on the Problem Define the Problem Operationally Identify Problem and Select Opportunitie for Improvement Implement and Evaluate Quality Improvement Effort Develop Solution and Action for Quality Improvement STEP 7 Identify Who Need To Work on the Problem determine whether other need to be involved identify pecific individual review activitie to date with new member Analyze and Study the Problem To Identify Major Caue Many problem or procee can be reolved or improved by the individual health worker or manager uing quality improvement practice. However, one peron uually doe not have all the information neceary to olve the problem; mot problem need more than one peron to undertand fully what i happening. Quality improvement effort work bet when thoe who are involved in the proce take part in the analyi and development of olution. Determining who hould work on the problem involve: identifying who need to take part and in what capacitie (team member, ad-hoc member, conultant, etc.), convening the team, and defining the team working procedure. A. Identify Other Who Need To Take Part Quality aurance often require team compoed of people from different department and function in the organization. Team are needed due to the increaingly complex and multifaceted problem in health care. Solving thee complex problem require many divergent point of view and the effective collaboration of many individual. The following are additional advantage derived from problem olving in team: a more thorough working knowledge of the proce, a more open atmophere with le blaming of other for problem, 1-16

29 a greater number of idea to reolve problem, and greater acceptance of olution and a higher implementation rate. Team memberhip i determined by the peron or group that developed the problem tatement. To help them to determine who need to take part, they need to anwer a few quetion: Where (what department/ection) i the problem oberved? What tak are involved? Who carrie out thee tak? Who determine how the tak hould be done? Who provide input to thee tak? Who ue the output of thee tak? If the anwer to all thee quetion i a ingle individual, then the problem-olving effort doe not require a team. If the anwer to any or all thee quetion include other, their involvement mut be conidered. The following quetion can help to identify the type of people that can be ueful to the quality improvement effort: Who work within the proce containing thi problem? Who i affected by the proce or the problem? Who make deciion related to the proce (who ha authority over it)? Who ha the technical expertie to help undertand the proce and the problem? EXAMPLE 1: Compliance with ARI Treatment Regimen To decide who might help, the upervior and uperviee reviewed the problem tatement: Patient do not finih their treatment for repiratory infection that can caue lingering health problem and reitance to antibiotic. Thi problem ha exited for a long time. They decided that patient non-compliance with the ARI treatment regimen wa the outcome of the proce that begin with the interaction between the patient and the nure, when diagnoi i made and medicine are precribed. It end with the actual taking of the medication at home. With thi in mind, they anwered the guiding quetion: Who work in the proce? The nure, the pharmacit, the patient. Who i affected by the proce? The patient, the family of the patient. Who make deciion about the proce? The upervior, the patient. Who ha technical expertie about the proce? The upervior, the community member. They decided to create a mall team compriing the upervior, the nure, and the pharmacit. The upervior convinced the nure that the caue of the problem could be bet undertood if the community were involved in problem olving, ince in the end, it i the member of the community who mut follow the treatment regimen. So they added two community repreentative. One ueful tool to help to identify people involved in the problem area i a flow chart (ee page 2-20). A flow chart point out who upplie input to the proce, who carrie out pecific tep, and who ue the output. 1-17

30 The people choen provide pecial knowledge, inight, and ervice during the problemolving journey. It i important to note that each peron elected hould have direct, detailed, peronal knowledge of ome part of the problem. They alo mut have time for meeting and between meeting aignment. A needed, the team may call upon other outide the team who have pecialized knowledge and experience about the problem. Thee part-time member can be external conultant or other within the organization. EXAMPLE 2: Prenatal Care: Waiting Time The Prenatal Care Proce [high-level flow chart] The team reviewed the problem tatement: Waiting time for pregnant women (elaped time from when they arrive at the health center to when they are een by the midwife) are up to three hour in duration. Thi ha been tated a one reaon that women do not make the deired four prenatal viit before delivery. They decided to make a high-level flow chart of the prenatal care proce to help to identify who wa involved in that proce. The Prenatal Care Proce Pregnant woman enter Receptionit take name and retrieve record Receptionit take weight and record it Nure aitant give immunization and take blood preure Midwife examine pregnant woman Given thi proce, the ditrict uperviory team decided that they hould include the following people on a proce improvement team: Receptionit (work in proce), Nure aitant (work in proce), Midwife (ha technical expertie), Ditrict MCH upervior (ha technical expertie, make deciion about the proce), Health center manager (make deciion about the proce). However, they realized that they could not have every receptionit, midwife, etc. within the ditrict on the team. They decided to focu on one facility that eemed to have the mot problem and complaint for their initial problem-olving effort. The ditrict MCH upervior notified the manager at that facility, who agreed to convene the initial meeting of a facility team to improve antenatal care by reducing waiting time. At the team initial meeting, the midwife wa aked to erve a team leader while the nure aitant agreed to take reponibility for documenting the team activitie, uing both a QA Storybook and QA Storyboard (ee page 2-46 thru 2-49). She began by poting the problem tatement, the high-level flow chart, and the name of all the member of the proce improvement team on the wall, and promied to have a poter and notebook ready for the next meeting. 1-18

31 B. Convening a Team A team i a group of people who make particular contribution toward achieving a common goal uch a reolving a quality-related problem. A dicued in part A, including people in the problem-olving proce i more likely to reult in greater participation and le likely to meet reitance later when trying to implement change. If a team i needed to olve the problem or to improve the proce, begin with a few team member (not to exceed 8). If more than 8 member are needed, it i wie to reconider the problem tatement. Perhap the problem elected i too large. The compoition of the team may need to change a more apect of the problem, the caue, or the type of olution are brought to light. If new group member join or replace thoe who left, it i important to bring the new member up to date. Not everyone who can provide ueful information need to be a full time member of the team. Help hould be olicited from thoe involved in the proce on an a-needed bai. Commonly, participation of pecific individual can bet be requeted at pecific moment to furnih information to help undertand the problem or it caue. C. Define the Team Working Procedure Once a team i formed, it need to convene regular meeting. During the early meeting, the team hould define the group working procedure, e.g., role and reponibilitie, how the team will make deciion, and how often they will meet. To be efficient, the team mut agree not only what i going to be done (goal) but alo on how the group will work together. There are a few tip for developing effective working procedure: 1. Determine team role and reponibilitie: leader, recorder, facilitator/timekeeper, team member. 2. Determine how deciion will be made: conenu, majority voting, leaderhip deciion. 3. Etablih ground rule for meeting: honety, dignity, do not interrupt, etc. 4. Determine how often and for how long the group will meet. 5. Develop meeting agenda (tak to be accomplihed, topic to be covered, and method to be ued) and adhere to them. 6. Decide how to document the team quality improvement progre: QA Storybook and QA Storyboard. Good documentation help to keep the team focued on the quality improvement proce and allow team member to preent their work to other. Many organization have uccefully employed QA Storybook and QA Storyboard (ee page 2-46 thru 2-49) to tell their quality improvement torie in a tructured and comprehenible way. Once a team ha defined it operating procedure, it firt tak i to review the problem 1-19

32 tatement and to gain a common undertanding. Sometime the problem tatement may need to be revied baed on freh inight or information. D. How To Know When To Proceed to the Next Step It i time to proceed to the next tep when all thoe who will work on the problem have reached a common undertanding of the problem tatement and the team procedure for working together. 1-20

33 IV. STEP 8. Analyze the Problem and Identify Major Caue Thi i the tep in which the team (or individual) will attempt to undertand more about the problem or quality deficiency: Why doe it happen? People often identify a problem, decide they already know everything about it (including the caue), and jump to a olution already in mind. When they do thi, they often find that the problem ha not gone away, even after the olution ha been implemented. Why? They did not broaden their thinking and verify their aumption with data. The caue of a problem are not alway obviou. Good problem olving mean reiting the temptation to jump to concluion. The tep decribed below i the crux of the quality improvement proce becaue it addree the quetion: What i really going on here? Define the Problem Operationally Identify Problem and Select Opportunitie for Improvement Identify Who Need To Work on the Problem Implement and Evaluate Quality Improvement Effort Develop Solution and Action for Quality Improvement STEP 8 Analyze and Study the Problem To Identify Major Caue clarify what i known already about problem undertand the proce around the problem develop hypothee about caue of the problem tet hypothee and determine major caue The objective of thi tep i to identify the problem major caue in order to chooe an appropriate olution. Thi can be done very quickly if the problem i imple and the caue i obviou, or it can take longer when the problem i more complex and there are everal poible caue. Problem analyi can be likened to peeling an onion: there are many layer to be removed before reaching the heart of the matter, i.e., the major caue. It can alo be thought of a a erie of invetigation to narrow down the problem. By expoing the problem component, it i poible to reach the root or underlying caue. Given the divere nature of problem, there i no ingle method for analyzing them. Yet the following tep will help the team to tay focued: Review the problem tatement (Step 6) and clarify what i already known about the problem: who, what, where, when, how often. 1-21

34 Undertand the proce in which the problem occur. Develop hypothee about the caue of the problem. Tet the hypothee and determine the major caue(). Examine the caue and determine if the makeup of the team need to be modified. A. Review the Problem Statement and Clarify What I Already Known About the Problem Before beginning analyi and data collection, it i important to paue for a moment to review what i already known about the problem and what ele mut be undertood. The problem tatement developed in Step 6 hould reflect the anwer given to the four following quetion. It i alo ueful to review the problem tatement in the light of information now available from team member and other informant and, if neceary, to agree on a revied problem tatement. That tatement hould decribe the problem in term of: Who i involved or affected by the problem? Where doe the problem occur? I it widepread or iolated? When doe the problem occur? Certain day? Certain time of day? Sporadically? What happen when the problem occur? Thi doe not require launching into an immediate, extenive data collection effort. The objective i to review available data to ee if thee quetion can already be anwered. If not, the team hould reconider whether a problem really exit. EXAMPLE 1: Compliance with ARI Treatment Regimen The upervior, the nure, the pharmacit, and the community repreentative convened to dicu what they already actually knew about the problem. Who: The team member felt that they repreented thoe worker involved in enuring patient compliance with ARI treatment regimen. Where: They realized that they had no data that would tell them how widepread the problem wa: Did it affect all the patient? Did it affect only patient from certain village? What percentage of patient were not tarting the treatment regimen? What percentage were not finihing them? When: Team member felt that the problem wa ongoing and did not eem to follow any periodicity. However they recognized that with no data to ay how extenive the problem wa, they could not know whether it wa eaonal or year-round. What: Evidence that patient were not finihing their treatment included the fact that they often dipoed of their drug, that they did not go to the pharmacy to have precription filled, that they did not come for follow-up injection, and that ome returned with worening condition. Although they did not think it neceary to revie the problem tatement, they aked the community repreentative to ee how widepread the problem wa in village in their area. 1-22

35 EXAMPLE 2: Prenatal Care: Waiting Time The team reviewed what they already knew about the problem: Who: pregnant women, receptionit, nure aitant, midwife. When: The problem appear to occur motly on Monday and, to a leer extent, on other day. It eem to be a regular pattern, not poradic. Where: The problem occur in mot health center, although the team wa not ure how widepread the problem wa. What: The pregnant women become dicouraged by the long waiting time. B. Undertand the Proce in Which the Problem Occur Mot problem or quality deficiencie relate to the way work i conducted (the proce). Yet people do not alway have a clear picture of the proce, epecially the link between their work and the work of other. Thu, one important tep in the analyi of the problem i to gain an undertanding of the proce itelf and to develop conenu among the team member about how the proce actually operate. The latter i ditinct from how it i uppoed to operate. Thi i the tart of the peeling of the onion : identifying where the problem i located within the proce. Team member mut have a common undertanding of the proce to ave time and energy while working through the remaining tep. One way to do thi i to viualize the actual flow of the proce in which the problem occur. There are two type of tool that can be applied: ytem modeling (ee page 2-17) and flowcharting (ee page 2-20). Occaionally while examining the proce, the group dicover that it i miing fact needed to undertand what i happening. Data may need to be collected. Table 1-2 preent ome guideline for determining which tool are mot appropriate for beginning the examination. 1-23

36 Table 1-2 Tool Sytem modeling Flowchart Caue-and-effect analyi (preliminary) Force-field analyi (preliminary) When to Ue Sytem modeling i mot ueful when an overall picture of the ytem in which the problem i occurring i needed: n to ee who provide reource (input), what the proce i, what output are produced, and who i affected by the output and how, n to better undertand the effect of the problem, i.e., how it affect the output of the ytem, the immediate effect of that output on the client, and any long term impact). Flowchart are ueful tool when the proce in which the problem i located ha already been clearly identified and pecific tep in the proce need to be examined. Occaionally: If the problem tatement ha not yet pointed to a pecific proce that i reponible for the problem, a preliminary caue-andeffect analyi may help locate the proce in which the problem i occurring. Caue-and-effect diagram erve to tructure braintorming about potential caue of the problem and may therefore help to identify procee that contribute to the problem. Occaionally: if the proce leading to the problem i not evident from the problem tatement, a preliminary force-field analyi may help to identify procee that potentially caue the problem, a well a thoe that might reduce it. Force-field analyi i particularly ueful for narrowing down where to look when the problem deal with ubjective iue, uch a morale, management effectivene, or work climate aociated with pecific procee. 1-24

37 EXAMPLE 2: Prenatal Care: Waiting Time Ditrict team member, already undertanding which proce they needed to examine, decided to expand on the high level flow chart they had developed when determining team memberhip. They firt developed a baic econd level or detailed flow chart and then went back and added in point where they thought pregnant women had to wait. The detailed flow chart wa poted on the Storyboard. The team felt that it did not know which of thee waiting pot wa mot reponible for the long time that pregnant women pent in the health center. The member decided to collect ome data to determine which delay wa the major caue of the long waiting time. They gave each pregnant woman a piece of paper marked with the time when he walked into the health center, and then each of the health worker wrote down what time he or he provided ervice. The data were collected for one week, tabulated, and poted on the Storyboard. They howed the following reult: Part of Proce Mon Tue Wed Thur Fri Weekly mean mean mean mean mean Average 1. Entry to 30 min 15 min 18 min 15 min 14 min 20 min receptionit 2. Receptionit to 32 min 18 min 21 min 20 min 21 min 26 min nure aitant 3. nure aitant 58 min 35 min 30 min 28 min 35 min 42 min to midwife Sum of mean waiting time 120 min 68 min 69 min 63 min 70 min 88 min Thee data howed them that there were two thing happening: the wait from when the patient firt aw the nure aitant to when he aw the midwife wa the longet, and thi wa wore on Monday than on other day. Becaue the root caue i often not obviou, it i bet to tart by generating a lit of a many poible caue a poible. A caue-and-effect analyi (ee page 2-26) help to look beyond the ymptom. C. Determine if the Team Compoition Mut be Modified At thi tage, it i wie to review the compoition of the team to determine whether additional member are needed. The team hould ak itelf the following quetion: Doe anyone on our team work in the area of the proce in which the problem i located? I anyone on our team directly affected by the problem? Are other affected? Doe anyone on our team have authority to make deciion related to the problem caue? Do we have the technical expertie to undertand the caue and what might rectify it? If the anwer to any of thee quetion i no, the team hould conider changing it 1-25

38 memberhip or adding new member who meet the above qualification. A with early change in memberhip, new member need to be brought up to date on what the team ha done and the reult it ha found. If the team ha documented it activitie uing a Storyboard and Storybook, bringing new member up to date i much eaier. EXAMPLE 1: Compliance With ARI Treatment Regimen Team member decided that before embarking on an analyi of the proce, they would ue a caue-and-effect diagram to help them ee the variou apect of the problem. They firt determined the poible categorie of caue: the patient, the health provider, the environment, material/upplie. Then, they ued the braintorm technique to develop the following diagram, which they poted on their Storyboard: Caue-and-Effect Analyi for Treatment Regimen PATIENT Doe not know need to finih treatment Doe not have money to buy drug Prefer only injection Too far to go for daily injection PROVIDER Precribe only tablet Doe not know treatment regimen Doe not explain treatment regimen Doe not have enough time Too expenive Drug Patient do not follow treatment regimen for ARI ENVIRONMENT MATERIALS/ SUPPLIES Out of tock They then dicued which caue were mot probable: patient do not know that they need to finih their treatment, they prefer injection, and the provider do not explain. They decided to look at the proce of care, tarting from when the patient arrive, to ee what happen there. They developed the following high level flow chart, again which they poted on their Storyboard: Patient arrive Health provider examine patient and determine diagnoi Health Patient provider goe to determine pharmacit treatment Pharmacit give drug Patient take drug Following contruction of the flow chart, they dicued how the couneling/explanation to the patient take place. They dicovered that the nure thought the pharmacit performed thi tak and the pharmacit thought the nure did. In reality, no one wa doing it. 1-26

39 D. Develop Hypothee About the Caue of the Problem Improving quality mean eliminating the problem root caue. Dieae are cured by treating their caue, not their ymptom; thi principle applie to problem olving a well. Once the problem ha been located more pecifically, it i time to develop hypothee about the caue. The term hypothee i ued becaue it remain unclear whether thee are the true caue. The validity of the caue will be verified later by collecting data. It i poible that the caue() will be revealed while flowcharting (ee page 2-20). Example of caue may include a tep in the proce that i miing, a part where there i confuion about what to do, or the preence of unneceary tep. Sometime the olution i evident a well, and the proce can be modified to eliminate the problem. It may be that trying to flowchart will demontrate that no ingle, clear proce ha been etablihed. In thi cae, the olution may lie in deigning a tandardized proce. If flowcharting uncover the obviou caue, the group may proceed to the next tep: Chooing and Deigning the Solution. If the caue remain unclear, the group hould continue analyzing the problem to identify the probable root caue() (ee page 2-26). Hint: Be wary of concluding that you already know the caue. Think about whether it i poible to verify your theory of the caue. See Teting the Theorie of Caue below. Becaue the root caue i often not obviou, it i bet to tart by generating a lit of a many poible caue a poible. A caue-and-effect analyi (ee page 2-26) help to look beyond the ymptom of the problem. It puhe one to ak, What caue that? and What i behind that? It i alo deigned to broaden thinking about caue and explore other area that might be contributing to the problem. Alternatively, other method uch a contructing a tree diagram (ee page 2-27), aking the five why (ee page 2-27), or conducting a force-field analyi (ee page 2-30) can be ued. When all poible caue have been uggeted, it i common to have more caue than could poibly be invetigated. The expertie of the team help to narrow down the poible caue to the mot probable. Several deciion-making method can lead to ome hypothee about root caue(), uch a expert opinion and voting. The point i to produce a few poibilitie from the vat array of potential caue identified. Hint: Start teting hypothee about caue which are eaiet to collect data on, thu helping to eliminate certain hypothee quite quickly. When collecting data to verify caue, try uing different information ource from the one ued to identify the problem. 1-27

40 E. Tet the Hypothee and Determine the Root Caue() Remember that the caue referred to above are only hypothee. Now it i time to collect and interpret data to prove or diprove thee hypothee. Determining caue hould be baed on fact, not opinion or aumption. A few key point about data collection are reviewed here. Hint: It i quite eay to fall into the trap of collecting more data than needed, data that do not provide any real information. The key meage here i that data collection hould be deigned to provide the information needed to anwer the quetion: What i (are) the major caue()? Table 1-3 Data repreent the hard fact that decribe the problem or proce in objective, meaurable term. But the problem-olving proce eek information, anwer to the quetion about why a particular problem i occurring or why a given proce ometime lead to unwelcome reult. Information quetion allow u to identify what we need to know to be able to move on in our problem olving effort. Table 1-3 provide ome generic information quetion to help undertand the nature of the problem and verify hypothee about poible caue. Information quetion about the nature of the problem Information quetion for verifying hypothee about caue of the problem Who i involved or affected by the problem? Where doe the problem occur (all over or in certain pecific area)? When doe the problem occur (certain time of day? certain time of the week? year?)? How big i the problem? What are the effect of the problem? Doe thi hypotheized caue really exit (do we experience it)? I thi hypotheized caue frequent and/or widepread enough to explain the extent of the problem? How many time doe the hypotheized caue occur? I the hypotheized caue aociated with the problem (for example, do they happen at the ame time or to the ame client)? The anwer to thee quetion mut be baed on fact (data), but the data in and of themelve do not necearily provide anwer. Data mut be analyzed and the reult preented in a way that tranlate them from mere fact into information. Although tatitician have many ophiticated method available for analyzing and interpreting data, there are everal relatively imple method of organizing and preenting data. Thee method uually help in communicating information in undertandable term. Data preentation tool (ee page 2-31 to 2-39) are viual diplay of data that make it eay to ee what i happening. They help team to interpret the variation that i preent in 1-28

41 the data. Every proce contain ome variation, but our objective i to reduce that variation o that the proce will function conitently at the ame high level of quality. To attain thi level of performance, it i neceary to undertand the variability in the proce. However, there are ome baic principle that need to be clarified firt. The firt principle tate that No two thing are alike. For example, rice that i cooked today will change in conitency by tomorrow. Uually the change are unnoticeable becaue they are mall. Thu variation hould be kept to a minimum. Each time rice i cooked, it will vary omewhat due to the quality of the ingredient, the heat of the tove, or the peron cooking the rice. Variation i natural and i found in every proce. Even the bet cook cannot prepare rice exactly the ame every day, depite uing the ame ingredient or monitoring the heat carefully. Variation i common and i to be expected. Variation become a problem when it become extreme. For example, if the cook burn the rice for the meal frequently, it become a problem and the cook will know becaue the family complain. The family expect rice that i cooked within a range of acceptability. Thi lead to the econd principle: Variation i caued. The ource of variation can be found in one or more of the following area: material ued in the proce, equipment ued to perform the proce, method ued in the proce, people who perform the proce, environment in which the proce i conducted, meaurement that are ued in the proce. EXAMPLE If you were to write the letter A five time, you would ee ome variation in the reult. Thi difference, termed common caue variation, i inherent in your proce of writing. If you were to break your hand and have to write the letter A with the other, the reult of the handwriting proce would be quite different. Thi would be called pecial caue variation, due to omething external to the proce (a broken hand). Management make the baic deciion about each of thee area. For example, in cooking rice, management would determine which raw rice to ue, where to get the water, which pot and tove to ue, the cooking tep, who would cook the rice, where it would be cooked, and what to meaure to indicate that the rice i done. Inherent variation of the proce i caued by thee element a originally et by management. Thi i ometime called common caue or chance variation. 1-29

42 However, if omething change in one or more of thee area, it i not inherent in the proce a it wa originally deigned by management. Thi type of variation i called aignable or pecial caue variation, ince it can be identified and corrected. Ditinguihing between thee two type of variation i important in electing the appropriate repone. For example, if the problem i due to pecial caue variation, the manager would look at the pecific area or area and repond accordingly (train the cook or get a new tove). However, if it wa due to common caue variation, the manager would evaluate the entire proce. The third principle tate that Variation can be meaured. Thi require the collection of data. To determine what data are to be collected and how, it i helpful to examine, for each information quetion: Data needed: the pecific fact we need to be able to anwer the information quetion; thee fact mut be meaurable (e.g., count, percentage, time pent, reaon why patient reject a particular ervice). Source of data: where the data can be obtained (e.g. clinic record, community member, client, provider). Method of data collection: how the data will be obtained from the ource (e.g., record review, houehold urvey, exit interview, obervation of provider performance). Who will collect the data: pecific individual who will be reponible for recording the data. How much data to collect: how many of each ource to collect data on and/or over what time period. How the data will be analyzed: what kind of data analyi tool will be ued (e.g., run chart, pie chart, Pareto chart). Once the type of data needed ha been determined, the following table can ait in chooing the appropriate tool to diplay them. 1-30

43 Table 1-4 To Show Ue Data Needed Frequency of Occurrence: Bar chart Tallie by category (data can be Simple percentage or comparion Pie chart attribute data [e.g., ex, language, etc.] of magnitude Pareto chart or variable data divided into categorie [e.g., age group, income group, etc.]) Trend Over Time Line graph Meaurement taken in chronological Run chart order, attribute or variable data can Control chart be ued Ditribution: Hitogram Forty or more meaurement Variation not related to time (not necearily in chronological order), variable data Aociation: Scatter Forty or more paired meaurement Looking for a correlation between Diagram (meaure of both thing of interet), two thing variable data In teting hypothee about the root caue(), it i uually helpful to look at the ame data in many different way o that the invetigator may determine, for example, whether age or marital tatu i more likely to have an impact on a peron ue of health ervice. A population being tudied may be divided into ubgroup or trata, may be baed on a ingle characteritic that place an individual in a clearly defined group, uch a marital tatu or facility ued for health care ervice. Another kind of ubgrouping relie on creating dicrete range within a cale of poible value, uch a income or travel time to the clinic. Once trata have been identified, it may become apparent that a certain characteritic i cloely related to the targeted problem. Graphic diplay of the reult (e.g., bar chart) are uually mot effective in uggeting relationhip. Uually, however, additional data will be neceary in order to confirm the relationhip uggeted by thee graph. Difference among trata can ugget an aociation between certain characteritic and the targeted problem. Graphic diplay of the reult (e.g., bar chart) are uually mot effective in uggeting relationhip. Uually, however, additional data will be neceary in order to confirm the relationhip uggeted by thee graph. An example, illutrated in the erie of bar chart below, may help to clarify the ue of tratification. A recent vaccination urvey had indicated that immunization coverage wa lower than expected in the ditrict. Hypotheizing that low coverage wa due to low ue of the Maternal and Child Health (MCH) center, the team orted the data by whether the familie had gone to an MCH center for treatment during the mot recent illne. The team alo calculated the percent of children immunized for each group. The reult indicated that children in familie who had ued the MCH facility for a recent illne had higher rate of immunization than thoe who had not. To identify the facilitie where underue wa mot acute, the team looked at attendance rate at each facility. Although there were difference among the facilitie, thee did not eem important. However, orting attendance by both facility and type of ervice (e.g., ervice for women and ervice for children 1-31

44 under age five) did ugget ignificant difference among facilitie in the pattern of utilization. One facility in particular (facility C in the bar chart below), whoe overall attendance rate wa the highet of the four MCH center, differed markedly from the other, both in it low attendance of children under five and it very high attendance of women. The team concluded that it hould concentrate on olving the problem of underue of child ervice at facility C before it could expect to increae immunization coverage. [They were alo intereted to learn more about the unuually high attendance by women!] Stratification 1. Percent immunized by utilization 2. Viit per week by facility tatu of family (vaccination urvey) (ervice tatitic) 80 % No USERS NON-USERS A B C D Facility 3. Viit per week for maternal ervice 4. Viit per week of children <5 by facility (ervice tatitic) year by facility (coverage urvey) No. No A B C D Facility A B C D Facility 1-32

45 F. How To Know When To Go on to the Next Step Thi tep contain two poible danger: 1) pending too much time collecting data, and 2) trying to move too quickly through thi tep without collecting ufficient data. Therefore, it i important to know when to top. There are no firm rule ince each problem require it own analyi, but there are a few guideline for knowing when the major caue identified: No other caue were verified by data. The group member agree on the caue and feel motivated to fix it. The caue explain the exitence of the problem from all point of view. The caue i logical and dipel confuion. The caue i omething the group can influence, control, or deal with. EXAMPLE 1: Compliance with ARI Treatment Regimen Now that they had narrowed down the caue of client non-compliance to the lack of couneling, the team member realized that they till did not really undertand why the patient did not finih their treatment: i.e., what would couneling need to addre? Through braintorming they came up with the following idea: Patient do not like tablet. Patient forget the doage. Patient top taking medication when Patient ue a few pill and ave they tart to feel better (even if the the ret for another illne. treatment i not finihed). Even with thi lit, they realized that they did not know the real caue. So they decided to collect ome data to determine which of thee hypotheized caue wa the root caue. They aked the community repreentative on their team to go to the patient home to ee whether they took all their pill, and if not, why not. (They felt the community repreentative would get the mot truthful anwer.) The team member felt that they hould not rule out any particular reaon ince they were not ure that their lit generated by braintorming included all the poibilitie. Community repreentative each took reponibility for viiting the patient in their village, baed on a lit provided by the nure each week. The data were collected over a three-week period. When the data were analyzed, they diplayed them in a Pareto chart (ee page 2-40 and 2-41), which they poted on the Storyboard. From their Pareto analyi, they found that the major caue for unfinihed treatment wa that the tablet the patient were aked to take were big and difficult to wallow. Thi wa a urprie to the team who had not thought of that poibility. Additional analyi alo howed that patient topped taking the medication when they tarted to feel better. Number of Patient not Finihing Treatment Reaon for Not Finihing Treatment 55% Tablet too big 27% Felt better 8% Forgot doage 5% 5% Don't like tablet Save for other illne % of Patient not Finihing Treatment 1-33

46 EXAMPLE 2: Prenatal Care: Waiting Time Although the midwife aid the delay were becaue he aw too many patient, the team decided to develop an even more detailed flow chart for the proce from the nure aitant to the midwife to ee if they could undertand why it took o long there. Patient arrive with record Nure review record Need immunization? Ye Are there ufficient women to finih ampule? Ye Patient goe with record to midwife No Nure take blood preure No Nure prepare and adminiter vaccine Thi flow chart led them to hypotheize that the delay wa caued by the way they delivered immunization (the nure wait until 10 women are aembled before opening a vial of vaccine). In addition, they wondered why Monday wa wore than other day. They ued the five why technique to examine thi iue of Monday. Why do the pregnant women wait longer on Monday? Becaue there are more people coming on Monday. Why do more women come on Monday? Becaue they think prenatal ervice are offered on Monday only. Why do they think prenatal ervice are only offered on Monday? Becaue that wa how we ued to do it. Reaon for Pregnant Women Coming on Monday (Exit Interview) After weekend 20% No reaon 20% Tranportation eaier 15% Think prenatal viit only offered on Monday 45% Thu, they hypotheized that women did not know that they now offered prenatal care every day. To verify thi, they firt ued a run chart on the data from their regiter of the number of women attending over time. They alo Number of Prenatal Conultation/Day decided to ak the women exiting the clinic on Monday 50 why they choe Monday to 40 come. The data were collected 30 and howed the reult below. The nure aitant poted both chart on the Storyboard. Number of Pregnant Women M T W Th F M T W Th F M T W Th F M T W Th F Day of the Week Data M 45 T 10 W 15 Th 20 F 18 M 38 T 20 W 15 Th 12 F 17 M 40 T 13 W 18 Th 23 F 18 M 42 T 22 W 18 Th 12 F

47 V. STEP 9. Develop Solution and Action for Quality Improvement Identify Problem and Select Opportunitie for Improvement Define the Problem Operationally Implement and Evaluate Quality Improvement Effort STEP 9 Develop Solution and Action for Quality Improvement examine caue and determine if team compoition hould change lit all potential olution elect criteria chooe olution formulate olution Identify Who Need To Work on the Problem Analyze and Study the Problem To Identify Major Caue Mot team or individual are eager to reach thi tep: the olution. Thi i the entire reaon for the quality improvement effort--to make thing better. The objective of thi tep i to develop a olution that olve the problem by eliminating it caue(). Developing olution i not alway a traightforward tak, and many olution fail becaue they were not carefully thought through before implementation. Thi i not the time to ruh to a olution given all the effort that ha been inveted in electing and analyzing the problem. The bet approach i to be open and to think creatively, firt to develop a lit of potential olution, then to review each carefully before electing one. Chooing and deigning olution entail everal ubtep: lit all potential olution, elect criteria to find which olution i bet, chooe a olution to implement, tate the olution in a practical, feaible manner. 1-35

48 A. Lit All Potential Solution Before liting potential olution, the team mut clarify the objective of the olution: What i the deired outcome? What are we trying to achieve? What i ucce? The group hould agree on thee iue before proceeding. Putting the objective of the olution in writing provide guidance throughout the election proce, a well a for planning and implementation later. Chooing ound olution require a good lit of option. Thi i where creativity i important. All too often, group get tuck in their thinking ( Thi i how we have alway done it ), or they let themelve get wayed by one peron idea without exploring other option. Conider inviting other to join with the team in uggeting poible olution. The additional member hould be thoe who have been working on imilar problem within the organization. Begin by reviewing previou uccee and, more importantly, previou failure. Why did thee occur? What leon can we learn from thee? It can alo be ueful to examine the experience of other. Benchmarking (ee page 2-44) combined with braintorming (ee page 2-7) can be a valuable way of timulating creativity. Benchmarking involve exploring a imilar proce that work well, or conidering olution other have tried who have had imilar problem or ituation and examining cloely what they have found ucceful. However, a word of warning it i eential to have a thorough undertand of one own proce before attempting any benchmarking. It i equally eential to undertand fully the other proce before uing it a a benchmark. If thi i not done, it may create more problem than are olved. Hint: Be careful when benchmarking, i.e., looking at olution that other have tried. One ituation i not likely to be exactly like ather, and one group' olution may not work for another group. Thi doe not mean you can never ue omeone ele' olution, but you will need to review it carefully to ee how your ituation and contraint differ from their and ee what adaptation may be needed. To generate idea, the team can hold a braintorming eion to develop a lit of both conventional and unconventional olution. The point i to be a creative a poible: there will be an opportunity to ort through thee option later. Think about what the team could ubtitute, adapt, combine, or rearrange. The following are general categorie of olution that may help to generate idea: reminder: adminitrative directive, letter, job aid, job decription; improving taff kill and knowledge to tandardize the proce: coaching, in-ervice training, formal training, changing policy or tandard: redeigning the proce, treamlining the proce (making it le cumberome, eliminating redundancie), clarifying procedure; 1-36

49 changing the allocation of tak among taff; changing the time when activitie take place; improving input to the proce, creating incentive to improve motivation. Hint: Additional reource and improved motivation alone may not olve the problem or lead to improved quality. Thee olution work bet if combined with other, uch a change in procee or tandard. B. Select Criteria To Determine Which Solution I Bet A dicued in the ection on Identification of Problem and Selection of Opportunitie for Improvement (Step 5), electing among option i bet accomplihed uing clearly tated criteria. Thi i epecially true a the team move toward the olution implementation tage, in which conenu and upport will be eential for making quality improvement effort work. Several poible criteria for chooing a olution can be ued. The team can develop it own or chooe from the uggetion below: affordable to implement, free from negative impact on other procee or activitie, feaible to implement, management upport, community upport, efficient, addree root caue, timely. Hint: Try to limit the number of criteria to three or four, ince too many criteria will make the election proce unwieldy. Identify which criteria any olution mut meet to be conidered eriouly, a thi will quickly eliminate certain choice. C. Chooe a Solution To Implement Before applying the choen criteria, the team hould review each of the potential olution and dicu it advantage and diadvantage. Force-Field Analyi (ee page 2-30) may be ued to identify thoe force that might be expected to help and thoe that might hinder implementation of a given olution. Think about how the olution could be modified to decreae the diadvantage and contraint. Then, when every team member ha a clear idea of each olution, apply the criteria uing one of the deciion-making method decribed in the firt tep: expert make deciion, voting, or matrice (ee page 2-14). 1-37

50 EXAMPLE 1: Compliance With ARI Treatment regimen Given the Pareto analyi (55% of patient reported finding the tablet too big to wallow), the group decided that it would tart with the patient dilike of the tablet. It alo felt they hould add the Regional Pharmacit to the team, ince he i the one reponible for determining what kind of drug the health center can order. The group invited him to come for an afternoon and preented their data to him. The member braintormed and came up with the following option a olution: Change the drug they precribe (one with maller tablet). Tell the patient to break up the tablet to make them eaier to wallow. Tell the patient to diolve the tablet in water and then drink the medication. Explain to the patient that the tablet are large but it i important to take them anyway. Give every ARI cae injection. The group choe management upport, cot, community upport, and feaibility, a criteria. Uing multivoting, they choe changing the drug they precribe a the mot effective olution. However, it would require getting management upport which would take time. The Regional Pharmacit uggeted that the upervior dicu with other upervior to ee if other health center were experiencing imilar problem with the ARI medication. If o, then he would upport the change of drug for ARI. Otherwie, it would be too much work to do o for a ingle health center. After verifying the technical appropriatene of changing how the medication wa ingeted, the team decided that, in the meantime, they would work on couneling of patient on how to take the tablet (uggeting breaking them up or diolving them in water) and having the nure provide couneling on the importance of finihing the ARI treatment. The team recorder entered thee deciion in the Storybook. 1-38

51 EXAMPLE 2: Prenatal Care: Waiting Time The team lited potential olution for the caue they identified. For the firt caue, waiting for 10 women before opening a vial of vaccine, they came up with the following option by braintorming: provide immunization on a eparate day, immunize the women after they have een the midwife, do not wait for 10 women, buy a mall thermo that the vial of vaccine can be tored in once they have been opened and adminiter the vaccine to the women a they are een by the nure aitant (do not wait for 10 women). The team debated over criteria for electing the olution and choe cot, feaibility, and management upport. For eliminating the firt caue (waiting for 10 women before opening the vial of vaccine), they ued a matrix to apply thee criteria to each potential olution. For the econd caue (the women think that prenatal care i available only on Monday), they decided it would be worthwhile to do ome benchmarking by dicuing with ome other health center how they had handled the tranition from weekly prenatal delivery to daily delivery. After uch dicuion, they ued braintorming to come up with the following lit: announce on the radio that prenatal care i available every day, put up a poter with that meage in the entrance to the health center, ak the community leader to announce it to their village, hand out a flyer to all patient telling them the day that ervice are available, have the receptionit tell the patient that prenatal care i available every day. Solution Option Low Cot Feaibility Criteria Management Support Total Immunize on eparate day Immunize after midwife Do not wait for Buy thermo, do not wait For the firt caue, the olution they choe wa to change the policy on opening a vial only if there are 10 women waiting, to adminiter the vaccine to women a they are een by the nure aitant, and to buy a mall thermo to tore the open ampule. For the econd caue, applying the ame criteria, they imply voted to have the regitrar tell patient that prenatal care i available every day. They added thee olution to the Storyboard. 1-39

52 D. State the Solution in a Practical, Feaible Manner Once the team ha elected a olution, it mut take a few precaution before carrying it out. Firt, it mut review the olution and dicu with the group whether the olution can be carried out a decribed or whether it need more reviion to make it feaible. Flowcharting (ee page 2-20) can help the team to determine if what it ha in mind will work. Can the olution be implified? Who will be doing what, where, and when? The team mut think about who need to be involved in the planning of the olution: Who will be implementing it? Who will be uperviing it? Thi i the moment to think about what the olution will really look like. For each component (who, what, where, when), everal option may exit. Review them and chooe the mot practical, feaible one. E. How To Know When To Go On to the Next Step The team hould ak itelf thee three quetion: Can we do it? Do we want to do it? Will other let u do it? Once the team can anwer ye to thee quetion, it i ready to proceed to the planning and implementing of the olution. Implementation hould begin when the team feel confident about the olution and ha developed ufficient motivation toward it. If ome diagreement or uncertainty remain, the team hould review the olution for way to make it better or for alternative olution. 1-40

53 VI. STEP 10. Implement and Evaluate Quality Improvement Effort Identify Problem and Select Opportunitie for Improvement Define the Problem Operationally STEP 10 Implement and Evaluate Quality Improvement Effort plan implementation implement olution follow-up olution make deciion to expand, modify, or chooe another olution Identify Who Need To Work on the Problem Analyze and Study the Problem To Identify Major Caue Develop Solution and Action for Quality Improvement Quality improvement depend on effectively implementing the appropriate olution. Even a well-choen olution will not reolve the problem if it i poorly planned, implemented, and monitored. Thi final tep, commonly known a the PDCA (or the Shewart) cycle: Plan, Do, Check, Act. It i deigned to enure that the olution i properly implemented. Thi final tep comprie four major activitie: planning implementation of the olution (PLAN), implementing the olution (DO), following up to determine if the olution ha had the intended reult (CHECK), making deciion about whether to expand implementation, to modify the olution, or to chooe another olution to tet (ACT). Almot every olution will require ome change in individual work, behavior, or role and reponibilitie. People often feel threatened by change unle they are convinced of the need for it, can enviion how circumtance will be improved, and undertand the change that will occur. It i eential to recognize reitance to change and to addre it 1-41

54 directly; otherwie, problem-olving effort will be undermined. Some trategie to reduce reitance to change include: inviting people to participate in planning the change, providing a clear picture of the change, haring information about the change: ecrecy and urprie create anxiety, demontrating commitment to the change: being a poitive role model, offering poitive reinforcement for change and early uccee. A. Planning for Implementation of the Solution Planning for any activity, including quality improvement, involve determining the who, what, where, when, and how. Planning for olution implementation hould include the following tak: Review the objective of the olution: What are we trying to achieve? What i ucce? Review the olution deign: What are the tep in the proce? Who will be doing what, where, and when? Review or develop a imple flowchart (ee page 2-20) of the proce. Identify who will be carrying out each tep. Identify potential reitance: The team mut think about who may be affected by each tep or change in the proce. Such individual may be ource of potential reitance. Could reitance be reduced by including thee individual in the planning proce? How ele can reitance be avoided? A force-field analyi (ee page 2-30) can help to identify trategie for increaing the likelihood of effective implementation. Determine the prerequiite to implementation: What need to be done or prepared before thi proce can be carried out? Think about what kind of training might be required, what kind of communication i neceary, and what kind of upport (material, uperviory, managerial) need to be organized. The team member hould think about everything that could go wrong and, after braintorming, ue an affinity analyi (ee page 2-9) to group thee for preventive action. Develop a tep-by-tep lit to lay the groundwork: What need to be done firt? How long will it take? How will we know when that activity i completed. What i the product? A Gantt chart (ee page 2-45) can help to plan the order of activitie. Hint: Tet the olution on a mall cale firt. If the olution require major change, affect many people, or ha never been tried, teting the olution on a mall cale firt will help: Work out the kink before large cale implementation Generate upport by howing that the olution actually work Save reource if the olution wa not a ucceful a aumed. 1-42

55 Aign reponibility for each activity: Who will ee that each activity i carried out? Thi peron() may not have to carry out the activity, but he or he will be reponible for eeing that it happen. Determine what information i needed to follow up the olution: What data are required to determine whether the olution wa actually implemented, whether it wa implemented well (according to the plan), and whether it had the intended reult? Where are the data available? Who can collect the data? When and how will it be collected? B. Implement the Solution Putting the implementation plan into action involve carrying out the ordered tep outlined above, implementing the change itelf, and collecting the information that will indicate how well it went. Team hould etablih check point periodically to verify that implementation i going a planned and to communicate progre to all thoe involved. Team hould alo be ready to provide encouragement and aitance a needed. Hint: Document anything that goe wrong in the implementation phae. Thee bit of information can help later in aeing the olution. Every problem or error i an opportunity for improvement, and thi i a valid during olution implementation a in problem identification. 1-43

56 EXAMPLE 1: Compliance With ARI Treatment Regimen - Firt Solution For the olution of changing the drug ued for ARI, the team decided to plan how to determine whether their problem wa widepread and, if o, what would need to be done to change the drug. Review the objective: The objective wa to increae the percentage of patient that finih their ARI treatment in order to improve health tatu and reduce antibiotic reitance. Review the plan for the olution: The olution would be to change the drug for ARI to one that i eaier to wallow. Thi drug would be precribed by the nure and dipened by the pharmacit. Identify people who might reit: Reitance to thi olution could come from many ide: the nure who would be required to change their precribing practice; the pharmacit who would have to order, tock, and dipene another drug; the community who may not like it preentation, ide effect, or cot; and the Regional Pharmacy and Central Medical Store which would have to change their current ordering pattern. Overcoming potential reitance from thee ource would require coniderable dialogue with the variou partie, and preentation of data from more than one health facility to jutify the need for uch a change. Lit tep needed before carrying out the plan: Before carrying out uch a change in drug policy, the team needed to know the extent of the problem and collect data to confirm the need for change. Develop a tep-by-tep lit to lay the groundwork: The firt thing to do would be to contact all the health facilitie in the ditrict and ee who ele had the problem of patient not completing ARI treatment. If other had the ame problem, imilar urvey hould be conducted to verify the caue, a wa done by thi team. Thee data could then be preented to a larger forum (Regional Pharmacit, Regional Health Officer, Director of Central Medical Store, etc.) for dicuion and deciion. Aign job to team member: The upervior took charge of contacting all other upervior in the ditrict and aking them to dicu with the nure at the health facilitie they upervied. If the problem appeared widepread, the whole team would prepare a preentation on conducting urvey to evaluate the caue. Again, the recorder made a careful record of each deciion and entered the detailed implementation plan in the Storybook. 1-44

57 EXAMPLE 1: Compliance With ARI Treatment Regimen - Second Solution The team went through the following tep to plan the olution of providing couneling to patient on how to take the drug o that it would be eaier to wallow: Review the objective: To increae the percentage of ARI patient who complete their treatment, in order to improve the health of the community and reduce antibiotic reitance. Review the plan for the olution: The olution choen wa to counel patient on how they can make the drug ued to treat ARI eaier to wallow. Both the nure and the pharmacit would provide couneling: the nure when writing the precription, and the pharmacit when dipening the drug. Wall poter in the pharmacy would alo explain the variou method: breaking up the pill and diolving them in water. Identify people who might reit: Thoe who would be giving the couneling the nure and the pharmacit were already on the team. However, reitance could alo come from the community who would till be taking the drug. The community repreentative uggeted that a mall health education campaign to promote the pill for their effectivene and low cot of treatment would help lower poible reitance to taking the pill. Lit tep needed before carrying out plan: Couneling meage would need to be developed (to enure that the pharmacit and nure were giving the ame information). Wall poter would need to be produced, too. Finally, the health education campaign would need to be planned. Develop a tep-by-tep lit to lay the groundwork: Firt the meage would need to be developed (whether poken or for the poter). Thee meage would be teted by the community repreentative with a few villager firt. Finally, the poter would need to be drawn and hung up. The meage for the health education campaign would be developed and teted a well. Aign job to member of the team: The upervior liked to draw poter and aid he would take charge of that. The community repreentative would tet the meage that the team would develop together. The community repreentative aid they would develop the meage for the health education campaign but would need aitance from the nure to enure that the meage were technically correct. Determine what information i needed for follow-up: The team developed the following lit of indicator: 1. The percentage of patient finihing their ARI treatment, 2. The percentage of patient receiving couneling about how to take their medicine o that it i eaier to wallow, 3. The percentage of patient who undertood the couneling meage, 4. The percentage of patient who practiced what the nure and pharmacit uggeted. For indicator 2-3, the team decided to have the community repreentative do exit interview with the patient. For indicator 1 and 4, the community repreentative would viit the patient in their home a week after treatment. The team recorder made a careful record of what wa decided and entered the detailed implementation plan in the Storybook. 1-45

58 EXAMPLE 2: Prenatal Care: Waiting Time Firt Solution The team worked out the detail of their two olution and recorded them in the Storybook. For the firt olution (changing the proce to open a vial of vaccine even if there i only one woman), they decided to: Review the objective: The objective wa to reduce waiting time for pregnant women in order to encourage them to make at leat four prenatal viit. Review the plan for the olution: The team revied the flow chart to reflect the new proce een below. Patient arrive with record Nure review record Patient goe with record to midwife Need immunization? No Nure take blood preure Ye Nure adminiter vaccine Identify people who might reit: Thoe affected by the change would be the nure aitant who give the immunization, and the pharmacit who i reponible for ordering and toring of the vaccine. The member decided that they hould ak the pharmacit to join them in the planning of the olution. Lit tep needed before carrying out the plan: Before they could carry out the olution, they would need to determine how the number of vial of vaccine conumed would change with thi new trategy and to order a thermo and ufficient vaccine. Develop a tep-by-tep lit to lay the groundwork: The firt tak wa to find the number of vial they would need, baed on the number of women they aw every day. The next tak would be to plan for torage of thee vial, then to order the vaccine and the thermo. They judged that it would take about 1 month to get everything in place before trying the olution. Aign job to each team member: The Health Center manager and the pharmacit took charge of finding the number of vial that would be needed. The pharmacit took charge of ordering the vaccine and the thermo. continued on page

59 EXAMPLE 2: Prenatal Care: Waiting Time Firt Solution continued Determine what information i needed for follow-up: The team pent time dicuing what data it would need to follow up the olution. They finally came to the following indicator: 1. percentage of women making at leat four prenatal viit 2. overall time pregnant women pend at the clinic 3. time pent from when the pregnant woman arrive at the nure aitant' tation to when he i een by the midwife 4. taff atifaction with new ytem 5. amount of wated vaccine (unfinihed ampule) 6. number of tock hortage of vaccine. The team decided that it would try the olution for a period of 2 month, after which it would evaluate indicator 1-4 (uing the ame ource that were ued during problem identification and problem analyi), while data on the 5th and 6th indicator would be collected continuouly by the pharmacit in hi inventory record. EXAMPLE 2: Prenatal Care: Waiting Time Second Solution For their econd olution of having the receptionit tell the patient that prenatal care i available every day, they came up with the following plan: Review the objective: to reduce waiting time for pregnant women in order to encourage women to make at leat four prenatal viit. Review the plan for the olution: The team decided that the receptionit, after taking the patient name and finding her record, would tell the patient about the fact that prenatal care wa available every day. Identify people who might reit: The change would add a tak for the receptionit. She thought that it would not take too much extra effort, and if everyone did not come on Monday, her job would be eaier, too. Develop a tep-by-tep lit to lay the groundwork: The only needed tep wa deciding exactly what the receptionit would ay o that it would be clear. They worked on the phraing in the three local language o that all women could undertand. Aign job to team member: The receptionit took charge of carrying out the olution. Determine what information i needed for follow-up: The team felt that many of the indicator for the firt olution were alo valid for thi one, but they added two additional one: number of women attending each day of the week, percentage of pregnant women leaving the clinic who knew that prenatal care wa offered every day. For the firt indicator, the number of women viiting the health center wa already recorded in their regiter. For the econd indicator, they decided that the midwife would conduct a brief exit interview with the women to ee if they knew when prenatal care wa available. The midwife would have a check heet on which he would mark their repone for a period of 2 week. Thee implementation plan were recorded in the Storybook. 1-47

60 C. Follow-up To Determine if the Solution Ha Had the Intended Reult At thi point the team hould paue a moment to determine what can be learned from the implementation proce. Uing the data collected and any other information (formal or informal) obtained during the implementation phae, the team hould anwer the following quetion: Did we meet our criteria for ucce? Did the olution have the deired reult? What did people think of the change? What apect of implementation went well? What apect were difficult? Did the olution create unforeeen problem for other or other procee? What kind of reitance did we encounter? EXAMPLE 2: Prenatal Care: Waiting Time - Solution One After two month, the team reviewed the reult from the two olution it had tried. They graphed the data to how before and after olution implementation and poted the graph on the Storyboard. The data howed women waiting much horter period of time overall and at the nure aitant tation. When aeing taff atifaction, the midwife and nure aitant were very pleaed with the new ytem. The midwife wa more relaxed becaue he no longer had 10 women waiting at a time to ee her (they were more evenly paced out). The nure aitant aid that women complained le to her about waiting. The pharmacit wa not a happy, ince vaccine watage roe from about 5 percent to 10 percent. However, they had no tock-out in the two month of the tet. Minute Average Time Pregnant Women Spent in Clinic Before Seeing the Midwife Total time from entering clinic to eeing midwife Time from eeing nure aitant to eeing midwife Before change in immunization policy After change in immunization policy 1-48

61 D. Make Deciion About What Action To Take Baed on what wa learned from evaluating olution implementation, the team now mut decide what action to take. Jut becaue a olution wa choen and implemented doe not mean that it mut be adopted. Referring to the reult obtained in the follow-up, determine whether it wa ucceful a implemented, whether it merit modification, or whether it hould be abandoned altogether and another olution tried. If modification are to be made, they hould be teted a well. Quetion to ak: How could we improve thi olution or it implementation? How could we reduce reitance that we encountered? What part of the proce or change need to be tandardized? How hall we communicate thee new tandard o that thing do not revert back to the old way? What iue mut we addre before implementing the change on a larger cale? What kind of reitance might we encounter? What kind of training i needed? What technical, logitical, and material upport need to be enured to make it utainable? How hall we continue to monitor to ee that the problem doe not return? To enure that gain are utainable, the team will need to look for opportunitie to tandardize the improvement and make it permanent uch a changing job aid and manual, inerting new material into pre- and in-ervice training, and getting official policy tatement. Additionally, utainability require vigilance: the team hould think about what indicator it will continue to monitor to ae whether the olution continue to be ucceful, i.e., that the problem doe not reoccur. 1-49

62 EXAMPLE 1: Compliance with ARI Treatment Regimen Graph of the data from the indicator the team monitored were poted on the Storyboard. They howed the following reult: Percent of Patient Finihing their ARI Treatment Regimen Couneling, Knowledge, and Practice of ARI Patient: Making Tablet Eaier to Swallow % of ARI Patient Finihing Treatment % 75% % of ARI Patient % 65% 48% Before Couneling Solution After Couneling Solution Received Coueling Undertood Meage Carried Out Advice The team felt that it had done a good job of carrying out the couneling and that it had ome effect on reducing the number of patient not finihing treatment. When the upervior dicued with other upervior, it appeared that the problem of patient diliking the ARI medication wa quite widepread, and the Regional Pharmacit decided to lobby for changing the treatment of choice for acute repiratory infection. The team wa glad it had adopted an interim olution to improve the percent of patient finihing treatment becaue it had been able to increae patient compliance while the much longer proce of changing the treatment regimen would be put into place. To enure that gain are utainable, the team will need to look for opportunitie to tandardize the improvement and make it permanent uch a changing job aid and manual, inerting new material into pre- and in-ervice training, and getting official policy tatement. Additionally, utainability require vigilance: the team hould think about what indicator it will continue to monitor to ae whether the olution continue to be ucceful, i.e., that the problem doe not reoccur. 1-50

63 E. How To Know When the Quality Improvement Proce I Completed Although quality can alway be improved, individual and team mut be able to ay, That wa a job well done. The team can conider the quality improvement effort a ucce when it ha evidence that the problem ha been reolved: the data how that the problem no longer exit and the change (olution) have been incorporated into routine procedure. The quality improvement effort are complete when the team feel happy about it effort and their effectivene. EXAMPLE 2: Prenatal Care: Waiting Time Solution Two The data on the number of women coming on each day of the week indicated that there had not been any change in the pattern; mot women continued to come on Monday. The midwife checkheet data howed that only about half the women knew that prenatal care wa offered every day, and of thoe coming on Monday, only a quarter knew. The receptionit, when quetioned about thee reult, aid that he wa very buy and could not alway remember. Intead of blaming the receptionit and accuing her of being lazy, the team felt that thi olution wa not a feaible one, and they decided to try another olution: putting up a poter. They agreed to continue monitoring the number of women coming on each day of the week for the next 3 month. Becaue the time for the evaluation wa hort, the team wa not able to evaluate the effect of the olution on the percentage of women making four prenatal viit. The member decided to keep monitoring thi indicator, along with vaccine watage and tock-out for 3 more month a well and ee what the overall impact would be. Number of Pregnant Women Number of Prenatal Conultation/Day M FM FM FM FM FM FM FM F Data Week M T W Th F Day of the Week At the end of the obervation period, the team found that prenatal coverage had increaed moderately, but to it urprie, coverage for tetanu toxoid immunization increaed dramatically in thoe women coming for prenatal care. Thee reult convinced the pharmacit that the watage of vaccine wa a mall price to pay for improved coverage. In addition, the number of women attending each day of the week became more evenly ditributed over time. The nure aitant poted thee reult on the Storyboard, and recorded the team concluion in the Storybook. Prenatal coverage wa till lower than the member would like it to be, o they decided to explore other poible caue of low coverage, and began the problem olving cycle again. 1-51

64 F. The Relationhip Between Part One and Two of Thi Monograph Part One of thi monograph ha decribed in detail the ix problem olving/proce improvement tep of the Quality Aurance ten-tep cycle, and ha illutrated thoe tep throughout with two example: 1) of improving client compliance with ARI treatment regimen, and 2) of reducing exceive waiting rime for prenatal ervice. Each of the example employ everal ueful tool at different tep in the problem olving proce; whenever one of the tool i mentioned in Part One, a reference i given to the beginning page of the ection in Part Two where that tool i decribed in greater detail. Part Two therefore erve a an aid for the reder of Part One, and can alo be ued a a eparate reference by thoe eeking to apply thee tool in olving problem and improving procee in their own etting. 1-52

65 Part Two Tool for Quality Improvement 2-1

66

67 TOOLS Page Table 2-1: Application of Quality Improvement Tool Braintorming Affinity Analyi Prioritization Tool: Making Deciion Among Option Sytem Modeling Flow Chart Caue-and-Effect Analyi Force-Field Analyi Statitical/Data Preentation Tool: Bar Chart and Pie Chart Run Chart Hitogram Scatter Diagram Pareto Chart Client Window Benchmarking Gantt Chart Quality Aurance Storytelling

68 2-4

69 Table 2-1 Application of Quality Improvement Tool TOOLS Step 5 Identify Problem Step 6 Define Problem Step 7 Identify Team Step 8 Analyze Problem Step 9 Chooe Solution Step 10 Carry Out Solution Braintorming X X X Affinity Analyi X X X Prioritization Tool X X X X Sytem Modelling X X X Flow Chart X X X X X X Caue and Effect Analyi X Force Field Analyi X X Statitical Tool Bar and Pie Chart X X X Run Chart X X X Hitogram X X Scatter Diagram X X Pareto Chart X X X Client Window X X Benchmarking X X Gant Chart X X 1 QA Storytelling X X X X X 1 for planning of data collection 2-5

70 2-6

71 Braintorming Braintorming i a way for group to generate a many idea a poible in a very hort period of time by tapping into group energy and an individual creativity. It wa developed by A. F. Oborne in the When To Ue It Braintorming i particularly ueful when trying to generate idea about problem, area for improvement, poible caue, other olution, and reitance to change. By bringing out many creative idea in a hort period of time and encouraging all group member to participate, thi ueful tool open up people thinking and broaden their perpective. It allow idea to build on one another. However, it i not a ubtitute for data. How To Ue It Write the quetion or iue to be explored through braintorming on a flipchart or any place where everyone can ee. Make ure that everyone i clear about the topic. Review the rule of braintorming: Do not dicu idea during the braintorming. No judgment: criticim of another idea i not allowed. Every idea i acceptable: be unconventional. Build on the idea of other. Quantity of idea count. Braintorming can be untructured or tructured. In untructured braintorming, each peron voice idea a they come to mind. Thi method work well if participant are outgoing and feel comfortable with each other. In tructured braintorming, each peron give an idea in rotation [a peron can pa if he or he doen t have an idea at the moment]. Structured braintorming work well when people are unfamiliar with one another or are le talkative: the tructure give everyone the chance to peak. Give people a few moment to think of ome idea before tarting. Write all idea on a flipchart. After all the idea have been generated (generally after about minute), review each one to make it clear and combine related idea on the lit. Agree on way to judge idea and ue data collection, voting, matrice, or Pareto chart to chooe among option. Group often ue voting technique firt to reduce the lit to about 6-10 top idea. Then they ue other technique to chooe among thi horter lit. 2-7

72 Caution Braintorming i a technique for generating idea, but each idea will need ubtantiating. Dicuing or judging idea while braintorming will low the exercie and limit the flow of creative idea. Save dicuion of idea till the end. If one or a few individual dominate the dicuion, the leader may want to hift to a tructured braintorming format (ee above). 2-8

73 Affinity Analyi Affinity analyi, a tool developed by Jiro Kawakita, help group gather a large amount of information and organize thi information on the bai of affinitie or natural relationhip. Affinity analyi let the idea determine the categorie or grouping, rather than letting pre-determined grouping determine or contrain the generation of idea. When To Ue It An affinity analyi can help a team or group organize many different idea or item in a hort period of time. Group often ue affinity analyi to generate idea about problem or area for improvement, about caue, about alternative olution, and about reitance to change. It i alo ueful for making ure that the lone idea doe not get lot in the huffle. It i chiefly ueful when iue appear too large or complex, when conenu i deired, or when creative idea are needed. Becaue everyone idea i included and grouping of idea are done by the team, it help develop conenu. How To Ue It State the iue or quetion to be conidered and make ure that all participant are clear on what i being aked. Generate and record idea on lip of paper. Each idea or item hould be recorded on it own lip. Pot-it Note or notecard, if available, are eaier to ue for thi exercie. Generate idea: through group braintorming, where one peron take charge of writing down each idea, or by having each peron record hi or her own idea. The firt method work bet when there are not many exiting idea and creativity i needed (people can build on the idea of other). The econd method work bet when it i important to capture everyone individual contribution, or to draw on each peron expertie. Place the lip of paper in any order in a manner that permit everyone to ee them (e.g., on a table or wall). Ak the team member to ort the idea on the lip of paper into related group by moving the lip of paper around, but without dicuion. After a while, the team member will no longer be moving item around. 2-9

74 If the group i large, have the member go to ort in group of 3-4, giving each group a few minute to do o. Then call the next group of 3-4. Let each group continue to have a turn until they are no longer moving item around. Do not force an item into a group; it i fine to have group with only a ingle item in them. If a lip of paper i contantly being moved back and forth between two grouping, either clarify the meaning or place it in both grouping by adding another paper. For each of the grouping, develop a name or category that reflect the meaning of that group and write it on a lip of paper. Look firt among the item in the group. If none capture the idea clearly, create one that doe. Tranfer the information onto a heet of paper, with line around the variou group. Ue prioritization tool to elect from among categorie. Caution Sorting hould be done a ilently a poible. Dicu the item on the lip of paper only if clarification i needed. Do not force an item into a group. It i acceptable to have an item in more than one group, although thi hould be done a little a poible. If a lip of paper i contantly moved back and forth between two grouping, either clarify the meaning or place it in both grouping by adding another paper. 2-10

75 Prioritization Tool: Making Deciion Among Option Group method for narrowing down and ranking a lit of idea include voting and prioritization matrice. Both method allow individual to expre their opinion or choice in order to reach a group deciion. Voting i a relatively untructured technique in which group member make a choice, uing either implicit or explicit criteria. Matrice allow the team to review the option againt a tandard et of explicit criteria. A B C A B C Voting When To Ue It Voting i mot ueful when the option are fairly traightforward or when time i limited. In voting, either implicit or explicit criteria can be ued. How To Ue It Team can tructure voting in everal way, but they all have the purpoe of letting each individual tate hi or her preference. Regardle of the type of voting ued, all group member mut undertand the variou option being voted on. Straight voting: All option are lited and each peron in the group i given one vote. All vote are weighted equally. The activity with the highet total i elected. Thi i the eaiet method for a group to tart electing an activity. Straight Voting Activity Vote Total Activity 1 3 Activity 2 5 Activity 3 1 Activity 4 1 Number of Participant N=

76 Multivoting: All option are lited and each peron i allowed to vote for a limited number of item (e.g., three or five). A general rule of thumb to determine the number of vote i: up to 10 option = 2 vote; option = 3 vote; option = 5 vote Add up the vote for each item, and the one with the highet core i the top priority for the group. Thi method i ueful when the group want to pick more than one item or the lit of item i very long and need to be reduced. Multivoting can be repeated everal time until the lit i horter or a ingle priority tand out. Thi voting method increae the likelihood that everyone will have at leat one of the item for which they voted in the reduced lit. Multivoting Activity Vote Total Activity 1 1 Activity 2 7 Activity 3 7 Activity 4 8 Activity 5 3 Activity 6 3 Activity 7 1 Activity 8 Activity 9 2 Activity

77 Weighted voting: All option are lited and each peron i given the poibility to give more weight to ome choice than to other. One way of doing thi i to give each peron a fixed amount of hypothetical money to pend. They can ditribute it any way they wih among the alternative: i.e., if given $10, one could pend all $10 on a ingle item that one felt very trongly about, or one could ditribute it evenly over five item, or any other combination. Thi method allow the voting to reflect the trength the individual feel about the variou choice. Weighted Voting Team Member Activity Total Activity 1 Activity Activity Activity Activity Activity Activity Activity Activity 9 Activity

78 Criteria (Prioritization) Matrice In each of the above voting option, each individual ue hi or her own internal criteria to make a deciion. A criterion i a meaure, guideline, principle or other bai for making a deciion. It i an agreed upon bai for making a group deciion. Often in making deciion, more than one criterion i ued at the ame time. Sometime the group may want to dicu and agree upon the criteria by which each participant hould bae the judgment. A criteria or prioritization matrix i a tool for evaluating option baed on a et of explicit criteria the group ha determined i important for making an appropriate, acceptable deciion. When To Ue It Matrice work bet when option are more complex or when multiple criteria mut be conidered in determining prioritie or making a deciion. The matrix preented below diplay the option to be prioritized in the row (horizontal) and the criteria for making the deciion in the column (vertical). Each option i then rated according to the variou criteria. Option Criteria C#1 C#2 C#3 C#4 Total Option 1 Option 2 Option 3 How To Ue It Step 1: Lit the option or choice to be evaluated. Make ure that all team member undertand what i meant by each of the option. Step 2: Select the criteria for making the deciion. The group can chooe thee criteria uing braintorming and then voting to determine the mot important/relevant one. 1 Be ure that everyone ha the ame undertanding of what i meant by the choen criteria. Criteria commonly ued for chooing problem to work on include: importance, upport for change, viibility of problem, rik if nothing i done, feaibility of making change 1 It i alo poible to weight the criteria if the group feel that ome are more important than other, but thi hould only be done when the added complexity will really yield a better deciion. 2-14

79 in thi area. For chooing olution, the following criteria are often applied: cot, potential reitance, feaibility, management upport, community upport, efficiency, timeline, impact on other activitie. Thee are not the only poible criteria, and the group hould develop a lit that i appropriate for it ituation. No minimum or maximum number of criteria exit, but three or four i optimal for matrice. More than four criteria make the matrix cumberome. One way to reduce the number of criteria i to determine if there are any criteria which all option mut meet. Ue thi criterion firt to eliminate option. Then, ue the other criteria to elect among the remaining option. Another way to make the matrix le cumberome i to limit the number of option being conidered. If the lit of option to chooe among i long (greater than 6 item), it may be eaier to firt horten the lit by eliminating ome option. For example, commonly ued criteria for eliminating potential problem area from conideration include: Problem i too big or complex to olve. Not feaible to make change in thi area (beyond the team' control or authority). Lack of interet among taff to work on the problem. Step 3: Draw the matrix and fill in the option and criteria. Step 4: Determine the cale to ue in rating the option againt each criterion. Way to rate option range from imple to complex: Example of rating cale: Simple: Score are baed on whether the option meet a given criterion, e.g., Are trained taff already available? Ye=1, No=0 Common: Option are cored according to how well each option meet the criterion, e.g., How much management upport i there for thi option? High=3, Medium=2, Low=1, (or a cale of 1-5 or 1-10, from Low to High) Note: Be ure that the rating cale ued for all the criteria are conitent, i.e., that the rating for each criterion all run from the bet =highet number to the wort =lowet number. In thi way an option overall core may be calculated by adding together it core on each criterion. For example, if the option were to be rated on the two criteria of feaibility and cot, each on a cale of 1 (leat deirable) to 5 (mot deirable), the criteria hould be cored a: Feaibility: mot feaible = 5 leat feaible = 1 Cot: lowet cot = 5 highet cot = 1 Overall rating: bet option = 10 wort option =

80 Complex: Different maximum core (weight) are aigned to each of the criteria and each option i cored on each criterion, from 1 up to the maximum weight of that criterion, e.g., Criterion Maximum point Opt.#1 Opt.#2 Feaibility: 50 point Client Acceptability: 35 point Low Cot: 15 point 5 15 Overall Rating: 100 point Step 5: Taking one option at a time, review each criterion and determine the appropriate rating, uing one of the method above. Thi ranking can be done individually and then added up. Or, if the rating method i imple, it can be done a a group dicuion. Step 6: Total the value for each option by adding the ranking for each criterion. Step 7: Evaluate the reult by conidering the following quetion: Doe one option clearly meet all criteria? Can any option be eliminated? If an option meet ome but not all criteria, i it till worth conidering? Caution Make ure that everyone clearly undertand the option under conideration. Everyone will need to undertand and to agree with the operational definition of the criteria. 2-16

81 Sytem Modeling Sytem modeling how how the ytem hould be working. Ue thi technique to examine how variou component work together to produce ome outcome. Thee component make up a ytem, which i compried of reource proceed in variou way (couneling, diagnoi, treatment) to generate direct output (product or ervice), which in turn can produce effect (e.g., immunity, rehydration) on thoe uing them, and longer term, more indirect impact (e.g., reduced meale prevalence or reduced mortality rate) on uer and the community at large. When To Ue It By diagramming the linkage between each ytem activity, ytem modeling make it eaier to undertand the relationhip among variou activitie and the impact of each on the other. It how the procee a part of a larger ytem whoe objective i to erve a pecific client need. Sytem modeling i valuable when an overall picture i needed. Sytem modeling how how direct and upport ervice interact, where critical input come from, and how product or ervice are expected to meet the need in the community. When team do not know where to tart, ytem modeling can help in locating problem area or in analyzing the problem by howing the variou part of the ytem and the linkage among them. It can pinpoint other potential problem area. It can alo reveal data collection need: indicator of input, proce, and outcome (direct output, effect on client, and/or impact). Finally, it can be helpful in monitoring performance. Element of Sytem Modeling INPUT PROCESS OUTCOME Sytem modeling ue three element: input, procee, and outcome. Input are the reource ued to carry out the activitie (proce). Thee input can be raw material or product and ervice produced by other part of the ytem. For example, with the malaria treatment ytem, input include anti-malarial drug and killed health worker. Other part of the ytem provide both of thee input: the drug by the logitic ubytem and the killed manpower by training ubytem. Procee are the activitie and tak that turn the input into product and ervice. For malaria treatment, thi proce would include the tak of taking a hitory and conducting a phyical examination of patient complaining of fever, making a diagnoi, providing treatment, and couneling the patient. Outcome are the reult of procee; thee generally refer to the direct output generated by a proce, and may ometime refer to the more indirect effect on the client themelve and the till more indirect impact on the wider community. Output are the direct product or ervice produced by the proce. The output of the malaria treatment ytem are patient receiving therapy and couneling. Effect are the change in client knowledge, attitude, behavior, and/or phyiology that reult from the output. For the malaria treatment ytem, thi would be reduced cae fatality from malaria (patient getting better) and patient or caretaker who know what 2-17

82 to do if the fever return. Thee are indirect reult of the proce becaue other factor may intervene between the output (e.g., correct treatment with an anti-malarial) and the effect (e.g., the patient recovery). Impact are the long-term and till more indirect effect of the output on uer and the community at large. For malaria treatment, the impact would be improved health tatu in the community and reduced infant and child mortality rate. Sytem Model for Malaria Treatment Support Sytem Input Proce Outcome Output Effect Impact Logitic Sytem Financing Sytem Superviion Sytem Training Sytem IEC Sytem Drug Skilled Worker Sick Patient Hitory Phyical Diagnoi Treatment Couneling Patient Treated for Malaria Patient Couneled for Malaria Other Sytem Other Sytem Reduced Malaria Cae Fatality Improved Knowledge and Practice Reduced Mortality Culture, SES, etc. A the figure above how, ytem contain many interconnected part that mut be woven together. The utility of ytem modeling i it ability to depict how part relate. It i at thee junction that the ytem diplay it trength or weaknee. How To Ue It Identify the major proce or ytem to be modeled and the need that ytem i to be erving (deired impact). Thi can be done by tarting with PROCESS or the IMPACT. If tarting from the PROCESS of interet, identify the part of the ytem to be modeled: a health care intervention (uch a immunization, malaria treatment, or hopital emergency ervice). It i alo poible to focu ytem modeling on a upport ervice, uch a uperviion or logitic. Next, identify the need in the community that thi PROCESS i uppoed to be addreing (remember that upport ervice meet the need of internal client). 2-18

83 OR If tarting with the IMPACT, identify what the ytem i uppoed to affect: e.g., what i the need in the community that the ytem i uppoed to meet? Then, identify what PROCESS i carried out to create the ervice or product (OUTPUTS) that would be expected to have an appropriate EFFECT on client, which could in turn be expected to reult in the deired IMPACT (meet that need). Draw and label the IMPACT and the PROCESS boxe. Work backward through the OUTCOMES, beginning with the need (DESIRED IM- PACT), and determine what EFFECTS the product or ervice (OUTPUTS) mut produce in the client to achieve that deired IMPACT. Think about the variou group affected by the product and ervice. Draw and label the OUTCOME box. Identify other factor that can affect the IMPACT: e.g., the economy or cultural factor, and add them to the model. No ytem operate in a vacuum, and the IMPACT will alway be influenced by factor outide the ytem. Identify the pecific OUTPUTS produced by the proce that lead to the OUTCOMES jut identified. In many intance, there will be more than one kind of OUTPUT: for example, the vaccination ytem hould produce vaccinated children and knowledgeable mother. Identify the major tak categorie in the PROCESS: e.g., hitory, phyical, diagnoi, treatment, and couneling. Write thee in the PROCESS box. Review the OUTPUTS and make ure that there i an OUTPUT identified for each beneficiary of the major tak. Identify the variou INPUTS needed to carry out the proce. Thee INPUTS hould include manpower, material, information, and financial reource. Draw boxe for the variou INPUTS and label them. Determine which upport ytem (uch a logitic, training, uperviion) produce each of thee INPUTS and write the ource in the boxe. Uing the Sytem Model for Problem Analyi Review the variou element of the ytem. Determine what data are needed to know if the ytem i ufficiently productive or adequately functioning to achieve the outcome and impact deired. Ue thee data to ae whether the ytem i performing a it ha been drawn. Identify weak or miing component of the ytem by eeing where in the proce quality fall hort. Caution Involve people who know the ytem being modeled, either while developing the model or a reviewer when it ha been completed. Be ure that the ytem model really addree the identified problem. 2-19

84 Flow Chart A flow chart i imply a graphic repreentation of how a proce work, howing, at a minimum, the equence of tep. Several type of flow chart exit: the mot imple (a high-level or firt-level flow chart), a detailed verion (a econd-level flow chart), and one that alo indicate the people involved in the tep (a deployment or matrix flow chart). When To Ue It A flow chart help to clarify how thing are currently working and how they could be improved. Thi tool alo ait in finding the key element of a proce, while drawing clear line between where one proce end and the next one tart. Developing a flow chart etablihe communication and common undertanding about the proce. In addition, flow chart are ued to identify appropriate team member, to identify who provide input or reource to whom, to etablih important area for monitoring or data collection, to identify area for improvement or increaed efficiency, and to generate hypothee about caue. Flow chart can be ued to examine procee for the flow of patient, information flow, flow of material, clinical care procee, or combination of thee procee. Type of Flow Chart Several different type of flow chart can be ued. Output Output Input Step Step Step Product Firt-level or Top-down Flow Chart A firt-level flow chart how the major tep in a proce. It can alo include intermediate output of each tep (the product or ervice produced), and the ub-tep involved. Such a flow chart i generally ued to gain a baic picture of the proce and to identify the change taking place within the proce. It i ignificantly ueful for identifying appropriate team member (thoe who are involved in the proce) and for developing indicator for monitoring the proce becaue of it focu on intermediate output. Mot procee can be adequately portrayed in 4 or 5 boxe that repreent the major tep or activitie of the proce. In fact, it i a good idea to ue only 4 or 5 boxe, becaue it force one to conider the mot important tep. Other tep are uually ub-tep of the more important one. Detailed or Second-level Flow Chart A detailed flow chart indicate the tep or activitie of a proce and include uch thing a deciion point, waiting period, tak that frequently mut be redone (rework), and 2-20

85 feedback loop. Thi type of flow chart i ueful for examining area of the proce in detail and for looking for problem or area of inefficiency. Deployment or Matrix Flow Chart A deployment flow chart map out the proce in term of who i doing the tep. It i in matrix form, howing the variou participant and the flow of tep among thee participant. It i chiefly ueful in identifying who i providing input or ervice to whom, a well a area where different people may be needlely doing the ame tak. MARC JUAN MARIAM When To Ue Which Flow Chart Each type of flow chart ha it trength and weaknee. The firt-level flow chart i the implet to contruct but may not provide ufficient detail for ome purpoe. In chooing which type to ue, the group hould be clear on their purpoe for flow charting. The table on the following page give ome indication, but perhap the bet guidance i to tart with the implet method firt, and if that doe not do the job, go on to the more complex, time-conuming chart. 2-21

86 Type of Flow Chart Indicated for Variou Purpoe How To Ue It Regardle of the type of flow chart, there are everal baic tep to it contruction. Purpoe High Level Detailed Deployment Initial undertanding of the proce, determining team memberhip Gaining group conenu about the proce Developing area or indicator to be monitored for proce information Looking for area where efficiencie can be gained Identifying who provide what to whom Searching for pecific problem area or tep that mut often be redone Tak allocation very ueful + + often ueful + ometime ueful Agree on the purpoe of the flow chart and which format i mot appropriate. Determine the beginning and end point of the proce to be flow charted. Get agreement from the group on thee. What ignal the beginning of thi proce? What are the input? How do we know when the proce i complete? What i the final output? Identify the element of the flow chart by aking the following quetion: Who provide the input for thi tep? Who ue it? What i done with thee input? What deciion need to be made? What i the output to thi tep? Who ue it to do what? Type of chart Firt-level: Second-level: Deployment: Baic Element major tep, input, and output tep or activitie, deciion point, input, and output tep, input and output, peron involved The tep and deciion point put into the flow chart hould reflect the true proce (what i actually done). Thi i the only way to ee what can or need to be improved. If idea 2-22

87 for improvement are generated while developing the flow chart, do not dicu their merit at thi time, but be ure to note them down for future reference. Review to ee whether the tep are in their logical order. Area that are unclear can be repreented with a cloud ymbol (cloudy area), to be clarified later. After a day or two, review the flow chart with the group to ee if the group i atified with it work. Ak other involved in the proce if they feel it reflect what they do. Baic Symbol for Any Type of Flow Chart Step or activity Start/End point in the proce Cloudy tep Additional Symbol for Second-level Flow Chart NO YES Deciion or branch point Documentation (or written information about the proce) Information into databae Wait/Bottleneck Connector to another proce 2-23

88 Hint for Contruction of Flow Chart Try to develop a firt draft in one itting, going back later to make refinement. Ue the five-minute rule which ay: do not let five minute go by without putting up a ymbol or box; if the deciion a to the ymbol or box i unclear, ue a cloud ymbol or a note and move on. To avoid having to erae and cratch out a idea develop, cut out hape for the variou ymbol beforehand and place them on the table. Thi way, change can eaily be made by moving thing around while the group i getting the proce clear. When uing deciion ymbol, ue them when thoe working in the proce mut make a deciion that will affect how the proce will proceed. For example, when the outcome of the deciion or quetion i YES, the peron would follow one et of tep, and if the outcome i NO, the peron would do another et of tep. Be ure to what i written inide the deciion ymbol in a way that the repone i either YES or NO, o that the flow of the diagram i logical. In trying to decide how much detail to put in the flow chart (i.e., how much to break down each general tep), remember the purpoe of the flow chart. For example, a flow chart to better undertand the problem of long waiting time would need to break down in detail only thoe tep that could have an effect on waiting time. Step which do not affect waiting time can be kept broad (not to much detail). Keep in mind that a flow chart may not need to include all the poible ymbol. For example, the wait ymbol ( ) may not be needed if a flow chart i not related to waiting time. Analyzing the Detailed Flow Chart To Identify Problem Area Once the flow chart ha been contructed to repreent how the proce actually work, examine potential problem area or area for improvement uing one or more of the following technique. Examine each deciion ymbol: I thi an activity to ee if everything i going well? I it effective? I it redundant? Examine each loop that indicate work being redone (rework): Doe thi rework loop prevent the problem from reoccurring? Are repair being made long after the tep in which the error originally occurred? Examine each activity ymbol: I thi tep redundant? Doe it add value to the product or ervice? I it problematic? Could error be prevented in thi activity? Examine each document or data bae ymbol: I thi neceary? I it up to date? I there a ingle ource for the information? Could thi information be ued for monitoring and improving the proce? 2-24

89 Examine each wait ymbol: What complexitie or additional problem doe thi wait caue? How long i the wait? Could it be reduced? Examine each tranition where one peron finihe hi part of the proce and another peron pick up: Who i involved? What could go wrong? I the intermediate product or ervice meeting the need of the next peron in line? Examine the overall proce: I the flow logical? Are there fuzzy area or place where the proce lead off to nowhere? Are there parallel track? I there a rationale for thoe? Caution Flow chart hould alway reflect the actual proce, not the ideal proce. A flow chart mut reflect what really happen. Involve people who know the proce, either while developing the flow chart or a reviewer when the chart ha been completed. Be ure that the flow chart really addree the identified problem. 2-25

90 Caue-and-Effect Analyi A caue-and-effect analyi generate and ort idea or hypothee about poible caue of problem within a proce. It lit item in graphic diplay. When To Ue It A caue-and-effect analyi organize a large amount of information by howing link between event and their potential or actual caue. A graphic preentation, with major branche reflecting categorie of caue, timulate and broaden thinking about potential or real caue and facilitate further examination of individual caue. Becaue everyone idea can find a place on the diagram, a caue-and-effect analyi help to generate conenu about caue. It can help to focu attention on the proce in which a problem i occurring and to allow for contructive ue of fact gained from reported event. However, it i important to remember that a caue-and-effect diagram i a tructured way of expreing hypothee about the caue of a problem or about why omething i not happening a deired. It cannot replace empirical teting of thee hypothee: it doe not tell which i the root caue. Type of Caue-and-Effect Analye There are two way of graphically organizing idea for a caue-and-effect analyi. Thee vary in how potential caue are organized and grouped: by category: called a fihbone diagram (becaue of it hape) or Ihikawa diagram (for the man who invented it), or een a a chain of caue: called a tree diagram. The choice of method depend on where the team get tuck. If the team tend to think of caue only in term of people, the fihbone diagram, organized around categorie of caue, will help to broaden the team thinking. If the team member thinking i too hallow, a tree diagram will encourage them to look more deeply for the chain of event or caue. Caue by Categorie (fihbone diagram) Effect 2-26

91 When uing a fihbone diagram, everal categorie of caue can be applied. Below are ome often ued categorie: manpower, method, material, meaurement, and equipment; client, worker, upplie, environment, and procedure; what, how, when, where. Other valid categorie for thi type of caue-and-effect diagram exit. The group hould chooe thoe categorie that are mot relevant to them, and hould feel free to add or drop categorie a needed. The econd type of caue-and-effect analyi preented i a tree diagram, which highlight the chain of caue. It tart with the effect and the major group of caue (by tep or by category) and then ak for each branch, why i thi happening? what i cauing thi? The tree diagram i a graphic diplay of a impler method known a the Five Why. It diplay the layer of caue, looking in-depth for the root caue. Tree Diagram Why? Why? The Five Why One imple tool for getting at the root caue i to ak the FIVE WHY, aking why? to each ucceive repone five time. Ue thi technique alone or with any of the caue-and-effect diagram. Effect Why? Why? Example Quetion 1: Anwer 1: Quetion 2: Anwer 2: Quetion 3: Anwer 3: Quetion 4: Anwer 4: Quetion 5: Anwer 5: Solution: Why did the patient get the incorrect medicine? Becaue the precription wa wrong. Why wa the precription wrong? Becaue the doctor made the wrong deciion. Why did the doctor make the wrong deciion? Becaue he did not have complete information in the patient chart. Why wan t the patient chart complete? Becaue the doctor aitant had not entered the latet laboratory report. Why hadn t the doctor aitant charted the latet laboratory report? Becaue the lab technician telephoned the reult to the receptionit, who forgot to tell the aitant. Develop a ytem for tracking lab report. 2-27

92 How To Ue Caue-and-Effect Analyi Although everal way to contruct a caue-and-effect analyi exit, the tep of contruction are eentially the ame. Agree on the problem or the deired tate and write it in the effect box. Try to be pecific. Problem that are too large or too vague can get the team bogged down. [Caueand-effect diagram can reflect either caue that block the way to the deired tate or helpful factor needed to reach the deired tate.] If uing a tree diagram, define the major categorie of tep or caue. Thi technique can be ued for a fihbone diagram a well. Or the team can braintorm firt about likely caue and then ort them into major branche. The team hould add or drop categorie a needed when generating caue. Each category (or tep) hould be written into the box. Generally, uing three to ix categorie work bet. Identify pecific caue and fill them in on the correct branche or ub-branche. Ue imple braintorming to generate a lit of idea before claifying them on the diagram, or ue the development of the branche of the diagram firt to help timulate idea. Either way will achieve the ame end. Ue the method that feel mot comfortable for the group. If an idea fit on more than one branch, place it on both. Be ure that the caue a phraed have a direct, logical relationhip to the problem or effect tated at the head of the fihbone. Each major branch (category or tep) hould include three or four poible caue. If a branch ha too few, lead the group in finding ome way to explain thi lack, or ak other who have ome knowledge in that area to help. Keep aking why? and "why ele?" for each caue until a potential root caue ha been identified. A root caue i one that: 1) can explain the effect, either directly or through a erie of event, and 2) if removed, would eliminate or reduce the problem. Try to enure that thee "why?" are plauible explanation and that, if poible, they are amenable to action. Be ure that the caue a phraed have a direct, logical relationhip to the problem or effect tated at the head of the fihbone. Check the logic of the chain of caue: read the diagram from the root caue to the effect to ee if the flow i logical. Make needed change. Have the team chooe everal area they feel are mot likely caue. Thee choice can be made by voting, baed on the team bet collective judgment. Ue the reduced lit of likely caue to develop imple data collection tool to prove the group theory. If the data confirm none of the likely caue, go back to the caueand-effect diagram and chooe other caue for teting. 2-28

93 Caution Remember that caue-and-effect diagram repreent hypothee about caue, not fact. Failure to tet thee hypothee, and thu treating them a if they are fact, often lead to implementing the wrong olution and wating time. To determine the root caue(), the team mut collect data to tet thee hypothee. The effect or problem hould be clearly articulated to produce the mot relevant hypothee about caue. If the effect or problem i too general or ill defined, the team will have difficulty focuing on the effect, and the diagram will be large and complex. It i bet to develop a many hypothee a poible o that no potentially important root caue i overlooked. Be ure to develop each branch fully. If thi i not poible, then the team may need more information or help from other for full development of all the branche. 2-29

94 Force-Field Analyi Force-field analyi, a tool developed by Kurt Lewin, identifie force that help and force that hinder reaching an outcome or the olution to a problem. It depict a ituation a a balance between two et of force: one that trie to change the tatu quo and one that trie to maintain it. Thi method can focu attention on way of reducing the hindering force. When To Ue It Force-field analyi force people to think together about what work for and againt the tatu quo, helping team member to view each cae a two et of offetting factor. It can be ued to tudy exiting problem, or to anticipate and plan more effectively for implementing change. When ued in problem analyi, force-field analyi i epecially helpful in defining more ubjective iue, uch a morale, management, effectivene, and work climate. Force-field analyi alo help keep team member grounded in reality when they tart planning a change by making them look ytematically at what kind of reitance they could meet. Conducting a force-field analyi can help build conenu by making it eay to dicu objection people may raie and by examining how to addre thee concern. How To Ue It State the problem or deired tate and make ure that all team member undertand. Force-field analye can be contructed in term of factor working for and againt a deired tate OR in term of factor working for and againt the tatu quo or problem tate. Braintorm on factor that move toward the deired tate and thoe that hinder movement toward that tate (or on factor that maintain the exiting problem tate and thoe that could olve it). Review and clarify each force or factor. What i behind thee factor? What work to balance the ituation? Determine how great the hindering force are (high, medium, low) on the deired tate (or problem tate). Thoe that have the bigget impact hould be teted a likely caue when the force-field analyi i ued for problem analyi. If ued while developing olution, thoe factor with the bigget impact may become the focu of plan to reduce reitance to change. Develop an action plan to addre the larget hindering force. Caution If a ignificant force i omitted, then it impact can negatively affect a plan of action. All ignificant force or factor mut be included and conidered. 2-30

95 Statitical/Data Preentation Tool Several type of tatitical/data preentation tool exit: Chart diplaying frequencie: bar chart, pie chart, Pareto chart. Chart diplaying trend: run chart, control chart. Chart diplaying ditribution: hitogram. Chart diplaying aociation: catter diagram. Different type of data require different kind of tatitical tool. There are two type of data: Attribute data: Thee are countable data or data that can be put into categorie: e.g., the number of people willing to pay, the number of complaint, percent who want blue/ percent who want red/percent who want yellow. Variable data: Thee are meaurement data, baed on ome continuou cale: e.g., length, time, cot The table below provide ome guidance for chooing the proper tool: To Show Ue Data Needed Frequency of Occurence Simple percentage or comparion of magnitude Trend Over Time Ditribution: Variation not related to time (ditribution) Aociation: Looking for a correlation between two thing Bar Chart, Pie Chart, Pareto Chart Line Graph, Run Chart, Control Chart Hitogram Scatter Diagram Tallie by category (data can be attribute data or variable data divided into categorie) Meaurement taken in chronological order (attribute or variable data can be ued) Forty or more meaurement (not necearily in chronological order), variable data Forty or more paired meaurement (meaure of both thing of interet), variable data 2-31

96 Bar Chart and Pie Chart Bar and pie chart ue picture to compare the ize, amount, quantitie, or proportion of variou item or grouping of item. When To Ue Them Bar and pie chart make it eaier to undertand data becaue they preent the data a a picture, allowing the reult to tand out. Thi i particularly helpful in preenting reult to team member, manager, and other intereted partie. Bar and pie chart preent reult that compare different group. They can alo be ued with variable data when the data have been grouped. Bar chart work bet when howing comparion among categorie, while pie chart are ued for howing relative proportion of variou item in making up the whole (how the pie i divided up). Thee chart can be ued in defining or chooing problem to work on, analyzing problem, verifying caue, or judging olution How To Ue a Bar Chart Team may chooe between three type of bar chart, depending on the type of data they have and what they want to tre: Simple bar chart ort data into imple categorie. 0 Grouped bar chart divide data into group within each category. Thi type of bar chart how comparion between individual group a well a between categorie. It give more ueful information than a imple total of all the component Stacked bar chart, like grouped bar chart, ue grouped data within categorie. They make clear both the um of the part and each group contribution to that total. 20 Step in contructing the chart: Chooe the type of bar chart that tree the reult to be focued on. Grouped and tacked bar chart will require two claification variable. If uing tacked bar 10 0 graph, tally the data within each category into combined total before drawing the graph. Draw the vertical axi to repreent the value of the variable of comparion (number, cot, time). Etablih the range for the data by ubtracting the mallet value from the

97 larget. Determine the cale for the vertical axi at approximately 1.5 time the range and label the axi with the cale and unit of meaure. Determine the number of bar needed. The number of bar will equal the number of categorie for imple or tacked bar chart. When uing grouped bar chart, the number of bar will equal the number of categorie multiplied by the number of group. Thi number i important for determining the length of the horizontal axi. Draw bar of equal width for each item and label the categorie and the group. Provide a title for the graph. Indicate the ample and the time period covered by the data. How To Ue a Pie Chart Taking the data to be charted, calculate the percentage contribution for each category by dividing the value of each category by the total and multiplying by % 10% 20% Draw a circle. Uing thee percentage, determine what portion of the circle will be repreented by each 25% category. Thi can be done by eye or by calculating the number of degree and uing a compa. By eye, divide the circle into four quadrant repreenting 25 percent. Draw in the egment by etimating how much larger or maller each category i. Calculating the number of degree can be done by multiplying the percent by 3.6 (a circle ha 360 degree) and then uing a compa to draw the portion. Provide a title for the graph. Indicate the ample and the time period covered by the data. Caution Be careful not to ue too many notation on the chart. Keep them a imple a poible and include only the information neceary to interpret the chart. Do not draw wide-reaching concluion from the data if they do not jutify them. For example, determining whether a trend exit may require more tatitical tet and probably cannot be determined by the chart alone. Difference among group alo may require more tatitical teting to determine if they are ignificant. Whenever poible, ue bar or pie chart to upport data interpretation. Do not think that reult or point are o clear and obviou that a chart i not needed for clarity. A chart mut not lie or milead! To enure that thi doe not happen, follow the guideline: cale mut be in regular interval, chart that are to be compared mut alo ue the ame cale and ymbol, chart hould be eay to read. 2-33

98 Run Chart Run chart give a picture of variation in ome proce over time, and help detect pecial (external) caue of that variation. They make trend or other non-random variation in the proce eaier to ee and undertand When To Ue Them If data analyi focue on tatitic that give only the big picture (uch a average, range, and variation), trend over time can often be lot. Thu, change could be hidden from view and problem left unreolved. Run chart graphically diplay hift, trend, cycle, or other non-random pattern over time. They can be ued to identify problem (by howing a trend away from the deired reult), and to monitor progre when olution are carried out. How To Ue Them A run i the conecutive point running either above or below the center line (mean or median). The point in a run chart mark the ingle event (how much occurred at a certain point in time). A run i broken once it croe the center line. Value on the center line are ignored: they do not break the run, nor are they counted a point in the run. The baic tep in creating a run chart follow: Collect at leat 25 data point (number, time, cot), recording when each meaurement wa taken. Arrange the data in chronological order. Determine the cale for the vertical axi a 1.5 time the range (the mallet value ubtracted from the larget). Label the axi with the cale and unit of meaure. Draw the horizontal axi and mark the meaure of time (minute, hour, day, hift, week, month, year, etc.) and label the axi. Plot the point and connect them with a traight line between each point. Draw the center line (the average of all the data point). The following provide ome guidance in interpreting a run chart: Eight conecutive point above (or below) the center line (mean or median) ugget a hift in the proce. Six ucceive increaing (or decreaing) point ugget a trend. Fourteen ucceive point alternating up and down ugget a cyclical proce. 2-34

99 Caution Be careful not to ue too many notation on a run chart. Keep it a imple a poible and include only the neceary information to interpret the chart. Do not draw wide-reaching concluion from the data if they do not jutify them. Certain trend and interpretation may require more tatitical teting to determine if they are ignificant. Whenever poible, ue a run chart to how the variation in the proce. Do not think that the variation i o clear and obviou that a run chart i not needed. A run chart mut not lie or milead! To enure that thi doe not happen, follow the guideline: cale mut be in regular interval, chart that are to be compared mut alo ue the ame cale and ymbol, chart hould be eay to read. 2-35

100 Hitogram Hitogram are chart that indicate how often ome event i likely to occur by howing the pattern of variation (ditribution) of data. A pattern of variation ha three apect: the center (average), the hape of the curve, and the width of the curve. Hitogram are contructed with variable uch a time, weight, temperature and are not appropriate for attribute data When To Ue It All data how variation; hitogram help interpret thi variation by making the pattern clear. They tell a viual tory about a pecific cae in a way that a table of number (data point) cannot. Hitogram can be ued to identify and verify caue of problem. They can alo be ued to judge a olution, by checking whether it ha removed the caue of the problem. How To Ue It From the raw number (the data), find the highet and lowet value, and determine the range (the highet value minu the lowet value). Determine the number of bar to be ued in the hitogram. If too many bar are ued, the pattern may get lot in the detail; if too few are ued, the pattern may get lot within the bar. The following will erve a a guide in chooing an appropriate number of bar. Number of data point Number of bar < > Determine the width of each bar by dividing the range by the number of bar. Then, tarting with the lowet value, determine the grouping of value to be contained or repreented by each bar. Create a compilation table like the one on the following page and fill in the boundarie for each grouping. Complete the above frequency table by counting the number of data point for each bar and calculating the total number of data point in each bar. 2-36

101 Compilation Table for Hitogram Bar Boundarie Tally Total Draw the horizontal and vertical axe, and label them. Draw in the bar to correpond with the total from the frequency table. Identify and claify the pattern of variation. The graph below preent the poible hape and their interpretation. Bell-haped the normal pattern Double-peaked ugget two ditribution Skewed Truncated Ragged plateau look for other procee look for reaon for no ingle clear proce in the tail harp end of ditribution or pattern Caution Simple daily obervation often do not tell enough about the proce, and average or range are not adequate ummarie of the data. The potential pitfall of a hitogram i not uing one; it i a ueful, neceary tool. If variation i mall, the hitogram may not be enitive enough to detect ignificant difference in variability or in the peak of the ditribution, epecially if uing a mallample data et. There are advanced tatitical tool that can be ued in uch ituation. 2-37

102 Scatter Diagram A catter diagram give a picture of the aociation between two variable. It can point to but doe not prove a caual relationhip. When To Ue It Scatter diagram make the relationhip between two continuou variable tand out viually on the page in a way that the raw data cannot. Scatter diagram may be ued in examining a caue-effect relationhip between variable data (continuou meaurement data). They can alo how relationhip between two effect to ee if they might tem from a common caue or erve a urrogate for each other. Scatter diagram can alo examine the relationhip between two caue. They are eay to contruct. How To Ue It Collect at leat 40 paired data point: paired data are meaure of both the caue being teted and of it uppoed effect at one point in time. Draw the grid, with the caue on the horizontal axi and the effect on the vertical axi. Determine the lowet and highet value of each variable and mark the axe accordingly. Plot the paired point on the diagram. If there are multiple pair with the ame value, draw a many circle around the point a there are additional pair with thoe ame value. Identify and claify the pattern of aociation uing the graph below of poible hape and interpretation Y Y X Strong correlation ugget trong relationhip.. Y X No correlation look for alternative relationhip Weak correlation look for alternative factor with tronger relationhip Y X J-haped aociation ugget complex relationhip X 2-38

103 Caution Stratifying the data in different way can make pattern appear or diappear. When experimenting with different tratification and their effect on the catter diagram, label how the data are tratified o the team can dicu their implication. Interpretation can be limited by the cale ued. If the cale i too mall and the point are compreed, then a pattern of correlation may appear differently. Determine the cale o that the point cover mot of the range of both axe and that both axe are about the ame length. Be careful of the effect of confounding factor. Sometime the correlation oberved i due to ome caue other than thoe being tudied. If a confounding factor i upected, then tratify the data by it. If it i truly a confounding factor, then the relationhip in diagram will change ignificantly. Avoid the temptation to draw a line roughly through the middle of the point. Thi can be mileading. A true regreion line i determined mathematically. Conult a tatitical expert or text prior to uing a regreion line. Scatter diagram how relationhip but do not prove that one variable caue the other. 2-39

104 Pareto Chart NUMBER A Pareto chart provide fact needed for etting prioritie % It organize and diplay information to how the relative 40 importance of variou problem or caue of problem. It 75% i eentially a pecial form of a vertical bar chart, which 30 put item in order (from the highet to the lowet) relative to ome meaurable effect of interet: frequency, 50% 20 cot, time. The chart i baed on the Pareto principle, 25% which tate that whenever many factor affect a ituation, 10 only a few factor will account for mot of the impact. By 0 0% placing the item in decending order of frequency, it i eay to dicern thoe problem that are of greatet importance or thoe caue that appear to account for mot of the variation. Thu, a Pareto chart help team to focu their effort where they can have the greatet potential impact. When To Ue It Pareto chart help team focu on the mall number of really important problem or caue of problem. Pareto chart are ueful in etablihing prioritie by howing which are the mot critical problem to be tackled or caue to be addreed. Comparing Pareto chart of a given ituation over time can alo meaure whether an implemented olution reduced the relative frequency or cot of that problem or caue. How To Ue It Develop a lit of problem, item, or caue to be compared. Develop a tandard meaure for comparion for thee item: how often it occur: frequency (e.g., utilization, complication, error); how long it take: time; how many reource it ue: cot. Chooe a time frame for collecting the data. Tally for each item how often it occurred (or cot or total time it took). Then add thee amount up to determine the grand total for all item. Find the percent of each item in the grand total by taking the um of the item, dividing it by the grand total, and multiplying by

105 Caue for Late Arrival Family problem Woke up late Had to take the bu Traffic tie-up Sick Bad weather Total Number of Occaion Percent (%) 11% 27% 6% 44% 8% 4% 100% Lit the item being compared in decreaing order of the meaure of comparion: e.g., the mot frequent to the leat frequent. The cumulative percent for an item i the um of that item percent of the total and that of all the other item that come before it in the ordering by rank. Caue for Late Arrival (decreaing order) Number of Occaion Percent (%) Cumulative Percent (%) Traffic tie-up Woke up late Family problem Sick Had to take the bu Bad weather % 28% 10% 8% 6% 4% 44% 71% 82% 90% 96% 100% Total % Lit the item on the horizontal axi of a graph from highet to lowet. Label the left vertical axi with the number (frequency, time, or cot), then label the right vertical axi with the cumulative percentage (the cumulative total hould equal 100 percent). Draw in the bar for each item. Draw a line graph of the cumulative percentage. The firt point on the line graph hould line up with the top of the firt bar. Analyze the diagram by identifying thoe item that appear to account for mot of the difficulty. Do thi by looking for a clear breakpoint in the line graph, where it tart to level off quickly. If there i not a breakpoint, identify thoe item that account for 50 percent or more of the effect. If there appear to be no pattern (the bar are eentially all of the ame height), think of ome factor that may affect the outcome, uch a day of week, hift, age group of patient, home village. Then, ubdivide the data and draw eparate Pareto chart for each ubgroup and ee if a clearer pattern emerge. Caution Try to ue objective data intead of opinion and vote. 2-41

106 Client Window A client window i a tool for gaining feedback from client about the product and ervice they ue. It differ from a client urvey in that a urvey ak client about product or ervice performance, baed on the urvey deigner idea about what client want and need. A client window ak quetion in very broad term, letting the client expre what they need, expect, like, and dilike in their own term and from their point of view. When To Ue It A client window can be ued to get information from client, in their own term, about what they want or what they like about the current ervice. However, thi i really only one tep in undertanding what i mot important to client. Not all thing lited will be of equal weight, and further dicuion with client may be needed to find which area are true prioritie. A client window can be ued by itelf, or a groundwork for more formal data collection through urvey; uing it in thi way can help deign more relevant urvey quetion. Client window can alo be ued when deigning olution, getting information that will make it eaier to avoid repeating pat mitake in planning. How To Ue It Determine the product, area, or ervice for which feedback i deired. Frame what kind of feedback i being ought. I feedback deired on the whole range of product and ervice provided? I the team more intereted in pecific area? For example, client could be aked to provide feedback on all health ervice they receive, or the team may want to focu on pecific health activitie, uch a MCH, immunization, curative care. Gather information from client by aking them to repond to the following quetion: 1. What are you getting that you want? What are you getting that i meeting your need and expectation? 2. What are you getting that you really don t want or need? 3. What do you wih you were getting that you are not? 4. What need do you expect in the future? 5. What uggetion do you have for how we can improve our product or ervice for you? There are two way to adminiter the client window: to a group of client at one time, or individually. Group Adminitration: Prepare a large client window framework on a piece of flip chart paper or blackboard. When the client are gathered, explain that the goal of thi activity i to get honet feedback about how their need and expectation are being met. Write the 2-42

107 area of focu on a flip chart or blackboard. Ak them to write individually the anwer to the above quetion. (It i bet that the client be given privacy at thi point o that they may anwer a honetly a poible; leave the room.) Have them place their repone on the client window. Individual Adminitration: In thi mode, client are aked to fill out the client window individually, and return their repone (no name required). Prepare intruction for them, including how their feedback will be ued, the area of focu, how to fill out the client window, and where and when to return it. Client write their repone to the above quetion directly on the client window form. Compile the information. If the client window wa adminitered in a group, record the anwer on a eparate heet of paper a they were written for each ection of the window. Review the anwer and count how often the ame feeling were expreed by everal people. If the client window wa adminitered individually, place all individual repone on a mater heet, and then count how frequently imilar repone were given. Client Window Want Getting Getting What You Want (#1) Not Getting Want But Not Getting (#2) Don't Want Getting But Not Wanted (#3) Don't Want Not Getting (#4) (anticipated need for future) Caution Be ure to have the correct people (the client) preent when completing the window. 2-43

108 Benchmarking Benchmarking i a technique for learning from other uccee in an area where the team i trying to make improvement. The term benchmarking mean uing omeone ele ucceful proce a a meaure of deired achievement for the activity at hand. When To Ue It Benchmarking i mot ueful when trying to develop option for potential olution. When trying to develop olution, team often have difficulty generating new idea. People frequently do not know what other nearby are doing. Benchmarking help timulate creativity by gaining knowledge of what ha been tried. It can alo be ued to identify area for improvement by eeing what level of quality i poible to achieve. How To Ue It Identify other group, organization, or health facilitie that erve a imilar purpoe and that appear to work well. Thee do not need to be doing exactly what the team doe, a long a it can be compared. For example, if the team i dealing with problem in hopital laundry ervice, the team could learn from hotel and dormitorie which provide imilar ervice, although they are not in the ame field. Viit thee ite and talk to manager and worker, aking them what they are doing, if they have imilar problem, what they have done about it, and what level of performance they have achieved. Ak a well what obtacle they have run into and how they have dealt with them. Review how the ituation and contraint for the proce in quetion are imilar to or different from their and determine if change are needed in carrying out their plan. Caution Be ure to undertand fully how the proce in quetion work before looking at other procee. Be ure that the other peron proce i fully undertood before adapting or adopting it to the proce in quetion. 2-44

109 Gantt Chart MONTHS A Gantt chart aid planning by howing all activitie that mut take place and when they are cheduled to be carried out. ACTIVITIES When To Ue It Gantt chart provide a graphic guide for carrying out a erie of activitie, howing the tart date, duration, and overlap of activitie. Gantt chart are mot ueful in the planning tage, to mark when each activity hould tart and to draw the linkage in timing between activitie. Gantt chart are alo ueful for keeping track of progre and recheduling activitie if progre i lowed. How To Ue It Lit all the activitie that need to be carried out to implement a olution. Determine when each activity mut tart and lit them in chronological order. Draw the framework for the Gantt chart by liting the month of implementation acro the top of a heet of paper. Lit the activitie down the ide. For each activity, mark it tarting date. Determine the duration for each activity and, uing a horizontal bar, mark the duration on the graph. Continue thi proce for each activity. Review the chart and determine if it i poible to carry out all the activitie that are to be conducted imultaneouly. 2-45

110 Quality Aurance Storytelling Quality Aurance (QA) Storytelling i an organized way of documenting the quality improvement proce of a team that i working ytematically to reolve a pecific problem and/or improve a given proce. QA torie are decribed in detail a they unfold in QA Storybook, and preented publicly through QA Storyboard. Initially developed a Quality Improvement Storytelling for indutrial quality improvement program, the technique ha more recently been adapted and applied to quality improvement effort in the health ector. Initially thi wa carried out by the Hopital Corporation of America (HCA). 1 It i increaingly ued by other in health a an effective way of documenting the activitie of quality improvement team in a variety of etting. The QA Storybook i a complete and permanent record of the improvement proce, uually kept in notebook format. The QA Storyboard i a large diplay area (ection of a wall, or a board or poter) which allow a team to diplay it work publicly in an ongoing, tructured, and viually undertandable way. It ha been decribed by HCA Batalden and Gillem a the team working minute. When To Ue It By ytematically documenting the quality improvement progre made by a team, QA Storytelling help to keep everyone focued on the tak at hand, and allow team member to decribe their work to other in a clear and comprehenible way. It i normally begun a oon a a problem tatement ha been drafted and a team aembled, and i continued throughout the quality improvement proce, from Step 8 (analyzing the problem) through Step 10 (implementing and evaluating a olution). When ued routinely, QA Storytelling can help make QA part of the ongoing life of the organization. How To Ue It QA Storybook One team member i uually deignated a recorder to maintain a complete and detailed record of the team activitie. The record hould include minute of team meeting a well a uch item a lit of peron contacted, preentation made, indicator monitored, ampling deign and analytical method employed, data collected, etc. From time to time the recorder may ue the information in thi record to prepare brief ummarie of the team progre in reolving the problem in quetion. From thi record item are elected for poting on the QA Storyboard (ee next page). 1 Batalden, Paul and Gillem, Paul. Hopitalwide Quality Improvement Storytelling. Quality Reource Group. Nahville, Tenneee: Hopital Corporation of American

111 QA Storyboard The QA Storyboard erve a an ongoing viual record of the team progre, helping to keep team member focued on the tak and erving a an effective way of haring their progre with other. Storyboard ue imple, clear tatement a well a picture and graph to decribe a problem, ummarize the analyi proce while it i under way, decribe the olution and it implementation, and diplay the reult. Step in creating and maintaining a QA Storyboard follow: Reerve a ection of the wall, or ecure a large board or poter board (meauring at leat 1.5 meter high by 2 meter in length) to erve a the QA Storyboard. Mark off and label different area of the Storyboard for diplaying the team progre during each of the quality improvement tep. In the example below, the team ha marked off eparate area to diplay the problem tatement, name of team member, a workplan, activitie undertaken during problem analyi and their reult, root caue() identified, olution() elected, olution implemented, and the reult. Pot a copy of the initial tatement of the problem and the name of the team member. A picture of the team may be added. Keep thee up to date a the problem tatement i refined and/or a team memberhip change. Pot a copy of the team workplan and chedule, and modify it a change are made during the problem-olving proce. A work progree, diplay the progre made in analyzing the problem to determine it root caue(). Include item uch a a flow chart of the proce in quetion, a caueand-effect diagram, the lit of indicator to be monitored, the data collection form, and graph diplaying the reult. Pot the root caue() identified and the olution() propoed and elected for implementation. Add any other apect of the proce of olution identification and election (e.g., election criteria or election method) to be diplayed for ready reference. Maintain an ongoing diplay of the progre of olution implementation. Show a much (or a little) detail a team member find helpful, either to focu their own work or to communicate their work to other. Finally, when the olution ha been implemented and evaluated, pot the reult for all to ee. 2-47

112 QA Storyboard Caution Be ure to ue it. It i a helpful tool to how the progre of a proce improvement team. 2-48

113 Gloary Affinity analyi A tool to facilitate conideration and organization of a group of idea about an iue by a team in a conenual manner. The group member take turn putting forth individual idea about an iue; next, the idea are written down by the individual, one idea to a piece of paper. The individual then group all the idea into natural (affinity) group, (or group the idea in a manner that allow thoe with a natural relationhip or relevance to be placed together in the ame group or category). Bar chart A graphic diplay of data in the form of a bar howing the number of unit (e.g., frequency) in each category. May be a compound graph or a horizontal graph. Negative number can be hown on a bar graph. Benchmarking An evaluation technique in which an organization compare it own performance on pecific quality program criteria to the performance of a recognized leader in the area of quality aurance. The evaluation help the organization identify hortcoming and etablihe a baeline or tandard againt which to meaure it progre in the development and maintenance of a quality aurance program. Boundary The beginning or end point in the portion of a proce that will help focu the proce improvement effort. Braintorming A group proce ued to generate idea in a nonjudgmental environment. Group member are preented with the iue and are aked, firt, to be wide-ranging in their own thinking about the iue and, econd, not to criticize the thinking of other. The purpoe of the tool i to generate a large number of idea about the iue. Caue-and-effect analyi (Fihbone or Tree diagram) A diplay of the factor that are thought to affect a particular output or outcome in a ytem. The factor are often hown a grouping of related ubfactor that act in concert to form the overall effect of the group. G-1

114 Caue-and-effect diagram (ee Caue-and-effect analyi) Client The receiver or beneficiary of an output of a proce, either internal or external to a hopital or an organizational unit. A client could be a peron, a department, clinic, etc. Client window A tool for gaining feedback from client about the product and ervice they ue. A client window ak quetion in very broad term, letting the client expre themelve in their own term and from their own point of view. Clinical guideline Clinical guideline are ytematically developed tatement that ait practitioner and patient in making deciion about health care. Thi approach focue on pecific clinical ituation with conideration to clinically relevant factor uch a ocial, organizational, or community-related factor. Thi method i alo baed on outcome and cot-effectivene data. Different method are ued to develop the guideline for deciion making, uch a pathway guideline, practice algorithm, and appropriate criteria. Common caue variation (ee alo Proce variation) Variation in a proce that i due to the proce itelf and i produced by interaction of variable of that proce. Conenu General agreement reached within a group. Contraint Force that hinder reaching an outcome or the olution to a problem. Continuou Quality Improvement (CQI) An approach to improving and maintaining quality that emphaize internally driven and relatively contant (a contrated with intermittent) aement of potential caue of quality defect, followed by action aimed either at avoiding decreae in quality or ele correcting it in an early tage. G-2

115 Control chart Graphical repreentation of the characteritic of a proce uing data gathered over time. The purpoe of control chart i to determine, uing the diperion of point of a chart, whether procee fall within precribed limit and whether variation taking place are random or ytematic. Couneling To provide information and guidance to a patient or client. Criteria Standard againt which omething can be judged or aeed. Criteria, explicit Criteria which explicitly define expectation of, for example, treatment and outcome of care. The criteria are baed on objective, quantitative meaure and are developed by a group of expert, and are ued a a bai for comparion with clinical record to ee how well the criteria for diagnoi and treatment have been met. Criteria, implicit Implicit criteria are the unwritten, internalized criteria of a group or a ingle expert for what repreent the tandard of performance for a particular medical problem. The validity of uing implicit criteria i heavily dependent upon the expertie of the individual and hi ability to convert hi own expertie into criteria in hi own mind. Ue of implicit criteria may reult in different qualitative judgment of the ame ituation by different individual. Data Highly pecific quantitative meaurement, uually numeric, which can be compared to tandard or norm directly or can be combined with other meaurement to produce new information for comparion with tandard or norm. Data collection Gathering fact on how a proce work and/or how a proce i working from the cutomer point of view. All data collection i driven by knowledge of the proce and guided by tatitical principle. Explicit criteria (ee Criteria) G-3

116 External client (ee Client) Fihbone diagram (ee Caue-and-effect analyi) Five Why A imple tool for getting at root caue of a problem by aking why? to each ucceive repone five time. Flowchart A graphical repreentation of the flow of a proce. A ueful way to examine how variou tep in a proce relate to each other, to define the boundarie of the proce, to verify/ identify cutomer/upplier relationhip in a proce, to verify or form the appropriate team, to create common undertanding of the proce flow, to determine the current bet method of performing the proce, and to identify redundancy and unneceary complexity. Focu group A client-oriented approach for collecting information wherein a group (10-12) of participant, unfamiliar to each other, meet to dicu and hare idea about a certain iue. Focu group are a ueful qualitative analyi tool for helping to undertand the belief and perception of the population repreented by the group. Force-field analyi A ytematic method for undertanding competing force that increae or decreae the likelihood of uccefully implementing change. Gantt chart A type of bar chart ued in proce planning and control to diplay planned work and target for completed work in relation to time. Guideline (ee Clinical guideline) Hitogram A graphical repreentation ued to plot the frequency with which different value of a given variable occur. Hitogram are ued to examine exiting pattern, identify the range of variable, and ugget a central tendency in variable. G-4

117 Hypothei An educated gue or cientific hunch about the underlying caue of a problem. A hypothei erve a a working theory that can be either confirmed or diproved through data collection and analyi. Impact meaurement Meaure of the effect of one or more outcome, a well a the external environment of the ytem. They uually are indicator of the goal of the ytem. Impact meaurement may be ued a the ultimate entinel event that indicate a likely need for improvement in care. Implicit criteria (ee Criteria, implicit) Incentive Factor that motivate a peron or group to behave in a certain way. Indicator A meaurable variable (or characteritic) that can be ued to determine degree of adherence to a tandard or achievement of quality goal. For example: Pot-operative infection rate a an indicator of adherence to aeptic urgical technique. Information Quantitative data and/or qualitative fact organized in uch a way a to allow rational judgment to be made in light of a deired et of goal. Input The reource neceary to carry out a proce. For example, the ervice or product a upplier provide to a proce. Input to one proce are the output from preceding procee. Internal client The recipient (peron or department) of the output of another peron or department (product, ervice, or information) within an organization. G-5

118 Matrix method A conenu development technique. A group of people who are familiar with the problem at hand are aked individually to array a lit of potential repone to a problem into a preferred order baed on a pecified et of criteria for the olution. Through variou coring technique, individual preference are combined to form a group preference. Method A ytematic procedure, technique or mode of inquiry employed by a particular dicipline. Multi-voting technique (ee Voting) A group deciion-making technique deigned to reduce a long lit to a horter one. Norm A level of performance that i deemed acceptable. Operational definition A precie definition of an important term or procedure ued by a health care team. Outcome meaurement Meaure of the effect of the output of the ytem. Output often repreent the variou objective of the ytem and may be ued a intermediate indicator of ub-optimal performance by the ytem. Output meaurement Output meaurement are direct meaure of the interaction of input and procee in the ytem. They may be ued a continuou monitor of ytem performance. Pareto chart A graphic repreentation of the frequency with which certain event occur. It i a rankorder bar chart that diplay the relative importance of variable in a data et and may be ued to et prioritie regarding opportunitie for improvement. Participative An approach to carrying out a program which emphaize obtaining input or participation from the group member who will carry out the program. G-6

119 Plan Do Check Act (PDCA) The key tep involved in implementation and evaluation of quality improvement effort. Preentation tool A et of chart to diplay different type of data. (See Run chart, Control chart, Hitogram, and Scatter diagram) Prioritization Application of an explicit et of criteria to et the order in which each of a group of problem will be reolved. Problem Exitence of a gap between a deired condition (or level of condition) and the condition that actually exit. Problem olving Action taken to cloe the gap between a deired condition and the actual level of the condition. Problem tatement A concie decription of a proce in need of improvement, it boundarie, the general area of concern where quality improvement hould begin, and why work on the improvement i a priority. Proce A erie of action that repeatedly come together to tranform input into output. Proce improvement The continuou endeavor to learn about all apect of a proce and to ue thi knowledge to change the proce to reduce variation and complexity and to improve the level of it performance. Proce improvement begin by undertanding how cutomer define quality, how procee work, and how undertanding the variation in thoe procee can lead to wie management action. G-7

120 Proce variation (ee Common caue variation and Special caue varation) The pread of proce output over time. There i variation in every proce, and all variation i caued. The caue are of two type-pecial or common. A proce can have both type of variation at the ame time or only common caue variation. The management action neceary to improve the proce i different depending on the type of variation being addreed. Protocol A precie and detailed plan for a proce, for example for the management of a clinical condition. A protocol implie a more tringent requirement than a guideline. For example: WHO protocol for diarrhea cae management. Quality The degree to which actual performance or achievement correpond to et tandard. Quality aurance A et of action taken to bring actual quality up to, or acceptably near, targeted quality. Quality criterion (criteria) An apect or characteritic of a product or ervice by which an internal or external cutomer judge whether quality i preent or not. For example: The technical training received by a health care worker who care for ick children. The characteritic() that define the mot important apect of input, procee, or outcome. Quality improvement Both a philoophy and a et of guiding principle that repreent the foundation of a continuouly improving organization. Rank To determine the relative poition of a problem, a caue, or a olution baed on criteria. Root caue The underlying reaon for the occurrence of a problem. G-8

121 Run chart A viual repreentation of data in uch a way a to monitor a proce to determine whether there i a ytematic change in that proce over time. Scatter diagram Scatter diagram are ued to plot the ditribution of cae in two dimenion. Scatter diagram are ued to rapidly creen for a relationhip between two variable. Special caue variation (ee Proce variation) Variation in proce that i aignable to a pecific caue or caue. It arie becaue of pecial circumtance. Stable proce A proce that doe not change or fluctuate. Standard Performance pecification that, if attained, would lead to the highet poible quality in the ytem. A tandard i a tatement made by an authority about expectation for a product, ervice, behavior, or outcome. Standard can be rule (e.g., protocol) or pecification. For example: A eparate terile needle mut be ued for each child being immunized. Statitical/data preentation tool (ee Preentation tool) Sytem The arrangement of organization, people, material, and procedure aociated with a particular function or outcome. A ytem i uually made up of input, procee, and output/outcome. A large ytem may have a number of ub-ytem. For example: A management information ytem (MIS). Sytem Modeling A mean for diagramming how element of a ytem relate to one another. The element may be a equence of event or action or a combination of both, adminitrative unit of an organization, the flow of ome entity uch a commoditie, information, or authority from one place to another, or a erie of action or other caue and ubequent effect. G-9

122 Team A group of interacting individual haring a common goal and the reponibility for achieving it. Tool A tangible device ued to help accomplih the purpoe of a technique. Total Quality Management (TQM) An approach to quality aurance that emphaize a thorough undertanding by all member of a production unit of the need and deire of the ultimate ervice recipient, a viewpoint of wihing to provide ervice to internal, intermediate ervice recipient in the chain of ervice, and a knowledge of how to ue pecific data-related technique to ae and improve the quality of their own and their team output. Tree diagram (ee Caue-and-effect analyi) Variation Difference in the output of proce reulting from the influence() of people, machine (equipment), material, and/or method. Voting A relatively untructured technique in which group member make a choice, uing either implicit or explicit criteria. Weighted voting A type of voting in which all option are lited and each peron i given the poibility to give more weight to ome choice than to other. G-10

123 Reference Adler, Nancy J., International Dimenion of Organizational Behavior, Kent Publihing Co., Boton, MA, Amden, David; Butler, Howard; and Amden, Robert, SPC Simplified for Service: Practical Tool for Continuou Quality Improvement, White Plain, NY, Quality Reource, Amden, David M. and Butler, Howard E. and Amden, Robert T., SPC Simplified Workbook: Practical Step to Quality, Quality Reource, White Plain, NY, Apen Reference Group, Ambulatory Care Form, Checklit and Guideline, Vol 1 & 2, Gaitherburg, MD, Bataldan, Paul and Gillem, Tom, Hopitalwide Quality Improvement Storytelling, Quality Reource Group, Hopital Corporation of American, Nahville, TN, November Braard, Michael, The Memory Jogger Plu, GOAL/QPC, Meuthuen, MA, Brown, Gordon D. and Feirman, Harry Aupha, Aupha Management Problem-Solving (Map) Module Community and External Relation, The Health Management Educational Conortium, Wahington, DC, September Brown, Lori D.; Franco, Lynne M.; Rafeh, Nadwa; and Hatzell, Therea, Quality Aurance of Health Care in Developing Countrie, Quality Aurance Methodology Refinement Serie, Center for Human Service, Betheda, MD, CEDPA/FHI, Service Quality Aement and Improvement: Procee and Tool, Wahington, DC, September Deming, W. Edward, Out of the Crii, Maachuett Intitute of Technology (MIT) Center for Advanced Engineering Study. Cambridge, MA, Doyle, Michael and David Strau, How to Make Meeting Work, Jove Book, New York, NY: Gitlow, H. et al., Tool and Method for the Improvement of Quality, Richard D. Irwin, Inc., Boton, MA, Health Manpower Development Staff, John A. Burn School of Medicine, Health Center Management: Working with the Health Team - Working with Support Sytem, tudent text, Univerity of Hawaii, Honolulu, HI, G-11 R-1

124 Imai, Maaaki, Kaizen: The Key to Japan Competitive Succe, Mcgraw-Hill Publiher, New York, NY, Ihikauwa, Kaoru, Guide to Quality Control, Aian Productivity Organization, Tokyo: Ihikawa, Kaoru, What i Total Quality Control: The Japanee Way, Prentice-Hall, Englewood Cliff, NJ, Johnon, Robert, Elementary Statitic, Fourth Edition, Duxbury Pre, Boton, The Joint Commiion Guide to Quality Aurance, JACHO, Chicago, Illinoi, Monitoring and Evaluation of the Quality and Appropriatene of Care A Home Care Example, JACHO, Chicago, Illinoi, Jone, Loui and McBride, Ronald, An Introduction to Team-Approach Problem Solving, ASQC Quality Pre, Milwaukee, Wiconin, Juran, J. M., Juran on Leaderhip for Quality: An Executive Handbook, The Free Pre, New York, NY: Juran, J.M., Juran Quality Control Handbook, McGraw-Hill, New York, NY, Katz, Karen and Hardee-Cleveland, Karen, Catalog of Aement Tool for Quality of Care, Family Health International, Durham, N.C., September Kelly, Michael R., Everyone Problem Solving Handbook: Step-by-tep Solution for Quality Improvement, Quality Reource, White Plain, NY: King, Bob, Hohin Planning: The Developmental Approach, Goal/QPC, Methuen, MA, Liebler, Joan G., et al., Management Principle for Health Profeional, Apen Sytem Corp., Rockville, Maryland, Longo, Daniel R. and Bohr, Deborah, Quantitative Method in Quality Management, American Hopital Publihing, Inc., Chicago, The Memory Jogger: A Pocket Guide of Tool for Continuou Improvement, Goal/QPC, Methuen, MA. Available in Spanih and French, 1985, Moran, John et al., Guide to Graphical Problem-Solving Procee, ASQC Quality Pre, Milwaukee, Wiconin, G-12 R-2

125 Nutting, Paul; Berkhalter, Barton; Cavney, John; and Gallagher, Kaia, Method of Quality Aement for Primary Health Care: A Clinician Guide, Community Sytem Foundation, Sydney, Precription for Primary Health Care: A Community Guidebook, Primary Care Development Project, Cornell Univerity, Ithaca, NY: PRICOR, Problem-Solving Reearch, Diarrhea Dialogue, Iue 20. London, AHRTAG, March, Primer on Indicator Development and Application: Meauring Quality in Healthcare, Joint Commiion on Accreditation of Healthcare Organization, Oakbrook, Illinoi, Problem Solving, Control of Communicable Dieae Program, World Health Organization, Geneva, Roemer, Michael, and Aquilar, Montoyer, Quality Aement and Primary Health Care, Publication No. 105, WHO, Geneva, Scholte, Peter R., The Team Handbook, Joiner Aociate, Inc., Madion, WI, Total Quality Improvement Sytem: Quality Action Team Team Member Workbook, Organizational Dynamic, Burlington, MA, Tranition: From QA to CQI: Uing CQI approache to Monitor, Evaluate and Improve Quality, The Joint Commiion on Ambulatory Health Care, Oakbrook Terrace, Il., Uing CQI Approache to Monitor, Evaluate, and Improve Quality, Joint Commiion on Accreditation of Healthcare Organization, Oakbrook Terrace, Vuori, Hannu, Quality Aurance of Health Service: Concept and Methodology, World Health Organization, Copenhagen, Vuori, Hannu, Quality Aurance: A Problem Solving Approach, World Health Organization, Copenhagen, Walton, Mary, The Deming Management Method, Putnam Publihing Group, New York, NY, G-13 R-3

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