Moving from “lack of resources” to“resourcefulness”: How to improvequality of programs amidst funding             constrai...
Outline of the session    • Quality: what it is and what it isn’t    • Approaches to improving quality    • The science of...
How do you define    quality?                    3
• How would you define Quality of Care?• Think about the last time you accessed a service. It  could be a service related ...
Dimensions of Quality    Institute of Medicine          Additional         Equitable                  Accessible          ...
USAID HEALTH CARE IMPROVEMENT PROJECT6
USAID HEALTH CARE IMPROVEMENT PROJECT7
USAID HEALTH CARE IMPROVEMENT PROJECT8
USAID HEALTH CARE IMPROVEMENT PROJECT9
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USAID HEALTH CARE IMPROVEMENT PROJECT14
Dimensions of Quality     Institute of Medicine          Additional          Equitable                 Accessible         ...
Approaches toImprovement                16
Terminology• Quality Assurance – purpose is to assess when we have achieved  the intended quality of service or product (s...
Quality Improvement• The techniques and methods used to take us from where  we are, to where want to be• Identifies where ...
Five Approaches to Improvement•    Design of a new service or product•    Redesign of an existing service or product•    D...
The science ofimprovement (and some       theory)                        20
Deming’s System of Profound Knowledge                              Appreciation                              of a system  ...
Two Types of KnowledgeSubject Matter Knowledge Technical knowledge.     Subject Matter     Knowledge                      ...
Knowledge for Improvement                                       Learn to combine subject                                  ...
•   The human side of Change – how do    people think, behave and feel as    individuals and how do they interact         ...
Appreciation• What do people know?                 of a System• How do people know?• How do we acquire  knowledge?        ...
Personality Theory TRUTH THEORY                                               Ch a o       Macroeconomic Theory           ...
What is a Theory?• A description of our best understanding about why  things are the way they are• Theories are used to pr...
Driver Diagram - a tool to visualize our Theory 28                      USAID HEALTH CARE IMPROVEMENT PROJECT
Appreciation• ―Every system is perfectly                of a System  designed to achieve the  results it gets‖            ...
Complex Dynamic Systems• Step 1 – Everyone stand up• Step 2 – Without speaking; pick two people but  don’t say who they ar...
Complex Dynamic Systems Exercise• What was the aim of this system?• What realizations did you have about the systems?• Wha...
Organization as a System                                                                Need                              ...
Why go to the trouble of developingthis understanding?―If each part of a system, considered separately, ismade to operate ...
Appreciation                                        of a System• Everything we observe or  measure varies• How do we know ...
USAID HEALTH CARE IMPROVEMENT PROJECT
Displaying data over time - Run          charts                                                     # treated for Malaria ...
If we don’t understand the variationthat lives in our data, we will betempted to• Deny the data (It doesn’t fit my view of...
38
A model for improvingany process or system                        39
The Model for Improvement                              Developed by                              Associates in            ...
P-D-S-A          USAID HEALTH CARE IMPROVEMENT PROJECT41
What makes this cycle work• Testing on a small scale allows you to know whether you  idea can work—gives you a way to try ...
Question 1: What are we trying toaccomplish?• Be specific• Focus more narrowly on what is in your power to  change• Don’t ...
Question 2: How will we know a change isan improvement?• ―No data, no improvement‖—Measurement is  critical to tracking ch...
Question 3: What changes can we make thatwill result in an improvement?• This is the creative part, where it helps to brea...
Change concepts from The Improvement     GuideIdeas for change      Ways of implementing the ideaDo things right       Use...
Organize your test• Plan your test—who will do it, when; questions to  be answered; your predictions for the answers; how ...
Repeated Use of the PDSA Cycle                                                    Changes That                            ...
Applying this in real life:An example from Ethiopia                               49
Focus on “SYSTEMS THINKING”       Model of a system           The sum of all elements                                   (i...
Community Health System           Savings &           Credit Group   $                                                    ...
Community QI team Members                            Kebele                   DevelopmentGaree Leaders             Adminis...
Community Quality ImprovementElements of QI:•    QI Teams•    Coaches•    Regular QI Team Meetings•    Testing Improvement...
QI Implementation Activities TimelineBL                         LS                           LS                           ...
QI Team     Members               QI Team               Meeting55
Processes : Community Health System                    Referral                                             Health CenterH...
Process map                       Fishbone diagram       3. What changes will lead   2. What are we trying to          to ...
Pregnant women identified by Community Group                QI team Member drawing line chart                             ...
First Learning Session                         USAID HEALTH CARE IMPROVEMENT PROJECT59
Show improvement by using local materials                                        QI team     Line chart showing        imp...
Change ideas developed in EthiopiaAchieved improvement by using the following change ideas:  • Gare leaders (part of a Keb...
Line charts showing change ideas and improvement                      % of pregnant women who attended ANC service        ...
Table Exercise• Your NGO supports a community health worker (CHWs) program  in a rural area. One of the tasks that the CHW...
Discuss at your table1. Who should be on your improvement team?2. How would you develop changes to test? What are   ways y...
Wrap-up• Report back:   – What did you decide about team members?   – How would you have developed changes?   – What would...
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Moving from "Lack of Resources" to "Resourcefulness"_Chamrad_Shrestha_Marquez_5.1.12

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  • Knowledge of the human side of change helps us understand how people think, behave and feel as individuals, and how they interact with each other and with a system. Deming (1986, p. 314) has described the tendency to commit the attribution error:“A fault in the interpretation of observations, seen everywhere, is to suppose that every event (defect, mistake, accident) is attributable to someone (usually the one nearest at hand), or is related to some special event. The fact is most troubles with service and production lie in the system.” Everett Rogers proposed five attributes of a change that facilitate adoption of change: 1.Relative advantage of the change over other changes or the status quo (including what is in it for me?) 2. Compatibility with current culture and values 3. Minimal complexity in explaining the change 4. Allowing people to try and test the new change 5. Opportunities for people to observe the success of the change for othersAttributes of Effective Teams:Interdependence – complementary skillsLeadership – will and desire to learnJoint Decision Making – members want to participateEqual InfluenceLewin and Weisbord (1987)
  • The discipline of seeing interrelationships gradually undermines older attitudes of blame and guilt. We begin to see that all of us are trapped in structures, structures embedded both in our ways of thinking and in the interpersonal and social milieus in which we live. Our knee-jerk tendencies to find fault with one another gradually fade, leaving a much deeper appreciation of the forces within which we all operate. This does not imply that people are simply victims of systems that dictate their behavior. Often, the structures are of our own creation. But this has little meaning until those structures are seen. For most of us, the structures within which we operate are invisible. We are neither victims nor culprits but human beings controlled by forces we have not yet learned how to perceive. Peter Senge, 5th Discipline
  • The hope is that now people will have some idea about how to read and interpret data presented over time
  • Study your system and define what you want to improveHow will you know you improve? (how can you measure that things got better)What changes -- P D S APlan: Develop ideas for changes to test (based on predictions of what will make things better)Do: Test your changes (go small scale to larger scale)Study: Analyze your resultsAct: Decide next steps—Changes successful? Implement!Not what you hoped? Test other changesMove on to other aims
  • In the context of project planning, this might be your overall aim or goal—your big picture goal, like reduce maternal mortality by 25%.However, when applying this model to address a specific quality problem that may relate to your big picture goal, you want to answer this question as specifically as you can—like get 90% of expectant mothers to develop a birth emergency plan, with transportation worked out
  • Formation Community QI Team:Each Community QI team consists of 15 members which represents Garea, Kabele, HC, religious groups, and teachers.
  • Moving from "Lack of Resources" to "Resourcefulness"_Chamrad_Shrestha_Marquez_5.1.12

    1. 1. Moving from “lack of resources” to“resourcefulness”: How to improvequality of programs amidst funding constraints Diana Chamrad Senior QI Advisor for Orphans and Vulnerable Children Ram Shrestha Senior QI Advisor for Community Health and Nutrition Lani Marquez Knowledge Management Director USAID Health Care Improvement Project/URC May 1 CORE Spring 2012 Meeting 1
    2. 2. Outline of the session • Quality: what it is and what it isn’t • Approaches to improving quality • The science of improvement • A model for improvement and concepts to help you improve • Applying this in a community health example • Table work: identify change ideas to test • Wrap-up and where to go for more USAID HEALTH CARE IMPROVEMENT PROJECT2
    3. 3. How do you define quality? 3
    4. 4. • How would you define Quality of Care?• Think about the last time you accessed a service. It could be a service related to health, food, having your car repaired. What made it a quality service?4
    5. 5. Dimensions of Quality Institute of Medicine Additional Equitable Accessible Safe Technically sound Timely Effective Affordable Sustainable Efficient Consistent Patient Centered USAID HEALTH CARE IMPROVEMENT PROJECT5
    6. 6. USAID HEALTH CARE IMPROVEMENT PROJECT6
    7. 7. USAID HEALTH CARE IMPROVEMENT PROJECT7
    8. 8. USAID HEALTH CARE IMPROVEMENT PROJECT8
    9. 9. USAID HEALTH CARE IMPROVEMENT PROJECT9
    10. 10. USAID HEALTH CARE IMPROVEMENT PROJECT10
    11. 11. USAID HEALTH CARE IMPROVEMENT PROJECT11
    12. 12. USAID HEALTH CARE IMPROVEMENT PROJECT12
    13. 13. USAID HEALTH CARE IMPROVEMENT PROJECT13
    14. 14. USAID HEALTH CARE IMPROVEMENT PROJECT14
    15. 15. Dimensions of Quality Institute of Medicine Additional Equitable Accessible Safe Technically sound Timely Effective Affordable Sustainable Efficient Consistent Patient Centered USAID HEALTH CARE IMPROVEMENT PROJECT15
    16. 16. Approaches toImprovement 16
    17. 17. Terminology• Quality Assurance – purpose is to assess when we have achieved the intended quality of service or product (standards) – yes/no identification.• Quality Improvement – purpose is to move the system from current state of performance to a new state of performance defined by our definition of Quality USAID HEALTH CARE IMPROVEMENT PROJECT
    18. 18. Quality Improvement• The techniques and methods used to take us from where we are, to where want to be• Identifies where gaps exist between services actually provided and expectations for services• TESTING AND CHANGE to reduce the gaps USAID HEALTH CARE IMPROVEMENT PROJECT 18
    19. 19. Five Approaches to Improvement• Design of a new service or product• Redesign of an existing service or product• Design of a new process• Redesign of an existing process• Improvement of the system as a whole• System = interdependent group of items, people, and processes with a common aim.• Process = steps through which inputs from suppliers are converted into outputs for customers USAID HEALTH CARE IMPROVEMENT PROJECT19
    20. 20. The science ofimprovement (and some theory) 20
    21. 21. Deming’s System of Profound Knowledge Appreciation of a system Building Knowledge Psychology Understanding Variation21 USAID HEALTH CARE IMPROVEMENT PROJECT
    22. 22. Two Types of KnowledgeSubject Matter Knowledge Technical knowledge. Subject Matter Knowledge Knowledge for ImprovementKnowledge for Improvement The interaction of thetheories of systems, variation, knowledge, andpsychology.22 USAID HEALTH CARE IMPROVEMENT PROJECT
    23. 23. Knowledge for Improvement Learn to combine subject matter knowledge and knowledge for improvement Subject Matter in creative ways to develop Knowledge effective changes Knowledge for Improvement USAID HEALTH CARE IMPROVEMENT PROJECT23
    24. 24. • The human side of Change – how do people think, behave and feel as individuals and how do they interact Appreciation with others? of a System• It helps us understand and predict: • differences in people • motivations of people and their behavior • how to gain commitment Building • learning styles Knowledge Psychology • common thinking errors • how to attract people to change • how people will react to a change • how to form effective teams Understanding Variation 24 USAID HEALTH CARE IMPROVEMENT PROJECT
    25. 25. Appreciation• What do people know? of a System• How do people know?• How do we acquire knowledge? Building Knowledge Psychology Understanding Variation 25 USAID HEALTH CARE IMPROVEMENT PROJECT
    26. 26. Personality Theory TRUTH THEORY Ch a o Macroeconomic Theory s Theory of Relativity Critical Theory Th e o X-Bar Theory Attachment Theoryy r26
    27. 27. What is a Theory?• A description of our best understanding about why things are the way they are• Theories are used to predict outcomes of future events• Theories are the starting place for generating new knowledge• How is a theory different from a belief? In theory it can be tested. USAID HEALTH CARE IMPROVEMENT PROJECT27
    28. 28. Driver Diagram - a tool to visualize our Theory 28 USAID HEALTH CARE IMPROVEMENT PROJECT
    29. 29. Appreciation• ―Every system is perfectly of a System designed to achieve the results it gets‖ » Paul Batalden Building Knowledge Psychology Understanding Variation 29 USAID HEALTH CARE IMPROVEMENT PROJECT
    30. 30. Complex Dynamic Systems• Step 1 – Everyone stand up• Step 2 – Without speaking; pick two people but don’t say who they are or point at them (Keep it a secret)• Step 3 - Move to be equidistant from both of the people USAID HEALTH CARE IMPROVEMENT PROJECT30
    31. 31. Complex Dynamic Systems Exercise• What was the aim of this system?• What realizations did you have about the systems?• What were the interdependencies among members of the system?• Why did it take so long to accomplish the aim?• How many elements of the system changed when one person moved?• Can you illustrate a similar experience with in your organization or organizations you work with? USAID HEALTH CARE IMPROVEMENT PROJECT31
    32. 32. Organization as a System Need Purpose of the Market Organization Plan to ResearchDriver ImproveProcess Design & Redesign of Measurement Processes, & Feedback Suppliers Products & Services A BMainstay Production of Product or Service DistributionProcess C Outcome for D Clients E F GSupport Support ProcessProcess ©API, Inc. 2002 All Rights Reserved 32 USAID HEALTH CARE IMPROVEMENT PROJECT
    33. 33. Why go to the trouble of developingthis understanding?―If each part of a system, considered separately, ismade to operate as efficiently as possible, the systemas a whole will not operate as effectively as possible.‖ Russell L Ackoff USAID HEALTH CARE IMPROVEMENT PROJECT33
    34. 34. Appreciation of a System• Everything we observe or measure varies• How do we know when to Building Knowledge Psychology act on our observations?• Plotting data over time Understanding Variation 34 USAID HEALTH CARE IMPROVEMENT PROJECT
    35. 35. USAID HEALTH CARE IMPROVEMENT PROJECT
    36. 36. Displaying data over time - Run charts # treated for Malaria # treated for Malaria 125 125 100 100 75 75 50 50 25 25 0 # children treated for Malaria 0 Nov Aug Apr May Jul Dec Feb Sep Mar Oct Jun Jan Jul Nov Feb Apr Aug Sep Dec May Mar Oct Jun Jan125100 Change Change75 Made Made5025 0 # treated for Malaria # treated for Malaria Mar Sep 125 125 100 100 Change to process made 75 75 in June 50 50 25 25 0 0 May Nov Aug Apr Jul Dec Feb Sep Mar Oct Jun Jan Mar Oct May Nov Aug Apr Jun Jan Jul Dec Feb Sep Change Made Change Made USAID HEALTH CARE IMPROVEMENT PROJECT 36
    37. 37. If we don’t understand the variationthat lives in our data, we will betempted to• Deny the data (It doesn’t fit my view of reality!)• See trends where there are no trends• Try to explain natural variation as special events• Blame and give credit to people for things over which they have no control• Distort the process that produced the data• Kill the messenger!• Miss opportunities for improvement37 USAID HEALTH CARE IMPROVEMENT PROJECT
    38. 38. 38
    39. 39. A model for improvingany process or system 39
    40. 40. The Model for Improvement Developed by Associates in Process Improvement and discussed in depth in The Improvement Guide, Jossey-Bass, 2009 (2nd ed.) USAID HEALTH CARE IMPROVEMENT PROJECT40
    41. 41. P-D-S-A USAID HEALTH CARE IMPROVEMENT PROJECT41
    42. 42. What makes this cycle work• Testing on a small scale allows you to know whether you idea can work—gives you a way to try out your ideas to improve the system before deciding to implement• Allows you to know quickly whether your change will work or not and even to try out ways to make it work better• Stating theories or assumptions helps us design tests-- tests to validate our theories/assumptions• The more knowledge one has about how the system under study, the better the prediction• Comparing predictions to results is a key source of learning USAID HEALTH CARE IMPROVEMENT PROJECT42
    43. 43. Question 1: What are we trying toaccomplish?• Be specific• Focus more narrowly on what is in your power to change• Don’t try to tackle a really big aim all at once— rather, break your problems into a series of discrete aims that build on each other USAID HEALTH CARE IMPROVEMENT PROJECT43
    44. 44. Question 2: How will we know a change isan improvement?• ―No data, no improvement‖—Measurement is critical to tracking change• You may need to capture data you don’t normally collect, such as data about a specific step in a process, or information from a specific group of people• Then continually measure, looking at data from each test, to see if things get better—see if your aim is accomplished USAID HEALTH CARE IMPROVEMENT PROJECT44
    45. 45. Question 3: What changes can we make thatwill result in an improvement?• This is the creative part, where it helps to break out of your usual thought process• Sources of ideas for changes to test:  Identifying underlying challenges (root cause analysis)  People who providing the service  Clients  Others who do it well  Guidelines, literature  Creativity methods  Change ideas/concepts USAID HEALTH CARE IMPROVEMENT PROJECT45
    46. 46. Change concepts from The Improvement GuideIdeas for change Ways of implementing the ideaDo things right Use and communicate standards. Spell out procedures. Use reminders. Build in ways to help people do things right. Think of ways to help people get better at their tasks. Reduce demotivating aspects of the way work is organized.Do the right things Set priorities consistent with organizational goals; do the important things first and don’t get sidetracked; listen to clients to understand what they want.Do away with things Stop doing things that don’t add value; eliminate things that are not used; notice any wasteful steps and stop doing them; eliminate multiple data entry; change the order of steps to increase efficiency.Do things better Give careful thought to your work: ask, Why is it done this way? Is there a better way? Listen to customers and coworkers; consider suggestions with an open mind. Look for opportunities to improve.Do things other Find out what are the best practices for your work. Who does them?people are doing Copy successful ideas. Make time for study and learning.Do things that Consider how new technologies could help. Be open to ―crazy‖ ideashaven’t been done that may not be immediately possible. When a possibility appears, ask, Why not? USAID HEALTH CARE IMPROVEMENT PROJECT 46
    47. 47. Organize your test• Plan your test—who will do it, when; questions to be answered; your predictions for the answers; how you will collect data on your test• Do—implement your plan. Record what happens, including unexpected things.• Study—look at your data and compare with your predictions. What did you learn? What can you do now?• Act—decide what to do next (which often is, repeat the cycle with a new change) USAID HEALTH CARE IMPROVEMENT PROJECT47
    48. 48. Repeated Use of the PDSA Cycle Changes That Result in AP Improvement SD Implementation of Change Wide-Scale Tests of Change AP Hunches SD Follow-up Theories Tests Ideas Very Small48 Scale Test
    49. 49. Applying this in real life:An example from Ethiopia 49
    50. 50. Focus on “SYSTEMS THINKING” Model of a system The sum of all elements (including processes) that interact together to produce a common goalQualityimprovement Process Outcomes A series or The outputsInputs sequence (services/products)Resources through which and outcomes (healthnecessary to inputs are outcomes) result fromcarry out a transformed the inputs andprocess into outputs. processes. USAID HEALTH CARE IMPROVEMENT PROJECT 50
    51. 51. Community Health System Savings & Credit Group $ Local Government CHW Women’ sSchools Group Religious Community Local Health Clinic
    52. 52. Community QI team Members Kebele DevelopmentGaree Leaders Administration Agent Health Community QI team members Extension Gare leader, Kabele manager, workers religious, school Health Facility staff IDIR Saving and Credit Religious Groups Groups 52
    53. 53. Community Quality ImprovementElements of QI:• QI Teams• Coaches• Regular QI Team Meetings• Testing Improvements (PDSA Cycle)• Participate in Learning Sessions USAID HEALTH CARE IMPROVEMENT PROJECT53
    54. 54. QI Implementation Activities TimelineBL LS LS LS EL Coaching Coaching Coaching Coaching Coaching Coaching Coaching Coaching Coaching Coaching Coaching Coaching QI QI QI QI QI QI QI QI QI QI QI QI m m m m m m m m m m m m 3rd 6th 9th 12th 1st month month month month month USAID HEALTH CARE IMPROVEMENT PROJECT 54
    55. 55. QI Team Members QI Team Meeting55
    56. 56. Processes : Community Health System Referral Health CenterHealth Post QI Team Follow up Referral Village USAID HEALTH CARE IMPROVEMENT PROJECT
    57. 57. Process map Fishbone diagram 3. What changes will lead 2. What are we trying to to an improvement? accomplish? Tools Desired Performance Inputs Processes Outcome Present Performance 4. How do we know if 1. Why do you need there is improvement? improvement?57
    58. 58. Pregnant women identified by Community Group QI team Member drawing line chart Line chart with annotated change ideas Indicators 1. Indicator 1: % of pregnant women who visited health post 2. Indicator 2: % of pregnant women who received ANC service at the health center 3. Indicator 3: % of pregnant women tested for HIV 4. Indicator 4: % of post natal women visited by HEWs 5. Indicator 5: % of HH who have latrine (any type of latrine) 6. Indicator 6: % HH using properly built latrine 58
    59. 59. First Learning Session USAID HEALTH CARE IMPROVEMENT PROJECT59
    60. 60. Show improvement by using local materials QI team Line chart showing improvement USAID HEALTH CARE IMPROVEMENT PROJECT60
    61. 61. Change ideas developed in EthiopiaAchieved improvement by using the following change ideas: • Gare leaders (part of a Kebele administration) reach out to pregnant women in their catchment areas and refer them to the health post • Idir (funeral management group) identify pregnant women in the Idir at bi-weekly meeting • Religious leaders asked to encourage families of pregnant women who have not been reached with other mechanisms USAID HEALTH CARE IMPROVEMENT PROJECT
    62. 62. Line charts showing change ideas and improvement % of pregnant women who attended ANC service at Alengo Health Post, Tullu Kebele X-axis: % of pregnant women who received ANC Y-axis: time (months starting Oct, Nov, Dec, Jan) Change ideas: house to house visit, Idir, Women group 62
    63. 63. Table Exercise• Your NGO supports a community health worker (CHWs) program in a rural area. One of the tasks that the CHWs perform is to counsel families on seeking care when young children have respiratory symptoms.• The nearest health post sees a lot of children with pneumonia, and most come in after the child has been sick for 2 days or more.• The aim of your improvement project: Increase early detection and treatment in the community of young children with pneumonia, from 20% of children treated within 24 hours of onset to 80%.• To know your changes have resulted in improvement, you will measure the % of children under two with fever and difficult or rapid breathing who receive treatment within 24 hours of onset of symptoms (# who received early treatment/# who needed treatment). USAID HEALTH CARE IMPROVEMENT PROJECT63
    64. 64. Discuss at your table1. Who should be on your improvement team?2. How would you develop changes to test? What are ways you could develop good ideas?3. How would you implement your test? USAID HEALTH CARE IMPROVEMENT PROJECT64
    65. 65. Wrap-up• Report back: – What did you decide about team members? – How would you have developed changes? – What would it take to organize and implement one or more tests of your proposed changes?• Final thoughts• Resources to learn more USAID HEALTH CARE IMPROVEMENT PROJECT65

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