1. Moving from “lack of resources” to
“resourcefulness”: How to improve
quality 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
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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
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3. How do you define
quality?
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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?
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5. Dimensions of Quality
Institute of Medicine Additional
Equitable Accessible
Safe Technically sound
Timely Effective
Affordable Sustainable
Efficient Consistent
Patient Centered
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6. USAID HEALTH CARE IMPROVEMENT PROJECT
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7. USAID HEALTH CARE IMPROVEMENT PROJECT
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8. USAID HEALTH CARE IMPROVEMENT PROJECT
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9. USAID HEALTH CARE IMPROVEMENT PROJECT
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10. USAID HEALTH CARE IMPROVEMENT PROJECT
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11. USAID HEALTH CARE IMPROVEMENT PROJECT
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15. Dimensions of Quality
Institute of Medicine Additional
Equitable Accessible
Safe Technically sound
Timely Effective
Affordable Sustainable
Efficient Consistent
Patient Centered
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16. Approaches to
Improvement
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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
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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
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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
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20. The science of
improvement (and some
theory)
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21. Deming’s System of Profound Knowledge
Appreciation
of a system
Building
Knowledge Psychology
Understanding
Variation
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22. Two Types of Knowledge
Subject Matter Knowledge Technical knowledge.
Subject Matter
Knowledge
Knowledge for
Improvement
Knowledge for Improvement The interaction of the
theories of systems, variation, knowledge, and
psychology.
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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
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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
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25. Appreciation
• What do people know? of a System
• How do people know?
• How do we acquire
knowledge? Building
Knowledge Psychology
Understanding
Variation
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26. Personality Theory TRUTH THEORY
Ch a o
Macroeconomic Theory s
Theory of Relativity Critical Theory
Th e o
X-Bar Theory Attachment Theoryy
r
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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.
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28. Driver Diagram - a tool to visualize our Theory
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29. Appreciation
• ―Every system is perfectly of a System
designed to achieve the
results it gets‖
» Paul Batalden
Building
Knowledge Psychology
Understanding
Variation
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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
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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?
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32. Organization as a System Need
Purpose of the
Market
Organization
Plan to Research
Driver Improve
Process Design & Redesign of Measurement
Processes, & Feedback
Suppliers Products & Services
A
B
Mainstay
Production of Product or Service Distribution
Process C
Outcome for
D Clients
E
F
G
Support Support Process
Process
©API, Inc. 2002 All Rights Reserved
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33. Why go to the trouble of developing
this understanding?
―If each part of a system, considered separately, is
made to operate as efficiently as possible, the system
as a whole will not operate as effectively as possible.‖
Russell L Ackoff
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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
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35. USAID HEALTH CARE IMPROVEMENT PROJECT

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
Jan
125
100
Change Change
75
Made Made
50
25
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
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37. If we don’t understand the variation
that lives in our data, we will be
tempted 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 improvement
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38. 38

39. A model for improving
any process or system
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40. The Model for Improvement
Developed by
Associates in
Process
Improvement and
discussed in depth in
The Improvement
Guide, Jossey-Bass,
2009 (2nd ed.)
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41. P-D-S-A
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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
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43. Question 1: What are we trying to
accomplish?
• 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
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44. Question 2: How will we know a change is
an 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
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45. Question 3: What changes can we make that
will 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
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46. Change concepts from The Improvement
Guide
Ideas for change Ways of implementing the idea
Do 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‖ ideas
haven’t been done that may not be immediately possible. When a possibility appears, ask,
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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)
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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 Small
48 Scale Test

49. Applying this in real life:
An example from Ethiopia
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50. Focus on “SYSTEMS THINKING”
Model of a system The sum of all elements
(including processes) that
interact together to produce
a common goal
Quality
improvement
Process Outcomes
A series or The outputs
Inputs sequence (services/products)
Resources through which and outcomes (health
necessary to inputs are outcomes) result from
carry out a transformed the inputs and
process into outputs. processes.
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51. Community Health System
Savings &
Credit Group
$ Local
Government
CHW
Women’
s
Schools Group
Religious Community Local Health Clinic

52. Community QI team Members
Kebele Development
Garee 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
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53. Community Quality Improvement
Elements of QI:
• QI Teams
• Coaches
• Regular QI Team Meetings
• Testing Improvements (PDSA Cycle)
• Participate in Learning Sessions
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54. QI Implementation Activities Timeline
BL 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
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55. QI Team
Members
QI Team
Meeting
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56. Processes : Community Health System
Referral
Health Center
Health Post
QI Team Follow up
Referral
Village USAID HEALTH CARE IMPROVEMENT PROJECT

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?
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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
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59. First Learning Session
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60. Show improvement by using local materials
QI team
Line chart showing
improvement
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61. Change ideas developed in Ethiopia
Achieved 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
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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
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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).
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64. Discuss at your table
1. 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?
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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
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