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1. MANAGEMENT FOR INTERNATIONAL PUBLIC HEALTH
COURSE
SUSTAINABLE
MANAGEMENT
DEVELOPMENT
PROGRAM

2. This workshop will teach you how to improve work
processes in your organization.
When you complete this workshop you will:
 Define a process
 Measure process performance
 Analyze causes of variation
 Implement changes
 Study the results of changes
 Act according to the results of the study
 Apply at least three process improvement tools to achieve
the above objectives

3.  Day 1
 Defining a process
 Day 2
 Defining a process (continued)
 Measuring process performance
 Day 3
 Analyzing causes of variation
 Generating and planning improvement
 Implementing, studying, and acting
accordingly

4.  A systematic, data-based method
for improving the quality of work processes.
 It uses team decision-making to improve processes
that affect the quality of products and services for a
customer.

5.  Satisfying the customers’ wants and needs for
products and services
while at the same time
 achieving the technical standards for public health
practice

6. Define Process
Measure
Process
Performance
Analyze
Causes of
Variation

7. PROCESS IMPROVEMENT RESULT
Allocate pediatric ward
beds
Introduced protocol on interdepartmental
referrals and collaboration
Availability of beds
balances demand
Collect sputum
specimens
Health officer & patient education
Increase in TB
patients having
sputum collected
Ensure patients with
mental illness adhere to
medication regime
Implemented patient/community support
systems
Reduced relapses
caused by medication
non-compliance

8.  The seven-step method applied to the delivery of
an antiretroviral therapy (ART) for HIV infection in a
community health clinic

9. PLAN
ACT
STUDY
DO
Analyze Causes
of Variation
Measure
Process
Performance
Define
Process

10. The Tennis Ball Game

11. PROCESS Outputs
Inputs
Customer
The Quality
The Quality
of
of
Inputs
Inputs
Rules
Rules
&
&
Regulations
Regulations
Equipment
Equipment
&
&
Technology
Technology
Competence
Competence
&
&
Motivation
Motivation
Work
Work
environment
environment

12.  A process is a repetitive sequence of activities
leading to desired outcomes for the benefit of
customers.
 Inputs are transformed by the process to achieve
products or services, the outputs.

13. 1. Person arrives at clinic
2. Person registers
3. Counselor provides pre-test counseling
4. Counselor takes blood sample
5. Laboratory staff conducts rapid AIDS test
6. Counselor provides post-test counseling

14.  A systematic, data-based method
for improving the quality of work processes.
 It uses team decision-making to improve processes
that affect the quality of services or products for a
customer.

15. Example 1:
Manage VCT/ART
(Manager’s Perspective)
Example 2:
Deliver VCT & ART
(Client & Counselor
Perspectives)

16. List Your Processes

17.  If we improve this process what will be the impact
on:
 Customer satisfaction
 Satisfaction of other stakeholders
 Waste
 Compliance with technical standards

18.  Does the team have the authority to make
improvements?
 Are resources available to achieve improvement?
 Can significant improvements be achieved quickly and
easily?
 Do the key stakeholders support the improvement
activity?

19. Select Process To Improve

20.  A customer is any person or group who receives a
product or service
 The term is used broadly—no financial transaction
need occur
 Can be internal or external to organization

21. 1. Person arrives at clinic
2. Person registers
3. Counselor provides pre-test counseling
4. Counselor takes blood sample
5. Laboratory staff conducts rapid AIDS test
6. Counselor provides post-test counseling

22. Defining Customers

23. Products and services can be tangible or intangible - a
thing, information, knowledge, a procedure, or a
function
 Examples:
 Pharmaceuticals
 Test results
 Free condoms
 Public health information
 Outbreak investigation procedures
 Medical protocols

24. Identifying Products
and Services

25.  Satisfying the customers’ wants and needs for
products and services
while at the same time
 Achieving the technical standards for public health
practice

26. Customers Wants
and Needs

27. A stakeholder is one person, or group of persons,
having an interest or concern in a particular process
resulting from some direct or indirect involvement.

28.  Suppliers provide goods, services,
and information to the organization or process
 They do not carry out the work

29.  Providers comprise key staff including
professionals, managers, partners, and
subcontractors.
 They carry out the process.

30.  Controllers define, regulate, and influence the
organization or process.
 Controllers include regulators, legislators, funding
agencies, expert advisory committees, and trustees.
 Technical standards are often set by the
“controllers”

31. VCT Clinics
Pharmaceutical companies
Laboratory supply
companies
Funders
People living with
HIV/AIDS
Family/relatives
Community
Physicians & nurses
Counselors
Phlebotomists & laboratorians
Pharmacists
Ministry of Health
Regional & District Health
PEPFAR/Global Fund
Clinical Advisory Committee
HIV/AIDS Advocacy Groups
Suppliers Customers
Controllers
Providers
Provide
Antiretroviral
Therapy

32.  E-mail
 Surveys
 Questionnaires
 Observing stakeholders, especially customers
 Visits
 Experiencing the service as a customer

33. Identifying Stakeholders

34.  Read the section on measuring good practices on
page 28 of your workbooks.
 Use the notes section in your workbooks (page 29)
to record any questions you have as a result of your
reading.

36. Day 2

37.  What were the main learning points from
yesterday’s training?
 What is the definition of quality?
 What is the definition of process improvement?

38. PLAN
ACT
STUDY
DO
Analyze Causes
of Variation
Measure
Process
Performance
Define
Process

39.  A flowchart gives you:
 An understanding of how a process works
 The sequence of all the steps, including feedback paths
 Clear data collection points
 Ideas for improvement
 A flowchart can show an existing process, a new
process, or a change to a process.

40. The activity is in a rounded
rectangle because it is the
start of the flowchart.
Arrows link symbols
and show the
directions of the flow

41. Because this is an
activity it is drawn
as a rectangle
Patient arrives for
counseling
Provide pre-test
counseling

42. Because this is a
decision it is drawn in
a diamond with two
outcomes
Patient arrives for
counseling
Provide pre-test
counseling
Agree to
test?
Yes
No

43. If they do not
agree to take the
test but agree to
more counseling
the flow loops
back into
providing more
pre-test
counseling.
This shape is called a
connector. It allows you to
flowchart over many
pages.

44. Flowchart your Process

45. PLAN
ACT
STUDY
DO
Analyze Causes
of Variation
Measure
Process
Performance
Define
Process
Define Process Summary
Define Process Summary

 Processes identified
Processes identified

 A process selected
A process selected

 Customers defined
Customers defined

 Products and services identified
Products and services identified

 Customers’ wants and needs
Customers’ wants and needs
understood
understood

 Other stakeholders identified
Other stakeholders identified

 Existing process is understood
Existing process is understood

46. PLAN
ACT
STUDY
DO
Analyze Causes
of Variation
Measure
Process
Performance
Define Process

47.  Measure what is important
 Check data with operational definition
 Keep it simple if you can
 Minimal interference
 Normal conditions
 Don’t reinvent the wheel

48.  No data - design a method for collection
 Create operational definitions
 Low numbers - show raw numbers, not percents
 Use graphs
 Don’t average percentages

49. Desired
Current

50.  The customers’ needs and reasonable expectations
 Other key stakeholders’ requirements
 The technical standards
 From within the process

51.  Generated from the voice of the customers and
their wants and reasonable needs.
 These typically include effective treatment, a safe
environment, timely care, confidentiality, respect
and dignity.

52.  Generated from key stakeholders’ wants.
 Often it is the funding agencies’ measures receive
priority.

53.  Generated from best practices as defined by
scientific research.
 These measures are often disease-specific and
based on medical protocols

54.  Taken at key points in the process
 They are not usually of direct interest to customers
and other stakeholders.
 They are selected because they have a significant
impact on the process outcomes.

55. Identify Measures

56. 1. The difference between your actual and your
desired performance.
2. The feasibility of making a dramatic improvement.
3. The importance set by customers, and other
stakeholders, such as a funding agency.
4. The impact that an improvement could have on the
overall performance of the process.
5. The feasibility of measurement. Is it possible? Do
you have data? Will it take a lot of time?

57. Select a Measure

58.  Read the sections on measurement tools (check
sheet, stratification, Pareto) from pages 35 to 40 of
your workbooks.
 Use the notes section in your workbooks to record
any questions you have as a result of your reading.

59.  Common causes result from the process itself
 They are inherent in the design, implementation, and operation of the
process.
 Common cause variation remains the same from day-to-day.
 Special causes come from sources outside the
process.
 They relate to some special event.
 It is sensible to investigate the actual reason for the variation.

60.  Monitor the process.
 Help distinguish between special and common
causes of variation.
 Provide the evidence as to whether an
implemented improvement idea has been
successful or not.

61.  A “run” exists when a number of consecutive
points lie on one side of the mean.
 If significant the “run” could indicate a special
cause or the start of a common cause shift.

62. Number of data
points
Run length is significant if there are this
many consecutive data points above or
below the mean
10 5
20 7
50 10

63. Dec 2004. This point is well
above any others and is likely to
be special. Something happened
during this month that was
attributable to special event.
Mean = 960 based on 11 data
points excluding the special
cause

64. From this point on 6
points are above the
previous mean. There
are 18 points so a run
of 6/7 should be a
signal.

65. Mayor
receives
VCT

66. Mayor
receives
VCT
National
campaign

67. Target
Mean

70.  Problem Statement
 From Jan 04 to Aug 05 only 48.5% of our clinic’s patients
were adhering to ART when the technical standard
specifies 70%.
 Improvement Objective
 We will improve the ART adherence for our clinic from a
mean of 48.5% to 70% by the end of May 2006.

71. Prepare a Problem
Statement and an Improvement
Objective

72. PLAN
ACT
STUDY
DO
Analyze Causes
of Variation
Measure
Process
Performance
Define Process
Measure Process Performance Check List
Measure Process Performance Check List

 Measure selected
Measure selected

 Data collected
Data collected

 Data analyzed and presented
Data analyzed and presented

 Problem stated
Problem stated

 Improvement objective stated
Improvement objective stated

74. Day 3

75.  What were the main learning points from
yesterday’s training?
 What kinds of information does a flowchart
provide?
 What are the four sources of measures?

76. PLAN
ACT
STUDY
DO
Analyze
Causes of
Variation
Measure
Process
Performance
Define Process

77. VCT Clinic not
able to meet
the new targets
set by the
ministry of health
Power outages
RECORDS STAFFING
ENVIRONMENT LAB SUPPLIES
Data collection
incomplete
Staff have additional
duties
Shortage of
space
Interruptions in supply
of test kits
Reagent shortages
High turnover of nurses

78.  T - totally within your control to improve
 P - partially within your control
 N - not in your control
 Focus on T or P causes.
 N’s can be assigned to other teams or individuals.

79.  High turnover of nurses (N)
 Interruptions in supply of test kits (N)
 Reagent shortages (P)
 Shortage of space (N)
 Power outages (N)
 Staff have additional duties (P)
 Data collection incomplete (T)

80. Mean
adherence
is 48.5%
when the
technical
standard
specifies 70%
Drug Supply
Environment
Communication
Workforce
Patient Health
Finance
Low level of patient knowledge (P)
Unstable living
Environment (N)
Remote geography (N)
Stigma (P)
Poor education
materials (P)
Poor communication
channels (T)
Lack of social support (P)
Inappropriate language
and culture (P)
Cost of staffing (N)
Drug interactions (P)
Mental health (P)
Side effects (P)
Other non-HIV/AIDS
Illness (P)
Lack of staff
to monitor (N)
Lack of staff
to provide
Support (N)
Unreliable
Logistics (N)
Bureaucracy (N)
Conflicts/wars (N)
Cost of latest drugs (N)
Cost of
Infrastructure (N)
Cost of technology (N)
Drug intolerance (N)

81. Explore the Causes

82. 1. Record list for everyone to see.
2. Eliminate duplications.
3. Each member is allowed a number of votes equal to
approximately 1/3 the number of causes.
4. Provide individuals with markers (i.e., sticky notes,
dots, etc.). – 1 per vote.
5. Each individual uses their dots to select the items they
consider important. All dots can be placed on one item
or spread among many.

83. Select a Critical Cause

84.  Totally or partially under its control
 It will deliver an improvement which is expected to
have the greatest impact on:
 customers’ needs and reasonable expectations; and,
 performance to technical standards.

85. PLAN
ACT
STUDY
DO
Analyze
Causes of
Variation
Measure
Process
Performance
Define Process Analyze Causes of Variation Checklist
Analyze Causes of Variation Checklist

 Many possible causes of
Many possible causes of
variation generated
variation generated

 Critical causes agreed
Critical causes agreed

 Critical causes have been
Critical causes have been
verified where possible
verified where possible

86. PLAN
ACT
STUDY
DO
Analyze
Causes of
Variation
Measure
Process
Performance
Define Process

87. PLAN
DO
STUDY
ACT

88. Generate Improvement Ideas

89. 1. Start with the end in mind—List the project
objective.
2. Determine the resources required to complete it.
3. Determine the tasks needed in order to complete
the project.
4. Continue to break tasks down in order to identify
specific resource requirements.

90. Plan Improvement Project

91. PLAN
ACT
STUDY
DO
Analyze
Causes of
Variation
Measure
Process
Performance
Define Process
Planning Checklist
Planning Checklist

 Brainstorm improvement ideas.
Brainstorm improvement ideas.

 Agree on ways to address the
Agree on ways to address the
critical causes.
critical causes.

 Create a work breakdown
Create a work breakdown
structure (WBS)
structure (WBS)

92. PLAN
ACT
STUDY
DO
Analyze Causes
of Variation
Measure
Process
Performance
Define Core
Process

93. PLAN
ACT
STUDY
DO
Analyze Causes
of Variation
Measure
Process
Performance
Define Core
Process Implement Change Checklist
Implement Change Checklist

 Changes communicated
Changes communicated

 Training conducted if needed
Training conducted if needed

 Change implemented
Change implemented

 Data collected
Data collected

94. PLAN
ACT
STUDY
DO
Analyze Causes
of Variation
Measure
Process
Performance
Define Core
Process

95. How Well Did You Do?

96. PLAN
ACT
STUDY
DO
Analyze Causes
of Variation
Measure
Process
Performance
Define Core
Process
Study Results of Change Checklist
Study Results of Change Checklist

 Improvement objective
Improvement objective
reviewed
reviewed

 Data analyzed
Data analyzed

 Findings communicated
Findings communicated

97. PLAN
ACT
STUDY
DO
Analyze Causes
of Variation
Measure
Process
Performance
Define Core
Process

98.  One – Expected improvement outcome
 Expand pilot
 Communicate
 Incorporate into Standard Operating Procedure
 Two – Not quite expected outcome
 Refine idea
 Run through PDSA again
 Three – No improvement
 Okay
 Refine theory
 Or move onto another process

99. PLAN
ACT
STUDY
DO
Analyze Causes
of Variation
Measure
Process
Performance
Define Core
Process
Act Checklist
Act Checklist

 Improvement successful?
Improvement successful?

 Success communicated
Success communicated

 Procedures updated
Procedures updated

 Training delivered if required
Training delivered if required

100. Storyboard

102.  Training Others
 Applied Projects

103. 1. Return to country.
2. Adapt materials.
3. Arrange teachings of process improvement.
4. Teach process improvement to selected ‘in-country’
trainees.
5. Monitor trainee’s projects (x2) at work site.
6. Use SMDP TA as required.
7. Evaluate trainee’s projects.
8. Graduate trainees.