The document discusses strategies for identifying and prioritizing problems related to maternal mortality within healthcare facilities, emphasizing the need for effective problem statements and aim statements to guide quality improvement efforts. Participants engage in exercises that leverage quality dimensions, data analysis, and prioritization tools like the Pareto chart to determine focal areas for improvement. Ultimately, the document underscores the importance of structured approaches in addressing healthcare quality issues to enhance patient outcomes.

1. Problem Identification, Prioritization
and Aim Setting

2. Plenary Discussion
 You have had an ongoing problem with
frequently occurring maternal mortalities
(more than 3 per month) in your facility. You
have been tasked to bring a solution to this
problem.
 What should be done differently to reduce
maternal deaths in the facility?
 Time: 5 minutes

3. Module Objectives
 Use appropriate problem identification and
prioritization tools for aim setting
 Identify problems using the dimensions of quality
 Utilize different types of data to identify problems
 Apply tools to prioritize problems
 Formulate problem statement
 Formulate aim statement for identified problems

4. Introduction
A problem is
“ the difference between things as perceived and
things as desired”
Gause and Weinberg (1989)
“ the gap between the existing state and the
desired state of a process”
Health Quality Ontario

5. Problem Identification

6. Problem Identification in QI
 What to improve?
 Need to identify the opportunity for improvement
 Effectiveness issues: system does not deliver
according to performance expectations
 Efficiency issues: system uses too many
resources to deliver its performance
 Responsiveness issues: system does not
address the needs of its clients
Federal Democratic Republic of Ethiopia, Ministry of Health (2017), HSTQ, QI-TC Participants Manual

7. Identify Problems in Quality of Care
Safe
Effective
Efficient
Equitable
Timely
Person
Centered
Six healthcare
quality
dimensions
Institute of Medicine, 2001
Adapted from Institute of Medicine (2001) Six Healthcare Quality Dimensions

8. Small Group Exercise
 Form groups of 3-5 participants
 Use the 6 dimensions of Quality Care and
brainstorm about existing performance gaps
in the Ethiopian Healthcare System (or
specifically the facility/organization they work)
 Time: 10 minutes

9. What Tool to Use?
Common tools for problem identification and
prioritization:
 Data from various sources
 Observation/ Walk through
 Pareto Chart
 Prioritization matrix
 Process map
 Root cause analysis – fishbone, 5 WHYs

10. Small Group Exercise – Data use
 Identify Problems using Data sources –
registers
 Work in groups of 3-5 participants
 Use the data provided in the Module 4 Annex,
page 182-185
 Analyze the data and identify an area for
improvement
 Time: 15 minutes

11. Compare Performance with Target (I)
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
0
5
10
15
20
25
30
35
40
45
50
First Trimester Registrants for ANC in Hospital X
1st Trimester registrants Total ANC registrants
Number

12. Observation
Data QI Clinical skills

13. Observation - Walk-through
 Enables providers to better understand the
experience of care from the patients’ and
families’ point of view
 It generates data that address the total
experience of the patient including
frustrations, confusion, anxiety
Adapted from Institute for Healthcare Improvement, Walk-through Tool

14. Prioritization Tools
Pareto Chart and Prioritization
Matrix
~~~~~~Vilfredo Pareto~~~~~~
If you’re Noah, and your ark
is about to sink, look for the
elephants first, because you
can throw over a bunch of
cats, dogs, squirrels, and
everything else that is just a
small animal and your ark
will keep sinking. But if you
can find one elephant to get
overboard, you’re in much
better shape.

15. Pareto Principle
 A small amount of effort accounts for most of
the results.
 80/20 rule

16. What is a Pareto Chart?
A graphical tool that helps to prioritize efforts to where
they will have the most impact.
It is made up of three (3) key components:
1. Bar/Column chart – representing
categories/frequencies displayed in order of size
2. Line graph – representing the cumulative percentage
3. Two vertical (y-) axis

17. Steps for Constructing a Pareto Chart
1. List all the possible categories/groups
2. Collect the data – how many of each
3. Arrange the categories/groups from the highest to the lowest
frequency/impact
4. Calculate the total, add up the frequencies
5. Calculate percentage for each category/group
6. Calculate the cumulative percentage
7. Draw the axes – horizontal: categories/groups
vertical left: frequencies/ ‘raw’ data
vertical right: cumulative percentage
8. Plot the data in your graph
9. Label the axes and annotate the graph (specifying the vital few
and useful many)

18. Prepare Pareto Chart (30 min.)
Contributing factor
(Causes of Neonatal deaths) Frequency Percentage
Cumulative
Percentage
Prematurity 49 32.2% 32.2%
Birth Asphyxia 45 29.6% 61.8%
Neonatal Sepsis 31 20.4% 82.2%
Congenital Abnormalities 11 7.2% 89.5%
Pneumonia 9 5.9% 95.4%
Tetanus 4 2.6% 98.0%
Malnutrition 1 0.7% 98.7%
Diarrhea 1 0.7% 99.3%
Birth injury 1 0.7% 100%
Total 152 100%

19. Pareto Chart on Neonatal deaths
 Causes of neonatal deaths in the scenario facility
0
10
20
30
40
50
60
0
20
40
60
80
100
Cause of Neonatal Deaths in 2016
Frequencies
Cumulative
percentage
Useful many
Vital few

20. Priority Matrix
 Which identified problem should be
prioritized?
 Common criteria used to prioritize problems
 Cost and/or gains when resolved
 Availability of solutions
 Availability of resources (staff, time, equipment,
etc.)
 Urgency of solving
 Size of problem
Adapted from National Association of Country & City Health Officials (NACCHO), First Things First

21. Step-by-Step Instructions
1. Create a matrix
2. List the problems vertically and the criteria
horizontally
3. Add one extra column on the right for
priority score
4. Weight the criteria, according to level of
importance
5. Rate the problems for the criteria according
to predetermined rating scale
6. Calculate priority scores
Adapted from National Association of Country & City Health Officials (NACCHO), First Things First

22. Example of Prioritization Matrix
*Rating Scale used: 0-15
Priority Score

23. Small Group Exercise
 Work in groups of 3-5 participants (per facility,
department, organization)
 Brainstorm with your group about prevailing
health problems in your work place
 List the problems and the criteria you use to rank
them
 Develop the prioritization matrix
 Which health problem are you prioritizing and
why?
 Use your project workbook (Annexed)
 Time: 20 minutes

24. Problem Statement

25. Components of Problem Statement
A clear and concise statement that describes
the symptoms of a problem. Guided by the
following questions:
1. What is the problem? What is not functioning as
desired? What are the boundaries? (Size)
2. How do we know it is a problem?
3. How long has it be a problem (time)?
4. What are the effects (impact) of this problem?
5. Where does the problem exist?
6. How will we know the problem is resolved?
Federal Democratic Republic of Ethiopia, Ministry of Health (2017), HSTQ, QI-TC Participants Manual

26. What is does NOT do…
 Does NOT include the causes
 Does NOT include the actions or corrections
required
 Does NOT assign blame
 Does NOT address more than one problem

27. Guiding Questions Example
A team at a hospital X noted a shortage in medication for
Acute Respiratory Infections (ARI) for under five children.
 What is the problem? A shortage of ARI drugs for children under
five
 How do you know it is a problem? Drugs run out by the third
week of the month
 How frequently does it occur? This shortage has occurred every
month for the past nine months
 What are the effects of this problem? Patients develop
complications causing an increase in referrals to a first-level
facility
 How will you know when it is resolved? The problem will be solved
when ARI drugs last until the end of the month
Federal Democratic Republic of Ethiopia, Ministry of Health (2017), HSTQ, QI-TC Participants Manual

28. Examples Problem Statement
Problem Statement Strong?
1. There are many errors in our data
2. Over the past 2 years, only 50% of ANC clients
was tested for HIV in hospital X, leading to high
risk deliveries with potential risk for baby and
health workers to be exposed
3. Maternal clients satisfaction is low
4. Since 3 months Hospital Z had a closed theatre
and an increase in referrals, so far 150 clients
were referred

29. Aim Statement

30. Purpose of Aim Statement
 1st
Principle of Improvement – know why to
improve
 An Aim Statement is an explicit description
with specific actions or focus
 An internal and external communication tool
for the work to be done

31. Components of Aim Statement
Specific
Measureable
Ambitious (Achievable)
Realistic
Time bound

32. Examples of Aim Statements
S M A R T
To increase the percentage of syphilis
tested pregnant mothers attending
ANC from 0% to 80% by the end of
January 2017.
To improve PNC within 48 hours
To increase number of 4th
ANC from
50% to 85% at Y.P. Hospital by the end
of June 2017.
To increase skilled delivery from 68% to
85% by the end of May 2017.
To increase the percentage of
inpatient referral feedback given from

33. Quality Improvement Project Work
Section I – Problem identification,
prioritization and aim statement
 Develop a problem statement and a SMART aim
statement for a problem identified in your
facility/organization
 If relevant use the prioritized problem from the
priority matrix exercise
 Document in your project workbook, subsequent
sessions will build on this (Annexed)
 Time: 20 minutes

34. Summary
 Problem identification is the first step in QI
 Prioritization tools can help focus which
problem to start with
 A good problem statement answers a series
questions including the size, impact, location
and frequency of the problem
 A aim statement should be SMART