moving from "lack of resources" to...
TRANSCRIPT
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Moving from “lack of resources” to “resourcefulness”: How to improve quality of programs amidst funding
constraints
Diana ChamradSenior QI Advisor for Orphans and Vulnerable Children
Ram ShresthaSenior 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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USAID HEALTH CARE IMPROVEMENT PROJECT
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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How do you define quality?
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• 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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USAID HEALTH CARE IMPROVEMENT PROJECT
Dimensions of Quality
Institute of Medicine Additional
Equitable Accessible
Safe Technically sound
Timely Effective
Affordable Sustainable
Efficient Consistent
Patient Centered
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USAID HEALTH CARE IMPROVEMENT PROJECT
Dimensions of Quality
Institute of Medicine Additional
Equitable Accessible
Safe Technically sound
Timely Effective
Affordable Sustainable
Efficient Consistent
Patient Centered
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Approaches to Improvement
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USAID HEALTH CARE IMPROVEMENT PROJECT
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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USAID HEALTH CARE IMPROVEMENT PROJECT
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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USAID HEALTH CARE IMPROVEMENT PROJECT
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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The science of improvement (and some
theory)
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Appreciation of a system
Understanding Variation
BuildingKnowledge Psychology
V
alues
Deming’s System of Profound Knowledge
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Two Types of Knowledge
Subject Matter Knowledge
Subject Matter Knowledge Technical knowledge.
Knowledge for Improvement The interaction of the theories of systems, variation, knowledge, and psychology.
Knowledge for Improvement
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USAID HEALTH CARE IMPROVEMENT PROJECT
Knowledge for Improvement
Knowledge for Improvement
Subject Matter Knowledge
Learn to combine subject matter knowledge and knowledge for improvement in creative ways to develop effective changes
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• The human side of Change – how do people think, behave and feel as individuals and how do they interact with others?
• It helps us understand and predict: • differences in people• motivations of people and their
behavior• how to gain commitment• learning styles• common thinking errors• how to attract people to change• how people will react to a change • how to form effective teams
Appreciation of a System
Understanding Variation
BuildingKnowledge Psychology
V
alues
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• What do people know? • How do people know? • How do we acquire
knowledge?
Appreciation of a System
Understanding Variation
BuildingKnowledge Psychology
V
alues
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Theory of EvolutionMUSIC THEORY Germ Theory String TheoryPersonality Theory TRUTH THEORY Macroeconomic TheoryTheory of Relativity Critical Theory X-Bar Theory Attachment Theory
Game theory
Chaos Theory
Big Bang Theory
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USAID HEALTH CARE IMPROVEMENT PROJECT
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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Driver Diagram - a tool to visualize our Theory
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• “Every system is perfectly designed to achieve the results it gets”
» Paul Batalden
Appreciation of a System
Understanding Variation
BuildingKnowledge Psychology
V
alues
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USAID HEALTH CARE IMPROVEMENT PROJECT
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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USAID HEALTH CARE IMPROVEMENT PROJECT
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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Organization as a System
Design & Redesign of Processes,Products & Services
Plan toImprove
MarketResearch
Measurement& Feedback
Outcome forClients
Distribution
Support Process
Production of Product or Service
Suppliers
A
B
C
D
E
F
G
NeedPurpose of the Organization
©API, Inc. 2002 All Rights Reserved
DriverProcess
MainstayProcess
SupportProcess
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USAID HEALTH CARE IMPROVEMENT PROJECT
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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• Everything we observe or measure varies
• How do we know when to act on our observations?
• Plotting data over time
Appreciation of a System
Understanding Variation
Building Knowledge Psychology
V
alues
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USAID HEALTH CARE IMPROVEMENT PROJECT
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USAID HEALTH CARE IMPROVEMENT PROJECT
Displaying data over time - Run charts
Mar Sep0
25
50
75
100
125
# children treated for Malaria
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec0
25
50
75
100
125
# treated for Malaria
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec0
25
50
75
100
125
# treated for Malaria
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec0
25
50
75
100
125
# treated for Malaria
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec0
25
50
75
100
125
# treated for Malaria
Change Made
Change Made
Change Made Change
Made
Change to process made in June
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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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A model for improving any process or system
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USAID HEALTH CARE IMPROVEMENT PROJECT
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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USAID HEALTH CARE IMPROVEMENT PROJECT
P-D-S-A
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USAID HEALTH CARE IMPROVEMENT PROJECT
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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USAID HEALTH CARE IMPROVEMENT PROJECT
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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USAID HEALTH CARE IMPROVEMENT PROJECT
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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USAID HEALTH CARE IMPROVEMENT PROJECT
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 serviceClientsOthers who do it wellGuidelines, literatureCreativity methodsChange ideas/concepts
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USAID HEALTH CARE IMPROVEMENT PROJECT
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 people are doing
Find out what are the best practices for your work. Who does them? Copy successful ideas. Make time for study and learning.
Do things that haven’t been done
Consider how new technologies could help. Be open to “crazy” ideas that may not be immediately possible. When a possibility appears, ask, Why not?
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USAID HEALTH CARE IMPROVEMENT PROJECT
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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Repeated Use of the PDSA Cycle
Hunches Theories
Ideas
Changes That Result in
Improvement
A PS D
APS
D
A PS D
D SP A
DATA
Very Small Scale Test
Follow-up Tests
Wide-Scale Tests of Change
Implementation of Change
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Applying this in real life: An example from Ethiopia
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USAID HEALTH CARE IMPROVEMENT PROJECT
Model of a system
Resources necessary to carry out a process
InputsA series or sequence through which inputs are transformed into outputs.
Process
The sum of all elements (including processes) that interact together to produce a common goalQuality
improvement
The outputs (services/products) and outcomes (health outcomes) result from the inputs and processes.
Outcomes
Focus on “SYSTEMS THINKING”
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Schools
Religious Community
Women’s
Group
Local Health Clinic
$Savings & Credit Group
Local Government
CHW
Community Health System
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Community QI team membersGare leader, Kabele manager, religious, school
Community QI team Members
Kebele Administration
Development Agent
Religious Groups
IDIR
Saving and Credit Groups
Garee Leaders
Health Extension workers
Health Facility staff
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USAID HEALTH CARE IMPROVEMENT PROJECT
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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USAID HEALTH CARE IMPROVEMENT PROJECT
LS LS LS
QI m
QI m
QI m
QI m
QI m
QI m
QI m
QI m
QI m
QI m
QI m
QI m
BL
Coaching Coaching Coaching Coaching Coaching Coaching Coaching Coaching Coaching Coaching Coaching Coaching
EL
3rd month
6th
month9th
month12th month
1st month
QI Implementation Activities Timeline
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QI Team Members
QI Team Meeting
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USAID HEALTH CARE IMPROVEMENT PROJECTVillage
Processes : Community Health System
QI Team
Health Post
Follow up
Health Center
Referral
Referral
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Present Performance
Desired Performance
1. Why do you need improvement?
2. What are we trying to accomplish?
Inputs Processes Outcome
3. What changes will lead to an improvement?
Process map
Fishbone diagram
4. How do we know if there is improvement?
Tools
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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
Indicators
Pregnant women identified by Community Group QI team Member drawing line chart
Line chart with annotated change ideas
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USAID HEALTH CARE IMPROVEMENT PROJECT
First Learning Session
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USAID HEALTH CARE IMPROVEMENT PROJECT
Show improvement by using local materials
QI team
Line chart showing improvement
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USAID HEALTH CARE IMPROVEMENT PROJECT
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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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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USAID HEALTH CARE IMPROVEMENT PROJECT
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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USAID HEALTH CARE IMPROVEMENT PROJECT
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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USAID HEALTH CARE IMPROVEMENT PROJECT
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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