Moving from "Lack of Resources" to "Resourcefulness"_Chamrad_Shrestha_Marquez_5.1.12

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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

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?

• 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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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 PROJECT6










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


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


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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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)

Appreciation of a system

Understanding Variation

BuildingKnowledge Psychology

V

alues

Deming’s System of Profound Knowledge


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





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



V

alues


• What do people know? • How do people know? • How do we acquire

knowledge?




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


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


• “Every system is perfectly designed to achieve the results it gets”

» Paul Batalden




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alues



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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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



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



Building Knowledge Psychology

V

alues




Displaying data over time - Run charts

Mar Sep0

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50

75

100

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# children treated for Malaria

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec0

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50

75

100

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# treated for Malaria


25

50

75

100

125



25

50

75

100

125



25

50

75

100

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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


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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P-D-S-A

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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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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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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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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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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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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


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

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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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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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

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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First Learning Session

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Show improvement by using local materials

QI team

Line chart showing improvement

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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

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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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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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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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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Health & Medicine

Moving from "Lack of Resources" to "Resourcefulness"_Chamrad_Shrestha_Marquez_5.1.12