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Quality Improvement Self-Study Guide for Faculty at Health Worker

Training Institutions
Background
The lack of competency of health care workers to continually improve the care they are providing
contributes to problems such as poor retention in HIV care and treatment or low uptake of highly active
antiretroviral therapy (HAART) among the pediatric HIV-infected population. To date, the majority of work
supported by the Presidents Emergency Plan for AIDS Relief (PEPFAR) in introducing improvement
methods to health workers has been done in the in-service, or on-the-job, setting. As one part of
institutionalizing improvement, health care systems need a critical mass of the health workforce
competent in using improvement approaches to identify and address gaps in care. Developing the core
competencies of health workers in improvement is a key contribution towards institutionalizing
mechanisms to strengthen health systems. The best way to begin systematic competency building is
through integration in pre-service training institutions.
This self-study guide was first developed by the USAID Applying Science to Strengthen and Improve
Systems (ASSIST) Project in Kenya for the faculty of four pre-service medical training institutions. It was
designed to provide faculty with an initial grounding in the theoretical and practical aspects of improving
the quality of health care. A few faculty used the original draft to learn about improvement before a
curriculum development workshop. Revisions were made in examples and text based on their
suggestions.
The guide has been adapted for a general audience and is intended to be used as a first step for faculty
to learn more about improvement methods and approaches before engaging in the development and
integration of an improvement module.
Recommendations for Self-Study
The original intent of the guide was to prepare faculty for the development of QI curricula and lay a
foundation for building competencies to teach QI. However, anyone interested in gaining a deeper
understanding of how to improve health care quality can utilize the resources below. The
recommendations begin with materials that provide an overview of improvement methods and then move
on to resources which provide a more in-depth look at different aspects of improvement. This can be
done at the readers pace.

JULY 2017
This Quality Improvement Self-Study Guide was prepared by University Research Co., LLC (URC) for review by the
United States Agency for International Development (USAID) and authored by Kim Ethier Stover, Lisa Dolan-Branton,
and Prisca Muange of URC under the USAID Applying Science to Strengthen and Improve Systems (ASSIST)
Project, with funding from the U.S. Presidents Emergency Plan for AIDS Relief (PEPFAR). USAID ASSIST is
managed by URC under the terms of Cooperative Agreement Number AID-OAA-A-12-00101. URC's global partners
for USAID ASSIST include: EnCompass, LLC; FHI 360; Harvard T. H. Chan School of Public Health; HEALTHQUAL
International; Initiatives Inc.; Institute for Healthcare Improvement; Initiatives Inc.; Johns Hopkins Center for
Communication Programs; and WI-HER, LLC. The contents of this report are the sole responsibility of URC and do
not necessarily reflect the views of USAID or the United States Government. For more information on the work of the
USAID ASSIST Project, please visit www.usaidassist.org or write assist-info@urc-chs.com.
1. Introduction to improvement: For an introduction to improvement, we recommend that all
faculty take the free online course Improvement Health Care Quality on the Global Health
eLearning site (https://www.globalhealthlearning.org/course/improving-health-care-quality). The
platform is designed for low bandwidth use. The course takes around three hours total and
learners can come and go from the course as their time allows.
2. Implementing improvement: A Modern Paradigm for Improving Healthcare Quality introduces
the reader to how the concepts of improvement are applied in different settings, providing case
examples and tools. This resource describes a four-step process for quality improvement and
how to apply it to increasingly complex problems. This resource is available for free at:
https://www.usaidassist.org/resources/modern-paradigm-improving-healthcare-quality-0 . The
chapters that best build on the topics in the online course are the chapters and subsections
below:
Chapter 2: The Modern Improvement Paradigm
Chapter 4: Quality Improvement (QI) Steps
Chapter 5: Approach A: Individual Problem Solving
Chapter 8: Approach D: Process Improvement
Subsection 9.1: Data collection
Subsection 9.8: Flowcharting
Subsection 9.9: Cause and Effect Analysis
Subsection 9.11: Statistical/Data Presentation Tools; specifically, pages 68-70; 72-73
Following the completion of the online course and reading the specified chapters of A Modern
Paradigm for Improving Healthcare Quality, the faculty can begin the improvement assignment in
the next section. Recommendations in points 4 and 5 are for a deeper understanding of
improvement and measurement for improvement.
3. Country-specific policies and guidelines for improvement: To understand the policy
framework of your specific country, we recommend that you read through any policy documents
or guidelines that have been developed by your countrys Ministry of Health at the national or
regional level. For example, in Kenya this is the Kenya Quality Model for Health Implementation
Guideline.
4. Deeper understanding of improvement: For a deeper
understanding of improvement methods and theories, and the
science and history behind it, we recommend that you read The
Improvement Guide: A Practical Approach to Enhancing
Organizational Performance, with a focus on the following
chapters:

Chapter One: Changes that Result in Improvement


Chapter Two: Skills to Support Improvement
Chapter Four: The Science of Improvement
Chapter Five: Using the Model for Improvement
Chapter Six: Developing a Change
Chapter Seven: Testing a change; and
Chapter Eight: Implementing a Change. These all go
more in-depth on these topics and are recommended if
the faculty has time.

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5. Measurement for improvement: To learn more about measurement for improvement, we
recommend three resources:
Guidance for Analyzing Time Series Charts: A simple overview of the use of time series
charts produced by the USAID Health Care Improvement Project:
https://www.usaidassist.org/sites/assist/files/hci_guidance_for_analyzing_time_series_ch
arts_sept10_0.pdf.
The second recommended resource for a deeper
understanding of measurement is The Health Care Data
Guide: Learning from Data for Improvement. Specifically, we
recommend that you read the following chapters as a starting
point:
o Chapter 2: Using Data for Improvement
o Chapter 3: Understanding Variation Using Run
Charts
o Chapter 4: Learning from Variation in Data
o Chapter 11: Learning from Patient Feedback to
Improve Care
o Chapter 13: Case Studies Using Shewhart Charts
Tips and Tools for Learning Improvement Series, including three handouts on
measurement:
o Measurement for Improvement
o Measurement: Time Series Charts
o Measurement: Variation vs. Improvement
All three can be found at: https://www.usaidassist.org/resources/tips-and-tools-
improvement-series
Assignment
Before in-person discussion of the curriculum on improving health care quality for pre-service students,
we recommend that each of the faculty try to use this approach to improve some aspect of their work in
order to get a better feel for the approach and possible complications. The chosen topic may be in a
personal, professional, or clinical area. Some examples would be:
Personal: getting to work on time; reducing the time to get to work; things that are meaningful to
the quality of life (increase time for pleasure reading, time with significant other/children, exercise
or eating more vegetables).
Professional: process of getting grades submitted on time; faculty meeting efficiency; or
improving record keeping or storage processes.
Clinical: offering HIV testing to all patients admitted in the ward; improving tracking or follow-up
process for HIV patients who have been lost to follow up.

You may do this on your own or with a small team, but we recommend that you keep your initial attempt
at using the Plan-Do-Study-Act (PDSA; small-scale test of change) cycle to improve something simple.
One tool that can assist you with documenting your effort is the QI Team Documentation Journal
(https://www.usaidassist.org/resources/qi-team-documentation-journal).
The assignment below will walk you through a simple improvement effort.
1. Choose an improvement aim: For a first try at using the Model for Improvement, we
recommend that you find a problem that will be relatively straightforward to resolve and which is
under the control of the staff on the improvement team. For example, this might be a patient flow

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problem or an administrative issue, such as record organization and retrieval. When choosing a
problem for this particular exercise, consider the following questions:
Why do you think this is a problem? How do you know?
Is it feasible to address this problem?
Write out: what will you improve, by how much, for whom, by when?
2. Choose a measure: Choose a measure that will let you know whether you are reaching your
aim. Clearly define your numerator, denominator, sources, and frequency of collection. Create a
time series chart to plot data (daily or weekly as appropriate) over time to monitor performance.
3. Choose an improvement team: Think about the process involved and all of the actors that have
a role in that process. Invite them to be on the improvement team.
4. Analyze the problem: Together as a team try to create a flowchart the process. For example, if
you were looking at file retrieval, you would first note the starting point, such as patient is
registered, and then list all of the steps and people involved in retrieving the file and getting it to
the physician. Note any areas that are vague, confusing, or problematic. Choose one problem
area of the process to test changes on.
5. Develop changes based on the results of the flowchart exercise.
6. Conduct and document Plan-Do-Study-Act cycles: As you plan a PDSA cycle, be sure to
include a simple measure that will tell you whether your change has been effective. Develop a
simple format to record your data and plot over time (time series chart), if appropriate. The larger
measure associated with the aim in step 2 may not be sensitive enough to immediately reflect
changes from your small-scale test.

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Example 1: Administrative Process

Problem: In an HIV clinic, the record filing system is set up such that HIV patient records are arranged serially
according to patient clinic identification numbers. Patients coming for clinic appointments have a long waiting
time as the registration officers search for their files before the clinical consultation.

Improvement team: Registration officers, head nurse, clinician, and community health worker

Aim: To reduce client waiting time for clinical consultation by 50% in the next two weeks by retrieving patient files
a day before their scheduled appointments.

Measure: Waiting time for clinical consultation. To record the data, the registration officer will record the time the
patient arrives at the registration desk and the clinician will record the time the patient arrives in the consultation
room. They will record their information in a simple table. The baseline average waiting time for clinical
consultation is 60 minutes.

Change idea: Community health workers will retrieve files for clients who are expected for clinic visits a day
before and arrange them by serial number. During clinic days, the client appointment cards will be received by the
registration officer and handed over to the community health worker on duty to retrieve the particular patient files.

Prediction: This change will reduce client waiting time for clinical consultation to 30 minutes.

Plan:
Who: Registration officers, community health worker
What: The registration officers will provide the appointment diary to the community health worker on duty
to retrieve the files for 10 expected appointments for the following day. These files will be arranged
serially in a box. The registration officer will have a list of the 10 clients included in the test. The
following day, as the clients in the test come in for their appointments, the registration officer will receive
the client appointment reminder cards and retrieve their file.
When: Two days after the QI team meeting; will last for 1 day
Where: HIV Clinic registration desk and file room
Data collection: The registration officer will give the 10 clients in the test a special table to record the
times of their visit, including registration time, start and end of consultation with the provider, and wait
time at pharmacy. The client will leave the card with the pharmacy as s/he picks his medication. At the
end of the day the registration officer will pick all the cards to summarize the waiting times in a summary
table.

Do: On Friday, the registration officers and community health workers retrieved the files for Mondays
appointments as per their plan. On Monday, they recorded the waiting time for clinical consultation.

Monday
Patient Time Patient Time
1 40 6 43
2 32 7 41
3 30 8 35
4 39 9 37
5 34 10 42
Monday average wait time: 37.3 minutes

Study: This change idea reduced the time by around 23 minutes, but they didnt quite reach their goal of reducing
wait time by 50% (30 minutes). Recording the time for when the patient came in and left did take extra time, but
they will only have to do this until they know the new system works.

Act: The team decided that this was a good change. They felt that they needed to try it on a larger scale to see if
they would get the same results. They decided to test the new record retrieval system for one day to see if
having all patients on the same system will improve times further. If they have still not reached their goal of 50%
reduction, they will look at other places where there are delays.

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Example 2: Clinical process

Problem: In a laboratory associated with an HIV clinic, there is a question about whether the lab technicians are
following the proper procedures that could affect the accuracy of the rapid test results.

Improvement team: Laboratory technicians, laboratory supervisor, nurse-in-charge of HIV clinic

Aim: To improve testing using rapid HIV tests in the laboratory within one month by improving compliance with all
steps of a competency-based check list.

Measure: Percent of completed tests where all checklist steps were completed. The team used the new providers
to observe providers for two days to create a baseline. They found that all steps were taken 68% of the time.

Change idea: Introducing a checklist for laboratory technicians to follow while conducting the rapid HIV tests.

Prediction: The checklist will help the laboratory technicians to complete all the steps correctly, leading to more
accurate results of the HIV rapid test.

Plan:
Who: laboratory supervisor, laboratory technicians
What: The laboratory supervisor will provide a refresher training for all staff on the proper procedure for a
rapid HIV test and introduce a checklist.
When: Refresher training and checklist introduction will take place at the next weekly staff meeting. All
laboratory technicians will use the check list for one day.
Where: Laboratory
Data collection: The supervisor will observe each of the three laboratory technicians using the checklist
for the test two times and record whether all steps were followed.

Do: On Tuesday, the laboratory supervisor assesses the rapid test procedure using the checklist on two tests per
lab technician.

Technician observation Completed all steps in checklist

Technician 1 observation 1 Yes

Technician 1 observation 2 No

Technician 2 observation 1 Yes

Technician 2 observation 2 Yes

Technician 3 observation 1 Yes

Technician 3 observation 2 No

Study: During the test and observation, there was some confusion of language for two steps of the checklist.
Sixty-seven percent (67%) of the time, the technicians complete all steps correctly. For the two observations
where the check list was completed, it was noted that the technicians couldnt find the cotton swabs for alcohol to
clean the area. Generally, the team agreed that the checklist was successful and revealed some process
problems with completing the steps of rapid HIV testing correctly.

Act: The team decided that they will continue to use the checklist as it was helpful for the staff. They were going
to fix the language on two steps to make the instructions clearer. They decided to create a permanent place
where the alcohol and cotton swabs would be kept so that no one placed them around the laboratory where
others could not find them. They will test the checklist again for two days, with 4 observations for each technician,
to see if they have improved their compliance to the checklist.

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Additional Resources

Measurement
PDSA Cycles
Improvement
Setting aims

Developing
Situational
Choosing
priorities

changes
analysis
teams
Type
Resource
Improving Health Care Quality (Global Health eLearning course)
Online
https://www.globalhealthlearning.org/course/improving-health-care- X X X X X X
course
quality
The Improvement Guide: A Practical Approach to Enhancing
Organizational Performance
Langley GJ, Moen RD, Nolan KM, Nolan TW, Norman CL, Provost LP. Book X X X X X X
2009. The Improvement Guide: A Practical Approach to Enhancing
Organizational Performance Second Edition. San Francisco, CA:
Jossey-Bass.
A Modern Paradigm for Improving Healthcare Quality
Massoud R, Askov K, Reinke J, Franco LM, Bornstein T, Knebel E,
Macaulay C. 2001. A Modern Paradigm for Improving Healthcare
Quality. QA Monograph Series 1(1). Published for the US Agency for Monograph X X X X X X X
International Development by the Quality Assurance Project. Bethesda,
MD: Center for Human Services.
https://www.usaidassist.org/resources/modern-paradigm-improving-
healthcare-quality-0
The Health Care Data Guide: Learning from Data for Improvement
Provost L, Murray S. 2011. The Health Care Data Guide: Learning from Book X
Data for Improvement. San Francisco, CA: Jossey-Bass.
USAID ASSIST Project website Web
X X X X X X X
www.usaidassist.org resource

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Measurement
PDSA Cycles
Improvement
Setting aims

Developing
Situational
Choosing
priorities

changes
analysis
teams
Type
Resource
Tips and Tools for Learning Improvement Series Exercises for
https://www.usaidassist.org/resources/tips-and-tools-improvement- learning X X X X X X
series improvement

Institute for Healthcare Improvement (IHI) website Web


X X X X X X
http://www.ihi.org/resources/Pages/HowtoImprove/default.aspx resource

Quality Improvement Toolkit (IHI)


http://www.ihi.org/resources/Pages/Tools/Quality-Improvement- Toolkit X X X X X X
Essentials-Toolkit.aspx
Guidance for Analyzing Quality Improvement Data
Using Time Series Charts Short report X
https://www.usaidassist.org/sites/assist/files/hci_guidance_for_analyzing
_time_series_charts_sept10_0.pdf
Tools for Analyzing a System or Process
Tools X
https://www.usaidassist.org/content/tools-analyzing-system-or-process
Tools for Developing and Selection Solutions
https://www.usaidassist.org/content/tools-developing-and-selecting- Tools X
solutions

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