International Journal for Quality in Health Care; Volume 19, Number 4: pp. 237 –243 10.

1093/intqhc/mzm021
Advance Access Publication: 15 June 2007

Case study

Introduction of a quality improvement

program in a children’s hospital in Tehran:
design, implementation, evaluation and
lessons learned
S. MEHRDAD MOHAMMADI1, S. FARZAD MOHAMMADI2, JERRIS R. HEDGES3,
MORTEZA ZOHRABI1 AND OMID AMELI4
1
Tehran University of Medical Sciences and Health Services, Center for Academic and Health Policy, 2Tehran University of Medical
Sciences and Health Services, Eye Research Center, 3Oregon Health and Science University, School of Medicine, Department of
Emergency Medicine, and 4Management Sciences for Health

Abstract
Background and Objective. Reports addressing continuous quality improvement (CQI) methods in developing countries are
scant and there are questions about the applicability of quality improvement methods in such settings. The structure and

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output of a formal quality improvement program implemented in a teaching hospital affiliated with the Tehran University of
Medical Sciences is presented.
Objective Method. During a nine-month period, a multi-stage quality improvement program was implemented. It comprised:
(i) training workshops; (ii) a steering committee; (iii) weekly consultation and facilitation of improvement projects; and (iv) a
day-long demonstration and recognition meeting. Four cycles of workshops were held in which 132 employees were trained in
the basics of CQI.
Results. Thirty improvement projects were initiated. Twenty-five of the projects were completed. In an evaluation survey
more than 70% of respondents assessed a ‘positive impact’ on organizational culture, work efficiency and quality of services.
More than 90% believed that the changes were sustained, and more than 60% reported that they have implemented additional
improvement projects.
Conclusion. Our quality improvement package supported rapid implementation of multiple projects. The underlying ‘change
structure’ comprised the improvement teams, top management and the university’s quality improvement office; it integrated
project management, support and facilitation functions by the respective participant. Organization-wide change was more
limited than anticipated. To institutionalize the program and ensure sustainability, a local structure for change should be orga-
nized, management coaching should be sustained, local facilitators should be developed, incentives should be established and
physician involvement should be emphasized.
Keywords: change in behavior, continuous quality improvement, hospital, structure for change

Introduction
Some state that healthcare organizations in developing
countries have little experience with continuous quality
improvement (CQI) methods [1] and the reports on such
initiatives are scant [2]. Several questions have been posed in
this regard: What specific process models and principles of
design make the most sense in these countries? Which man-
agement approaches work in cultures very different from
those in which quality improvement was first described?
What permits quality interventions to work or prevents them
from working? How should successful quality improvement
efforts be reinforced, disseminated and supported over time
[3]? In addition, authorities asserted that Western advocates

Address reprint requests to: S. Mehrdad Mohammadi, Center for Academic and Health Policy, Tehran University of
Medical Sciences and Health Services, 12 Nosrat, Postal code: 1417965173, Tehran, Iran. Tel: (þ9821) 6649 5859; Fax:
(þ9821) 6641 9537; E-mail: mmohamadi@tums.ac.ir

International Journal for Quality in Health Care vol. 19 no. 4

# The Author 2007. Published by Oxford University Press on behalf of International Society for Quality in Health Care; all rights reserved 237
Mohammadi et al.

of quality could learn from the innovation of colleagues and
challenges in the non-Western world [4].
This paper reports a formal quality improvement program
in the Children’s Medical Center, a teaching hospital affiliated
with Tehran University of Medical Sciences and Health
Services (TUMS), which was led and facilitated by the TUMS
quality improvement office. We provide a description of the
entire program and present a profile of the improvement
projects undertaken (including process measures of pre- and
post-intervention and the respective corrective actions). The
results of a follow-up evaluation survey are presented. We also
analyse the structure for change, discuss the role of facilitators
and examine the overall success, limitations and long-term
viability of the program.
Method
Setting
TUMS is a public organization whose mission is higher edu-
cation in the health sciences, medical research, administration
(regulation and provision) of health services in its catchment
area and provision of specialized hospital services for refer-
rals from other regions of the country. TUMS has 8 schools,
preparedness of the managers of the hospital towards
improvement. The hospital provides both general and special-
ized services. This children’s hospital, with around 175 staffed
beds, 87% bed occupancy, nearly 450 employees, and 80 phys-
icians, is a major referral center in Iran. The participants of
the program were nurses, doctors and administrative depart-
ment heads.
Intervention
The intervention, known as the Quality Improvement
Training Cycle, was a multi-stage program comprised:
(i) Training Workshop; (ii) Consultation and Facilitation;
(iii) Demonstration and Recognition Meeting; (iv) Evaluation
Survey; and (v) Retraining. Stages 1 through 3 were
implemented during a nine-month time course (February
2002 – November 2002). The evaluation survey was adminis-
tered in September 2004. The ultimate goal of the program
was behavioral change of the employees and enabling the
process of change within the organization. The phases of the
course along with the methods and approaches used in each
phase are summarized in Table 1. (The retraining phase empha-
sized the cyclical and continuous nature of the process.)
Each workshop was organized as four 6-h days (24 h
total) of training with 30 trainees. Almost half of the time

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15 hospitals and 186 primary healthcare centers and oversees
18 private hospitals and 3170 other healthcare facilities.
The TUMS chancellor requested the quality improvement
initiative to be undertaken ( piloted) in one of its affiliated
units. The impetus was to determine what could be achieved
by such a quality program. The Children’s Medical Center was
chosen due to the prevailing supportive attitudes and
was dedicated to didactic education and the other half to
team exercises and experiential learning. TUMS’ quality
improvement office consultants, who were physicians with
advanced training in quality improvement philosophy and
tools (including the courses by the national quality improve-
ment committee), provided the training. As mentioned in
Table 1 above, workshop content was a process improvement

Table 1 Quality improvement training cycle

Phase Name Description or content Time Associated human resources

training terminologya
.............................................................................................................................................................................
b
One Training FOCUS-PDCA methodology In a weak (4 days) Lectures, educational pamphlet,
workshops questions and answers, group
discussions
Two Consultation Giving instructions, follow-up and One day a week, 6 Coaching (positive reinforcement
and facilitation answering questions along the nine-step months and encouragement), case study
methodology in the hospital
Three Demonstration Lecture presentations, poster In one day Seminar method, opportunity for
and recognition (storyboard) presentations, recognition reporting results of efforts,
meeting ceremony recognition, monetary rewards
Four Evaluation Trainees/participants assessment of A year and a half
survey effects on culture and hospital following phase
performance, sustainability of three
improvement efforts and obstacles to
change
Five Retraining Beginning PDCA cycle and
experimenting anew
a
For a comprehensive list of human resources training methods, the interested reader may refer to the Lussier’s book on management [36].
b
FOCUS-PDCA refers to a generic nine-step method for process improvement projects involving the use of 11 quality improvement tools
by teams [5]. PDCA stands for: Plan, Do, Check, Act, respectively; and FOCUS for Find, Organize, Clarify, Understand and Select.

238

methodology known as FOCUS-PDCA. This managerial
package includes: brainstorming, block diagram, flow chart,
run chart, affinity diagram, cause and effect (fishbone)
diagram, nominal group, multi-voting, decision matrix and
planning sheet techniques [5]. (A sample improvement
project along with the tools used is detailed in an appendix
available on http://tums.ac.ir/cahp/qiprog_sampleproj.html)
Structure and leadership
The Management Consultancy and Quality Improvement
Office that reports to the TUMS chancellor managed and
facilitated the program. The office’s mission is: ‘To provide
consultancy and training services in the areas of improve-
ment and management for the managers and employees of
TUMS and to give advice to TUMS’ management leaders
regarding organizational development policies.’ Its activities
range from holding training workshops, facilitating quality
improvement projects and guiding strategic planning work-
shops to facilitating problem solving projects.
Measurement and evaluation
Performance measures of the intervention were number of
the workshops delivered and number and percentage of per-
sonnel participating, trainers’ performance, trainees’ multiple-
choice test, number of improvement projects (initiated and
completed) and attitudes of the participants towards the
program and institutionalization of improvement activities.
Trainer’s performance score was based on a four-criteria test,
namely, scientific competence, chain of topics, eloquence and
trainee participation with each criterion being measured on the
three-tiered scale of good (2), fair (1) and poor (0). Participants
scored the trainers after every session. Participant satisfaction
was measured in the areas of session timing, logistical issues,
volume of material, level of participation and overall satisfac-
tion, again on a three-tiered scale at the course conclusion.
Participants’ satisfaction and judgment about the quality
improvement training cycle effect on organizational culture,
work efficiency and hospital performance (quality of care,
patients’ and students’ satisfaction, and occupancy) were
questioned in the evaluation survey. The extent of institutio-
nalization of the improvements and whether the participants
have undertaken fresh initiatives later were also evaluated.
Participants were asked to enumerate the obstacles they
encountered and their suggestions for future improvement
activities. A sample of 29 people were surveyed.
Analogous to Kirkpatrick’s four-level model, we aimed to
evaluate the impact of training at the levels of reaction, learn-
ing (knowledge), behavior (skill) and results [6].
Results
Four workshops were held in which a total of 132 (of the some
530 hospital personnel) were trained (76% were female); 62%
were nurses, 17% paramedics, 7.6% physicians and 13% other
staff. Mean trainer performance score (based on the four-
criterion test; maximum score: 8) was 5.1 with a 0.75 standard
Quality improvement program in a children’s hospital in Tehran
deviation (SD). Mean of the trainee multiple-choice test
score administered prior to workshop improved from 1.67 (SD:
0.22) to 3.25 (SD: 0.17) post-workshop (maximum score: 5).
Observations regarding the University’s and
hospital’s senior management involvement
and support
Being very interested in the program, the University’s top man-
agers (chancellor and vice-chancellor for logistics) supported it
symbolically and through their actions. The chancellor believed
that the best way for showing the value of the quality improve-
ment approach is through example. The vice-chancellor for
logistics gave an opening speech for all workshops. The process
was supported financially in various ways. The top managers
awarded bonuses and citations in the closing meeting. Hospital
managers participated in the workshops and were involved in
the improvement projects implementation and facilitation.
The second phase involved consultation and facilitation of
improvement projects. Overall, 187 consultation sessions
were offered on a weekly basis on 16 separate dates. Ideas
for 30 projects were formed; 25 were started and facilitated
in the five-month period; and 20 went through all the nine
formal steps. Table 2 lists the projects.
The conception of improvement projects was not just
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based on solving a perceived problem; some were conceived
just to study and ‘improve’ an existing process. Seven pro-
jects were initiated but not completed, i.e. DCA or CA stages
of FOCUS-PDCA were not followed through. In all, a cor-
rective action was formulated but it was either not
implemented (four instances) or its effect was not measured
post-action (three instances). The reasons were: impracticality
of the recommended action, group dynamics problem or
lack of a need for another measurement.
A representative quality improvement project is detailed
in an appendix available on http://tums.ac.ir/cahp/qiprog_
sampleproj.html. Analysis of individual projects is beyond
the scope of this report.
Phase 3 was implemented as described in Table 1. An
evaluation survey was conducted a year and half after the
formal closing of the program (i.e. following the demon-
stration meeting). All 29 distributed questionnaires were col-
lected. More than 70% of the respondents believed that the
exercise had a ‘positive impact’ on organizational culture
development, work efficiency and speed, quality of services,
patient satisfaction and number of patients (including bed
occupancy). The survey scale used ‘positive impact’, ‘indiffer-
ent’, ‘negative impact’ and ‘no comments’ levels. In more
than 90% of instances, respondents believed that the changes
were sustained; and more than 60% of the respondents
reported that they have implemented additional improvement
projects after the program’s formal closure. The impact on
employees’ satisfaction scored the lowest; only 35% believed
that the impact has been positive, and 45% described it as
indifferent (Figure 1). Lack of sufficient resources (budget,
staff and equipment) and an ineffective incentive payment
system were the two most frequently cited obstacles against
improvement initiatives. The employee comment of ‘what’s
239
Mohammadi et al.

Table 2 Target processes for quality improvement and Table 2 Continued

projects team composition
No. Title Team
No. Title Team
composition
composition
(staff mix)
(staff mix) ....................................................................................
....................................................................................
24. Doing work at registration/sorting Support staff
1. Transferring the stable infant from the Nurses
office
neonatal ICU to the ward when
25. Patients’ visit by the surgical fellow in Nurses
admitting an unstable one
different shifts
2. Transferring patient from surgery ward Nurses
to the operation theater in the morning An extension to this table (Table 3) provides more information on
shift (elective operations) the projects, i.e. quality measure used, pre- and post-improvement
3. Distributing food to patients in wards Support staff statuses of the measure (mostly in the form of median and range)
4. Embedding tissue in paraffin in Paramedics and the corrective action implemented. It can be accessed at http://
pathology specimens preparation tums.ac.ir/cahp/qiprog_projdata.html.
5. Lending books in the library Support staff
6. Washing hands in the pediatric ICU Nurses in it for me’ was common and represented the main inherent
7. Delivering medicine to outpatient Paramedics, challenge to change.
patients support staff
8. Distributing sugar and tea in the Support staff
hospital Discussion
9. Transferring cerebrospinal fluid Paramedics,
specimen from the wards to the support staff A variety of approaches for quality improvement, including
clinical lab process improvement, quality assurance, re-engineering and

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10. Infectious diseases ward admissions of Nurses participative management, are available. In our program we
the patients for whom isolation is adopted a CQI and project-by-project approach. The specific
indicated method for improvement and problem-solving taught and used
11. Connecting patients to ventilators in Nurses by the teams was a package of analysis, teamwork and planning
pediatric ICU tools acronymed FOCUS-PDCA (see above). Many empirical
12. Hydrotherapy in the physical therapy Paramedics, papers report its application in dealing with specific projects in
unit support staff US academic healthcare centers [7–12] or on an organizational
13. First visit of the (insured) patients in Nurses, basis [2, 13, 14]. Others have reviewed the utility of the method
the specialized clinics following paramedics, [15, 16] and still others suggest modifications [17–19].
discharge support staff CQI has been found efficient in hospital settings [20–23].
14. Admitting neonates with respiratory Nurses Francois et al. evaluated a decentralized approach for quality
distress in the neonatal ICU improvement in a hospital and concluded that implementing
15. Providing service to non-emergent Nurses CQI in hospital departments is a viable alternative to
patients in specialty clinics organization-wide implementation strategies [20]. Project-by-
16. Placing intravenous lines for the Nurses project quality improvement is a conventional option and
patients through culture building, in the long run, it may bring about
17. The ward X’s daily visits Nurses organization-wide improvements. In our case, program
18. Admitting non-emergent patients in the Nurses, implementation was led in an efficient manner (considering
morning shifts from the time entering paramedics the number of projects finalized, mean trainer’s performance
the ward Y to the time resting on the scores, satisfaction scores and post-test trainee scores, and the
bed uneventful delivery of the successive stages of the package).
19. Submitting blood tests from the surgical Paramedics Further, top management’s support was present throughout.
wards to the clinical lab Although we do not have detailed observations character-
20. Service provision for the outpatient Paramedics, izing the improvement projects outcomes and behavioral
referrals at the sample taking room support staff change in the participants, we did survey the attitudes of the
21. Copying service in the library Support staff participants. Given that 60% of the respondents reported
22. Transferring an icteric infant from the Nurses having conducted further improvement projects, we infer
emergency department to the ward Z that favorable behavioral change has occurred. Given that
23. Implementing CT scan orders for the Paramedics more than 70% of participants rated a positive impact on a
hospitalized patients variety of outcomes, beneficial organizational changes can be
inferred. More importantly, the exercise provided an oppor-
(continued )
tunity for teamwork, two-way communication between staff
and managers, and led to organizational learning.

240

Figure 1 Evaluation survey results. Quality improvement participants judgment of the outcomes of the program.
It has been reported that the introduction of quality man-
agement systems has positive effects on the staff ’s work satis-
faction [24], although in our evaluation, despite a positive
assessment in all other areas, the impact on employee satisfac-
tion was relatively low. This can partly be attributed to less than
optimal feedback and incentives; the roles of these factors have
been emphasized elsewhere [25, 26]. This perspective was
articulated by our participants as ‘what’s in it for me?’
Quality improvement in a developing
country setting
Some state that hospitals in developing countries have little
experience with CQI methods [1] and the outcome of
quality improvement initiatives may not be similar to those
of the developed countries. Developing country conditions
that may impede such programs include relatively lower
employee income and morale, little competitiveness (arising
from low or absent external incentives, low peer pressure
from organizations and limited mechanisms for management
accountability), more frequent unfair management practices,
management turnover, lower consumer expectation, over-
whelming working conditions, lower training, lack of local
expertise and leadership, and a higher ratio of patients to
providers [3, 4]. Similarly, it is reported that the compliance
with case management and clinical practice guidelines is not
high in developing countries [27].
We found scant evidence in the literature for comparative
analysis of quality improvement programs in developing
countries but some suggest that properly adapted improve-
ment methods may be even better suited to the developing
world than to the developed nations [28]. In developed
Quality improvement program in a children’s hospital in Tehran
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countries, quality improvement often encounters old-style,
control-oriented management, a leadership system far more
focused on finance and revenue than on improving oper-
ational processes, a strong sense of professional hierarchy
and entitlement, and a lack of integration of the health care
system with community resources [3]. In developing nations,
the ‘crust’ of old-style management may be thinner or even
absent, leaders may already be focused on the task of getting
the best they can out of current resources, teamwork among
health care workers may seem more familiar and community
structures may be more accessible as part of health care [3].
In addition, it is expected that systematic quality improve-
ment would optimize resource allocation and use and can
break through to new performance levels [3] and might
enhance development of management skills and processes in
a practical manner in such countries.
Structural considerations
Structure is critical if total quality management (TQM) is
going to work [29]; quality improvement office views improve-
ment in TUMS as a concerted participation of three players:
the operational unit (hospital staff and improvement teams),
top management and the institutional quality improvement
office. Quality improvement was in fact a product of collabor-
ation and synergism between these elements which, respect-
ively, performed the functions of project management,
support and facilitation—thus making quality improvement/
change (as an outcome) a ‘systems property’ [30]. From the
perspective of organizational power, the quality improvement
office’s responsibility and role with respect to improvement
has been one of ‘staff authority’, i.e. to assist and give advice
241
Mohammadi et al.
[31]. The quality improvement office is outside the chain of
command and lacks ‘line authority’ to make decisions and
issue orders down the chain of command. The office’s
‘expert’ status and ‘connection’ (to the university’s chancellor)
power helped it influence the staff and effect change [32].
In the evaluation survey, respondents cited the absence of
a long-term support [resources (budget, staff and equip-
ment)] and incentive payment system as major barriers to
improvement activities and their sustainability. A formal
intramural support and an evaluation structure (including
local facilitators and improvement project champions) should
address these factors; a specific procedure for improvement
activities should be defined that clarifies the following
elements: how improvement projects are identified and for-
mulated, how teams are organized, how facilitation and tech-
nical support are to be provided, how they are to be
followed-up and how they are rewarded. Attention to these
steps should institutionalize quality improvement activity
within the working of an organization, i.e. make them
routine and intrinsic (see below).
Project ownership and facilitation
Considering the type of involvement and participation,
implementation of an institutional quality improvement
program can be achieved in two primary ways: (i) expert-
owned—a consultant- or quality-specialist-driven program
employed on an ad hoc basis and (ii) self-owned—a program
owned and driven by the staff, but potentially supported
by outside consultants or specialists. Beckford [33] suggests
that the latter approach is preferable. From the Children’s
Hospital’s perspective, quality improvement office members
are considered external consultants but from the perspective
of TUMS top management, they are internal change agents
assisting a program within the entire organization. Regardless
of the perspective chosen, the quality improvement training
cycle was established to enable the process of change through
behavior modification and empowerment of the employees to
take charge of their own operations.
The role of facilitators cannot be over-emphasized as they
help organizations apply improvement principles and tools
and help them manage change [34]. Since our quality
improvement office members were exposed to extensive
quality improvement experience, they could transfer their
experience between improvement projects and teams. Thus,
each team benefits from lessons learned elsewhere and the
insights are shared across the organization.
Institutionalization
Sustainability of quality improvement initiatives is always a
concern and even the applicability of CQI approaches to
healthcare for long-term changes has been questioned and
evaluated [26, 29]. Godfrey observed ‘It’s easier to begin
than to keep going’ [29]. We had a similar experience.
Although the evangelical fervor of TQM can help initiate
projects, tangible incentives are needed to sustain the
momentum or to prevent initiative fatigue.
242
Ensuring involvement of the staff and ultimately enabling
change within the system needs: opening of communication
channels and listening to the employees, a continuous push
or encouragement toward higher standards, coaching, recog-
nition of accomplishments, removal of favoritism and an
atmosphere of teamwork (instead of power and politics).
These are significant leadership challenges. Only with sus-
tained motivation can the quality improvement process be
sustained. Externally the organization and its management
should receive incentives from a market-driven competitive
environment or through quasi-market policies adopted by
the regulators or higher-level management.
CQI is an organizational culture and largely the product
of the organization’s leadership and motivational system.
Building a culture takes time. Although CQI is a long-term
effort, we should not wait until the ideal culture has evolved.
Results themselves build culture. Although our improvement
initiative was successful in many ways, the employees’ percep-
tions suggest cultural change is incomplete. This transform-
ation and behavioral change may require the establishment of
support systems and financial incentives [25].
Physician involvement
Relatively few physicians were involved in both workshops
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and projects. Time constraints, limited interest and account-
ability and the perception that physicians’ involvement was—
at least at this stage—not necessary might explain this
limited participation. This low level of physician involvement
was an obstacle for several of the improvement projects and
was a source of complaint and grievance among the nurses.
There is a large, relatively untapped opportunity for quality
improvement in medical processes; relevant projects could
culminate in the development of clinical practice guidelines
or critical pathways. Previous reports have also highlighted
the difficulty of achieving physicians’ involvement and
importance of physician involvement [35].
Quality metrics
In most of the projects, the quality metrics used (i.e. as per-
formance indicators of the processes) were a time measure—
e.g. time taken for completion of a task, time delays until a
task is initiated, etc. (see Table 2 legend). There are other
quality measures (e.g. characteristics of the interaction with
the patient by the healthcare workers, patient comfort or
pain control, and patients’ perception of the technical excel-
lence), which are more directly related to patient satisfaction.
Time measures are relatively easy and ready for operationali-
zation, but quantification of other measures in a reliable,
valid and practical fashion can be challenging.
Acknowledgements
We are thankful to Ms. A. Khadem, as the local program
coordinator and to our assistants, Ms. Z. Ghomian and Mr.
R. Dehghan, for their contribution in the evaluation survey.

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Accepted for publication 21 March 2007
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