Global Health eLearning Center

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Improving Health Care Quality

Overview of Quality of Health Care
This session focuses on explaining quality in health care and its aims. We discuss the "know-do gap" - i.e.,
the gap that exists within health care systems between "what we know" and "what we do." The session ends
with explaining the need for a comprehensive quality approach to the global health agenda in order
to ensure the delivery of evidence-based services for every patient, every time.

Health Care Quality

Health care quality can be defined in a variety of ways. One definition states that "high quality care is a
function of the system’s ability to produce care that will address the client’s needs in an effective,
responsive, and responsive and respectful manner [across the continuum of care]" (D. Nicholas, Director,
USAID Quality Assurance Project 1990-2007). While various experts in quality improvement may define the
term quality differently, they generally agree on a comprehensive definition that reflects the complexity
inherent in any effort to improve, optimize, or maximize health status.

The following case illustrates the complexity of uniting theory, knowledge, and practice at the point of
service delivery. Quality health care is experienced as a tangible and personal experience for patients, their
families, and communities - often with life or death consequences.
 A Nicaraguan woman who was about to give birth called on a traditional birth attendant in her village for
assistance. The birth attendant had been trained to recognize that if the placenta was not delivered 30
minutes after the baby was born, there was the danger of hemorrhage. In fact, hemorrhage due to
retained placenta is the leading cause of maternal mortality in Nicaragua. When the placenta was not
delivered in that time, she sent the brother of the woman to the road to flag down a vehicle to take him
to the nearest health center. He reported the problem and an ambulance was sent to fetch the woman.
When the woman arrived at the health center she was bleeding due to her retained placenta. The health
center team admitted her quickly, inserted an IV, and began an Oxytocin drip. Her placenta was removed
manually just a few minutes after her arrival at the center. One half hour later, and only two hours after
the baby's birth, the mother was resting comfortably in bed nursing her infant.

In this case study, many factors contributed to the positive outcome which allowed the health center staff
to provide effective care:

Patient trust of the birth attendant

Birth attendant's training that allowed her to understand her role as part of a continuum of care
Decision to evacuate from village to health center
Availability of transportation
Efficient reception at the health center
Rapid mobilization of emergency care
Availability of comfortable bed and appropriate follow-up care, making it possible for the mother to
initiate breastfeeding
It may be tempting to attribute the outcome of a case like this one to luck or providence, but, in fact,
providers, administrators and the community had worked hard to improve and design a system that would
work this way. The goal of a quality health care system is to provide its population with quality care by
making timely, effective, and efficient use of all available resources.
Glossary Term: 
Health care quality

Achieving Quality in Health Care

The health care field is overburdened with multiple definitions, terms, and jargon describing essentially
similar or overlapping methods and concepts to achieve quality in health care and improve health
outcomes. A range of different approaches have been applied to improve health care - developing standards
and guidelines, supervision, training, process improvement, audit and feedback accreditation, among others.
Some methods are branded and copyrighted. Often these different approaches may be a repackaging of the
same basic concept every few years in a “new” method that enjoys popularity and then fades away at the
next new approach (Walshe 2009).

Many global health professionals and ministry of health officials are convinced of the need to improve the
quality of health care. However, they are often overwhelmed by the multitude of different approaches and
methods available (Massoud et al. 2012).

Some common terms include quality assurance, quality improvement, or continuous quality improvement,
quality control, quality management, and total quality management. Many of these terms can overlap or be
subsets of one another depending on who is explaining them. The term “quality improvement” is especially
confusing as many people refer to “doing QI” but mean different things by it. Therefore, this course focuses
on improving health care or "improvement," understanding that anything that makes health care better is
improvement.
Glossary Term: 
Quality assurance
Quality improvement

Systems View
In order for health care quality to be achieved, there needs to be an effort to focus on all parts of a health
care system. A system is the sum of all the total elements—inputs, processes and outcomes—that interact
together to produce a common goal.

Inputs in a health system include trained staff, equipment, infrastructure, drugs, guidelines and policies, for
example. A process is a series of activities that are needed to provide care including things such as medical
or laboratory procedures, managing personnel, record and data management, or procurement. The outputs
include the number of patients served or number of drugs procured, while the outcomes focus on the
patients. Health care is a complex system that requires many types of processes to come together in a
coordinated way to provide quality services for patients and their families.

A lot of attention and funding have gone towards inputs in low- and middle-income countries due to the
shortage of drugs and equipment or trained staff. These inputs are critical, but there is also a need to look
at how health care processes utilize these inputs to maximize their efficiency and effectiveness to improve
outcomes. This course focuses mainly on improving processes of care.

Source: Heiby et al. 2014 

Glossary Term: 
Health care quality

The Know-Do Gap

A deep gap exists within health care systems today between “what we know” and “what we do.” The
problem is that many interventions known to improve patient outcomes are not always being practiced or
implemented consistently.

The figure below shows the main causes of maternal mortality. The purpose of implementing improvement
approaches is to achieve better outcomes of care, to have babies born healthy, to have mothers survive
childbirth, to have those people needing treatment for HIV receiving it, etc.

Source: WHO 2014

In the case of maternal mortality, we know why women are dying in the process of giving life and what is
needed to save more lives. We know that an injection of oxytocin immediately after childbirth reduces risk of
bleeding; infections can be mitigated through good hygiene, recognition of symptoms, and immediate
treatment; treatment with magnesium sulfate can reduce the chances of eclampsia due to pregnancy-
induced hypertension; and the management of HIV and prophylactic treatment of malaria can save lives. But
this knowledge is not always translated into practice.
Source: WHO 2014
Consider first describing the quality problem. Clinical (and non-clinical) guidelines are widespread and based
on evidence, but studies consistently show that providers often do not follow them. Over the past 25 years, we
have developed strategies for addressing this problem. That is what this course is about.

Bridging the Gap

Incredible gains have been made in the last two decades in
improving health care and health outcomes globally. However, there
is still more to be done. The global health agenda is being defined
by goals and global calls for action, including the following:

Millennium Development Goals (MDGs) from 2000-2015

Sustainable Development Goals (SDGs) for the post-2015
agenda
Ending Preventable Child and Maternal Deaths (EPCMD)
AIDS-Free Generation (AFG)
The problem is that health care interventions that are known to save lives, or are “evidence-based,” are not
being implemented consistently. Consistent improvement in health care quality which bridges the know-do
gap can only be achieved by addressing both evidence-based knowledge, or technical content, and the
organization of care processes. Traditionally, health care improvement has focused on technical content
such as the development of standards and guidelines, training, and measuring compliance with standards.
More recent improvement approaches combine the traditional improvement approaches with improving
organization of processes of care to achieve better, more reliable health outcomes. Achieving quality health
care requires re-organizing care delivery in order to provide the appropriate content of care to every patient
who needs it every time it is needed.
Glossary Term: 
Millennium Development Goals (MDGs)
Sustainable Development Goals (SDG)
Evidence-based interventions

Concepts and Principles of Improvement

In this session, you will learn about the fundamental concept of improvement as well as the key principles
for improvement.

Fundamental Concept of Improvement

Insanity has been defined as "doing the same thing over and over again and expecting different results." The
fundamental concept of improvement is that you must change something in order to get a different result. If
a system is not changed, it can only be expected to continue to achieve the same results. In order to
achieve a different level of performance, changes must be made to that system in ways that permit it to
produce better results.

Fundamental Concept of Improvement

"Every system is perfectly designed to get the results it gets."
Batalden and Stolz 1993

A related concept is that while improvement requires change, not every change is an improvement. Because not
every change makes care better, each change must be tested and studied to determine whether it improves
care quality. When doing improvement work, people should ask themselves, “Did my change work?” If it did
work, they should keep it and test it at a larger scale. If it did not work, they should modify or discard it. 

There is a tendency in health systems to punish health workers for not achieving goals or to tell them simply
to “work harder,” with no consideration of what is stopping their achievement. Another common response is,
“If we only had more money!” However, millions of dollars poured into a broken system will not necessarily
result in improvement.  

Dimensions of Quality Health Care

Quality within a health system requires that all stakeholders – health professionals, policymakers, public
and private purchasers of care, regulators, organization managers and governing boards, and consumers –
need to have a shared vision. The following six dimensions of quality have been proposed by the World
Health Organziation (WHO) for a common understanding of quality health care:

1. Effective: Delivering evidence-based care that results in improved outcomes and is based on need;
2. Efficient: Delivering care in a manner which maximizes resource use and avoids waste;
3. Accessible: Delivering care that is timely, geographically reasonable, and provided in a setting where skills
and resources are appropriate to medical need;
4. Acceptable/patient-centered: Delivering care which takes into account the preferences and aspirations of
patients and the cultures of their communities;
5. Equitable: Delivering care which does not vary in quality because of personal characteristics such as
gender, race, ethnicity, geographical location, or socioeconomic status; and
6. Safe: Delivering care which minimizes risks and harm to patients.

These six dimensions sum up many aspects that need to be considered when improving care. However,
there is no one definitive set of dimensions of quality.  

Various groups and stakeholders, such as the US Institute of Medicine (IOM) and the US Agency for
International Developmental (USAID), have proposed different dimensions of quality, which are related and
complementary to the WHO list.

All of these dimensions remind us that no one factor can independently create quality care. 

Source: WHO 2006

In the video below, the Institute of Healthcare Improvement's former Chief Executive Officer, Don Berwick,
describes the six IOM dimensions of health care quality which are very similar to the WHO dimensions
above.
 Defining Quality: Aiming for a Better Health Care Sy…
Sy…

The World Health Organization (WHO)'s people-centered and integrated health services strategy outlines
directions for making care people-centered through empowering and engaging people, strengthening
governance and accountability, coordinating services, reorienting the model of care, and creating an enabling
environment. 

Principles of Improvement
There are many different versions of the key
principles for improvement. Four of these
principles, shown below, run through many
improvement approaches. In addition, shared
learning is gaining acceptance as an
additional principle in improvement.  

People-centered care: Services should be

designed to meet the needs and
expectations of clients and communities.
Understanding systems and processes:
Providers must understand the service
system and its key service processes in
order to improve outcomes of care.
Teamwork: Improvement is achieved
when all actors who have knowledge
about a process come together on a team
to identify problems and create locally-appropriate solutions.
Testing changes and emphasizing the use of data: Changes are tested to determine whether they yield
the required improvement. Data are used to analyze processes, identify problems, and to determine
whether changes have resulted in improvement.
Shared learning: Multiple teams work on common aims and exchange insights about what worked, what
did not, how it worked, and why. The goal is to learn from each other and hasten the rate of
improvement.
The next few pages will cover people-centered care, understanding systems and processes and shared
learning. Teamwork and testing changes and emphasizing the use of data will be covered in the Sessions
Methodology for Improvement Health Care I and II respectively.
Source: Massoud et al. 2001
Glossary Term: 
Changes
People-centered care

Ideas in Action

Do you have experience applying any of these principles in your work? What have you used and how? What is
new for you?

People-Centered Care
While it is widely recognized that people-centered care is an essential part of quality health care, what we
mean by people-centered care is much harder to define.

The World Health Organization Department of Service Delivery and Safety has developed a strategy on
people-centered care and integrated health services (WHO 2015). The key pillars of the WHO people-
centered care strategy are as follows:
1. Empowering and engaging people with information, skills, and resources
2. Strengthening governance and accountability
3. Re-orienting the model of care to focus on primary and community care services, increased prevention,
focus on a holistic approach to health care, and shifting from inpatient to outpatient and ambulatory
care
4. Coordinating services
5. Creating an enabling environment that encourages large-scale, transformational changes

Dr Ed Kelley, Director, Service Delivery

and Safety, World Health Organization
(WHO) - ICIC15
Foundation for Integrated Care

03:40

So how do you integrate these people-centered care principles in improvement work? Approaches, for
example, can include the following:

Focus group discussions with both service delivery teams and clients to determine client's perspectives
of quality care
Improving clinical and counseling capacity of service delivery teams
Developing counseling aids and/or job aids
Defining measurement methods and indicators of people-centeredness to complement routine tracking
and analysis of indicators (e.g., client exit interviews, focus groups, provider observations, etc.) and
ensuring regular review of the data collected
 Build capacity of ministry of health supervisors to support
service delivery team members to provide people-centered and
effective services
Periodically convene meetings with service delivery teams,
clients, and community representatives to collectively set
priorities for people-centered services
Develop/adapt communication and education materials to help
clients make informed choices

An overarching goal of people-centered care is to achieve optimal

experience and quality of care, quality of life, and positive health
outcomes for clients.

Source: WHO 2015

Glossary Term: 
Indicators
People-centered care

Case Study: People-Centered Care Example

Glossary Term: Antiretroviral Therapy
Glossary Term: 
Changes
Improvement team
Antiretroviral therapy

Understanding Systems and Processes

An important principle of improvement is that in order to improve
quality, providers must understand the services that are being
provided and the processes used to provide them and that these
processes make up a complex system. If providers look at
processes out of the context of the system, they may miss a major
constraint in the system that limits individual process
improvement. There may be some improvement in a process, but
they will never maximize results of the system.

By improving processes, you aim to reduce complexity, eliminate

unnecessary steps, avoid extra work or re-work, eliminate patients'
back and forth between providers, rationalize the steps, and reduce
waste. Processes can be simple or complex, involve few or many
steps, and involve few or many people. Within the health care
profession, various types of processes exist, including those that are used to make clinical decisions,
manage treatment, and manage supplies. 

Source: Massoud et al. 2001

Methodology for Improving Health Care I

This session presents the Model for Improvement, the foundation for improvement activities for decades
around the globe. You will learn how to develop an aim for improvement, how to define measures for
improvement, how to choose a team for improvement, and how to develop changes.

Choosing Improvement Priorities

Whether working at the global, national, or individual facility level, leaders must determine the priority
areas for improvement from which specific improvement aims can be set.

The global agenda set by the Millennium Development Goals and Sustainable Development Goals often
drives national improvement priorities as countries strive to meet their targets. Donors also often set
priorities for improvement. Reviewing existing data to determine the primary reasons for morbidity and
mortality among the population is a key step. Priorities for improvement may also be determined by patient,
health worker, community, or other stakeholder needs. These needs may be based on surveys or other
methods of stakeholder feedback.   

Priorities for improvement should be evidence-based. Existing scientific knowledge and standards can
inform what the performance of the system should be. The actual level of performance may be determined
through existing data and reports or baseline studies when data is unreliable or missing. 
Glossary Term: 
Millennium Development Goals (MDGs)
Sustainable Development Goals (SDG)

Model for Improvement

The Model for Improvement has become the
foundation for improvement activities for decades
around the globe. It asks three fundamental
questions that form the basis of improvement and
includes a cycle of testing the changes made to see if
they lead to improvement.

Different variations of this cycle have been called the

Shewhart Cycle, the Deming Cycle, and the Plan-Do-
Study-Act (PDSA) cycle (see figure to the right). The
cycle provides a framework for an efficient trial-and-
learning methodology. 

The Model for Improvement involves several steps:

Developing an aim for improvement (by
answering, “what are we trying to accomplish?”).
Developing a measure that tells you if a change is
an improvement (“how will we know that a
change is an improvement?”).
Thinking about the changes you could make to
help you achieve that aim (“what changes can we
make that will result in improvement?”).
Testing the hypothesized solution and collect data to see if it yields improvement using a PDSA cycle;
based on the results, decide whether to abandon, modify, or implement the solution. 

Source: Langley et al. 2009

Glossary Term: 
Model for Improvement
Changes

What Are We Trying to Accomplish?

An earlier session discussed setting priorities for improvement at a leadership level, which may mean at a
national, regional, sub-regional, facility or community setting. Once these priorities are set, specific aims for
the service delivery level need to be determined. This will answer the question, "What are we trying to
accomplish?"

Improvement aims should be ambitious, but achievable. An ambitious aim that is not realistic will
demotivate you and your colleagues, while a realistic aim that is not ambitious will fail to motivate you to
make as much of a change as you are capable of making.
A good aim statement is: 

Specific: It has a defined boundary that specifies the scope of the improvement. This may include a
specific geographic area such as a village or city, a specific population such as all HIV patients or all
children under 5 years of age, or the catchment population of a facility. 
Measurable: It has specific numerical targets for outcomes that are ambitious but achievable. Targets
may be set based on the best available evidence, on what has been achieved elsewhere, or set based
on baseline assessment information. There are times when a target may be hard to set due to a lack of
evidence or baseline information. Even if no target is stated, the aim must be able to be measured
quantitatively.  
Time-bound: It has a clearly defined timeframe for how much improvement you expect to see and by
when. Setting a timeframe helps motivate the team to keep up momentum for the improvement. 
Guidance: When known, it provides guidance on how the aim will be achieved, for example through the
use of evidence-based practices, application of existing guidelines, etc.  
Throughout the rest of this course, we highlight a case study on how an organization, Uganda Health Center,
navigated each part of the improvement process.

CASE STUDY: Uganda Health center - Aim

As one part of a larger priority to improve HIV services, the Ugandan Ministry of Health wants to improve
the nutritional status of HIV positive patients throughout the country. Their goal is to identify and cure all
moderately and severely malnourished HIV positive patients, returning them to normal nutritional status.
There are several processes required to achieve this goal including the integration of regular monitoring of
nutritional status into HIV services, nutritional counseling, regular follow-up visits, and in some cases,
prescription of therapeutic food.
The Uganda Health Center was interested in joining this improvement effort and set an aim for their own
clinic to address the first critical process of integrating regular monitoring of nutritional status into HIV
services in order to understand who is truly malnourished. The previous practice was ad hoc with staff
addressing nutrition issues only if the patients looked thin. The improvement aim that the Uganda Health
Center adopted for themselves was: "Uganda Health Center will improve routine assessment and
categorization of nutritional status using mid-upper arm circumference (MUAC) for 100% of HIV patients
coming to the clinic within the next 6 months." This aim was the first step in the clinic's improvement
effort to determine who was malnourished and cure them.

Glossary Term: 
Improvement aim

Ideas in Action

Create an aim statement for the health improvement work in your setting. Make sure that this statement is
specific, measurable, timebound, and provides guidance.

Practice Your Skills!

To learn more about setting an aim for improvement and practice your skills, check out the Tips and Tools for
Learning Improvement: Aim Statements . 

You can check your answers .

How Do We Know a Change Is an

Improvement?
After developing a good aim statement for improvement, the next
step is to define measure(s) for improvement. Through measures,
we are able to answer the question: How will we know that a
change is an improvement?

A measure, or indicator, of improvement should be linked to a

strong aim statement. It is used to spur improvement, guide the
choice of changes to test, and allow the improvement teams to
learn. Measures should be limited to only the key information that
is needed; collecting too much data can easily overwhelm a new
improvement team and impede action.  

A good indicator is defined in such a way that allows it to be collected and measured consistently. It should
be clear and unambiguous so that improvement teams will not confuse what is meant by the indicator. It
should be quantifiable. A definition of the indicator should describe a clear numerator and denominator, the
source of the data, the frequency of collection, and who is responsible for collecting the data. 
Glossary Term: 
Changes

Practice Your Skills!

You can learn more and practice your skills at developing an indicator with the Tips and Tools for Learning Imp
rovement: Measurement for Improvement worksheet .

Check your answers . 

Types of Indicators
Indicators for improvement generally focus on process, output, and outcome indicators, with emphasis on
outcome. Improvement often requires two measures: one measure to determine if the team is making
progress towards their aim (output or outcome indicator) and one to check whether the changes tested
were effective (process indicator). The figure below shows several types of indicators related to the goal of
improving the nutritional status for HIV-positive clients.

Input indicators measure the availability of key resources (human, material, etc.) needed to carry out a care
delivery process.
For example, % of health workers trained in a procedure or % of facilities without stock-outs of HIV test
kits might be considered as input indicators useful to measure progress toward achievement of an
 improvement aim.

Process indicators measure the degree of adherence with an evidence-based intervention or set of
interventions.  
An example of a process indicator is the % of patients on antiretroviral therapy (ART) who were
screened for tuberculosis according to protocol at their last ART appointment.

Output indicators measure the immediate results of the service (i.e., the number or percent of services
provided or products delivered to patients or clients), often to show the short-term results of the key
processes being improved.  
An example of an output indicator would be the proportion of malnourished HIV-positive clients that
received ready-to-use therapeutic food. 

Outcome indicators evaluate how a system is performing with respect to the health of a defined population
or individual.
For example, in a clinical health care improvement activity, an outcome indicator measures the health
status of a defined population with respect to the clinical area for improvement (e.g., maternal mortality
ratio; incidence of adverse events following voluntary medical male circumcision; or % of patients on
ART who have good clinical status).

Indicator Case Study

Based on the aim of the Uganda Health Center case study - In Uganda Health Center, we will improve the nutritional
status of HIV clients by assessing the nutritional status using mid-upper arm circumference (MUAC) of 90% of HIV
clients within 6 months - we derived the output indicator of percent of HIV-positive clients assessed for
malnutrition using MUAC. The overarching outcome measure would be reduction in mortality due to malnutrition. 

The table below describes the definition of this indicator in more detail, with emphasis on the numerator,
denominator, source, person responsible, and frequency. 

CASE STUDY: Uganda Health Center - Measure

INDICATOR: % of HIV -positive clients assessed for
Describe what you are measuring. malnutrition using MUAC

NUMERATOR: # of HIV-positive clients who had their nutritonal

The number of times your process was completed status assessed
properly

DENOMINATOR: # of HIV-positive clients seen in the clinic

The total number of times you ran your process

SOURCE: Client cards

Where you are getting your data from?

RESPONSIBLE PERSON: Nurses and data clerk

Individual who will ensure that the data is collected
and maintained?
 FREQUENCY: Weekly, followed by monthly
How often it will be collected

Ideas in Action

Try to write an output indicator for the improvement aim you have defined previously.

What Is the Role of Teams?

Before you can begin to develop changes, you need to have a team of knowledgable people who know the
problems in detail and can determine possible solutions. 

Why is teamwork so important for improvement? Teams are important for several reasons:

Health care processes consist of inter-dependent steps

that are executed by different people. The group
working within a process will understand it better than
any one person. Engaging key people in the
improvement of a process often involves clarifying and
incorporating the insights and needs of different people
involved in, or affected by, the process, including
clients.
Quality faults often occur when patients or clients move
between providers. The involvement of key people with
insight into the process, such as representatives from
each function, helps reveal the errors that occur when
patients move from the receptionist to nurse to doctor,
etc. For example, when a prescription is not clearly written by a doctor, the pharmacist may make a
mistake.
Given the opportunity, staff can often identify problems and generate ideas to resolve them. The
participation of people involved in the process improves the ideas generated and builds consensus
about changes.
Participation increases buy-in and reduces resistance to change. This atmosphere of shared action and
responsibility discourages blaming others for problems and promotes ownership over the changes.
Accomplishing things together increases the confidence of each team member, which empowers
organizations.

Improvement team responsibilities

Teams are responsible for reviewing the current performance in relation to the aim, conducting problem
analysis, developing and testing ideas to change their current processes, repeatedly measuring data to
determine if their changes are leading to improvement, and acting on that information. They also have a duty
to keep their leaders and co-workers informed of the improvement activities.

Team Composition
Teams consist of key players in the parts of a process being improved, as well as people affected by the process
(e.g., patients). The figure above shows the steps in the process of nutrition support for HIV patients and the
respective people involved. Their participation increases the overall understanding of how each job contributes to
the achievement of organizational goals and communicates that their opinions are valued in the improvement effort. 

Team members should be chosen by leadership to represent each step in the process. If there are multiple people
who complete one step, such as several nurses, they should be represented by one or two people on the team.
Health care teams often benefit from including both patient and community representatives. There may be some
influential people who need to be on the team to give it credibility, such as village elders in a community setting or a
representative of management in a hospital setting. 

A team is generally composed of 7 to 12 members. A team that is too large may have trouble focusing, listening to all
voices and making progress. Selected members should have an interest in improving quality and have an ability to
work with and listen to others. For example, a team working on tuberculosis care may involve representatives of
patients, community groups, nurses, nursing assistants, physicians, treatment supporters, laboratory technicians,
pharmacy staff, and also cleaners who play a role in infection prevention.

CASE STUDY: Uganda Health Center – Improvement

Team
The team that the Uganda Health Center formed included a representative of the People Living with HIV
community group, a volunteer expert patient, a community health worker, a registrar, a nurse, a clinician,
and a pharmacy assistant

Ideas in Action

Which individuals from your organization would be important to include in an improvement team?

Practice Your Skills!

To build your skills in determining team competition, check out the exercises in Tips and Tools for Learning Im
provement: Improvement Teams .

Check your answers .

What Changes Can We Make?

Once a clear aim and measure have been set, you need to ask yourself, what changes can we make that will
lead to improvement?

As a first step, teams will often try to better understand the problem they are dealing with and the situation
at their facility. Using a flowchart can be useful for providers to better understand their current processes,
including where there are problems or unclear areas. A flowchart is a tool for mapping a process to better
understand all of the steps and handoffs involved and where there is repetition, confusion, waste, or
opportunity for making it more efficient.

Improvement teams can also use root cause analysis tools such as a fishbone diagram  or the “why, why,
why” approach to understand underlying problems. This analysis should become the primary guidance for
developing solutions.

Solutions for addressing problems discovered through analysis are often called changes - changes in what
you do and changes in how you do it. These solutions or changes to address problem areas found in the
analysis may be generated from known best practices found in literature, guidelines, standards, normative
documents, or by asking experts. In addition, changes may come from improvement team brainstorming,
benchmarking, or learning from other teams. 

All improvements require change, but not every change yields an improvement. Many changes may not
result in improvement. Some may make things worse. When you are part of an improvement team
developing changes, you need to think about:
Something that you have never done before
Something you can do tomorrow
Something that worked elsewhere
Something that addresses identified gaps

Teams should avoid: 

Doing what has been done before (“Let’s have a training.")
Low-impact changes (“Let’s put up a poster.”)
Technical slowdowns (“We will build a computer program to do this.”)

A team should brainstorm all of their possible solutions and changes and then prioritize those that they
think are most likely to have the greatest impact. It is advisable for teams to start with easier changes that
could be tested within a few days and move on to testing more complicated changes once they have
learned to use the PDSA cycle. 

Ideas in Action

What is a change you want to consider in your setting in order to improve health care?

Practice Your Skills!

You  can learn more about flowcharts and develop skills to create them using the Tips and Tools for Learning I
mprovement: Flowcharts . 

Check your answers here . 

For more information on developing changes and to practice new skills in determining appropriate changes,
check out Tips and Tools for Learning Improvement: Developing Changes .

Check your answers here .

Methodology for Improving Health Care II

This session presents more detailed information on how to conduct a PDSA (Plan-Do-Study-Act) cycle.

Plan-Do-Study-Act Cycle
The final element of the Model for Improvement introduces a testing cycle. This cycle provides guidance on
how to test changes on a small scale to establish if they result in an improvement before being tested and
implemented on a larger scale.

The Plan-Do-Study Act (PDSA) cycle allows for continuous improvement as hypotheses are regularly created,
tested, revised, implemented, and then adapted further. This iterative process allows teams to make
continual changes and deepen their understanding of organizational improvement needs and solutions. The
four steps of a PDSA cycle are described below.
Source: Langley et al. 2009

Plan a Test
You should introduce a change initially on a very small scale (e.g., for a few days or on a small sample of
patients) to see if the change is looking promising. If the change works, you will subsequently introduce it at
a larger scale and under different conditions.

During the planning phase, the improvement team needs to decide the following:
What they are going to do;
When and how they will do it;
Who will be involved;
What they predict will happen;
How they are going to collect data to monitor the effects of change; and
What resources are needed and the time frame for implementation. 

In addition, they need to inform people about the test of change, including those people involved in the change to be
sure they are willing to try it.

Revisiting the earlier case study example, in this session, we will see how the Uganda Health Center applied
the PDSA cycle in meeting its improvement aim: Improving the nutritional status of HIV clients by assessing
the nutritional status using mid-upper arm circumference (MUAC) of 90% of HIV clients within 6 months.

We start with "Plan."

 CASE STUDY: Uganda Health Center - Plan
The improvement team plans to create a station for the nurse to take and record the MUAC of each
patient who comes to the HIV clinic. They plan that the person at the registration desk will tell all
patients to go see that nurse after registering. Patients who are seen at the station by the nurse and are
classified as either moderately or severely malnourished will be sent to see the doctor. The team will test
this change for two days to see whether all patients are assessed by MUAC and classified. The nurse will
record the data, and the registrar will compile the data for review at the end of the two days.

Do the Test
To test the proposed solution, a team needs to carry out the planned activities and record what happened. They
need to communicate progress to all those involved and provide encouragement and assistance as needed. While
conducting the test, it is important to check that the data are complete and accurate. Document what worked and
what did not work during the testing process. This information is important to assess the solution for the problem
that was identified. 

In the example below, you can see how Uganda Health Center carried out their planned test and how they
documented the activities in order to assess the testing process.  

CASE STUDY: Uganda Health Center – Do

The team carried out their planned test to have a nurse do MUAC readings after registration. The nurse
stayed at the registration desk all day the first day but had to go to the wards for part of the second day.
Some patients therefore were not seen by the nurse. The data collected by the registrar showed that this
change worked well the first day but not as well the second day. Their results are presented below.
Day Total number of Total number of patients who were Percentage of patients who were
patients in HIV clinic assessed for nutritional status assessed for nutritional status

Day 57 39 68%
1

Day 52 27 52%
2

Study the Results

During this step, the team will decide whether the solution tested had the desired results. Examine the
results of your solution from both formal (e.g., graphs of time series data) and informal data collection (e.g.,
team members’ observations about processes that worked). Here, the team needs to ask, What is the data
really telling us? 

It is important to compare baseline data and the data gathered during the PDSA to measure the impact of
the solution. A team should ask itself the following:

Did we meet the criteria for success? Did the solution have the desired results? What did people think
of the change?
Which aspects of the test went well? Which aspects were difficult?
Did the solution create problems for others or other processes that we did not anticipate?
What kind of resistance did we encounter?
Let us explore how the Uganda Health Center
studied the results of their small-scale test.

CASE STUDY: Uganda

Health center - study
The team reviewed their data for the two-day
test. The first day, they had decent results
with 68% Of patients assessed for nutritional
status. The second day, their results were
worse because the nurse had ward duties in the afternoon so no one was responsible for assessing
nutritional status. Some patients did not follow instructions to see the nurse. There were also longer lines to
see the nurses because one nurse was no longer seeing patients. The part Of the idea that worked well was
having one person assigned to taking the nutritional status for each patient. The part that did not work as
well was having the nurse be the person responsible for doing so.

Act on the Results

Based on what was learned from the study results, the team can decide what action to take. Not every
solution that is tested is then adopted. Often, a solution needs to be reassessed, modified, or abandoned
altogether.

The team should ask itself the following:

Did the tested change show promise? If not, they may need to abandon the idea and test another
change.  
Does it need to be modified to work better?  If so, they need to adapt it and run PDSA again on a small
scale.  
Did it work very well? If so, they will need to test it at a larger scale before they can be ready to adopt
it. 
What did the Uganda Health Center team decide based on studying the results of their test?

CASE STUDY: Uganda Health Center — Act

Based on the results, the team felt that having someone responsible for MUAC assessment at registration
was a promising change, but it needed to be modified to work better. The team decided that they would
teach several volunteer expert patients to help with MUAC assessment and have them located at the
registration desk for their next test of change.

In this video, Lloyd Provost, co-author of The Improvement Guide, shares his advice on how long PDSA cycles should
last.
 How Long Should a PDSA Cycle Last?

Practice Your Skills!

The last few pages have given you a brief introduction to the PDSA cycle.  For more information and for
exercises to practice skills, check out Tips and Tools for Learning Improvement: Plan-Do-Study-Act .

Check your answers here . 

Ongoing Tests of Change

Before making a change a permanent new part of a process, the team needs to have good evidence that the
change is working. Often teams need to run multiple PDSA cycles to adapt changes to get them to work
better, to increase the scale, as well as testing under different conditions.

Once the change has been tested at a larger scale (e.g., with more patients or for a longer time) and under
different conditions (e.g., at different times of day or days of the week) and still found to be successful, it is
ready to become a permanent part of that facility’s functioning. The improvement team, as representatives,
are responsible to communicate the changes to staff, patients and others who need to be aware of the new
process. This often means documenting the change in a standard operating procedure or job aid or taking
steps to make sure the change is made a permanent part of how things are done and scaled up to all the
units in the system that could benefit from the change.
This video tells the story of one improvement team’s ongoing tests of change:

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Shared Learning
Deliberate sharing across teams is an important part of scaling up improvement and a proven way of making
care better.

Shared learning across teams participating in improvement efforts allows for rapid spread of ideas. Providing
opportunities for teams to discuss and learn from each other about changes that did and did not work and
why accelerates improvement, maximizes resources, and allows for developing an evidence base for how to
improve a specific area of care in a particular setting. 

The exchange of learning among peers ("many to many") shifts the focus away from one-way knowledge
transfer (from one "expert" to many teams) and instead draws broadly on the experiences of many teams,
allowing for faster spread of effective changes.
After an improvement activity has been completed, the
work often yields lessons and guidance that could help
others improve the same area of care. (The USAID Applying
Science to Strengthen and Improve Systems (ASSIST) Project
 offers more information about shared learning activities.)

CASE STUDY: Peer-to-peer

learning in Uganda
Representatives from 34 improvement teams from
facilities across Uganda that were working on integrating
nutrition into routine HIV care were brought together in
December 2009 to discuss and agree on emerging best
practices. This exchange enabled all sites to learn about successful practices that had been tested by
some sites and led to rapid uptake of effective changes by all sites.

Glossary Term: 
Shared learning

Support for Improvement

Practical support to teams in the form of coaching or supportive supervision is critical to help teams:
Form representative teams;
Set aims and targets specific to their local needs, usually within larger national improvement aims;
Develop measurement systems, including proper recording, data collection, aggregation and analysis;
Facilitate discussions of the problems and possible solutions to test;
Provide ongoing training and support for improvement cycles (plan-do-study-act);
Advocate for resolution to larger system issues such as supply chain, financial, or policy problems;
Integrate improvement into their ongoing work; and
Synthesize learning.
Coaching is most effective when built into existing government systems and structures, rather than creating
outside or parallel systems. This can take the form of coaches external to the facility or community, such as
a district representative, or from within the local site, such as an enthusiastic nurse or employee. Whoever
the coach is, they should always approach the improvement team with an attitude of supportive problem
solving rather than critical evaluation. 

In the video below, Harriet Egesa, an improvement coach for the USAID ASSIST Project in Uganda, explains
the roles of coaches in her HIV work.
 Sorry
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Measurement for Improvement

In this session you will learn about the importance of measuring data over time and using reliable data
systems to accurately measure improvement. We will also showcase how to develop good time series
charts, a tool used to document improvement work.

Measuring Data Over Time

The crux of quality improvement is answering the question, How will we know that a change is an
improvement?  Without data, or the skills to graph and interpret the change, we are unable to know.
Measurement is the only way to know if a change has led to improvement.

Improvement teams should measure and review data frequently (i.e., daily or weekly) to determine progress
towards their improvement goals. More frequent data collection will show the team whether the changes
they are testing are leading to improvement.  

The bar chart on the right shows only two points in time - perhaps baseline and endline information - but
does not give the entire story of what happened for the purposes of improvement. We see that changes
were made in August, which leads us to believe that the changes led to improvement by January. However,
this may not be the whole picture.
Improvement Story
Over Time
The graphs below, however, show that there
are several possible stories for the two points
from July to January. 
Time Series A - This graph shows that
this process is already improving due to
other existing trends or factors. The
changes made by the team did not
impact the improvement.
Time Series B - Natural variation is when
the performance of a process falls within
the expected or understood variabiliability
of that process. This graph shows that
the process which the team is trying to
improve is generally stable, with natural
variation. The July and January points
happen to be lower and higher points of variation. The changes made by the team do not have an
impact on the process.
Time Series C - In this graph, we see a clear change in the performance of the process following the
changes made by the team. This graph shows the team that their changes worked and led to
improvement and should be implemented permanently.
Time Series D - In this graph, we see that the January result is unusual and falls outside of the natural
variation. This is considered an astronomical point or a rare event. The team's changes have not
improved the system. Rather the improvement in January may be a result of a visit from officials, other
outside influence, or data error. 
In improvement, frequent data collection is crucial to understand the true story hidden in the data. The rest
of this session which focus on how we can better analyze and understand time series charts.

Glossary Term: 
Trend

Time Series Charts

Time series charts help track the performance of a process over time and document the story of
improvement work. The ongoing monitoring of an indicator through a time series chart, together with
annotation, is valuable because it helps track when specific changes were introduced, see their impact on a
process, and tell whether improvement is sustained over time.

In a time series chart, the time interval is displayed on the X (horizontal) axis and can be any interval of time
(e.g., minute, hourly, daily, weekly, monthly, quarterly, yearly, etc.). The indicator being tracked is plotted on
the Y (vertical) axis. Common types of indicators are percentages (e.g., percent of patients receiving care
according to standards), rates (e.g., number of times postpartum women have vitals taken per hour), time
(e.g., waiting time), quantities (e.g., stock levels), or numbers (e.g., weight).
Glossary Term: 
Time series charts

Practice Your Skills!

To practice creating time series charts, check out the Tips and Tools for Learning Improvement: Measurement
– Time Series Chart .

Check your answers here .

Time Series Chart: Example 1

The figure below presents a time series chart illustrating the work of a quality improvement team at the
Uganda health center that has been highlighted throughout the course. This team sought to increase the
percent of HIV-positive patients assessed for nutritional status using mid-upper arm circumference (MUAC)
for the purpose of identifying those needing therapeutic food.  

Graphing the data over time like this helps the team track their progress and demonstrates that
improvement is not always linear—there may be ups and downs in the results.  

Understanding a Time Series Chart

Time series charts can be used to track any indicator over regular time intervals. Good time series charts
help analyze whether tested changes yield improvements by including clear labeling and definitions, a
median line, and annotations.

Clear labeling and definitions

Time series charts should be easy to read and interpret, such that anyone could interpret the chart without
explanation from the person who actually drew it. To accomplish this clarity, time series charts need to have
clear titles, labels for X and Y axes, definitions of the numerator and denominator, denominator values, data
sources, sampling strategy, and a legend.

Annotation
Annotation is the process of adding commentary or explanatory notes to a time series chart. Annotating
when changes were implemented connects the numerical results (the data displayed in the graph) with the
changes introduced by the improvement team. It also can provide context about other possible explanations
for the data.

Annotating a time series chart involves simply drawing a text box (by hand or on a computer) next to a data
point with a brief explanation of what change was introduced or what key event occurred that may have
affected the result at that point in time. Annotation allows you to see if variations in results are linked in
time with changes made to the process.  

Calculating the median

The median represents the middle value in a set of data. You will need a minimum of 10 data points to plot
the median of your data. When using time series charts for improvement, you should include a baseline from
six or more months before you started your improvement work. This helps you identify variation and the
median of performance prior to the introduction of changes, and contributes to the number of data points
required to plot the median.

Analyzing the data 

Drawing a horizontal line through the median of a data set allows you to detect shifts (that is, six
consecutive points above or below the median line) that suggest a statistically significant change in the
process. If you have fewer than 10 data points, it is still useful to plot the data even without the median. A
trend for a time series chart indicating that the performance of a process is changing requires a minimum of
five data points continuously increasing or decreasing. It is possible to detect a trend without a median line.

The more data points you have, the better understanding you can gain about your process over time. If you
would like to draw conclusions sooner about your process, consider collecting data more frequently (e.g.,
daily or weekly instead of monthly).
Glossary Term: 
Shift

Practice Your Skills!

For more detailed explanation of analysis of time series charts and exercises to practice analysis, check out
the Tips and Tools for Learning Improvement: Measurement – Variation vs. Improvement .

Check your answers here .

Time Series Chart: Example 2

Referring back to first time series example, we see that the use of MUAC seems to be improving over time,
but this version of the chart does not show what the improvement team did to achieve these results. It also
does not help the team from the health center determine which changes are most effective, nor does it
convey learning to other interested stakeholders.
In contrast, the example below shows the same time series chart but with annotation about specific
changes introduced. This annotated version is more helpful than the version in Example 1, as it clearly
documents what and when the team tried different interventions.

Using a Time Series Chart for Improvement

The time series chart shown in Example 2
reflects multiple PDSA cycles. Below is the
story of another improvement team in Uganda
working on similar issues as those in our case
study.

In the beginning, the team received the

training and equipment provided by a donor-
funded project in collaboration with their
district officials, but nothing changed because
they did not incorporate assessment into their
regular work processes.

Before the first coaching visit, the

improvement team wanted to show that they
were assessing patients for nutritional status,
so they asked all health care workers to assess all patients with MUAC and note the results in the patient
records.  This was an all-hands-on-deck effort, but was not sustainable. After they saw one week of great
results in May, the motivation for continuing to assess for MUAC slowed and so did their results.

Following a coaching visit, they planned their first test of change which was described earlier, where a nurse
was designated to assess and record MUAC. The team monitored the results of this change and realized they
were only achieving about 70% coverage of patients being assessed. The nurse was only in the HIV clinic part
of the day, and as a result, many patients were missed. 
This was a new team who was still learning and waited too long, several weeks, to test their next change.
The team then did another test of change to teach expert patients to take MUAC readings as part of
registration, which was more sustainable. The expert patients could work on rotation. Anyone found to be
moderately or severely malnourished was sent to see the clinician for verification, counseling, and
treatment. Again, the team used the data collected and plotted over time to determine that this test did
increase their coverage of nutrition assessment. However, they will need to continue to test changes until
their new or improved process for assessment becomes a routine, sustainable part of their ongoing clinic
practice. 

Reliable Data Systems

In order to have accurate data to measure improvement, a team needs to have a reliable data system. If the
data system itself is in need of improvement in order to be brought up to a functional level, the following is
what a team is aiming for:

Clearly-defined indicators
Standard records and recording tools
Timely, consistent, and accurate entry of data into records or tools; accurate data should reflect the
actual situation such as numbers of patients seen, correctly recording medical procedures, etc.
Valid sampling technique, if sampling is required
Accurate abstraction of data from records on a regular basis
Communication of data from abstraction to data entry clerk or other person responsible for aggregation
Concise tools for summarizing and aggregating data
Data entry process and systems, such as Excel databases
Creation of charts or graphs to display results
Communication of results to team or group responsible for improvement as well as for higher levels of
the system
Validation approaches to check for accuracy of the data
Many improvement teams have found it useful to apply the same improvement approach of small tests of
change to making their data systems more reliable and valid in the areas mentioned above. One example of
what improvement teams have done to improve their data collection process is captured in the Guidance on
How to Improve the Completeness and Accuracy of Data for the Elimination of Mother-to-Child Transmission
of HIV . 

Ideas in Action

What do you think is needed to create more reliable data systems in your setting?

Responsibilities for Improving Health Care

In this session, you will learn how improving health care processes often requires activities at each level of
the health care system. In addition, you will learn about factors to consider when choosing improvement
priorities.
Activities for Each Level of the Health Care
System
While improvement can happen in an isolated way at an individual facility, improving care processes often
requires support and action at multiple levels of the health system.

Every level of the health system has a role to play in supporting and promoting improved quality of health
care. A culture for improvement needs to be fostered throughout the system that encourages ongoing review
and use of data, allows for testing new ways of working, promotes teamwork, values the contribution of all
stakeholders, and focuses on improving health outcomes.  

"Quality improvement must be a continuous process of program assessment, evaluation, and

improvement with interdependent responsibilities at each level of the health system. Epidemic change
(i.e. population level incidence reduction) can only be achieved if services and programs achieve quality at
every level. If quality is not implemented well at every level, achieving quality outcomes for each patient
or epidemic change in populations remains unattainable."

PEPFAR 2014

Improvement at Every Level

The figure below shows that, ideally, improvement work is implemented with quality at all levels (left-hand
side of the figure) in order to achieve large-scale change and to ensure sustainability.

The next few pages will provide some examples of how improvement activities at each level interact.
Linking Improvement Efforts at All Levels:
Afghanistan Example
Starting in 2009, the Ministry of Public Health (MoPH) in Afghanistan and the USAID Health Care
Improvement (HCI) Project worked to address gaps in quality and outcomes of maternal and newborn care
at different levels - national, provincial, facility, and community - through multiple improvement teams.

Implementation design

The work took place in Kunduz and Balkh

provinces to develop and test a scalable model
of high-impact, evidence-based interventions in
antenatal, delivery, and postpartum care. This
model would link different levels of care, from
that provided in the home and community by
traditional birth attendants and community
health workers, all the way to health posts, basic
health centers, comprehensive health centers,
and district and regional hospitals.

Provincial level
HCI worked with provincial public health
authorities to establish one provincial-level
quality improvement team (QIT) in both
provinces. The provincial QITs included Provincial
Public Health Officers, representatives of non-governmental organizations, and HCI staff. Based on baseline
data, the provincial QITs prioritized a package of high-impact interventions to introduce at the facility and
community levels. In addition, they facilitated regular coaching visits and meetings to share experiences for
facility and community-level QITs.

Facility level
The provincial QITs supported 25 facility-level QITs. The facilities that participated included a regional
hospital, comprehensive health centers, basic health centers, and sub-centers. Facility-level multi-
disciplinary QITs were composed of facility-level obstetrics/gynecology (OB/GYN) doctors and/or midwives,
administrative staff, and sometimes management of the hospital (when needed). They worked with coaches
and their teams to introduce and test change ideas that had been discussed in the learning sessions and
review their data on indicators that had been defined with provincial health teams in order to measure the
overall results of the improvement work. For example, QITs focused on correct and increased use of the
partograph – an essential tool for decision making during labor. Use of the partograph increased from
around 20% in 2009 to almost 100% in 2012.

Community level
In parallel to the facility-level work, evidence-based interventions were introduced by the provincial QITs at
the community level in Balkh and Kunduz provinces. The purpose was to improve the performance of
individual community health workers in making antenatal and postnatal home visits, improve their
counseling skills, and strengthen community-to-facility linkages for increased uptake and coverage of skilled
birth services, including prompt referral and management of maternal and newborn complications. Results,
for example, showed that after the provision of training, job aids, and monthly simulation sessions,
community health workers' compliance with postnatal care and counseling standards improved from about
60% to over 90% from December 2010 to October 2011. 

National level
By the end of 2012, measurable gains were achieved in both demonstration and scale-up sites for use of the
partograph, compliance with antenatal care counseling, active management of the third stage of labor, and
compliance with newborn and postnatal care standards. The positive results achieved on the ground  led
the MoPH to develop a health care quality improvement strategy and implementation plan for Afghanistan as
well as a Unit for Improving Quality in Health Care (IQHC). The IQHC Unit has become a strong advocate of
improvement through its technical leadership role within the MoPH.  

Source: Rahimzai et al. 2014

Glossary Term: 
Evidence-based interventions

Global, National, Regional, and District

Responsibilities
GLOBAL
International organizations, donors, and the wider public health community have the responsibility to:
Determine through research or evaluation the most efficacious high-impact interventions
Develop guidelines and recommendations based on the evidence for clinical practice that can be
adapted by country governments
Provide guidance and technical assistance to host country governments and public/private stakeholders
on effective improvement strategies

NATIONAL
The government, often through the ministry of health, has the responsibility to:

Provide leadership and policy that promote improvement, which include creating guidelines and
standards based on high-impact, evidence-based interventions; monitoring to determine performance;
setting priorities for improvement; determining approaches to improve quality for all levels of the
system and budgeting and planning for these activities; and preparing a competent health workforce
 Learn from improvements being made at the regional/district and facility levels and adjust policies and
guidelines accordingly
Focus on involving the private sector, including professional associations, consumer groups, and/or
insurance mechanisms

REGIONAL

DISTRICT
Regional and district authorities have the responsibility to:

Plan, budget, and coordinate activities for improvement, including any necessary training
Provide mentoring and supportive supervision for improvement
Provide oversight and monitoring of improvement
Address system-level problems such as lack of drugs, equipment, or staff, which are outside of the
ability of a single facility to improve on their own

Facility, Community, and Individual

Responsibilities
FACILITY

Facility leadership has the responsibility for:

Operationalizing priorities within larger programs
Setting up improvement teams
Oversight and monitoring of the improvement
Advocating to higher levels to address system-wide problems
Incorporating improvement into job descriptions and roles

The improvement team has the responsibility to:

Analyze the current practice or process for the area they are trying to improve
Develop and test changes or solutions to improve the process
Collect and review data on a frequent basis
Analyze and determine which changes or solutions are effective and should be implemented
throughout the facility  
Facility leadership and teams also have the responsibility to keep in mind the need to be people-centered in
their solutions. 

COMMUNITY
Community groups and leaders should support and work with community health workers and facilities to
determine improvement in areas in which the community can be influential in improving quality of health
care. These include:
Case identification
Referral
Facility linkages and follow-up
Health messaging and promotion 

Improvement teams can be set up at the community-level to address these issues and strengthen ties with
the formal health system.

INDIVIDUAL

Patients have the responsibility to become active participants in their individual health care. Every patient
deserves the chance to make well-informed decisions and learn how to self-manage their condition when
appropriate.

Representatives of patients and clients should be involved and have a voice in all levels of discussions and
activities to improve the quality of health care. 

Lessons Learned
Take a moment to consider the Uganda health center case
study as well as what you have learned in this course. How
did the Uganda team improve the percentage of HIV-positive
patients assessed for nutritional status? What are some
lessons you have learned to improve health care in the work
that you do? 

For more useful resources on health care improvement, see:

The USAID ASSIST Project: www.usaidassist.org 

Institute for Healthcare Improvement: www.ihi.org 
HealthQual International: www.healthqual.org 