Participant Manual / Module 4

MODULE 4: FOUR STEPS OF QUALITY IMPROVEMENT

Module Introduction

Quality Improvement efforts can be large or small, simple or complex, and

involve few or many people. Regardless of the size and complexity of the
improvement effort, it will likely follow the same basic four-step sequence.
The focus of this module is to introduce you to the four steps of quality
improvement.

Module Objectives

At the end of this module, you should be able to:

Identify the four steps of quality improvement

Explain (at a high level) what is involved in each step

State questions that can be asked to help develop a problem

statement

Discuss the benefits of creating a problem statement

Discuss Shewhart’s PDSA Cycle

Explain the relationship between Shewhart’s PDSA Cycle and Step 4

of quality improvement

Identify what activities occurred during the different QI steps of the QI

Success Stories

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fff 4 STEPS OF QUALITY IMPROVEMENT

The four steps of quality improvement are identified below. They include the steps of
identify, analyze, develop, and test/implement.

1. Identify Determine what we want to improve

2. Analyze Understand the problem

3. Develop Hypothesize about what changes will improve the

problem

4. Test / Implement Test the hypothesized solution to see if it yields

improvement. Based on the results, decide whether
to abandon, modify, or implement the solution.

Notes:

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fff 4 STEPS OF PATIENT TREATMENT

The four steps of quality improvement, listed on the previous page, are similar in nature
to the four steps of patient treatment known by physicians, nurses, and other healthcare
workers, and listed below.

4 Steps of Patient Treatment

1. Assess
2. Diagnose
3. Treat
4. Evaluate

4 Steps of Patient Treatment / Discussion

Directions: In groups of 3 to 4 people generate examples of activities that occur during

each stage of patient treatment. Write your examples in the space provided below.

Patient Treatment Four Example

Steps

1. Assess

2. Diagnose

3. Treat

4. Evaluate

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fff FOUR STEPS OF QUALITY IMPROVEMENT: A CLOSER LOOK

This section provides a close look of the four basic steps of quality improvement: (1)
identify, (2) analyze, (3) develop, (4) and test/implement.

fff STEP 1: IDENTIFY

The first step of quality improvement begins when someone recognizes that an
opportunity for improvement exists. Problems can be identified in a number of different
ways. A patient might express dissatisfaction with quality of care provided, an adverse
event might draw attention to a flawed process, or an organization might systematically
capture and monitor statistical information it believes to be important. The following
questions are helpful in problem identification.

− What is the problem?

− How do you know that it is a problem?
− How frequently does it occur, or how long has it existed?
− What are the effects of this problem?
− How will you know when it is resolved?

Notes:

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Problem Statements

Problem statements are concise statement about a problem to be addressed. While it

is not always necessary to begin with a problem statement, the practice of creating a
problem statement is very helpful in bringing about a shared understanding of the
improvement opportunity. Therefore, the creation of a problem statement is highly
recommended when more than one person will be working to solve the problem or
improve a process.

A good problem statement answers the questions listed on the previous page (e.g.,
what is the problem) and accomplishes four things:

1) provides insight into the process that needs to be improved,

2) identifies when the process starts and stops (its boundaries),
3) identifies the general concern that the quality improvement effort should
address, and
4) includes a general statement as to why it is a priority.

Additionally, a problem statement should not include statements of blame or discuss

potential causes or solutions to the problem. Provided below is an initial version of a
problem statement and the way it was modified to meet the criteria identified above.

Example 1: Problem Statement, Niger

Initial Statement of the Problem:

In areas without electricity, refrigerators are powered by gas in bottles, which
need regular refills. Deficiencies in the transportation and refill of the bottles,
however, disrupted the refrigeration of vaccines.

Rewritten Problem Statement:

Interruptions in the supply of butane to most health centers in the district have
become increasingly frequent and long lasting. An improvement in this situation
would reduce the number of interruptions of the cold chain.

Example 2: Waiting Times

Initial Statement of the Problem:

Waiting times for pregnant women are long because the midwives take too long
for tea breaks. This discourages women from coming for prenatal care.

Rewritten Problem Statement:

Waiting times for pregnant women have been shown to take up to three hours.
This has been stated as a reason that women do not make the desired four
prenatal visits before delivery.

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Problem Identification / Exercise

Directions: In small groups or individually, evaluate each of the statements below.

Determine if you would need to know more to begin addressing the problem and what
questions you would ask to learn more. Write your ideas in the space provided and be
prepared to share your ideas with the class.

Statement Assessment

1. Patients do not come to the health center because

they fear getting HIV from the staff.

2. Mothers do not use supplemental feeding programs.

3. We need to stress the importance of using bed nets.

4. Health workers do not maintain records on Growth

Monitoring and Vitamin A Supplementation regularly.

5. All pregnant women who come for antenatal care do

not receive iron supplements, as the heath center
does not have sufficient stock.

6. Reduce the amount of time it takes for urgent

laboratory tests to have results available to the
clinical officer.

7. Exit interviews of mothers with sick children

indicated that 78% of the mothers were not told
about the nutritional status of their children.

8. Contaminated needles are lying on the ground

where children play.

9. The oxygen tank is empty.

10. In a focus group conducted with health workers in a

village, it was found that most were not certain of the
breastfeeding guidelines for mothers who tested
positive for HIV.

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fff STEP 2: ANALYZE

The second step of quality improvement begins once an opportunity for quality
improvement has been identified. Like Step 1 - Identify, Step 2 will vary based upon the
size and complexity of the process improvement effort. Analysis is performed to better
understand the process that needs to be improved or the system in which the
improvement effort will be based. Listed below are some objectives of the problem
analysis stage. They are:

− Clarify why the process or system produces the effect that needs to be improved
− Measure the performance of the process or system that produces the effect
− Learn about internal and external clients
− Formulate research questions, including
− Who is involved or affected?
− Where does the problem occur?
− When does the problem occur?
− What happens when the problem occurs?
− Why does the problem occur?

To achieve these objectives, the analysis stage involves the use of data. Some of the
data may already exist, or new data can be collected.

Notes:

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fff STEP 3: DEVELOP

The third stage begins when enough data has been collected to develop hypotheses
about what changes or interventions might improve the existing problem. A hypothesis
is an educated guess about the underlying cause of a problem. Because it has not
been tested, it is only a theory at this point.

fff STEP 4: TEST AND IMPLEMENT

The fourth and final stage of the quality improvement process focuses on testing and
implementation of hypothesized solutions. As with the other stages of the quality
improvement effort, the nature of this step will be influenced by the size and complexity
of the quality improvement effort. For example, in some situations it might make sense
to conduct several small tests of the solution(s), while in other situations it might make
sense to make one large test of all the solutions.

The process that is used to test and implement hypothesized solutions is known as the
PDSA Cycle.

Notes:

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fffSHEWHART’S CYCLE FOR LEARNING AND IMPROVEMENT (PDSA)

Within the domain of process improvement, a methodology is used to build knowledge

that will lead to process improvement. The methodology, known as Shewhart’s Cycle
for Learning and Improvement, is a four-step process included within the testing and
implementation stage of the four-step quality improvement process. Shewhart’s Cycle
is often referred to as the “PDSA Cycle” with the acronym relating to the words “Plan,”
”Do,” “Study,” and “Act.”

The PDSA Cycle

4: Act 1: Plan:
− Modify/abandon unsuccessful plan − Make a plan for the change
− Implement successful plan − Collect baseline data
− Develop ongoing monitoring − Communicate the test of the
− Consider implementing change change
throughout system

4: Act 1: Plan

3: Study 2: Do

2: Do
3: Study − Test the change
− Verify the effects of the change − Document the results of the
− Check Results change
− Continue to monitor the data

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Activities Associated with the PDSA Cycle

Phase of Cycle Activities

1. Plan Develop a plan of change to address:

− What changes will occur and why?
− Who is responsible for making the change?
− When and how the changes will occur?
Collect baseline data to measure the effects of change. Plan to
monitor the effects of change through a data collection system.
Educate and communicate with others about the change.
Inform and include people involved in the change and make
sure they accept it.

2. Do Test the change (intervention).

Verify that the change is being implemented as planned.
Collect data about the process being changed.
− Check that the data are complete.
− Document any changes not included in the original plan.

3. Study Verify that the change was implemented according to the plan.
See if the data are complete and accurate.
Compare the data with the baseline information to look for an
improvement.
Compare predicted or desired results with the results from the
test.

4. Act Summarize and communicate what was learned from the

previous steps.
If the plan does not yield the desired results, modify or abandon
the plan and repeat the PDSA cycle if necessary.
Implement the change as standard procedure if it proved to be
successful.
Monitor the change over time to check for improvements and
problems.

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fff QI SUCCESS STORIES / 4 STEPS OF QI DISCUSSION

Directions: In groups of 3 to 4, review the four cases discussed in Module 2, and

identify the various activities associated with each step.

Case 1: Helping Patients Find Their Way

Step 1: Identify

Step 2: Analyze

Step 3: Develop

Step 4: Test and Implement

Case 2: Decreasing the Duration of Phototherapy

Step 1: Identify

Step 2: Analyze

Step 3: Develop

Step 4: Test and Implement

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Case 3: Improving Malaria Treatment Outcomes

Step 1: Identify

Step 2: Analyze

Step 3: Develop

Step 4: Test and Implement

Case 4: Increasing Patients’ Attendance at Postpartum Appointments

Step 1: Identify

Step 2: Analyze

Step 3: Develop

Step 4: Test and Implement

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MODULE 5: INTRODUCTION TO QUALITY IMPROVEMENT CONCEPTS

Module Introduction

In addition to the Four Steps of Quality Improvement and Shewhart’s

Learning and Improvement Cycle, there are some other concepts that are
central to quality improvement. They include:
The four approaches to quality improvement
The use of quality improvement tools
The four principles of quality improvement
This module is designed to introduce you to these three concepts. Each
will be explored in greater detail in later modules of this program.

Module Objectives

At the end of this module, you should be able to:

Name the four basic approaches to quality improvement

Explain that different situations require the use of different approaches

Name several of the quality tools that are used in quality improvement
initiatives

Determine the appropriateness of different tools for different steps in a

quality improvement initiative

Name the four principles of quality improvement

Identify examples of the four principles of quality improvement from the

QI Success Stories (Module 2)

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fff Four Approaches to Quality Improvement

Quality improvement initiatives take place in a number of settings, from large urban
hospitals to small rural health posts. Some initiatives involve many people, while others
involve as few as one person. To accommodate for the variety of settings and
situations in which quality improvement efforts might be initiated, four different
approaches to quality have been developed. They are: individual problem solving,
rapid team problem solving, systematic team problem solving, and process
improvement. Each is briefly described below.

1. Individual problem solving

Very often, a single person can improve quality. This occurs when the individual
recognizes a problem, identifies a solution to it, and is able to solve it. Of course, in
order to be able to solve a problem independent of others, the individual must have
autonomy over the situation.

2. Rapid team problem solving

This team approach improves quality through a series of small incremental changes
that are tested to verify that they result in an improvement. Teams that use this
approach often make use of a mentor or have had previous experience in problem
solving. Often existing data is used as well as the teams’ wisdom, minimizing the
need for data collection.

3. Systematic team problem solving

This team approach is used for complex or recurring problems. It makes use of a
detailed analysis that requires the collection of data. The detailed analysis allows for
the design of a more targeted solution. Because this approach involves the
collection of data and a detailed analysis of the data, it requires the use of more time
and resources.

4. Process improvement

This is the most complex of the four approaches. Process improvement entails the
use of a permanent team that continuously collects, monitors, and analyzes data to
improve a process over time. It normally occurs in organizations where resources
are continuously allocated to process improvement.

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fff Matrix of Quality Improvement Approaches by QI Step

Quality Improvement Approaches

Less Complex ¾ ¾ ¾ ¾ ¾ ¾ ¾ ¾ ¾ ¾ ¾ ¾ ¾ ¾ ¾ ¾ ¾ ¾ ¾ ¾ ¾ More Complex
QI Step Individual Problem Rapid Team Systematic Team Process
Solving Problem Solving Problem Solving Improvement
Identify Individual An ad hoc team An ad hoc team A permanent team
decision-making identifies an addresses a addresses a core
for a small intuitive or obvious complex, recurring process or issue in
problem that is not problem based on problem the organization
interdependent on intuition,
others observation, and
existing data

Analyze Relies on Generally requires The team Requires detailed

individual analysis, minimal analysis examines the root process
using existing using mainly causes of a knowledge from
data, observation, existing data and problem from on-going data
and intuition group intuition existing data collection and
and/or data monitoring
collection

Develop The change is A series of small Generally a large A change in a key

usually minor and changes change that process
not interdependent addresses the root
on others cause of the
problem

Test & “Trial and error” Many small to Generally requires Depends on the
approach to medium tests in extensive testing approach used
Implement
testing similar systems before and the magnitude
implementation of the change;
permanent teams
continue to
monitor / improve
the process

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Four Approaches to Quality Improvement / Exercise

Directions: In teams of 3 to 4 people, make a preliminary determination as to which
quality improvement approach might be most appropriate to address the problem as it is
currently understood.

Statement Suggested QI Approach

1. Patients do not come to the health center because

they fear getting HIV from the staff.

2. Mothers do not use supplemental feeding programs.

3. We need to stress the importance of using bed nets.

4. Health workers do not maintain records on Growth

Monitoring and Vitamin A Supplementation regularly.

5. All pregnant women who come for antenatal care do

not receive iron supplements, as the heath center
does not have sufficient stock.

6. Reduce the amount of time it takes for urgent

laboratory tests to have results available to the
clinical officer.

7. Exit interviews of mothers with sick children

indicated that 78% of the mothers were not told
about the nutritional status of their children.

8. Contaminated needles are lying on the ground

where children play.

9. The oxygen tank is empty.

10. In a focus group conducted with health workers in a

village, it was found that most were not certain of the
breastfeeding guidelines for mothers who tested
positive for HIV.

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fffQuality Improvement Tools

Similar to the way that a variety of tools are used to treat patients, a variety of tools are
used in quality improvement efforts. The table below lists the most common tools and
identifies the various steps of quality improvement where they are often used.

Matrix of Quality Improvement Tools by QI Step

Quality Improvement Step
Step 1: Step 2: Step 3: Step 4:
Tool Identify Analyze Develop Test &
Implement
Data Collection 9 9 9 9
Brainstorming 9 9 9
Affinity Analysis 9 9 9
Creative Thinking Techniques 9 9
Prioritization Tools
Voting 9 9 9
Prioritization Matrices 9 9 9
Expert Decision Making 9 9 9 9
Systems Modeling 9 9 9
Flow Charts 9 9 9 9
Cause and Effect Analysis 9
Force Field Analysis 9 9
Statistical & Data Presentation
Bar & Pie Charts 9 9 9
Run Charts 9 9 9
Pareto Charts 9 9 9
Benchmarking 9 9
Gantt Charts 9 9
Quality Assurance Storytelling 9 9 9 9

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fff The Four Principles of Quality Assurance

There are four basic tenets or principles of quality assurance. Each is explored in detail
in later modules of this program.

The Four Principles of Quality Assurance

Client Focus.
Services should be designed so as to meet the needs and expectations of clients
and community.

Understanding Work as Processes and Systems.

Providers must understand the service system and its key service processes in
order to improve them.

Testing Changes and Emphasizing the Use of Data.

Changes are tested in order to determine whether they yield the required
improvement. Data are used to analyze processes, identify problems, and to
determine whether the changes have resulted in improvement.

Teamwork.
Improvement is achieved through the team approach to problem solving and
quality improvement.

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MODULE 6: THE RED BEAD EXPERIMENT

Module Introduction

In this module you will participate in or observe a simulation called the

Red Bead Experiment. Dr. W. Edwards Deming, considered one of the
founders of the quality improvement, created the experiment. While the
experiment simulates a manufacturing environment, its lessons are
applicable to a healthcare environment.

Module Objectives

Recognize management practices that are not conducive to improving

quality

Develop and discuss your own ideas about the role of management in
quality improvement

Recognize Deming’s 14 Points

Explain some of the lessons learned through the Red Bead Experiment

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fff Red Bead Experiment / Background Information

A company is expanding to accommodate a new customer. The new customer is

interested in purchasing white beads, but only white beads. The company must hire
several new employees to manufacture the white beads. If the customer is satisfied
with the beads and the company is profitable, it will be able to retain the customer and
the new employees.

Observation Guide: Record your observations of the red bead experiment in the
space below.

Hiring of new employees and orientation:

Day 1:

Day 2:

Day 3:

Day 4:

Day 5:

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White Bead Company

Manufacturing Results

Name Day 1 Day 2 Day 3 Day 4 Day 5 Total

Subtotal Subtotal Subtotal Subtotal Subtotal Total

Worker 1

Worker 2

Worker 3

Worker 4

Worker 5

Worker 6

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Discussion Questions

What role does management assume in this simulation?

What kinds of messages did the plant manager send as he/she oriented the
employees to do the job?

What caused the production variation?

What caused some workers to be better than others? Why were some better on
some days than on others?

Why did the quality of the production never improve?

How helpful were the slogans?

What did the plant manager think was the cause of the poor quality?

What do you believe was the cause of poor quality?

What might you do to make the plant profitable?

How might you want to change the working culture?

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Red Bead Experiment / Lessons Learned

Directions: In the space provided below, record what the class found to be the
important lessons learned from the Red Bead Experiment.

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fff Deming’s 14 Points

Dr. Deming created 14 points that should be followed during a quality improvement
effort. He used these 14 points to communicate the principles of quality improvement
around the world.

Deming’s 14 Points

1. Create constancy of purpose for improvement of produce and service. The goal
should be to stay in business and provide jobs through innovation, research, constant
improvement, and maintenance.
2. Adopt the new philosophy. We are often tolerant of poor service and workmanship. We
must become intolerant of mistakes and naive attitudes.
3. Cease dependence on mass inspection. Eliminate the need for inspection on a mass
basis by building quality into the product in the first place.
4. End the practice of awarding business on the basis of price tag alone. The practice of
purchasing supplies and services from the lowest priced vendor often results in purchasing
supplies of lesser quality. Instead, it’s important to seek the best quality and work with the
vendor to develop a long-term relationship.
5. Improve constantly and forever the system of production and service. Improvement is
not a one-time effort; it is a philosophy that results in improved quality and productivity and
reduced costs.
6. Institute training. Too often, workers learn their jobs from another worker who was never
trained properly. They often can’t do their jobs because they don’t know how.
7. Institute leadership. The job of a supervisor is not to tell people what to do but to lead.
Leading consists of identifying through objective methods what can be done to help people
perform their jobs better.
8. Drive out fear. Often people are afraid to ask questions even when they do not understand
what they are supposed to be doing or how they should do it.
9. Break down barriers between staff areas. Often staff areas are in conflict with one
another and are unable to work together as a team to solve problems.
10. Eliminate slogans, exhortations, and targets for the workforce. These things have
never helped anybody do a good job. Allow people to create their own slogans.
11. Eliminate numerical quotas. Quotas focus only on numbers, not quality or methods.
12. Remove barriers to pride of workmanship. People are eager to do a good job. Remove
barriers that prevent them from doing so.
13. Institute a vigorous program of education and retraining. Both management and the
workforce need to be educated in the new methods, including teamwork, and statistical
techniques.
14. Take action to accomplish the transformation. Develop a plan of action that empowers
everyone within the organization to participate in the transformation. The transformation
should be everyone’s job.

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MODULE 7: FOCUS ON PROCESSES AND SYSTEMS

Module Introduction

Module 5 introduced the idea that quality improvement efforts are based
upon four basic principles: client focus, understanding work as processes
and systems, testing changes, and emphasizing the use of data and
teamwork. This unit explores the principle of understanding work as
processes and systems more closely.

Module Objectives

At the end of this module, you should be able to:

Explain that a focus on systems and processes is one of the four

principles of quality improvement

Explain the meaning of the term “process”

Explain the meaning of the term ‘”system”

Differentiate between a process and a system

Identify dependencies and decision points within a process

Depict a process by creating a basic flowchart

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fff The Four Principles of Quality Improvement

The four basic principles of quality improvement introduced in Module Five are reviewed
below.

The Four Principles of Quality Assurance

Client Focus
Services should be designed so as to meet the needs and expectations of clients
and community.

Understanding Work as Processes and Systems

Providers must understand the service system and its key service processes in
order to improve them.

Testing Changes and Emphasizing the Use of Data

Changes are tested in order to determine whether they yield the required
improvement. Data are used to analyze processes, identify problems, and to
determine whether the changes have resulted in improvement.

Teamwork
Improvement is achieved through the team approach to problem solving and
quality improvement.

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fff Understanding Work as Processes and Systems

An important principle of quality improvement is that in order to improve quality,

providers must understand the services that are being provided and the processes used
to provide them. To understand this principle, it’s important to first understand what is
meant by the terms “process” and “system.”

Process Defined

A process is a series of steps used to perform a task or accomplish a goal. During an

ordinary day, without even giving it a thought, you probably follow hundreds of different
processes. For example, your day began with several different processes, which may
have included eating breakfast, getting dressed, brushing your teeth, leaving your
home, and so on.

Processes can be simple or complex, involve few or many steps, and involve few
or many people. Within the healthcare profession, various types of processes
exist, including those that are used to make clinical decisions, manage treatment,
and manage supplies.

Flowcharts are a valuable way to depict a process. A sample flowchart is

available on the next page, and is also provided in the tools appendix.
Flowcharts can be written at a “high” level (only the big steps are listed) or at a
more detailed level.

System Defined

A system is a set of interacting and interdependent parts and processes. The human
body, the ecosystem, a computer system, a family, a healthcare facility, a local
community, a school, and a nation are all examples of different systems. Systems can
be small or large, simple or complex, and they can be comprised of few or many parts.

Each system has its own processes that are often based upon the needs of the system.
For example, the process you used to get to class this morning was likely influenced by
the different systems with which you interact.

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fff Flowcharts

A flowchart is an illustration of the actual sequence of steps that make up work. It is a

powerful quality improvement tool as it helps people to:

Understand the sequence of activities and processes that make up a

task
Look at relationships between activities and decisions
Identify opportunities to fix bottlenecks, add missing steps, and
eliminate unnecessary work

Creating a Flowchart

The following symbols are often used in the creation of a flowchart

Box — Activity or step

Diamond — Decision to be made (yes or no)

Arrow — Direction of flow between steps

Oval — Start and end points in the process

Cloudy Step — A step that is currently uncertain

A Sample High Level Flowchart: Process of Getting to Class

Get out Get Get Eat

of bed washed dressed breakfast

Walk to Ride bus Walk

bus stop from bus
to class

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Exercise: Exploring Interdependencies

Directions: Think about the process that describes how you got to class this morning.
In the left column list the main steps in your process. In the right column, determine
how your process was dependent upon other people and things. For example, taking a
bus to class would mean you interacted with a transportation system, eating breakfast
would mean you interacted with a food supply system, and getting a child ready for
school would indicate interaction with a family system.

Process Step Dependent Upon

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

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fff Creating Flowcharts

The following basic steps can be followed when creating a flowchart.

Step 1: Assemble* the people that are involved in the process.

Step 2: Decide where the work begins and ends.
Step 3: List the main steps and decisions involved in the process.
Step 4: Arrange the steps and decisions in their proper order.
Step 5: Draw the flowchart using the correct symbols.

Directions: Use the space provided below to draw the flowchart created by the class.

* If you are not able to assemble the people and enlist their help in describing the
process, then list them (by role).

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Exercise: Create an “Applying a Dressing” Flowchart

Directions: In small groups of 3 to 4, follow the steps demonstrated in class and create
a flowchart that explains the process used to apply a dressing. Draw your flowchart on
flipchart paper to share with the class, and use the space below to draw a copy for your
personal use.

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fff More about Processes

There are several different types of processes in healthcare that can be explained
through flowcharting. They include:

Clinical algorithms: the processes by which clinical decisions are made

Information flow processes: the process by which information is transmitted among

the different persons involved in the care of the patient

Material flow processes: the processes by which materials (drugs, supplies, food)
are passed through the organization to care for patients

Patient flow processes: the processes which show the movement of patients in the
medical facility as they receive care

Multiple flow processes: most processes are actually multiple flow processes
whereby patients, materials, information, and others are involved simultaneously in
the same process of care

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MODULE 8: FOCUS ON MEASUREMENT: PART I

Module Introduction

One of the four principles of quality assurance states that data are needed
to analyze process, identify problems, and measure performance. This
module will introduce you to several concepts associated with
measurement.

Module Objectives

At the end of this module, you should be able to:

Explain why it is important to use data to analyze processes, identify

problems, and test interventions

Determine how to measure various quality improvement goals

Explain the difference between quantitative and qualitative data

Explain why there is variation in all measures

Explain the difference between common cause and special cause

variation

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fff Focus on Measurement

Testing changes and emphasizing the use of data is one of the four principles of quality
assurance. Other principles include a client focus, understanding work as processes
and systems, and teamwork. The four principles of quality assurance were introduced
in Module 5. Each is briefly described below.

The Four Principles of Quality Assurance

Client Focus
Services should be designed so as to meet the needs and expectations of clients
and community.

Understanding Work as Processes and Systems

Providers must understand the service system and its key service processes in
order to improve them.

Testing Changes and Emphasizing the Use of Data

Changes are tested in order to determine whether they yield the required
improvement. Data are used to analyze processes, identify problems, and to
determine whether the changes have resulted in improvement.

Teamwork
Improvement is achieved through the team approach to problem solving and
quality improvement.

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fff Why Measure?

A difference that makes no difference is no difference.

The measurement of data is key to quality improvement initiatives because it provides

information about how an initiative is proceeding. Data makes it possible to make
decisions based upon fact, not opinion. Data provides objective information that allows
for the development and testing of hypotheses, as well as charting progress after a
change has been implemented. In summary, the measurement of data is useful in
quality improvement efforts to:

Identify and analyze problems

Verify possible causes of problems
Show if a change yielded initial improvement
Monitor change to ensure improvement is maintained over time
Make decisions based upon fact, not opinion

Notes:

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Exercise: Identifying Measures

Directions: In groups of 3 to 4 participants, determine how you might measure each of

the following quality improvement goals. Write them in the space to the right.

Quality Improvement Goals Measures

1. Decrease infant mortality

2. Increase number of clients cared for

each day

3. Shorten the length of time required to

admit a patient

4. Improve the availability of clinical

supplies

5. Improve client satisfaction

6. Improve employee satisfaction

7. Improve the reliability of equipment

8. Increased use of family planning

methods

9. Improve the safety of employees

10. Reduced staff turnover

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fff Types of Data: Quantitative and Qualitative

There are two broad categories of data: quantitative data and qualitative data.
Quantitative data is measured with numbers and often makes use of statistical
procedures. Qualitative data is formed with words, and often reports the detailed views
of informants. Informants might be clients, family members of clients, healthcare
providers, or community members. While both are helpful in understanding a problem
or issue, they answer different kinds of questions.

Quantitative Data is… Qualitative Data is…

Objectively based Subjectively based in many cases
Easy to measure and quantify Difficult to measure and quantify
Often measures quantity, cost, and Usually behaviorally oriented
time Often incorporates individuals attitudes,
Sometimes referred to as ”hard data” perspectives, and opinions
Examples include: Sometimes referred to as “soft data”
Examples include:

Notes:

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Exercise: Qualitative or Quantitative?

Directions: In a group of 3 to 4 people, review the sample client satisfaction survey

found below and discuss the questions that follow it.

Healthcare Facility Client Satisfaction Survey

Directions: Circle the response that best represent how you feel about your recent
experience at the healthcare facility.

1. Healthcare providers treated me Strongly Agree Neutral Disagree Strongly

courteously. Agree Disagree

2. The facility where I was placed was clean Strongly Agree Neutral Disagree Strongly
and tidy. Agree Disagree

3. I received service promptly. Strongly Agree Neutral Disagree Strongly

Agree Disagree

4. I was informed of my healthcare options Strongly Agree Neutral Disagree Strongly

before being asked to make a choice. Agree Disagree

5. Overall, I was satisfied with my experience Strongly Agree Neutral Disagree Strongly
at the healthcare facility. Agree Disagree

1. Is the survey collecting quantitative or qualitative data?

2. If you answered quantitative, how could it be modified to collect qualitative data?

3. If you answered qualitative, how could it be modified to collect quantitative data?

4. What are some of the steps that would need to be followed to create a survey like
this?

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fff Data Variation

An important concept to keep in mind as you interpret data is the idea that there is
variation in every measurement. Some of the variation is normal, while other variation
can signal that there has been an improvement in or worsening of the current situation.
The different types of variation are known as common cause variation and special
cause variation.

Common cause variation – variation that is predictable or expected within a stable

situation or process.

Example:

Special cause variation – variation that is neither predictable nor expected. Variation
that occurs as a result of a special cause can point to a possible worsening or
improvement in a situation and should therefore be examined.

Example:

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