Team Dynamics and problem solving

Chapter 4
April 24, 2025 QI Training 1
 Team formation, Problem
Identification, Prioritization and Aim
Setting

ጤና ሚኒስቴር - ኢትዮጵያ
MINISTRY OF HEALTH –
ETHIOPIA
የዜጎች ጤና ለሃገር ብልጽግና!
HEALTHIER CITIZEN FOR PROSPEROUS NATION! by
Designed Alemu
Kejela Feb 2021
Outline
 Introduction
 QI Team formation and composition of QI teams.
 Roles and Responsibilities of Quality Improvement Teams
 Stages of team development
 Identify Quality Gaps/Identify Problems using Data
 Prioritization Tools
 Problem Statemen and Aim Statement
 Quality Improvement Project Work – Section I
 Summary
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Enabling Objectives
 Discuss team formation: QIT establishment, composition
their roles and responsibilities, and QI team meetings
 Identify problems using the dimensions of quality, Data
and Donabedian framework.
 Apply tools to prioritize problems.
 Develop problem statement.
 Develop SMART aim statement for identified problems.
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 QI Team Formation
and Functionality

ጤና ሚኒስቴር - ኢትዮጵያ
MINISTRY OF HEALTH –
ETHIOPIA
የዜጎች ጤና ለሃገር ብልጽግና!
HEALTHIER CITIZEN FOR PROSPEROUS NATION! by
Designed Alemu
Kejela Feb 2021
Activity 1: Reflection questions
• What is team and its difference with a group?
• Who should be included in a QI team?
• How big should the team be?
• How frequent should the team meet?
Time allowed-10 min

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What is a team?

• A team is a group of two or more individuals who:

 Interact dynamically
 Have a common goal/Objective
 Have been assigned specific tasks for each
 Who have a limited lifespan of membership.
 Who have been each assigned specific roles or functions to
perform
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Difference between group and team
Group Team

Individual goals Shared goals

Individual accountability Individual and mutual accountability

Individual work Collective work

Individual success or failure Collective success or failure

Discussion, decision, delegation of a Discussion, decision and sharing of work

work for each individuals

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Composition of QI team
System
Leader
(CEO,MD, Dep’t head..)

Day-to-day
Technical QI Leader
Expertise Devote significant

Subject Matter Expert

Team amount of time
on QI

Beneficiaries
Patient/their
families/community
representatives

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 During Team Formation Things Should Be
Considered

• Those interested in QI and/or

those who are involved in the
area that needs improvement

• The team should be

multidisciplinary and relatively
small (6-10)

• Client representation on the

team is encouraged

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 Example: QI team
• If your QI team focus is on MNCH you probably will have a core team that
includes representatives of: Maternity and Pediatric Wards, Laboratory,
Pharmacy, Management, and Clinician/ Pediatrician/ Obstetric
Gynecologist. Any change targeting on improving MNCH is likely to impact
on some of the care processes of these units/ departments. Often senior
staff of the unit or the unit in-charge is selected to be part of the core team,.
This situation would result in a core QI team of 6-10 members.

Reflect question
What do you observe from the above examples ???

10 minutes

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 Key positions/roles of a QI team

System leader(Facility leader):

 Agree on the improvement topic and aim
 Identify the leader of the QI team.
 Stay informed about the progress of the QI effort
 Communicate with boards for decision making issues
 Provide necessary resources as required
 Attend learning sessions and provide guidance
 Stay informed about the progress of the QI effort.

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Key positions/roles ……

Unit Head (Day-to-day Leader):

 Keep the team focused on the aim and charter.
 Plan and organize team meetings.
 Identify needs for and request additional support.
 Assign responsibilities to team members.
 Liaise with the management team.
 Represent the team during the learning sessions.
 Develop an implementation plan for the Changes.
 Serve as coaches to new teams during the Scale-up process
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Key positions/roles ……

Subject matter expert

• Though this role is often covered by the systems leader
or day-to-day leader,
• But we may also require the relevant subject matter
experts when trying to make change to the system.
• Moreover, this person should have a good working
relationship with colleagues and have interest in driving
change.
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Key positions/roles ……

Clients and Beneficiaries (often part of the QI team)

 Identify issues of access and service quality, and communicate these to the
QI team.
 Engage in problem analysis, change idea development
 Identify changes in patient behavior and promote them through a network
of patients.
 Attend learning sessions. (Clinical audit reports, Death audit reports….)
 Report on progress to peers

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Innovators of Improvement

• Identify and prioritize problems

• Develop and test change

ideas - PDSA

• Get results – early wins

• Involve colleagues

• Convince early adopters

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Leadership Engagement/Buy-in

 At some point the team may need additional

resources to test a change idea
 Change is not always well accepted by all
individuals
 Leadership can give additional support the
team’s idea by instructing staff to cooperate to
testing the change
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Leadership Engagement/Buy-in
Leaders engagement could be
beneficial
 To guide on how to analyze the
current performance of the HF

 To help create a burning platform

(agendas)

 To align QI aims with facility goals

The frog in the burning platform

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 Effective Team

• Clear communication among all

members
• Regular brainstorming sessions with
all members participating
• Problem solving done by the team
• Commitment to the project and the
other team members
• Regular team meetings that are
effective and inclusive

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 Conducting regular QI Team Meetings
• New QI teams should meet at least every
other week (twice per month)
• Experienced teams should have monthly
meetings
• Each meeting should be documented;
meeting minutes serve as reference
material for the QI team, QI coach and
(senior) leadership.
• QI teams should debrief/ update leadership
regularly (preferably every month but at
least once a quarter).
A QI team in action

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 QI Team Meetings
What it should be: What it should not be:

• focused on aims • a team meeting

• identifying barriers to reaching aims • a meeting where every problem in the

• creating or sourcing change ideas facility is addressed

• planning PDSAs • a complaining session without the

generation of change ideas
• reviewing PDSAs & change ideas
• disconnected from previous meetings

Designed by Alemu Green C. 2010

Kejela Feb 2021 QI Training April 24, 2025 21
Stages of Team Development : Tuckman Model

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 Problem Identification,
Prioritization

ጤና ሚኒስቴር - ኢትዮጵያ
MINISTRY OF HEALTH –
ETHIOPIA
የዜጎች ጤና ለሃገር ብልጽግና!
HEALTHIER CITIZEN FOR PROSPEROUS NATION! by
Designed Alemu
Kejela Feb 2021
Activity – 2: Plenary Discussion
• You have had an ongoing problem with frequently occurring
maternal mortalities (more than 3 per month) in your facility.
You have been tasked to bring a solution to this problem.

 What should be done differently to reduce maternal mortality in

the facility?

• Time: 5 minutes
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Introduction
A problem is

“ the difference between things as perceived and things as

desired”
Gause and Weinberg (1989)

“ the gap between the existing state and the desired state
of a process”
Health Quality Ontario
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Problem Identification

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 Identifying Quality Gaps
• What to improve?
 Need to identify the opportunity for improvement
• Safety issues: system fails to detect risks and adverse
events that will eventually harm the patient or provider
• Effectiveness issues: system does not deliver
according to performance expectations
• Efficiency issues: system uses too many resources to
deliver its performance
• Responsiveness issues: the system does not address
the needs of its clients to their satisfaction.
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Federal Democratic
Kejela Feb 2021Republic of Ethiopia, Ministry of Health (2017), HSTQ, QI-TC Participants Manual
QI Training April 24, 2025 27
Identifying Quality Gaps…

• People-centered: the system does not respond to the individual’s, family and
caretaker needs and values. The care is not considerate of the patient and family
choices.

• Timely: the system is unable to use the time efficiently.

• Equitable: the system is designed in a way where clients are favored based on
personal characteristics.

• Integration: The system fails to provide coordinated and comprehensive care.

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Identify Problems in Quality of Care
Seven Healthcare
Quality Dimensions

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Donabedian’s Model: Evaluating QoC

STRUCTURE PROCESS OUTCOME

Effect of
Physical and Focus on the care
organization delivered to healthcare on
characteristics patient the status of
where e.g. services, patient and
healthcare diagnostics or population
occurs treatment

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Donabedian’s Model

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Donabedian, A (1966).
Kejela Feb Evaluating
2021 QI Training
the quality of medical care. Milbank Quarterly, 44 (Suppl.), 166-206. April 24, 2025 31
Activity 3: Small Group Exercise
Instruction: Form group of 3-5 participants per facility/department
• Think about existing performance gaps in your facility/department using

 Dimensions of Quality of care

 Data: Mortality and Morbidity reports

 Donabedian’s model

 Present the existing performance gaps

 Time: 30 minutes
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Problem identification: What Tools to Use?
• Common tools for problem identification,
 Data from various sources
 Conducting audit
 Comparing performance with targets: Review
 Observation/ Walk through
 Patient Compliant
 Others

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Compare Performance with Target

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Observation

• Clinical skills

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Using Data sources –Registers

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Data sources Audit
Data Quality

Chart audit

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Walk-through
• Is repeated real-time observation of patients and
families as they move through each step of their
healthcare journey.
• Enables providers to better understand the true care
pathway, experience of care from the patients’ and
families’ point of view
• It generates data that address the total experience of
the patient including frustrations, confusion, anxiety
Designed by Alemu
AdaptedKejela
from Feb
Institute
2021 for Healthcare Improvement, Walk-through Tool
QI Training April 24, 2025 38
 Prioritization Tools
If you’re Noah, and your ark is about to
sink, look for the elephants first, because
1. Pareto Chart
you can throw over a bunch of cats, dogs,
squirrels, and everything else that is just
a small animal and your ark will keep
Vilfredo Pareto sinking. But if you can find one elephant
to get overboard, you’re in much better
shape.
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Pareto Principle

• A small amount of effort accounts for

most of the results.

• 80/20 rule

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What is a Pareto Chart?
A graphical tool that helps to prioritize efforts to where
they will have the most impact.
It is made up of three (3) key components:
1.Bar/Column chart – representing
categories/frequencies displayed in order of size
2.Line graph – representing the cumulative percentage
3.Two vertical (y-) axis
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Steps for Constructing a Pareto Chart

1.List all the possible categories/groups

2.Collect the data – how many of each
3.Arrange the categories/groups from the highest to
the lowest frequency/impact
4.Calculate the total, add up the frequencies
5.Calculate percentage for each category/group
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Steps for Constructing…
6. Calculate the cumulative percentage
7. Draw the axes – horizontal: categories/groups
vertical left:frequencies/ ‘raw’ data
vertical right: cumulative percentage
8. Plot the data in your graph
9. Label the axes and annotate the graph (specifying the
vital few and useful many)
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Prepare Pareto Chart (30 min.)
Contributing factor Cumulative
(Causes of Neonatal deaths) Frequency Percentage Percentage
Prematurity 49 32.2% 32.2%

Birth Asphyxia 45 29.6% 61.8%

Neonatal Sepsis 31 20.4% 82.2%

Congenital Abnormalities 11 7.2% 89.5%

Pneumonia 9 5.9% 95.4%

Tetanus 4 2.6% 98.0%

Malnutrition 1 0.7% 98.7%

Diarrhea 1 0.7% 99.3%

Birth injury 1 0.7% 100%

Total 152 100%

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 Pareto Chart on Neonatal deaths
• Causes of neonatal deaths in the scenario facility

60 Cause of Neonatal Deaths in 2016 100

50 80

Cumulative per-
40 Vital few 60
Frequencies

centage
30
40
20
Useful 20
10
many
0 0

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Activity 4: Small Group Exercise
Instruction: Prepare pareto chart using your
facility data of Neonatal death
• Complete the table and construct the complete
Pareto Chart
• Allow 3 groups to present using flip chart
• Time: 30 minutes

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Priority Matrix

• Which identified problem should be prioritized?

• Common criteria used to prioritize problems
 Cost and/or gains when resolved
 Availability of solutions
 Availability of resources (staff, time, equipment, etc.)
 Urgency of solving
 Size of problem
Adapted from National Association of Country & City Health Officials (NACCHO), First Things First

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Step-by-Step Instructions
List the problems
Create a matrix vertically and the
criteria horizontally

Add one extra column

on the right for priority
score

Weight the criteria, Rate the problems for

Adapted from National Association of Country & City Health Officials (NACCHO), First Things First
according to level of
Designed by Alemu
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according
24, 2025 to 48
rating scale
Example of Prioritization Matrix
Problem or Opportunity Impact Frequency Feasibility Alignment Total
with Strategic priority
Goals Score
Low rates of immunization coverage 4 5 4 4 17

High rates of maternal mortality 5 4 4 5 18

Low rates of antenatal care utilization 4 3 4 4 16

Lack of access to essential maternal 5 5 4 5 19

and child health services in rural
areas
High prevalence of stunting among 5 3 3 3 14
children

In adequate access to prenatal care 4 3 3 2 12

*Rating Scale used: 0-5

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 Activity 5: Small Group Exercise
• Work in your previous groups (per facility, department, organization)

 Brainstorm with your group about prevailing health problems in

your work place
 List the problems and the criteria you use to rank them
 Use prioritization tools and prioritize performance gaps
 Present to the plenary

• Time: 20 minutes
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 Problem prioritization matrix : Group exercise(20 min)

Sn List of identified problems Within control/Feasibility Frequency of the Cost Total score
problem

10

11

12

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 Problem Statement

ጤና ሚኒስቴር - ኢትዮጵያ
MINISTRY OF HEALTH –
ETHIOPIA
የዜጎች ጤና ለሃገር ብልጽግና!
HEALTHIER CITIZEN FOR PROSPEROUS NATION! by
Designed Alemu
Kejela Feb 2021
Components of Problem Statement

• What is the problem? What is not functioning as

desired? What are the boundaries? (Size)
• How do we know it is a problem?
• How long has it been a problem (time)?
• What are the effects (impact) of this problem?
• Where does the problem exist?
• How will we know the problem is resolved?

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What it does NOT include…
• Causes

• Actions or corrections required

• Assign blame

• Address more than one problem

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 Guiding Questions Example
A team at a dream hospital noted a shortage in medication for Acute
Respiratory Infections (ARI) for under five children.
• What is the problem? A shortage of ARI drugs for children under five
• How do you know it is a problem? Drugs run out by the third week of the
month
• How frequently does it occur? This shortage has occurred every month for
the past nine months
• What are the effects of this problem? Patients develop complications
causing an increase in referrals to a first-level facility
• How will you know when it is resolved? The problem will be solved when
ARI drugs last until the end of the month
Federal Democratic
Designed by AlemuRepublic of Ethiopia, Ministry of Health (2017), HSTQ, QI-TC Participants Manual
Kejela Feb 2021 QI Training April 24, 2025 55
Examples Problem Statement
Problem Statement Strong?
1. There are many errors in our data
2. Over the past 2 years, only 50% of ANC clients was tested for
HIV in Dream Hospital, leading to high-risk deliveries with
potential risk for baby and health workers to be exposed

3. Maternal client's satisfaction is low

4. For 3 months Dream Hospital had a closed OR and an

increase in referrals, so far 150 clients were referred

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 Setting Aim Statement

ጤና ሚኒስቴር - ኢትዮጵያ
MINISTRY OF HEALTH –
ETHIOPIA
የዜጎች ጤና ለሃገር ብልጽግና!
HEALTHIER CITIZEN FOR PROSPEROUS NATION! by
Designed Alemu
Kejela Feb 2021
 Model for Improvement

What are we trying to Aim

accomplish?
How will we know that a
change is an improvement?
What changes can we make that
will result in improvement?

Act Plan

Study Do

The Model for Improvement was developed by © 2004 Institute for Healthcare
Associates in Process Improvement. Improvement
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Purpose of Aim Statement

• 1st Principle of Improvement – know why to

improve
• An Aim Statement is an explicit description with
specific actions or focus
• An internal and external communication tool for
the work to be done

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Components of Aim Statement
SMART aim template
Specific Be specific about what you want to improve. Where and for who?

Include a measurement that will evidence improvement. create a

Measurable baseline performance

Achievable Set a numerical target that can be realistically achieved

Your aim to the facility goals and will improve patient care, experience
Relevant and outcomes.

Include a timeframe for your project thinking about when you might see
Time-bound the outcomes
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 Aim Statement

Date:
I/we,_________________,aim to
improve/reduce/initiate/redesign_________
______________from_________________to
__________by______________.

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 Example: Aim statement

• Date:
• Problem: Babies are cold at one hour following birth
• We will reduce the % of newborns with low temperature (<36.5 C ) from the
current 50% to less than 10% within six weeks
 Who (which patients) - Newborns
 What (the outcome) - low temperature (<36.5 C )
 How much (the amount of desired improvement ) - from 50% to less than 10%
 By when (time over which improvement will occur) - within 6 weeks

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Examples of Aim Statements
S M A R T
We Emergency OPD QI team at Tena Lehulum
Hospital aim to reduce the length of stay of cardiac
patients from 72 hours to 48 hours in Adult
Emergency department from May 20, 2022, to
August 30, 2022

To increase number of 4th ANC from 50% to 85% at Tena

Lehulum Hospital by the end of June 2022

To increase the percentage of inpatient referral feedback

given from 20% to 50% from June 23/2022 to Jan 7/
2023G.C.

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Quality Improvement Project Work
Section I – Problem identification, prioritization and aim
statement
• Develop a problem statement and a SMART aim statement for a
problem identified in your facility/organization
 use the prioritized problem from the priority matrix exercise
 Present your work

• Document in your project workbook, subsequent sessions will

build on this (Annexed)

• Time: 30 minutes
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Summary
. Team is group of individuals who work
common goal
together to achieve

QI teams should constitute system leaders, day to day leadership

and subject matter experts

Tuchman's models of stage of team are

forming,storming,normingand performing

Conducting regular QI meeting is key role of team improving

quality

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Summary…

The first step in improvement journey after team formation is problem identification

Prioritization tools can help focus which problem to start with

A good problem statement answers a series questions including the size,

impact, location and frequency of the problem

A aim statement should be SMART

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 THANK YOU!

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