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Improving Quality

Improving quality involves applying appropriate methods to close the gap between current and expected levels of quality as defined by standards. This core QA activity uses quality management tools and principles to understand and address system deficiencies, enhance strengths, and improve healthcare processes. A range of quality improvement approaches exist, from individual problem solving, rapid team problem solving, and systematic team problem solving to process improvement and redesign and organizational restructuring/reengineering. QA topics that are part of Improving Quality include:

The Four-Step Approach to Quality Improvement. Quality improvement (QI) methodology has evolved over the years. Early QI efforts assumed that improvements could be readily attained by adding new or more things, such as new machines, procedures, training, or supplies. It was believed that simply adding more resources or inputs would improve quality. People working to improve quality learned that increasing resources does not always ensure their efficient use and, consequently, may not lead to improvements in quality. In fact, a key lesson is that in many cases quality can be improved by making changes to healthcare systems without necessarily increasing resources. Interestingly, improving the processes of healthcare not only creates better outcomes, but also reduces the cost of delivering services by eliminating waste, unnecessary work, and rework.Inspecting main activities or processes is another approach that managers have used to identify and solve problems. This method tried to increase control over staff and often blamed people for mistakes. This philosophy of improving quality showed limited success because it did not necessarily identify barriers to improvement or generate the support of workers, who felt resistant to being evaluated. In contrast, current QI approaches examine how activities can be changed so employees can do their work better. For example, poor employee performance may stem from a lack of supplies, inefficient processes, or the lack of training or coaching rather than worker performance. The philosophy behind the QA Project’s approach to QI recognizes that both the resources (inputs) and activities carried out (processes) must be addressed together to ensure or improve the quality of care.In response to the wide variety of settings and circumstances it has encountered in over 30 developing countries, the QA Project defines quality improvement as consisting of four key steps.

  • Step one: Identify > Determine what to improve
  • Step two: Analyze > Understand the problem
  • Step three: Develop > Hypothesize about what changes will improve the problem and develop solution strategy based on these changes
  • Step four: Test and implement > Test the hypothesized solution

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QI is not limited to carrying out these four steps, but rather emphasizes continuously looking for ways to further improve quality. When improvements in quality are achieved, teams can continue to strive for further improvements with the same problem and/or address other opportunities for improvement that have been identified.

Step one: Identify. The goal of the first step, identify, is to determine what to improve. This may involve a problem that needs a solution, an opportunity for improvement that requires definition, or a process or system that needs to be improved. Examples of problems or processes that are commonly identified include low coverage, inadequate counseling, lack of drugs, lost lab reports, and excessive waiting time.This first step involves recognizing an opportunity for improvement and then setting a goal to improve it. Quality improvement starts by asking these questions:

  • 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 we know when it is resolved?

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Step two: Analyze. Once areas for quality improvement have been identified, the second step is to analyze what we need to know or understand about this opportunity for improvement before considering changes. The objectives of the analysis stage can be any combination of the following:

  • Clarifying why the process or system produces the effect that we aim to change
  • Measuring the performance of the process or system that produces the effect
  • Formulating research questions, such as the following:
    • 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 reach these objectives, this step requires the use of existing data or data collection. The extent to which data are needed depends on the quality improvement approach chosen. Techniques to analyze problems include clarifying processes through flowcharts or cause-effect analyses, reviewing existing data, and, when needed, collecting additional data.

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Step three: Develop. The third step, develop, uses the information accumulated from the previous steps to explore what changes would yield improvement. A hypothesis is formulated about which changes, interventions, or solutions would reduce the problem and thus improve the quality of care. A solution strategy is then developed based on this hypothesis. It is important to remember that at this point the hypothesis remains a theory, as it has not yet been tested. A hypothesis is a tentative assumption made in order to test its consequences. It is based on people’s knowledge and beliefs about the likely causes and solutions of the problem.

Step four: Test and implement. This step, test and implement, builds on the first three. A hypothesis is tested to see if the proposed intervention or solution yields the expected improvement. Because interventions that prove to be effective may not yield immediate results, allowing time for change to occur is important in the testing process. The results of this test determine the next step.

Determining the Next Step after Solution Testing

Test Result

Next Step

Proposed change did not produce an improvement

Start the improvement process again or look for flaws in the proposed change

Proposed change yields improvement that is not completely satisfactory

Modify the proposed change and then re-test the modification

Proposed change yields satisfactory improvement

Begin the implementation of the change or intervention


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The Spectrum of Quality Improvement Approaches

Rapid Team Problem Solving. Rapid team problem solving is an approach in which a series of small incremental changes in a system is tested—and possibly implemented—to improve quality. This approach entails many small to medium size tests of individual changes in similar systems. Like individual problem solving, this approach could be used in any setting, although it generally requires that teams have some experience in problem solving and/or seek a mentor to help implement this approach quickly. This approach to quality improvement is less rigorous in the time and resources required than the next two approaches because it largely relies on existing data and group intuition, thereby minimizing lengthy data collection procedures. Rapid team problem solving may involve cause analysis, but implemented in a less rigorous fashion than in systematic problem solving. Teams are ad hoc (temporary) and disband once the desired level of improvement has been achieved.

Systematic Team Problem Solving. Systematic team problem solving is often used for complex or recurring problems that require a detailed analysis; it frequently results in significant changes to a system or process. The mainstay of this approach is a detailed study of the causes of problems and then developing solutions accordingly. This detailed analysis usually involves data collection and therefore often requires considerable time and resources. While systematic team problem solving can be used in any setting, due to its indepth nature, it is most appropriate when the ad hoc team can work together over a period of time. Typically, such teams disband once sufficient improvement objectives are reached.

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Process Improvement. The most complex of the four approaches, process improvement, involves a permanent team that continuously collects, monitors, and analyzes data to improve a key process over time. Process improvement generally occurs in organizations where permanent resources are allocated to quality improvement. The permanent team may use any of the other three QI approaches, for example, forming ad hoc teams to solve specific problems. Process improvement is often used to assure the quality of important services in a health facility or organization. Since this approach is often used to respond to core processes of a system, various stakeholders contribute to the analysis stage.The table below compares the four QI approaches.


Individual Problem Solving

Rapid Team Problem Solving

Systematic Team Problem Solving

Process Improvement

When to use the approach

When you know the problem is dependent on only one person

When the team needs quick results and has a lot of intuitive ideas

When the problem is complex or recurring, requiring analysis

When a key process or system requires ongoing monitoring or continual improvement



Ad hoc

Ad hoc



Almost none

Can succeed with little data

Need data to carry out root cause analysis to understand the causes of the problem

Data from continuous monitoring; may need to collect more




Limited to the time necessary


In sum, experience with quality improvement has rendered it a simpler, more robust methodology, and the application of QI methodology to a wide range of settings has become clearer. The settings include both clinical and nonclinical environments, with the approaches ranging from individual problem solving to process improvement by permanent teams. In all of these approaches, the methodology and principles remain unchanged, though their specific methods may vary.

Continue to Improving Quality (Performance Improvement & Benchmarking)

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The Quality Assurance Project (QAP) is funded by the U.S. Agency for International Development (USAID) under Contract Number GPH-C-00-02-00004-00.