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Case Studies

Case studies report QAP experiences in helping developing countries apply quality assurance (QA) approaches at various levels of their health systems. These papers are grouped below by the major QA activity that serves as the focus of each: quality assessment, standards development, quality design, quality improvement, and analyzing cost and quality.


Cost-Effectiveness of Self-Assessment and Peer Review in Improving Family Planning Provider-Client Communication in Indonesia: This cost analysis is based on QAP research on the effectiveness of two interventions (self-assessment and peer review) in sustaining or increasing the effectiveness of interpersonal communications training that midwives had taken. The research had measured the effectiveness of the interventions in terms of the number of utterances midwives made during family planning consultations, and this case study followed on, measuring the cost of each intervention in terms of the number of utterances generated. Activities/tools: Sample provider self-assessment form, sources of costs, evaluation of marginal benefit.
Download report (18 pages)


Assessing the Quality of Healthcare at the District Level in Rwanda: Clinical (i.e., vaccinations) and support (i.e., community participation) activities served as the focal point of assessments of two healthcare facilities. Several data collection instruments were developed (observation guides, health worker questionnaires, inventory checklists, etc.) to measure input and process indicators. Activities/tools: Performance indicators; data collection strategy; interpreting, presenting, and disseminating findings.
Download report (14 pages)

Assessing Health Worker Performance of IMCI in Kenya: District health management teams in two districts of Kenya collaborated to measure health worker compliance with IMCI. With a local NGO tasked with reducing malarial morbidity/mortality, the teams selected assessors, trained data collectors, developed data collection instruments, and found low compliance. Team problem solving and reassessment showed significant improvement. Activities/tools: 2 pages of a 4-page IMCI performance assessment, 1-page provider competence assessment.
Download report (13 pages)
Evaluación del desempeño en AIEPI de los trabajadores de salud en Kenya

Assessing the Quality of Facility-Level Family Planning Services in Malawi: Eighteen staff members from two hospitals and four health centers assessed family planning services at each other's facilities. Interesting insights describe team-based problem solving, service reorganization to reduce waiting times, and attitude change. Activities/tools: Five data collection instruments are described, a client-flow data compilation form is pictured, and two examples of assessments are shown.
Download report (11 pages)
Evaluación de la calidad de los servicios de planificación familiar a nivel de establecimiento en Malawi

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Assessing Malaria Treatment and Control at Peer Facilities in Malawi: An advisory committee designed a program to assess compliance with standards for treating and preventing malaria at 26 facilities in Blantyre, a largely urban district. Medical assistants and nurses peer reviewed their counterparts at other facilities using observations, exit interviews with clients, health worker interviews, a facility inventory checklist, etc. The results informed the design of an initiative to reduce malaria. Activities/tools: Using bar and pie charts to present data, triangulating data (using two or more data sources to improve understanding of data).
Download report (11 pages)

Designing Quality Essential Obstetric Care Services in Honduras: A regional steering committee identified 6 facilities-2 health centers, 2 hospitals, and 2 clinics-for quality design of obstetric services. Facility-based teams identified the process or service (e.g., recognizing danger signs) that, if improved, would most likely lead to higher maternal survival rates. Importance of community involvement and inter-team collaboration is highlighted. Activities/tools: Flowchart, networking, rewarding quality, institutionalization.
Download report (29 pages)


Using Quality Assessment to Improve Maternal Care in Nicaragua. This case study describes the work of healthcare providers who improved the quality of obstetric care at health centers and posts in a Hurricane Mitch-damaged area. Quality improvement (QI) teams monitored the quality of care by gathering data relating to seven indicators, such as the number of prenatal care visits and the use of emergency obstetric care standards. To the extent the monitoring indicated that standards were not being met, the teams applied rapid team problem solving to redirect the healthcare providers toward meeting those standards. Performance improved in all indicators, and maternal mortality rates declined. This work shows that QI teams can set goals for themselves and monitor their progress in reaching those goals, that many improvements can be made with the investment of few resources, and that provider attitudes will change with information about client needs and expectations. Activities/tools: Rapid team-based problem solving, assessing client needs and expectations, monitoring standards compliance.
Download report (23 pages)


Using Team Problem Solving to Improve Adherence with Malaria Treatment Guidelines in Malawi: A team at the Lifuwu Health Center decided that its first problem-solving experience would reduce the number of people who return with malaria symptoms within a week of receiving treatment after having been treated for that disease. The team used a fishbone diagram to determine that lack of compliance with malaria treatment stemmed from treatment, the environment, patient/family, and/or staff/provider. Twenty days of data collection (covering 761 clients, 173 of them reattendants), including interviews with reattendants, convinced the team that improving patient/community understanding of the importance of adhering to treatment and how to do so would go a long way in reducing reattendance. Solutions were brainstormed, selected on the basis of utility, and implemented. Results: Reattendance dropped from 31 percent of patients to 5 percent within a year and stayed down for the next year, saving enough in drug costs alone to treat over 2000 malaria patients (savings in personnel time were not calculated). Activities/Tools: Six-step quality improvement process, decision matrix, fishbone diagram, and run chart.
Download report (18 pages)

Using Client Satisfaction Data for Quality Improvement of Health Services in Peru: A private, nonprofit clinic in Peru was alarmed by low utilization when a natural disaster forced community members to forego health services to meet more pressing personal needs. Lowering services fees brought clients back but was not viable long term. Client satisfaction data from focus groups, suggestion boxes, and exit interviews shed light on causes of client dissatisfaction so that systematic team problem solving would bring clients back to the clinic, restoring its financial stability and preserving its vital position in the community.
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Using Screening Data to Improve Hypertension Care in Russia: An oblast-level team used the four-step quality improvement method to determine the most effective screening approach to identify people with hypertension and ultimately to reduce hypertensive crises. Activities/tools: Developing indicators, four-step QI method.
Download report (9 pages)

Developing Evidence-Based Standards for Pregnancy-Induced Hypertension in Russia: Teams comprising oblast leadership and maternity staff ranging from physicians to midwives at selected facilities in Tver Oblast revised the system of care for pregnancy-induced hypertension (PIH), at the time Tver's leading cause of maternal death. The teams flowcharted their then-current system, studied PIH-related evidence-based medicine, and gradually introduced evidence-based changes, monitoring the results as they progressed. After changing the clinical practice of care, they then returned to their flowcharts to see what system changes could further improve care. Full implementation resulted in no maternal deaths, no progression to eclampsia, and a 77 percent reduction in hospitalizations from PIH (three facilities; 18 months). Activities/tools: Six-step methodology for developing clinical-organizational guidelines, flowcharts, timeline, run chart.
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Improving Compliance with Standards for Essential Obstetric Care in Bolivia: Labor and delivery teams at three hospitals improved processes for labor and delivery care. After identifying the four standards they believed would result in better health outcomes, they measured their compliance to collect baseline data. Using those data, they defined the problems and solved many using rapid team problem solving. Activities/tools: Four steps of quality improvement; the Plan, Do, Study, Act Cycle; developing and measuring indicators; flowchart; fishbone diagram; brainstorming; hypothesizing causes and solutions; presenting results with line charts.
Download report (29 pages)

Quality in Action in Rwanda: Case Studies: This collection of brief case studies presents examples of experiences of 30 instances of quality improvement team efforts in Rwanda from 1998 to 2002. Medical, sanitary, and administrative personnel directly involved in delivering healthcare services and representatives of the local population formed multidisciplinary teams that identified different gaps between actual care and care stipulated by implicit or explicit norms. The teams used quality improvement tools and techniques to reduce those gaps. These five accounts concern quality improvement by managers of a shock trauma unit, expanding measles vaccination coverage in 18-month-old children, increasing the family planning rate, improving the frequency of curative consultations and increasing health center receipts by lowering costs, and increasing the rate of pregnant women who receive antenatal care during their first trimester
Download report (45 pages)

La Qualité en Action au Rwanda: Études de Cas: Cette collection détudes de cas en bref décrit examples des experiences de 30 instances de laméloration de la qualité par lidentification et la résolution des problems en équipe. Ce travail été exécuté en Rwanda de 1998 à 2002. En effect, le personnel médical, dhygiène, et dadministration, impliqué directement dans la production des soins de santé y compris parfois les représentants de la population béneiciaire, forme des équipes multidisciplinaires qui identifient les différents écarts entre les manières de travailler et ce que les normes tant implicites quéxplicites préconisent. Ces équipes utilisent des outils et techniques pour combler ces écarts. Les cinq recueil de cas concerne laméloriation de la qualité de la prise en charge des polytraumatisés choqués, laugmentation de la couverture vaccinate effective de la rougeole qui se fait au huitième mois, laméloration du taux dacceptation de la planification familiale, laugmentation de la fréquentation des services de consultation curative et des recettes financires en abaissant les tarifs, et laugmentation de taux de femmes enceintes consultant au premier trimestre.
La Qualité en Action au Rwanda Études de Cas, Ministère de la Santé Rwanda (52 pages)

A Team in Malawi Uses Quality Assurance to Address Cholera Issues: This two-page report presents the dynamic results of a quality improvement (QI) effort by a health center team that sought to eliminate the incidence of cholera, which had been as high as 100 cases per year in its catchment area. In addition to health center staff, village headmen, village health committees, and community members from the 12 villages surrounding the health center participated on the QI team. The report relates the problem analysis, descriptions of the intervention and results, and insights. Activities/Tools: Decision matrix (mentioned), presentation of data using run charts.
Download report (2 pages).


Developing Family Planing Standards in Jamaica: Recognizing that motivating providers of family planning services was critical for improving contraceptive usage rates, the Jamaica Ministry of Health updated national family planning guidelines using a systematic and thorough draft and review process. The process, including field testing, and dissemination strategy are carefully detailed. Activities/tools: Field test questions and sample responses, dissemination action plan (objectives, target audiences, activities, etc.) Download report (11 pages)

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Designing the Integration of District and Refugee Health Services in West Nile, Northern Uganda: The daunting task of integrating refugee healthcare into an established local system is addressed in this case study centered on meeting the needs of 120,000 Sudanese living in Uganda. Quality design brought two distinct service delivery systems into parallel to improve the quality of care while absorbing the huge influx of people. The case study calls attention to the importance of establishing leadership, creating a common vision among stakeholders, using a systems approach, and collecting and using information from stakeholders to continuously improve processes. Activities/Tools: a systems view (graphic) of the integration of immunization services, using a systems view to identify common and divergent issues, and action plan matrix.
Download report (24 pages).

Designing and Integrating Quality Family Health Services at Salt Model Center in Jordan: The Ministry of Health modified the 10-step quality design process to develop an urban model center for the provision of family planning and other healthcare services. The number of clients seeking family planning services, vaccinations, and other indicators improved dramatically. Activities/tools: Identification of internal and external client needs; sample mission statement, standards, and job description.
Download report (13 pages)

Designing Obstetric Services to Reduce Maternal Mortality in Guatemala: Multidisciplinary teams at seven public hospitals followed a 10-step quality design methodology to design client-driven reception, labor monitoring, or other specific obstetric hospital service. Activities/tools: Ten steps of QD, multi-voting, flowchart, error proofing, benchmarking.
Download report (19 pages)
Diseño de servicios obstétricos para reducir la mortalidad materna en Guatemala


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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.