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PVO
Quality Improvement Workshop: Practical Applications June 811,
1999
Dina
Towbin
Jolee Reinke
Thada Bornstein October
1, 1999 PVO
Quality Improvement Workshop Introduction A four-day, practical,
hands-on workshop on improving the quality of child survival interventions
in the developing world was held for private voluntary organizations (PVOs)
in the Child Survival CORE Group June 8-11, 1999, in Calverton, Maryland.
About 25 people attended, including headquarters and field staff from
11 PVOs and staff from the USAID Child Survival Office (BHR/PVC/CS). The Quality Assurance
Project (QAP) and Macro Internationals Child Survival Technical
Services (CSTS) Project conducted the workshop. They developed the sessions
in collaboration with the Child Survival CORE Group and its Quality Improvement
(QI) Working Group. The event supported
the QI Working Groups Objective #4: Organize a series of practical,
hands-on QI workshops for health providers at both the headquarters and
field levels, to be followed by technical assistance as needed. For this
work, it was decided that quality improvement and quality assurance were
terms that could be used interchangeably. Using sequenced learning
and participatory techniques, the workshop aimed to educate headquarters
PVO staff about the following:
- The advantages
of using QI techniques to improve the quality of child survival interventions
- The variety of
QI interventions and activities available
- The skills needed
to use QI tools and techniques
- The next steps
that they might take to adopt or adapt QI approaches to the PVO environment.
The various sessions
and speakers got the audience thinking about ways to integrate QI tools
and techniques into their child survival programs. Participants also drew
up plans to act on this new information. These plans were taken home with
participants, and copies were retained by CORE, CSTS, QAP and the QI Working
Group PVO attendees came
from Adventist Development & Relief Agency International (ADRA), Africare,
Andean Rural Health Care, Inc., International Eye Foundation, Islamic
African Relief AgencyUSA, Medical Care Development Inc. (MCDI)/International
Division, Mercy Corps International, The Pearl S. Buck Foundation, Project
HOPE, Salvation Army World Services Office (SAWSO), and World Vision.
Planning the Workshop
The workshop took
about a year to plan. This long lead-time was due to several factors.
First, the QI Working Group comprises volunteers from CORE PVOs who
have only limited time to devote to this activity. In addition, the
QI Working Group wanted to be sure they had assembled sufficient information
on the PVO communitys QI needs. Third, ongoing discussions between
the QI Working Group and the QAP trainers on what the workshop should
cover meant the agenda became an evolving document. The original central
theme of stressing skill-building in problem solving for promoting child
survival, for example, evolved to encompass a wider variety of QI approaches.
In addition, the planners had to reach consensus on the level of staff
to be invited (i.e., midlevel vs. senior) and the duration of the workshop.
Some difficulties with recruiting participants and finalizing the dates
also delayed the start.
Workshop Events
An agenda is included
as Attachment A.
The QAP trainers,
Jolee Reinke and Thada Bornstein, began by discussing concepts of quality
and quality assurance in general and in specific application to health
care activities in child survival programs. The participants then applied
the concepts to exercises and case studies.
On Day 2, Leo Ryan,
the CSTS trainer, discussed ways to introduce the quality management
approach into an organization. His presentation addressed change management
and included a checklist for designing a change strategy. Ms. Reinke
introduced the concept of measuring change and ways to determine if
change results in improvement. This included a discussion of variation
analysis. Participants practiced using tools for process analysis, cause-effect
analysis, data interpretation, prioritization and decision making. Sara
Espada and Hernan Castro from Andean Rural Health Care discussed their
organizations experience with using a performance checklist to
standardize and improve key procedures performed by health workers.
They also discussed the value of monthly committee meetings to discuss,
identify, and report on ways to improve the quality of local health
services.
On Day 3, participants
considered a variety of methods to improve quality, and practiced root
cause analysis using a case study. Participants also discussed the use
of another tool, the health facility checklist, to improve their own
facilitys quality improvement processes. An MCDI representative,
V. J. Rao, discussed the issues involved in COREs ongoing development
of a health facility checklist used as an assessment tool. The class
then used techniques they had just learned to examine the process of
developing the checklist and suggest ways the process could be improved,.
They used brainstorming and affinity analysis to generate recommendations
and then narrow them down to represent the essence of the groups
thinking.
A third QAP trainer,
Tisna Veldhuyzen van Zanten, led several sessions Day 4 on the practical
application of QI to PVOs child survival programs. Participants
identified the potential benefits of QI, the drawbacks of adopting QI
approaches, and challenges to using QI. The trainers then asked participants
to consider "What can QI do for me?" at the facility, headquarters,
and field levels.
In informal discussions
after the workshop, most attendees noted that learning how to use QI
tools and techniques (such as flow charts, cause-effect analysis, system
checklists, and data displays) was the most useful part of the four
days.
Recommendations As
might be expected, participants came up with different approaches for
incorporating QI in their work and using the tools and techniques to achieve
objectives. However, many made the same recommendations for actions within
their organizations. These include the following:
- Include more hands-on
training for headquarters and field staff, emphasizing QI tools. These
practical tools were seen as very useful.
- Fully document
field experience with implementing QI on a more regular basis, including
positive examples from PVO participants who have used QI in child survival
programs. Disseminate this information within the organization in which
the activities occurred; within CORE; between the PVOs, CORE and the
CAs who work with PVOs; and from CORE to USAID.
- Involve upper management
in this type of workshop to ensure that QI techniques become part of
the routine of the organization, and quality becomes part of the corporate
culture, specifically targeting key PVO decision makers. Explain why
QI is important at all levels of an organization.
When
asked what the QI Working Group could do to help participants achieve
their goals, many attendees suggested further dissemination of QI information
via workshops, training modules, reference materials, working papers,
the Internet, and other working groups. Next Steps
Because PVOs vary
in their mission, staff size, and goals, there is no common set of next
steps that the participants themselves could take to spread the use
of QI. However, all PVOs identified appropriate next steps for their
organizations. Within two weeks of the workshop, MCDI decided to take
advantage of QAPs nearby location. They invited QAP to conduct
a 2-hour quality assurance session at MCDI headquarters for field staff
visiting the area from Madagascar, Mozambique, and South Africa. According
to MCDI, its field staff was very interested in quality assurance. At
the meeting, the QAP trainers included information on how to access
QI specialists for follow-up work in the field.
The planned next
steps from the other organizations were generally positive and goal-oriented.
One or two mentioned that they had not yet seen "a practical use
of the program" or needed more time to "digest [the] process
and map out next steps." Some were planning activities to sensitize
others in their organizationsfrom top management and board members
to other staff, counterparts, and regional/field officesto QI
topics. Plans included conducting QI training, discussing QI in staff
meetings, and circulating QI reading materials. Other participants focused
on incorporating QI into their daily activities to develop quality child
survival programs.
Trainers also asked,
"Where would you like your organization to be in 6 months in terms
of QI activities?" and "What would your organization or field
activities look like if you used QI approaches?" Answers varied,
but many focused on achieving better teamwork and developing an organizational
culture of quality.
After observing
one session, a USAID official stated that the Child Survival Office
was interested in seeing how "PVOs will implement QA in action
plans and with field staff."
Challenges
Several participants
were sensitive to possible negative reactions from others within their
organizations to introducing QI ideas or attending a quality improvement
course. The feared that such actions would be perceived as a sign that
the attendees were not already providing a quality product or service.
Also, workshop participants said that the 4-day workshop, which most
of them had found to be productive, posed a constraint on others who
could not attend the entire time.
A QI Working Group
member pointed out another challenge: Some potential participants responded
to the workshop publicity by stating that they were "workshopped
out," i.e., they had gone to too many workshops.
Asked to identify
barriers to incorporating QI into their organizations, participants
had a long list that included funding, communication, management, and
teamwork issues, plus a lack of a corporate culture of quality.
In the workshops
closing remarks, Dr. James Heiby, MD, MPH, the USAID Contracting Officers
Technical Representative (COTR) to QAP, asked participants to examine
what PVOs stand to gain by using quality assurance methods and what
the field can gain from PVOs using these methods. He suggested that
PVOs compile case studies documenting their pioneering activities. Given
the tighter funds in development and the growing need for accountability,
PVOs need to show results, he said, urging them to evaluate their efforts
in terms of "measures of improvement." For example, higher
quality services can be measured as improved provider compliance with
standards, which in time will lead to measurable declines in mortality
rates. As QI programs produce a better level of care, other measures
of quality, such as a reduction in waiting time, will also show up.
"How do you easily define quality? By using examples." Dr.
Heiby added that quality involves improving processes.
Workshop information
The participants
list, agenda, workshop materials, handouts from ARHC and references
used in preparing this workshop are available on the web: www.urc-chs.com,
click on the PVO headline. This site also will connect the reader to
other QI checklists used by consultants who have worked with PVOs.
Attachments Attachment
A: Workshop Agenda Quality
Improvement: Practical Applications
(Its not just Quality in a Can!) Day 1 Tuesday June
8 8.45 9.00 Gathering
9.00 10.30 Opening, introductions, expectations, ground rules,
housekeeping
10.30 10.45 Break
10.45 12.30 What is Quality?
12.30 1.30 Lunch
1.30 3.30 What is QA?
3.30 3.45 Break
3.45 4.45 Focused Discussion PVO experience: Community defined
quality
4.45 5.00 Summary, feedback
5.00 Close Day 2 Wednesday June
9 8.45 9.00 Review/Preview
9.00 10.30 Change management, role of leadership
10.30 10.45 Break
10.45 11.30 Variation
11.30 12.30 Focused Discussion PVO experience QI
checklists ARHC
12.30 1.30 Lunch
1.30 3.30 Basic tools and techniques
Understanding processes, Determining cause, Making decisions
3.30 3.45 Break
3.45 4.45 Focused Discussion PVO experience Organizing
for Quality ARHC/IEF
4.45 5.00 Summary, feedback
5.00 Close Day 3 Thursday June
10 8.45 9.00 Review/Preview
9.00 10.00 Alternatives for Improving Quality
10.00 10.30 Problem Solving Case Study
10.30 10.45 Break
10.45 11.45 Finish case study
11.45 12.30 Quality Control Monitoring and Supervision
12.30 1.30 Lunch
1.30 2.15 Focused Discussion PVO experience - HFA
2.15 3.15 Small group discussion making field visits
3.15 3.30 Break
3.30 4.45 Exercise pertinence to PVO
4.45 5.00 Summary, daily eval
5.00 Close Day 4 Friday June
11 8.45 9.00 Review/Preview
9.00 10.30 Facilitated Discussion
10.30 10.45 Break
10.45 11.15 Next steps action plan "form"
11.15 12.00 Groups report on next steps
12.00 12.40 Discussion advice to QIWG on their next steps
12.40 1.00 Closing, course eval
1.00 2.00 Lunch Back to Training |
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