Model for

improvement
Developing change
ideas
Federal Ministry of Health
 Outlines
• Introduction
• Generating change ideas
• Traditional problem solving
• Avoiding type 3 error
• Fundamental and reactive changes
• Methods to develop change ideas
• Prioritizing solutions
 “Not all changes lead to
improvement, but all improvement
requires change”

So, what kinds of changes will

 lead idea
A change to isimprovement?
specific idea that if introduced may lead to an
improvement.
 Where do changes come from?
 Sometimes it is luck!

Federal Ministry of Health Health Service Quality Directorate

 Generating Change
Ideas
“It is not the strongest
of the species that
survive, nor the most
intelligent, but the ones
-most
Charles responsive to
Darwin
change.”
Federal Ministry of Health Health Service Quality Directorate
Federal Ministry of Health Health Service Quality Directorate
 Generating Change Ideas

 Relationship exists b/n theories of how organizations work

and effective change ideas
 Fundamental changes requires knowledge of how the current
system works

 We might introduce fundamental changes without

understanding the theory behind
 Difficulty in spread!
Federal Ministry of Health Health Service Quality Directorate
 Common problems in
generating change
ideas
 Restoring more of the same – more resources
 Inspection for decrease performance
 More procedure or defining them more rigorously for problem of adherence
to procedure
 More restrictions for problem in discipline
 Utopia syndrome – looking for perfection
 Fear for failure
 To make a change is to make a risk

Federal Ministry of Health Health Service Quality Directorate

 Traditional Problem
Solving
• When facing quality challenges, practitioners
often think that the cause is obvious
• The tendency is to jump in and make
improvements without exploring the situation
• This increases the risk of a mismatch between
the intervention and the true cause of the
quality problem
Federal Ministry of Health Health Service Quality Directorate
 Individual mental model

Federal Ministry of Health Health Service Quality Directorate

 Avoiding “Type 3” Error
The perfect solution
to the wrong
problem
Schwartz, S. & Carpenter, K.
1999

Federal Ministry of Health Health Service Quality Directorate

 Example 1: Type 3 Error

• Quality challenge: Very

long wait
times for HIV test results

• Intervention: Increase
number
Federal Ministry of Health
of technicians in lab
Health Service Quality Directorate
 Example 1: Type 3 Error

Staffing may have been a

contributing factor, but a
more immediate problem
was stock-outs and
shortages of latex gloves in
Federal Ministry of Health
the lab Health Service Quality Directorate
 Example 2: Type 3 Error

• Quality challenge:
Survey teams taking
much longer than
anticipated to complete
areas
• Proposed Intervention:
Hire more teams,
Federal Ministry of Health
purchase more
Health Service Quality Directorate
 Example 2: Type 3 Error

 Observers in the field

noticed many team members
with down time
 Involving data collectors,
community mobilizers,
drivers, and team leaders
produced many more
Federal Ministry of Health
solutions
Health Service Quality Directorate
 Avoiding Type 3 Errors

“Every improvement project

must start with a thorough
understanding
of the quality
- Donald Lighter issue”
2013

Federal Ministry of Health Health Service Quality Directorate

 Shared Mental Model

A shared mental model can

reduce the chances of a type 3
error by:
• Including multiple
perspectives
• Surfacing assumptions
• Gaining insight into
situations and systems
Federal Ministry of Health Health Service Quality Directorate
 Fundamental vs Reactive
changes
Reactive changes Fundamental changes
 Often routine reaction to solve a problem  Result from design or redesign of some
 Often return the system back to where it or all aspects of a system – prevent
was problems from recurring
 Usually trade – off form in competing  Alter how the system works and what
interests or characterstics people do
 Quality vs cost
 Often result in improvement of several
 Error vs volume
measures simultaneously
 Impact is felt immediately or in near future
 Impact is felt in the future

Federal Ministry of Health Health Service Quality Directorate

 Methods to develop
fundamental changes
1.Logical thinking about the current system
2.Benchmarking
3.Using technology
4.Creative thinking
5.Using change concepts

Federal Ministry of Health Health Service Quality Directorate

 Logical thinking about the
current system
 Using flow diagrams, videos, picture and already existing knowledge of subject
matter
 Rich picture
 Root Cause Analysis
 5 why’s
 Fishbone
 Process mapping and analysis
 Driver Diagram
 Studying in detail a sample of one – case study approach
 Statistical analysis

Federal Ministry of Health Health Service Quality Directorate

 Systems Thinking Tool: Rich
Picture

• A drawing of the way your team sees a given

situation
• Used to gather and capture information
about complex situations
• Ideally built through a repeated process of
engagement and reflection with a group of
key stakeholders
Federal Ministry of Health Health Service Quality Directorate
 Pediatric
Treatment
Federal Ministry of Health Health Service Quality Directorate
 Why Use Rich Pictures?
• Encourage shared mental
models
 Helps teams take a step back, review the
entire situation, identify complexity and
potential leverage points

• Engage stakeholders and/or

develop consensus
 Sweeps in multiple perspectives,
helpful for engaging diverse
Federal Ministry of Health Health Service Quality Directorate
stakeholders
 Why Use Rich Pictures?
• Represent dynamics over time
• Surface assumptions
• Make tacit knowledge explicit
• Gain insight into complex issues
• More effective at capturing complexity than
verbal and written media
Federal Ministry of Health Health Service Quality Directorate
 When to Use Rich Pictures?
• When dealing with difficult/complex quality
challenges
• When working with diverse groups with
different perspectives
• As a first step towards identifying variables
that are drivers, outcomes and leverage
points
 Variables from Rich Pictures can feed
Federal Ministry of Health
into
Health Service Quality Directorate
 Developing a Rich Picture
• Attend to relationships and • Remember to consider behavior
feedback over time

• Avoid wordiness; use symbols • Focus on patterns of change over time

rather than isolated events
• Sweep in multiple perspectives
• Discuss how and why something is
– Who is involved in the system? Who changing
isn’t present that you should
consider?

Federal Ministry of Health Health Service Quality Directorate

 Rich Pictures:
•Common Traps
Trap 1: Representing the problem and not the situation
– Tip: Focus on the system
• Trap 2: Impoverished Rich Picture
– Tip: Include details
• Trap 3: Interpretation, structure, and analysis
– Tip: Draw the what, not the why
• Trap 4: Words and wordiness
– Tip: Pretend you lose a point for every letter you write
• Trap 5: Final version trap
– Tip: It’s never final!
Federal Ministry of Health Health Service Quality Directorate
 In Summary: Rich Pictures
• Depict a health system and Understanding the system in which a problem is
situated is crucial to identifying possible solutions
• Help us consider the overall structure, patterns, and relationships in the health
system over time

• Enable careful consideration of possible consequences of policies

and actions
• Allow us to identify problems and gaps

• Provide an opportunity to develop a shared mental model which

can lead to more efficient problem-solving and reduce the odds of a4
Federal Ministry of Health Health Service Quality Directorate
3
 Group Work for hospital
teams

• In your teams, draw a rich

picture depicting the
system in which your
quality challenge is
situated
• Consider: relationships,
multiple perspectives,
context, change over time,
feedback loops, possible
Federal Ministry of Health
points for intervention, Health Service Quality Directorate
 Root cause analysis - Direct, Contributing & Root
Causes
Direct Cause
Directly results in
the problem

The
Problem Contributing
Poor Cause Part of the
patient problem, but not
outcomes enough to cause the
problem on its own

Root Cause
If fixed, would
prevent the problem
from happening
Federal Ministry of Health Health Service Quality Directorate
 Root Cause
Definition
“The most basic cause (or causes)
that can reasonably be identified
that management has control to fix
and, when fixed, will prevent (or
significantly reduce the likelihood
of) the problem’s recurrence.”
- Paradies (2005)

Federal Ministry of Health Health Service Quality Directorate

 Examples of Root Causes
• A process that is not
working
• A behavior that is adjustable
• Gaps in knowledge
• Lack of established
standards
• Lack of guidelines
• Others?
Federal Ministry of Health Health Service Quality Directorate
 QI Tools: Root Cause
Analysis
• Makes issues less ambiguous
• Minimizes bias
• Incorporates the perspective of multiple team
members
• Allows for a full understanding of all processes
• Provides baseline data
Federal Ministry of Health Health Service Quality Directorate
The “Five Whys” Why

Technique Why
Repeated question-asking
technique used to explore Why
cause-and-effect
why
relationships why
• Primary goal is to why
determine the root
why
cause
• May require more
than five!
Federal Ministry of Health
• Often uncovers layers Health Service Quality Directorate
 5 Whys
• Why is this problem occurring? Answer 1
• Why does Answer 1 occur? Answer 2
• Why does Answer 2 occur? Answer 3
• Why does Answer 3 occur? Answer 4
• Why does Answer 4 occur? Answer 5
You continue asking “Why?” until you get to what you
believe to be the root cause of the problem

Federal Ministry of Health Health Service Quality Directorate

 Example: 5 Whys
• Why don’t HIV+ women bring their babies back for a PCR test at 6 weeks?
• They don’t want to know if the baby is HIV+
• Why don’t they want to know if the baby is HIV+?
• They think the baby will die and they feel guilty
• Why do they think the baby will die and they feel guilty?
• They don’t understand that ARVs and NVP are effective in keeping a child HIV negative. They feel
guilty because they may have passed the virus on to their child.
• Why don’t they understand ARVs ?
• Root Cause: No one explained it to them during pregnancy, labour and delivery.
In identifying the root cause of the problem we can start to develop interventions to
address it

Federal Ministry of Health Health Service Quality Directorate

 Example 5 Whys:
1. Theatre was running very behind today, starting with the first
patient. Why?
2. There was a long wait for a trolley to bring them in. Why?
3. A replacement trolley had to be found. Why?
4. The original trolley's wheel was worn and had eventually
broken. Why?
5. It had not been regularly checked for wear. Why?
Root Cause: Because there is no equipment maintenance
schedule.
Federal Ministry of Health Health Service Quality Directorate
 Exercise (choose one)
 Why do men not participate in antenatal care visits with their partners?

 Why are midwives/clinicians not adherent to partograph usage in labour

ward?

 Why do babies come back with neonatal sepsis?

 Why do caregivers delay in seeking care for under-five children?

37

Federal Ministry of Health Health Service Quality Directorate

 Using a Fishbone
 Also known as Cause & Effect Diagram or Ishikawa Chart
 It’s a more sophisticated and structured way of doing brain-storming.
 The headings in the boxes force more thinking across a broader range of topics
 As a facilitator, you control the topics that go in the boxes.
 You can guide people’s thinking to help them come up with the most likely causes of poor
performance
 Used in this way, the fishbone diagram helps you to analyse the problem but it
doesn’t automatically generate change ideas.
 You can use the fishbone to organise ideas around themes/topics rather than
suggest these up-front 38

Federal Ministry of Health Health Service Quality Directorate

 Building a Fishbone
Diagram
Major Cause Category
Cause Category
Major

Cause
Cause

Cause

Cause

Cause Cau Cau Effect

se se Probl
Cau Cau
Cause
se se em
Event
Caus Cause
e
Cause Cause
Major Cause Major Cause
Category Category

Federal Ministry of Health Health Service Quality Directorate

 Building a Fishbone
Diagram
• The problem statement is placed at the head of
the “fish”
• Brainstorm the major categories of the problem
or use common cause categories:
» People. What staff behaviors and characteristics lead to the
problem?
» Process/Policy. What procedures lead to the problem?
» Equipment/Supplies. Is there equipment that leads to the problem?
» Environment. Does the immediate environment contribute?

Federal Ministry of Health Health Service Quality Directorate

 Root Cause Analysis -
Leadership
Fishbone
Data Clinic System

Effect
CAUSE
Problem
or Aim

Community Patient/ Family Guidelines/Standards

Federal Ministry of Health Health Service Quality Directorate

 Building a Fishbone
Diagram
For each cause identified, ask
variations of
why?• Cost • Patient
Other factors/characteristics
options could include:
• Culture
• Measurements • Team factors
• Methods • Individual factors
• Education and • Organizational factors
training • Task factors
Federal Ministry of Health Health Service Quality Directorate
 Root Cause Analysis or Cause & Effect Diagram or Fishbone Diagram
Leadership Data Health Facility
Lack of
funds Poor record-keeping Poor staff attitude

Lack of
commitment No data analysis No privacy

Lack of Strict rules about

motivation birthing position

Inadequate equipment Low

and supplies
Skilled
Cultural Fear of facility Long distance from Deliver
beliefs health facilities
environment y
Poor risk Lack of means of
awareness Lack of funds transport
Require permission
from family heads Bad road
conditions

Community Patient/ Geographical

Federal Ministry of Health Family Barriers Health Service Quality Directorate
 Reverse fishbone diagram for solutions and outcomes
what do we need in place to ensure this solution or outcome is met?

improve the
institutional
delivery from
30% to 80%

44

Federal Ministry of Health Health Service Quality Directorate

 Fishbone Diagram
Summary
•Strengths
• Weaknesses
 Cannot be used to
• Because “bones”
define the importance
represent multiple or frequency of a
factors, many team particular issue
members will have
knowledge to freely
 As a result, teams will
engaged and
need to use
participate complementary
• Great brainstorming methods and tools to
technique to prioritize problems

• elicit multiple
 Doesn’t always capture
opinions
Federal Ministry of Health
allService
Health of the issues
Quality related
Directorate
 Process Map
Do you agree with this statement?

“If you can’t describe

what you are doing as a
process, you don’t know
what
- W.E. Deming you are doing.”

Federal Ministry of Health Health Service Quality Directorate

 QI Tool: Process Map
A pictorial representation of how a process works that illustrates
the way things get done by tracing the steps involved.
• Also called a flow chart
• Provides multidisciplinary teams with opportunities to learn the
different steps in a process where multiple players are involved
» Often, team members do not actually agree on the steps
• Identifies root causes:
• Bottlenecks, duplicative steps, wasteful steps, disagreement
about steps, rework due to errors, sources of delays, role
confusion…
Federal Ministry of Health Health Service Quality Directorate
 When to Use a Process
• Map
Document and understand a process and its
steps
• Clarify the teams’ understanding of a
process
• Identify opportunities to improve a process
• Standardize a process
• Communicate a standardized process to team
Federal Ministry of Health Health Service Quality Directorate
Federal Ministry of Health Health Service Quality Directorate
 Process Map:
Steps
1. Identify start and end points
2. Agree on mapping method and symbols:
» Start with steps in the process that are actually happening
» Start with steps in the ideal process and compare to what’s actually
happening
3. Ask questions to facilitate Process Map development:
» What happens next?
» Who is responsible?
» How long does it take?
4. Consider each step from a different perspective, like that of a
client or consumer
Federal Ministry of Health Health Service Quality Directorate
Federal Ministry of Health Health Service Quality Directorate
Federal Ministry of Health Health Service Quality Directorate
Federal Ministry of Health Health Service Quality Directorate
 Process Map:
Analysis
Utilize the “5 Whys” Technique
(Why is it done? Why its done this way? By this person? At this
place and time?)

• Are there any disagreements?

• Are there any duplications?
• What is the time between steps?
• Are the steps in the right order?
• Is the right person doing the job?
Federal Ministry of Health Health Service Quality Directorate
 Prioritizing
Problems
After the team has drawn a Process Map or
Fishbone Diagram, it may be useful to rank
the problems.
• Consider different issues in terms of:
» Frequency
» Severity/impact
» Ease and cost of intervention
Federal Ministry of Health Health Service Quality Directorate
Federal Ministry of Health Health Service Quality Directorate
 Process Map Summary
Weaknesses
Strengths
• If the right people
aren’t engaged from • Allows multidisciplinary
the start, some process teams to gain a deep
steps may be unclear or understanding of how a
missed process actually works
• During meetings, some • Facilitates ownership
team members may get among staff
stuck on mapping the
ideal process rather • Great tool to visualize a
than the actual process process

• The process may • Creates a shared mental model

need to be from which to develop change
Federal Ministry of Health
repeated ideas
Health Service Quality Directorate
 Driver Diagrams
Help to answer the question,
What change can we make that will lead to
improvement?
• Conceptualize a quality issue and generate change ideas
linked to root causes
• Explore systems and process mechanisms through primary
and secondary drivers
• Generate theories and hypotheses about change
Federal Ministry of Health
initiatives that can lead to improvement aim
Health Service Quality Directorate
Federal Ministry of Health Health Service Quality Directorate
 Driver Diagrams:
Purpose
• Strategic planning and analysis tool that is updated
systematically throughout an entire project
• Breaks down an aim into the drivers that contribute to
and the detailed actions that could be done to achieve the
aim
• Helps to focus on the cause-and-effect relationships that
exist in complicated systems
• Provides a pathway for change which identifies the types
ofinterventions
Federal Ministry of Health
that can bring about the desired outcome
Health Service Quality Directorate
Federal Ministry of Health Health Service Quality Directorate
 Driver
Diagrams
• Logically links change ideas to drivers
• Often used with Fishbone Diagrams and
Process Maps as part of the participatory
improvement process to utilize the list of
identified causes and organize them into
action steps that will lead to improvement aim
Federal Ministry of Health Health Service Quality Directorate
 Driver Diagrams
• Where possible, driver diagrams should be measurable
and SMART
• Can serve as both a change and measurement
framework for
tracking progress towards aim
• There is no right or wrong driver diagram, diagrams
represent the team’s shared mental model
Diagrams are living documents and will
Federal Ministry of Health
adapt as change ideas are tested and results
Health Service Quality Directorate
 Developing a Driver
Diagram
• Team approach: Gather key stakeholders
• Start with the improvement aim
• Brainstorm: What main factors influence the aim?
» Where? What? When? Who? Why?
• Group drivers into primary or secondary
• Generate change ideas related to the drivers
• Link the drivers and change ideas with arrows
• Include indicators and measurements
Federal Ministry of Health Health Service Quality Directorate
 Primary Drivers
• High-level factors that directly influence aim
• Can form the basis for outcome indicators
• Examples can include the major categories in a
fishbone diagram:
Manpower, Machines, Management, Measurement, Methods &
Materials

Price, Promotion, People, Process, Place, Policy, Procedure & Product

Federal Ministry of Health Health Service Quality Directorate

Surroundings, Suppliers, Systems & Skills
 Secondary
Drivers
• Lower-level, more actionable drivers
• Drivers that can form the basis for specific
interventions
• Situation-specific causes or factors that
are related to the primary driver
• Measurable components are usually
process indicators
Federal Ministry of Health Health Service Quality Directorate
 Completing
Driver Lists
Is My Set of Primary and Secondary
Drivers Complete?
To determine if the driver lists are complete, ask:
If I could influence or improve all these
drivers, is there anything else that could go
wrong and prevent me from achieving my aim?
Federal Ministry of Health Health Service Quality Directorate
 Determining Driver Category
• Is This a Primary or Secondary Driver?
• To differentiate between drivers, ask: If I made an
improvement in this driver what would it
achieve?
• If the answer closely describes the improvement aim, it is
most likely a primary driver
• If the driver is very closely linked with a specific
intervention, it is likely a secondary driver
Federal Ministry of Health Health Service Quality Directorate
Federal Ministry of Health Health Service Quality Directorate
 Reducing U5
mortality in
children

Federal Ministry of Health Health Service Quality Directorate

 QI Tool: Focusing
• Matrix
Also called Prioritization Matrix
• Simple tool to sort ideas by:
» Importance: How much impact they may have
» Ease of Implementation: How easy they are to
accomplish
• Provides team with a structured decision-making
process
• Can be helpful for explaining change ideas to stakeholders
and/or getting buy-in
Federal Ministry of Health Health Service Quality Directorate
Federal Ministry of Health Health Service Quality Directorate
 EXAMPLE: FOCUSING
MATRIX

Federal Ministry of Health Health Service Quality Directorate

 Pareto Principle

• Italian economist Vilfredon Pareto observed in

1906 that 80% of the land in Italy was owned by
20% of the population
• He developed the principle by observing that
20% of the pea pods in his garden contained
80% of the peas
• InbySouth Africa, 20% of the population is served
the private sector, 80% by the public sector

74

Federal Ministry of Health Health Service Quality Directorate

 Pareto Principle
A small number of causes account for most of a problem

 The 80-20 rule - in many situations roughly 80% of the

problem is caused by only 20% of the contributors

We can frequently solve a problem by identifying and

attacking its vital few contributors
Federal Ministry of Health Health Service Quality Directorate
 Benchmarking
 Improvement in our organization has already been made in other
organization
 Customize to you context
 Popularized in recent years
 Sometimes the closest competitors may not be happy
 Do not copy without understanding
 Mechanisms
 Interview
 Visit
 Volunteering to work in an organization

Federal Ministry of Health Health Service Quality Directorate

 USING TECHNOLOGY TO DEVELOP
CHANGES
 Practical use of science – equipment, information system, methods
 Can bring fundamental change but
 Much cost and time
 Sometimes, may not even lead to improvement
 May be wise to test first
 Leasing, renting new equipment
 Make sure the front line workers adapt to new technology
 Support the transition process

Federal Ministry of Health Health Service Quality Directorate

Technology Warnings:
Do not automate a bad system
Try to reserve technological solutions for improving stable
systems rather than fixing special causes
Direct changes that involve technology at a bottleneck
A technology that is unreliable is worse than none at
all

78

Federal Ministry of Health Health Service Quality Directorate

 Creative thinking
 Inventing new idea  Three modes of thinking are
 Not gifted to few people, rather a important to develop change ideas
capacity of every one possible  Creative thinking to produce new
ideas and possibilities
 Mind attempts to find meaning and
order with increase perception and  Logical positive thinking
experience  Logical negative/critical thinking
 Less experience - usually produce more
of the same change ideas

 Existing normal thought pattern

 Sharpened logic over time
 But, new idea – not yet acquired
logical pattern to support it
 Easily defeated by existing well –
developed logic
Federal Ministry of Health Health Service Quality Directorate
 Creative thinking
 General methods to provoke new thought pattern
 Take time
 Be in the right place and the right time
 Challenge boundaries
 Attack the solution
 Use unrealistic goals
 Focus on the need
 Provoke new thoughts and bring them to life with expression
 Ideas are slippery things – expression and representation stabilize them

Federal Ministry of Health Health Service Quality Directorate

 Change concepts
 Using already existing concepts for change
 72 change concepts dealing with
 Eliminating wastes
 Improving work flow
 Optimizing inventory
 Managing variation and designing system
 Better management of time
 Producer – customer relationship
 Focus on product or service

Federal Ministry of Health Health Service Quality Directorate

 Change Ideas: Project
Level
• Eliminate redundant steps
• Minimize handoffs
• Use multiple reminders, job aids, checklists
• Move steps in the process closer together
• Create closed-loop communication
• Remove bottlenecks
• Do tasks in parallel, use “coordinators”
• Increase access to information
• Use cross-training and optimize supportive supervision and
mentoring
Federal Ministry of Health Health Service Quality Directorate
 Change Ideas: Program Level

• Redesign processes
• Update and standardized treatment guidelines
• Reorganize staff and supervision
• New technology
• Bundle a package of changes
• Engage clients and communities
• Benchmark sites and teams

Federal Ministry of Health Health Service Quality Directorate

 Change Ideas: System
Level
• System redesign
• Task-shifting and sharing, introduction of new cadres
• Integration of services
• Regulatory changes
• Benchmarking of programs and regions
• Linking payments and performance, for example
performance-based financing

Federal Ministry of Health Health Service Quality Directorate

THANK
YOU!!