Partnership Defined Quality: A toolbook for community and health provider collaboration for quality improvement

Transcript

1 Partnership Defined Quality a tool book for community and health provider collaboration for quality improvement Prepared by: Ronnie Lovich Marcie Rubardt Debbie Fagan Mary Beth Powers

2 Bhattarai, Ram Ashis Roy, and Naramaya Limbu and other health based in Siraha; and The authors of this manual are grateful for the support from the Hewlett Originally published by Save the Children/US January 2003 Quality (MAQ) Initiative, USAID Nepal, and our partners on the NGO Networks fo Armenia, Georgia,West Bank/Gaza and Ethiopia. testing this methodology with SC in the field. We also appreciate the advice and assistance of colleagues at the Quality Assurance Project as their tools have been widely utilized by our field counterparts in implementing analysis of access and quality challenges. Within the SC family, there are many to thank, especially the Health Team in Nepal; Bharat Kumar Shrestha, Ravindra Kumar Thapa, Laxmi F Narayan Tamang from District Health Office Siraha, who agreed to serve as the pilot test site and helped to collect the data to measure changes in the quality of services, customer satisfaction, and increased utilization. Colleagues who helped develop and field test the methodology include Ronnie Lovich, Marcie Rubardt, Debbie Fagan, Mary Beth Powers, Lisa Howard Grabman, Adelaida Gallardo, Gail Snetro, Laura W Adapted for use in Nigeria, June 2005 oundation, USAID's Office of Population in support of the Maximizing Access and r Health, PRIME II and Health Communications Partnership projects who are edeen, Amy Weissman and our colleagues in Pakistan, Uganda, Peru, Rwanda,

3 Save the Children/US has more than 70 years of Foreword ow experience empowering communities to solve their f coverage of preventive health services was low and community understanding of and demand for key health services. Recognizing that we were often mobilizing demand for services which were of poor quality or sometimes even non-existent, Save the Children launched our "Community Defined Quality" (CDQ) initiative in 1996 to document the r mobilization and district level strengthening work, improve quality and the availability of health services. The CDQ effort began with field level research in Haiti which confirmed our hypothesis - communities and their health service providers had somewhat different definitions and priorities in terms of the quality of care provided. This field research helped us define the preliminary and the follow up steps to gather the differing perspectives and share the various understandings in a way that led to a collaborative plan for improving access and quality. Save the Children's Field Office in Nepal volunteered to integrate this quality improvement methodology into their program in Siraha District in the terai of Nepal. Despite a number of years of community ocused significant attention on improving esults of community involvement in efforts to n problems. Our work in the health sector status and quality of life for all.That is our end goal clients and providers recognize their own care delivery, and in doing so, achieve better health f needs – both in health and others.We hope that people will use the approach creatively so that every community member understands and is able to exercise their right to quality services and that r Armenia, the West Bank, Georgia and Ethiopia. We many disenfranchised, minority groups rarely used health facilities. Moving people from being passive, develop a rights-based approach to programming. periodic recipients of health care services toward active engagement and advocacy for the improvement of health services took time. The complete process, re-named "Partnership Defined Quality" to recognize that the effort requires a partnership between health providers and the community, was developed in Nepal and Peru, and subsequently utilized in Pakistan, Uganda, Rwanda, We or creating this process. esponsibility to maintain and improve the health hope that people will adapt it to their program hope others will be able to use this manual to Mary Beth Powers Senior Reproductive Health Advisor Save the Children/US

4 PLANNING & DESIGN CONSIDERATIONS A tool book for participatory INTRODUCTION PA CONTENTS O quality improvement VERVIEW OF PDQ How to use this manual The PDQ process PDQ in relation to other QI initiatives PDQ in Relation to Other Sectors Why was PDQ developed? Identifying needed skills & resources Defining your goals Who should use this manual? Services & community mapping Planning for participation & re What is PDQ? Identifying other QI initiatives/partners Identifying the level of service R presentation TNERSHIP DEFINED QUALITY PHASE 2: EXPLORING QUALITY PHASE 3: BRIDGING THE GAP STEPS IN THE PDQ PROCESS PHASE 4: WORKING IN PARTNERSHIPS PHASE 1: BUILDING SUPPORT EVALUATING THE PROCESS AND OUTCOMES Select QI Teams Developing a shared vision Problem identification Provider defined quality Bridging the Gap participation Pa Community defined quality T T Preparing for Bridging the Gap action planning Monitoring and evaluation T ools for self management ools for problem analysis and eam building r tnership action cycle

5 mobilization. While it began by addressing health Pa methodology to improve the quality and accessibility of services with community involvement in defining, implementing, and monitoring the quality improvement process. Partnership Defined Quality (PDQ) links quality assessment and improvement with community What is PDQ? services, it has subsequently been adapted to other sectors such as education. Why was PDQ developed? • • • • improvements in the quality of services are not achieved. that equip facilities and train staff, lasting Central or National level quality improvement initiatives do not always reach peripheral field settings. Often, despite system strengthening efforts Many settings lack sufficient top-down supervisory support, limiting provider accountability. community concerns and perspectives about Efforts to improve quality may not consider r tnership Defined Quality is a 1 • • • • r service quality; therefore improvement efforts e those services increases. of both modern health and education services, traditional concepts of health and illness, and traditional values around education. can fail to meet the needs of the community. Solutions to service or facility deficiencies can be found beyond the health and education systems. Remedies for service quality issues may rest within the community, or in other There is frequently a social distance/ culture gap between service providers and the The responsibility for better health or education g quality, accessibility for all, and acceptability of Individual and communities to some extent control their own health. A partnership process can involve community members more fully in the struggle for better health. communities they serve.This gap can affect Our guiding assumption: Equitable use of services should increase as the perceived public or private sector entities. elations between clients and providers and is oes beyond the health and education systems. videnced by the lack of mutual understanding

6 guide for exploring and planning quality This manual offers tools that can be used by be used by health workers, teachers, or community advocates, who would like to work to make a difference in the quality of services a Who should use this manual? can help the users to plan programs that will mobilize both service providers, and communities to work toward better service quality and a yo How to use this manual This manual was designed to be a resource and administrators or facilitating agencies. It can also improvement activities through partnership activities involving service providers and the community members that they are meant to serve. The chapters reflect the different phases of the PDQ methodology. The goals for each phase are listed in the beginning of the chapter. The tools and exercises are not meant as a prescription for what must be done but instead should be used as suggestions. We encourage project managers, health service managers, school vailability. vailable in their area.The tools in this manual u to be creative and use tools with which you 2 Nepal, Peru, Haiti and Nigeria. The variation of r problem solving that you may wish to use. When a are familiar or have found to work well in a further exploration. T or tools. re A visual model of the methodology can be found on page 5. Boxes: Open Book: Shaded boxes reflect PDQ field experience in and pitfalls to avoid for the facilitators. implementation strategies displays the flexibility of this methodology to local culture and needs. The Non-shaded boxes contain tips, suggestions, particular culture. There are also many excellent esources in the areas of team building and ppropriate, other references are listed for abs: fe r ences for further exploration of ideas The tab colors correspond to the phase. Field Experience, Facilitation Tips Gives the reader suggested

7 As with most innovations, the process needs to THE PDQ PROCESS STEPS which requires commitment from key members of the community and the service delivery system. Building Support involves presenting the process and obtaining commitment for participation from these groups. For community support, this involves identifying and meeting with community leaders and other groups that may potentially be mobilized to represent the community voice in quality improvement. The PDQ process is a collaborative process, have the approval and support of the decision makers at the local level and district levels, and maybe even at the national level depending on the country. However, it is even more important that health center and school staff understand the process and are willing to participate, since they will be active partners on the quality improvement team. Overview of PDQ Phase 1 – Building Support 3 community and provider partnership are The definition of quality is not fixed, it comes opportunity to understand different perspectives on quality within a community, it's health system and its schools. During this step meetings are held separately with community members and service providers to explore their ideas in an open and safe environment.The tools provided in this step have been developed to facilitate this exploration. Additionally during this step, the benefits of a rights and responsibilities.This step provides the explored.This is particularly important because service providers often are not accustomed to w Phase 2 – Exploring Quality assurances that this process will be beneficial for both. The findings from these meetings are then organized for presentation during the next phase – Bridging the Gap. from peoples' own understanding of their needs, orking with community partners, and need

8 T Phase 3 – Bridging the Gap identified. Each group has separately defined characteristics and issues of quality services. Now, health w w members come together to hear each others' ideas.Through discussion they begin to work as a team to develop a shared vision of quality. f and service providers.This team will continue to and constraints that make it difficult to achieve quality health services. Participants of this meeting also establish a quality improvement team comprised of both community members This key step initiates the partnership necessary or subsequent activities in quality improvement. ogether they identify and prioritize problems orkers, teachers and representative community ork on the quality improvement issues 4 achieving the desired level of quality. The group Phase 4 – Working in Partnership the Gap workshop, the team has a greater understanding of various viewpoints and is sculpting a collective vision of what quality in health care and schools means for their locale and some gaps in achieving that vision. But the improvement process moves beyond identifying the issues to solving them. Through dialogue and analysis the group looks at the issues to determine root causes and identify solutions for quality improvement team. Through the Bridging also establishes indicators to monitor progress and determine when a given problem has been adequately addressed. This cycle of identifying, analyzing and acting requires a productive team that can work well together. This manual also addresses team management skills needed for the team to sustain productivity, diversity and r The PDQ process is now in the hands of the espect.

9 PLANNING AND DESIGN UILDING SUPPORT B HEALTH / EXPLORING COMMUNITY EDUCATION QUALITY DEFINED W ORKER DEFINED 5 BRIDGING THE GAP Analyze Results Assessment W ORKING IN PA R TNERSHIP Action

10 and use of activities and services. PDQ is not a The scope and tools for quality improvement adopted standards and technical guidelines for both health care and school services. Although PDQ contains QA components, the initial input and assessments are from the communities' and service providers.These perspectives provide essential information for a quality improvement process that will lead to greater participation in extensive. In addition most governments have substitute for a technical assessment of quality. An understanding of the current practices and problems with service delivery from a technical perspective is an important part of a successful QI effort. Many tools for standardized quality assessment at the facility level are available. (QI) and quality assurance (QA) efforts are PDQ in Relation to Other QI Initiatives 6 development activities seeking to involve community people in responsibility for their own lives and the factors that affect their health and w While PDQ was originally developed for health, service delivery issues in a variety of sectors, and to address different quality issues within these sectors. its approach and goals are applicable to any PDQ in Relation to Other Sectors adhere to safety expectations, and QI teams In Uganda, the PDQ process was used in their education program to involve parents, teachers and students in addressing issues around safety. Participants subsequently signed agreements to changes. we ell-being. The process can be used to address re f ormed to enforce and support the

11  Useful References: www.sacmeq.org – Southern and East Africa Consortium for Monitoring Educational Quality information about tools developed for specific service areas or quality improvement efforts is a www.unesco.org – Monitoring Program Quality or Monitoring Learning Achievement (MLA) COPE- Client Oriented, Provider-Efficient Services. EngenderHealth www.engenderhealth.org QAP Health Managers Guide – Monitoring the Quality of Primary Health www.QAProject.org Health Facility Assessment collection of tools on the CORE web site ww.coregroup.org/tools/monitoring/HFA_table.html EDUCATION RESOURCES: vailable on their web sites. There are many tools available from each of these organizations. More 7

12 As with any program the PDQ process requires dedicated and motivated staff to initiate the effort. In The PDQ process depends on open communication and interaction.Without experienced facilitators this can be difficult to achieve in situations where gender and power relationships are entrenched or where there is unresolved conflict. A good facilitator can encourage participation and invites all ideas to be expressed. It is recommended that the facilitator of the discussion groups be neutral and not be viewed as part of the government systems nor have a political role in the community. Additionally, all facilitators should be provided training on the PDQ process because a clear understanding of PDQ is also crucial for facilitation. addition, the PDQ implementation team needs staff with specific skills and experience to succeed. Identify staff with facilitation skills AND DESIGN PLANNING IDENTIFYING NEEDED SKILLS • Components • Planning and Design Considerations • Before beginning the PDQ process many decisions must be made. This section will • • • • essential groundwork for the quality improvement process. guide planners through the program design process. These decisions are the Health services, schools and community mapping Identifying the level of service Planning for participation & representation Defining your goals Identifying other QI initiatives or partners Identify the community Identifying needed skills 8 PLANNING AND DESIGN

13 PLANNING AND DESIGN Language same language and cultural barriers faced by the service providers and the community. Often, people do not speak a common language; translation adds an additional layer onto the process. In instances where portions of the community speak a different language or dialect, it is recommended that creative solutions be explored to maximize input from all members throughout the process. The implementation team can face some of the Once the PDQ Implementation Team has been established it is important they review the manual as a group and select the tools they want to use. 9 broad membership of the community, including mobilization and who know how to reach the W the marginalized members. In PDQ, the community is not asked just for their views or opinions, they are asked to participate and share responsibility and efforts for quality improvement. This requires implementation team members who have experience with community orking with Communities

14 Goals should be formulated at the beginning of the Additionally, your goals will become the basis for important that they are stated to be sure that they are shared and understood by the implementers and supporters of the project. People must be supportive of the goal in order to be willing to participate and take action. PDQ process. Although they may seem obvious, it is process. It is important to be able to state your goals when you are presenting the PDQ process to others. programs may have different specific goals for the e Any program that is considering implementing PDQ has an interest in quality improvement. But different valuating your quality improvement initiative. DEFINING YOUR GOALS 10 • • Examples of PDQ goals: • • • To communities and providers for better health and education services. r providers and shared responsibility between To To and schools services by all members of the To community, regardless of gender or economic between clients and health service providers. To status. and education services among the community problems in quality service delivery and access. who can assist providers in finding solutions to esources. r create local accountability for service mobilize advocates for improved health improve interaction and communication increase equitable use of health services educe waste and rationalize use of available DEFINING YOUR GOALS

15 IDENTIFY THE LEVEL OF SERVICE There are multiple levels in the health system from go the central and state ministry of health to local hospitals and health centers / dispensaries. For education, there are primary and secondary schools, the local government education authority, and the State Primary Education Board. Your goals and the r • determine on which levels of services to focus your efforts.Who you work with will also depend on the scope of your program and your access to resources f • Level of Service: National, District or Health Center Level Decide what level(s) of health care services you are seeking to improve. • • or supporting this initiative. eason you were interested in PDQ will help you vernment departments and hospital authorities to Back-up or referral health center Health post or health center District level hospital Community based care and outreach IDENTIFY THE LEVEL OF SERVICE 11 are seeking to improve. • • Decide what level(s) of education services you • Selection of Target Health Centers: Determine whether all health centers and schools in a region will be selected or only selected ones. may be unnecessarily limiting. Determine whether you are going to focus on service quality in general, or a particular area of services.The advantage of a narrower focus is a more limited list of topics and problems to address. However, many service delivery problems are broad and cross cutting and service delivery is integrated, thus, the focus on one component Program Focus: School Administration Secondary School Primary School

16 y Like quality, "a community" does not have a fixed health services or schools were designed to serve.This is most likely comprised of many smaller "communities". Ask people who are already in the community to identify participants willing to work constructively and who are potentially interested in improving services.The particular population groups to be selected will depend on social and cultural factors in the community, as well as on the kinds of services people who live in the catchment area that the discussion groups and sharing their ideas. Examples of possible groups might be parents, w members to feel comfortable with participating in law, youth, or marginalized people.These groups may need to be segregated in order for all group definition.The community in this case is the ou are targeting for quality improvement. omen of childbearing age, fathers, mothers-in- IDENTIFY THE COMMUNITY 12  In Nigeria, the project decided to define a community using a functional integrated primary health care center with its catchment area as a nucleus.This meant that there could be several schools and perhaps a dispensary or two that were providing services of interest to the project within one catchment area. It also meant that some of the areas defined as “communities” were quite large. In each community, there are several or more active community based organizations on which the project could also draw. As a result, the project decided on a two-tiered structure. At the facility level, there is a quality improvement team which focuses of specific facility issues – identifying problems in quality and working to address them. However, there is also an “umbrella organization” at the community level called a community coalition. This group has a range of functions depending on the individual circumstances in the different states. Functions might include assisting with the formation and oversight of quality improvement teams, coordinating activities across different facilities in their areas, and participating in coordinating activities on a larger scale with those of other communities. They also assist the quality improvement teams with implementing their action plans through activities such as advocacy, community mobilization, and fundraising. IDENTIFY THE LEVEL OF SERVICE

17 HEALTH SERVICE, SCHOOL, AND COMMUNITY MAPPING K K • • • examining whether you have broad representation of both the community and the service providers. designing a PDQ program. This information will be the foundation for planning your intervention and for An understanding of the existing health and education structures and the communities served, is essential for • guide and are neither imperative nor exhaustive. • • • The bullets under each topic are meant as a • Existin need to obtain. Y • HEALTH SERVICE, SCHOOL, AND COMMUNITY MAPPING ou may have this map already. If not, the questions below can serve as a guide for the information you will Who has formal and informal power? What are Are the staff from the same region where they e e How much staff turnover is there and at what Informal health system - traditional healers, Private providers of health services Private schools F levels? the lines of supervision? share the same culture? TBA’s, community volunteers, etc. w Alternative schools e.g. Koranic Schools F health posts, sub health posts, referral sites secondary schools y Education Structur y ser ormal Public School System – primary and ormal health system – District health services, ork? Do they speak the local language and g health structur vice pr o viders: es: es: 13 Comm Comm • • • • • • • • • Interface Betw • • Which key groups in the community should be Who has informal power? Who has formal power and authority? Where do people go for routine care, acute What are different community voices that may What are the existing community organizations? What are barriers to attending schools? What is the role of the local government? Who goes to which schools? How does the health system currently involve How are parents involved in schools? involved? care, emergencies? (marginalized persons, mothers in law, etc.) need representation in the PDQ process? the community? groups, literacy groups, etc.) (committees, political groups, churches, women’s unities: unity structur een Health Ser es: vices and

18 work done, but not so many that the process Developing a design for adequate representation and catchment area of the health services being addressed. This includes getting representation of key segments of the society including those most in need as well as the gatekeepers. Each phase must include enough people to establish momentum and get the ch becomes unmanageable. THE IDEAL STRUCTURE WILL INCLUDE: • participation at each phase in this initiative is a • • • and men.  In Nepal separate meetings were held with health workers, older women, women of child-bearing age, groups as well as men existing power structures P A balanced membership between providers and community Both users and non-users of services Representation of women and marginalized PLANNING FOR PARTICIPATION AND REPRESENTATION allenge. The design needs to fully represent the eople from outside as well as inside the 14 EACH STEP SPECIFIC PLANNING CONSIDERATIONS FOR How involved will the District level staff be? How should responsibility be shared? maximized with minimum disruption of service involved? How much time should be allotted to each phase of the process? Where and when should each meeting be held to permit maximum participation? Building Support: How can health worker and teacher input be Who needs to be convinced to take action? Who provides support for change at the lower levels and who might be a barrier to change? Which organizations and staff are likely to be champion)? Planning: Who will take the lead in the process (a PDQ time? PLANNING FOR PARTICIPATION AND PRESENTATION

19 PLANNING FOR PARTICIPATION AND REPRESENTATION r How large should each of the discussion groups be? Are there language barriers? How many separate discussion groups should be conducted to How many recorders will be needed? Exploring Quality: What steps will you need to ensure on-going participation of w How many group facilitators will be needed? epresent all the necessary perspectives? or moving on to other areas while a community organizes itself. Pitfall In countries where previous projects have paid incentives for participation or where the expectation fo question of incentives will be resolved among themselves.This may, however, entail canceling meetings In addition, if there are costs such as transport due to a large catchment area, they may preclude participation of the poorest people, thus threatening the representation the project is seeking. It becomes tempting to succumb to the expectation and offer some kind of incentive to “get the job done”. Similarly, if the promise of grant money or significant donor inputs is people’s reason for participating, it will significantly undermine both the level of ownership and the ability of the groups to view problems more superficially. However, it is vital to return to a key question in this process: “Whose process is this?” If the project takes responsibility for participation from the beginning because they are supposed to “deliver” a certain number of quality improvement teams, the process is likely to fail from the start. However, if project staff are patient, allowing the community time to figure out why they want this process, the omen? r some kind of remuneration has become the norm, it may be challenging to bring people together. 15  In the Uganda education program, the meetings were held between parents, teachers, and students for each school.

20 discussion groups attend? ensure that the process can be locally sustained? How should the demand for allowances or incentives be addressed to the Bridging the Gap workshop or should all participants in the Do you want representatives from each discussion group to attend Bridging the Gap community members, from the five sub-areas of the project. People decided they wanted a QI team for  In Haiti, the Bridging the Gap workshop involved more than 60 people, both health workers and each of the sub areas, but they also wanted an “umbrella” team with representation from each which w territoriality, ownership, and role clarity for that team. P wanted to have a QI team for Bridging the Gap workshop and and 3-10 health posts. The However, as time went on it original plan was to have one  In Nepal, the local government structure covers a health center we became apparent that there one QI team for the whole area. eople decided they really ould meet less frequently for coordination and exchange of ideas. re problems with members; thus logistics and re of a challenge for providing less costly. technical support and supervision, it fits better with the local authorities and spheres they use, and for which they are is actively working to improve the services in the health post each health post as well as the r health center. While this is more closer to home for most of influence. Now, each QI team esponsible. Meetings are now freshments considerations are 16 provision.  In Uganda health workers included lab technicians and porters, as there is limited staff who share r was the focus for the activities. The initiative ended up including more than 100 people throughout the process, ending up with a sub- group for implementing activities during the team phase, but with everyone still involved in an advisory and oversight capacity.  In Peru, while planning occurred at the regional level, the health center esponsibility for ser vice PLANNING FOR PARTICIPATION AND REPRESENTATION

21 PLANNING FOR PARTICIPATION AND REPRESENTATION W How large should each QI team be? Is it possible for each facility in the target area to have a QI team of its own? How many QI teams should there be? schools and health facilities? If QI teams cover more than one facility, how will r How should responsibility be shared between the esponsibility and ownership be shared? coalition.There is no “correct” approach as long as the goals of representation and commitment for functioning as “sub-committees” of the coalitions while in others they are only represented on the f others, coalitions were formed first, then used to facilitate the exploring quality, bridging the gap, and community coalitions were formed out of the exploring quality and bridging the gap process, while in nu settings with differences in population density, and on the staffing structures available relative to the whether there were previously existing structures to build upon, the predominance of urban or rural coalitions was consistent, the process for getting there varied widely.The process depended on In Nigeria, while the goal of forming representative quality improvement teams and community  the membership is achieved. ormation of quality improvement teams. Similarly, in some cases quality improvement teams are orking in Partnership – QI Teams mber of targeted local government areas. In some cases, both quality improvement teams and 17 PDQ process.The most numerous were the PTAs. These had to be adjusted to assure participation  built upon for determining participants for the In Nigeria in some states, there were a significant by n up, it was clear why this adjustment needed to be e made. varying levels of actual activity, which became the starting point for identifying participants in the PDQ process. Again, representation by non-users was usually the adaptation that needed to be made. the issues (such as increased girl enrollment) came On the health side, there were also previously xisting variations of health committees, with umber of existing organizations that could be people who were not attending school, but as

22 It is important to know if there are other community mobilization, system strengthening or QI initiatives standards are being developed or rewritten, these initiatives could be incorporated into the PDQ program. The PDQ methodology recognizes the need for collaboration. Although this collaboration is predominately between the community and health workers, it should be extended to other QI initiatives currently in place. Summary of Design Considerations Planning Efforts in place. If an NGO is working to improve the supply of medicines in the country or national quality ■ ■ KEY PLANNING DECISIONS CHECK LIST ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ IDENTIFY OTHER QI INITIATIVES OR PARTNERS Who should be involved to ensure community representatives Who attends which schools? What other system strengthening / QI processes are in place? than others? are truly representative? Do we have representation of both service providers and What level of services do you want to affect? What other health services are available in the community? Who will facilitate the process? What do you want to achieve? support staff? Who uses health services? Are some groups better served How many QI teams will be established? How many discussion groups will be held and where? 18  In Nigeria, the PDQ process was embedded in the much larger COMPASS project.The project included interventions in child survival, reproductive health, basic education, institutional capacity building and advocacy. It also had a significant small grants component.These other interventions were in a position to significantly enhance an r enhanced. improvement team, just as the quality improvement teams we benefits were also significantly more challenging, the potential coordination and collaboration enhance the activities of these other components.While the n einforce the work of the quality umber of players made re in a position to significantly PLANNING FOR PARTICIPATION AND REPRESETNATION

23 PHASE I: BUILDING SUPPORT B SUPPORT UILDING  you begin to build the needed support. A great deal depends on how much is already being done to strengthen services, how much commitment or incentive there is to better serving clients, and whether the services you are working with are public, NGO or private sector. Purpose: The purpose of this step is to develop the support necessary to implement the PDQ process from the health and school systems, and the communities involved. Components: Determine Who to Contact P Present PDQ to Potential Partners Useful References: as a priority. PDQ needs involvement and action from the service providers, their support system and the community. By explaining the purpose and the benefits of BOTH the quality improvement process, as well as the partnership approach, Decide How Best to Present PDQ Guide eople will take action only on those issues that they understand and perceive , The SARA Project, HHRAA, USAID PHASE I: BUILDING SUPPORT 19 Sharma R., An Introduction to Advocacy – Training

24 NGOs...). Determine Whom to Contact groups that should be contacted for project support.To get support and commitment from the service delivery systems, it is necessary to meet not only with health workers and teachers in the local facilities, but also with people in the structures that support the target services (MOH and MOE supervisors, District Health and Education Officers, completed in the design phase, list key people or Decide How Best to Present PDQ Using your program goals and structure, provide an ov Using the results of your communities' health partnership process. By developing a targeted explanation of the purpose of PDQ to the different stakeholders you acquire the initial interest and support needed for the projects’ long term success. services, schools, and sources map that was might be just as effective. It will be up to the team to decide how much of this kind of mobilization is necessary.While broad efforts at this point may seems like a g moving more quickly to the community level ood idea, they also take time and money when erview of what can be achieved through the 20 not happen. interest and support, the mobilization process will happen. Without developing this kind of initial willing to contribute some effort toward making it is beneficial, and explain why they should be Present PDQ to Potential Partners This is your chance to convince people that PDQ considerable credibility to the process and In Nigeria, the health and education members closely with the project staff in the initial building support and implementation of the PDQ at the community level.This added members from local NGOs worked very greatly facilitated the level of participation and the formation of the quality improvement teams and coalitions.  of the Local Government as well as some • involved in the PDQ initiative such as: • •  In Uganda a variety of stakeholders were P Health Unit Management Committees Representatives District Health Management Committee arish Development Committee PHASE I: BUILDING SUPPORT

25 PHASE I: BUILDING SUPPORT The following ideas are a guide to assist you with key points you may want to mention when explaining describe some of the potential benefits and the reasons for seeking the community out as partners in the quality improvement process. PDQ to people who are likely partners. This is NOT meant as a script, but rather to provide ideas to • • • • Why include the community? • • • • What is the cost of poor quality? REASONS WHY YOUR PARTNERS MIGHT BE INTERESTED IN PDQ • • • • Why improve quality? Pe Improved quality means safer, more effective health care is provided. Improved quality potentially leads to increased utilization of services and improved socio-economic Improved quality leads to increased satisfaction for both the client and the provider. Improved quality means increased access to education and improved learning. The community members have responsibility for their own health and education, and share don’t make the investment in raising education levels. Community members can work with providers to develop shared responsibility for problem solving. Community members can favorably influence the use of the services by their neighbors. r Community members and leaders can advocate for assistance from other levels and institutions when health workers have not been able to mobilize needed resources. P Pe and health status. Some resources for improving quality are available within the community. service which can lead to greater morbidity and mortality. esponsibility for making good use of the services provided in their daily lives. oor quality can lead to complications due to ineffective treatment or unsafe practices. r r ception of poor quality education services means parents don’t send their children to school and ception of poor quality health services can cause delays in seeking and receiving appropriate 21

26 COMMUNITY EXPLORING QUALITY PROVIDER DEFINED DEFINED SERVICE Quality services are not “one size fits all.” Instead, perceptions of and expectations for quality comes from peoples’ own understanding and personal experience. During this phase you will begin to explore the perceptions of quality from the people that provide services, those that use them, and those that never or no longer use the services in question. To teacher, and community members’ perspectives separately. All these perspectives must be • thoroughly explored, in order to understand where potential barriers to the provision of quality care and use of services exist. • Purpose: • T Health Worker Defined Quality • Components: eacher Defined Quality To and provider rights and To community, health worker and teacher To schools. quality in their health center and r perspectives on the quality of care. w To w existing services. esponsibilities. f ell as strengths in the delivery of ork as part of a team to improve acilitate open and free discussions it is recommended you explore health worker, PHASE 2 – EXPLORING QUALITY gain a better understanding of the identify people who would like to establish concepts of client identify potential problems as 22 It is critical to accurately record the r Preparation: How will the results be recorded? Preparation for Bridging the Gap Community Defined Quality esults of the discussions. only hear the words but see the was able to view their video and opinions were conveyed. Each group people and their expressions as their proved to be key in bridging the because it enabled each group to not In Peru, the use of video was chosen  cultural gap that existed. use of video was labor intensive but decide if they wanted to use it. The PHASE 2 – EXPLORING QUALITY

27 SERVICE PROVIDER DEFINED QUALITY Although the health workers and teachers have already had the PDQ process explained to them, they are activities in this section will not only provide an opportunity for these providers to discuss quality issues but to understand the process and to determine what they can learn from it.These activities may be approached as a 1- 2 day workshop, or as a series of meetings. It probably makes sense to go through the process separately with teachers and health workers since their situations and cultures are different enough that you will get more information if they are treated separately. probably not yet clear as to exactly how the process will work and how it can benefit them and their work.The • • • • • Suggested Activities: • • • • • The goals for these activities are: SERVICE PROVIDER DEFINED QUALITY will remain involved in the partnership process To What Do We Want to Gain from this Process Rights and Responsibilities for Quality of, the QI process Problem Identification for Quality To To Health Workers’/Teachers’ Perspective on Quality quality Review of Technical Standards To quality services Why We Became Health Workers / Teachers perceptions of the obstacles to delivering mobilize health workers and teachers who continue to build interest in, and ownership explore health worker and teacher explore health worker and teacher views on 23 think about the activities or infrastructure FA f P primary school, this information might also associated with the health center. However, as facilitator, if there are data that suggest specific problems such as high maternal mortality, low family planning usage, or low girl enrollment in  afternoon meetings - making it easier for all health post staff to attend since they could provide services in the morning and still attend In Nepal:This session was held as two the meetings. It also kept expenses down. eed into the exploring quality process. eople’s first take on quality will likely be to CILITATOR TIP

28 original vision of our jobs compared to the current reality. Reflection by • vision we had for our work. It can be done as a two part exercise, or either can be done on it’s own. Purpose: work, and the realities they face in their day to day duties. The satisfaction felt in daily work may be influenced • Preparation Often, the farther a person gets in their career, the more distance they find between their original vision for their Methods: • Think back to the time you were young. When you we Reflection a health worker / teacher? Was there an event in y When did you first begin to think about becoming someone in your family? Was there a person who we influenced you? When did you decide to seek training? EXERCISE: WHY WE BECAME HEALTH WORKERS / TEACHERS our life? Did something happen to you or Large sheets of paper for the facilitator One piece of paper for each participant Crayons for each participant the gap between expectations and reality. The goal of this exercise is to achieve reflection on the original re re older? What did you expect for yourself? a child, what did you want to do when you To explore issues around our motivation to become health workers or teachers, and our 24 w expected it to be? What was better than you had imagined? Were there things that disappointed you? Now think about your first job as a health How was that experience? Was the training as you What was different? Now consider your work now...how does compare with the vision you had when you were younger? orker...what was as you had imagined it to be? 45 minutes SERVICE PROVIDER DEFINED QUALITY

29 SERVICE PROVIDER DEFINED QUALITY • • • • DISCUSSION:  could benefit by providing quality services or doing a good job. w In one case, several of the health workers indicated that the primary reasons they became health Do you feel respected by the community? How does the vision you first had for Note the similarity in reasons for becoming Group members should share some of their y from the image you have now? Why? health workers or teachers. personal reflections ourselves as health workers or teachers differ orkers were economic and parental influence. If this is the case, you should further explore ways they improve quality of care. TDR\GEN\95.2) Useful References: W Similar exercises can be found in, omen’s Health Project. Johannesburg, South Africa / UNDP (WHO: 25 KEY POINTS: • • • This is influenced both positively and negatively Many people enter into health care or teaching Morale can be a problem where the system is with the goals of service and helping others. by not functioning well, and where resources are conditions. lacking. However, providers can sometimes w ork collectively to improve their working our experiences and opportunities. Health Workers for Change: A manual to

30 Preparation: • often determined by standards created by others, or by test results.This exercise provides service providers the opportunity to provide their own perceptions of the elements of quality for the services they provide. Purpose: quality. services.Then ask them to do the same for poor down three or four characteristics of good quality paper or index cards. Ask each person to write Quality health care or education means different things to different people.To those who deliver services, quality is • Provide each participant with seven pieces of • • Written List • Methods: • EXERCISE: HEALTH WORKERS / TEACHERS PERSPECTIVES ON QUALITY Categorizing and summarizing responses use them, so that you do not influence the r Six to seven index cards (or paper divided in half) Hand newsprint or signs with headings f Written list K Role play or each health worker esponses of the group. eep the headings covered until you are ready to To explore health workers’ and teachers’ thoughts on the elements of quality services. Suggested time: 15 minutes 26 (Note: If you have more than 10 or 12 participants then it is suggested that you only r participant. Otherwise the amount of information to sort becomes excessive and repetitive.) equest two or three responses from each HEADINGS THAT EMERGED IN NEPAL: • Access / Availability • Client – Provider Relations • Communication / Information • Safety • Facility • Equipment and Supplies / Medicines • Systems (Support and Supervision / Policies / headings included pregnancy, defilement, discipline, and community involvement. • Cultural Compatibility/Comfort Similar headings are also relevant for education. In Uganda, where the focus was on safety, the Processes and Procedures) 60 minutes SERVICE PROVIDER DEFINED QUALITY

31 SERVICE PROVIDER DEFINED QUALITY Categorizing & Summarizing Responses Role Play As an alternative to the written list exercise, the identifying good quality education.They can do r the responses. It may be preferable to start re participants can act out a scenario when they considered part of teacher / student relations. In mentioned lack of respect, these could both be By this point the facilitator has compiled a list of many different aspects of quality, based on the group responses. Many of these are unique aspects of quality, while others are different variations of the same thing. For example, if someone had listed a characteristic of quality as "having privacy during examination" and another person had listed "no separate exam room" as a characteristic of bad quality, these basically describe the same characteristics which is the need for an a private place for examination. Similarly, if someone listed teachers yelling at students and someone else this session, the group will have the opportunity to eceived or provided good quality health care or view the list, make any changes and summarize Suggested time: 15 minutes Suggested time: 30 minutes 27 ev what elements of quality service were shown. participants need to do the role play but the same with poor quality service. Not all characteristics should be listed.The categories are group that pertain to that element.The facilitator then reads each participant's response cards or list and, with the help of the group, decides in which without categories, and group the components as when the same response has been made by another participant but in the end, only unique y not meant to be restrictive but instead to provide some structure for grouping. These lists will be used during the exercises that f headings (such as facility and surroundings), and modify them as you gain descriptions from the category the item belongs. It is important to note ollow. ou go along.You may want to start with general eryone can be involved in the discussion about

32 considering issues on quality, there is also the consideration of technical quality.There are certain basic practices that must be in place for safety and rational service provison.These must be incorporated when prioritizing activities for quality improvement. In this section, health workers and teachers draw on any existing technical standards, guidelines or protocols to enhance the definition of quality services. While the PDQ process is a participatory approach that uses provider and community perspectives when standards necessary for quality. • • • Purpose: Preparation: • • • Methods: REVIEW OF TECHNICAL STANDARDS standards documents (if available). Identifying current documented standards Small groups exploration of technical standards standards that relate to the particular areas of service that are the focus of the QI efforts. Large group discussion Flip charts or large poster size pieces of paper. Choose guidelines, treatment protocols, or Obtain the most recent version of technical To identify and incorporate technical 28 60 minutes SOURCES OF THIS INFORMATION COULD INCLUDE: • Standards and guidelines from MOH or MOE • Treatment protocols • Facility or supervision check lists • Job descriptions SERVICE PROVIDER DEFINED QUALITY

33 SERVICE PROVIDER DEFINED QUALITY Small Groups Exploration Of Technical Standards – The participants should be divided into 3 groups, with the assignment to discuss the minimum technical standard for quality. Explain that while the first exercise asked for their personal view of what is good or bad quality, this exercise asks for their understanding of the minimum standards they should follow as professionals. F and case management. more focused. Groups can therefore review these in light of what they think should be their minimum standard. F general areas such as appropriate examinations one of the three following categories for this exercise: 1-safety, 2-communication/information, and 3-diagnosis and treatment. At the end of the discussion, the groups are asked to write their answers on a flip chart, and post them. The diagnosis and treatment group should be provided guidance on which practices or interventions they should focus otherwise the category can be too broad.The topics could be particular health areas, such as Family Planning, or or the health providers, each group should take or teachers, standards and guidelines may be 30 minutes 29 either as a poster session where other participants circulate for review and comments, or as a general group discussion. All participants are asked to provide suggestions, additions, and/or alterations to the standards proposed by the small groups. However it is done, it is important for the group to review the suggested standards and come to a preliminary consensus on their acceptance as a guideline for practice. Identifying Current Documented Standards Reconvene the whole group to review each of This step provides the health workers and the small groups’ answers. This can happen documented standards are available and how they compare to the list developed by the group. If available, compare the answers given to the current documented standards. DISCUSSION TOPICS • • • teachers with the opportunity to learn what Large Group Discussion – Areas of discrepancy between standards and practice Are the standards available and widely used? Which ones impact your work? 15 minutes 15 to 30 minutes

34 the "Review of Technical Standards" sessions, the group can explore the barriers that prevent some of these quality elements from being achieved. Even though this step will be revisited during problem analysis and solving exercises in later phases of the PDQ process, this step will help the providers understand the process and it's potential benefits.This step should highlight areas of both achievement of standards or elements of quality as well as areas that are lacking. Now that you have lists of quality components - created during "Service Providers’ Perspectives on Quality" and perspective. characteristics they created as a check list, and Purpose: previous exercise, explore what elements of a problems in your area facilities and outreach quality are being met and what areas have Methods: • • • w Using the list compiled by the group in the Explain Exercise – pply this check list to their setting. Groups PROBLEM IDENTIFICATION FOR QUALITY Explain exercise Group discussion of the results Break into subgroups for analysis ork.The group can think of the quality To begin to identify challenges and gaps in service quality from the service provider 5 minutes 30 met by the health services or schools, and which should identify which areas of quality are being explore the reasons why there is a gap between the ideal and what typically happens at the facility. Stress that Quality Improvement is a continuous process. are areas where improvement is needed. Briefly 55 Minutes SERVICE PROVIDER DEFINED QUALITY

35 SERVICE PROVIDER DEFINED QUALITY Group Discussion Of The Results Break Into Subgroups For Analysis Have each subgroup report their conclusions to the entire group allowing time for discussion. Depending on the time available, the facilitator may also suggest that the group select one or two problems for further problem definition. A choice of several more detailed problem If multiple facilities are represented for these discussions you may want to divide into work groups by health facility or school. If time is short, FA • Help the groups state the underlying problem. later. For example, “not enough health post hiring more staff. This is covered in more depth problem really is “trained staff not giving the section “Working in Partnership.” injections”. Using this definition of the problem Sometimes the “problem” listed is really a Further exploration could find that the staff “ is suggesting a potential solution. can reveal other possible solutions beyond chance for more analysis and creative action the cause/solution first the group may lose the cause or a potential solution. By starting with under “Tools for Problem Analysis” in the CILITATION TIPS 20 minutes 30 minutes 31 • • next step of the PDQ process as well. of the causes of the problems will happen in the definition exercises such as fishbone analysis are suggested in the "Working in Partnership" section. Remind the group that deeper exploration each group could be assigned a few of the characteristics of quality as compiled on the lists. Each group should record notes on their discussions. Tr It is sometimes easier to focus on problems It would be better to start with “patients don’t take their medicine”. Once the groups analyze make a difference, or make a difference with medicine correctly because they don’t listen”. that are beyond our control. However, it is f possible to identify problems for which we can the additional support the community partnership can bring. hoped through these activities that it will be the problems together they may have additional understanding of the causes. or problems. “patients don’t take their y to help participants avoid assigning blame

36 choose two or three significant points concerning what rights you feel your patients or students Small Group Discussion take notes. After discussing all the questions, think about the following questions (see list). Please Instructions: Singly or in twos or threes, begin to right to quality care. discussions there will be some understanding of the potential value that the community's input can have in the quality improvement process. Service providers have differing views on what the rights and expectations of their clients and their community Purpose: re • r should be. Depending on the socialization during basic training as professionals, the support received (or not Methods: • elationships with clients and the communities through many different lenses. It is hoped that by the end of these Small group discussion DISCUSSION: RIGHTS AND RESPONSIBILITIES FOR QUALITY Large group conclusions ceived) from the administrative systems, and the attitudes of coworkers, service providers perceive their To clarify service provider values and create a favorable climate for the concept of a client’s 32 should have regarding their health care, what rights y will be shared the large group at the end of this ideas might contribute to improving services.These exercise. ou as providers have, and how client views and 45 Minutes SERVICE PROVIDER DEFINED QUALITY

37 SERVICE PROVIDER DEFINED QUALITY and explained if necessary. take special care to see that they are well translated they may be difficult to understand. It is important to 1. Some of these concepts are abstract enough that Note to facilitators: Large Group Discussion: • What conclusions do we want to make about: • 2. What rights or expectations do patients or prevent problems? Is the amount of information they need different than what is normally provided? How should this kind of information be given? 4. Do parents have a right to information about information? What can they expect from these 3. Do clients have a right to information about their health problems? Treatment? How to QUESTIONS TO BE DISCUSSED: 1. What rights do we as health workers or teachers have in our work? services? What should they be able to expect? students have when they come for services and What rights do we as providers have in our w challenges? rights and help communities understand our How can this process help us achieve our ork? 33 select three questions out of a hat. questions. An alternative would be to have each group 2. It may not be necessary for all groups to discuss all • • • 7. What responsibilities do clients have in What, if any information should be confidential? need different than what is normally provided? obtaining better health? Do students have in ment process? What roles could they play? services? Why or why not? their children? Is the amount of information they 6. Does it matter how the community views our services to people? practices into consideration when we provide 5. How do we take community beliefs and their own learning? 8. What could be gained by including community members in the quality improve- What does this mean for provider job performance? What are client’s rights to quality care? What are potential roles for community members in the improvement of services.

38 are likely have more ownership of the quality improvement process.This exercise is valuable for providers to think about what kinds of things they might want to learn from the community in order to do a better job and what the community can learn from them. By understanding PDQ and exploring how the process can be beneficial to them and the community, providers from the process. paper, then request four volunteers to work together and determine in what order they should be Purpose: here. There is no wrong answer. You can then take the opportunity to explain what is meant by each step, addressed. It is quite possible that the group will come up with a different order than what is suggested Present the phases of PDQ to the participants. On a flip chart, write the phases of the PDQ process and and why this process follows the steps in the order it does. Methods: • As an alternative to listing the steps, you can write each step with a short description on a separate piece of • • describe each one. The description of each step in the introduction section of the manual can be helpful. Overview Of The PDQ Process WHAT DO WE WANT TO GAIN FROM THIS PROCESS? Overview of the PDQ process What do we want to learn from the community? What can we gain from this process? To have providers understand the PDQ process and determine what they would like to gain 34 30 minutes SERVICE PROVIDER DEFINED QUALITY

39 SERVICE PROVIDER DEFINED QUALITY What Do We Want To Learn From The This discussion can be introduced with an example of how different people see things differently and how we can benefit from different perspectives.Think about what we have been talking about for the past two days. Are there attitudes or beliefs in the community you would like to understand better? Do they think the same things contribute to quality services as you do? Do communities value the services that you provide? How does your work have an impact on the lives of community members? Community? paid for new signs and other materials/ members contributed gasoline for motorcycle assistance on various occasions. Community to sub-regional MOH office to request MOH  In Peru, during the action phase, health facilities members paid for transport and materials to go equipment to upgrade services. Community 35 changes could also create a better working environment, and impact their job satisfaction. what you would like to gain from this process. The goal is for the participants to realize there are benefits to providing good quality and that Ta health and education service provision. These the community can help them achieve quality fund in one community. One community g the health post and they are now working on and other transport in cases of emergency transport. Women established an emergency system that benefited both the community and contributed funds and labor to put in a water What Can We Gain From This Process? etting electricity. ke some time to brainstorm as a group about

40 • The community is a diverse group of people with varying roles and voice in their society. It is comprised of men they structured and how to plan representative discussion groups to talk about quality. Now is the time to ask the those groups for their definitions of quality. Suggested Activities: • • • Throughout the Design Considerations section, you have been asked to determine who is the community, how are • Preparation: • • • • and women, elders and children and typically a variety of races, religions and socio-economic status levels. Icebreakers and Introduction Community’s Perception of Quality Healthcare Finalize the number and type of groups Schedule meetings Select a location Community’s Perception of Quality Education Determine transportation needs by the participants When You are the Customer Organizing and Summarizing COMMUNITY DEFINED QUALITY 36 • The goals for these activities are: • • • To of, the partnership process To To barriers to quality for education and health To r emain involved in the partnership process continue to build interest in, and ownership explore the community views on quality explore the community perceptions of the mobilize community members who will COMMUNITY DEFINED QUALITY

41 COMMUNITY DEFINED QUALITY groups. However, it is essential to go through some kind of settling in process – introductions, explanation of the purpose, and clarification of the group “rules”. The need to have an ice breaker will vary depending on the culture and the comfort level of the discussion Discussion Guide: 1. Why we are here? 2. Introductions • • 4. The purpose of the recording or note taking Suggested Rules: • 3. What is going to be done with the • • ICE BREAKER AND INTRODUCTION There are no wrong answers Everyone’s input is important mu Sincere dialogue does not just happen. There This is an opportunity to find new ways to solve problems This is not an exercise to find blame information? st be trust and respect 37 10 minutes

42 see their role in health and education services as consumers not just patients. By exploring areas where the concept of quality is more familiar, participants will be better prepared to describe the elements of quality that they value in health and education services. make choices for quality in material goods. Linking quality to purchasing decisions helps community members Often participants do not feel they have a lot of choice about the quality of services they receive, but they do Market place discussion we Methods: Purpose: Market Place Discussion Before we talk about health services or schools, demanding quality. To help participants realize that they do exercise a right to quality in the market place. information, but don’t make suggestions – (e.g., buy them? Facilitator probe for specific Think about when you go to the market to buy color, smell, freshness...) the onions you choose that makes you want to commonly available local food). What is it about when we all have the right to determine what is g something, for example, onions (or any other when you are the customer, you decide what is quality. ood quality. Think about the market place – WHEN YOU ARE THE CUSTOMER should think about times in our daily lives To help participants think about other situations where they are setting standards for and 20-30 minutes 38 anything? When the group feels satisfied with the list, ask about what they expect from the seller or the v Review what has been said. Can anyone add F Are there those you avoid? Why? thing, what makes you go to the one that you do? endor? or instance, if ten vendors are selling the same COMMUNITY DEFINED QUALITY

43 COMMUNITY DEFINED QUALITY • “healthcare” can mean many things. Still, most community members have accessed some kind of health care in their lifetime. By exploring their role as consumers of health care services, community members can better understand their rights and potential contribution to the quality improvement process. QI efforts. Purpose: • health services and level that are the focus of the Depending on the services available to the community – traditional, non-traditional, public, or private, the term (traditional and modern) when discussing quality. free to talk about any form of health care they seek • quality. It is important that the participants feel help facilitate the discussion about health care health setting. Below are suggested questions to This discussion branches from the local market to The conversation can later be focused on the F acilitated Group Discussion On Quality Health Services To and poor quality health services. To services. To COMMUNITY’S PERCEPTION OF QUALITY HEALTH CARE identify problems or barriers to quality explore the concept of patient’s rights. examine the communities’ views on good 39 lets talk about quality in health care. • • • Now that we have discussed quality in the market, • choices about your health care? What are the most important factors in deciding if and where to go for health services? Like the market, do you feel like you make Where is your first choice of places to get health services? Why? Are there places you will not go for health services? Why? • Method: Services or Role Play Facilitated Group Discussion on Quality Health 60 minutes

44 • • • • • • • • about any aspect of education, or any of the schools. important that the participants feel free to talk discussion on the quality of the education. It is suggested questions to help facilitate the education your children are getting. Below are Now let’s talk about the schools and the F Do you feel you receive good quality from How would you describe poor services? those practitioners? Some people prefer to use traditional health Do you pay for those services? services.What are the reasons? How would you describe good services? Like the market, do you feel like you make acilitated Group Discussion On Quality Education for our Children What are the most important factors in Is it different for boys than girls? Where is your first choice of schools to send y choices about the education for your children? deciding if and where to send them to school? our children? Why? 40 • • • • • • • • • • the formal system? Do they have to pay for those services? Do you feel you have a right to good quality health services whether you pay or not? What prevents people from getting services at or private schools instead of government ones. What are the reasons? Do you pay to send your children to school? How would you describe poor education? Do you feel your children are getting a good education? Why or why not? How would you describe good education? What makes it difficult for parents to send their children to school? Some people prefer to use traditional schools Do you feel you have a right to good quality health services whether you pay or not? COMMUNITY DEFINED QUALITY

45 COMMUNITY DEFINED QUALITY P groups or role plays • Can you explain further? If something negative is raised, ask – what would make this better? this important to you? What makes this good? • Probe for more information as needed – why is • • • How can you illustrate this? How can you show can be a nurse, doctor or any other provider and care you were not happy or satisfied with. Think about a time when you received health another person a client. this? Y Role Play for “Bad/Poor Quality Health Service” otential areas to discuss during discussion Providers – private versus public, traditional v Cultural sensitivity and compatibility. Equipment, supplies Other barriers to accessing services T ersus nontraditional echnical aspects ou can do whatever you want – one person 41 Guide For Role Plays should be told they can role play health care F discussion. Again with role play, the participants from any type of service provider. show “poor quality service”. Allow the group to spend about 10 minutes together reflecting on how they are going to or certain groups role play is easier than provided are good or positive. highlight what aspects of the care being session. It is equally important for people to problem list without slipping into a complaining Balance between developing a carefully defined FA CILITATOR TIP

46 Not everyone has to participate. Even if they don’t want to participate in the role play, they can Education” Depending on the availability of time and the r Role Play for “Poor and Good Quality plays can be carried out representing quality education, or it may make sense to do a mixture of the two. participate in the analysis and discussion afterward. epresentation of the participants, similar role • Probe whether there are other elements of • Probe anything else you noticed that made it • Probe whether there are other elements of presented? DISCUSSION: What did you see in the role play? What was quality that were covered in the role play. “bad service”? quality that were not covered in role play. 42 health care that you were happy or satisfied with. We service. Role Play for “Good Quality Service” Now think about a time when you received show this “good quality service”. Again, you can show whatever roles or activities are necessary to demonstrate what you believe is good quality made you feel that way? DISCUSSION: g • Probe whether there were other elements or • Probe “Is there anything else that made it Does everyone agree that the client received ood quality service? What did you see that aspects of quality that were not covered. go w od service?” ould like to ask you to do a role play to COMMUNITY DEFINED QUALITY

47 COMMUNITY DEFINED QUALITY obtained. re Because the recorder had to summarize what the participants were saying or doing (role play), it is necessary to done with in the section on Provider Defined Quality, it is important to consolidate and summarize this list. Also if the QI efforts are focused on a particular aspect of health or education services, now is the time to consider how the identified elements are relevant to the services that are the focus of this QI initiative.Which of the mentioned elements of quality are met my the targeted services and which elements are lacking? Refer to the Provider Defined Quality section for suggestions on grouping and summarizing the information ORGANIZING & SUMMARIZING f skill for program planning and development, in this situation it led to the loss of important information and some inaccurate definitions of problems and solutions. It is important that the groups have the opportunity to make sure the information collected accurately represents their perceptions.  or participants’ comments, they were quick to generalize the responses. While this is often a necessary view the information with the participants to be certain it accurately portrays their perceptions of quality. As was In Nepal, while facilitators had been quite complete in their probing for explanations and causes 43

48 Gap workshop. • Purpose: Components: schools.This step will help provide a better understanding of the PDQ process beyond this initial community input. • health center and school staff to identify and address problems and concerns regarding their health centers and The group should understand that they have completed the first step of a process for working as partners with community to understand their role extends to the community. It is important for the the providers in analyzing problems and There are many ways to convey the PDQ process beyond this initial input. They will be partners with identified quality issues. determining the causes and solutions to the Overview Of PDQ Overview of PDQ WHAT IS PDQ? Next Step To provide an understanding of the PDQ process, and elicit participation for the Bridging the 15 minutes 44 FA shown in “Working in Partnership” Y ou can also introduce the QI Action Cycle as CILITATORS TIP COMMUNITY DEFINED QUALITY

49 COMMUNITY DEFINED QUALITY Next Step The group should understand that this is the first step of a process. Next there will be a workshop with participants from other communities and school and health center staff to review what was learned from these discussions and to begin to develop ways to work towards improving identified problems. Depending on the initial thinking done in the planning and design phase, each group will need to have a certain number of representatives who w nominated now. w communities and the providers contributed Providers contributed transport to meeting contributed meeting space for all meetings. snacks). Communities and providers In Peru, during the group meetings both the communities breakfast, project team lunch and sites in most cases.  f ood for the whole group (providers dinner, ould be able to come to this Bridging the Gap orkshop. Those participants should be 15 minutes 45 become an issue for continuous participation in these meetings. It is probably preferable to limit this to the extent possible, since payment of • sustainable the PDQ process will be. We r • greatest extent possible. allowances will significantly determine how • Other Considerations: The issue of allowances or per diems is likely to ecommend sharing of costs and effort to the meeting. Ask group to nominate participants to about what has been said. Ask for participants comments and thoughts Summarize what we have learned. r epresent their viewpoints for the next PDQ

50 Categorizing Information to be lost. than one school that fall within the catchment area of the health facility such that one team may target one health facility and several schools. Now is the time for the implementation team to review the information to establish a common voice for the local community. Also determination of who can best represent and present the community perspective and the provider perspective should be discussed. • By defining possible categories, the observations can be grouped to better show patterns and key elements and define problems. However, it is important that this grouping and labeling not cause the details provided regarding each issue input. Often these groups provided their views separately (i.e. men, women, community elders).There may be more Once the group has agreed upon labels for the different categories, put the labels on separate team. Even if each facility is going to have it's own QI team, many different groups within the community provided walls around the room. Using different colored paper to indicate community versus health w This step can vary widely depending on the implementation choices made earlier by the PDQ implementation sheets of flip chart paper and place them on the Purpose: • Methods: Categorize information PREPARATION FOR BRIDGING THE GAP Integrate for presentation orker responses versus teacher, have each To re view information obtained earlier and prepare information for presentation. 46 check mark. their own observations and notes.They will copy one quality element on a colored paper and place the information under the most appropriate category heading. If there is an associated quality problem/issue with this element it can be written below.This way both the quality elements and associated problems can be discussed together. If m "facilitator - recorder" team review and synthesize same observations, it should be noted with a • • • Confirm findings Analyze the gaps Bridging the gap ultiple discussion groups come up with the PREPARATION FOR BRIDGING THE GAP

51 PREPARATION FOR BRIDGING THE GAP beliefs, etc. Place/Environment: medical or school services. schools e.g. privacy, distance, waiting space, cleanliness, availability of latrines, etc. Supplies and Equipment / Medicines: how people's traditional beliefs and practices are accepted by or taken into consideration by the formal e Cultural Compatibility / Traditional Beliefs and Practices: or the school – resource materials, books and supplies, chalk boards, desks and furniture, etc. Providers - Technical Competence: need, whether they understand the information, whether they feel listened to, etc. Communication / Information: whether they arrive at appropriate diagnoses and treatment regimens, and whether they practice safe medicine. Appropriate sterile technique would be included here. For education, this primarily includes the capability of the teachers to teach and the administrators to run a school. Client / Provider Relations: whether students have access to the services they need. here e.g. respect, greetings, openness, discrimination, fairness, confidentiality, tolerance for traditional THE FOLLOWING ARE SOME EXAMPLES OF CATEGORIES THAT CAN BE USED: Systems and Procedures: F school and clinic hours, supervision, policies and procedures, etc. Service Availability: whether people have adequate information about the availability of services, hours of operation, etc. wanted) services are available at all, whether services are integrated or provided on different days, or education this includes whether students are being taught what people think is important, and .g. medicines, equipment, soap, furniture, etc. (medicines may be pulled out into a category all its own) This covers the physical setting as well as the location for health services or F or health this includes types of services available, whether the needed (or This includes cost of services - both formal and informal, staff availability, How the provider or teacher treats their clients or students is covered This includes whether clients get the information they want or F or health, this includes the capabilities of the providers, This includes all the materials that are needed in the clinic - 47 This includes everything related to

52 Integrate For Presentation with many observations placed on them. The challenge is to synthesize these observations into elements of quality that are considered significant by teachers. Y analysis, may lead people to conclude there are problems with the supply system. However, if the during the next phase as part of a more detailed problem analysis. original information about injections and same medicine is recorded during the analysis, it can be used separate observations. If they both become summarized to “lack of medicine” then the focus of the FA indicated there are no injections and they receive the same pill for every illness these should remain At this point in the process, it is important to write down the original ideas and not merge unique perspectives. For example, if one group commented that there are no medicines, and another group ou now have a series of flip chart “categories” community members and health workers and CILITATOR TIP 48 These synthesized elements or definitions of quality then become the basis for defining the perspectives on quality, how they differ, how they are similar and where quality improvements are needed. PREPARATION FOR BRIDGING THE GAP

53 PREPARATION FOR BRIDGING THE GAP components of quality, an analysis of their Draw two large interlocking circles, using three sheets of newsprint. The middle page will be the area of overlap represents. The area of overlap r Analyze The Gaps done using a Venn Diagram. similarities and differences is needed. This can be In order to present the two perspectives on epresents common views of quality between the Community Community T W Health eachers orker 49 Each non-overlapping section of circle will contain key elements of quality as mentioned by only the community, or only health workers, or only the teachers. This diagram can represent both the key elements of quality and the problems. By highlighting those elements that are perceived as problems, the diagram can show both good and bad quality elements. community and the health workers or teacher. Equality Cost Example for Health From Haiti CDQ HWDQ Access/Distance Referral System Confidentiality Wa Information Counseling W Choice iting Time Order elcome tradition meds Acceptance of Environment Integration F ollow up

54 Gap before the presentations are being made, or Confirm Findings Bridging the Gap accurately portrays each groups perceptions. This step can be conducted during Bridging the being presented to the other group during a separate meeting can be conducted to present the summary to the community and the health w will present the gathered information. This is the final opportunity to make sure what is Bridging The Gap Participation w Improvement Team are participants at the that likely persons who may join the Quality discussion group, it is important to make sure comprised of a few representatives from each can skip this step. But if participation will be attending the Bridging the Gap session, then you If all discussion group participants will be participants for each step of the process was orkers. The groups should also determine who orkshop. The decision on the number of 50 determined during the planning phase, but it w health workers and teachers so that quality have not grown beyond what is manageable. The g different segments of the community and from improvement teams can be developed. oal is to have appropriate representation from necessary. After much discussion, the groups they had said and make any changes if of their video. This allowed them to see what In Peru, each group viewed the edited version  group. decided that the videos did accurately portray their issues and could be shown to the other ould be valuable to make sure that the numbers PREPARATION FOR BRIDGING THE GAP

55 PHASE 3: BRIDGING THE GAP BRIDGING GAP THE • • quality and to integrate those perspectives into a shared vision of quality. Each group has had the opportunity to express their own views on quality.The improvement process will now mostly follow two parallel paths with one section working on education while the other one works on health.This will depend on how many of the issues and interested people overlap. Purpose: in sincere dialogue about their definitions of quality.Then they must develop a shared vision and begin working as a team.This phase is the launching point for the ongoing QI initiative. A fundamental question that will need to be answered is whether it makes sense Components: • f • • The goals for these components are: groups must now bridge the language, cultural, user and provider gaps to engage • • or groups to work on both education and health issues at once, or if the quality To To To Developing a Shared Vision Select QI Teams T Problem Identification eam Building create a new definition of quality as a team engage in sincere and respectful dialogue about quality concerns mobilize participants who will remain involved in the QI process PHASE 3: BRIDGING THE GAP To provide an understanding of the varying perspectives of 51

56 environment, reduce barriers to communication, and create a positive atmosphere for working together. and can be threatening to the health workers and teachers. If social and cultural barriers were one of the quality issues, then team building has added importance. and design one of your own. are many others that can be used or be creative we Exercises are examples of tools/icebreakers that F • • Methods: workers, teachers and community members working together can be intimidating for some community members  Purpose: • or all groups, creating a common understanding and common ground is essential to PDQ.The concept of health Introduction excercise TEAM BUILDING T T our of a health facility our of the community re used during PDQ implementation. There Mambo Press T Information Collection and Exchange, December 1996 Useful References: raining for Transformation, A Handbook for Community Workers. Anne Hope & Sally Timmel, To begin to create a non-threatening PAC A: Pa r ticipatory Analysis for Community Action 52 These types of exercises can be reintroduced throughout the process, especially once the final QI teams have been established. ,P eace Corps PHASE 3: BRIDGING THE GAP

57 PHASE 3: BRIDGING THE GAP T participants to meet and learn a little bit about each other. It requires that you have items that have at least two of all items. This can be fruit, pictures, squares of colored paper. You randomly distribute fruit, pictures, or colored paper. Have the participants find the person who has a matching item and introduce themselves. Each person should tell the other a little bit about himself or herself. Then each will introduce the other person to the group. T Introduction Exercise: “To understand me you must understand where I come from and how I live”. This exercise can be as simple as having the community present their community map to the group. Or the interaction can involve sharing a meal at the homes of community members. F This exercise provides the opportunity for facility, as the schools is for the teachers. By bringing the community through their facility, they can "introduce" them to their services and the challenges they face. For some members of the community this may be the first time they have entered these facilities. our Of A Health Facility / School: or the health workers, their setting is their health our Of The Community: 53 it desirable to have one group address the problems. At no point is group working with the other to begin to develop trust and get each ex that were identified.The previous b service providers are confronting or the Gap is setting up a situation to the other directly. The major pitfall to avoid in Bridging address the other or posing questions where community members and home. ov the community, let alone staying  In Peru, the health workers actually spent the night in the homes of community members. This was w unprecedented because health laming each other for the problems orkers had rarely spent any time in ercises are examples of ways to ernight in a community members

58 allowed for discussion. After the community presentation time should be of view. Although the views are most often different, many things are the same.This is the time to merge the visions. Preparation: There are many options for presenting the viewpoints on quality.The presentations can made by r • such as the facilitator of those discussion groups. Methods: • and the community. As a first step to developing a shared vision, it is necessary to understand each other's point • Until now, quality of services has been explored separately through the eyes of the health worker, the teachers, • How The Community Defined Quality views? What is different? presented here? What is similar between the two Does anyone want to add to what has been Suggested discussion topics after the presentations: How Health Workers Defined Quality epresentatives from health worker, teacher and community groups, or a neutral person may present, DEVELOPING A SHARED VISION Developing a shared vision How health workers defined quality How teachers defined quality How the community defined quality 54 see the people’s vie time. This allowed the other group to hear and In Peru, each group’s video was shown at this  and in their own setting. Bridging the Gap workshop for both education and health, and that their issues both being addressed, the teams used the the community level. interventions.While different small groups we many of the problems were similar between In Nigeria, where education and health were  could be addressed in an integrated way at f orum allowed people to recognize that re w orking on different issues, the shared wpoints in their own words PHASE 3: BRIDGING THE GAP

59 PHASE 3: BRIDGING THE GAP and schools that can be addressed together? Are there common issues between health services teacher and community views? What is different? presented here? What is similar between the Does anyone want to add to what has been Suggested discussion topics after this presentation: How Teachers Defined Quality re  less frequently for coordination and exchange of involved more 60 people, both health workers and community members, from the five sub- areas of the project. People decided they wanted a QI team for each of the sub-areas, but ideas. they also wanted an “umbrella” team with In Haiti, the Bridging the Gap workshop facilitator presented the community’s views. views and the community discussion group In Nepal the MOH presented the health workers  presentation from each which would meet 55 planning use, etc. Some of these problems may If there are specific data that might also influence the development of the vision for quality and /or the action plan to follow, now might be a good time to introduce it. For e process. data to indicate there is a problem with girls’ enrollment, immunization coverage, family consideration during the bridging the gap be partly due to issues with the local facility that could be improved by an organization such as a QI team or coalition. Alternatively, a specific situation might recently have come up, such as a maternal death or a disease outbreak, that could be used as a talking point to spur discussion and FA xample in Nigeria, the COMPASS project has CILITATOR TIP

60 Developing A Shared Vision For Quality groups. It may be easier not to go into the causes of why certain aspects and understanding of quality are lacking. But instead develop an integrated vision of quality that reflects each group’s viewpoint. Display the Venn diagram that was created in preparation for this workshop. Be sure it still accurately portrays what has been presented or changed during the last discussions. This may take sometime but it is important that the vision reflect the aspects of quality important to all W Health orker Shared Vision Community T eachers 56 DISCUSSION • How are the perceptions of quality the • Where do the views on quality differ? • How has hearing the presentation from • Now that we have heard quality defined the other perspective affected your thinking on what is important for good quality care? Has anything changed for same? y from both perspectives, what would a shared vision of quality include? ou? PHASE 3: BRIDGING THE GAP

61 PHASE 3: BRIDGING THE GAP problematic.) If the problems with the quality have not been fully discussed, they should be identified now. views on the elements of quality and the problems. (Remember not all elements of quality will be described as Depending on how the quality presentations were approached, the groups may have already presented both their Purpose: 1) provide an overview of problems or gaps identified through the exploratory discussions 2) to validate the problems 3) prioritize those that need attention Methods: • • • Ke Introduction Before presenting the problems identified, it may be helpful to review some key points about this process. As problems are discussed, it will be important to remember that exploring problems is as a first step toward solving them. • • PROBLEM IDENTIFICATION We Review problems care / better health / better education Introduction F viewpoints on the same issue Respect that people can have different y points: ocus on the problems – not individual blame all share the same goals – better quality 57 Divide into small working groups. If more than one health facility catchment area or school is participating then you could divide by geographic division with health workers, teachers and Review Of Problems catchment area working together. An alternative is to divide into different groups for health or education. Within each group, review identified quality elements and any associated problems through exploratory dialogue with community members’ health workers and teachers. community representatives from each village or

62  7) Are there any trends that we can see in the types of problems that each group has identified? 1) Do the problems identified exist in our facilities? 2) Do some problems need to be restated? 3) Are these the main problems? 4) Do you want to add anything? 5) How do the HW, teacher and community descriptions of a given problem overlap? 6) How are they different? DISCUSSION  In Nepal the original design called for four Quality Improvement Teams, each would represent a health center and the associated health post. After the “bridging the gap” workshop each health post group felt that it would be better for them to have their own QI team. Now there are 30 QI teams instead of four. But each team feels more empowered and locally driven than the original design. In Uganda, each school had its own QI team with its own agreement for school safety under which participants we re w orking on improvements and monitoring changes. Useful References: www.QAProject.org A Modern Paradigm for Improving Healthcare Quality,The Quality Assurance Project Regroup and present any changes from the subgroup’s discussions. 58 PHASE 3: BRIDGING THE GAP

63 PHASE 3: BRIDGING THE GAP It is important that the QI Team be able to w locations need to be addressed. be addressed. Who will be on the team, and where and when they will meet should be discussed among the participants. The original design can be changed to meet the participants’ needs. Before completing the “bridging the gap” r transportation, convenient meeting times, and community and health workers and teachers. Unfortunately, diverse groups often have diverse needs. Barriers to participation such as epresent the diverse viewpoints of both the SELECT QI TEAMS orkshop, a concrete plan for the QI teams should 59 separate teams for education and health In Nigeria, if the community coalition had Gap meeting served as the opportunity for f we community coalitions. In some instances, QI team that were responsible for both education and health were formed with sub-committees for each, while in others not already been formed, the Bridging the  clearly have significant involvement from the PTAs. orming both the QI teams and the re f ormed. For education, the QI teams

64 PA W ORKING IN R TNERSHIP • process necessary for the QI teams to continue the cycle of change. Some of this problem analysis work may initially take place during the "bridging the gap" workshop but those results will need to be reconsidered by the Quality Improvement Teams in this cyclical process. Most of these tools and processes are g • • • The groups have agreed on a common vision of quality and some challenges that determine causes, solutions and action plans.This requires a creative team working together in cooperation and respect. In this step, the tools are provided f • education. Purpose: • • Components: they face. Now the creativity and ingenuity of the QI teams is needed to or problem analysis and action planning as well as to strengthen the group eneric and can be used in a variety of situations not specific to either health or PHASE 4:WORKING IN PARTNERSHIP including a mechanism to determine when problems are r a continuous quality improvement process. To The QI Action Cycle T To Solutions and Strategies T Reviewing Progress esolved and to identify new challenges to address. ools for Self Management ools for Problem Analysis establish a process for ongoing review of progress provide tools necessary for the QI teams to implement 60 Although these tools will be reused many times by the teams in the ongoing quality improvement process, initially the teams will need technical support to expand their action planning skills. PHASE 4:WORKING IN PARTNERSHIP

65 PHASE 4:WORKING IN PARTNERSHIP understand how this fits into the quality improvement cycle. By discussing this as a continuous process, of problem identification, proposal of problem solutions, implementation and assessment, the teams can see their permanent role in the QI process. It is important for the quality improvement teams to review all they have achieved to this point and to Method: Review a diagram of the action cycle Preparation: • • THE QI ACTION CYCLE Draw the action cycle on large paper for display If literacy is an issue, include pictorial r epresentations of each stage 61 Provide an overview of the action cycle using the diagram. It is important the team understand that this is a continuous process for improving quality. Discussion Guide: discussion. Where are we in this cycle? And what is next? Can this process be used for new problems? Use the following questions as guide to facilitate

66 (Are users more satisfied with services?) FA how this applies to their work as a QI team. Once these steps are outlined on the board, you may want to facilitate a discussion in the group on QI ACTION CYCLE DIAGRAM CILITATOR TIP (Did the quality changes occur?) (Were the actions completed?) Monitoring and Evaluation Developing an Action Plan (How do we improve quality?) (What are people’s perceptions of the Exploring and identify quality issues problems, what are priorities, etc.) 62 (What are the underlying causes of Determining solutions Y Analyzing the issues ou are here the problems) ✘ PHASE 4:WORKING IN PARTNERSHIP

67 PHASE 4:WORKING IN PARTNERSHIP problem can appear to be due to one cause, further analysis usually reveals that there are many contributing f r utilized to explore a problem more fully. perspective when analyzing problems. Problem solving is a skill that the team can develop together. Although a Many eyes can look at one thing and see something different. This is a benefit of the PDQ QI Teams’ diverse problems • Purpose: Methods: •  * there are many methods for helping groups discover root causes of problems. These are two analysis while others will require a lot of examples that we found useful. The reference problems are easier and do not require complex section lists sources for additional tools. Some exploration. actors or causes to each problem. Often by really exploring problems and gaining a better understanding of the oot causes, solutions and strategies become more visible. This section provides a series of tools that can be T Tr Fishbone Analysis OOLS FOR PROBLEM ANALYSIS ee Analysis www.QAProject.org Assurance Project Useful References: to identify the root causes of A Modern Paradigm for Improving Healthcare Quality,The Quality 63 Ke • • • • To FA group “but why”. Asking but why helps the group identify all the contributing factors, and root causes. actions, underlying causes must be identified. Y F Is there something else causing the problem? Why is it a problem? What is the problem as we see it? participants should ask themselves: ou will find yourself repeatedly asking the or each of the selected priority problems, the y Points: CILITATOR TIP be able to determine effective solutions and

68 Fishbone Analysis assigned to the bones. In instances where the same contributing cause comes up for many different problems, it may be beneficial to analyze that cause as the primary problem. For example if lack of support was a cause listed for many In fishbone analysis the problem becomes the head of the fish. Contributing causes are access to medicine Need more info on medicine Didn’t understand look alike medicine v erbal explanations needed packaged the same Can’t read, better All medicine Stock outs Cost Improper Overuse at health post storage injection with quality treatment Community equates medicine or 64 from the cause. problem would be explored. You may also have other factors which contribute to a cause that should be noted as additional “bones” branching problems, then you could do another analysis where lack of support was listed at the head of the fish and the factors contributing to that team is struggling to use the tool maybe another one w There is no right way or right answers to the problem identification process. If you have too many bones or it has become too complicated y FA broad. You may want to break it down into more specific problems and analyze each of those separately. Remember that the tools are supposed to help. If the our problem may be too ould be better. CILITATOR TIP PHASE 4:WORKING IN PARTNERSHIP

69 PHASE 4:WORKING IN PARTNERSHIP Tr This diagram branches out with each “But Why?” Problem ee Diagram Why? Why? Why? Why? Why? Why? 65 Why? Why? Why? Problem: Girls tend to be But why? EXAMPLE OF FLOW boys take priority. enough money for everyone and Why? underenrolled for school married and having children, ev Why? as far as boys and the schools time to walk the distance because they are busy with household chores. But why? need to be able to support household are still traditional while boys are more free. themselves. What are other reasons for the problem? culture has women getting are far away. en though increasingly women Because there isn’t Girls don’t have enough Girls’ roles in the Because traditional Girls can’t walk

70 there is a possible solution. Some of the solutions would require action beyond the bounds of the teams but needed for sustaining the quality improvement process. The problem analysis has revealed that each problem is really the sum of many causes. And within each cause many solutions are achievable. Focusing on what can be accomplished by the team creates the momentum • Purpose: • • Ke and determining an action plan to achieve change. strategies for addressing the problems identified the next page to record the problem, contributing through brainstorming. The teams can use the chart on factors and suggested solutions. Develop Solutions Based On Identified Causes Starting with one problem, use the causes identified in the problem analysis to explore appropriate solutions SOLUTIONS AND STRATEGIES necessary to ask the group, “if that is not As possible solutions are identified, it may be a particular problem. F possible, then what?” There is likely to be more than one solution for ocus on solutions that are realistic and feasible y Points: To identify possible solutions and 66 • • • • Methods: F and not on blame. Include shared solutions that involve the community Develop an action plan Develop solutions based on causes identified ocus on positives, ways to make things better FA achieved at the local level. Often the initial solutions involve actions from outside sources such as the go solutions that can be guided to also look for Initially, the group should be v CILITATOR’S TIP ernment or the donor. PHASE 4:WORKING IN PARTNERSHIP

71 PHASE 4:WORKING IN PARTNERSHIP PITFALL e are not in school”) problems and solutions that money can fix, and dependence on external resources is reinforced. In contrast, when communities are encouraged to develop low or no cost solutions, or to at least consider which of their solutions they can manage internally, the definition and solutions for problems is greatly expanded. Where the possibility for grants or external resources don’t have a female health worker because our girls solutions often refer to improved infrastructure and equipment. (“we need a renovated health facility”) However, if internal solutions are also encouraged, people begin to recognize how their own attitudes and practices are contributing to the problems and they recognize they can do something about it. (“we F xists, there is a tendency to think only in terms of or example, when money is the driving factor, 67 teams and coalitions were encouraged In Nigeria, because the structures and QI teams, each developed an action plan, but each had a different focus. At  specific activities to improve the quality of services in a specific facility. For the coalition, their action plans involved broader activities such as advocacy, community mobilization and sensitization, and fund raising. With the COMPASS project in Nigeria, the availability of grant money and interventions from other sectors greatly broadened the possibilities for solutions and actions. As a result, QI included both community coalitions to come up with solutions they could r organizations. solutions which needed additional r participating community based the option to advocate for technical or r assistance through on of their both within and outside the project and/or to develop proposals for grant the QI team level, the focus was on the esource assistance from other sectors esources or assistance.They then had esolve themselves internally, and

72 Develop An Action Plan After solutions have been identified for the problem, the team needs the skills to take the potential solutions or strategies and translate them into specific activities and plans for implementation. Starting with those challenges that have the most feasible solutions, develop a specific plan for how, who and when the activities will occur. The sample chart below is one way the team can keep track of the issues. There is often more than one solution to a problem, as well as, more than one action for a solution. 1. 3. 2. Problem Contributing factors A.__________ B .__________ Solutions 2. 1. 3. Action 68 r esponsible Who is Resources/ re materials needed When Status PHASE 4:WORKING IN PARTNERSHIP

73 PHASE 4:WORKING IN PARTNERSHIP teams to evaluate their progress, they can determine whether they are ready to move on to new issues. Or if actions have been implemented but the results in quality were not achieved then the problem can be re-evaluated and new strategies can be explored. This quality improvement process is a cycle, which includes tracking progress. By creating mechanisms for the • Purpose: • • Ke used when evaluating QI activities and ways to measure them. the action was never implemented or completed. not resolved because the solution was not right or It is important to know whether the problem was T REVIEWING PROGRESS racking Progress information the group collects, the team will burdened by monitoring. The indicators or benchmarks of progress and In order to be able to use the monitoring T need to have some way to organize it and draw conclusions w Upon review the group may note their activities ways to measure these need to be kept simple. eams want to know if the solutions are y Points: orking but they don’t want to be over To identify indicators that can be 69 in the action matrix. During QI team meetings the status of the actions can be reviewed. That is what the “status” column was designed for Methods: • • • problem). In either case, this would indicate that the team should refine the problem are not leading to changes. They would then the QI cycle. need to determine whether their indicator is not the right one (doesn’t measure the impact of the activity) or whether the activity is not the right one (doesn’t address the real definition, strategies, or monitoring as part of Evaluation Tools Creating an tracking table T racking progress

74 If actions did not meet their completion date the team can decide if it will just take longer than steps make sense in your situation. The main Creating A Tracking Table The following table provides a framework for the group to begin to consider how they want to measure change as a result of their activities. It may be adapted to whatever column titles or PROBLEM WHAT SHOULD BE? (Quality standard) TRACKING TABLE FOR QI TEAM PROOF OF CHANGE? (Indicator) 70 expected or maybe new or additional people could be assigned to the task. problems. purpose is to come up with indicators that are simple to define and measure but that will accurately reflect a change in the identified HOW WILL YOU MEASURE? GOOD ENOUGH? HOW GOOD IS (Benchmark) PHASE 4:WORKING IN PARTNERSHIP

75 PHASE 4:WORKING IN PARTNERSHIP Students feel there is information Clients lack necessary discrimination PROBLEM WHAT SHOULD BE? • •A • • •A (Quality standard) info on how to about care. All clients receive All clients receive info about how to take medicine. complete and All clients receive understandable info prevent problem in the future equally to politely ll students spoken ll students treated TRACKING TABLE FOR QI TEAM EXAMPLE PROOF OF CHANGE? r are treated with Client can explain care Client can explain use of medicines Client can explain preventive actions to take. Students receive equal grades for equal work. Students feel they espect. (Indicator) 71 Po periodically review Exit interview by QI T produced. HP coordinator or in-charge. Clients Voting Jar – Once a weeks students v grades relative to work f Committee members by the voting jar. a happy or sad face in eel they are respected ote on whether they eam member or ssible methods: HOW WILL YOU placing a bean with MEASURE? they received information about their diagnosis. XX% of clients could explain how to take their medicine correctly. XX% of clients know prevention strategies Students all report fair treatment Outside review indicates grades are given fairly. More than half of clients interviewed indicate GOOD ENOUGH? HOW GOOD IS (Benchmark)

76 Evaluation Tools These tools can be adapted to pictorial versions to overcome literacy barriers as was done in Nepal. members or providers could administer 1. Happy face / Sad face jar 2. Suggestions jar 3. Simple exit interviews 4. Simple observation check list which QI team injections, whether a sterilized syringe was used, whether the provider interacted politely and listened to the patient’s problem, whether a queue was maintained, and whether medical waste was disposed of properly. A score was given for each observed case. This information was shared with the QI Team members during their monthly meetings. PICTORIAL EVALUATION TOOL In order to bridge the literacy gap for evaluation, the QI Team in Nepal created a pictorial tool to be used by clients to monitor planned quality improvements. The tool allowed both literate and non- literate clients to give anonymous feedback. The tool included, whether trained staff provided the 72 5. Provider self assessment 6. Client evaluation form PHASE 4:WORKING IN PARTNERSHIP

77 PHASE 4:WORKING IN PARTNERSHIP Proper Disposal of Medical Waste Maintenance of Queue. 73

78 Components: • productive QI team requires skills in group process, team building, and facilitation. The goal is to have a group of diverse volunteers working together as a team with the skills to set agendas, run meetings, problem solve, and develop action plans. As with quality definition and improvement, the group together can determine what is needed to strengthen the group process. The exercises are designed to help the group explore several aspects of group strengthening that will contribute to the growing independence and success of the QI team. Just as quality improvement is a learning process, so is working together as a team. Sustaining a cohesive and • • • encouraged to develop their own, or to adapt these or others to the needs of their particular groups. • The exercises that follow are suggested tools. The people guiding the PDQ process are strongly  T Facilitation exercises Mobilizing resources Understanding how leadership can work in our team Representation Te OOLS FOR SELF MANAGEMENT am effectiveness evaluation and Exchange. December 1996 Anne Hope & Sally Timmel, Mambo Press (Chapter 6 – Leadership and participation) PA Useful References: CA :P articipatory Analysis for Community Action Tr aining for Transformation, A Handbook for Community Workers. 74 ,P eace Corps, Information Collection PHASE 4:WORKING IN PARTNERSHIP

79 PHASE 4:WORKING IN PARTNERSHIP gaining an understanding of how leadership works and establishing a group with shared leadership, the group becomes more self-reliant and can effectively draw on the unique contributions of each of its members. In any team, leadership is an essential component. The team maybe comprised of one or several leaders. By within the team. It may be useful for the people who are guiding the PDQ process to work with the group in a self diagnosis process to identify their leaders, their strengths, and ways to be sure the group has the leadership it needs. the respect of the group. If this is not the case, f Methods: influence. Groups will likely function well if the Supervisor, School Principal, etc. However, they of leadership. Purpose: out, or the group may have difficulties with lack F may not necessarily be those who have the most There are formal and informal leaders in most groups.The formal leaders are those who have the titles: Chairman, Mayor, Health Services there may be other "leaders" who are helping effective function. ormal leader is also active, committed, and has ormal and Informal Leaders UNDERSTANDING HOW LEADERSHIP CAN WORK IN OUR TEAM To Group discussion of formal and informal leaders, and identification of leadership strengths explore different options for managing QI team leadership in order to assure the most 75 Initially, it is likely that the selected leader (Chairman) may be called on to respond to needs of the group on his or her own. As the Roles of Leaders/ Shared Leadership members will assume more of the leadership r shared among the team. more responsibility for the function of the group, the leader can become less active and the role is group gets to know each other, gradually different oles themselves. As the group members take

80 of formal, informal, and shared leadership suggested above and have a more general discussion. This discussion might be repeated as you notice problems or gaps with leadership during the evolution of the group. Leadership and choices of leaders can be changed as the group matures and the group’s needs change. Y FA • • • Rotating Leader/Chairman for QI Team w tasks and accomplishments achieved during the meeting. Where an outside organization is facilitating or serving as a catalyst for initiating the PDQ process, this may start out as a shared role where one member from the agency works with one or two group members to plan and lead the meetings. As group members become more confident in these processes, agency participation will be less necessary. One way to encourage shared leadership, is to assign the chair person job on a rotating basis. This role ou may want to ask the following questions, or you may just want to offer the leadership framework QI team be more effective? (who schedules (Chairman, secretary, local government leader) Who are the formal leaders in our group? Is our team able to accomplish the necessary The informal leaders? (the most active people, the people most respected by the group or community, the elders) out resources, makes decisions, etc.?) meetings, shares information with others, seeks How do the formal and informal leaders work together or complement each other to help the ould probably include development of the agenda, facilitation of the discussion, and a summarizing the CILITATOR TIPS: 76 • • will keep control of the group themselves? What might be some of the reasons a leader these difficulties? What are ways we can encourage more shared leadership and r If our team is having difficulties functioning, why is that? Can we identify people (leaders) within our team who might be able to help overcome ev r activities to be effective? Do we manage to have esponsibility among the members? egular meetings? Is the discussion useful? Does eryone feel comfortable participating? PHASE 4:WORKING IN PARTNERSHIP

81 PHASE 4:WORKING IN PARTNERSHIP are fully committed to the actions taken by the team. Although not defined as such, team members use f F success, the can team will begin to create their own group norms. • Discussion Questions: • • agreeing on an approach. The role play does not have to be scripted and the facilitator is not being rated F Using some of the members, role play a meeting with typical facilitation challenges. The facilitator in the r After 10 minutes, stop the role play and give the group a chance to discuss. Write the feedback on newsprint. on their success. This is just an opportunity for the group to think about the role of the facilitator. • Purpose: • • acilitation skills in their daily lives. By defining the facilitator’s roles and exploring the skills needed for their or the QI team, a facilitator’s role is to enable open and equitable communication ensuring that all the members ole play should be predetermined. Choose a topic for the role play that involves soliciting ideas and acilitation Role Play I FA What functions did the facilitator serve? Where did the facilitator have difficulties? Why? group discuss in an open and participatory way? What did he or she do that really helped the team. To To facilitation. To CILITATION EXERCISES determine the roles of the facilitator by the determine methods for successful begin to establish group norms. 35 minutes 77 • • Methods: • • • • with those situations? What do you think are the best ways to deal order to overcome these difficulties. that the facilitator would have to deal with? What other situations could be encountered Facilitation Role Plays Defining the Facilitators Role Managing Participation We re there things they could have done in

82 • • Discussion Questions: • • F are able to contribute to the effective functioning of a group, but there are also times when we are not. Sometimes people, for some reason, work against this ideal of equal participation. This may mean they are too dominant or controlling, but it may also mean they are too shy to speak up. It is the facilitator’s r In the ideal situation, all members in a group feel comfortable and participate equally. Unfortunately, this Procedure: rarely happens. Depending on the setting and how comfortable we feel, there are times when all of us This second role play can be used to further the discussion on how to deal with challenging situations. in addition to assigning a facilitator, also secretly assign specific challenging behaviors to a couple of the norms that are suggested on newsprint for the team to review. Carry on role play for 10 minutes as done previously, then stop and discuss. Write down any group participants in the group. ole to try and limit dominating behavior and to try and encourage non-participants to speak up. manifest themselves? r What were the disruptive behaviors these behaviors? acilitation Role Play II leading? How is facilitating different from managing or Does the rest of the team agree with that a What did the facilitator do to try and manage epresented in your group? How did they pproach? Set up the exercise in the same way the previous role play was set up. However, this time 45 minutes 78 • • • • used to limited these behaviors? Are there other ways the facilitator could have the group? What responsibility do the participants have to to do? r Why do we want to understand other people’s What are some of the things a facilitator needs ealities and perceptions? PHASE 4:WORKING IN PARTNERSHIP

83 PHASE 4:WORKING IN PARTNERSHIP develop a way to pictorially represent the key area of team effectiveness. communities for ongoing quality improvement. It is important that the QI teams take a look at their own process and interactions from a quality improvement perspective. The team can apply their skills in problem solving to r Establishing and maintaining an effective QI team can often be the largest obstacle faced by many of the We esolve any issues that result from feedback. used by team members to monitor team effectiveness. Each picture, representing an area of team interaction, was ranked on a scale of one to three. PICTORIAL TEAM EFFECTIVENESS EVALUATION TOOL Due to the varied literacy skills of the QI Team in Nepal, they developed a pictorial evaluation tool to be TEAM EFFECTIVENESS EVALUATION encourage teams to develop their own tools together. Again if literacy is an issue than the team can Active Participation Monitoring and Follow Up 79 Mutual Cooperation

84 Questionnaire adapted from Training for Transformation,Volume 2 our goals? Do all members contribute to the decision team is doing? ideas and opinions? Are all members treated with respect for their making? Are you satisfied with the progress the team is How strongly involved do you feel in what this creativity of our members for accomplishing How fully do we use the resources and decisions? Are all members included when making making? TEAM EFFECTIVENESS QUESTIONNAIRE Never Not at All, 80 Little A Few, A Somewhat Sometimes, Mostly Strongly Always, PHASE 4:WORKING IN PARTNERSHIP

85 PHASE 4:WORKING IN PARTNERSHIP It is said that a picture says a thousand words. In this case by drawing the community and the resources and mobilize the people in charge to support the QI efforts.This could mean persuading local government officials that they should commit funds to a health service improvement project, or convincing community members they should become involved with monitoring quality improvement in the school. It could also mean identifying additional funds and developing a specific proposal for a quality improvement activity. In any case, the fi Mapping Resources Exercise address the problems we have identified. Purpose: • human and/or financial - may be needed.The team will have to identify where they might find those resources, NOTE:This is an exercise that might be worth repeating periodically as part of the assessment step of • efforts. In the process of developing an action plan, the QI team may have identified actions where additional resources - within the community, the team can begin to explore visually what may be potential partners in their QI Methods: • the quality improvement cycle. It can provide information on whether we are doing the right things to • r MOBILIZING RESOURCES Selling the QI process To Mapping Resources To st step is to identify potential sources for the resources needed. help identify resources. mobilize identified resources. 45 – 60 minutes 81

86 identified during the mapping exercise as Procedure: QI effort. convincing groups to become involved with the Purpose: “SELLING” The QI Process selecting one of the “target” groups or people convince, etc. They should draw the QI team in drawing a map, tape for putting them up diagram) of their community (s) – noting all the different groups, institutions and people they might try to work with, influence, relate to, and the environment with the goal of identifying the picture. potential resources for supporting the QI process. Materials: Procedure: Purpose: To To poster paper and markers for Divide into subgroups, each Have the team draw a “map” (or practice identifying key points for practice looking at the community 60 minutes 82 • • • When completed, ask the group to discuss: Discussion Questions: • develop a strategy and/or presentation for convincing these people to become more involved with QI. someone who they might better be able to involve in the QI efforts. They should then re we currently interacting with who might really be able to help us with our QI efforts? might we do differently? currently interacting with regarding QI? Which groups are our best allies? What are we doing to encourage this relationship? Which of these groups or people are we How well are we relating with the different groups on our map? Are there groups where view their problem list and action plan to Are there groups or people who we are not are having problems connecting? Why? What PHASE 4:WORKING IN PARTNERSHIP

87 PHASE 4:WORKING IN PARTNERSHIP Each group should select people to role play the different parts in the presentation. They should take then present their role play to the group as a whole. time to decide how each person should play their role and to practice once through. Each group can Discussion Questions: • • particularly convincing? Why? What arguments or strategies left you feeling What arguments or strategies did you find uninterested in the QI efforts? Why? 83 • • What have we learned about presenting QI that will help get more people involved in the effort? What are some of the constraints this person or group may have regarding participation?

88 committees reflect on their roles as community and provider representatives. discuss what it means to represent others in these teams.This exercise can also help pre-existing development Since every service provider and member of the community can not be part of the QI Team it is important to • Purpose: • and responsibilities as representatives of their r Methods: Ke • The privilege to represent people comes with r • esponsibilities: espective groups. REPRESENTATION Communication with the people who are r Communication of people’s concerns and needs with the QI team and the health center or school health center or the school Plan for Next Steps Group Discussion epresented about what is going on at the y Points: Orient team members to their role 84 Group discussion to answer the following questions: 1. Who needs to be represented? 2. Who am I representing? 3. How can I best find out the ideas and r 4. How can I best let people know about they can take to improve their role as questions and decide upon two next steps that 5. How can the people I represent become more consider their answers to the discussion Each person (or group of representatives) should Next Steps epresentatives. or the school? involved in the activities at the health center the health center and school? what is happening with the QI team and concerns of the people I represent? PHASE 4:WORKING IN PARTNERSHIP

89 EVALUATING THE PROCESS AND OUTCOMES While the quality improvement effort is itself as discussed in the Working in Partnership chapter. In addition to monitoring the process, a re underway, it is important to monitor the process the Partnership Defined Quality effort should be re students questions near school. toward the specific objectives. There are many ways and tools that that can be used to measure the impact of the quality improvement efforts. In particular, you may want to look at: Client satisfaction questions just outside the clinic door or asking exit surveys or printed anonymous questionnaires may result in greater honesty in the responses than when asking clients the view of the goals established at the beginning of viewed to determine if progress is being made EVALUATING THE PROCESS AND THE OUTCOMES monitoring tools such as 85 Standard measures of the quality and a checklists and protocols can be administered to check progress and highlight areas in need of attention. These tools are developed locally or are government issued standards. References for health facility and service assessment tools, which can be locally adapted, can be found on page 9. Student test scores are often a standard measure of quality for schools. Beyond this, there may be techniques such as health facility assessments, the country that could be used. Utilization of health services and promoted health behaviors services by the community. monitored through regular review of health services statistics and registers, the logistics management system for contraceptive and drug supplies (as evidence of demand), and knowledge, practices and coverage (KPC) surveys to evaluate adoption of health care practices and use of checklists for standards and guidelines available in vailability of health services can be tools and

90 the services they deliver.Whatever combination Improved equity in health services delivery community in the evaluation process. intake records or other facility or community level data specifically track utilization by disenfranchised or low-income groups.The PDQ processes may help reach these groups that are consistently under-represented among users of health and education services, and build their interest and trust in the service providers and or school attendance of approaches to evaluation and documentation of the effectiveness of the PDQ effort that is chosen, it is important to regularly review the g process and to ensure the involvement of the oals that the team set at the beginning of the can be measured if 86 EVALUATING THE PROCESS AND OUTCOMES

91

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