© How could we improve this solution or its implementation? © How could we reduce resistance that we encountered?
© What parts of the process or change need to be standardized? How shall we communi- cate these new standards so that things do not revert back to the old ways?
© What issues must we address before implementing the change on a larger scale? What kind of resistance might we encounter? What kind of training is needed?
© What technical, logistical, and material support needs to be ensured to make it sustain- able?
© How shall we continue to monitor to see that the problem does not return?
To ensure that gains are sustainable, the team will need to look for opportunities to stan- dardize the improvement and make it permanent such as changing job aids and manuals, inserting new material into pre- and in-service training, and getting official policy state- ments. Additionally, sustainability requires vigilance: the team should think about what indicators it will continue to monitor to assess whether the solution continues to be suc- cessful, i.e., that the problem does not reoccur.
EXAMPLE 1: Compliance with ARI Treatment Regimen
Graphs of the data from the indicators the team monitored were posted on the Storyboard. They showed the following results:
100 80 60 40 20 % of ARI Patients 48% 65% 82%
Counseling, Knowledge, and Practice of ARI Patients: Making Tablets Easier to Swallow
Received Couseling Understood Message Carried Out Advice 100 80 60 40 20
% of ARI Patients Finishing Treatment
After Counseling Solution Before Counseling Solution 55% 75%
Percent of Patients Finishing their ARI Treatment Regimen
The team felt that it had done a good job of carrying out the counseling and that it had some ef- fect on reducing the number of patients not finishing treatments.
When the supervisor discussed with other supervisors, it appeared that the problem of patients disliking the ARI medication was quite widespread, and the Regional Pharmacist decided to lobby for changing the treatment of choice for acute respiratory infections.
The team was glad it had adopted an interim solution to improve the percent of patients finishing treatment because it had been able to increase patient compliance while the much longer process of changing the treatment regimen would be put into place.
To ensure that gains are sustainable, the team will need to look for opportunities to standardize the improvement and make it permanent such as changing job aids and manuals, inserting new material into pre- and in-service training, and getting official policy statements. Additionally, sustainability requires vigilance: the team should think about what indicators it will continue to monitor to assess whether the solution continues to be successful, i.e., that the problem does not reoccur.
E. How To Know When the Quality Improvement Process Is
Completed
Although quality can always be improved, individuals and teams must be able to say, “That was a job well done.” The team can consider the quality improvement effort a success when it has evidence that the problem has been resolved: the data show that the problem no longer exists and the changes (solution) have been incorporated into routine procedures. The quality improvement efforts are complete when the team feels happy about its efforts and their effectiveness.
EXAMPLE 2: Prenatal Care: Waiting Times—Solution Two
The data on the number of women coming on each day of the week indicated that there had not been any change in the pattern; most women continued to come on Monday. The midwife’s checksheet data showed that only about half the women knew that prenatal care was offered ev- ery day, and of those coming on Mondays, only a quarter knew. The receptionist, when questioned about these results, said that she was very busy and could not always remember. Instead of blam- ing the receptionist and accusing her of being lazy, the team felt that this solution was not a fea- sible one, and they decided to try another solution: putting up a poster. They agreed to continue monitoring the number of women coming on each day of the week for the next 3 months. Because the time for the evaluation was short, the team was not able to evaluate the effect of the solutions on the percentage of women making four prenatal visits. The members decided to keep monitoring this indicator, along with vaccine wastage and stock-outs for 3 more months as well and see what the overall impact would be.
At the end of the observation period, the team found that prenatal coverage had increased moder- ately, but to its surprise, coverage for tetanus toxoid immunizations increased dramatically in those women coming for prenatal care. These results convinced the pharmacist that the wastage of vac- cine was a small price to pay for improved coverage. In addition, the number of women attending each day of the week became more evenly distributed over time. The nurse assistant posted these results on the Storyboard, and recorded the team’s conclusions in the Storybook.
Prenatal coverage was still lower than the members would like it to be, so they decided to explore other possible causes of low coverage, and began the problem solving cycle again.
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