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Building Improvement Capacity and Capability at Scale
Ghana’s Improvement Coaches Program
By
Dr Sodzi Sodzi-Tettey, Project Director
Ernest Kanyoke, MSc, Project Lead
International Forum on
Quality & Safety in Healthcare
ExCeL, London
22nd April 2015
Background
Improvement Coaches (ICs) Program Aim and designParticipant Selection
Assessment results Capacity Capability
Key Lessons/Observations
Recommendations
AIM:
Assist and accelerate Ghana’s efforts to achieve
Millennium Development Goal 4 (66% reduction in Under-5
mortality to 40/1000 livebirths by 2015)
through the application of quality improvement methods
Funded by the Bill & Melinda Gates Foundation
COLLABORATORS:
What are we trying toaccomplish?
How will we know that achange is an improvement?
What change can we make thatwill result in improvement?
Model for Improvement
PlanAct
DoStudy
Source: Associates for Process Improvement
LS 2LS 1
PDSA cycles
PDSA cycles
LS 3
regular site visits for coaching & mentoring
LS 4
PDSA cycles
Improvement Collaborative
Network
Source: Institute for Healthcare Improvement
Change package of process improvements that had been shown to be effective in similar contexts
Indicator Pre SU SU Phase Total Comment
# HW Trained
635 av./LS (for LSs1-4)
586 av./LS(for LSs 1&2)
3712 Total count represents ‘total contacts at LS’
# Change Agents
73 Nil 73 Loose Curriculum
# I. Coaches (Hosp.)
Nil 180 av./LS(for LSs 1-3)
248
Structuredinterrupted 10W Curriculum
# I. Coaches(District)
Nil 68 av./LS(for LSs 1-3)
# trained as at March 14
LEADERSHIPEXECUTION
UNIT
QI
CAPACITY
BUILT
CULTURE-
CHANGES
HARD
WIRED
RESPONSIVE
INFO.
SYSTEMS
The Improvement Coach Program curriculum jointly developed by PFA! team and IHI in response to a growing need to rapidly build capacity at scale using relevant QI content with rich local examples
Target participants were middle managers and leaders at the front line in the health system
The broad aim was to develop health careimprovement coaches to lead improvement teamsand be facilitators for the improvement strategies intheir organizations
Copyright © Institute for Healthcare ImprovementSlide 2
(11 weeks time frame)
Prework WS 1 WS 3WS 2
Action Period Support
Phone calls with Program Facilitators
Site Visits by Facilitators to Participants projects
AP1 AP2 AP3
WS – Workshop AP – Action Period
Project SelectionWeek 2 Week 6 Week 11
18 month development
1. Officer with QI/QA as normal job description
2. Keen interest working with data/ developing analytical skills
3. Possess basic facilitation skills/developing same
4. Knowledge and interest in maternal and child health
5. Willing to stay in the Region/District/Hospital for at least 2 years to support QI work
6. Keen interest to learn new concepts and methods
7. Ability to work with others in a team
8. Willing to take on additional responsibilities
9. Willingness to provide on site coaching and mentoring
10. Ready to make time for Learning Sessions if granted permission
Program runs for < 3 months
All ICs will have an improvement project
Some ICs will not have a PC in class or at work
Some ICs will not have Excel Skills
Use articles and printed handouts with local examples participants could relate to
Continuous QI mentorship from project officers to build capability during activity period visits
257
188
217
173
0
70
140
210
280
Workshop 1 Workshop 3
Wave 4A
# o
f Part
icip
ants
# of Participants
# of participants who filled the assessment form
113 110110
89
0
40
80
120
Workshop 1 Workshop 3
Wave 4B
# o
f Part
icip
ants
# of Participants
# of participants who filled the assessment form
0
5
10
15
20
25
System
leaders
Nurses/
Midwives
Health
Information
Officers
Technical
Officers
Medical
Officers/
Specialists
Unknown Physician
Assistant
Program
Managers
Perc
enta
ge
Graduated ICs
Workshop 1
Science of Improvement
Aim Setting
Understanding Measures
Data Quality
Introduction to PDSA cycles
Workshop 3
PDSA
Run Charts
Time Between Cases
Spread & Scale Up
MUSIQ tool
Workshop 2 Designing PDSAs Run Charts Scatterplots Coaching
improvement team Creative Thinking
Specific Method, Tool, or Skill
Information:
Know what tool is
Skill:
Can apply in identified situations
Knowledge: Know
how, when, and where to use
Understanding
experience; Can adapt, explain
why
Wisdom:
Can teach theory and use of
method
Assessment Scale:
1 10 20 21 30 40 41 50 60 61 70 80 81 90 100
0
20
40
60
80
100
Scie
nce o
f Im
pro
vem
ent
Quality
Contr
ol (o
r Q
uality
…
Aim
Sta
tem
ent
Measure
s f
or
Impro
vem
ent
Develo
pin
g C
hanges
PD
SA
Cycle
Testi
ng C
hanges
Imple
menti
ng C
hanges
Spre
ad a
nd S
cale
up o
f C
hanges
Conducti
ng
Team
Meeti
ngs
Team
D
ynam
ics (
vari
ati
on in…
Flo
w D
iagra
m (
syste
m m
ap)
Form
s f
or
Collecti
ng D
ata
Surv
eys
Benchm
ark
ing
Sam
pling M
eth
ods
Cre
ati
vit
y M
eth
ods
Aff
init
y D
iagra
m
Fis
hbone(C
ause a
nd E
ffect…
Matr
ix D
iagra
ms
Tre
e D
iagra
ms
Run C
hart
Shew
hart
Contr
ol C
hart
s
Pare
to C
hart
Fre
quency P
lot
Scatt
er
Plo
ts
Tw
o-W
ay T
able
s
Desig
nin
g P
DSA
Tests
of…
Change C
oncepts
Dri
ver
Dia
gra
m
Syste
ms T
hin
kin
g A
naly
sis
Reliabilit
y C
oncepts
Assessm
ent
(1-1
00
)
Tools , Methods and Skills
Min Median Average Max
Understanding Stage (61-80): Have experience with the method, tool, or skill to the
point that you can adapt it to a situation and can explain why you are using it to others
Understanding
Stage
0
20
40
60
80
100
Scie
nce o
f Im
pro
vem
ent
Quality
Contr
ol (o
r…
Aim
Sta
tem
ent
Measure
s f
or…
Develo
pin
g C
hanges
PD
SA
Cycle
Testi
ng C
hanges
Imple
menti
ng C
hanges
Spre
ad a
nd S
cale
up o
f…
Conducti
ng
Team
…
Team
D
ynam
ics…
Flo
w D
iagra
m (
syste
m…
Form
s f
or
Collecti
ng…
Surv
eys
Benchm
ark
ing
Sam
pling M
eth
ods
Cre
ati
vit
y M
eth
ods
Aff
init
y D
iagra
m
Fis
hbone(C
ause a
nd…
Matr
ix D
iagra
ms
Tre
e D
iagra
ms
Run C
hart
Shew
hart
Contr
ol C
hart
s
Pare
to C
hart
Fre
quency P
lot
Scatt
er
Plo
ts
Tw
o-W
ay T
ab
les
Desig
nin
g P
DSA
Tests
…
Change C
oncepts
Dri
ver
Dia
gra
m
Syste
ms T
hin
kin
g…
Reliabilit
y C
oncepts
Assessm
ent
(1-1
00
)
Tools, Methods and Skills
Min Median Average Max
Understanding Stage (61-80): Have experience with the method, tool, or skill to the
point that you can adapt it to a situation and can explain why you are using it to others
Understanding
Stage
0
20
40
60
80
100
PD
SA C
ycle
Ru
n C
har
t
Des
ign
ing
PD
SA T
ests
of…
Par
eto
Ch
art
Aim
Sta
tem
ent
Shew
har
t C
on
tro
l Ch
arts
Test
ing
Ch
ange
s
Mea
sure
s fo
r Im
pro
vem
ent
Dev
elo
pin
g C
han
ges
Fish
bo
ne(
Cau
se a
nd
Eff
ect…
Scie
nce
of
Imp
rove
men
t
Ch
ange
Co
nce
pts
Flo
w D
iagr
am (
syst
em m
ap)
Ben
chm
arki
ng
Imp
lem
enti
ng
Ch
ange
s
Spre
ad a
nd
Sca
le u
p o
f C
han
ges
Syst
em
s Th
inki
ng
An
alys
is
Team
Dyn
amic
s (v
aria
tio
n in
…
Dri
ver
Dia
gram
Scat
ter
Plo
ts
Cre
ativ
ity
Met
ho
ds
Rel
iab
ility
Co
nce
pts
Tree
Dia
gram
s
Mat
rix
Dia
gram
s
Aff
init
y D
iagr
am
Two
-Way
Tab
les
Freq
uen
cy P
lot
Co
nd
uct
ing
Tea
m M
eeti
ngs
Qu
alit
y C
on
tro
l (o
r Q
ual
ity…
Form
s fo
r C
olle
ctin
g D
ata
Surv
eys
Sam
plin
g M
eth
od
sAss
ess
men
t o
f K
no
wle
dge
an
d S
kill
(1-1
00
)
Tools, Methods and Skills
Average Before Program Average After ProgramUnderstanding
Stage
Understanding Stage (61-80): Have experience with the method, tool, or skill to the
point that you can adapt it to a situation and can explain why you are using it to others
0
20
40
60
80
100
Scie
nce o
f Im
pro
vem
ent
Quality
Contr
ol (o
r Q
uality
…
Aim
Sta
tem
ent
Measure
s f
or
Impro
vem
ent
Develo
pin
g C
hanges
PD
SA
Cycle
Testi
ng C
hanges
Imple
menti
ng C
hanges
Spre
ad a
nd S
cale
up o
f…
Conducti
ng
Team
Meeti
ngs
Team
D
ynam
ics (
vari
ati
on…
Flo
w D
iagra
m (
syste
m m
ap)
Form
s f
or
Collecti
ng D
ata
Surv
eys
Benchm
ark
ing
Sam
pling M
eth
ods
Cre
ati
vit
y M
eth
ods
Aff
init
y D
iagra
m
Fis
hbone(C
ause a
nd E
ffect…
Matr
ix D
iagra
ms
Tre
e D
iagra
ms
Run C
hart
Shew
hart
Contr
ol C
hart
s
Pare
to C
hart
Fre
quency P
lot
Scatt
er
Plo
ts
Tw
o-W
ay T
able
s
Desig
nin
g P
DSA
Tests
of…
Change C
oncepts
Dri
ver
Dia
gra
m
Syste
ms T
hin
kin
g A
naly
sis
Reliabilit
y C
oncepts
Assessm
ent
(1-1
00
)
Tools , Methods and Skills
Min Median Average Max Understanding
Stage
0
20
40
60
80
100
Scie
nce o
f Im
pro
vem
ent
Quality
Contr
ol (o
r Q
uality
…
Aim
Sta
tem
ent
Measure
s f
or
Impro
vem
ent
Develo
pin
g C
hanges
PD
SA
Cycle
Testi
ng C
hanges
Imple
menti
ng C
hanges
Spre
ad a
nd S
cale
up o
f…
Conducti
ng
Team
Meeti
ngs
Team
D
ynam
ics (
vari
ati
on…
Flo
w D
iagra
m (
syste
m m
ap)
Form
s f
or
Collecti
ng D
ata
Surv
eys
Benchm
ark
ing
Sam
pling M
eth
ods
Cre
ati
vit
y M
eth
ods
Aff
init
y D
iagra
m
Fis
hbone(C
ause a
nd E
ffect…
Matr
ix D
iagra
ms
Tre
e D
iagra
ms
Run C
hart
Shew
hart
Contr
ol C
hart
s
Pare
to C
hart
Fre
quency P
lot
Scatt
er
Plo
ts
Tw
o-W
ay T
able
s
Desig
nin
g P
DSA
Tests
of…
Change C
oncepts
Dri
ver
Dia
gra
m
Syste
ms T
hin
kin
g A
naly
sis
Reliabilit
y C
oncepts
Assessm
ent
(1-1
00
)
Tools, Methods and Skills
Min Median Average MaxUnderstanding
Stage
Understanding Stage (61-80): Have experience with the method, tool, or skill to the
point that you can adapt it to a situation and can explain why you are using it to others
0
20
40
60
80
100
PD
SA C
ycle
Ru
n C
har
t
Des
ign
ing
PD
SA…
Par
eto
Ch
art
Fish
bo
ne
(Cau
se…
Test
ing
Ch
ange
s
Aim
Sta
tem
ent
Ch
ange
Co
nce
pts
Shew
har
t C
on
tro
l…
Scie
nce
of…
Dev
elo
pin
g…
Dri
ver
Dia
gram
Spre
ad a
nd
Sca
le…
Mea
sure
s fo
r…
Syst
ems
Thin
kin
g…
Aff
init
y D
iagr
am
Imp
lem
enti
ng…
Cre
ativ
ity
Met
ho
ds
Mat
rix
Dia
gram
s
Rel
iab
ility
Co
nce
pts
Flo
w D
iagr
am…
Tree
Dia
gram
s
Be
nch
mar
kin
g
Qu
alit
y C
on
tro
l…
Team
Dyn
amic
s…
Two
-Way
Tab
les
Scat
ter
Plo
ts
Co
nd
uct
ing
Tea
m…
Freq
uen
cy P
lot
Form
s fo
r…
Surv
eys
Sam
plin
g M
eth
od
s
Ass
ess
me
nt
of
Kn
ow
led
ge a
nd
Ski
ll (1
-1
00
)
Tools, Methods and Skills
Average Before Program Average After ProgramUnderstanding
Stage
Understanding Stage (61-80): Have experience with the method, tool, or skill to the
point that you can adapt it to a situation and can explain why you are using it to others
Facilitation Code:1. Poor: is not able to facilitate a discussion
2. Fair: can lead a discussion, but the flow and organization is weak
3. Good: is able to lead a discussion that is well organized, engages the group, and achieves the meeting aim
4. Excellent: exhibits all of the “good” qualities but is able to do so independent from the Project Officer.
CapabilIty/Capacity Code:
1. No exposure: has never seen or heard of the tool
2. Exposure: has been introduced to the tool but doesn’t know how to use it
3. Knowledge of use: understands how to use the tool
4. Experience using: has used the tool in his/her work
5. Confident in applying: has the ability to apply this tool to new work/settings
6. Can teach others: can teach other change agents and QI teams how to use the tool
0
1
2
3
4
5
6
Rd1 2 3 4 5 6 7
Cause and Effect
Diagram
0123456
Rd1 2 3 4 5 6 7
Pareto Chart
0
1
2
3
4
5
6
Rd1 2 3 4 5 6 7
Avera
ge S
core
Site Visit Number
Run Chart
0
1
2
3
4
5
6
Rd1 2 3 4 5 6 7
PDSA
0
1
2
3
4
Rd1 2 3 4 5 6 7
Facilitation Skill
0123456
Rd1 2 3 4 5 6 7
Avera
ge S
core
Site Visit Number
Process Map
By IC
By PO
More practical sessions especially run chart
Three days instead of two for WK2 and WK3
Data sessions should be in the morning
Should end by 5:00 PM on last day to avoid traveling in
the dark
More data for practicing on your own- run charts &
Pareto Charts
Invite at least two members of the facility
Provide copies of slides
Large IC workshop class leads to lack of attention for some ICs in meeting their learning needs
Instances of two or three ICs prefer to pair an improvement project
Participants missing some workshops due in part to parallel programs
Others register for the workshop and do not sit in throughout (common with managers)
Great promise of some ICs co-facilitating meetings & LSs
Printing of presentations and articles as reference material for coaches is beneficial
We are now using more Ghanaian context examples in the training slides that participants can relate easily with
During site visits engage management and ICs to make ICs play their designed role
Rope ICs into the facilitation of LS
Quick roll call on flip chart shows attendance gaps
Check to be sure the composition of each hospital QI team remains active in team activities
For hospitals without trained coaches often due attrition, leadership should assign district ICs to support these hospital teams
The Demographic Health Survey of Ghana coincided with the start (2008) and end (2015) of the Project. Current results show:
U5 mortality in Ghana reducing from 80 to 60 per 1,000 live births, representing a 25 reduction in U5 mortality
15.8
10.2
0
5
10
15
20
25
30
Jan-1
2
Ma
r-1
2
Ma
y-1
2
Ju
l-1
2
Se
p-1
2
No
v-1
2
Ja
n-1
3
Ma
r-1
3
Ma
y-1
3
Ju
l-1
3
Se
p-1
3
No
v-1
3
Ja
n-1
4
Ma
r-1
4
Ma
y-1
4
Ju
l-1
4
Se
p-1
4
No
v-1
4Dea
ths/1
00
0 L
ive
Birth
s +
Ad
mis
sio
ns
Collaborative (134 Hospitals) in 7 Regions
U5 Mortality Rate
(>30 % reduction)
…so given PFA!’s aim is to assist in the acceleration of the achievement of MDG 4, we are so pleased to think that the Project had made contribution the remarkable outcome
