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PVO Quality Improvement Workshop: Practical Applications June 811, 1999

Dina Towbin
Jolee Reinke
Thada Bornstein

 October 1, 1999

PVO Quality Improvement Workshop


A four-day, practical, hands-on workshop on improving the quality of child survival interventions in the developing world was held for private voluntary organizations (PVOs) in the Child Survival CORE Group June 8-11, 1999, in Calverton, Maryland. About 25 people attended, including headquarters and field staff from 11 PVOs and staff from the USAID Child Survival Office (BHR/PVC/CS).

The Quality Assurance Project (QAP) and Macro Internationals Child Survival Technical Services (CSTS) Project conducted the workshop. They developed the sessions in collaboration with the Child Survival CORE Group and its Quality Improvement (QI) Working Group.

The event supported the QI Working Groups Objective #4: Organize a series of practical, hands-on QI workshops for health providers at both the headquarters and field levels, to be followed by technical assistance as needed. For this work, it was decided that quality improvement and quality assurance were terms that could be used interchangeably.

Using sequenced learning and participatory techniques, the workshop aimed to educate headquarters PVO staff about the following:

  • The advantages of using QI techniques to improve the quality of child survival interventions
  • The variety of QI interventions and activities available
  • The skills needed to use QI tools and techniques
  • The next steps that they might take to adopt or adapt QI approaches to the PVO environment.

The various sessions and speakers got the audience thinking about ways to integrate QI tools and techniques into their child survival programs. Participants also drew up plans to act on this new information. These plans were taken home with participants, and copies were retained by CORE, CSTS, QAP and the QI Working Group

PVO attendees came from Adventist Development & Relief Agency International (ADRA), Africare, Andean Rural Health Care, Inc., International Eye Foundation, Islamic African Relief AgencyUSA, Medical Care Development Inc. (MCDI)/International Division, Mercy Corps International, The Pearl S. Buck Foundation, Project HOPE, Salvation Army World Services Office (SAWSO), and World Vision.

Planning the Workshop

    The workshop took about a year to plan. This long lead-time was due to several factors. First, the QI Working Group comprises volunteers from CORE PVOs who have only limited time to devote to this activity. In addition, the QI Working Group wanted to be sure they had assembled sufficient information on the PVO communitys QI needs. Third, ongoing discussions between the QI Working Group and the QAP trainers on what the workshop should cover meant the agenda became an evolving document. The original central theme of stressing skill-building in problem solving for promoting child survival, for example, evolved to encompass a wider variety of QI approaches. In addition, the planners had to reach consensus on the level of staff to be invited (i.e., midlevel vs. senior) and the duration of the workshop. Some difficulties with recruiting participants and finalizing the dates also delayed the start.

Workshop Events

    An agenda is included as Attachment A.

    The QAP trainers, Jolee Reinke and Thada Bornstein, began by discussing concepts of quality and quality assurance in general and in specific application to health care activities in child survival programs. The participants then applied the concepts to exercises and case studies.

    On Day 2, Leo Ryan, the CSTS trainer, discussed ways to introduce the quality management approach into an organization. His presentation addressed change management and included a checklist for designing a change strategy. Ms. Reinke introduced the concept of measuring change and ways to determine if change results in improvement. This included a discussion of variation analysis. Participants practiced using tools for process analysis, cause-effect analysis, data interpretation, prioritization and decision making. Sara Espada and Hernan Castro from Andean Rural Health Care discussed their organizations experience with using a performance checklist to standardize and improve key procedures performed by health workers. They also discussed the value of monthly committee meetings to discuss, identify, and report on ways to improve the quality of local health services.

    On Day 3, participants considered a variety of methods to improve quality, and practiced root cause analysis using a case study. Participants also discussed the use of another tool, the health facility checklist, to improve their own facilitys quality improvement processes. An MCDI representative, V. J. Rao, discussed the issues involved in COREs ongoing development of a health facility checklist used as an assessment tool. The class then used techniques they had just learned to examine the process of developing the checklist and suggest ways the process could be improved,. They used brainstorming and affinity analysis to generate recommendations and then narrow them down to represent the essence of the groups thinking.

    A third QAP trainer, Tisna Veldhuyzen van Zanten, led several sessions Day 4 on the practical application of QI to PVOs child survival programs. Participants identified the potential benefits of QI, the drawbacks of adopting QI approaches, and challenges to using QI. The trainers then asked participants to consider "What can QI do for me?" at the facility, headquarters, and field levels.

    In informal discussions after the workshop, most attendees noted that learning how to use QI tools and techniques (such as flow charts, cause-effect analysis, system checklists, and data displays) was the most useful part of the four days.


As might be expected, participants came up with different approaches for incorporating QI in their work and using the tools and techniques to achieve objectives. However, many made the same recommendations for actions within their organizations. These include the following:

  • Include more hands-on training for headquarters and field staff, emphasizing QI tools. These practical tools were seen as very useful.
  • Fully document field experience with implementing QI on a more regular basis, including positive examples from PVO participants who have used QI in child survival programs. Disseminate this information within the organization in which the activities occurred; within CORE; between the PVOs, CORE and the CAs who work with PVOs; and from CORE to USAID.
  • Involve upper management in this type of workshop to ensure that QI techniques become part of the routine of the organization, and quality becomes part of the corporate culture, specifically targeting key PVO decision makers. Explain why QI is important at all levels of an organization.

When asked what the QI Working Group could do to help participants achieve their goals, many attendees suggested further dissemination of QI information via workshops, training modules, reference materials, working papers, the Internet, and other working groups.

Next Steps

    Because PVOs vary in their mission, staff size, and goals, there is no common set of next steps that the participants themselves could take to spread the use of QI. However, all PVOs identified appropriate next steps for their organizations. Within two weeks of the workshop, MCDI decided to take advantage of QAPs nearby location. They invited QAP to conduct a 2-hour quality assurance session at MCDI headquarters for field staff visiting the area from Madagascar, Mozambique, and South Africa. According to MCDI, its field staff was very interested in quality assurance. At the meeting, the QAP trainers included information on how to access QI specialists for follow-up work in the field.

    The planned next steps from the other organizations were generally positive and goal-oriented. One or two mentioned that they had not yet seen "a practical use of the program" or needed more time to "digest [the] process and map out next steps." Some were planning activities to sensitize others in their organizationsfrom top management and board members to other staff, counterparts, and regional/field officesto QI topics. Plans included conducting QI training, discussing QI in staff meetings, and circulating QI reading materials. Other participants focused on incorporating QI into their daily activities to develop quality child survival programs.

    Trainers also asked, "Where would you like your organization to be in 6 months in terms of QI activities?" and "What would your organization or field activities look like if you used QI approaches?" Answers varied, but many focused on achieving better teamwork and developing an organizational culture of quality.

    After observing one session, a USAID official stated that the Child Survival Office was interested in seeing how "PVOs will implement QA in action plans and with field staff."


    Several participants were sensitive to possible negative reactions from others within their organizations to introducing QI ideas or attending a quality improvement course. The feared that such actions would be perceived as a sign that the attendees were not already providing a quality product or service. Also, workshop participants said that the 4-day workshop, which most of them had found to be productive, posed a constraint on others who could not attend the entire time.

    A QI Working Group member pointed out another challenge: Some potential participants responded to the workshop publicity by stating that they were "workshopped out," i.e., they had gone to too many workshops.

    Asked to identify barriers to incorporating QI into their organizations, participants had a long list that included funding, communication, management, and teamwork issues, plus a lack of a corporate culture of quality.

    In the workshops closing remarks, Dr. James Heiby, MD, MPH, the USAID Contracting Officers Technical Representative (COTR) to QAP, asked participants to examine what PVOs stand to gain by using quality assurance methods and what the field can gain from PVOs using these methods. He suggested that PVOs compile case studies documenting their pioneering activities. Given the tighter funds in development and the growing need for accountability, PVOs need to show results, he said, urging them to evaluate their efforts in terms of "measures of improvement." For example, higher quality services can be measured as improved provider compliance with standards, which in time will lead to measurable declines in mortality rates. As QI programs produce a better level of care, other measures of quality, such as a reduction in waiting time, will also show up. "How do you easily define quality? By using examples." Dr. Heiby added that quality involves improving processes.

Workshop information

    The participants list, agenda, workshop materials, handouts from ARHC and references used in preparing this workshop are available on the web:, click on the PVO headline. This site also will connect the reader to other QI checklists used by consultants who have worked with PVOs.


Attachment A: Workshop Agenda

Quality Improvement: Practical Applications
(Its not just Quality in a Can!)

Day 1 Tuesday June 8

8.45 9.00 Gathering
9.00 10.30 Opening, introductions, expectations, ground rules, housekeeping
10.30 10.45 Break
10.45 12.30 What is Quality?
12.30 1.30 Lunch
1.30 3.30 What is QA?
3.30 3.45 Break
3.45 4.45 Focused Discussion PVO experience: Community defined quality
4.45 5.00 Summary, feedback
5.00 Close

Day 2 Wednesday June 9

8.45 9.00 Review/Preview
9.00 10.30 Change management, role of leadership
10.30 10.45 Break
10.45 11.30 Variation
11.30 12.30 Focused Discussion PVO experience QI checklists ARHC
12.30 1.30 Lunch
1.30 3.30 Basic tools and techniques
Understanding processes, Determining cause, Making decisions
3.30 3.45 Break
3.45 4.45 Focused Discussion PVO experience Organizing for Quality ARHC/IEF
4.45 5.00 Summary, feedback
5.00 Close

Day 3 Thursday June 10

8.45 9.00 Review/Preview
9.00 10.00 Alternatives for Improving Quality
10.00 10.30 Problem Solving Case Study
10.30 10.45 Break
10.45 11.45 Finish case study
11.45 12.30 Quality Control Monitoring and Supervision
12.30 1.30 Lunch
1.30 2.15 Focused Discussion PVO experience - HFA
2.15 3.15 Small group discussion making field visits
3.15 3.30 Break
3.30 4.45 Exercise pertinence to PVO
4.45 5.00 Summary, daily eval
5.00 Close

Day 4 Friday June 11

8.45 9.00 Review/Preview
9.00 10.30 Facilitated Discussion
10.30 10.45 Break
10.45 11.15 Next steps action plan "form"
11.15 12.00 Groups report on next steps
12.00 12.40 Discussion advice to QIWG on their next steps
12.40 1.00 Closing, course eval
1.00 2.00 Lunch

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