Process improvement, design and re-design

As applied to health care, process improvement is a method to introduce changes in core health care processes to improve adherence to identified best practices (Massoud et al. 2001). Such changes could include removing unnecessary steps in a process, adding new steps, reducing waste, or standardizing the process to increase its reliability.

Process redesign applies the same approach to completely redesign or restructure an existing process to address opportunities for improvement, while taking into consideration the needs of internal and external clients, as well as available resources. (Process design applies similar methods to create a new process where one did not exist previously.)

Process improvement and redesign teams comprising health workers, supervisors, and community members analyze where current gaps in performance or service delivery processes exist and where changes can be made. Improving processes requires detailed knowledge of the area identified for improvement and ongoing data collection to monitor the process over time. Teams may use a number of tools for analyzing the underlying process, such as flowcharts and cause-and-effect analysis. Time series charts are a useful data presentation tool for analyzing the performance of a process over time to determine whether changes introduced have improved the process (HCI 2008a; Zeribi & Franco 2010).

After a team thoroughly understands the problems with the current process, it can develop and implement changes, study the results, and test changes based on the results. A commonly used iterative testing approach is the PDSA cycle, which is also used in the Model for Improvement (Taylor et al. 2014).

A helpful resource for process improvement is The Improvement Guide: A Practical Approach to Enhancing Organizational Performance (Langley et al. 2009). Part One of the book addresses the basic skills needed to support process improvement: (1) using and learning from data, including understanding variation in data; (2) understanding processes and systems of work, and the relationships among the processes that make up the activity you are trying to improve, (3) how to apply creative thinking and other strategies to come with ideas to test; (4) how to organize tests of these ideas; (5) how to implement (scale-up) an idea or set of ideas that work; and (6) how to engage people in supporting and embracing change.

The Improvement Guide also includes a “Resource Guide to Change Concepts” that provides an inventory of generic ideas of how to change any process, organized by nine categories of change: (1) eliminate waste, (2) improve work flow, (3) optimize inventory, (4) change the work environment, (5) enhance the producer-consumer relationship, (6) manage time, (7) manage variation, (8) design systems to avoid mistakes, and (9) focus on a product or service.

Text box: Mobilizing Community Teams to Support HIV Chronic Care in Uganda

In Uganda, village health teams (VHT) promote primary health care and community participation, but they had not played a role in community-based chronic care of patients with HIV. Since 2012, the USAID Health Care Improvement (HCI) Project and subsequently the USAID ASSIST Project, has supported a community-level improvement effort to support chronic care for HIV in Buikwe District, targeting VHTs in 10 villages. The intervention was based on working with the existing community-level structures and actors to overcome barriers in care for chronic conditions.

The intervention focused on improving the ability of informal community structures to support HIV patients by identifying, following up, and supporting them to manage their condition. It also focused on creating linkages between health facilities and communities, as well as helping patients address other social-economic and psychological challenges that affect their health. Community quality improvement teams were formed and included representatives from village health teams, patients, health workers, local leaders, women groups, religious leaders, schools, savings groups, and other community-based organizations’ representatives. This constituted a network of community resources to expand community support for patients with HIV. The community group representatives mobilized HIV support organizations, formed patient-to-patient linkages, sensitized members of the community through village meetings, schools and churches, and coordinated with facility-based health workers to follow up with patients who had missed appointments.

Data were collected each month from community registers by project coaches and community teams on the number of HIV patients identified, patients with poor clinical status (low or unstable weight, non-functional, or with medical complaints), patients who were setting and implementing health plans to manage their condition, and patients who had improved clinical status. At baseline (June 2012), the number of HIV patients known and followed up by the community was 15. By April 2013, the cumulative number of HIV patients known and followed up was 526, of whom 465 were on antiretroviral therapy (ART). (At baseline, no patient was enrolled on ART.) All patients on ART were assessed for clinical improvement and classified as poor if they had low or unstable weight, were non-ambulatory, or had medical complaints. As a result of the intervention, community teams improved their ability to identify patients with poor clinical status to support them in developing health improvement plans. By the end of April 2013, the community improvement teams could identify 230 (43%) of patients with poor clinical status. Of these, 212 (92%) were helped to developed health plans, 194 (84%) implemented them, and 125 (64%) of those who implemented goals had their clinical status improve.