Coaching through challenges Choosing a solution

Challenge: Team does not know how to choose a solution to a gap Possible problems: They lack the knowledge (discussed earlier) There is conflict (discussed earlier) They don’t know how to get started Too many opinions Too few opinions Overwhelmed by work Feeling as if nothing could work Adapted in part from NQC

Problem: They don’t know how to get started (1) Make sure they understand how to do a root cause analysis. If necessary, walk them through it. Flow chart Brain storm Choosing a solution

Problem: They don’t know how to get started (2) Simplify: Use the following 4 questions to help a team get started. What is the problem? What is the goal? How will you measure? Who should be on the team? Then…..help them start the rest (flow chart, gap analysis, design the first QI project)

Example Problem: CD4 tests are not being done regularly on new patients, with only 76% in last 6 months Goal: increase CD4 testing at registration to 95% in 3 months Indicator: percent of patients with CD4 tests in the chart within one month of first visit Team: clinic nurse, clinic doctor, lab, logistics/supply, M and E

Too many opinions Guide them through a priority matrix Effective: high or low Resources/effort needed (feasibility): high or low Scoring Table for choosing solutions Vietnam National QI training Build consensus Facilitate discussion to come to agreement that the team will move forward with what the majority chooses to try

Principles of consensus decision making in QI Inclusion: Involve the whole team Participation: Every person is expected to participate, contribute opinions and suggestions Cooperation: Team members agree to collaborate with aim to come to a decision Everyone’s opinion is important Solution oriented: All are working towards common goal. Improving a quality gap. Adapted from www.wikihow/reachaConsensus

Steps for Building consensus Ensure team understands the process and goals of consensus building Brainstorm all possible solutions Make a list Briefly discuss all options (e.g. with a 2 min time limit) Combine similar ideas or concepts to remove duplicates Add any new ideas that come up Ask the team to review options and select a single solution from the list If consensus cannot be reached: agree to vote Ref. Six Sigma

Problem: Too few opinions/overwhelmed Use directed questions to guide discussion Remember your goal is for them to do the work, rather than you telling them how to do it.

Some possible questions you might ask What are some options you have to solve this gap? That’s one possibility, any others? How can we break this into smaller steps (ie use a flowchart)? How will we define success? (What outcome do you want)? What do you think you need to change to make the problem better?

Despair: Nothing can ever change Share examples from other clinics. “Clinic A had a similar gap and they tried XYZ” Facilitate communication with peers “Would you like to talk with the QI lead in Clinic B?” Focus on small steps What can we do by next Tuesday? Be ready to celebrate any changes What else might you as a QI coach try?

References NQC HIVQUAL JSI PIH Six Sigma www.wikihow.com

Exercise: 30 minutes Goal: practice negotiating consensus building Clinic is focusing on improving ART start They have done a root cause analysis and decided the problem is patients do not come back They brainstormed solutions and came up with a list Looking at the list, use one of the consensus building tools to choose the first one you would try

The list Call patients Decrease pre-ART counseling steps Make sure the clinic has the right address and contact for the patient Longer clinic hours Decentralization (open ward clinics closer to patient home) Peer educator visit home Give the patient a reminder card

Debrief: