1. Coaching through challenges
Choosing a solution

2. 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

3. 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

4. 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)

5. 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

6. 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

7. 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

8. 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

9. 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.

10. 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?

11. 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?

12. References
NQC
HIVQUAL
JSI
PIH
Six Sigma

13. 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

14. 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

15. Debrief: