Supporting research and evidence-based interventions to promote access and quality of reproductive health and family planning services

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Subcommittees

Notes on MAQ Organization of Work (OOW)
Sub-Committee Meeting

16 September 2002, 10:00 - 2:00
PaL-Tech Large Conference Room

Participants:

See below.

Meeting objectives:

1. Review and finalization of the mission statement of the OOW Sub-Committee.
2. Definition of principles and best practices for each element of OOW.
3. Further discussion and definition of next steps for development of products and other priority activities.

Result:

The objectives were met.

Agenda:

1. Introductions and review of agenda

   Result: participants endorsed the agenda. The group welcomed the participation of new participants interested in OOW.

2. Review and finalization of OOW mission statement

   DRAFT statement: "The purpose of the OOW Sub-Committee is to: a) conceptualize the topic; b) capture what's known about organization of work based on evidence; c) produce products (e.g., state-of-the-art paper, revised modules for the MAQ Exchange); and d) disseminate and apply effective technical assistance approaches and best practices."

   Result: the group approved the draft mission statement.

   Discussion: There was useful discussion of objectives a) through d) of the mission statement prior to its endorsement, as follows:

   1. conceptualize the topic
      • "Choreography". What people actually do at the clinic.
      • We need to distinguish between the content of work and the organized delivery of that content. It was suggested that about 10% of organization of work concerns the content of work (e.g., clinical aspects of health service delivery). The remaining 90% concerns how a clinic organizes itself to deliver services, specifically with respect to systems and processes for client flow, physical space, ritual paperwork, etc.
      • Processes exist and are designed for a purpose -- in our context to deliver health services. Examination of OOW and specific interventions to address the elements of OOW need to be guided by the specific clinic or organization's goals for the delivery of health services. In sum, interventions to address OOW should optimize processes (how work is delivered) to deliver services (content of work) that benefit clients.
   2. capture what's known about OOW based on evidence
   3. Our effort should focus on capturing:
      • our own experience
      • other experience documented in domestic and foreign literature, and perhaps from other sectors and industries

   Recommendation: Re-review the literature review prepared by PRIME and shared with sub-committee members at the 2 July 2002 meeting. Review the relevance of interventions identified to address various elements of OOW, and accept or reject them in terms of their suitability in developing country contexts.

   3. produce products (e.g., state-of-the-art paper, revised modules for the MAQ Exchange)
      • Uncouple provider perspective from OOW in the MAQ slides.
   4. disseminate and apply effective technical assistance approaches and best practices
      • Mechanisms for dissemination include publications and presentations as well as sub-committee members serving as informants and change agents in their home institutions

Other points raised about OOW:

• Standards tell people what and how to do things, but not why
• Factors that influence the organization of work: psychosocial environment; leadership; participatory decision-making; commitment; and motivation. Are these overarching principles that should be mentioned before addressing the individual elements of OOW?
• Creativity is another factor influencing how groups and individuals approach their work, and how workers organize their work. Creativity means looking for the best way to achieve a specific result. Work needs to be organized in such a way that people can be creative, and they can apply creative techniques to how work is done.
• Empowerment is key to people being creative. Empowerment is dependent upon leadership and organizational culture
• Organizational values go hand-in-hand with principles
• At what level are we talking about? Need to focus on the health system and specific practices at the facility level undertaken by individuals
• Address OOW through operations research; find an opportunity to develop creative interventions; identify an opportunity to test the validity of OOW principles
• Identify knowledge management opportunities

3. Small group work: Define principles, best practices, and any additional tools for each element of OOW, and IV. Plenary review of small group work

   Example of a principle: For ritual paperwork: "Collect only those data that you will use at your level in the health system."

   Participants were randomly assigned to two groups. Each group discussed four of the OOW elements and brainstormed principles. Although examples from country experience came up in small group discussion, there was not sufficient time to also brainstorm best practices and additional tools.

   Results: Elements of the Organization of Work and Principles

   1. Right health interventions (includes procedural barriers)
      • Know the state-of-the-art for delivery of the specific health service
      • The health interventions conducted should be cost effective, given the local context
      • Do the right health intervention
      • Do evidence-based interventions appropriate to the service delivery setting
      • Interventions should meet client expectations
   2. Division of labor/job design
      • Understand one's own role in the bigger picture
      • Roles and responsibilities should be clear
      • Authority and responsibility should be aligned
      • Employees should have a reasonable level of empowerment over their own work
      • There needs to be a rationale for the current organizational structure. The preferred structure is a flat one, although a hierarchical one may be appropriate in certain situations. Inasmuch as possible, reduce the layers of the hierarchy.
      • Strive for simplicity and flexibility in rules, principles, and processes. This requires looking at the local and organizational values and culture (reference Context of Complexity Theory).
      • Let people do what they are safely capable of doing
      • Division of labor and staff utilization: balance expenditures between human resources (e.g., salaries) and physical resources (e.g., physical space, supplies, equipment)
   3. Hours/scheduling/follow-up
      • Find out what clients want
      • Provide for flexibility of hours, etc.
      • ppropriate gate keeping, both in terms of referrals from the clinic, and watchmen keeping the clinic gates open during official clinic hours.
      • More "targeted" follow-up: define what is really needed and when (how frequently) it is really needed
   4. Ritual paperwork:
      • Collect only what is really needed, for whatever purpose
      • Make proper use of what you collect
      • If some one isn't using data, the chances are they won't collect it correctly
      • Provide feedback on data collected
      • Post-meeting input from Bill Boyd: CDC has recently published "Updated Guidelines on Evaluating Public Health Surveillance Systems". Though this reference material goes well beyond the immediate issue of OOW, there may be some useful verbiage, possible for referencing in the OOW products.
   5. Client flow (design and execution)
      • Clients should see only the provider(s) necessary for the purpose of the visit
      • Clients should spend only the time necessary (with the provider, at the clinic) to be meaningful/sufficient, based on client need and not provider convenience. Address clinic/provider efficiency issues.
      • Obtain client input on what is the best client flow; obtain stakeholder (e.g., community, providers, managers, etc.) input, in general, when designing and implementing client flow processes
      • Client-load versus client flow: access issue - see scheduling and flexibility OOW elements. (This relates to the tension between increasing access to more clients vs. allowing adequate time to serve each client well, and keeping waiting time to a minimum)
      • Make sure there are signs posted at the facility to support client flow

   Participants agreed that additional principals from Institute for Healthcare Improvement, "Reducing Delays and Waiting Times Throughout the Healthcare System" should be added to the meeting notes for consideration by the sub-committee. Note that these principles and examples are taken directly from the referenced material; their relevance to service delivery settings and services in which sub-committee participants' programs work will need to be considered at a later date, perhaps in conjunction with the re-review of the domestic literature review prepared by PRIME in July.

   • Do tasks in parallel: instead of doing tasks sequentially, redesign the system to do some or all tasks in parallel. Examples of process changes: prepare patient for surgery while setting up instruments; obtain patient information during waiting times in the course of treatment; begin discharge teaching during admit process.
   • Use multiple processes: Rather than use a single "one size fits all" process, use multiple versions of the process, each tailored to the different needs of customers or users. Examples of process changes: use separate processes for two classes (complex, acute but straightforward) of patients; use separate process for emergency department patients with less serious conditions; use separate process for emergency department patients with extremity injuries.
   • Minimize handoffs: redesign the work flow to minimize any handoffs in the process. Examples of process changes: train the clinic receptionist to decide whether to schedule appointments; have the same emergency department clinician perform various procedures; order x-rays at triage.
   • Synchronize: time all of the steps in a process with reference to a clearly defined, agreed upon synchronization point. Examples of process changes: make synchronization point for surgery the incision time; make synchronization point for ambulatory care the moment when the physician walks into the examining room.
   • Use pull systems: when work is being transferred through a process, instead of "pushing" it from one step to the next, have the later step "pull" it from the previous step. Examples of process changes: pull patients from the emergency department to inpatient unit; pull asthma patients from emergency department to primary care site.
   • Move steps closer together: move the physical location of adjacent steps in a process close together so that work can be passed directly from one step to the next. Examples of process changes: move radiography suite next to emergency department; move outpatient surgery support to outpatient surgery area; move patient's charts to the bedside.
   • Use automation: improve the flow of processes by the intelligent use of automation. Examples of process changes: use hand-held computers in preop testing; use faxes to notify nurses on receiving units.
   • Consider people to be in the same system: take steps to help people see themselves as part of the same system working toward common goals. Examples of process changes: consider surgeon's office and hospital as parts of the same system; see all processes leading to surgery as parts of the same system; consider emergency department and floor nurses as parts of the same system; consider x-ray, lab, and emergency department as parts of the same system.
   • Use multiple processing units: to gain flexibility in controlling the flow of work, try to have multiple work stations, equipment, or processes in a system - all of the same type. Examples of process changes: use several small centrifuges instead of one large centrifuge; designate an alternate site for sub-specialty patients; use identical room set-ups for surgery.
   • Extend the time of specialists: have specialists do only the tasks that require their specific skills. Examples of process changes: use skills and expertise of each member of the primary care team; use video and information technology to extend specialists' time (i.e., use video for patient education, not time of specialist).
   • Convert internal steps to external: convert tasks that are done as part of the process to tasks that are performed ahead of time or deferred until later. Examples of process changes: have standardized doses available ahead of time; move consultations from the emergency department to inpatient setting; customize central supplies for particular physicians.
   6. Physical factors (space, resources, supplies, etc.)
      • The building/physical design should be guided by local conditions, i.e., the availability of water and electricity; climate; and socio-cultural considerations, including gender
      • The physical layout should be organized such that different functions are correctly placed in relation to each other
      • The organization and use of space should be guided by considerations of efficiency; privacy & confidentiality; infection prevention (includes safety of the client and of the provider); occupational safety/ergonomics; and aesthetics (as reasonable)
      • Supplies: orderers and providers need to communicate so that the right supplies are ordered
   7. Links to other sites/services
      • Services should be linked to increase access for clients, and maximize facilities' efficient use of supplies/resources
      • Coordination and communication between service sites should be based on and guided by common goals, e.g., access, quality, health outcomes
      • For effective referrals, staff need to know and understand: how to refer; facilities' common goals; roles of different providers and incentives for referring; and what other services/resources are available
      • Schedule the appointment for service delivery, and associated/necessary information delivery/counseling, to take place at the lowest level facility possible in order to increase access
      • Referrals include both internal and external (within the same facility/between facilities)
      • Consider the client perspective so that clients don't get "lost"
   8. Flexibility/resilience vs. brittleness
      • For ownership of change, there must be stakeholder input/involvement (the degree of input depends on the context)
      • Leadership, empowerment, motivation, feedback, and clear technical standards are key for flexibility/resilience
      • Do the least harm and maximize the benefit
      • Mass customization: Tailor services based on knowledge of the client
      • Build in redundancy to allow for "crises" in the system, e.g., staff absences
      • Try to expand your circle of influence: you, the environment you work in that you can change, the environment you cannot change
4. Plenary discussion: Next steps for development of products and other priority activities and VI. Date for next meeting and closing:

   Results:

   1. The next OOW meeting will likely be scheduled in December, immediately prior to Christmas. The agenda will likely focus on:
      • Re-review of the domestic literature review prepared by PRIME to identify appropriate interventions/solutions for OOW elements
      • Discussion of additional evidence for each element of OOW (participants will be requested to prepare in advance and share evidence during the meeting ["knowledge bullets"]).
      • Discussion of opportunities in the field where elements of OOW may be tested (participants will be requested to prepare in advance).
   2. Jim Shelton will coordinate with Pop Reports about the availability of staff to prepare a draft outline for the State-of-the-Art paper on OOW. If the outline is available, it will be shared with participants prior to the December meeting.
5. Evaluation

   What worked well?	What should be changed
   Good discussion clarifying OOW and its elements	Assign certain elements to specific individuals to develop further
   Well organized meeting
   Objectives of the meeting were met
   Diversity of participants
   Physical setting ok (quiet), except see change column	Have break-out room(s) for small group work

Parking Lot (pending issues/questions)

• Rashad to provide references for: Complex Adaptive Systems, Mass Customization
• Balanced Score Card technique as a tool for applying OOW elements; Rashad to examine usefulness
• Bill Boyd of CDC left the meeting early, but provided a copy of the RW CareWare Version 3.1, Software Manual for CARE Act Grantees and Providers, dated August 2002, prepared by the U.S. Department of Health and Human Services, HIV/AIDS Bureau. (Alison has this document.) CAREWare collects data to meet national (U.S.) reporting requirements, but also enables users to track a range of services (HIV primary care) and aspects of care including medications, lab and screening tests, immunizations, opportunistic infections, and referrals to supportive care. The software is easily customized so that users can satisfy unique data collection and reporting needs; it is also downloadable from the web at hab.hrsa.gov/careware. Its use in developing country settings to monitor care and treatment is being investigated and a version for use on a wide area network is under development.
• Is training a means to disseminate OOW products?
• What do we want for the provider?
  OOW Sub-Committee: 16 September Meeting Participants

Participants:

Name	Organization	E-mail Address
Tisna Veldhuyzen Van Zanten	URC/Quality Assurance Project	tveldhuyzen@urc-chs.com
Bill Boyd	CDC	Wboyd@cdc.gov
Edgar Necochea	JHPIEGO	enecochea@jhpiego.net
Erin Mielke	EngenderHealth	emielke@engenderhealth.org
Jim Shelton	USAID	Jshelton@USAID.gov
Marc Luoma	TRG/PRIME 2	mluoma@prime2.org
Alison Ellis	M&L Program/MSH	aellis@msh.org
Rashad Massoud	URC/Quality Assurance Project	rmassoud@urc-chs.com
Kellie Stewart	USAID	kestewart@usaid.gov
Caitlin Auld	USAID	cauld@usaid.gov
Sarah Thomsen	FHI	sthomsen@fhi.org
Rachel Jean-Baptiste	URC/Quality Assurance Project	rjeanbaptiste@urc-chs.com
Vidya Setty	Populations Report/CCP	vsetty@jhuccp.org
Jim Griffin	USAID	jagriffin@usaid.gov
Gail Rae	Population Leadership Program	grae@popldr.org

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