Demonstrate leadership commitment. When top leaders are committed to good quality, employees accept it as a guiding principle for their own work.
Strengthen Systems and Processes
"Systems thinking" can help improve the delivery of family planning and other health care
services. A systems perspective sees an organization as a collection of interdependent systems
and processes (403). Because the work of an organization crosses the boundaries of different
hierarchical levels, functional departments, and geographic units, many problems can be
understood and solved only in the context of the whole organization.
From a systems perspective, the weakest subsystem in an organization determines its overall
performance, just as the weakest link in a chain determines the overall strength of the chain (80). For example, if the supply of contraceptives is not reliable, improvements in counseling will be undermined.
Human and technical systems. Human systems organize
people. They include salaries and incentives, management and supervision,
staff training and development. Technical systems are specific to
the work of an organization, for example, the service delivery system
in health care. In any organization, problems can be caused by weaknesses
in either the human system, such as poor motivation caused by inadequate
salaries, or by technical systems, such as lack of supplies resulting
from poor logistics. Each system affects the other, as when failures
in the technical system frustrate workers' efforts to do a good job
and sap their motivation (79, 92, 113).
At the same time, such employee problems as interpersonal conflicts,
poor communication, and fear can cripple the technical systems.
In most organizations fixing flawed processes helps to improve staff performance (92, 324).
Even the most conscientious employees cannot do a good job if the systems they depend on are
deficient—for example, if employees lack training, equipment, supervision, or a clear idea of
their responsibilities (343). Once managers see poor employee performance as a symptom of failure, rather than its cause, they stop blaming employees for problems. Employees then stop feeling defensive and can focus on finding and correcting the real causes of poor performance.
Structures and processes. Avedis Donabedian, an
early leader in defining the quality of health care, divides health
care organizations into structures, processes, and outcomes (93).
Structures are the inputs that make care possible. They include the
organization's staff and other physical and financial resources, such
as facilities, equipment, supplies, training, payroll, and operating
budgets. Processes are the tasks—such as counseling, contraceptive
ordering, and supervision—that transform these inputs into products
and services (113). Together, structures
and processes determine clinical outcomes.
Adequate structures—that is, appropriate staffing, equipment, and funding—are necessary to
provide good-quality services, but they are not sufficient. Well-designed and implemented
processes also are crucial.
It might seem easier to strengthen structures—by buying more equipment or paying for a training
course, for example—than to improve processes (394). Most quality improvement approaches,
however, focus on improving processes in order to use resources more efficiently, although they
also address structures and outcomes. For example, defects in the contraceptive logistics process
might best be cured by revising the process of ordering, storing, and distributing the supplies to minimize wastage and ensure timely delivery, rather than by purchasing more supplies. Indeed,
front-line supervisors and middle managers usually have focused their quality improvement
efforts on processes because they have little authority over program inputs; that is, they cannot
hire more workers or buy more equipment, no matter how important these might be.
