For example, when rising demand for measles vaccinations overwhelmed a rural health center in Niger, the limiting factor was the capacity of the center's refrigerator to make freezer packs. Without more freezer packs, the staff could not safely transport vaccines to surrounding villages each day. The problem was solved when the head nurse took matters into her own hands and rearranged the interior dividers in the refrigerator so that more packs could fit inside. A quality improvement initiative gave her the authority and confidence to act (314).

Workers who participate in decision-making typically feel committed to making the proposed course of action work (113, 129, 219). Participation generates enthusiasm and increases workers' motivation (44, 70, 113). Solving problems, even small or simple problems, gives staff members a sense of achievement and boosts their self-confidence (119, 219, 265).

Crossfunctional teams. Crossfunctional teams, sometimes called "quality circles" in industry, are a common technique to encourage people from different departments to work together (81). By bringing together all the people who are involved in a process, crossfunctional teams can assemble a complete picture of what is happening, examine weaknesses throughout a system, and generate a wide variety of ideas about the possible causes of a problem and its solutions (113, 119, 129). Crossfunctional teams also can help overcome barriers caused by differences in employees' power, status, attitudes, and values (216).

These teams are important because a single person, or even a single department, rarely controls or understands an entire process. For example, many workers contribute to preventing infection in a clinic, including the providers who practice no-touch technique, the assistants who clean and sterilize or disinfect the equipment, the custodians who clean the facility, and the administrators who order the necessary supplies. Many family planning programs have used crossfunctional teams and team problem-solving to help improve the quality of services.

Often, however, family planning managers operate without reliable information about service delivery (258). Service statistics often are forwarded to higher levels, aggregated, and reported in ways that are not useful for decision-making (65, 127). For example, in Ghana in the late 1980s not more than 10% of the health information entered on 27 different client cards, registers, and tally sheets (and collated in 38 different reporting forms) was ever used to improve management in any meaningful way (65).

In the absence of accurate, relevant information, decisions are based on assumptions, intuition, and anecdotal information that may be incorrect or biased (65). In The Gambia, for example, managers commonly thought that all health facilities were understaffed—a problem too big for them to tackle. After district health teams collected and analyzed data on staffing, attendance, and workloads, however, they found that only certain facilities needed additional staff. Using these data, the teams successfully lobbied the Ministry of Health to add staff to the facilities with the greatest need (70).

A good way to ensure that information is useful and used is for the front-line managers and service providers who collect information also to analyze it, interpret it, and make decisions based on it (127, 344, 364). Then staff are more likely to understand why they are gathering the data and have more incentive to be accurate. Also, local managers can check accuracy immediately (36).

Often, front-line managers must first be trained in basic data analysis, such as calculating rates or making charts, and shown how to interpret and act on their findings (36, 65, 127). In Tanzania family planning workers in an AVSC International program are learning these skills and have begun to examine service delivery statistics that previously were forwarded to headquarters without discussion (43).

For quality improvement, data collected should reflect the quality of services rather than just their quantity (33, 127). Substantial progress has been made recently in identifying new indicators of quality in family planning programs (see Chapter 6.1, Measurable Indicators of Quality) and in developing methods to track these indicators.