Step 1: Identify problem areas. First, managers or QI teams identify a problem or an opportunity for improvement. They draw on existing sources of information, including service statistics, staff and supervisor concerns, client feedback, and external evaluations, and they also may gather their own data (23, 113, 129, 165). In Albania, Russia, and Senegal, SEATS projects have found research on client expectations and satisfaction, such as focus-group discussions, especially valuable, providing clients' perspective on services (163).

Problems are defined from a systems perspective—that is, as deficiencies in structures andprocesses and not in individual performance. In family planning facilities, commonly identified problems include long waiting times (see sidebar, Shortening the Client's Wait). lack of privacy, inadequate equipment and supplies, poor clinical technique, inadequate information to clients, incomplete and hard-to-find records, staff shortages, and poor supervision (219, 223, 266, 297, 377).

Some QI methods ask teams to prioritize problems so that they can focus on a few important concerns (132). Alternatively, a QI team might choose to tackle first some small, easily solved problems in order to generate broader support for the approach (113, 383). Still other QI teams, usually those working at the facility level, work on a complete list of problems (16).

Step 2: Analyze the root causes of the problem. Next, the QI team must analyze the process that needs improvement, consider all possible reasons for the problem, and collect data to determine its root causes (61, 113, 129, 132). Teams must remain open-minded and not make assumptions about the reasons for a problem (113). For example, a sudden drop in the number of clients attending a family planning clinic could indicate dissatisfaction with services, or it could be that competitive new clinics or pharmacies have opened, or community workers may have run out of informational handouts about the clinic (364).

Step 3: Design and implement solutions. As much as possible, QI teams try to devise practical solutions that can be implemented with little or no additional resources or outside help (184, 383). These solutions can be simple or pervasive. In Togo a clinic resolved its most pressing problems by placing a sign at the clinic door so that new clients knew where to go, adding doors and curtains for privacy, cleaning the waiting area, and fixing a leaky roof (184). In Chile a health center needed to take broader actions. Few staff members followed a work schedule, used correct clinical techniques, or accomplished all the tasks in the job description. Changes included developing new norms, supervision plans, and a supervision checklist, training the entire staff in hygiene, improving communication between managers and staff, and increasing the availability of supplies and equipment. After these changes, more than three-quarters of the personnel performed properly (297).

Step 4: Evaluate and refine the solution. The QI process continues even after changes have been made. The QI team evaluates the effectiveness of its solutions and decides whether they should be retained, refined, or abandoned (23, 113, 129). When an innovation is successful, it should become the standard operating procedure at the original site and at similar locations elsewhere (95, 377). Sustaining the improvement may require changes in support systems—for example, revising manuals and creating new job aids (113).

In Mexico at the Fundación Mexicana para la Planeación Familiar (MEXFAM), members of the MIS department had first to devise a training course in basic computer skills for staff in other departments and then to shorten and revise it. Only then could they solve their most pressing problem: that trouble-shooting computer problems for other departments left them too little time for software and systems development (61).