International Journal for Quality in Health Care; Volume 19, Number 4: pp. 237 –243 10.

1093/intqhc/mzm021
Advance Access Publication: 15 June 2007

Case study

Introduction of a quality improvement

program in a children’s hospital in Tehran:
design, implementation, evaluation and
lessons learned
S. MEHRDAD MOHAMMADI1, S. FARZAD MOHAMMADI2, JERRIS R. HEDGES3,
MORTEZA ZOHRABI1 AND OMID AMELI4
1
Tehran University of Medical Sciences and Health Services, Center for Academic and Health Policy, 2Tehran University of Medical
Sciences and Health Services, Eye Research Center, 3Oregon Health and Science University, School of Medicine, Department of
Emergency Medicine, and 4Management Sciences for Health

Abstract
Background and Objective. Reports addressing continuous quality improvement (CQI) methods in developing countries are
scant and there are questions about the applicability of quality improvement methods in such settings. The structure and

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output of a formal quality improvement program implemented in a teaching hospital affiliated with the Tehran University of
Medical Sciences is presented.
Objective Method. During a nine-month period, a multi-stage quality improvement program was implemented. It comprised:
(i) training workshops; (ii) a steering committee; (iii) weekly consultation and facilitation of improvement projects; and (iv) a
day-long demonstration and recognition meeting. Four cycles of workshops were held in which 132 employees were trained in
the basics of CQI.
Results. Thirty improvement projects were initiated. Twenty-five of the projects were completed. In an evaluation survey
more than 70% of respondents assessed a ‘positive impact’ on organizational culture, work efficiency and quality of services.
More than 90% believed that the changes were sustained, and more than 60% reported that they have implemented additional
improvement projects.
Conclusion. Our quality improvement package supported rapid implementation of multiple projects. The underlying ‘change
structure’ comprised the improvement teams, top management and the university’s quality improvement office; it integrated
project management, support and facilitation functions by the respective participant. Organization-wide change was more
limited than anticipated. To institutionalize the program and ensure sustainability, a local structure for change should be orga-
nized, management coaching should be sustained, local facilitators should be developed, incentives should be established and
physician involvement should be emphasized.
Keywords: change in behavior, continuous quality improvement, hospital, structure for change

Introduction design make the most sense in these countries? Which man-
agement approaches work in cultures very different from
Some state that healthcare organizations in developing those in which quality improvement was first described?
countries have little experience with continuous quality What permits quality interventions to work or prevents them
improvement (CQI) methods [1] and the reports on such from working? How should successful quality improvement
initiatives are scant [2]. Several questions have been posed in efforts be reinforced, disseminated and supported over time
this regard: What specific process models and principles of [3]? In addition, authorities asserted that Western advocates

Address reprint requests to: S. Mehrdad Mohammadi, Center for Academic and Health Policy, Tehran University of
Medical Sciences and Health Services, 12 Nosrat, Postal code: 1417965173, Tehran, Iran. Tel: (þ9821) 6649 5859; Fax:
(þ9821) 6641 9537; E-mail: mmohamadi@tums.ac.ir

International Journal for Quality in Health Care vol. 19 no. 4

# The Author 2007. Published by Oxford University Press on behalf of International Society for Quality in Health Care; all rights reserved 237
Mohammadi et al.

of quality could learn from the innovation of colleagues and preparedness of the managers of the hospital towards
challenges in the non-Western world [4]. improvement. The hospital provides both general and special-
This paper reports a formal quality improvement program ized services. This children’s hospital, with around 175 staffed
in the Children’s Medical Center, a teaching hospital affiliated beds, 87% bed occupancy, nearly 450 employees, and 80 phys-
with Tehran University of Medical Sciences and Health icians, is a major referral center in Iran. The participants of
Services (TUMS), which was led and facilitated by the TUMS the program were nurses, doctors and administrative depart-
quality improvement office. We provide a description of the ment heads.
entire program and present a profile of the improvement
projects undertaken (including process measures of pre- and Intervention
post-intervention and the respective corrective actions). The
The intervention, known as the Quality Improvement
results of a follow-up evaluation survey are presented. We also
Training Cycle, was a multi-stage program comprised:
analyse the structure for change, discuss the role of facilitators
(i) Training Workshop; (ii) Consultation and Facilitation;
and examine the overall success, limitations and long-term
(iii) Demonstration and Recognition Meeting; (iv) Evaluation
viability of the program.
Survey; and (v) Retraining. Stages 1 through 3 were
implemented during a nine-month time course (February
2002 – November 2002). The evaluation survey was adminis-
Method tered in September 2004. The ultimate goal of the program
was behavioral change of the employees and enabling the
Setting
process of change within the organization. The phases of the
TUMS is a public organization whose mission is higher edu- course along with the methods and approaches used in each
cation in the health sciences, medical research, administration phase are summarized in Table 1. (The retraining phase empha-
(regulation and provision) of health services in its catchment sized the cyclical and continuous nature of the process.)
area and provision of specialized hospital services for refer- Each workshop was organized as four 6-h days (24 h
rals from other regions of the country. TUMS has 8 schools, total) of training with 30 trainees. Almost half of the time

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15 hospitals and 186 primary healthcare centers and oversees was dedicated to didactic education and the other half to
18 private hospitals and 3170 other healthcare facilities. team exercises and experiential learning. TUMS’ quality
The TUMS chancellor requested the quality improvement improvement office consultants, who were physicians with
initiative to be undertaken ( piloted) in one of its affiliated advanced training in quality improvement philosophy and
units. The impetus was to determine what could be achieved tools (including the courses by the national quality improve-
by such a quality program. The Children’s Medical Center was ment committee), provided the training. As mentioned in
chosen due to the prevailing supportive attitudes and Table 1 above, workshop content was a process improvement

Table 1 Quality improvement training cycle

Phase Name Description or content Time Associated human resources

training terminologya
.............................................................................................................................................................................
b
One Training FOCUS-PDCA methodology In a weak (4 days) Lectures, educational pamphlet,
workshops questions and answers, group
discussions
Two Consultation Giving instructions, follow-up and One day a week, 6 Coaching (positive reinforcement
and facilitation answering questions along the nine-step months and encouragement), case study
methodology in the hospital
Three Demonstration Lecture presentations, poster In one day Seminar method, opportunity for
and recognition (storyboard) presentations, recognition reporting results of efforts,
meeting ceremony recognition, monetary rewards
Four Evaluation Trainees/participants assessment of A year and a half
survey effects on culture and hospital following phase
performance, sustainability of three
improvement efforts and obstacles to
change
Five Retraining Beginning PDCA cycle and
experimenting anew
a
For a comprehensive list of human resources training methods, the interested reader may refer to the Lussier’s book on management [36].
b
FOCUS-PDCA refers to a generic nine-step method for process improvement projects involving the use of 11 quality improvement tools
by teams [5]. PDCA stands for: Plan, Do, Check, Act, respectively; and FOCUS for Find, Organize, Clarify, Understand and Select.

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 Quality improvement program in a children’s hospital in Tehran

methodology known as FOCUS-PDCA. This managerial deviation (SD). Mean of the trainee multiple-choice test
package includes: brainstorming, block diagram, flow chart, score administered prior to workshop improved from 1.67 (SD:
run chart, affinity diagram, cause and effect (fishbone) 0.22) to 3.25 (SD: 0.17) post-workshop (maximum score: 5).
diagram, nominal group, multi-voting, decision matrix and
planning sheet techniques [5]. (A sample improvement
Observations regarding the University’s and
project along with the tools used is detailed in an appendix
hospital’s senior management involvement
available on http://tums.ac.ir/cahp/qiprog_sampleproj.html)
and support
Structure and leadership Being very interested in the program, the University’s top man-
agers (chancellor and vice-chancellor for logistics) supported it
The Management Consultancy and Quality Improvement symbolically and through their actions. The chancellor believed
Office that reports to the TUMS chancellor managed and that the best way for showing the value of the quality improve-
facilitated the program. The office’s mission is: ‘To provide ment approach is through example. The vice-chancellor for
consultancy and training services in the areas of improve- logistics gave an opening speech for all workshops. The process
ment and management for the managers and employees of was supported financially in various ways. The top managers
TUMS and to give advice to TUMS’ management leaders awarded bonuses and citations in the closing meeting. Hospital
regarding organizational development policies.’ Its activities managers participated in the workshops and were involved in
range from holding training workshops, facilitating quality the improvement projects implementation and facilitation.
improvement projects and guiding strategic planning work- The second phase involved consultation and facilitation of
shops to facilitating problem solving projects. improvement projects. Overall, 187 consultation sessions
were offered on a weekly basis on 16 separate dates. Ideas
Measurement and evaluation for 30 projects were formed; 25 were started and facilitated
Performance measures of the intervention were number of in the five-month period; and 20 went through all the nine
the workshops delivered and number and percentage of per- formal steps. Table 2 lists the projects.
sonnel participating, trainers’ performance, trainees’ multiple- The conception of improvement projects was not just

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choice test, number of improvement projects (initiated and based on solving a perceived problem; some were conceived
completed) and attitudes of the participants towards the just to study and ‘improve’ an existing process. Seven pro-
program and institutionalization of improvement activities. jects were initiated but not completed, i.e. DCA or CA stages
Trainer’s performance score was based on a four-criteria test, of FOCUS-PDCA were not followed through. In all, a cor-
namely, scientific competence, chain of topics, eloquence and rective action was formulated but it was either not
trainee participation with each criterion being measured on the implemented (four instances) or its effect was not measured
three-tiered scale of good (2), fair (1) and poor (0). Participants post-action (three instances). The reasons were: impracticality
scored the trainers after every session. Participant satisfaction of the recommended action, group dynamics problem or
was measured in the areas of session timing, logistical issues, lack of a need for another measurement.
volume of material, level of participation and overall satisfac- A representative quality improvement project is detailed
tion, again on a three-tiered scale at the course conclusion. in an appendix available on http://tums.ac.ir/cahp/qiprog_
Participants’ satisfaction and judgment about the quality sampleproj.html. Analysis of individual projects is beyond
improvement training cycle effect on organizational culture, the scope of this report.
work efficiency and hospital performance (quality of care, Phase 3 was implemented as described in Table 1. An
patients’ and students’ satisfaction, and occupancy) were evaluation survey was conducted a year and half after the
questioned in the evaluation survey. The extent of institutio- formal closing of the program (i.e. following the demon-
nalization of the improvements and whether the participants stration meeting). All 29 distributed questionnaires were col-
have undertaken fresh initiatives later were also evaluated. lected. More than 70% of the respondents believed that the
Participants were asked to enumerate the obstacles they exercise had a ‘positive impact’ on organizational culture
encountered and their suggestions for future improvement development, work efficiency and speed, quality of services,
activities. A sample of 29 people were surveyed. patient satisfaction and number of patients (including bed
Analogous to Kirkpatrick’s four-level model, we aimed to occupancy). The survey scale used ‘positive impact’, ‘indiffer-
evaluate the impact of training at the levels of reaction, learn- ent’, ‘negative impact’ and ‘no comments’ levels. In more
ing (knowledge), behavior (skill) and results [6]. than 90% of instances, respondents believed that the changes
were sustained; and more than 60% of the respondents
reported that they have implemented additional improvement
Results projects after the program’s formal closure. The impact on
employees’ satisfaction scored the lowest; only 35% believed
Four workshops were held in which a total of 132 (of the some that the impact has been positive, and 45% described it as
530 hospital personnel) were trained (76% were female); 62% indifferent (Figure 1). Lack of sufficient resources (budget,
were nurses, 17% paramedics, 7.6% physicians and 13% other staff and equipment) and an ineffective incentive payment
staff. Mean trainer performance score (based on the four- system were the two most frequently cited obstacles against
criterion test; maximum score: 8) was 5.1 with a 0.75 standard improvement initiatives. The employee comment of ‘what’s

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Mohammadi et al.

Table 2 Target processes for quality improvement and Table 2 Continued

projects team composition
No. Title Team
No. Title Team
composition
composition
(staff mix)
(staff mix) ....................................................................................
....................................................................................
24. Doing work at registration/sorting Support staff
1. Transferring the stable infant from the Nurses
office
neonatal ICU to the ward when
25. Patients’ visit by the surgical fellow in Nurses
admitting an unstable one
different shifts
2. Transferring patient from surgery ward Nurses
to the operation theater in the morning An extension to this table (Table 3) provides more information on
shift (elective operations) the projects, i.e. quality measure used, pre- and post-improvement
3. Distributing food to patients in wards Support staff statuses of the measure (mostly in the form of median and range)
4. Embedding tissue in paraffin in Paramedics and the corrective action implemented. It can be accessed at http://
pathology specimens preparation tums.ac.ir/cahp/qiprog_projdata.html.
5. Lending books in the library Support staff
6. Washing hands in the pediatric ICU Nurses in it for me’ was common and represented the main inherent
7. Delivering medicine to outpatient Paramedics, challenge to change.
patients support staff
8. Distributing sugar and tea in the Support staff
hospital Discussion
9. Transferring cerebrospinal fluid Paramedics,
specimen from the wards to the support staff A variety of approaches for quality improvement, including
clinical lab process improvement, quality assurance, re-engineering and

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10. Infectious diseases ward admissions of Nurses participative management, are available. In our program we
the patients for whom isolation is adopted a CQI and project-by-project approach. The specific
indicated method for improvement and problem-solving taught and used
11. Connecting patients to ventilators in Nurses by the teams was a package of analysis, teamwork and planning
pediatric ICU tools acronymed FOCUS-PDCA (see above). Many empirical
12. Hydrotherapy in the physical therapy Paramedics, papers report its application in dealing with specific projects in
unit support staff US academic healthcare centers [7–12] or on an organizational
13. First visit of the (insured) patients in Nurses, basis [2, 13, 14]. Others have reviewed the utility of the method
the specialized clinics following paramedics, [15, 16] and still others suggest modifications [17–19].
discharge support staff CQI has been found efficient in hospital settings [20–23].
14. Admitting neonates with respiratory Nurses Francois et al. evaluated a decentralized approach for quality
distress in the neonatal ICU improvement in a hospital and concluded that implementing
15. Providing service to non-emergent Nurses CQI in hospital departments is a viable alternative to
patients in specialty clinics organization-wide implementation strategies [20]. Project-by-
16. Placing intravenous lines for the Nurses project quality improvement is a conventional option and
patients through culture building, in the long run, it may bring about
17. The ward X’s daily visits Nurses organization-wide improvements. In our case, program
18. Admitting non-emergent patients in the Nurses, implementation was led in an efficient manner (considering
morning shifts from the time entering paramedics the number of projects finalized, mean trainer’s performance
the ward Y to the time resting on the scores, satisfaction scores and post-test trainee scores, and the
bed uneventful delivery of the successive stages of the package).
19. Submitting blood tests from the surgical Paramedics Further, top management’s support was present throughout.
wards to the clinical lab Although we do not have detailed observations character-
20. Service provision for the outpatient Paramedics, izing the improvement projects outcomes and behavioral
referrals at the sample taking room support staff change in the participants, we did survey the attitudes of the
21. Copying service in the library Support staff participants. Given that 60% of the respondents reported
22. Transferring an icteric infant from the Nurses having conducted further improvement projects, we infer
emergency department to the ward Z that favorable behavioral change has occurred. Given that
23. Implementing CT scan orders for the Paramedics more than 70% of participants rated a positive impact on a
hospitalized patients variety of outcomes, beneficial organizational changes can be
inferred. More importantly, the exercise provided an oppor-
(continued )
tunity for teamwork, two-way communication between staff
and managers, and led to organizational learning.

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 Quality improvement program in a children’s hospital in Tehran

Figure 1 Evaluation survey results. Quality improvement participants judgment of the outcomes of the program.

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It has been reported that the introduction of quality man- countries, quality improvement often encounters old-style,
agement systems has positive effects on the staff ’s work satis- control-oriented management, a leadership system far more
faction [24], although in our evaluation, despite a positive focused on finance and revenue than on improving oper-
assessment in all other areas, the impact on employee satisfac- ational processes, a strong sense of professional hierarchy
tion was relatively low. This can partly be attributed to less than and entitlement, and a lack of integration of the health care
optimal feedback and incentives; the roles of these factors have system with community resources [3]. In developing nations,
been emphasized elsewhere [25, 26]. This perspective was the ‘crust’ of old-style management may be thinner or even
articulated by our participants as ‘what’s in it for me?’ absent, leaders may already be focused on the task of getting
the best they can out of current resources, teamwork among
health care workers may seem more familiar and community
Quality improvement in a developing structures may be more accessible as part of health care [3].
country setting In addition, it is expected that systematic quality improve-
ment would optimize resource allocation and use and can
Some state that hospitals in developing countries have little break through to new performance levels [3] and might
experience with CQI methods [1] and the outcome of enhance development of management skills and processes in
quality improvement initiatives may not be similar to those a practical manner in such countries.
of the developed countries. Developing country conditions
that may impede such programs include relatively lower
employee income and morale, little competitiveness (arising
Structural considerations
from low or absent external incentives, low peer pressure
from organizations and limited mechanisms for management Structure is critical if total quality management (TQM) is
accountability), more frequent unfair management practices, going to work [29]; quality improvement office views improve-
management turnover, lower consumer expectation, over- ment in TUMS as a concerted participation of three players:
whelming working conditions, lower training, lack of local the operational unit (hospital staff and improvement teams),
expertise and leadership, and a higher ratio of patients to top management and the institutional quality improvement
providers [3, 4]. Similarly, it is reported that the compliance office. Quality improvement was in fact a product of collabor-
with case management and clinical practice guidelines is not ation and synergism between these elements which, respect-
high in developing countries [27]. ively, performed the functions of project management,
We found scant evidence in the literature for comparative support and facilitation—thus making quality improvement/
analysis of quality improvement programs in developing change (as an outcome) a ‘systems property’ [30]. From the
countries but some suggest that properly adapted improve- perspective of organizational power, the quality improvement
ment methods may be even better suited to the developing office’s responsibility and role with respect to improvement
world than to the developed nations [28]. In developed has been one of ‘staff authority’, i.e. to assist and give advice

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Mohammadi et al.

[31]. The quality improvement office is outside the chain of Ensuring involvement of the staff and ultimately enabling
command and lacks ‘line authority’ to make decisions and change within the system needs: opening of communication
issue orders down the chain of command. The office’s channels and listening to the employees, a continuous push
‘expert’ status and ‘connection’ (to the university’s chancellor) or encouragement toward higher standards, coaching, recog-
power helped it influence the staff and effect change [32]. nition of accomplishments, removal of favoritism and an
In the evaluation survey, respondents cited the absence of atmosphere of teamwork (instead of power and politics).
a long-term support [resources (budget, staff and equip- These are significant leadership challenges. Only with sus-
ment)] and incentive payment system as major barriers to tained motivation can the quality improvement process be
improvement activities and their sustainability. A formal sustained. Externally the organization and its management
intramural support and an evaluation structure (including should receive incentives from a market-driven competitive
local facilitators and improvement project champions) should environment or through quasi-market policies adopted by
address these factors; a specific procedure for improvement the regulators or higher-level management.
activities should be defined that clarifies the following CQI is an organizational culture and largely the product
elements: how improvement projects are identified and for- of the organization’s leadership and motivational system.
mulated, how teams are organized, how facilitation and tech- Building a culture takes time. Although CQI is a long-term
nical support are to be provided, how they are to be effort, we should not wait until the ideal culture has evolved.
followed-up and how they are rewarded. Attention to these Results themselves build culture. Although our improvement
steps should institutionalize quality improvement activity initiative was successful in many ways, the employees’ percep-
within the working of an organization, i.e. make them tions suggest cultural change is incomplete. This transform-
routine and intrinsic (see below). ation and behavioral change may require the establishment of
support systems and financial incentives [25].
Project ownership and facilitation
Physician involvement
Considering the type of involvement and participation,
implementation of an institutional quality improvement Relatively few physicians were involved in both workshops

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program can be achieved in two primary ways: (i) expert- and projects. Time constraints, limited interest and account-
owned—a consultant- or quality-specialist-driven program ability and the perception that physicians’ involvement was—
employed on an ad hoc basis and (ii) self-owned—a program at least at this stage—not necessary might explain this
owned and driven by the staff, but potentially supported limited participation. This low level of physician involvement
by outside consultants or specialists. Beckford [33] suggests was an obstacle for several of the improvement projects and
that the latter approach is preferable. From the Children’s was a source of complaint and grievance among the nurses.
Hospital’s perspective, quality improvement office members There is a large, relatively untapped opportunity for quality
are considered external consultants but from the perspective improvement in medical processes; relevant projects could
of TUMS top management, they are internal change agents culminate in the development of clinical practice guidelines
assisting a program within the entire organization. Regardless or critical pathways. Previous reports have also highlighted
of the perspective chosen, the quality improvement training the difficulty of achieving physicians’ involvement and
cycle was established to enable the process of change through importance of physician involvement [35].
behavior modification and empowerment of the employees to
take charge of their own operations. Quality metrics
The role of facilitators cannot be over-emphasized as they
help organizations apply improvement principles and tools In most of the projects, the quality metrics used (i.e. as per-
and help them manage change [34]. Since our quality formance indicators of the processes) were a time measure—
improvement office members were exposed to extensive e.g. time taken for completion of a task, time delays until a
quality improvement experience, they could transfer their task is initiated, etc. (see Table 2 legend). There are other
experience between improvement projects and teams. Thus, quality measures (e.g. characteristics of the interaction with
each team benefits from lessons learned elsewhere and the the patient by the healthcare workers, patient comfort or
insights are shared across the organization. pain control, and patients’ perception of the technical excel-
lence), which are more directly related to patient satisfaction.
Time measures are relatively easy and ready for operationali-
Institutionalization zation, but quantification of other measures in a reliable,
Sustainability of quality improvement initiatives is always a valid and practical fashion can be challenging.
concern and even the applicability of CQI approaches to
healthcare for long-term changes has been questioned and
evaluated [26, 29]. Godfrey observed ‘It’s easier to begin Acknowledgements
than to keep going’ [29]. We had a similar experience.
Although the evangelical fervor of TQM can help initiate We are thankful to Ms. A. Khadem, as the local program
projects, tangible incentives are needed to sustain the coordinator and to our assistants, Ms. Z. Ghomian and Mr.
momentum or to prevent initiative fatigue. R. Dehghan, for their contribution in the evaluation survey.

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 Quality improvement program in a children’s hospital in Tehran

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