QA Workbook

QA Workbook – The Problem Solving Approach – 2nd Edition section 1
c. Formulate a problem statement.

Example of problem statement:

Problem Statement

Introduction
• Skin biopsy is a common procedure in the skin clinic.
Problem
• High incidence of wound infection for diagnostic skin biopsy in Skin Clinic, HRPBI
Effect
• Non healing wound due to secondary infection can cause higher morbidity and

increase cost of health care
Possible cause
• Multiple risk factors can influence the risk of postoperative wound infection e.g.

improper aseptic technique and wound care
Aim of study
• To reduce skin biopsy wound infection rate to < 2% (national target)

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QA Workbook – The Problem Solving Approach – 2nd Edition

Notes

section 1

40

CHAPTER 6: section 1

QA STUDY

Able to identify & formulate objectives, variables, indicators, criteria,
standard and MOGC for the various phases of the study.

Able to plan for data collection.
Able to analyse data and draw conclusions from the findings.

QA Workbook – The Problem Solving Approach – 2nd Edition

6.1 FORMULATING STUDY OBJECTIVES

Study objective = what we want to achieve.
It can be divided into General and Specific objectives. General objective is the overall
intention of the study. Specific objectives outline the steps we are going to take.
We can have separate objectives for different phases of the study:

No Study Phase Example of general objectives
1. Verification study
To verify if there is a large number of diabetics
2. Pre-remedial study re-admitted to the medical ward with poor glycaemic
control
3. Post-remedial /
re-evaluation To reduce the number of diabetics re-admitted to the
medical ward with poor glycaemic control
section 1
To evaluate the effectiveness of remedial measures in
reducing the number of diabetics re-admitted to medical
ward with poor glycaemic control

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QA Workbook – The Problem Solving Approach – 2nd Edition

6.1.2 EXERCISE
a) Formulate general and specific objectives of the study.

section 1

Example of general and specific objectives:

General Objective
To reduce incidence of wound infection for diagnostic in the skin clinic of
Hospital Raja Permaisuri Bainun Ipoh.

Specific Objective
1. To verify the incidence of wound infection for diagnostic skin biopsy.
2. To identify the causes of wound infection.
3. To formulate and implement proper remedial measures.
4. To evaluate the effectiveness of remedial measures.

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QA Workbook – The Problem Solving Approach – 2nd Edition

6.2 MEASURING QUALITY

6.2.1 IDENTIFY INDICATORS

An indicator is a measurable form of a standard relating
to structure, process or outcome.

section 1 A good indicator should meet certain requirements:
Specific/objective
Verifiable
Comprehensive (covering all)
Reliable (can get same result with anybody doing it)
Valid (pertaining to quality of care)
Easy to Use
Sensitive (able to differentiate good care from bad)
Acceptable (to all concerned)

Example of some indicators

Indicators Area of care looked at

POP complication rate Quality of POP application for fractures.
Quality of surgical infection control.
Clean wound infection rate Quality of nursing of bed-ridden patients.
Adherence to antibiotic policy.
Bedsores in non ambulatory patients

Incidence of multiple resistance organism
in culture and sensitivity samples

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QA Workbook – The Problem Solving Approach – 2nd Edition

Sometimes it is only possible to get as close as to the real problem and use a proxy indicator.
This indicator is used to measure the problem indirectly. It is not very accurate because the
problem itself is usually a result of many other factors, sometimes totally unrelated and
beyond control. It is useful only as a flag to indicate that a problem may exist.

Example:

1. Myocardial infarction case fatality rate as a proxy indicator of medical management of
AMI.

2. Death due to head injury as a proxy indicator of head injury management.
3. ARI case fatality rate as a proxy indicator of paediatric management of respiratory

infections.

Examples of indicators

Possible indicators Quality of care for section 1

Asthma readmissions rate Asthma management
Waiting time (duration) OPD patients
Waiting time Emergency Surgery
Postponement rate Elective Surgery
Rate of anaemia in pregnancy Antenatal care

For further information, please refer to Measuring &
Managing Quality of Health Care - Implementing
Quality Module on page 189-200

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QA Workbook – The Problem Solving Approach – 2nd Edition
6.2.2 IDENTIFY VARIABLES

No. Study phases Objective Example of variables required

1. Verification study To verify if there is a large Variables required:

number of diabetics re-admitted a. Number of diabetics

to the medical ward with poor re-admitted with poor

glycaemic control glycaemic control

b. Number of diabetics with

poor glycaemic control

2. Study proper To reduce the number of Variables required:
diabetics re-admitted to the a. Number of diabetics
medical ward with poor
glycaemic control re-admitted with poor
glycaemic control
section 1 b. Total number of diabetics
admitted with poor
glycaemic control
c. Causes of poor glycaemic
control

3. Re-evaluation To evaluate the effectiveness Variables required:
of remedial measures in a. Number of diabetics
reducing the number of
diabetics re-admitted to admitted with poor control
medical ward with poor b. Total number of diabetics
glycaemic control
admitted with poor
glycaemic control

Variables used in verification phase is similar to that in
re-evaluation phase

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QA Workbook – The Problem Solving Approach – 2nd Edition

6.2.2.2 OPERATIONALISING VARIABLES

Some variables are expressed vaguely and cannot be measured objectively.
Operationalising means making them measurable. Vague variables are called
conceptual variables.

Example:

Conceptual Variables Operational Variables

Knowledge Passing a certain test

Compliance to treatment Presence of drug in urine

Experience Number of years in that field

Renal colic Certain symptoms and signs

Fever Presence of temperature >38°C on 2
occasions
section 1
By being operational, it assumes a certain scale of measurement (eg. centigrade for temperature, certain response
to an attitude questionnaire).

Criteria in simple terms mean prerequisites or
definitions. This can be applied to indicators, variables
(data) or MOGC

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QA Workbook – The Problem Solving Approach – 2nd Edition
6.2.3 IDENTIFY CRITERIA

Criteria Explanation

Inclusion Criteria Used to define the sample to be included in the study.

Exclusion Criteria Used to define the sample not to be included in the study.

Implicit Criteria Subjective assessment by peers or 'experts'. Example: Good
care means, if the evaluation by at least 3 out of 5 peers
indicate so.

Explicit Criteria A definite written model set by a Committee that everybody
understands.

Problem Specific Criteria Looks at the process of care. Sets a model for each process of
care for a certain disease specific condition. Example: Model of
process for management of acute cholecystitis.

section 1 Ideal Criteria It is a criteria put into a perfect [Dreamland] model. Example:
Criteria for good surgery = zero complication rate.

Empirical Criteria It is simply a guesswork criteria especially when no reference
can be found elsewhere.

All criteria should be tested before using them. In the
literature sometimes, there are contradictory
requirements for good criteria.

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QA Workbook – The Problem Solving Approach – 2nd Edition section 1
6.2.4 SET STANDARDS

A standard will:
a. Decide if a problem exist (problem verification).
b. Decide if a contributing factor is responsible for the problem (second level standards).
Example:
Problem: Long waiting time at Outpatient department.
• The standard for the indicator is not >15% of patients should wait > 1hour.
This is sometimes called THRESHOLD. Setting of standards must involve all concerned with
the process just like identifying criteria.

For further information, please refer to Measuring &
Managing Quality of Health Care-Implementing Quality
module on page 259 to 276.

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QA Workbook – The Problem Solving Approach – 2nd Edition

6.2.5 EXERCISE
a) Formulate an indicator for the identified problem.

section 1 Example of an indicator for the problem:
Proposed Indicator & Standard

b) From the problem identified, list down variables that need to be collected to verify that
the problem exists.

What is to be verified? Your quality problem
Numerator
Denominator

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QA Workbook – The Problem Solving Approach – 2nd Edition

Example:

What is to be verified? Percentage of patients that
Numerator variable (data) developed wound infection
Denominator variable (data)
Number of patients with wound infection

Total number of patients underwent
diagnostic skin biopsy

c) List the inclusion and exclusion criteria.

section 1

Example of inclusion and exclusion criteria:
Inclusion & Exclusion Criteria
• Inclusion Criteria

Patient undergo diagnostic skin biopsy in the skin clinic of Hosp RPBI
• Exclusion Criteria

Patient with infected preoperative skin surface
Patient unable to turn up for suture removal in our clinic
Patient undergo diagnostic skin biopsy in ward

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section 1 QA Workbook – The Problem Solving Approach – 2nd Edition
d) Set the standard for your quality problem.

Example of a standard for the problem:

Wound infection for diagnostic skin biopsy should be less
then 2% (based on national indicator value)

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QA Workbook – The Problem Solving Approach – 2nd Edition section 1

6.3 MODEL OF GOOD CARE (MOGC)

MOGC is a process of care that is thought to fulfill the standard set. The standards are values
that distinguished good from bad care.

MOGC is the process of care with a ‘good design’.
`GOOD’ is based on the ‘specifications’ considered optimum and achievable.
`GOOD’ is defined by Criteria and Standards.
The good steps can be adopted from the professionally accepted standard or normal,
SOP, guidelines, circulars, CPG, etc.
It may also be innovations thought of by the group.
MOGC can change with time.
Each step in a process will contribute to the final service outcome.
Critical steps are steps that should be accomplished within the set criteria and standard.
If the critical steps not followed, it might cause a ‘multiplying effect of failure’ in the
series of care.
Usually lead to the undesired outcome

For further information, please refer to Chapter 5 of this
workbook on page 31-40.

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QA Workbook – The Problem Solving Approach – 2nd Edition

6.3.1 EXERCISE

a) Develop Model of Good Care for your process and highlight the
critical steps

No. Process Criteria Standard

section 1 Example of criteria of good care:
Model of Good Care

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QA Workbook – The Problem Solving Approach – 2nd Edition

6.4 DATA COLLECTION (PROCESS OF GATHERING
INFORMATION

There are five important questions to ask in the process of data
collection; for example:
Problem : Long waiting time to see doctor in clinic.
Indicator : Percentage of patient with long waiting time
Formula : Patient with long waiting time x 100%

Total number of patient sampled

QUESTIONS EXPLANATION DATA TO BE COLLECTED
TO ASK?
• Waiting time (for each patient),
WHAT What data needs to be collected? • Total number of patient sample

HOW How to collect data-technique, methods • Record time patient registered section 1
and tools? upon arrival (A)

WHO Who will collect the data? • Record time when patient see
WHERE Where will the data be collected? the doctor (B)
WHEN When will the data be collected?
Thus, waiting time = B-A

Clinic nurse

Clinic

Clinic days

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QA Workbook – The Problem Solving Approach – 2nd Edition

6.4.1 VARIOUS DATA COLLECTION TECHNIQUES

Techniques Explanation

Review of The location and analysis of information that has already been collected. For

Recorded Sources example: Literature, statistics, medical records.

Observation Systematic selection, watching and recording of behaviour and characteristics of
living beings, objects and phenomena. For example: Observing - CPR, LSCS,
wound dressing, POP cast application.

Interview There are four methods that can be used which are:
• Face-to-face
• Telephone interview
• Group interview
• In-depth interview

Interview technique can be conducted in two ways which are fixed and flexible.

section 1 Flexible Fixed

1. Using open-ended questions with 1. Using prepared questionnaires with
varied answers fixed answers

2. Sequence of questions changeable 2. Follow order of questions

3. Difficult to analyse / interpret 3. Easier to analyse / interpret

4. Suits small exploratory studies 4. Practical for larger samples

Written 1. Collected through written response.
Questionnaire 2. Questions can be open-ended or fixed (preferably fixed).
3. Questionnaire can be mailed / hand delivered / gathering respondents in

one place / phone cells.

For further information, please refer to module
Measuring & Managing Quality of Health Care –
Implementing Quality Module on page 203-220.

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QA Workbook – The Problem Solving Approach – 2nd Edition

6.4.2 EXERCISE

a) Using the indicator identified from the problem chosen, outline a
plan for data collection to:

i. Verify that the problem exists.

ii. Identify factors contributing to the problem.

VARIABLES WHERE TO COLLECT? WHO? WHEN HOW
(WHAT TO
COLLECT?)

Example of data collection plan: section 1

Data Collection

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QA Workbook – The Problem Solving Approach – 2nd Edition

6.5 DATA ANALYSIS

Quantitative Data Qualitative Data

• Frequencies Can be summarised using graphic displays
• Percentages such as matrix, diagrams, flow charts or
• Proportions tables.
• Ratios
• Rates
• Mean
• Median
• Mode
• Cross tabulations to describe

sample Measure of Dispersion
(Standard Deviation)
• Normal Distribution Curve

section 1 For further information on matrix, diagram, flow chart
and table, please refer to Measuring & Managing
Quality of Health Care-Implementing Quality module on
page 202.

From the results obtained, we should have information that should enable us to answer our
study objectives.

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QA Workbook – The Problem Solving Approach – 2nd Edition

6.5.1 EXERCISE
a) Plot a Gantt chart for the study.

Example of Gantt chart: section 1

Gantt Chart

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section 1 QA Workbook – The Problem Solving Approach – 2nd Edition
b) Draw master sheet for data collection.

Example of Master Sheet:

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QA Workbook – The Problem Solving Approach – 2nd Edition section 1
c) Draw dummy tables.
Example of a dummy table:

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section 1 QA Workbook – The Problem Solving Approach – 2nd Edition
d) Identify/decide appropriate tools to display your data

Example of data displays tools.
Problem analysis chart
Flow chart
Pie chart
Pareto chart
Bar chart
Histogram
Run chart
etc

For further information on tools to present your data
appropriately, please refer to Measuring & Managing
Quality of Health Care-Implementing Quality module;
Chapter 11 on page 235-258.

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CHAPTER 7: PLANNING section 1

FOR CHANGE

Able to formulate innovative
strategy for change based on
contributing factors identified.

Able to plan and implement
strategies for change / remedial
measures.

section 1 QA Workbook – The Problem Solving Approach – 2nd Edition

7.1 STEPS IN RECOMMENDING REMEDIAL ACTIONS

7.2 GUIDE ON IMPLEMENTING CHANGE

1. Go for simple measure that can be carried immediately.
2. Go for sustainable measures.
3. Process owners must be involved in decision to change.

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QA Workbook – The Problem Solving Approach – 2nd Edition

7.3 TYPE OF CHANGES THAT MAY BE REQUIRED

PEOPLE SYSTEM STRUCTURE

• Knowledge problems More often than not the Presence or absence of
- Focus on in-service system is usually at fault certain structure. This
training. rather than the individual. includes number of
- Improved orientation A change in the system personnel. Do not abandon
programmes. may also change the it if it is very important. The
- Feedback on past attitude. data and evidence gathered
results. from the study can be used
- Provision of • System problem to justify the need for extra
references. - Changes in staff, allocation of budget
- Guidelines, manuals communication or new equipment.
and protocols. channels.
- Written policies. - New division of section 1
labour.
• Attitude and behavior - Changes in
problems organisational
- Rewards and structure.
sanctions. - Changes in physical
- Feedback on past environment.
results. - Changes in policies.
- Counseling (formal - Changes in
and informal). management
- Changes in duties. procedures.
- Supervision. - Additional resources.
- Transfer. - Changes in the use
of equipment or
technology.

It is easier to change the system than attitude of
individuals although it is well known that the attitudes
of certain individuals are responsible for certain quality
problems.

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section 1 QA Workbook – The Problem Solving Approach – 2nd Edition

7.4 EXERCISE

a. Review study results and make conclusion.
………………………………………………………………………………………………………..
………………………………………………………………………………………………………..
………………………………………………………………………………………………………..
………………………………………………………………………………………………………..
………………………………………………………………………………………………………..
………………………………………………………………………………………………………..

b. Review study objectives and answer them using study findings.
………………………………………………………………………………………………………..
………………………………………………………………………………………………………..
………………………………………………………………………………………………………..

c. Note other findings that you may have discovered during data collection/
analysis phase.

………………………………………………………………………………………………………..
………………………………………………………………………………………………………..

Small deeds done are better than great deeds planned.

d. Based on the findings, plan strategy for change (remedial measures).

What needs to How Who When
Study findings

change

66

CHAPTER 8: MONITORING section 1

CHANGE & RE-EVALUATION

Able to plan monitoring
process.

Able to ensure remedial
measures are carried out.

Able to plan data collection for
re-evaluation of the problem.

QA Workbook – The Problem Solving Approach – 2nd Edition

Appropriate time to re-evaluate will depend on how long the remedial actions are expected
to produce change.

VARIABLES WHERE TO COLLECT? WHO WHEN HOW
(WHAT TO
COLLECT?)

section 1 8.1 WHY EVALUATE?

1. To evaluate the effectiveness of the remedial measures carried out.
2. To assess the progress of the implemented remedial measures.
3. To provide evidence to further modify or improve the remedial measures if necessary.

For further information, please refer to
module Measuring & Managing Quality of
Health Care – Implementing Quality
Module on page 323-333.

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CHAPTER 9: WRITING A section 1

QA PROPOSAL

Able to produce a proposal to
improve quality.

QA Workbook – The Problem Solving Approach – 2nd Edition

Section EXPLANATION

Introduction Should include statement of the problem:
• Introduction to the service.
• What is the problem?
• What are the possible causes?
• What are the possible effects of this problem if not solved?
• Why this study is carried out?

Literature review • Any evidence to support that the above problems exist.
• Summarise the findings from the other studies.
• Justify why the study needs to be done.

Objectives 1. General objective (Related to the topic).
2. Specific objectives

• To determine presence of shortfall and magnitude of the
problem.

• To identify causes of the problem.
• To recommend and implement remedial measures.
• To re-evaluate the effectiveness of the remedial measures.

Methodology (Key measures 1. Definition and criteria.
for improvement)
Problem Magnitude = Number of problem
section 1 X 100

Total number of the sample population

Standard =%

2. Variables (data) related to the problem verification:
• What data? How it will be collected (instrument used)?
• Sample size?
• Where? When? Who?

3. Inclusion and exclusion criteria (can also be tabulated).

What Data How Where Who When

4. Variables (data) that related to the possible causes:
Factor 1

Variable How Where Who When

Factor 2 How Where Who When
Variable

Appendices 5. Gantt chart and budget planning (if required).

70 This section should include:
• Flowchart of process of care.
• Model of good care table.
• Problem analysis chart or Ishikawa chart.
• Data collecting formats (Including questionnaires, checklist).

Able to write a QA report based section 2
on appropriate format.

CHAPTER 10: WRITING A

QA REPORT

QA Workbook – The Problem Solving Approach – 2nd Edition

Following the completion of a study, a report should be prepared. The format below is
recommended.

Section Explanation Related
Chapter(s) in
this workbook

Cover page Should include: -
• Title and department
• Names of authors (Titles & position)
• Institution that publishes the report
• Month and year of publication -

Abstract or summary It tells what the study is all about and 2
enables the reader to decide whether
he wants to read the whole report.

Introduction 1. Information or literature to support the 2, 3 & 4
choice of topic.

2. Describe also the relevant features
of your hospital and quality assurance
programme.

Selection of 1. Statement to elaborate on the problem: 5
opportunities • What effects it has on patient care?
(Problem statement) • To convince that the study was
required.

2. Mention the possible causes and
remedy intended.

Selection of 1. General objectives 6

opportunities (Objectives) 2. Specific objectives

Key measures for Set the variables, indicators, criteria, 6
improvement (Set standards and MOGC for the study.
variables, indicators,
section 2 criteria, standards, MOGC)

Process of gathering Includes a small series of problem 6
information (Data verification study, then the whole study:
collection) • Study type
• Sampling techniques
• Inclusion / Exclusion criteria
• Definitions
• Data collection tool & technique

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QA Workbook – The Problem Solving Approach – 2nd Edition

Section Explanation Related
Chapter(s) in
Analysis & interpretation Present clearly in appropriate data this workbook

(Data analysis) display tools. 6

Strategy for change Suggested and carried out 7
(Planning for change)
8
Strategy for change How to ensure it was done.
(Monitoring change) 8

Effects of change Data after remedial action carried out. 6
(Re-evaluation) –

Conclusion Should answer specific objectives.

Appendices Should include:
• Problem Analysis Chart or Ishikawa

Diagramme
• Gantt chart
• Forms used in data collection
• New formats
• Relevant circulars
• Sample data

section 2

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Notes

section 2

74

To assist in the preparation of section 2
the oral or poster presentation
of the project.

CHAPTER 11: ORAL & POSTER

PRESENTATION
(THE DO’S & DON’TS)

QA Workbook – The Problem Solving Approach – 2nd Edition

11.1 ORAL PRESENTATION

Section No of slide(s)
Title & Authors Tips recommended
Introduction
Content (total of 25 slides)

• Read title. 1
• Do not read author’s names, affiliation etc.

• Outline the reason why the problem is 1
important. (Why you did this QA study?)

1. Selection of opportunities for improvement 2-3
(Outline of Problem) :
• What is the opportunity for improvement?
(What is the quality problem?)
• Brief description of context
(Description of the physical work
process, etc. where relevant,
to introduce the project)
• Why is this opportunity for improvement
chosen?
(Why is this problem chosen?)
• What are you trying to accomplish?

2. Key Measures 1-2
• What would constitute improvement?
• How did you measure/assess the
opportunity for improvement? (How did
you measure/assess the problem?)
• Evidence to support choice of the measures

3. Process of gathering information 3-4
• Methods and tools used to assess the
section 2 opportunity for improvement
(Methods and tools used to assess
the problem)

4. Analysis and interpretation 3-4
• What are the perceived factors that
could contribute to opportunity for
improvement?
(What are the perceived factors that
might have contributed to the existence
of this problem?)

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QA Workbook – The Problem Solving Approach – 2nd Edition

Section No of slide(s)
Tips recommended

(total of 25 slides)

• What were the results?
• What did the results tell you of the

opportunity for improvement?
(What did the results tell you of the
problem?)

5. Strategy for change 2-3
• What actual changes and/or innovation
were made?
• How were these changes and/or
innovation implemented?
• Who was or were involved in the
change and/or innovation process?

6. Effects of change 3-4
• How did the changes and/or innovation
lead to improvement?
• How did you know that improvement
had taken place?
• What have you achieved?
• What have you learned?

7. The next step 1
• How will you take this forward?

8. Value added features (only for NIA project) 1-2
• Specific creativities and innovations in
data collection, analysis and strategies
for change

References • Listed but not read out. 1
1
Acknowledgment • Listed but not read out. section 2

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QA Workbook – The Problem Solving Approach – 2nd Edition

Section Tips
Slides
Slides should be self explanatory, easily understood, appropriate graphic,
Presentation colour scheme and font size, smooth and logical flow of presentation
etc.
section 2 • Construct all slides in “landscape” orientation.
• It is advisable to construct slides in your presentation with black

text (and black illustrations) on a white background.
• Adjust font size so that that approximately 10 words fit

horizontally (24 point is usually a good size), and line spacing so
that only 10 lines would fit per slide.
• Use appropriate graph design to show your findings
• Your audience will read 100% of the text on a slide, so delete any
text that is not essential.
• Use italics instead of underlining.
• Avoid using strings of all capital letters in slide titles (and
elsewhere).
• Do not include repeated banners, logos, or backgrounds on your
slides. They are often pretentious, always distracting.
• Do not use transition fades, bouncing text, or swooshing noises

Clarity and ability of the presenter to demonstrate good understanding
about the project. (including the ability to respond to questions posed by
the judges)
• Test your presentation in the room where you will give the

presentation
• When verbally referring to a specific portion of a slide, use a

pointer to orient the audience.
• If you must use a laser pointer, do not blind people by directing

the beam in their eyes.
• Do not put your hands in your pockets.
• Do not draw more attention to bad slides by apologizing for them.
• Minimize your use of the crutches, “OK,”"like,” "um,”"er,”"sort

of,”"you know,” and “kind of.”
• Adjust your speed. Attempt a response to all questions even when

you think there is an audience member who might be able to
field it better than you.

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11.2 POSTER PRESENTATION

Section TIPS section 2
Content
General • Please refer Appendix 1

Title • Know your audience and time allocated.
• Understand the objectives of the presentation.
• Know your subject well as to be able to answer questions.
• Practice.
• Posters with 500-800 words or less are ideal. Do not make

your poster too densely packed with high word-count.
• Select appropriate font style for title, headings and body

text that is easy to read at smaller font sizes). Avoid using
dark backgrounds.
• Set line spacing of all text to be exactly 1.
• Doing this protects the aesthetics if you have used super- or
subscripted text.
• Avoid using acronyms or shorthands in your poster
• The width of text boxes should be approximately 40
characters (on average: 11 words per line). Lines that are
shorter or longer are harder to read quickly.
• Avoid blocks of text longer than 10 sentences.
• Whenever possible, use lists of sentences rather than
blocks of text.
• Use italics instead of underlining your word as it will draw
more attention to the word.
• Select color for poster diligently. In general, avoid using red
and green together, and opt to use symbols and patterns
instead of colors for graph elements.
• Do not “bullet” or punctuate section headers. Use a larger
font size for headers, with a simple “bolded” format, is
sufficient for demarcating sections.
• When using acronyms and numbers (e.g., MOGC, 2012)
within the body of text, scale down the font size by a
couple of points so that their sizes don’t overpower the
lowercase text.
• Set the tab amount manually, with the ruler feature. Do not
use “tab” feature when you are indenting a paragraph.
• When you have quotations, do not use the “double prime”
glyph, as they are used for inches (Eg: 5’11”) and
mathematical formulae.

• Format the title in “sentence case”. Avoid “Title case” and
“ALL CAPS” case.

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11.2 POSTER PRESENTATION

Section TIPS
Graphic
• Avoid titles with colons. However, if you must have a
Printing coloned title, make it short.
References
Acknowledgement • Don’t clutter the top of the poster with logos because its
presence undermines the visual impact of the images in the
rest of the poster.

• Align Y-axis labels in a graph horizontally for easy readings.
• All graphs should have axis labels formatted in “sentence

case” (not in “Title Case” and not in “ALL CAPS”).
• Never give your graphs colored backgrounds, grid lines, or

boxes.
• Never display two-dimensional data in 3-D. as it tend to

obscure true difference among bar heights.
• Make sure that details on graphs and photographs can be

comfortably viewed from 6 feet away. Axes labels, figure
legends, and numbers on axes are not exempted from font-
size guidelines.
• Use a digital camera, to get a high quality photograph. Run
your best image through Photoshop to adjust contrast,
image size, and sharpening.
• Add a thin gray or black border (but not overly thick line) to
a photograph to make it more visually appealing.

• Before printing, review the color of your poster in
Photoshop to ensure that the color scheme is of original
color setting. Printing directly from PowerPoint or PDF
cause the color rendering doesn’t work.

• List the references using font size that are the same as the
size of the normal body text.

• Listed but not read out.

section 2

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appendices section 2

section 2 QA Workbook – The Problem Solving Approach – 2nd Edition
APPENDIX 1: JUDGING CRITERIA USED IN QA MOH CONVENTIONS (ORAL & POSTER)

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QA Workbook – The Problem Solving Approach – 2nd Edition

APPENDIX 2: RESEARCH PROPOSAL

Reducing Wound Infection Rate for Diagnostic Skin Biopsy in Dermatology Clinic
Dr. Tang Jyh Jong, Sister Kong Siew Hong, Khairul Nizam

1. INTRODUCTION diagnostic skin biopsy can lead to non-healing wound
and increase workload and cost of health care.
Diagnostic skin biopsy in a common procedure done Multiple risk factors can influence the risk of
in a skin clinic to assist dermatology diagnosis. It postoperative wound infection such as poor skin
includes punch biopsy and elliptical biopsy. Wound biopsy technique, break in aseptic technique,
infection can complicate diagnostic skin biopsy and inappropriate postoperative wound care counseling,
increase morbidity to the patients. However it can be lack of cleanliness in procedure room, inappropriate
prevented with appropriate measures before, during site of biopsy, high risk patients with diabetes mellitus
and after diagnostic skin biopsy. The monthly census and smokers [Figure 1]. The aim of our study is to
in 2008 showed that the average skin biopsy infection reduce skin biopsy wound infection rate to the
rate at Dermatology Clinic of HRPBI was as high as national indicator target of less than 2%.
10%. High incidence of wound infection for

Figure 1: Problem Analysis Chart of the study

2. LITERATURE REVIEW 3. OBJECTIVES section 2

According to a study by Shyamal et al (2007), wound 3.1 GENERAL OBJECTIVE
complications as a results of diagnostic skin biopsy
occurred in 29 of 100 biopsies (29%) and out of this Our general objective is to reduce the incidence of
27 (93%) is due to wound infection. They also found wound infection for diagnostic skin biopsy in our skin
that complications occurred significantly more frequently clinic.
with biopsy performed below the waist (P=0.02), in
the ward compared with the outpatient operating 3.2 SPECIFIC OBJECTIVES
theater (P=0.001) and in smokers compared with non-
smokers (P=0.001). On the other hand, J.M. Amici et The specific objectives of this study are:
al (2005) reported only 2.09% of infectious complications 1) To verify the incidence of wound infection for
in a total of 3788 dermatology surgical procedures.
diagnostic skin biopsy

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QA Workbook – The Problem Solving Approach – 2nd Edition

2) To identify the possible contributing factors of Our study population will be dermatology patients
wound infection (either inpatient or outpatient) who underwent diagnostic
skin biopsy in clinic with sample size of 30. Exclusion
3) To formulate and implement proper remedial criteria including those with infected preoperative
measures skin surface, patients who had biopsy done in wards
and those unable to turn up for suture removal.
4) To evaluate the effectiveness of remedial
measures A data collection form will be used to collect
demographic data of patients and procedural data
Our clinical indicator is the percentage of patients regarding skin biopsy process (preoperative,
who developed wound infection out of total numbers intraoperative and postoperative steps) (Appendix 1).
of patients underwent diagnostic skin biopsy and the A photo of the skin biopsy wound will be taken after
standard is less than 2%. (National Indicator Value) wound closure which will then be assessed by our
panel of dermatologist to determine the wound
4. METHODOLOGY closure technique. It will then be classified into
satisfactory or non satisfactory technique. Wound
This is a cross sectional study which will involve 3 assessment and suture removal will be done on the
phases. The first phase is to assess the post skin biopsy designated date according to site of biopsy (Appendix
wound infection rate and to identify the possible 2). Wound outcome will then be classified into four
causes of high infection rate. This study will be done groups: 1) healed with good union 2) gaped but not
from October till November 2008. This study then infected 3) Infected but not gaped 4) Infected and
will be followed by implementation of remedial measures gaped. Wound infection rate will be calculated based
from December till February 2009. Finally the post on the total of group 3 and 4. Complete data will then
remedial evaluation will be conducted to reassess the be transferred to a master sheet as in Appendix 3.
wound infection rate from March till April 2009.

Variables Variables Scale of measurement
Operational Definition

Age of patient Age of patient as of completed year Years
Sex of patient
Answer provided to specific question Male/Female
Smoking status in questionnaire
Comorbids
Current smoking status of the patient Smoker/non-smoker
Dermatologic diagnosis
Preoperative skin biopsy site Current comorbids status of the patients If diabetic, check FBS; if FBS>12mmol/dl
Type of skin biopsy pls defer the procedure
Punch size
Number of skin biopsy As diagnosed by the medical practitioner
Site of biopsy
Size of suture Clean/infected
OT
Punch/elliptical
Standard Operating Procedure
4mm/6mm
Wound care counseling and pamphlet
given to patient 1/2
CMC ointment was used as immediate
post op dressing As examined by the medical practioner
CMC ointment given to patient for
home wound dressing As examined by the medical practioner
Photo after biopsy
Which OT that the biopsy take place _ [OT1 nearer to Room 5; OT 2 nearer to
computer room]
section 2
Compliance to the SOP ie Yes/no
Using OT slipper / Wearing mask /
Sterile glove / Proper hand washing /
Proper clean and drap

Counseling and pamphlet given or not Yes/no

Yes/no

Yes/no

Taken/not taken

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QA Workbook – The Problem Solving Approach – 2nd Edition

5. PLAN FOR DATA ANALYSIS AND end of study. The performance of the indicator set will
INTERPRETATION calculated to assess whether the standard set is
achieved. The number of patients with infected
The raw data will be processed and entered for data wound based on risk factors will also be tabulated as
analysis starting as soon as patient are recruited until below.

Table 1: Risk factors associated with post skin biopsy wound infection

section 2

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QA Workbook – The Problem Solving Approach – 2nd Edition

6. PROJECT MANAGEMENT

Proposed Gantt Chart

7. REFERENCES 3) Patrick C. Alguire, MD, Barbara M.Mathes Skin
biopsy technique for internist., MD. Journal
1) Shyamal Wahie, MB, MRCP; Clifford M. General Internal Medicine 1998; 13:46-54
Lawrence, MD, FRCP Wound Complications
Following Diagnostic Skin Biopsies in 4) American Diabetes Association Consensus
Dermatology Inpatients . Arch Dermatol/Vol Recommendations for Target Inpatient Blood
143 (NO. 10), Oct2007 Glucose Concentrations

2) J.M. Amici, A.M. Rogues, A. Lasheras,_ J.P. 5) Goldminz D, Bennett RG. Cigarette smoking
Gachie, P. Guillot,_ C. Beylot,_ L. Thomas and and flap and full-thickness graft necrosis. Arch
A. Taıeb , A prospective study of the incidence Dermatol. 1991;127(7):1012-1015.
of complications associated with dermatological
surgery British Journal of Dermatology 2005 6) Silverstein P. Smoking and wound healing. Am J
153, 967–971 Med. 1992;93(1A):22S-24S.

7) National Health Service United Kingdom / Patient
information programme /Skin biopsy2007

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QA Workbook – The Problem Solving Approach – 2nd Edition

8. APPENDICES

Appendix 1: Skin Biopsy Data Collection Form

1. Name of Patient: _______________________

2. I/C: ________________

3. Sex: M / F

4. Age: _______

5. Smoking status: Smoker / Non smoker

If smoker, please counsel patient to stop smoking for at least 1 week after skin biopsy, longer if possible

6. Comorbids: _______________________________________________
If Diabetic, please check FBS: __________
If FBS >12 mmol/dl, please defer the procedure.

7. Dermatologic Diagnosis: ____________________________________

8. Preoperative skin biopsy site: Clean / Infected

9. Type of skin biopsy: Punch / Elliptical

10. Punch Size: 4 mm / 6 mm

11. Number of skin biopsy: 1 / 2

12. Site of biopsy: 1)_________ 2)_________

13. Size of sutures: _____________________

14. OT : 1/2
OT 1 : OT nearer to Room 5
OT 2 : OT nearer to computer room

15. Standard of Operating Procedure: Doctor Assistant
a. Using OT slipper: Yes / No Yes / No
b. Wearing mask: Yes / No Yes / No
c. Sterile glove: Yes / No Yes / No
d. Proper hand washing ( 6 steps): Yes / No Yes / No
e. Proper clean and drap: Yes / No Yes / No

16. Wound care counseling and pamphlet given to patient? Yes/ No

17. CMC ointment was used as immediate post op dressing? Yes/ No
If No, please state the type of dressing: ______________

18. CMC ointment was given to patient for home wound dressing? Yes/ No section 2
If No, please state the type of dressing: ______________

19. Photo after biopsy: Taken / Not Taken

Skin biopsy done by : DR ______________________
Skin biopsy assisted by : S/N ______________________
Date of biopsy: ____________
Date of STO: ________ (Face: 5 days ; Body/Arms/Scalp :7 days ;

Back and leg: 10 days )0

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QA Workbook – The Problem Solving Approach – 2nd Edition

Apendix 2 : Skin Biopsy : Wound Assessment Form
1) Name of patient: __________________
2) Date of STO: _____________________
3) Biopsy technique (review by panel): Satisfactory / Not Satisfactory
4) Wound Inspection: (please tick in the relevant box)

Healed with good union
Gapping but not infected
Infected but not gapping
Infected and gapping

5) Wound Care at home: Yes / No
• Counseling given after biopsy? Yes / No
• CMC ointment given to patient?
Yes / No
6) If wound is infected, Yes / No
• Any antibiotic given? Yes / No
• Swab C+S taken?

7) Photo taken after STO?
8) Assessed by: Dr _______________

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