House of Quality Analysis in Health Care

Siamak Aghlmand
Department of Health Management and Economics, School of Public Health, Tehran
University of Medical Sciences, Iran,
saghlmand@razi.tums.ac.ir
&
Rhonda Small
Mother & Child Health Research, Faculty of Health Sciences, La Trobe University, Australia,
r.small@latrobe.edu.au

Abstract
Background: Adopting a formal and reliable method for linking patient requirements
with the relevant performance measures of a care process is a top priority for high
quality clinical care.
Objective: To describe the concept and process employed in house of quality analysis,
the heart of quality function deployment, by providing a step-by-step methodology and a
case study from the maternity ward of Fayazbakhsh hospital in Iran.
Methodology: We considered the house of quality analysis as a process with both input
and output data. Major input data were patient requirements that were converted to key
performance measures and targets, as principle output data, by two matrices including a
relationship matrix and a correlation matrix.
A case study: We illustrate the steps of translating the top 20 maternal requirements into
six key performance measures throughout the house of quality analysis. Based on
identified key performance measures, we also identified six necessary organizational
functions to meet the 20 selected maternal requirements and increase maternal
satisfaction.
Discussion: The house of quality analysis provides a unique and rigorous method to
translate patient information into relevant process performance measures. This is a key
step in clinical process improvement. However, it is time-consuming and complex to
adopt. Decreasing the amount of input data can simplify the house of quality analysis.

Keywords: Quality, quality function deployment (QFD), house of quality (HoQ),

maternity care, Iran

Introduction
In view of the fact that meeting or exceeding ‘customer’/patient needs and requirements is essential to
improve quality of care processes (Iacobucci et al., 1995), patient satisfaction has gained widespread
recognition as a measure of quality in many health care organizations since the late 1980s.
Nevertheless, care providers have given less attention to converting patient data into a set of useful
decision-making information for quality improvement strategies to occur. The process for translating
patient information into organizational terms for the improvement of care has become one of the key
challenges in health care settings (Williams, 1994).
Lack of action is partly attributable to entrenched attitudes, lack of interest, limited resources,
restricted time, structural and cultural barriers, fear of negative experiences, and lack of experience in
using quality tools and techniques (Bamforth et al., 2002 and Dodek et al., 2004).
Quality function deployment (QFD) is a well-known product/service/process planning approach. It
ensures that customer requirements are systematically taken into account throughout the
product/service/process planning and design stages (Dodek et al., 2004 and Garon, 1992). QFD

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emerged in Japan in the late 1960s and it was subsequently used by both manufacturing and service
industries worldwide, yet its concept is still new in the health care arena (Akao et al., 2003).
The house of quality (HoQ), as the heart of QFD, is a matrix that provides a conceptual map for
process design and quality improvement. It is used as a construct for establishing priorities for process
performance measures to satisfy customer requirements (Büyüközkan et al., 2004). Performance
measures or quality attributes/characteristics specify what should be measured to predict customer
satisfaction so that they are used to evaluate whether or not customer requirements are fulfilled
(Madu, 2006). In summary, HoQ translates customer requirements into performance measures and
their operational targets, in order to meet customer requirements and improve satisfaction with care
(Terninko, 1997). Once customer requirements are combined with the process performance, the
probability of experiencing real improvement is significantly increased (Lloyd, 2004). The result of
HoQ analysis can derive the best combination of performance measures along with their target levels
to design a process based on important customer requirements (Lin et al., 2006).
HoQ also studies the relationship between the various elements of a system. According to general
systems theory, external and internal environments interact with each other. In addition, the internal
parts of a system interact with each other, and the interest of any part may conflict with the interests
of other parts (Bertalanffy, 1950). HoQ quantitatively analyses the interaction between the outside of
an organization (customer requirements) and the inside (performance measures). It also assesses the
synergies and conflicts among the internal parts of an organization (Shin et al., 2000).
The main objective of this paper is to convey the conceptual content and process of HoQ analysis and
illustrate its application in a clinical area by providing a step-by-step methodology and a case study
from the maternity ward of Fayazbakhsh hospital, an Iranian Social Security affiliated hospital in
Tehran.

Methodology
HoQ is a process with both input and output data (Figure 1). The input data are:
1. Important customer requirements along with their weight
2. Important performance measures
3. Benchmarking data (benchmarks)
The output data are:
1. The weight and correlation values of performance measures
2. Key performance measures (with high-weight and high-correlation)
3. Target level for each key performance measure (Chaplin et al., 2000)

Some primary activities should be performed before starting data collection. First, a cross-functional
and multidisciplinary team must be assembled based on the process to be studied. Team membership
must include people who know the process best. Just-in-time training needs to be provided for the
team members. Topics for inclusion are the concepts and background of quality improvement,
teamwork, HoQ, and the overview of statistical process control (SPC). The team members then
review the process by creating a detailed flowchart (Brown et al., 2005). Subsequently, the team
identifies the most important customer segment of the process (e.g., patient, physician, nurse or
insurer). At this time, the team members can commence to gather the necessary input data of HoQ
process in the following order:

Important customer requirements along with their weight

This step is the most important but also the most difficult and time-consuming stage of HoQ analysis
because all the following steps depend on this stage. This step is called the voice of customer (VoC)
analysis. Here, our aim is not to explain VoC analysis in detail and we only highlight some basic
methodological issues.
At the first stage, the team members interview a small sample of customers (15 to 20 people) and ask
‘why’ and ‘how’ they use the services. Customer requirements or demanded qualities (DQs) are then
extracted by re-framing customer responses as brief positive statements. Subsequently, the team
organizes DQs on a tree diagram to rank them by ‘analytical hierarchy process (AHP)’ in which the
data are compared pairwise using a 1-9 scale (Terninko, 1997 and Chaplin et al., 2000).

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The most highly ranked DQs, a maximum of 20, are used to conduct a baseline survey with a larger
group of customers (representative sample) to assess: (1) their preferences tied to selected DQs, (2)
their satisfaction level with given services in the study organization and its competitor(s), (3) the
Kano levels of requirements, including assumed (basic), expected (revealed), and unexpected
(exciting) requirements.
The results of the customer survey are then entered into the quality-planning table (QPT), in which the
weight of DQs is determined. To this end, the team identifies three variables including, target,
improvement ratio, and sales point by assessing the survey results. A target value for a DQ is found
by comparing customer preference, customer satisfaction, and the Kano’s level of the DQ, which is
determined by a 1-5 scale. The improvement ratio is the ratio of the target value to the current
customer satisfaction with the target organization’s services. Finally, sales point represents
organizational ability to meet a DQ. The rating scales of 1, 1.2, and 1.5 are used to express no,
medium, and strong ‘sales points’, respectively. The weight of a DQ is calculated by multiplying the
DQ’s importance by improvement ratio, and sales point. The weight of DQs is also expressed as a
percentage (DQs’ relative weight) (Chaplin et al., 2000 and Duhovnik et al., 2006).
Finally, selected DQs along with their relative weight are entered into HoQ matrix (Figure 1)

Important performance measures

The team uses brainstorming to generate performance measures for each selected DQ. Brainstorming
should include a review related to categories such as people, methods, equipments, materials, and the
process environments. An affinity diagram and a fishbone diagram (a DQ as effect and relevant
performance measures as causes) can be used to organize the generated ideas into like categories.
Identified performance measures are subsequently ranked for each DQ by a set of appropriate criteria
(e.g. effectiveness, cost, feasibility) using a 1-5 scale. Lastly, a few highly ranked performance
measures, as important performance measures, are selected for HoQ analysis (Figure 1), while at least
one important performance measure is kept for each of the selected DQs (Chaplin et al., 2000 and
Brown et al., 2005).

Benchmarking data
The last input data of the HoQ matrix are benchmarking data (benchmarks). A benchmark is a
measure of the best practice or performance standard against which an organization’s performance is
compared. The first step in benchmarking is to identify a competitor organization(s). Then, another
team must be organized at the competitor organization. This team assesses ‘key performance
measures’ on their own process (this will be more fully described later) (Lloyd, 2004).
As shown in Figure 1, selected DQs along with their weights, important performance measures, and
benchmarks are entered into the HoQ matrix as the input data. The output data of the HoQ process are
provided by two matrices (Figure 1):

1. Relationship matrix
The relationship matrix, as the central part of HoQ analysis, evaluates the strength of linkages
between DQs and performance measures. Selected DQs and important performance measures are
entered into the rows and columns of the matrix, respectively. The strength of relationships is assessed
by an asymmetrical four-point scale, which uses zero, 1, 3, and 9 to represent no, weak, medium, and
strong relationships, respectively. Then, the absolute and relative weights of performance measures
are calculated as follows:
The absolute weight of the jth performance measure equals the sum of the values obtained by
multiplying the relationship with the ith DQ by the corresponding relative weight of that DQ. The
absolute weight is given by Equation (1):
n
Pj = ∑ ( Di × Rij ) (1)
i =1
Where n represents the total number of DQs, Pj represents the absolute weight of the jth performance
measure, Di represents the relative weight of the ith DQ, and Rij represents the relationship between the
ith DQ and the jth performance measure (Lin et al., 2006).

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Each relative weight of a performance measure is the corresponding absolute weight, which is
rescaled as a percentage. The number of DQs predicted and how effectively they are predicted
influences the weight of the performance measure. The higher-ranking performance measures
highlight key points on the process where important DQs can be significantly met (Chaplin et al.,
2000).

2. Correlation matrix
A correlation matrix is constructed on the roof of the HoQ based on the relationships among
performance measures. In fact, the synergies and conflicts among performance measures are studied
by this matrix (Chaplin et al., 2000). A five-point asymmetrical scale is used to measure the strength
of relationship between two performance measures. The rating scale 9, 3, 0, -1, and -3, represents a
strong positive relationship, a positive relationship, the lack of any relationship, a negative
relationship, and a strong negative relationship, respectively. The mean of values related to each
performance measure (average correlation rate), are placed at the base of the corresponding column
(Figure 1). The average correlation values close to 9, 3, 0, -1, -3 represent strong positive, positive,
no, negative, and strong negative correlation, respectively (Lin et al., 2006).

Key performance measures

After determining the weight and correlation values of important performance measures, the team
uses these criteria (i.e., weight and correlation) to select a few performance measures as ‘key
performance measures’ from the list of important performance measures. The combinations of key
performance measures must cover the whole range of selected DQs (Chaplin et al., 2000).
For accurately calculating the extent of key performance measures, the current process performance
must be evaluated in the target organization and its competitor(s) at the same time, using appropriate
control charts.
There are many different kinds of control charts based on the type of assembled data (e.g., measurable
or countable data with Poisson or binomial distributions). Control charts show how a process is
performing over time and whether it is varying within an expected range or not. A control chart has
three basic components: (1) a centreline, usually the mathematical average of all the samples plotted;
(2) upper and lower statistical control limits (= Centreline ± 3δ ) ; and (3) performance data plotted.
Control charts distinguish between two types of variation: one caused by common causes and the
other caused by special causes. When variation comes only from common causes, the data points fall
within the control limits and the process is said to be ‘stable’. In contrast to common causes, special
causes of variation are out-of-the-ordinary events that disrupt the usual flow. Points outside the
control limits indicate special causes, which require immediate attention. After removing special
causes and stabilizing process performance in the target organization and its competitor(s), the
averages of data are considered as the values of key performance measures and benchmarks (Kelley,
1999). Finally, these values are entered into the base of the HoQ columns for analysis (Figure 1).

The target values of key performance measures

In the final step of HoQ analysis, the team begins to plan the actual services by setting target values
for key performance measures. Benchmarking data are incorporated at this step. Target values for
each key performance measure can be determined based on the following criteria (Chaplin et al.,
2000):
1. The importance of the key performance measure
2. The gap between the levels of the performance measures in the target organization and the
competitor organization (benchmark)
3. The technical capacity of the target organization to improve the key performance measure
4. The availability of the necessary resources
At the conclusion of this step, key performance measures and their target values are identified as the
output data of HoQ analysis. Lastly, the team can clearly define a set of organizational functions and
tasks to reach the target levels of key performance measures for meeting customer needs and
requirements.

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A Case Study
In October 2005, a team consisting of two physicians and five midwives was formed at the maternity
ward of Fayazbakhsh hospital to set improvement targets for maternity care by HoQ analysis. This
team mapped the process of maternity care and identified ‘women in labour’ as the key customer
segment of the process.
Between 31 January and 4 February 2006, the midwives conducted in-depth structured interviews
with women following birth (n=18) to identify their needs and requirements. Through these
interviews, 54 maternal requirements (DQs) were identified and numbered. Identified DQs were
organized on a tree diagram to rank by analytical hierarchy process (AHP). From the rank order, the
twenty highest-ranked DQs were selected to design a three-part questionnaire for collecting data from
a large sample of women.
To this end, a self-completed questionnaire, using Likert scale type responses was designed based on
the previously identified top twenty DQs. The questionnaire was then piloted with 15 women. From
piloting, the team could estimate the variance related to maternal preferences (=1.92) and calculate the
required sample size (n=82 with α=0.05, S2=1.92, and d=0.3). After modifying three questions, the
final questionnaire provided scale scores ranging from 0–21 and was found to be reliable, with a
Cronbach’s α of 0.90 indicating very high internal consistency (DeVellis, 2003). Between 23 July and
19 September 2006, the questionnaires were voluntarily completed by a random sample of women
(n=89), who had given birth at Fayazbakhsh hospital within the previous year.
For weighting the 20 selected DQs, the median of the answers to the questionnaires, as the results of
the survey, were entered into the quality-planning table (QPT). The team calculated the DQs’ weights
by determining three variables i.e., targets, improvement ratios, and ‘sales points’ (Table 1).
In the next stage, the team generated 160 performance measures using brainstorming and 20 cause-
and-effect diagram. The performance measures were then ranked by the consensus of the team
members using the three criteria of ‘feasibility’, ‘sustainability’, and ‘intervention possibility’. By
doing this, the twenty-seven performance measures which acquired the highest ranks, were numbered
as ‘important performance measures’ for HoQ analysis.
For weighting the first-rated performance measures, the 20 selected DQs along with their weights, and
the 27 performance measures were entered into the rows and columns of the HoQ matrix,
respectively. After determining the strength of relationship cell-by-cell between each row and column
using the asymmetrical 4-point scale, the absolute and relative weights of the performance measure
were calculated by the ‘QFD Designer V4’ software (Figure 2).
For checking the synergies and conflicts among the 27 performance measures, each cell of the roof,
which was the intersection of two performance measures, was assessed using the asymmetrical 5-
point scale. Next, the mean of scores related to each performance measure were considered as the
average correlation rate of the performance measure (Figure 2).
Subsequently, the team selected six performance measures as ‘key performance measures’ to evaluate
the 20 selected DQs, based on the highest weight and correlation values, including:
1. % of clinicians using agreed clinical guideline
2. % of obstetricians present 24 hours a day in the maternity ward
3. % of women receiving labour and childbirth education at the antenatal unit
4. % of women with a companion in the postnatal unit
5. % of doctor visits where a folding screen was used in the labour unit
6. % of women who have access to warm water during their hospital stay
In the next stage, data connected to key performance measures were collected in Fayazbakhsh and
Babak (competitor) hospitals for a period of 25 days by a constant sample size per day (n=4). The
team then studied the current process performance of maternity care at the two hospitals by
developing ‘np charts’ for each key performance measure because the data related to all key
performance measures had ‘binomial distributions’. The control charts showed the out of control
points and instability in the process at Babak hospital (Figure 3). After removing special causes, the
average of all the samples plotted, as the level of the key performance measures in Fayazbakhsh
hospital and benchmarks from Babak hospital were entered into the base of the HoQ matrix.
In the final stage, the team identified the target values for the key performance measures based on the
resources and capacities of the study hospital, as well as the benchmarks (Figure 2).

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By completing the HoQ analysis, the team established six necessary functions for maternity care at
Fayazbakhsh hospital that would better meet maternal requirements and increase maternal satisfaction
(Table 2).

Discussion
The identification of customer requirements is only a starting point for quality improvement; the next
important step is how to link the customer requirements with process performance (Lloyd, 2004).
In health care, much patient data are gathered, but these are not usually connected with clinical
processes and organizational functions. The applied method confirmed that HoQ provides a logical
and systematic means to achieve this goal. The results of the case study also showed that we could
meet the top 20 maternal requirements and significantly increase maternal satisfaction through just
simple 6 functions with defined valid targets. We are not aware of any alternative methods or
techniques to achieve these results (Ramaswamy, 1993). However, there is a clear need to test the
impact of implementing the identified functions on maternal satisfaction in future studies.
In spite of many successful applications of HoQ worldwide, there are some notable impediments to its
adoption. The large size of the HoQ matrix and the time-consuming nature for the method make it
challenging and inefficient to manage a large project, or to apply it in everyday clinical settings
without considerable resources and organizational commitment (Shin et al., 2000 and Logan, 1997).
Using a well-trained team with a good background in quality improvement as well as applying
appropriate software can help to solve this dilemma. Since the number of the matrix cells is equal to
the product of the rows and columns, so the number of customer requirements (DQs) and performance
measures selected for HoQ analysis will determine the size and complexity of the matrix. Therefore,
proper ranking of input data and selecting only a few highly ranked items can reduce the level of
detail in HoQ analysis (Chaplin et al., 2000). It is also useful to anticipate the barriers of HoQ analysis
before attempting to use this method (Dodek et al., 2004).
Comparing our work with what has appeared in the literature, we found few health care related QFD
articles in Medline and just a few papers published in industry journals. Most of the papers were not
about clinical processes nor were patients the key customers. The review of the literature also revealed
some methodological shortcomings that we have attempted to overcome in this study:

Evaluation of current process performance

For the purpose of process improvement through process redesign using QFD strategy, studying
current performance of the process is mandatory. Otherwise, the process improvement will not be
demonstrable. Control charts can be used to document that the process is stable, and QFD process can
be applied confidently. Furthermore, we cannot acquire an accurate quantity of performance measures
as well as benchmarks, without removing special causes. This important step is ignored in most
published studies (Chaplin et al., 1999, Einspruch et al., 1996, Moores, 2006, Lim, 2000, Lim et al.,
1999, Dijkstra et al., 2002, Radharamanan, 1996 and King, 1994).

Benchmarking
Although, identifying relevant benchmarks is required for objective goal setting, a technical
benchmarking process has not been applied in most of the published studies. As a result, the target
levels of key performance measures have been subjectively determined without using a set of valid
criteria (Chaplin et al., 1999, Einspruch et al., 1996, Moores, 2006, Lim, 2000, Lim et al., 1999,
Dijkstra et al., 2002, Radharamanan, 1996 and King, 1994).

In conclusion, relating patient data to care processes is a key part of any quality improvement
initiative. HoQ analysis, as the heart of the quality function deployment (QFD) strategy, is a well-
established method for this purpose, although there is as yet little experience of it in the health care
arena. Here, we have presented a step-by-step methodology, which proved feasible and useful in the
context of improving maternity care at our study hospital. Whether the methods of our case study
have value in other settings and with other clinical processes will only be seen with further work using
the methods described.

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Acknowledgements
Our thanks are due to Tehran University of Medical Sciences (TUMS) and Iranian Social Security
Organization (SSO) for financial support of this research. The authors are most grateful to Soheila
Mohammadi, Faeze Bahrami, Tahmineh Farkhani, Parisa Ghafari, Zahra Pourkalhor, Hila H. Vaziri,
and Shahnaz T. Zahrani for their invaluable contributions as members of the study team. We would
also like to thank Fayazbakhsh Hospital and La Trobe University for their sincere collaboration in
development of this research.

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Table 1: The quality-planning table

A B C D

(competitor) Rating

Improvement Ratio
Importance Rating

DQ Kano Level*

Importance (%)
Hospital Rating
Babak Hospital
Fayazbakhsh

DQ Absolute

DQ Relative
Importance
Sales Point
Customer

Target
Demanded Qualities
1. Provision of comfort 4.0 4.0 5.0 E 5.0 1.25 1.0 5.0 4.5
2. Well-being of mother 5.0 4.0 4.5 E 5.0 1.25 1.5 9.4 8.5
3. Painless vaginal examination 3.0 5.0 5.0 U 5.0 1.00 1.0 3.0 2.7
4. Normal vaginal delivery 4.0 3.0 3.0 U 4.0 1.33 1.2 6.4 5.8
5. Companionship after delivery 3.0 3.0 5.0 E 5.0 1.67 1.0 5.0 4.5
6. Listening to the fetal heartbeat 4.0 4.0 5.0 E 5.0 1.25 1.2 6.0 5.4
7. Immediate opportunity to see the newborn 4.0 4.0 5.0 E 5.0 1.25 1.0 5.0 4.5
8. Low-pain Labour 4.0 5.0 5.0 U 5.0 1.00 1.5 6.0 5.4
9. Quick response to requests 4.0 4.0 4.5 E 4.5 1.13 1.0 4.5 4.1
10. Helping mother with breastfeeding 3.0 4.0 4.0 E 4.0 1.00 1.2 3.6 3.2
11. Caring and sensitive staff 5.0 3.5 5.0 E 5.0 1.43 1.0 7.1 6.4
12. Labour and childbirth education 4.0 5.0 5.0 E 5.0 1.00 1.0 4.0 3.6
13. Well-being of baby 5.0 3.5 5.0 E 5.0 1.43 1.2 8.6 7.7
14. Bed linen changed frequently 4.0 4.0 3.5 A 4.0 1.00 1.2 4.8 4.3
15. Privacy during delivery and vaginal examination 4.0 4.0 4.5 E 4.5 1.13 1.0 4.5 4.1
16. Clean maternity ward 5.0 5.0 5.0 A 5.0 1.00 1.2 6.0 5.4
17. Improved hospital facilities 4.0 3.0 4.0 A 4.0 1.33 1.0 5.3 4.8
18. Quick admission 4.0 4.0 5.0 E 5.0 1.25 1.2 6.0 5.4
19. Short labour 4.0 5.0 5.0 E 5.0 1.00 1.2 4.8 4.3
20. Frequent monitoring 4.0 4.0 5.0 E 5.0 1.25 1.2 6.0 5.4
*A: Assumed, E: Expected, U: Unexpected
The table has listed high-ranked maternal requirements (column A) and the results of maternal survey (column
B). Targets, improvement ratios, and ‘sales points’ (column C) have been identified by assessing the survey
results. The weight of the DQs has been calculated as the output data of QPT (column D).

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Table 2: The key elements for improving the process performance of maternity care based on the maternal requirements at Fayazbakhsh hospital

Performance (%)

Performance (%)
Current

Target
No Key Performance Measure Necessary Organizational Function

1 % of clinicians using agreed clinical guideline 0 70 Using agreed evidence-based clinical guideline by clinicians

2 % of obstetricians present 24 hours a day in the maternity ward 60 80 Full-time residing obstetrician in the maternity ward
% of women receiving labour and childbirth education at the antenatal Labour and childbirth education in the prenatal and admission
3 17 80
unit units
4 % of women with a companion in the postnatal unit 36 60 Having a companion after normal vaginal delivery

5 % of doctor visits where a folding screen was used in the labour unit 0 80 Using a folding screen in the labour and delivery units

6 % of women who have access to warm water during their hospital stay 57 70 Access to warm water during the hospital stay

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 Assessing correlations among performance measures by the
asymmetrical 5-point scale:
Strong Positive = 9
Correlation Positive = 3
Matrix No Relation = 0
Negative = -1
Strong Negative = -3

(3) Important Performance Measures

Quality-planning Table
(1) Important DQs

Relationship Matrix:
Field Interview and

Important DQs
(2) Weight of

Identified by
Identified by

Assessing relationships between DQs and performance measures

by the asymmetrical 4-point scale:
AHP

1 2
Strong = 9
Medium = 3
Weak = 1
No Relation = 0

1) Weight of Performance Measures

2) Average Correlation Rate of Performance Measures

3) Selected (Key) Performance Measures

(4) Benchmarks

4) Targets of key Performance Measures

DQs: Demanded Qualities

AHP: Analytical Hierarchy Process

Figure 1: The data of house of quality (HoQ)

HoQ is constructed in six parts: 1) Important DQs 2) DQs’ weight derived from quality-planning table 3)
Important performance measures, 4) Relationship matrix that identifies relationships between DQs and
performance measures, 5) Correlation matrix (top roof) that identifies correlation rates among
performance measures, and 6) Benchmarks
The output data of HoQ are (the down rows): 1) Performance measures’ weight identified by the
relationship matrix, 2) Average correlation rate of the performance measures identified by the correlation
matrix, 3) Selected (key) performance measures for improvement (based on their weight and correlation
rates), 4) Target levels of the selected performance measure (based on the organizational recourses and
comparison of the selected performance measures values with the benchmarks)

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 Fayazbakhsh Hospital Babak Hospital

np Chart: % of women receiving labour and childbirth education at the antenatal unit, September 2006

np Chart: % of women with a companion in the postnatal unit, September 2006

np Chart: % of women who have access to warm water during their hospital stay, September 2006

Figure 3: The ‘np charts’ of three key performance measures of maternity care at Fayazbakhsh hospital and
Babak hospital. The charts show that the process performance at Fayazbakhsh hospital was stable, but
unstable in Babak hospital

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