Human resource management reform in the Indonesian civil service : towards strategic fit?

Studies of strategic HRM have dominated HRM research over the last three decades. Focusing on the HRM-organisation performance relationship, researchers take various themes and perspectives in their approach to strategic HRM. Among these themes, two contrasting approaches of strategic HRM continue to flourish: first, the best practice approach suggests that certain HRM practices will have the same effect irrespective of context and, second, the best fit approach suggests that the choice of HRM practices should be designed in accordance with an organisations’ specific context. While there is little consensus on what constitutes strategic HRM, the most common feature agreed in this field is the notion of the strategic integration; aligning HRM practices with organisations’ overall strategic objectives (vertical fit) and with each other (horizontal fit). Utilising the best fit approach as its theoretical framework, this study examines how vertical and horizontal fit is practised in the Indonesian civil service and what factors likely influence the prevalence of vertical and horizontal fit in the Indonesian civil service context. This study is significant for two important reasons. Firstly, the literature suggests that there are limited studies examining the best fit concept in the civil sector despite its implementation in the private sector positively contributing to organisational performance improvement. Secondly, the study provides enlightenment on how the best fit approach could contribute to performance improvement in the Indonesian civil service. This is in line with the fact that negative images of the Indonesian civil service are continuously highlighted although various HRM reform initiatives have been put in place. To achieve the objectives of the study, the qualitative case study approach accompanied by semi-structured interviews was employed involving 53 senior officials and one focus group discussion from eight Indonesian government agencies, consisting of three central agencies mandated to manage human resources, the National Bureaucratic Reform Team and four line agencies from both central and local governments. Thematic analysis was employed for data analyses and NVIVO software was used to manage the data. The study suggests three main findings. First, various HRM initiatives in relation to the HRM reform have been introduced in the Indonesian civil service differentiating them from the old HRM practices. However, the findings indicate that some HRM policies are still contradicting and hinder vertical and horizontal fit. Second, despite the contradictory policies, vertical and horizontal fit can be seen in the line agencies which have been acknowledged as ‘reformed agencies’. This demonstrates that the line agencies play an important role in aligning HRM practices with the line agencies’ goals and objectives and with one another although they are bounded by HRM policies that are unlikely to support the vertical and horizontal fit concept. Third, factors influencing the prevalence of vertical and horizontal fit include knowledge of contemporary HRM in both central agencies and line agencies, commitment from the line agencies’ leaders, devolvement of HRM to the line agencies and the socio-political and economic environments of the Indonesian civil service. The findings of the study raise policy, practical and theoretical implications. In terms of policy implications, the study highlights the importance of fit in HRM policies to support the achievement of the line agencies’ goals. Therefore, when formulating an HRM policy, the central agencies need to ensure that the HRM policy is linked to line agencies’ goals and to other HRM policies. This is to ensure synchronisation among the policies and thus maximising the achievement of the line agencies’ goals. From the practical perspectives, the study highlights important points which can be learned by the central agencies in carrying out their strategic role with regard to the formulation of HRM policies; by the line agencies in maximising the contribution of HRM to the achievement of the goals and objectives of the agencies through the implementation of the best fit concept, and by the leaders of the agencies in providing continuous support to each of the involved parties in the line agencies and involving the HRM department in all agency’s strategic decision-making. In relation to the theoretical implication, it is clear that the best fit approach is not thoroughly applied due to factors discussed previously. However, this does not mean that the best fit concept cannot be implemented. As argued by McCourt & Ramgutty-Wong (2003), instead of adopting the whole concept of best fit, a modulated approach reflecting the best fit concept, such as selecting individual HRM practices and experimenting with devolution, is possible for civil service organisations which still embrace centralised HRM systems. As demonstrated in the findings, some of the line agencies being studied seem to be ready to adopt the best fit approach given that they have knowledge of the best fit concept, strong support from the top leader, less political intervention and less corruption, collusion, and nepotism practices in their HRM practices.

Subjective comparison of consumer television technologies for 3D visualization

This paper presents a comparison among different consumer 3D display technologies by means of a subjective assessment test. Therefore, four 55-in displays have been considered: one autostereoscopic display, one stereoscopic with polarized passive glasses, and two with active shutter glasses. In addition, a high-quality 3D video database has been used to show diverse material with both views in high definition. To carry out the test, standard recommendations have been followed considering also some modifications looking for a test environment more similar to real home viewing conditions, with the objective of obtaining more representative conclusions. Moreover, several perceptual factors have been considered to study the performance of the displays, such as picture quality, depth perception, and visual discomfort. The obtained results show interesting issues, like the performance improvement of active shutter glasses technology, the high performance of the polarized glasses technology in terms of quality and comfort, and the need of improvement of the autostereoscopic displays to complement the visual comfort to reach a global high-quality visual experience.

Distance and overcurrent relay coordination considering non standardized inverse time curves

Protective relaying comprehends several procedures and techniques focused on maintaining the power system working safely during and after undesired and abnormal network conditions, mostly caused by faulty events. Overcurrent relay is one of the oldest protective relays, its operation principle is straightforward: when the measured current is greater than a specified magnitude the protection trips; less variables are required from the system in comparison with other protections, causing the overcurrent relay to be the simplest and also the most difficult protection to coordinate; its simplicity is reflected in low implementation, operation, and maintenance cost. The counterpart consists in the increased tripping times offered by this kind of relays mostly before faults located far from their location; this problem can be particularly accentuated when standardized inverse-time curves are used or when only maximum faults are considered to carry out relay coordination. These limitations have caused overcurrent relay to be slowly relegated and replaced by more sophisticated protection principles, it is still widely applied in subtransmission, distribution, and industrial systems. In this work, the use of non standardized inverse-time curves, the model and implementation of optimization algorithms capable to carry out the coordination process, the use of different levels of short circuit currents, and the inclusion of distance relays to replace insensitive overcurrent ones are proposed methodologies focused on the overcurrent relay performance improvement. These techniques may transform the typical overcurrent relay into a more sophisticated one without changing its fundamental principles and advantages. Consequently a more secure and still economical alternative can be obtained, increasing its implementation area

Práticas de observação e análise de jogo

A Observação e Análise é uma área em crescimento nos últimos anos. Hoje em dia, a presença de um departamento de Observação e Análise nos clubes é visto como essencial uma vez que, no futebol de alto rendimento, os jogos estão cada vez mais equilibrados, sendo decididos muitas vezes por pormenores. Neste sentido existe uma maior necessidade de inclusão de equipas técnicas multidisciplinares com o objetivo de melhorar o rendimento da equipa e alcançar o sucesso. As equipas de topo devem controlar ao máximo todos os fatores que influenciam o rendimento dos jogadores e, a Observação e Análise de jogo é um deles. Este relatório surge no âmbito do estágio realizado no Sport Lisboa e Benfica, mais concretamente no departamento de Observação e Análise do Benfica LAB, na época desportiva 2014/2015. Encontra-se dividido em três partes fundamentais. A Área 1 (Prática Profissional) foca-se na exposição detalhada das formações específicas que nos foram proporcionadas bem como todas as tarefas operacionais e complementares realizadas ao longo do estágio, subjacentes a um departamento de Observação e Análise. A segunda parte é referente à Área 2 (Inovação e Investigação) – desenvolvimento de um estudo de investigação que carateriza as ações técnico-táticas individuais do Sport Lisboa e Benfica por posição (posto específico) com o objetivo de averiguar diferenças significativas entre épocas desportivas. Concluiu-se a existência de diferenças significativas. As posições que apresentaram o maior número de diferenças entre épocas desportivas foram as posições médio defensivo e primeiro avançado. Finalmente, a última parte deste relatório centra-se na Área 3 (Relação com a Comunidade). São explicados detalhadamente todos os procedimentos da organização e dinamização de um evento vocacionado para a formação de agentes que intervém direta ou indiretamente na Observação e Análise de Jogo.

Eficiência das unidades de saúde familiar na diabetes – uma abordagem por Data Envelopment Analysis

Dissertação de Mestrado, Gestão de Unidades de Saúde, Faculdade de Economia, Universidade do Algarve, 2016

System-on-a-Chip (SoC) based Hardware Acceleration in Register Transfer Level (RTL) Design

Today, modern System-on-a-Chip (SoC) systems have grown rapidly due to the increased processing power, while maintaining the size of the hardware circuit. The number of transistors on a chip continues to increase, but current SoC designs may not be able to exploit the potential performance, especially with energy consumption and chip area becoming two major concerns. Traditional SoC designs usually separate software and hardware. Thus, the process of improving the system performance is a complicated task for both software and hardware designers. The aim of this research is to develop hardware acceleration workflow for software applications. Thus, system performance can be improved with constraints of energy consumption and on-chip resource costs. The characteristics of software applications can be identified by using profiling tools. Hardware acceleration can have significant performance improvement for highly mathematical calculations or repeated functions. The performance of SoC systems can then be improved, if the hardware acceleration method is used to accelerate the element that incurs performance overheads. The concepts mentioned in this study can be easily applied to a variety of sophisticated software applications. The contributions of SoC-based hardware acceleration in the hardware-software co-design platform include the following: (1) Software profiling methods are applied to H.264 Coder-Decoder (CODEC) core. The hotspot function of aimed application is identified by using critical attributes such as cycles per loop, loop rounds, etc. (2) Hardware acceleration method based on Field-Programmable Gate Array (FPGA) is used to resolve system bottlenecks and improve system performance. The identified hotspot function is then converted to a hardware accelerator and mapped onto the hardware platform. Two types of hardware acceleration methods – central bus design and co-processor design, are implemented for comparison in the proposed architecture. (3) System specifications, such as performance, energy consumption, and resource costs, are measured and analyzed. The trade-off of these three factors is compared and balanced. Different hardware accelerators are implemented and evaluated based on system requirements. 4) The system verification platform is designed based on Integrated Circuit (IC) workflow. Hardware optimization techniques are used for higher performance and less resource costs. Experimental results show that the proposed hardware acceleration workflow for software applications is an efficient technique. The system can reach 2.8X performance improvements and save 31.84% energy consumption by applying the Bus-IP design. The Co-processor design can have 7.9X performance and save 75.85% energy consumption.

Modelling and predictive control techniques for building heating systems

Model predictive control (MPC) has often been referred to in literature as a potential method for more efficient control of building heating systems. Though a significant performance improvement can be achieved with an MPC strategy, the complexity introduced to the commissioning of the system is often prohibitive. Models are required which can capture the thermodynamic properties of the building with sufficient accuracy for meaningful predictions to be made. Furthermore, a large number of tuning weights may need to be determined to achieve a desired performance. For MPC to become a practicable alternative, these issues must be addressed. Acknowledging the impact of the external environment as well as the interaction of occupants on the thermal behaviour of the building, in this work, techniques have been developed for deriving building models from data in which large, unmeasured disturbances are present. A spatio-temporal filtering process was introduced to determine estimates of the disturbances from measured data, which were then incorporated with metaheuristic search techniques to derive high-order simulation models, capable of replicating the thermal dynamics of a building. While a high-order simulation model allowed for control strategies to be analysed and compared, low-order models were required for use within the MPC strategy itself. The disturbance estimation techniques were adapted for use with system-identification methods to derive such models. MPC formulations were then derived to enable a more straightforward commissioning process and implemented in a validated simulation platform. A prioritised-objective strategy was developed which allowed for the tuning parameters typically associated with an MPC cost function to be omitted from the formulation by separation of the conflicting requirements of comfort satisfaction and energy reduction within a lexicographic framework. The improved ability of the formulation to be set-up and reconfigured in faulted conditions was shown.

Virtual knowledge brokering : describing the roles and strategies used by knowledge brokers in a pediatric physiotherapy virtual community of practice

Introduction: Knowledge transfer in pediatric rehabilitation is challenging and requires active, multifaceted strategies. The use of knowledge brokers (KBs) is one such strategy noted to promote clinician behavior change. The success of using KBs to transfer knowledge relies on their ability to adapt to ever-changing clinical contexts. In addition, with the rapid growth of online platforms as knowledge transfer forums, KBs must become effective in virtual environments. Although the role of KBs has been studied in various clinical contexts, their emerging role in specific online environments designed to support evidence-based behavior change has not yet been described. Our objective is to describe the roles of, and strategies used by, four KBs involved in a virtual community of practice to guide and inform future online KB interventions. Methods: A descriptive design guided this study and a thematic content analysis process was used to analyze online KB postings. The Promoting Action on Research in Health Sciences knowledge transfer framework and online andragogical learning theories assisted in the coding. A thematic map was created illustrating the links between KBs' strategies and emerging roles in the virtual environment. Results: We analyzed 95 posts and identified three roles: 1) context architect: promoting a respectful learning environment, 2) knowledge sharing promoter: building capacity, and 3) linkage creator: connecting research-to-practice. Strategies used by KBs reflected invitational, constructivism, and connectivism approaches, with roles and strategies changing over time. Discussion: This study increases our understanding of the actions of KBs in virtual contexts to foster uptake of research evidence in pediatric physiotherapy. Our results provide valuable information about the knowledge and skills required by individuals to fulfill this role in virtual environments.

Un aporte a la comprensión de las estrategias emergentes en las organizaciones a través del concepto de improvisación y la metáfora musical

Este trabajo se inscribe en uno de los grandes campos de los estudios organizacionales: la estrategia. La perspectiva clásica en este campo promovió la idea de que proyectarse hacia el futuro implica diseñar un plan (una serie de acciones deliberadas). Avances posteriores mostraron que la estrategia podía ser comprendida de otras formas. Sin embargo, la evolución del campo privilegió en alguna medida la mirada clásica estableciendo, por ejemplo, múltiples modelos para ‘formular’ una estrategia, pero dejando en segundo lugar la manera en la que esta puede ‘emerger’. El propósito de esta investigación es, entonces, aportar al actual nivel de comprensión respecto a las estrategias emergentes en las organizaciones. Para hacerlo, se consideró un concepto opuesto —aunque complementario— al de ‘planeación’ y, de hecho, muy cercano en su naturaleza a ese tipo de estrategias: la improvisación. Dado que este se ha nutrido de valiosos aportes del mundo de la música, se acudió al saber propio de este dominio, recurriendo al uso de ‘la metáfora’ como recurso teórico para entenderlo y alcanzar el objetivo propuesto. Los resultados muestran que 1) las estrategias deliberadas y las emergentes coexisten y se complementan, 2) la improvisación está siempre presente en el contexto organizacional, 3) existe una mayor intensidad de la improvisación en el ‘como’ de la estrategia que en el ‘qué’ y, en oposición a la idea convencional al respecto, 4) se requiere cierta preparación para poder improvisar de manera adecuada.

La construcción de sentido (‘sensemaking’) de un entorno estratégico turbulento por parte de los altos directivos: un estudio en una multinacional automotriz

Este artículo presenta los resultados de una investigación realizada al interior de dos contextos. Por un lado, el teórico, en el marco de uno de los discursos más relevantes en los campos de la estrategia organizacional, de la managerial and organizational cognition (MOC) y, en general, de los estudios organizacionales (organization studies): la construcción de sentido (sensemaking). Por el otro, el empírico, en una de las grandes compañías multinacionales del sector automotriz con presencia global. Esta corporación enfrenta una permanente tensión entre lo que dicta la casa matriz, en relación con el cumplimiento de metas y estándares específicos, considerando el mundo entero, y los retos que, teniendo en cuenta lo regional y lo local, experimentan los altos directivos encargados de hacer prosperar la empresa en estos lugares. La aproximación implementada fue cualitativa. Esto en atención a la naturaleza de la problemática abordada y la tradición del campo. Los resultados permiten ampliar el actual nivel de comprensión acerca de los procesos de sensemaking de los altos directivos al enfrentar un entorno estratégico turbulento.

Evaluation of financial incentives as a quality improvement strategy in the public hospital context : clinician attitudes, design variables, and economic costs

In 2008, a three-year pilot ‘pay for performance’ (P4P) program, known as ‘Clinical Practice Improvement Payment’ (CPIP) was introduced into Queensland Health (QHealth). QHealth is a large public health sector provider of acute, community, and public health services in Queensland, Australia. The organisation has recently embarked on a significant reform agenda including a review of existing funding arrangements (Duckett et al., 2008). Partly in response to this reform agenda, a casemix funding model has been implemented to reconnect health care funding with outcomes. CPIP was conceptualised as a performance-based scheme that rewarded quality with financial incentives. This is the first time such a scheme has been implemented into the public health sector in Australia with a focus on rewarding quality, and it is unique in that it has a large state-wide focus and includes 15 Districts. CPIP initially targeted five acute and community clinical areas including Mental Health, Discharge Medication, Emergency Department, Chronic Obstructive Pulmonary Disease, and Stroke. The CPIP scheme was designed around key concepts including the identification of clinical indicators that met the set criteria of: high disease burden, a well defined single diagnostic group or intervention, significant variations in clinical outcomes and/or practices, a good evidence, and clinician control and support (Ward, Daniels, Walker & Duckett, 2007). This evaluative research targeted Phase One of implementation of the CPIP scheme from January 2008 to March 2009. A formative evaluation utilising a mixed methodology and complementarity analysis was undertaken. The research involved three research questions and aimed to determine the knowledge, understanding, and attitudes of clinicians; identify improvements to the design, administration, and monitoring of CPIP; and determine the financial and economic costs of the scheme. Three key studies were undertaken to ascertain responses to the key research questions. Firstly, a survey of clinicians was undertaken to examine levels of knowledge and understanding and their attitudes to the scheme. Secondly, the study sought to apply Statistical Process Control (SPC) to the process indicators to assess if this enhanced the scheme and a third study examined a simple economic cost analysis. The CPIP Survey of clinicians elicited 192 clinician respondents. Over 70% of these respondents were supportive of the continuation of the CPIP scheme. This finding was also supported by the results of a quantitative altitude survey that identified positive attitudes in 6 of the 7 domains-including impact, awareness and understanding and clinical relevance, all being scored positive across the combined respondent group. SPC as a trending tool may play an important role in the early identification of indicator weakness for the CPIP scheme. This evaluative research study supports a previously identified need in the literature for a phased introduction of Pay for Performance (P4P) type programs. It further highlights the value of undertaking a formal risk assessment of clinician, management, and systemic levels of literacy and competency with measurement and monitoring of quality prior to a phased implementation. This phasing can then be guided by a P4P Design Variable Matrix which provides a selection of program design options such as indicator target and payment mechanisms. It became evident that a clear process is required to standardise how clinical indicators evolve over time and direct movement towards more rigorous ‘pay for performance’ targets and the development of an optimal funding model. Use of this matrix will enable the scheme to mature and build the literacy and competency of clinicians and the organisation as implementation progresses. Furthermore, the research identified that CPIP created a spotlight on clinical indicators and incentive payments of over five million from a potential ten million was secured across the five clinical areas in the first 15 months of the scheme. This indicates that quality was rewarded in the new QHealth funding model, and despite issues being identified with the payment mechanism, funding was distributed. The economic model used identified a relative low cost of reporting (under $8,000) as opposed to funds secured of over $300,000 for mental health as an example. Movement to a full cost effectiveness study of CPIP is supported. Overall the introduction of the CPIP scheme into QHealth has been a positive and effective strategy for engaging clinicians in quality and has been the catalyst for the identification and monitoring of valuable clinical process indicators. This research has highlighted that clinicians are supportive of the scheme in general; however, there are some significant risks that include the functioning of the CPIP payment mechanism. Given clinician support for the use of a pay–for-performance methodology in QHealth, the CPIP scheme has the potential to be a powerful addition to a multi-faceted suite of quality improvement initiatives within QHealth.

Integrated Lean Six Sigma approach for patient flow improvement in hospital emergency department

Because of increased competition between healthcare providers, higher customer expectations, stringent checks on insurance payments and new government regulations, it has become vital for healthcare organisations to enhance the quality of the care they provide, to increase efficiency, and to improve the cost effectiveness of their services. Consequently, a number of quality management concepts and tools are employed in the healthcare domain to achieve the most efficient ways of using time, manpower, space and other resources. Emergency departments are designed to provide a high-quality medical service with immediate availability of resources to those in need of emergency care. The challenge of maintaining a smooth flow of patients in emergency departments is a global problem. This study attempts to improve the patient flow in emergency departments by considering Lean techniques and Six Sigma methodology in a comprehensive conceptual framework. The proposed research will develop a systematic approach through integration of Lean techniques with Six Sigma methodology to improve patient flow in emergency departments. The results reported in this paper are based on a standard questionnaire survey of 350 patients in the Emergency Department of Aseer Central Hospital in Saudi Arabia. The results of the study led us to determine the most significant variables affecting patient satisfaction with patient flow, including waiting time during patient treatment in the emergency department; effectiveness of the system when dealing with the patient’s complaints; and the layout of the emergency department. The proposed model will be developed within a performance evaluation metric based on these critical variables, to be evaluated in future work within fuzzy logic for continuous quality improvement.

Patients Undergoing Subacute Physical Rehabilitation following an Acute Hospital Admission Demonstrated Improvement in Cognitive Functional Task Independence

Objective. This study investigated cognitive functioning among older adults with physical debility not attributable to an acute injury or neurological condition who were receiving subacute inpatient physical rehabilitation. Design. A cohort investigation with assessments at admission and discharge. Setting. Three geriatric rehabilitation hospital wards. Participants. Consecutive rehabilitation admissions () following acute hospitalization (study criteria excluded orthopaedic, neurological, or amputation admissions). Intervention. Usual rehabilitation care. Measurements. The Functional Independence Measure (FIM) Cognitive and Motor items. Results. A total of 704 (86.5%) participants (mean age = 76.5 years) completed both assessments. Significant improvement in FIM Cognitive items (-score range 3.93–8.74, all ) and FIM Cognitive total score (-score = 9.12, ) occurred, in addition to improvement in FIM Motor performance. A moderate positive correlation existed between change in Motor and Cognitive scores (Spearman’s rho = 0.41). Generalized linear modelling indicated that better cognition at admission (coefficient = 0.398, ) and younger age (coefficient = −0.280, ) were predictive of improvement in Motor performance. Younger age (coefficient = −0.049, ) was predictive of improvement in FIM Cognitive score. Conclusions. Improvement in cognitive functioning was observed in addition to motor function improvement among this population. Causal links cannot be drawn without further research.

THE RELATIONSHIP BETWEEN ATTITUDE ASSESSMENT/ROLE PERCEPTION AND THE FINANCIAL PERFORMANCE OF HOSPITAL DEPARTMENT MANAGERS

Much of the current healthcare financial literature addresses the concern of government officials, the public, and healthcare providers regarding the need for control of health care costs. The literature suggests that attitudes of hospital department managers toward their role in financial management affects their ability to effect favorable financial results.^ There were several objectives of the dissertation: (1) To identify whether or not there exists a relationship between the attitude/role perception of hospital managers and the financial performance of their departments. (2) To compile a descriptive survey data base of key factors identified in the financial literature from individual hospitals. (3) To compile a brief descriptive survey of hospital managers' financial management background and training (both formal and informal). (4) To conduct an attitude assessment/role perception survey regarding the importance or relevance of a suggested financial management role set (i.e., issues discussed in the current literature) as viewed by the selected hospital managers and their matched administrators. (5) To propose plausible theoretical models and statistical tests of seven proposed hypotheses.^ The statistical results of a variety of methods generally suggested, for the sample population, that the null hypothesis should not be rejected concerning the relationships between a department manager's financial attitudes and role perceptions and the resultant financial performance.^ The fact that the results of this study did not suggest that there was a significant relationship which existed between role perception and financial performance does not necessarily indicate that the theories supporting such a relationship in literature are false, not that such a relationship does not exist. Several alternative theories were postulated to explain the apparent lack of statistical relationship, and suggestions for refinement and/or improvement of further research were discussed. ^

Measuring the impact of a quality improvement collaboration to decrease maternal mortality in a Ghanaian regional hospital.

OBJECTIVE: To evaluate the performance of a continuous quality improvement collaboration at Ridge Regional Hospital, Accra, Ghana, that aimed to halve maternal and neonatal deaths. METHODS: In a quasi-experimental, pre- and post-intervention analysis, system deficiencies were analyzed and 97 improvement activities were implemented from January 2007 to December 2011. Data were collected on outcomes and implementation rates of improvement activities. Severity-adjustment models were used to calculate counterfactual mortality ratios. Regression analysis was used to determine the association between improvement activities, staffing, and maternal mortality. RESULTS: Maternal mortality decreased by 22.4% between 2007 and 2011, from 496 to 385 per 100000 deliveries, despite a 50% increase in deliveries and five- and three-fold increases in the proportion of pregnancies complicated by obstetric hemorrhage and hypertensive disorders of pregnancy, respectively. Case fatality rates for obstetric hemorrhage and hypertensive disorders of pregnancy decreased from 14.8% to 1.6% and 3.1% to 1.1%, respectively. The mean implementation score was 68% for the 97 improvement processes. Overall, 43 maternal deaths were prevented by the intervention; however, risk severity-adjustment models indicated that an even greater number of deaths was averted. Mortality reduction was correlated with 26 continuous quality improvement activities, and with the number of anesthesia nurses and labor midwives. CONCLUSION: The implementation of quality improvement activities was closely correlated with improved maternal mortality.