EQUATION for QUALITY: Cost + Satisfaction + Outcomes = Value

“Quality is not an act. It is a habit.” Aristotle,Greek philosopher and scientist.

QUALITY IMPROVEMENT: A KEY FOR SUCCESS
“Quality is never an accident, it is always the result of high intention, sincere effort, intelligent direction
and skillful execution. It represents the wise choice of many alternatives.” – Willa Foster
EQUATION for QUALITY: Cost + Satisfaction + Outcomes = Value
What is Quality Improvement?
Quality Improvement (QI) is any action taken to increase value to the customer or other stakeholder by improving effectiveness and efficiency of processes and activities throughout the organization.Underlying QI is the notion that people can continuously improve all processes and activities through the application of systematic techniques. It also embraces the idea that there should be a relentless, ongoing hunt to eliminate sources of inefficiencies, re-work, errors, waste, and consumer or other stakeholder dissatisfaction. The Japanese use the term “Kaizen” to capture the concept. For them, Kaizen means commitment to excellence and the actual efforts to accomplish ongoing quality improvements. Quality improvement as a philosophy and process relies on each individual in the organization to build quality into every step of service development and delivery. As W. Edwards Deming, a quality founding father, said, “Quality means doing things right the
first time.”
QI is a management philosophy and tool, which contends that most things can be improved. This
philosophy does not subscribe to the theory that “if it ain’t broke, don’t fix it.” Very simply, QI is a
method of continuously examining processes and outcomes and making them more effective.
In a quality improvement context, defining quality sets the foundation for institutionalizing
improvement in an organization. Definitions of quality and philosophies are built on the notion
that people want to do their best, want to be involved in decision-making, and want the power to
help make things better.
QI is a continuous process--not merely a one-time effort, but an ongoing pursuit. If that sounds at
all discouraging, consider the alternative: if an organization does not continue its QI efforts, it runs
the risk of returning to the status quo, where processes are difficult, costly and frustrating. A key
part of QI, then, is learning to hold on to whatever gains have been achieved.
QI can bring about substantial, lasting, and positive change in
your organization. It all begins with identifying the opportunities
for improvement.

Where Does Quality Improvement Come From?
QI is a set of values, concepts and methods developed from quality principles proposed by
early and current quality coaches: W. Edwards Deming, Joseph Juran, Philip B. Crosby,
Armand Feigbaum, Robert Hayes, Kaoru Ishikawa, Ken Blanchard, Brian Joiner, Tom Peters,
Mikhail Henry (Six Sigma) and many, many others (see also – Influential People in the Quality
Field).
QI started in the Japanese and American business community as companies looked for better
ways to produce better products and services for their customers. These QI principles, tools,
and techniques have been found to work effectively in business and industry for over 40 years.
Quality improvement has been defined within business and industry as meeting and exceeding
customer needs and expectations, ensuring customer delight, and doing the right things right
each time rather than just meeting quotas and numerical goals.
Over the last three decades, QI has spread into healthcare and more recently into education and
human services. An increasing number of human service provider organizations have turned to
QI theories to improve the clinical care, service delivery and operational aspects of their
organizations. Its principles have helped to:
• Improve outcomes for consumers
• Improve consumer satisfaction
• Improve workforce retention and satisfaction
• Increase the use of preventive interventions
• Improve the organization/program defined outcomes
• Increase best practices/innovation
• Prevent loss of funding
• Reduce waste
• Reduce re-work
• Reduce errors
• Save resources – a key point for both governmental and non-profit
organizations
• Improve processes for persons served/other stakeholders (including
effectiveness, efficiency, accessibility, availability, responsiveness,
continuity, timeliness, cultural sensitivity/respectfulness, appropriateness,
etc.)
How Do Quality Assurance and Quality Improvement Compare?
Quality has gone from past emphasis on reducing things gone wrong to emphasis on increasing things
gone right.
QUALITY ASSURANCE QUALITY IMPROVEMENT

The customer comes first.
All work is part of a process.
Quality improvement never ends.
Prevention is achieved through planning.
Quality happens through people.
1. Customer Focus – Emphasis on identifying and understanding customer needs, requirements,
aspirations, preferences, and expectations. Customer-driven quality means anticipating, meeting, and exceeding customer requirements and preventing customer/stakeholder dissatisfaction. Quality is a moving target that is defined and/or judged by the customer.Services must be designed to meet the needs/requirements of consumers and/or communities served. By listening to the “Voice of the Customer,” organizations gain valuable information to drive improvement initiatives, design/implement new services, support the improvement of outcomes for consumers and brand name recognition for the organization.
2. Systems View – A holistic view that emphasizes analysis of the whole system providing
service or influencing an outcome(s). This orientation is critical in pursuing quality
enhancements across departments/program boundaries in service providing organizations.
3. Data-Driven Focus – Emphasis on the gathering and use of objective data on system or
process performance. Data are needed to analyze processes, identify problems/barriers, and
measure performance. Changes can then be tested and the resulting data analyzed to verify
that the changes have actually led to improvements.
As Mikel Harry, an implementer of Six Sigma, says, “It is only by measuring that we can
know the value of something, and we can’t improve what we don’t measure.” Without
measurement there is no way to know how a process is performing, therefore no way to
improve it. By measuring the voice of the customer and the voice of the process,
performance gaps can be identified.
! Measure the process, not the people.
! Measure for improvement, not for defense.
! Measure what you can control, not what you can't.
! Make sure data represents reality (fact), not assumption.
4. Involvement of People (Service Providers/Executive Management/Managers/ Supervisors/
Contractors/ Board Members – Everyone!!!) – Emphasis on involving the owners of all
components of a system/ process within the organization in seeking a common
understanding of service delivery processes.
Because work is accomplished through processes and systems in which different people
fulfill different functions, improvement initiatives should involve representatives of the
people who fulfill these functions. Everyone’s insight is necessary to understand changes
that need to be made and to effectively implement appropriate, improved processes, as well
as to develop ownership of the improved processes and systems.
5. Multiple Causation – Emphasis on identifying the multiple root causes of a system or
process issue/ problem/barrier/bottleneck. What causes something to be unsatisfactory?
What is the “root” of the problem?
6. Solution Identification – Emphasis on seeking a set of solutions that enhance overall
system/process performance through simultaneous improvements in a number of normally
independent functions.
7. Process Optimization – Emphasis on optimizing (making stable and capable) a process to
meet customer or other stakeholder needs/requirements, regardless of existing territories,
boundaries, and fiefdoms. Looking at a process to identify non-valued added steps,
redundancies, bottlenecks, inefficiencies, and dissatisfaction.

8.Continuing Improvement – Emphasis on continuing system’s analysis even when a
satisfactory solution to a problem is obtained. Improvement needs to be a regular part of
daily work in order to achieve the highest levels of quality and performance excellence.
9. Organizational Learning – Emphasis on organizational learning so that the organization’s
capacity to generate process improvement and foster positive changes is enhanced.
What Are Key Drivers for Quality Improvement?
Practitioners in the field of quality improvement and management have identified the building blocks
necessary for an organization’s critical success with quality improvement. What do you believe to be the
most critical block for success? What have researchers found to be the most critical?
The answer: total commitment of senior management and leadership. The total commitment of
leadership is frequently referred to as the organization’s “integrity DNA.” By possessing and consistently
adhering to the drivers for improvement, an organization’s managers and leadership will ensure a robust
quality improvement program. The “practice of quality” must be embraced by senior management and
instilled within the organization's culture. Quality is not just about implementing a system or working
towards a set of standards. It is an attitude, a way of working, that not only improves an organization but
also the way the organization works.


However, process improvement should start at the beginning, building quality into the process,
thus improving the way service/care is delivered for customers. A process must be taken apart and
conceptually put back together in a better way.
QI focuses on looking at the quality of the process and finding causes of why a process is not
performing well. Unintended variation in a process can lead to unwanted variation in outcomes.
Therefore, the workforce must seek to reduce or eliminate unwanted variation.
3. Total Commitment of Senior Managers – As stated earlier, management commitment is vital to
overcoming uncertainty, establishing credibility and providing the stability to allow change to gain
a foothold in the organization. Senior managers must create and maintain buy-in for quality
improvement at all levels of the organization. Leadership must manage the organization’s culture
and be a visible advocate for quality--“talk the talk and walk the walk.”
Talk is free, but quality takes work. Researchers in business and industry have found that there is
still a gap between what senior management says about the subject of quality and what their
organizations actually do.
Senior management must set the organization’s quality policy and strategies. Leaders must create
sensitivity to changing and emerging customer requirements/needs throughout the organization.
To create a foundation for success, senior management must demonstrate commitment to change
by removing roadblocks, providing necessary resources (training, time, etc.) and inviting
contributions from all members of the workforce.
Quality improvement places a stronger emphasis on leadership rather than management
competencies and attributes. Leadership’s critical task is to integrate, institutionalize and
internalize quality.
4. Customer Orientation – As described earlier, quality is achieved by knowing, meeting, and
exceeding the customer’s expectations.
5. Education and Training – Everyone must receive training on the organization’s quality
practices and values. All members of the workforce (the board, contractors, managers, and
staff) must know the organization’s quality values, goals for consumers/other stakeholders and
the outcomes associated with these goals. This information must be provided to new members
of the workforce. Retraining for all staff members should be provided as the organization’s
quality values and the quality program evolve. Experts in the field of managing quality also
recommend training for the workforce in customer-supplier relationships.
“In God we trust, all others send data” is the mantra for a quality-driven organization. Quality
decisions are based on objective data. The right changes are uncovered through statistical
methods and finding the root causes of process deficiencies. To use data proficiently requires
that the workforce receive training in quality tools1, problem-solving tools, measurement and
understanding of variation.
6. Employee Participation in Making Improvements – Those that do the work are most
knowledgeable about how to improve it. They are frequently referred to as the “process
owners.” Empowering the workforce and helping everyone to be a change agent or steward for
quality is critical to an organization’s success with quality improvement. The workforce must
be supported in their efforts to facilitate review and analysis, prioritize opportunities for
improvement and initiate positive change. QI operates on the breaking down of old paradigms.
Its beliefs include:
• Work can be enjoyable.
• Employees prefer self-control.
• Employees with creative capacity for solving problems are widely distributed throughout the organization.
• Employees can be self-directed and creative if motivated.
7. Teamwork – Teamwork integrates behaviors that help the total organization exceed the sum of its parts. Teamwork promotes cooperation, coordination, information sharing, mutual support, consensus decision-making, etc. Working together across functions and departments,breaking down silos and problem-solving are critical drivers for improvement teams.
8. Recognition and Reward – People will act accordingly to how they are received and
rewarded. QI thrives on the elimination of blame, finger pointing, and fire fighting. QI
concentrates on catching persons doing something right. Workforce reward and recognition
must be aligned with an organization’s quality values and improvement initiatives. In assessing
reward systems, an organization must consider what process behavior the reward or
recognition promotes or inhibits.
9. Organizational Culture Supports Quality Goals – To create a culture of quality, an
organization must align its organizational processes with quality planning and desired
outcomes. Quality leadership starts with the leaders who plant the seeds, create the
environment for success, empower others and deploy quality throughout the organization.
What are the Steps in Quality Improvement?
Improvement is based on building knowledge of what works and does not work, and applying it
appropriately. When an organization engages in true process improvement, it seeks to learn what
causes things to happen in a process and to use knowledge to reduce variation, remove activities that
1 Quality improvement tools are numeric and graphic devices used to help individuals and the workforce work with, understand and improve processes. There are seven tools of quality that have made an indispensable contribution to the quality improvement movement: 1. Pareto diagram, 2. cause-and-effect diagram, 3. histogram,
4. control chart, 5. scatter diagram, 6. flowchart, and 7. run chart.

do not add value to service delivery or consumers/other stakeholders and improve satisfaction or
outcomes.
Quality improvement offers a “trial and learning” approach that helps reveal the outcomes of change.
Testing a change can be accomplished by using the PDCA Cycle: P=Plan; D=Do; C=Check; A=Act.
Plan
• Identify and/or clarify what is not working, what slows things down, adds unnecessary steps or
does not meet customer needs or requirements. Define the problem and the aim. Where are we
now and where do we want to be.
• Design a "best-guess" solution--a new process model based on best practices for care or service
delivery. Research the literature, benchmark with similar service delivery providers to learn
what best practices they are employing or partner with them to set some benchmarks or goals
to measure performance (what?) against.
• Ensure that the new process won't irritate people, slow them down or cost too much of their
time or other resources.
Do
• Carry out your change, perhaps on a pilot or small-scale basis.
• Collect the least amount of data that you need to make a quick check of the outcome and how
it adds value – is it increasing or decreasing frustration, productivity, cost or
outputs/outcomes?
• Correct obvious mistakes on the fly.
• Roll out the new process agency-wide.
• Mandate feedback from individuals about why they diverge from the new process.
• Change the process based on the feedback until there is 80 percent conformance.
• Share data with those doing the work (the process owners). Individuals generally will move
themselves toward best practices or the best solutions for problem solving if presented with
meaningful data.
• Allow for time to improve performance.
Check
• Monitor for assignable variation, both positive and negative (i.e., consumers/staff doing better
or worse, other stakeholders unhappy or happy, the process/system not doing well).
• Ask the end-users again for ways to improve the process.
Act
• Act on what you have learned. Continue to make improvements in the process by going
through the cycle again, starting at "Plan." Remember a good outcome starts with a good
process.
Three basic questions that need to be addressed in any improvement initiative (see Figure 1 below):
Figure 1: BASIC MODEL FOR QUALITY IMPROVEMENT
What are we trying to accomplish?
How will we know a change is an
improvement?
What change can we make that will
result in improvement?
Act Plan
Check Do
1 Identify a process
2 Define the purpose of the process
3 Identify the primary customers
4 Determine the customer’s expectations about the process
5 Determine if expectations are being met and identify opportunities for improvement
6 Identify root causes of problems/challenges/deficiencies/etc.
7 Plan improvements
8 Implement improvements
9 Evaluate improvements
10 Revise as needed
Bringing it Full Circle
The plan-do-check-act (PDCA) cycle or the ten-step model is used throughout the quality
improvement process and provides a framework that encourages either rapid or incremental
change. Quality improvement does not end after a change has been enacted. To hold the gains,
an organization must work through the cycle again and again.
Reality Check
Perhaps the most important key to holding the gains of QI is harnessing basic human behavior. If
the new process or system is to succeed in the long run, individuals must want it to succeed. And
most individuals will only want it to succeed if it decreases work, increases efficiency, decreases
frustration/ dissatisfaction or improves outputs or outcomes. If you've created a new process that
is cumbersome (too many steps) or costs too much time, for example, you will have great
difficulty maintaining that process, even if following it does result in better outcomes. As you
work to hold the gains from the improvement, then, you must continually check to make sure

that whatever changes you have made, or plan to make, will satisfy the basic needs and
requirements of consumers/other stakeholders.
Keeping the Momentum
The main purpose of the PDCA or ten-step framework is to set targets for improvement,
develop a yardstick for measuring improvement, formulate and implement actions to achieve
improvement, and check the yardstick to see whether the actions worked.
Via the cycle, you want to maintain momentum and enact useful changes as quickly as
possible. At this stage of QI, your organization has already gone through the cycle at least once
to enact your improvement idea, but practical and useful ideas are bound to surface after the
fact. An organization should implement good ideas as soon as they appear and then check their
impact.
When studying the impact of a change, harvest as little data as necessary. Often, you need as
few as six data points to arrive at a quick check of an improvement. If the data look promising,
keep the change and continue to collect more data. If they don't look promising, modify the
change or discard it. Whatever you do, keep the momentum going.
Successful implementation of quality improvement requires commitment, focus and
patience, but the rewards are substantial. Beyond the obvious practical benefits,
organizations become empowered to solve persistent process and performance challenges
while raising the expectations they set for themselves. A quality organization understands
that the realization of quality must be continually energized and regenerated.