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 andhuman 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.
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