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

 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?

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.

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

• 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.)

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.

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 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

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.