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Performance Improvement - The Starting Place -

Quality Improvement Science

A Discussion

Why do it?

Creating an excellent and quality product or service is thrilling and extremely rewarding. It is not passé. It is a significant strategic advantage.

While the BroadBaker Group, Ltd. consults broadly in community health strategy, governance, and breakthrough performance up and down the organization, and is not simply a “TQM” consulting firm, we have come increasingly to the firm conclusion, along with many leaders in the field, that if an organization lacks the insights and competencies derived from quality science, it is at a significant strategic disadvantage in today’s medical economy. The discipline of quality or performance improvement is probably the best current strategic doorway to achieving excellence and assuring continuing, even accelerating success. We are convinced disciples of Dr. W. Edwards Deming and the power of systematic application of his principles.

Advantages: Genuine quality improvement science correctly customer focused and diligently applied:

Strategically positions,

Improves services,

Facilitates reengineering,

Improves morale,

Stimulates creativity,

Improves market,

Improves working relationships,

Improves problem solving ability,

Improves decision making,

Significantly improves quantitative assessment skills, and,

Reduces cycle times, both development and process.

In short, there is growing consensus that the science, taken in its entire breadth, with additional contemporary tools that have been added ( such as those included in the Six Sigma movement), is one of, if not perhaps the best, current doorway to progressive leadership and management improvement that is known today. It is not simply a tool; it is a strategy.

We believe that the new full scope of the science of quality improvement leads, not only to better and better methods, but better and faster ways of identifying better methods, including process breakthroughs, all the way to including "transformation." The diagram below illustrates the accelerating nature of diligently applied quality principles:

Consequently, true quality science is profoundly strategic and integrative. It has the potential to have far-reaching advantageous effects on an organization. It’s effects reach from the manner in which top-level problems are approached, thought about, and solved and decisions made, down to basic tactical improvements in the operational corridors of the organization.

It provides the tools to understand the needs and wants of interdependent components of the organization (internal customers) as well as medical staff, patients, and guests. And since it teaches process thinking, it also readies the user for the larger world of systems thinking.

Conceptual Approach:

One way of looking at the components of the content of quality science is to break it into five areas or domains of the whole (four of them are Deming’s four parts of profound knowledge):

Understanding of systems and processes,

Understanding of variation (the voice of the process – the statistics part of quality),

Understanding people and achieving human high performance (including how teams work),

Understanding knowledge, organizational learning, retention of learning, the role of theory in knowledge development, etc.,

Knowing how to hear and understand the voice of the customer and focus strategies around the customer.

An organization cannot cherry pick these components and be successful in achieving continuous quality improvement. All the components are important and work together in an integrated manner. Well-designed training should cover all of them sufficiently to enable staff, usually in the form of teams, to begin to work on simple problems. The training teaches the skills and competencies of how to go about finding the way to improve…any problem.

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What about implementation?

Concerning implementation methods, there are three schools of thought regarding implementation of quality improvement training in an organization, 1.) to implement targeted quality improvement training on a just-in-time basis for teams as they are formed to work on specific problems, 2.) total, internalized organization-wide training (which is sustained), and 3.) a variation on the first, but focusing on vital customer-oriented processes and accelerate the training and improvement in those areas (cf. Robin Lawton’s work).

After extensive study, and review of the successful health organizations making rapid improvements, we have become convinced that experts such as Juran, Batalden (who pioneered quality improvement at HCA), et. al. are correct in their recommendation that, to gain the commitment of the organization, the organization must internalize its training and saturate the organization, top to bottom, with a knowledge of QI. This provides the basis to achieve rapid improvement and at least the basic capability to begin improvement efforts throughout the organization. This training is transformational. It gives everyone the same vocabulary and a shared vision. Additionally, it has the added benefit of accelerating and assuring the necessary cultural transformation

The method used by those organizations that do that is cascaded training, beginning at the top. Each “level” of the organization participates in training the next level (perhaps augmented by a training unit – but not to be seen as simply the responsibility of a staff-training department). It also is less expensive in out-of-pocket terms; expensive outside consultants are not required. The organization becomes permeated with the culture of QI because of its own efforts, Management levels learn and know the science (since they help teach it), and the organization gains ever increasing capability at an accelerating rate. Furthermore, the organization is much easier to align in terms of quality deployment.

On the other hand, however, successful rapid performance improvement, especially important to organizations in crisis due to serious market loss and customer unhappiness, is based on focusing on high customer requirements (or dissatisfactions) areas and core product value streams. Then selective accelerated team training in rapid performance improvement tools while launching the team-based improvement initiatives. This approach is represented by Robin Lawton's work and can show visible success to customers over a shorter period of time.

Both work, appropriate for the circumstances and Management's objectives and timing.

We are able to provide consulting in any of the options, just-in-time, customer-focused (and rapid) performance improvement or cascaded implementation depending on client preference and urgency.

We have a preferred excellent commercial training curriculum (16 hours) and have the agreement of the vendor to allow us to use it to train one senior management tier of an organization. The advantage for our clients is that this permits Management and the steering group to assess it at no addition investment and decide whether to continue to use it or select or develop a different one.

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What about clinical care?

Clinical care can be subject to the same improvement principles as other production processes. However, nationally it is proving much harder to accomplish for a variety of reasons, one of them is its complexity amplified by patient individuality. Nevertheless, certain successful implementation principles are emerging. Very divergent care patterns currently exist for the same conditions and only physicians are in a position to evaluate and appropriately alter care processes in order to optimize care. Progressive, cutting edge health care systems are discovering how to do this. It is not accomplished by mandate or by any other coercive method. Physicians, within physician organizations, are accomplishing it. That body of knowledge is also available and applicable. And the effects are the same, improved and more consistent outcomes, improved cycle times, improved patient satisfaction, and reduced cost.

Once training is underway BBG is able to assist and train in quality improvement planning and in quality deployment including quality team formation, training, facilitation, and in appropriate tool usage.

What About Safety?

Safety is a vital contemporary issue. Lack of it can destroy an organization! It should receive the highest of priorities and the necessary analytical attention. Unfortunately, in many organizations a systematic approach to safety is neither understood nor executed well.

Quality science provides the perspective and analytical tools to progressively and powerfully improve safety, the safety of both employees and customers (patients or clients). Quality science teaches us to think up-stream, up the chain of causality, and improves our causal analysis capability, (e.g., root cause analysis). Quality science also teaches us how to construct an appropriate safety information system.

However, we bring even greater power to the safety assessment process than simply the quality science tools, and that is the use of system dynamics and modeling. Modeling enables us to dynamically simulate systems and processes, which provides even greater in-depth insight into underlying systems that affect unwanted incident issues.

Most of the traditional safety improvement tools, such as root cause analysis, are linear, this-leads-to-that thinking. Most real world causal systems are multifactorial and involve complex relationships of causal factors, often, if not usually, containing feedback loops as well, adding significant complexity and unpredictability. These cannot be adequately understood without dynamic modeling.

Yes, we can teach and assist out clients in conducting the vital but traditional causal analyses and improvement actions necessary to address safety issues as required as part of responsible management (and by such entities as the Joint Commission on the Accreditation of Health Care Organizations).*

Other Domains or Competencies important for an Understanding of Performance Improvement:

These particularly include: 1.) the science or understanding of Lean Thinking (see the Lean Institute - www.lean.org), rigorous waste removal (both in knowledge work and in production work), an application of which is used in our services regarding clinical office improvement and open access, 2.) Theory of Constraints developed by Eli Goldratt, author of The Goal, and 3.) system dynamics discussed on our page dealing with system dynamic modeling. In our opinion Six Sigma competency is a more rigorous and stylized (some would say advanced - and more expensive) form of the fundamentals of quality improvement.

All are full disciplines in their own right, but their understanding and integrated application in an organization leads to breakthrough performance and a way of seeing the world in totally new ways.

* But we can also provide an additional and significant increased level of sophistication to the analytical process, if desired, by looking at safety issues through the eyes of system dynamics and its tools.

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