From Rules & Regulations to

Continuous Improvement

Presented by:Elaine Griffin, PhD, MHA, MBA, FACHELipscomb UniversityNashville, Tennessee

And the benefits of CQI… Improved learning outcomes of

the educational process (student learning outcomes)

Increased student satisfaction

Increased faculty and staff satisfaction

Improved organizational performance

Improved financial strength

Objectives for this session…

At the conclusion of this session, you will be able to: Answer the question, “Why quality?” Discuss the philosophy of CQI with its components:

- Customers and requirements- Process focus- Continuous improvement

Describe and explain the process focus of:- Quality planning- Quality measurement and reporting- Quality improvement- Cultural changes

I. Philosophy of CQI

Customers andrequirements

Process focusContinuous improvement

II. Process focus and continuous quality improvement (CQI)

Quality planning

Quality measurement and

reportingCultural changes

Qualityimprovement

We’re going to spend our time on CQI

Quality planning

Quality measurement and reporting

Quality improvement

Cultural changes

But first, let’s note some pressures on education…

Competition for students

Increased awareness by customers of educational quality

Cost of education

Continuous changes in job skills requirements to meet stakeholders’ needs

Regulatory agencies and accrediting bodies

More pressures…

Pressure from all constituents to lower educational costs

Pressure from all constituents to improve quality

How do you define quality?

Our definition:

Customers (students) define

what quality is for them. The

product or service is quality if it

meets the customer’s expectations

or requirements

Customer requirements for education

Learning outcomes

Service requirements

Cost requirements

Continuous improvement is a journey

The goal is to provide services that meet our customers’ expectations

It cannot be accomplished overnight It is accomplished over time by measuring the

performance of our processes (everything is a process)

We must take actions to improve our processes

The journey requires…

Identifying our current level of performance Setting goals for improvement Identifying new ways to improve work processes Pursuing goal achievement Celebrating Setting new goals to continuously improve

Four components

I. Quality planning

II. Quality measurement and reporting

III. Quality improvement

IV. Cultural changes

I. Quality planning

Purpose of planning: to define a corporate-wide strategy to meet customer needs and achieve the vision

Provides framework for innovation and creation of new services

Concept of customers and requirements is further developed and put into action for organization as a whole

Starts with mission, vision, values, and goals

1. Organization’s mission, vision, values, goals

Mission: purpose for existence Vision: where organization

wants to be in the future Values: principles by which

organization conducts business Goals: what organization needs

to accomplish in short run to achieve the vision

2. Department mission Each department adopts a mission, vision, values, and

goals which contribute directly to the organization’s mission, vision, values, and goals

Example:- University mission: To provide an undergraduate liberal arts education for any student, regardless of race, age, political preference, or religious preference- Department of Management mission: To educate students in the art and science of management and to prepare them for positions in the profession of management

Another way to look at it…

Organization mission, vision, values, goals

Departmental mission,vision, values, goals

Departmental mission, vision, values, goals

Departmental mission, vision, values, goals

Your turn to participate … Corporate vision: to become a

premier nationally recognized university

Finance:

Student enrollment:

Computer Center:

Your department:

Write the mission for your department Mission

Vision

Values

Goals

3. Let’s summarize quality planning Integrates departmental operations

into corporate mission and vision (alignment)

Results: corporate-wide strategy on how to meet customer requirements

Achieves vision of organization

II. Quality measurement and reporting

Includes:

Performance measurement: indicators and goals

Alignment of goals

Department continuous improvement plan

1. Performance measurement:indicators and goals

Must manage by facts Information obtained allows

decisions based on objective data Indicators are used to measure

performance Quality indicator measures the

performance of a process which meets customer requirements

Examples of indicators Student achievement

Accurate billing

Student registration process

Retention rate

Student satisfaction

How do you select indicators? Guiding principle #1:

MEASURE WHAT MATTERS

Guiding principle #2:

SET PRIORITIES

- Required by agencies (legal,

accreditation, state, strategic plan)

Guiding principle #3:

BE REASONABLE

And next?

When the measurement of an indicator demonstrates that a process needs improvement, then a goal may be established

Goals give us a target or milestone at which to aim

2. Department continuous improvement plan (CIP)

The departmental plan contains indicators for the end results or outcomes important for the department to measure, and goals for those outcomes where customer requirements are not being met

3. Let’s develop a plan…Answer these questions: What is my mission? How am I organized? Who are my stakeholders/constituents/students? With whom am I affiliated? Products and services offered (courses) How do I conduct my business (meetings, etc)? What have I promised (mission) and what are the major program

outcomes/learning objectives for my stakeholders? What are the indicators used to determine performance? What is my current performance at meeting their expectations (program

outcomes)? What is my goal for continuous improvement on this performance?

Write your own plan…YOUR UNIVERSITY

CONTINUOUS IMPROVEMENT PLAN

I. DATE:II. DEPARTMENT:III. MISSION: IV. ORGANIZATION:V. CONSTITUENTS:

Internal constituents: External constituents:

VI. AFFILIATIONS:VII. MEETINGS:VIII. STANDING COMMITTEES:IX. PROGRAM OUTCOMES:X. PERFORMANCE INDICATORS: 1. Strategic plan 2. Continuous improvement

3. Other

A little review…

UNIVERSITY MISSIONAND VISION

UNIVERSITY INDICATORS/GOALS(CORPORATE CIP)

DEPARTMENT INDICATORS/GOALS(DEPARTMENT/MAJOR CIP)

Learning Objective or Outcome For Each Major

Quality Indicators

Present (2006) Performance

CQI goal

1. Recognize, understand, and develop skills to perform and interpret accounting principles

MFT

CPA exam

GSS

Internal exams

95th percentile

Etc.

Etc.

98th percentile

2. Recognize, understand, and develop skills to perform and interpret managerial accounting principles

MFT

CPA exam

GSS

Internal exams

87th percentile 98th percentile

3. Recognize, understand, and develop skills to perform and interpret auditing principles and processes

MFT

CPA exam

GSS

Internal exams

89th percentile 98th percentile

4. Recognize, understand, and develop skills to perform and interpret cost accounting principles

MFT

CPA exam

GSS

Internal exams

85th percentile 98th percentile

5. Recognize, understand, and develop skills to perform and interpret federal income tax principles

MFT

CPA exam

GSS

Internal exams

82nd percentile 98th percentile

Bachelor of Arts in Accounting

Major Field Test Scores

0

1020

3040

5060

7080

90100

2002 S 2003 S 2004 S 2005 S 2006 S

Acc PMg Ac PAud PCA PFIT P

Semester

Per

cent

ile

Legend: Acc P = Accounting Principles; Mg Ac P = Managerial Accounting Principles; Aud P = Auditing Principles; CA P = Cost Accounting Principles; FIT P = Federal Income Tax Principles

70

75

80

85

90

95

100

2002 S 2003 S 2004 S 2005 S 2006 S

% w Job

Job upon graduation

Per

cent

of

acco

unti

ng g

radu

ates

Semester

Student satisfaction with advising (Graduating Senior Survey: GSS)

010

2030

4050

6070

8090

100

2003 S 2003 W 2004 S 2004 W 2005 S 2006 S

Sat/advis

Semester

Per

cent

sat

isfi

ed w

ith

advi

sing

CIP WorksheetYOUR UNIVERSITY

CONTINUOUS IMPROVEMENT REPORT

DEPARTMENT: Department of Accounting

OPPORTUNITY FOR IMPROVEMENT: Student achievement (Accounting Principles – Acc P)

INDICATOR: Major field test (MFT)

PRESENT LEVEL OF PERFORMANCE: 80th percentile (2002 S)

GOAL: Incremental improvement until 98th percentile

TEAM MEMBERS: Department of Accounting faculty, students, alumni, business representatives

Date initiated

Plan of action Internal or external constituent

Source of data Resources required

Estimated completion date

Measure of effectiveness

May 2003 Review curriculum Internal Accounting Curriculum

Budgeted August 2003 Improved Acc P scores if successful

Dec 2003 Identify root cause of low Acc P MFT scores

Make appropriate changes as determined

Internal and external

Students, scores, curriculum, faculty, teaching methods, etc.

NA: budgeted May 2004 Improved Acc P scores if successful

Summary FormDegree Learning Objectives/

Outcomes

How Measured

Bachelor of Arts in Accounting

Recognize, understand, and develop skills to perform and interpret accounting principles

MFT, CPA exam, GSS, Internal exams

Recognize, understand, and develop skills to perform and interpret managerial accounting principles

MFT, CPA exam, GSS, Internal exams

Recognize, understand, and develop skills to perform and interpret auditing principles and processes

MFT, CPA exam, GSS, Internal exams

Recognize, understand, and develop skills to perform and interpret cost accounting principles

MFT, CPA exam, GSS, Internal exams

Recognize, understand, and develop skills to perform and interpret federal income tax principles

MFT, CPA exam, GSS, Internal exams

Use of results: Describe how you used the data to make changes in the teaching process that ultimately led to increased student learning and improved scores

Verbs for stating general instructional objectives

Analyze Compute Interpret Perform Translate

Apply Create Know Recognize Understand

Appreciate Demonstrate Listen Speak Use

Comprehend Evaluate Locate Think Write

Verbs for stating specific learning outcomes (Complex, Logical, Judgmental Behaviors)

Analyze Conclude Deduce Formulate Plan

Appraise Contrast Defend Generate Structure

Combine Criticize Evaluate Induce Substitute

Compare Decide Explain Infer

Verbs for stating specific learning outcomes (Language Behaviors)

Abbreviate Edit Punctuate Speak Tell

Accent Hyphenate Read Spell Translate

Alphabetize Indent Recite State Verbalize

Articulate Outline Say Summarize Whisper

Call Print Sign Syllabify Write

Capitalize Pronounce

Verbs for stating specific learning outcomes (Mathematical Behaviors)

Add Derive Group Number Square

Bisect Divide Integrate Plot Subtract

Calculate Estimate Interpolate Prove Tabulate

Check Extrapolate Measure Reduce Tally

Compute Extract Multiply Solve Verify

Count Graph

4. In education, indicators frequently measure the following…

Student achievement/effectiveness of educational process- was a planned, successful outcome achieved?

Appropriateness of programming/curriculum- was the curriculum appropriate for desired outcomes?

Student satisfaction- were students satisfied with advising, etc.?

Retention rates- were retention rates acceptable?

Graduation rates- were graduation rates acceptable?

More education indicators… Customer (students, parents, community) satisfaction

- were customers satisfied with products/services and outcomes of educational process?

Enrollment management- did enrollment meet planning goals?

Campus climate- does campus climate meet mission/goals for LU?

Resource utilization- was product/service delivered in cost-effective manner?- was product/service a good value for the cost?- was product/service affordable?

5. Summary of quality measurement and reporting

Uses objective data for continuous improvement purposes Provides opportunity to know and manage current

performance Identifies opportunities to improve Prioritizes attention Requires departmental continuous improvement plan (CIP)

- measures operational and management indicators- establishes departmental goals that support corporate

goals- reports on progress towards goals

III. Quality improvement

Includes actions taken to improve processes that deliver products/services to customers

Actions can be efforts of individuals or quality improvement teams/departments

Here’s what we will discuss:

- action for improvement

- faculty/staff involvement

- continuous quality improvement teams/departments

1. Action for improvement

Here’s the process:

- identify the opportunity to improve

- analyze the problem

- take action to resolve problem

- actions can be made by individuals and teams

- requires skills that may be new to many faculty

and staff

Skills and required concepts… Understanding stakeholders

and their requirements

Measurement by facts

Process definition and analysis

Root-cause identification

Plan-Do-Check-Act on-going improvement cycle

Plan-Do-Check-Act cycle (PDCA)

Plan

DoCheck

Act

1. Plan what to do

2. Do what you planned3. Check the results

4. Act to improve what you did

2. Faculty/staff involvement in CQI

Invaluable resources Know and use the processes/deliver

the product and service Know how best to improve the

processes Closest to the “customer” Need to know:

- CQI philosophy- Department CIP plan- Problem solving skills- Customer relations skills

3. Quality improvement teams (QITs)

Groups of faculty/staff who analyze problems and recommend actions to resolve problems

Two kinds of teams:- functional (one department)- cross-functional (from different departments)

4. Summary of quality improvement

Individuals or teams can make improvements Problem-solving skills include:

- managing by facts

- process analysis

- root-cause identification and elimination

- PDCA (plan, do, check, act)

IV. Cultural changesHere are our topics for this one: Management commitment

and leadership in process Organize for CQI Education and training Communication Our professional attitude and

behavior Recognition

Paradigm shift… The shift is from one of

looking for assessment activities (narrow) to one of pursuing continuous improvement (inclusive) opportunities

Requires a “higher” approach to the process

1. Management commitment and leadership responsibilities

Knowledge of CQI Encourage innovation and

risk-taking Remove barriers Speak about CQI and process Encourage participation Provide necessary resources Become a role model

Let’s exercise…

List some barriers to CQI in the organization and in your area of responsibility

1.

2.

3.

2. Organize for CQIOrganize so everyone will know:

1. Who will develop the plan2. Who will oversee implementation3. How employees will be involved in development and

implementation4. What will be the responsibilities of:

- the board- executive staff- deans/department directors- front-line employees

5. Communication channels

3. Education

Management education CQI awareness training Problem-solving skills

- management by facts- process analysis- root cause identification- PDCA

Tools for CQI

Tools and techniques… Brainstorming Multi-voting Selection matrix Checklist Graphs Pareto diagram Process flow chart Histogram Cause-and-effect diagram Problem statement

Brainstorming Technique used to generate a large quantity of

ideas in a short time

It is useful because it encourages participation and contributions from all team members

There is a right way and a wrong way

Benchmarking Benchmarking is a process of comparing one’s

performance on a specific achievement with that of another department/organization, etc.

Usually compares one’s own performance with a “best in class”

Can be useful in setting and reaching realistic goals Can be harmful if you select one that is just a

mediocre department/company

Check-sheetWrong

Question #1

Question #2

Question #3

Etc.

Sept Oct Nov Dec Jan Feb

A check-sheet is an easy-to-use form for collecting and processing data. It is usedby teams to collect data and help identify and quantify problems.

Checklist

Registration checklist Yes No

Student ID

Admission number

Meal plan

Housing location

Adviser assigned

A checklist is a list of items or steps to be checked off or referred to in completinga process. It provides an organized way of proceeding.

Bar graph

0

10

20

30

40

50

60

70

80

90

1st Qtr 2nd Qtr 3rd Qtr 4th Qtr

East

West

North

Bar graphs visually represent comparisons among groups of data. Quantities are shown by means of uniform-width bars (rectangles) whose length is proportional tothe number being represented.

Line graph

0

10

20

30

40

50

60

70

80

90

100

1st Qtr 2nd Qtr 3rd Qtr 4th Qtr

East

West

North

A line graph is a way to visually display data for trends or comparisons.

Histogram

0

2

4

6

8

10

12

14

16

18

20

2001-02 2002-03 2003-04 2004-05

Admissions

A histogram is another type of bar chart. It is a graphic representation of the distribution of a set of data. It displays patterns that are difficult to see in a simple table of numbers.

Adm

issi

ons

in 0

00’s

Pie chart20.4

27.4

90

20.4

Section 1

Section 2

Section 3

Section 4

A pie chart is used to visually show relative relative proportions or frequency of items.It can be used to show real numbers or percentages.

Pareto chart

0

10

20

30

40

50

60

70

80

Santaoverslept

Sleighbroken

Wrong toy Wrongaddress

Reindeerill

Nu

mbe

r of

com

plai

nts

Pareto analysis is a ranked comparison of factors that make up the subject being analyzed. It helps a team focus on the vital few problems or causes of problems that have the greatest impact on what the team is trying to improve. The 80-20 rule: 80% of the problems result from 20% of the causes

Cause-and-effect diagram

Problem statement

Man Machine

Materials Methods

This technique is used to generate, organize, and display the factors that mightcontribute to a problem. Lines and arrows show relationship between problem and potential causes

Mean machineNight technician

Day super

Cleaning sol

MopsProcess for cleaning

Floors are dirty

Process flow chartRegistered for class

Arrived on campus

Found dorm room

Confirmed student identityWent to class

Picked up packet

A process flow chart is a graphic representation of the sequence of steps in a process.It also helps clarify the relationship between steps.

Problem statementIt must: Be measurable Be specific State the pain of how customers are affected

It must not: Imply blame Imply solutions

Problem statement says in specific and concrete terms what the data have revealed and what the team will now focus on improving

10 – 4 exercise Used to quickly determine priorities among

issues and/or ideas Each member given 10 points to “spend” Can vote on ideas as desired, but upper limit

is 4 points on any particular item Ideas getting the most points are declared

winners Top numbers established in advance, i.e., top

5, top 10, etc.

4. Communication

Varied – newsletters, bulletin boards, e-mail, etc.

Wide-spread

Frequent

Timely

5. Our professional attitude and behavior

We have been working “in” our profession

We must begin working “on” our profession

We are responsible for the success of (fill in the blank) University

Stakeholders expect the very best from us

We are a million dollar business unto ourselves

If this were your business, would you manage it differently?

6. Recognition Spontaneous and planned events

Individual and team recognition

Small wins and large wins

CQI efforts and successes

7. Summary of cultural changes Management’s actions demonstrate leadership

Organization’s structure must support CQI

New skills are needed for faculty and staff to participate

Information must be communicated

We must manage our business as though it were our business

Recognition should reinforce continuous improvement activities

Summary of CQI process

Quality planning

Quality measurement and reporting

Quality improvement

Cultural changes

And the benefits of CQI… Improved outcomes of the educational

processes (student learning outcomes)

Increased student satisfaction

Increased external stakeholder satisfaction

Improved organizational performance

Improved financial strength

Questions…

Verbs for stating specific learning outcomes (Creative Behaviors)

Alter Paraphrase Reconstruct Rephrase Rewrite

Ask Predict Regroup Restate Simplify

Change Question Rename Restructure Synthesize

Design Rearrange Recognize Retell Systemize

Generalize Recombine Reorder Revise Vary

Verbs for stating specific learning outcomes (General Discriminative Behavior)

Choose Detect Identify Match Place

Collect Differentiate Indicate Omit Point

Define Discriminate Isolate Order Select

Describe Distinguish List Pick Separate

Verbs for stating specific learning outcomes (Social Behaviors)

Accept Communicate Discuss Invite Praise

Agree Compliment Excuse Join React

Aid Contribute Forgive Laugh Smile

Allow Cooperate Greet Meet Talk

Answer Dance Help Participate Thank

Argue Disagree Interact Permit Volunteer

Verbs for stating specific learning outcomes (Study Behavior)

Arrange Compile Itemize Mark Record

Categorize Copy Label Name Reproduce

Chart Diagram Locate Note Search

Cite Find Lock Organize Sort

Circle Follow Man Quote Underline

Verbs for stating specific learning outcomes (Music Behavior)

Blow Compose Hum Pluck Strum

Bow Finger Mute Practice Tap

Clap Harmonize Play Sing Whistle

Verbs for stating specific learning outcomes (Physical Behaviors)

Arch Bend Catch Climb Float

Bat Carry Chase Face Grab

Grasp Kick Pull Skip Swim

Grip Knock Push Somersault Swing

Hit Lift Run Stand Throw

Hop March Skate Step Toss

Jump Pitch Ski Stretch Walk

Verbs for stating specific learning outcomes (Arts Behaviors)

Assemble Dot Illustrate Press Stamp

Blend Draw Melt Roll Stick

Brush Drill Mix Rub Stir

Build Fold Mold Sand Trace

Carve Form Nail Saw Trim

Color Frame Paint Sculpt Varnish

Construct Hammer Paste Shake Wipe

Cut Handle Pat Sketch Wrap

Dab Heat Pour Smooth

Verbs for stating specific learning outcomes (Drama Behaviors)

Act Display Express Pass Show

Clasp Emit Leave Perform Sit

Cross Enter Move Proceed Start

Direct Exit Pantomime Respond Turn

Verbs for stating specific learning outcomes (Laboratory Science Behaviors)

Apply Demonstrate Keep Prepare Specify

Calibrate Dissect Lengthen Remove Straighten

Conduct Feed Limit Replace Time

Connect Grow Manipulate Report Transfer

Convert Increase Operate Reset Weigh

Decrease Insert Plant Set