quality section 2 intro

7/28/2019 Quality Section 2 Intro

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Section two: Introduction to quality management


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Introduction to quality management

Quality management explained

Quality assurance (QA) provides the basic components required of a quality system. Quality

assurance incorporates standards against which internal or external assessment is

undertaken, together with the processes in place to control the components of the quality

system. Quality assurance systems are designed to provide assurance that a particular

standard of quality has been met and maintained.

Key point

With a quality management approach, continuous improvement systems are added to QA

by incorporating a quality cycle of continuous improvement. Unlike QA, where the goal is

to meet the specified standard, quality management is seen as an ongoing journey of

continuous improvement.

A quality management system is designed to provide evidence that a specified standard

of quality has been met and continuously improved.

It is accepted as good management practice that organisations need to establish structural

supports (e.g. documented plans, policies, standard operating procedures) to provide

parameters for practice and enable them to demonstrate that those practices are sustainable.

However, in determining quality it is also acknowledged that a mechanism is needed to

measure service user outcomes and the impact of service delivery in meeting service users

needs and improving quality of life. Service users have an integral role to play in monitoring

the quality of services they receive, so providers have a responsibility to investigate and

implement a range of mechanisms for service user feedback on levels of satisfaction and

opportunities for service users to participate in the decision-making processes of the service.

The focus on outcomes is a particular strength of a quality management system approach.

Disability SectorQuality System Section 2 Introduction to quality management1

Focused on outputs

Uses a standard as the benchmark of quality

Control of systems and processes

Focused on efficiency

Driven from the top

Assures quality

Components of quality assurance

Section two


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Planning and implementing a continuous improvement strategy benefits from as much

organisational input as possible. Involving all stakeholders in continuously improving systems

and processes has significant benefits for:

service users and their families (in terms of improved outcomes, active involvement

in decision-making processes, high-quality services)

staff members (in terms of empowerment, gaining of knowledge, active involvement,

pride in achievements), and

management (in terms of more efficient deployment of resources, improved service

delivery, satisfaction of a job well done).

Section 2 Introduction to quality management Disability SectorQuality System

Introduction to quality managementcontinued

2

Quality

assuran

ce Continuousimp

rovem

en

t

Organisationalperformance

Standards Documentation Standardisation

of process Process control Planning &

evaluation

Leadership Consumer focus Participation Culture that

embraces change Continuous

improvement

Outputs

Outcomes

Quality Management System


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Focused on outcomes

Aims to establish new benchmarks for best practice

Continuous improvement of systems and processes

Focus on effectiveness

Embraced organisation-wide

Improves quality

Components of quality management

Key point

Quality mangement principles

The International Standard 8402 defines a quality system as the organisational

structure, procedures, processes and resources needed to implement quality management

(ISO 8402:1994). The driving principle is commonly accepted as customer orservice usersatisfaction. Quality is not something that occurs as an independent activity it needs to

be designed into all elements and functions of the organisation, and then systematically

controlled. Objective evidence of a quality system is provided through its documentation

(which standardises processes and procedures), through monitoring of how personnel within

the organisation implement and control those procedures, and from recorded feedback from

service users. A quality management system therefore recognises the interrelatedness of the

key components of paper, process and people in contributing to quality.

Customer or service user satisfaction comes from providers knowing what service users want,

and developing systems and processes to incorporate responses to individual needs.

Focusing on the service user and identifying his / her wants and needs is essential to

delivering effective quality services. Integral to quality management is the concept of

variation. What we are aiming to do is improve efficiencythrough elimination of waste

(of resources, time) and we do this by identifying and addressing the causes of variation and

by standardising processes. This is not to say that we do not want variation in output (e.g. a

variety of activities, a range of services, individualised service user plans). However, what we

do want to do is streamline our systems to control for process variation (e.g. the processes

we use for determining entry, for individualised service planning) to ensure our documented

procedures are being consistently applied.


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Once we have documented our processes to standardise them, we then need to continually

monitor their effectiveness. Where variation is identified, or a process is shown to be

ineffective, an opportunity for improvement exists. Significant benefits accrue through the

involvement all of the sections of the organisation in the quality system, including an

increased understanding of all systems of the organisation, and their interdependence.

Participation provides opportunities for service users, staff and management to share

knowledge, skills and experiences; to learn through review and improvement; and to share

successes. This concept is equally true for both small and large organisations.

It is important to recognise that, when you adopt a quality management approach, quality

is not something you can put in place and just forget. It is not like an obsolete policy

document on the shelf. Quality management is a journey, not a destination. Quality viewed as

a destination is really quality assurance, where you are aiming to meet a required standard,

with no commitment to improvement. Quality assurance is more applicable when your output

is a product. However, where your output is the delivery of a service, quality becomes anongoing journey. The concept of quality improvement needs to be embedded in all levels of

the organisation, and drive decision making and resource allocation. It needs to become part

of your culture. It is a way of operating. A good starting point is to include quality

improvement as a standing agenda item on all management committee meetings and

team meetings.

Key point



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Quality is defined by service user outcomes

Standardisation of processes

Continual process review and improvement

Measurability

Continual systems monitoring

Continuous improvement

Continual learning

People are the most valuable resource

Organisation-wide commitment/ involvement

Leadership

Principles of quality management

Quality management is a journey, not a destination


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Anecdotal evidence from the disability sector suggests that many providers believe they do

provide a quality service with a strong focus on service users. However, much of what theydo is not documented or formalised. The disadvantage of informal systems is their lack of

sustainability. They are highly dependent on the knowledge of key individuals within the

organisation, and this leaves an organisation and its service users vulnerable. Should those

people leave the organisation, levels of consistency may flounder, resulting in increasing

variance in the application of what had previously been commonly accepted practices. Small

services typically rely on informal systems, presenting a significant risk that corporate

knowledge will be lost in the event of the resignation of a key person. The establishment of

formal systems reduces an organisations exposure to risk.

A quality system framework includes formalisation of the services plans, policies and

procedures, as well as documentation of processes and practices such as position

descriptions, work instructions, forms, schedules, meeting minutes and system controls.

The framework may include a range of formats, such as videos, electronic systems, flowcharts

etc. Compliance with legislative and statutory requirements are integral to an organisations

quality system, necessitating development of mechanisms to monitor regulatory changes to

ensure that adjustments to policy and practices are made when appropriate.

However, it is theprocesses adopted to implement the system which are of critical

significance in ensuring that the quality initiative is effective and sustainable.

The systems approachA system can be defined as interrelated processes and their support structures

(e.g. documentation, resources) put in place to achieve a specified purpose.

A system is static. It IS.

Key point


A system is.

A system is a static concept. It exists.

It is made up of interrelated processes established to achieve

a specific purpose.

What is a system?


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Processes are the series of steps, and the resources needed, to complete a task. Processes

add value, or transform the inputs of the system to create the desired output. They are

goal-oriented, with the desired outcome directing the process. A process may be one of many

processes within the system.

A process is dynamic. It DOES.

Key point

Disability service providers have many systems, such as a system for service entry, service

user care planning, information management, grievances and complaints, financial

management, maintenance, and human resource management. Some will also have sub-

systems. For example, your human resource management system will have sub-systems for

recruitment, selection, orientation, staff training, performance management, grievances etc.,

each of which will have its own processes. Sometimes the outputfrom one system will

become the inputto another; for example, the results from staff performance monitoring may

identify the need for education on a particular topic, and this then feeds into your training

system.

Once you start thinking in terms of systems and processes, the interdependence of all

sections of the organisation become increasingly clear. The systems model encourages a

planned (rather than an ad hoc) approach to service delivery. It reminds us to set clear goals,

plan what activities we need to undertake to accomplish those goals, determine and allocate

the resources required, monitor and evaluate the effectiveness of activities, and use

evaluation findings to inform continuous improvement.

The challenge is to build in quality. Your quality system is not something that stands apart,

but is integral to your practice. The inputs to your quality system will include the results

of all your quality monitoring activities. The systems approach to quality model shows the

components of a system. These are the components, or stages, by which inputs are

transformed into outputs. By driving towards outcomes, and taking action for continuous

improvement through the feedback loop, we move the model from one of quality assurance

to quality management (refer back to the key points in the components of quality assurance

and the components of quality management, and note the different focus).



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A process does.

A process is a dynamic concept.

It is a series of steps taken to complete a task.

What is a process?


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A systems approach to management is simply a way of thinking that helps us to link

continuous improvement to all internal processes or activities. In each stage of a system

there will be processes which require monitoring for opportunities for improvement. In the

systems approach to quality model, it is the feedback loop that acts as the trigger to remind

us to thinkprocess improvement. In applying this approach, lets take as an example, the

complaints system (Service standard 7).

Scenario:

A service user complains of being late to an aqua-exercise class because the support worker

arrived late.


Inputs

Mission

Vision

Values

Throughputs Outputs

Suppliers

Processevaluation

Processevaluation

Processevaluation

Outcomes

Feedback loop

A systems approach to quality


9/19Section 2 Introduction to quality management Disability SectorQuality System


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The Happy Campers Support Service Inc.Complaints system

Who are the suppliers? the supplier of the complaintthe service user

the supplier of the complaints policythe organisations management

the management of the pool which runs the aqua-exercise class

What are the inputs? (the resources needed)

the complaint

the service users individual plan/schedule

the supervisor dealing with the complaint

the complaints policy and documented procedures

What is our goal? (What outcome do we want?) appropriate resolution of the complaint using relevant standards process

What are the throughputs? (the activities required to complete the task; these will

be dependent on the organisations policy guidelines)

The supervisor, Maree, contacts the complainant, Bill, to explain how the issue will be

investigated and to ask whether he would like to access an independent support

person.

The supervisor investigates the complaint, and finds that the times for the aqua-

exercise class had recently changed from the summer to the winter timetable.

The service users individual plan had just been changed accordingly, but the

support worker, Sue, stated that she was unaware of the changes. (Feedback loop trigger!) Poor communication was the causative factor for this

complaint. The quality improvement activity may include a review of the processes

for internal communication when individual plans are changed outside of the

organisations normal quarterly timeframes.

The supervisor contacts the management of the pool to explain the situation and

to advocate on behalf of the service user. She is able to negotiate with the

manager that the service user receive an additional class free of charge.

The supervisor enters the details in the complaints register and the service users file.

The supervisor contacts the service user to explain how the complaint has been

resolved, and to inform him that a letter will be sent confirming what has been

discussed.

What are the outputs? (the measure of activity)

the complaints register entry showing how the complaint has been resolved

the letter to the service user

the quality improvement plan

What is the outcome? (the measure of achievement)

resolution of the complaint

better communication systems which reduce the likelihood of recurrence

service user satisfaction with the resolution of the complaint


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Outputs and outcomes explained

There is often a significant amount of confusion about outputs and outcomes. Think of

the outputas the product or service that is produced from an activity. The outcome is

the result of the output. Outcomes are measured by the customer in terms of the level of

satisfaction, or the customers perception of the level of success of the activity. (The term

customeris used deliberately here, as depending on the system you are monitoring, the

customer may be the service user, staff members, or other stakeholders.)

Key point

Outcomes are subjective. They are the customers perception of quality, and are therefore

difficult to measure or to demonstrate as evidence. However, outcomes can be negotiated

in advance. This participatory approach to quality can help you to demonstrate positive

outcomes (achievements). A service users individual plan, or a staff members performance

improvement plan, can evidence practice if it stipulates the goals to be achieved.

For example, negotiating with the service user, and documenting what he or she wants to

achieve within a given timeframe (in levels of independence, social networks, recreational

goals etc.) gives you something objective to measure in relation to outcomes. The output

(activity) is the result of the plan you put in place, with all the associated steps, to enable

the service user to achieve the negotiated outcome. Similarly, following a performance

appraisal, a supervisor and staff member may negotiate and document what skills or

competencies he or she wants to develop or improve over the next year. The output may be

the courses or training attended. The outcome would hopefully be an increased level of

competence and confidence in the specified task.

An outputis a measure of activity, e.g. a meal, an individual

plan, the number of service users.

An output is an objective measure.

An outcome is a measure of achievement, e.g. service user

satisfaction, improvement of wellbeing, the ability to complete

a new task.

An outcome is a subjective measure.

Outputs and outcomes


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The intent of continuous improvement

What we are aiming to do in applying principles of continuous improvement is to improve

efficiency(by identifying critical points and controlling for variation) by maximising our use

of resources, and to improve effectiveness (by identifying individual needs, and developingappropriate responses to achieve improved outcomes). Both may require changes to existing

processes in order to gain the desired result. Sometimes organisations experience

considerable resistance to change.

We can apply a systems approach to improvement to any scenario where we are seeking to

improve or maximise service user outcomes. We are aiming to transform the inputs

(resources) into a product or service that improves client outcomes.

Key point

A simple example to illustrate the concepts ofsystems, processes and continuous

improvementcould be drawn from everyday life, such as baking a birthday cake for a friend.

Lets step through the systems approach to quality scenario shown on page 11:



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To improve efficiency (to do things right)

To improve effectiveness (to do the right things)

In order to: Improve client outcomes

Continuous improvement intent


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A homefront scenario

Baking a birthday cake for a friend (this constitutes the system)

Supplier: The provider of ingredients and equipment

Inputs: The ingredients, equipment, skills and knowledge of the person baking the cake

Throughputs: The recipe (work instructions), applied skills and knowledge (to add value

to the inputs)

Output: Delicious chocolate cake

Outcome: Delighted friend

To achieve our desired goal (outcome) we have to manage and control the processes in

each stage of the transformation process.

By monitoring the processes involved in each stage of the system, we are able to identify

potential problems and take some corrective action if a problem is identified that will

impact adversely on our desired goal. The feedback loop reminds us at each stage to

identify problems that require further planning or action for improvement.

Process monitoring may involve:

Supplier: The contractual arrangements with our suppliers ensure that our quality

requirements are met. Is this process satisfactory, or is there something we can

improve? (If an action for improvement is identified, use the feedback loop.)

Inputs: Check the ingredients are fresh, the refrigerator has maintained cold

ingredients at a safe temperature, we have suitable equipment (mixers, bowls,

oven etc.), and the person baking the cake knows how to do it! (If there is a

problem, use the feedback loop, and take some corrective action.)

Throughputs: Is the recipe a tried and true one? Is the person baking the cake an

expert or a novice (level of competency)? Is he/she following the

documented procedure (i.e. the recipe)? (These activities/resources are

critical to achieving the desired outcome. If you identify an area for

improvement here, use the feedback loop.)

Output: The cake is produced. Does the result meet our expectations? The quality

of the output is determined by the quality of the previous stages in the

system. (If the output is poor, use the feedback loop to take corrective

action, and determine what you will do to prevent a poor result next time.)

Outcome: Did we achieve our desired goal? (Even if the output is successful, the

outcome may not be positive if our friend does not like chocolate cake!

Use the feedback loop to make sure next time you consult with the friend

about likes and dislikes BEFORE commencing the transformation process.)




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As you can see from this illustration, within a system some process or activity occurs within

each stage, but most of the critical action occurs in the throughputstage. When people or

teams are new to the concept of the systems approach to management, they can get bogged

down in complexity and confusion. A useful tip to remember is: rather than looking at end

results, focus onprocess improvementand you will improve the system (and the outcome)!

Many people focus their attention just on end results (outputs), and to shift the focus to

process monitoring (throughputs) is a big mental leap. But it seems irrational to spend large

amounts of time analysing and graphing end results, and spend little or no time or thought

on planning and evaluating the processes that produce those results. End results are

represented by lag indicators, which show what happened at the conclusion of an activity.

The outcome is influenced by the quality of the output and if this is not successful the only

option may be to start again.

It is far more logical to closely monitor the processes or activities right through the

transformation process (and particularly in the throughput phase). An in-process monitoring

will give you some lead indicators that suggest what you may be able to do to correct or

improve the process, so that you can still achieve a satisfactory outcome. For example, if a

brokered agency is inconsistent or unreliable, lead indicators through frequent monitoring of

a service users progress in achieving the goals in his or her plan will give us an early

indication of a potential problem. We can then proactively address the problem through

taking corrective action by replacing the brokered agency, or preventive action by clarifying

with the agency our quality expectations, and perhaps providing some education to the

support workers the agency employs. If we do not identify that there is a problem until the

service users plan is due for formal review (that is, using lag indicators), we may have a very

dissatisfied service user who has lost confidence in our ability to provide appropriate

support, and who has made only a little progress in achieving his or her personal goals.


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Key point

Key point

The birthday cake illustration helps us understand process-focused thinking. People tend to

resist change when they are content with the way things are. If they see a reason to change

(i.e. better use of time or resources, or improved consumer outcomes) they are more likely to

embrace the change. For example, if our well-meaning cake baker was not an expert in the

kitchen, and was not following a recipe, but rather guesstimating quantities, the outcome

could have been disastrous. If the output (the cake) is a flop, there will be costs in terms

of wasted human and material and financial resources, and a disappointing outcome.

Process monitoring of lead indicators at each stage during the activity (rather than waiting

until the cake comes out of the oven) will help in identifying opportunities for improvement.

Driven by his or her desired goal (the outcome), the well-meaning friend may see the value

of seeking advice from someone more competent in the task, and documenting a procedure

(a recipe) to follow. There would be added value in that our novice baker now not only has

the confidence to bake the cake but also knows the task can be replicated in the future (i.e.

the recipe makes the process sustainable). Similarly, documenting your standard proceduresmakes your practices sustainable (and able to be evidenced).



Lag indicators are those measurements taken at the end of the

process, that is, after the horse has bolted. They focus on end results

which may be good or bad, and lead to an acceptance/rejection

mentality, rather than continuous improvement.

Lag indicators

Lead indicators are the measurements taken throughout the

process. This process focus helps you think in terms of

variation, cause and effect, methods, measurements, prevention,

and continuous improvement.

Lead indicators




Process-focused thinking helps us to be proactive in identifying and addressing potential

problems. We can then take some preventive action. Think of it as evaluation in action, to

maximise efficiencyin resource deployment.

The second element in achieving our goal (outcome) relates to knowing what our birthdayfriend would like best. Our friend may not like chocolate cake, but may love fruit cake.

Outcomes are more likely to be successful if they are negotiated in advance! This gives us

a much higher likelihood that our system and processes will be effective.

Service providers may well be utilising many of these quality management principles in the

development of individualised plans for service users. A systems approach to quality

management means that these principles need to be applied at an organisational level. The

following scenario applies the concepts of the systems approach to quality model to a

personalised plan (Service standard 2). Please note that your Individual needs planning and

review system will apply for all service users.

Scenario

Annabelle is a new service user of the Happy Campers Support Service. At the initial

interview with Annabelle and her advocate it was ascertained that her major interests were

related to country and western music and dancing. She maintained these interests at the

group home where she lived, through television programs and listening to music. Her primary

goal was to expand her social networks. Her parents lived in town, and she saw them weekly,

but she missed her brother and sister, both of whom had recently moved away from home.

A personalised plan was developed with Annabelle to help her achieve her goal (outcome).

One objective of this goal was to maintain family and friendship networks. The

following strategies were directed towards achieving the objective: charting of extended

family birthdays and special occasions to send greeting cards; weekly telephone calls to

her siblings; and re-establishing contact with old school friends.

A second objective was to establish new social networks in her local community. The

following strategies were directed towards achieving the objective: researching country

and western festivals; attending the Gympie Muster with Crossroads; joining a line-

dancing club; and joining the local council library to borrow country and western tapes.

The Happy Campers Support Service Inc. routinely brokers Handi-Help Inc. for the provision of

support workers for its service users.

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1

2


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The Happy Campers Support Service Inc.Individual needs planning and review system

Who are the suppliers?

Handi-Help is the supplier of support workers.

Happy Campers Support Service is the supplier of the personalised plan.

What are the inputs? (the resources needed)

Annabelles personalised plan

the plan coordinator

the support workers the brokerage contract

the policy and documented procedures for individual needs planning

What is our goal? (What outcome do we want?)

to achieve Annabelles goal of expanding her social networks

What are the throughputs? (the activities required to complete the task; these will

be dependent on the organisations policy guidelines)

The plan coordinator will undertake any necessary research or establish links to

achieve the stated objectives.

No country and western festivals were identified in Annabelles region but the line-dancing club was able to provide information on a country and western music

club (a feedback loop trigger ). The quality improvement activity may then be a

re-negotiation with Annabelle of the strategies in her personalised plan.

The plan implementation is negotiated with Handi-Help, with agreed support hours,

frequency, costs and reporting responsibilities included in the contract.

The plan coordinator contacts Annabelle for feedback on her support workers. She says

that Handi-Help had sent two support workers, but she didnt really like one of them

(feedback loop trigger). The plan coordinator contacts Handi-Help to arrange for a

replacement support worker. The quality improvement activity may be an amendment to

the brokerage contract to include the service users choice in engaging support workers.

The plan coordinator reviews Annabelles personalised plan in accordance with

policy guidelines.

What are the outputs? (the measure of activity relates back to throughputs)

Performance indicators in Annabelles personalised plan show the objectives and

strategies have been successfully achieved within the specified timeframes.

What is the outcome? (the measure of achievement relates back to goal)

Annabelle is happy with her success in expanding her social networks, and is

satisfied with how that process has been facilitated.




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Key point

Dissatisfaction with the current state of affairs, and a shared vision for the future, is a

strong stimulant for change. There is a cost to change in terms of time, energy and emotionalcommitment. People need to see it as adding value in some way to make it worth their

while. Participation in planning and implementing the changes develops a greater

understanding of the purpose, benefits and costs, and direct involvement in achieving

improvements is positively reinforcing for all parties.

It is the combination of all of an organisations operational systems that forms the

overarching quality system. While adoption of a quality system may necessitate considerable

effort and organisational change, it isplannedchange that has purpose and direction. In

relation to implementing a quality system, Fred David (1993:16)* argues that it is the process

rather than the decision or document [that] is the more important contribution ... Participation

is the key to gaining commitment for needed changes. When the decision to adopt a quality

management approach is related to perceived benefits in outcomes for service users, rather

than a sense of external imposition, acceptance and involvement is likely to be higher.

Key point

*David, Fred R. (1993) Strategic Management (4th edn), Macmillan Publishing Company: New York

Look to the means, and the end will look to itself (Mahatma Gandhi)

That is, focus on continually improving processes to ensure that

the output and outcomes meet your quality goals.

Focus on process, not end results

Improved service delivery outcomes

Increased consistency and reliability in service provision

Opportunities to participate in service planning, evaluation

and improvement

Confidence in the quality of services offered

Benefits of a quality management approach for service users


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Key point

Summary of core concepts in Section 2

The model of the Queensland Disability Services Quality System on page 18 graphically

depicts the interconnectedness of all the concepts presented in this section. Process

monitoring and control occurs at each stage within each system and its sub-system/s.

Inputs (information resources) for your quality system come from the results (outputs) of

activities in your continuous improvement system. Inputs for the continuous improvement

system are in turn informed by customer feedback (service users, management, staff,

stakeholders) and the results of quality monitoring processes of all sub-systems relating to

each of the ten Queensland Disability Service Standards.

Outputs from your quality system will have an impact on the decisions you make regarding

resource allocations for each system within your organisation which relate to each of the ten

standards (some of which may have their own sub-systems). Therefore, there is a two-way

flow of information/resources between systems. We are managing organisational performance

through our quality system.

Positive outcomes from your quality system lead to positive outcomes for its consumers

(which may be service users, staff or other stakeholders, depending on the area of focus

within that standard /sub-system). Within each system and/or sub-system, all our resources,

planned activities and results are directed towards improving levels of consumer satisfaction,

that is, achieving positive outcomes. In this model, consumers are not depicted as entities

that are separate to the quality system; rather, they, their needs, and our responses to meet

those needs, are integral to each component of our quality system.

A stylised interpretation of this model has been designed as the logo for the Queensland

Disability Services Quality System. The logo reminds us that every activity undertaken withinthe organisation has a direct link to the quality system, continuous improvement cycle,

performance management and service user outcomes.

Improved performance

Satisfied service users

Improved image for your service

A culture of continuous improvement

Creates a learning organisation

Increased efficiencies

More effective service delivery

Benefits of quality management approach for service providers


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Queensland Disability Services quality system model

Service user outco

mes

Continu

ous

improvementcy

cle

Qualitysystem

Individ

ual needs

Complaints & d

ispu

tes Va lued

status

Participation

&

i

n

te

gra

tion

Service

management

Le

gal&

h

uman

righ ts

Servic

eacc

ess

Decis

ion making&

choic

e

Recruitme

nt,

em

ploym

ent

& developm

ent

Priv

acy, dignity&

confid

en

tiality

quality section 2 intro

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