Quality Management System: 90-day innovation cycle

Quality Management System: 90-day innovation cycle Second literature review

Supporting better quality health and

social care for everyone in Scotland

© Healthcare Improvement Scotland 2018

Published May 2018

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Contents

Questions informing the second literature review ................................................................................. 4

Key findings ............................................................................................................................................. 4

Developments in quality management principles/components ............................................................. 5

Theoretical principles from Juran and Deming ................................................................................... 5

The relationship between quality control and quality improvement ................................................. 6

High performance management systems ........................................................................................... 7

Key challenges when implementing quality management systems........................................................ 9

Leadership ......................................................................................................................................... 10

Structure and function ...................................................................................................................... 11

Customer focus and person-centred care ......................................................................................... 11

References ............................................................................................................................................. 10

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Questions informing the second literature review

What can be learned from quality management models and frameworks in the published literature

about an effective and coordinated approach to quality management?

How do theoretical principles from Juran and Deming inform how to achieve an effective quality

management approach?

What can be learned from high performance management systems?

Key findings

The Institute for Healthcare Improvement’s (IHI’s) white paper, Sustaining Improvement, outlines an

integrated framework for achieving quality management which is grounded in Juran and Deming’s

principles and informed by the attributes of high performing systems.

IHI’s framework for high-performance management systems requires a focus on developing

standard work and using quality control to monitor and adjust the system as needed. Without

quality control, IHI argue that even the best quality improvement is likely to fall short. However,

quality control is distinguished from activities relating to quality assurance or inspection.

Quality control is seen as acting as a mechanism embedded within operations for monitoring and

adjusting what should be standard for quality. When problems arise that are beyond the scope of

the local team at the front line (such as fundamental changes in clinical protocols or problems

requiring interdepartmental coordination) this is escalated to quality improvement.

Any framework for quality management requires to be translated to a specific context or situation if

it is to be implemented successfully. IHI outlines a range of factors needed to implement and

maintain a high-performance management system specific to healthcare that relate to structure,

process and culture.

Leadership and structure are key considerations for overcoming obstacles to quality management in

health and social care. The application of hard factors of quality management without addressing

structural issues and soft factors is a common cause of implementation failure.

Juran recognised the leadership challenge in healthcare organisations and how their traditional

structure is likely to feature divided leadership. The learning from high performance systems is that

flattened structures are required to reduce boundaries between units and ensure cross-function

collaboration.

In health and social care there are multiple customers with different needs, and subsequently

variable ways of defining quality. Therefore, quality planning is key for being able to identify and

addressgaps in the delivery of services to meet customer needs.

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Developments in quality management principles/components

Theoretical principles from Juran and Deming

The Juran trilogy1 is used to explain the interrelationship of three quality functions that bring about quality

management for performance: quality planning, quality control, and quality improvement. Together these

functions constitute an integrated system for coordinated and integrated attention to customers’ (that is

patients’) needs, the design and delivery of services consistent with the best technical specifications to

consistently meet those needs, and the ongoing management of the systems of delivering these services.

These processes are described in Juran’s Quality Handbook as being universal to quality management in any

context and also as being interrelated in order to achieve continuous improvement. The initial activities in

the series that relate to quality planning are described as involving planners determining who the customers

are and what their needs are1. From there, the planners then develop process designs to respond to those

needs as part of quality control which is finally handed over to operations to produce the planned design

features as part of quality improvement. IHI’s white paper, Sustaining Improvement2, describes how the

trilogy principles should work in healthcare:

Quality planning: requires an understanding of customer needs which in healthcare is

conceptualised in relation to the Triple Aim. Quality planning also includes the design and

operation of quality management systems including the principles of high performance

management.

Quality control: focuses on monitoring operations in terms of whether process remains stable in

relation to performance. When gaps in performance are identified then quality improvement

should be implemented to address these at the front line of operations.

Quality improvement: involves designated teams of managers and staff with expertise and

technical support from quality improvement specialists carrying out initiatives to develop, test

and implement changes to improve performance using a variety of tools and, if needed, carrying

out redesign. Quality control is then used to monitor the redesigned process as a result of quality

improvement to ensure it performs at a new level (with new upper and lower control limits).

Deming also shared the view that quality control was key for continuous improvement and described how

management should be responsible for establishing and maintaining quality management systems as a set

of interdependent components relating to structures, people and processes. While Juran focused

considerations of control in relation to sporadic vs chronic waste and the cost of poor quality related to

processes and systems as creating the opportunity for continuous improvement, Deming focused on causes

of variation from set standards. Both agreed that management must be responsible for implementing

necessary actions in constantly improving the quality due to common causes.

To achieve standardisation through continuous learning and improvement, the Deming Cycle, also known as

the Shewhart Cycle, was developed as a model for incremental and continuous improvement through

creating a balance between ‘planning’, ‘studying’, ‘doing’, and ‘acting’. For Deming, the cycle was how

quality management should be planned and a programme for quality control should be achieved. At a

roundtable discussion on product quality at the US Government Accounting Office, Deming is described as

having said that ‘The Deming circle is a quality control program. It is a plan for management. Four steps:

Design it, make it, sell it, then test it in service. Repeat the four steps, over and over, redesign it, make it,

etc’3. In 1991, Moen, Nolan and Provost developed Deming’s cycle to require the use of prediction and

associated theory. This enhanced the study step to compare observed data to the prediction that was made

and therefore provided the deductive-inductive process necessary for learning.

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The relationship between quality control and quality improvement

Juran’s quality control is described by IHI as being an integral component of everyday work and

management required for quality3. It involves the routine enactment of standard tasks and monitoring

performance. Juran distinguished quality control from quality assurance or inspection in the Quality

Handbook: ‘Quality control and quality assurance have much in common. Each evaluates performance. Each

compares performance to goals. Each acts on difference. However they also differ from each other. Quality

control has its primary purpose to maintain control. Performance is evaluated during operations, and

performance is compared to goals during operations. The resulting information is received and used by the

operating forces. Quality assurance’s main purpose is to verify that control is maintained. Performance is

evaluated after operations, and the resulting information is provided to both the operating forces’. 1 (p4.3)

Figure 1 from IHI’s white paper, Sustaining Improvement3, shows how quality control and quality

improvement components of quality management can be seen as interlocking cycles. Quality control acts as

a mechanism for monitoring and adjusting according to what should be standard. The ‘Adjust’ step in this

cycle is seen to involve frontline application of the Model for Improvement, with its own nested Plan-Do-

Study-Act, or PDSA, cycles to test and refine changes that will lead to improvement. When problems arise

that are beyond the scope of the local team at the front line (such as when a new protocol is introduced

that fundamentally changes processes of care or patient expectations, or when the problem requires

interdepartmental coordination), this is escalated to a higher-level quality improvement initiative to

redesign the process as part of quality improvement.

Figure 1. Quality control and quality improvement relationship from IHI (Scoville et al, 2016, p.8)3

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High performance management systems

The characteristics of high performing organisations and systems are consistent with the Juran Trilogy.

There are number of frameworks describing the characteristics of high performing systems in the literature.

A review by MacIntosh-Murray et al (2006) identified nine key attributes of high-performing organisations

and their component elements which are summarised in Table 1. For an organisation or system to achieve

high performance then they would be expected to be fulfilling the majority of these.

Table 1: Attributes of high performing systems (MacIntosh-Murray et al 2006)4

Attribute Description

Culture Organization/leaders support and expect learning and innovation.

Organization/leaders value staff and empower all members to participate.

Organization/leaders focus on customers/patients.

Organization/leaders value collaboration and teamwork.

Organization/leaders are flexible.

Leadership Strong administrative leadership that provides role models for organizational

values.

Leadership celebrates and even participates in improvement initiatives.

Emphasis on developing, fostering and inclusion in decision-making for clinical

leadership and champions.

Board support: Board sets expectations by asking for reports on improvement

initiatives and results.

Board provides continuity of expectations if administrative leadership changes.

Strategy and

policy

Leaders set clear priorities for improvement.

Improvement plans are integrated in the overall strategic plan as the means to

achieve key strategic goals.

Leaders demonstrate both constancy of purpose and flexibility.

Operational policies and procedures, including human resources policies, provide

incentives, rewards and recognition.

Incentives, rewards and recognition are aligned to support improvement work.

Structure Roles and responsibilities for improvement are clearly articulated.

Steering/oversight committees provide direction. Teams and teamwork are part of

structure.

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Attribute Description

Resources Organization provides time for staff members to learn skills and participate in

improvement work.

Financial and material resources and human resources are available for

improvement.

Quality improvement support/expertise: A core group of improvement experts is

available to help teams and individuals.

Quality improvement department coordinates and supports initiatives.

Information Needed clinical and administrative data are readily available.

Communication

channels

Organization has vehicles to communicate with stakeholders regarding priorities,

initiatives, results and learning.

Ample forms of communication, including newsletters, forums, meetings and

intranet sites.

Skills training Includes training in improvement methods, team and group work, project and

meeting management, and epidemiology.

Physician

involvement

Physicians are involved in planning improvement initiatives and participate as team

members.

Clinicians "own" improvement.

IHI has incorporated the learning from high performing systems to develop a framework for high-

performance management systems that sets out the key factors required to establish and maintain such a

system. Figure 2 displays IHI’s driver diagram in Sustaining Improvement that summarises the key factors for

implementing high performance management through management tasks, quality control (as defined by

Juran to mean monitoring the system), coordinate quality improvement and culture development to

support and sustain all of these activities. Primary drivers P1 and P2 in Figure 2 correspond with Juran’s

principles of focusing on quality control and quality improvement. The third driver explains the practices

required for achieving the culture that underpins the activities across quality planning, quality control and

quality improvement.

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Figure 2: Key factors for implementing high performing quality management systems (Scoville et al, 2016,

p.8)3

Key challenges when implementing quality management systems

Successful quality management implementation in healthcare has tended to be limited to individual

organisations or departments or in a specific area of organisational performance. Øvretveit (2000)5 analysed

all European TQM implementations in the healthcare sector concluding that only few small-scale efforts

have had great success. In a comprehensive literature review, Mosadeghrad (2013)6 identified different

categories of failures to explain why quality management has limited success in healthcare. These failures

correspond with the attributes known to be important for high performance in organisations such as

leadership and structure. Table 2 summarises the key obstacles explained in the review in relation to each

of the nine attributes required for high performance4. Juran also considered the challenges for quality

management in healthcare and how those leading quality management might respond to these.

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Table 2: Obstacles to achieving high performance attributes (Mosadeghrad 2013)6

The key challenges in relation to leadership, structure and customer focus are summarised in the following

sections.

Leadership

Juran recognised the leadership challenge in healthcare organisations as being particularly pronounced

since they are traditionally structured in a way that features divided leadership1. According to Mosadeghrad

(2013), the most inappropriate environment for quality management is where there is a lack of supportive

leadership6. The author suggests that “complementary management theories” are needed to guide quality

management implementation. The application of hard factors of quality management without addressing

structural issues and soft factors is also described as a cause of implementation failure6. A review of

High performance attributes Obstacles for quality management

Culture

Organisational culture is mentioned as a factor influencing TQM success, p155. The importance of overcoming obstacles is seen as an important cultural feature for organisations that are high performing or implementing TQM.

Leadership Leadership style is important. Poor leadership was a problem along with top-down authoritative leadership styles, p153.

Strategy and policy A successful TQM implementation needs a long-term strategic plan, p155.

Structure

Organisational structure of healthcare organisations can make it difficult to implement TQM. Mosadeghrad suggest a quality management infrastructure that consists “of a quality management council, a quality management department, a quality steering committee, functional and cross-functional quality improvement teams, and quality audit teams.” p156.

Resources

Allocating necessary resources are essential for TQM programmes to be continued effectively. Not providing adequate resources to support quality improvement programmes can be a reason for TQM failure so it is important to allocate necessary resources so improvement programmes can be implemented effectively, p158-9.

Information Fundamental to TQM is collecting timely, reliable and relevant data and information from both inside and outside the organisation for assessing, improving and evaluating purposes, p159.

Communication channels Communicating well with employees is important to improve understanding of TQM and how and why things will be done, p158.

Capacity and capability Mosadeghrad mentions that poor education and training are obstacles to TQM projects and the capacity and capability attribute mentions improvement training as being important, p155.

Clinician involvement It is important to involve and engage with frontline staff, p157.

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leadership difficulties in relation to implementing quality management in healthcare suggests that quality

management implementation needs “monolithic” visionary leadership, as described by Deming7. One

recognised category of leadership failure is a lack of senior management involvement and commitment. The

authors propose two other categories as being important, namely “combined leadership” and “political

leadership”. The former is described as being typical of large healthcare organisations with many

departments and senior managers who need to be aligned. The second category is the effect of political

influence which is particular to public healthcare which can hinder the leadership quality required for

successful implementation.

Structure and function

The complexity of the healthcare systems and their bureaucratic and departmentalised structure is

suggested to be one of the most significant challenges to achieving quality management for high

performance6. The autonomy of action that features in this structure makes resistance to change more

likely, while the multiple layers of authority inherent can impede the empowerment of employees for

ensuring quality at the front line. The traditional structure of how healthcare is delivered can therefore

make it difficult to ensure that there is coordination and integration of improvement efforts in the system

which is necessary for effective quality management. Juran considered the problem of structure for crucial

aspects of quality management. Breaking down these barriers across functions and professional autonomies

is necessary for the system change required in quality management which requires quality control and

improvement of the system of care as a whole. The characteristics of high performing organisations are how

they effectively use flattened structures with reduced boundaries between units and cross-function

collaboration4.

Customer focus and person-centred care

Quality management requires that customers are identifiable and that they can recognise and define

quality1. However, in health and social care, it is challenging to identify the range of customers and their

needs. Furthermore, the patient is not necessarily the ultimate customer because of the influence of

external stakeholders. The lack of ability of customers to judge the technical aspects of healthcare services

and variability of needs is a further challenge for having customer focus. There is the view that healthcare

organisations can tend to focus on internal quality requirements rather than actual customer needs1. Juran

considered how customer focus can be achieved in healthcare and highlighted the importance of taking a

person-centred approach in order to have ‘health care that continually views itself from the patient’s

perspective and adjusts processes to meet needs’1. Leaders in quality management are explained by Juran

as needing to understand that there are multiple ‘customers’, including patients, families, communities, and

referring institutions, and that each defines quality differently. He also describes how high performance

requires communities’ participation in collaborative health improvement and coordinated services,

especially for the elderly and people with multiple problems.

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References

1. Juran JM, Godfrey AB (eds). Juran's Quality Handbook. 5th ed. New York: McGraw Hill; 1999.

2. Moen R, Norman C. Circling back: clearing up the myths about the Deming cycle and seeing how it keeps

evolving. Qual Progress 2010;42:23–8.

3. Scoville R, Little K, Rakover J, Luther K, Mate K. Sustaining Improvement. IHI White Paper. Cambridge,

Massachusetts: Institute for Healthcare Improvement; 2016.

4. MacIntosh-Murray et al, 2006 in Baker GR, MacIntosh-Murray A, Porcellato C, Dionne L, Stelmacovich K

and Born K. High Performing Healthcare Systems: Delivery Quality By Design. Toronto: Longwoods

Publishing. 2008.

5. John Øvretveit. Total quality management in European healthcare. International Journal of Health Care

Quality Assurance, 2000;13(2):74-80.

6. Mosadeghrad AM. Obstacles to TQM success in health care systems. International journal of health care

quality assurance. 2013;26(2):147-73.

7. Andrea Chiarini, Emidia Vagnoni. TQM implementation for the healthcare sector: The relevance of

leadership and possible causes of lack of leadership, Leadership in Health Services, 2017; 30 (3):210-216.

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