Section two: Introduction to quality management

Section two

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 Components of quality assurance

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

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.

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Quality Management System

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Standards Documentation Standardisation of process Process control Planning & evaluation Organisational performance

Leadership Consumer focus Participation Culture that embraces change Continuous improvement

Outputs

Outcomes
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).

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Introduction to quality management

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Introduction to quality management

Key point Components of quality management
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

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 or service user satisfaction. 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 efficiency through 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 an ongoing 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 Principles of quality management

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 Quality management is a journey, not a destination

Section 2

Introduction to quality management

Disability Sector Quality System

Introduction to quality management

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 they do 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 the processes adopted to implement the system which are of critical significance in ensuring that the quality initiative is effective and sustainable.

The systems approach

A 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 What is a system?

A system is. A system is a static concept. It exists. It is made up of interrelated processes established to achieve a specific purpose.

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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 What is a process?

A process does. A process is a dynamic concept. It is a series of steps taken to complete a task.

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 subsystems. 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 output from one system will become the input to 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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Introduction to quality management

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Introduction to quality management

A systems approach to quality Mission Values Vision Suppliers Inputs Throughputs Outputs Outcomes

Process evaluation

Process evaluation

Process evaluation

Feedback loop

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 think process 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.

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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 the the the complaint service users individual plan/schedule supervisor dealing with the complaint 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 aquaexercise 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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Introduction to quality management

Outputs and outcomes explained
There is often a significant amount of confusion about outputs and outcomes. Think of the output as 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 customer is 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 Outputs and outcomes

An output is 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.

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.

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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 developing appropriate 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 Continuous improvement intent

To improve efficiency (to do things right) To improve effectiveness (to do the right things) In order to: Improve client outcomes

A simple example to illustrate the concepts of systems, processes and continuous improvement could 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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A homefront scenario

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

Supplier: Inputs: The provider of ingredients and equipment 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: Outcome: Delicious chocolate cake 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.) 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.)

Inputs:

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 throughput stage. 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 on process improvement and 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 Lag indicators
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.

Key point Lead 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.

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 procedures makes your practices sustainable (and able to be evidenced).

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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 efficiency in resource deployment. The second element in achieving our goal (outcome) relates to knowing what our birthday friend 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 linedancing 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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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 linedancing 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 Focus on process, not end results

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.

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 emotional commitment. 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 is planned change 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 Benefits of a quality management approach for service users

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

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

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Key point Benefits of quality management approach for service providers
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

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 within the organisation has a direct link to the quality system, continuous improvement cycle, performance management and service user outcomes.

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Queensland Disability Services quality system model

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