Leading Change through Quality Improvement
We all agree that change is more likely when organizations are ready for it.
Sometimes, and for some organizations, change is in the air. When you want to
change things, everything falls into place. Everyone comes on board easily and
willingly. Other times, every thing is a fight. Change seems impossible. It
seems reasonable to think that organizations differ in their readiness for
change. But how do we know if an organization is ready? What if it is not; what
do we do then? These two questions are the topic of today's lecture.
Readiness for Change
Often when we face a situation, we think it is unique. We think we are different from
others. We think we will work harder and smarter than others. So we go about our business,
without imagining what can we learn from others and from their attempts to change. Almost
everyone thinks that they are better at changing things than the average person! Here is a
contradiction in terms. How is it possible that everyone, or even most people, are better
than average. By definition half should be worst than average. We tend to think we can beat the odds. We are optimistic and have confidence in
ourselves. But no matter how unique the situation, and how experienced we are, there is a
lot we can learn about our own chances from experience of others. Researchers have
examined and compared organizations and found that certain characteristics of the
organization improve the chances for success. Understanding the organization's readiness is important because there are situations
where we will succeed despite ourselves and situations where we are likely to fail no
matter how hard we try. Without learning from the failures and successes of others, we are just as likely to
repeat their mistakes. With learning, we can stand on their shoulders and see problems
before it is too late.
Leadership is the ability of making organizations change for the better. Much has
been written on leadership. We do not wish to replicated many fine books that have already
been written on leadership. Drucker, for example, has arrived to the following conclusion
For another example, Kotter in his book titled "Leading change, Harvard Business
Review 1996" lists eight steps in successful efforts to change organizations:
- Establish a sense of urgency
- Create the guiding coalition
- Develop a vision and strategy
- Communicate the vision
- Empower employees for broad-based action
- Generate short term wins
- Consolidate gains and produce more change
- Anchor new approaches in the organization culture
One way to look at Total Quality Management is as a set of steps to help managers lead
organizational change. In this perspective, leaders create the environment in which others
succeed. The following presents the key
principles that leaders can take to
create an exciting environment for change.
- Discuss if continuous quality improvement is effective
- Discuss the importance of creating a positive environment for change.
- Describe how to create an environment that encourages change.
- Describe the principles of Total Quality Management
Does Continuous Quality Improvement Work?
This course is about managing
change in organizations; and this lecture, in particular, is about preparing
organizations for change. The course
focuses on continuous quality improvement techniques.
Naturally, before we start you want to know what data we have that it
works and that you can succeed using this approach. Of course, almost all
quality improvement projects lead to some kind of improvement in one corner of
the organization, but the real question is whether these individual projects are
big enough to leading to lasting improvements in the entire organization.
At least 7 studies address this issue:
- Shortell and colleagues in survey of 61 hospitals found that "a participative, flexible, risk-taking
organizational culture was significantly related to quality improvement
implementation. Quality improvement implementation, in turn, was positively
associated with greater perceived patient outcomes and human resource
- Curley, McEachern and Speroff randomly assigned patients to a unit where clinicians were trained in continuous quality improvement (interdisciplinary
team work) concepts. The unit trained in continuous quality improvement had
lower cost of care. In particular, "the mean LOS for interdisciplinary rounds
was 5.46 days, compared with 6.06 days for traditional care (P = 0.006),
whereas mean total charges were $6,681 and $8,090 (P = 0.002) for the two
- Goldberg and colleagues conducted a randomized controlled trial of Continuous Quality Improvement teams
and academic detailing ( a procedure where a clinicians from an academic medical center visits the community clinic and walks through cases together). They examined the relative
effectiveness of these two methods in changing care of hypertensive and
depressed patients. They found that clinics differed considerably in their
implementation of Continuous Quality Improvement. Because of this
variability in implementation, not all organizations were effective.
Continuous Quality Improvement was most effective when it was implemented
faithfully and when it was combined with detailing.
- Alemi and colleagues study of 92 improvement efforts found that improvement projects self-reported changes in
a number of organizational variables. Two percent
report reducing cost of services, 8% report increasing market share, 12% report
increasing patient satisfaction with care, up to 13% report improved patient
care outcomes and up to 30% of projects report improving employee work life.
So what does all this tell us about whether continuous quality improvement
works? Ad Shortell puts it: the glass could be half empty or half full.
These data tell us that continuous quality improvement works sometimes but all
the time. It tells us that continuous quality improvement can help if:
Steps to Successful Improvements
We present the content of continuous quality improvement through 10 steps:
- Organization leaders set mandate
- Organization leaders set culture including customer focus, no blame,
reliance on data, reliance on teams and involving everyone
- Organization leaders allocate funds and resources (time of employees) to
teams working on organization's priorities
- Quality improvement unit selects problems for teams
- Quality improvement unit assigns members of the team
- Teams plan, do, check, and act to bring about an improvement
- Leaders and teams celebrate success
- Leaders and teams spread improvement efforts
The first five of these steps are
addressed in this lecture.
1: Set Mandate
Start from the Top
Change is difficult. Without top management support change is not likely to succeed.
Clinicians who want to bring about organizational changes should engage top management and
managers who want to change practice patterns should engage clinicians. Both groups
need each other.
Gustafson and Hundt reviewed studies examining the role of top management in
successful implementation of innovations. Six studies supported the
assertion that top management involvement helps. These six findings were:
Firms that do not innovate tend to use resources already allocated for other purposes
for new changes.
Firms that innovate successfully have funds designated for the innovation.
Firms that innovate successfully sponsor the innovation through out the organization.
Firms that do not innovate successfully lack a formal commitment from organization.
Firms that innovate successfully have sufficient human resources and funds allocated to
When implementation is sponsored by organizations, innovations are more likely to
In addition to budgets and human resource allocations, top management also set the
environment in which the change will occur. Without a positive change environment change
is less likely. The very principles of TQM, blaming the system not the people, requires
top management initiative and example.
What should the top management do?
Cummings TG, and Worley CG (Organization development and change, 1993) suggest the
following steps for managing change:
Create readiness for change by highlighting the discrepancies between now and the
Overcome resistance for change by involving people in the change, by dealing with the
emotions concerning the change, and by clear communications.
- Create a vision.
- Statement of the vision. Management gives a picture of the future.
- What are the valued outcomes. Give tangible goals.
- What are the valued conditions. Clarify what are valuable responses to the environment.
- What are the mid point goals. Show to get there from here.
- Develop political support.
- Assess the change agent power and acknowledge that the process is sanctioned at the highest level of the organization.
- Identify key stakeholders that may be affected by the change, both inside and outside the organization.
- Influence stakeholders to see in broad terms why change is necessary.
- Manage the transition
- Plan for key activities including the specification of sequence of activities to take place, and when will we know if we have succeeded.
- Plan for commitment. Get the support of key people concerning specific activities.
- Set management structure and resources. Set up parallel learning structures in order to
experiment, to facilitate, or to provide leadership in the change process.
- Sustain momentum
- Provide resources for change.
- Build a support system for change agents. Without emotional support, change agents may burn out from their early failures.
- Develop new competencies and skills. Allow for acquisition of skills missing.
- Reinforce new behavior. Set clear incentives for implementing the new innovation.
Step 2. Set Culture
Before you implement TQM, you need to make sure that the culture
of the organization is supportive. To do so, you need to take the
Rely on Customers' Experiences
Not long ago there was a pervasive feeling among health care managers and clinicians
that patients are not aware what is the best quality of health care services. In this
sense, asking from the patient about quality was considered inappropriate. Instead,
judgments of quality were left to the clinicians, hence the creation and promotion of peer
review organizations. But TQM requires a focus on the patient experiences. While the
patient may not know the latest medical advances, the patient does know about his/her own
experiences. The patient is aware of his life style objectives. The patient is aware of
his functional capabilities. In this context, medical services are evaluated by the
patient through how they affect his/her day to day life. "Did the operation help me
walk easier?" asks a patient undergoing hip fracture operation. A patient undergoing
cancer treatment may ask "Does the treatment let me stay with my loved ones
longer?" Patients can report their health status in terms of their daily living
activities, socialization, ability to keep up with their social roles, and other things.
Although they may not understand the medical aspect of the health services, patients can judge the effect of these services on their health status.
Organizations grow through increasing their market share. TQM helps organizations
increase their market share through improving the quality of services provided to the
customers. Larger market share requires organizations to keep their current customers and
attract new ones. By focusing on customers, diverse and sometimes conflicting
professional agenda can come to address a common perspective: that of the patient. A focus
on customers provides a clearer picture of what is wrong with the organization and what
needs to be fixed. Customers can tell organizations what is not working without thinking
through inter-organizational politics. In the end, patients and their families choose
health care services. Despite a growth of contractual arrangements, third party referrals,
and other disease management innovations, in the end it is the patient who decide which
health plan he/she belongs. A focus on the patient helps the organization sell its product
more effectively to other intermediary decision makers who also share the organization's
concerns about patient care.
People who apply TQM believe that problems in delivery of services is not as much a
function of the people involved as it is a function of the systems and processes
supporting health workers. Thus, TQM cannot be used to cut people's jobs. It cannot be
used to focus training resources on a few individuals. The purpose of TQM is not to find
the bad apples and toss them but to improve every apple in the basket, the good and the
bad. This improvement is expected to occur not through changing personnel but through
on-the-job training, re-designing delivery systems and improving management. Here is an
example that students may readily identify with:
I was teaching a class in Total Quality Management and a group of students approached
me to tell me how frustrated they were that one group member was not contributing as much
as they had been. I though about this complaint and it occurred to me how un-TQMish (yes,
this is an English word!) their reaction was. Essentially, they wished to punish a person
for poor performance. They were blaming the other group member for being lazy. A manager
following TQM would try to understand the process that prevents the group member from
participating and then suggest solutions. He may gather data on the group member's
participation before and after implementing the solution. He would see the lack of
participation as a function of the communication processes, resource availability, or
other functions. So next time you are frustrated by an unhelpful partner, don't ask how
you could get rid of him/her. Put yourself in his/her seat and try to understand why. Help
him/her do more.
That will be the spirit of TQM. There are two logic for this principle. First, many believe system problems occur more
often than people problems. Health workers, given properly working systems, will carry
through with their jobs.
The second argument is that a focus on deficient people will force them to become
defensive and resistant to change. The atmosphere will worsen. Workers will become angry,
defensive, and communication channels will suffer. In this regard, Don Berwick MD writes
in New England Journal of medicine [1989, 320 (1): 53]:
"Practically no system of measurement - at least none that measures people's
performance, is robust enough to survive fear of those who are measured. Most measurement
tools eventually come under the control of those studied, and in their fear such people do
not ask what measurement can tell them, but rather how they can make it safe. The
inspector says, "I will find out if you are deficient." The subject replies,
"I will therefore prove I am not deficient" -- and seeks not understanding, but
Blaming people makes them fear their jobs. In an atmosphere of fear, little
constructive and participatory change can occur.
Rely on Data
There is no guarantee in medicine. Some variations in outcomes occur by chance.
Occasionally, even the best clinicians have unexpected adverse outcomes. The focus should
not be on these occasional unexpected events but on whether a pattern exists. Data can
help us examine patterns of outcomes. Analysis can help us understand whether the observed
outcomes are due to our effort or to random chance.
This TQM principle says that our experience, to the extent that it relies on one case
study, is not relevant. What matters is observed patterns. This is hard to accept
sometimes. After all, if we can not trust our own judgment, then what can we trust. TQM
suggests that we should trust observed data. Data across different experiences rather than
a single situation.
Within the TQM approach, it is not enough to haphazardly select a problem to work on.
You must have data for the extent of problems and select to work on the most significant
problem first. You need to show that the proposed problem is real. You need to point to
repeated customers experiences that documents a problem.
In short, when a person using TQM faces an advertiser's claim that their hamburger is
better, he/she will ask "where is the beef?"
When a claim is made that the problem is solved, again you need data. It is not enough
to believe that the problem has disappeared. You must give evidence that this is the case.
You must observe the process before and after implementing your solution to show that
indeed you have solved the problem. You must prove your point. Even if the point is being
made just to yourself, you still need data to convince yourself. TQM suggests that you
need data for each claim. Furthermore, that you need to analyze the data to make sure that
it meets your claims. The emphasize of TQM on statistical quality control distinguishes
this approach from many other management approaches. Data has different meaning to people. Data could be qualitative. Data could be based on
experience. TQM does not exclude qualitative data. What TQM insists on that there be a
pattern. Claims cannot be supported by pointing to one case or one experience. There must
be a number of cases or experiences so that we are sure that the observation is not due to
random chance events. Data is needed to distinguish between random variation and variation due to changes in
the underlying process. Why is the understanding and control of variation so important?
Dr. Donald Berwick writes in Medical Care [1991, 29 (12): 1212-1225.]:
"The answer, simply put, is that variation is a thief. It robs from processes,
products and services the qualities that they are intended to have. Variations is in
processes what heat is in mechanical systems: evidence of wasted energy. Variation in
processes is what entropy is in thermodynamic systems: evidence of the loss of information
and of confounding of prediction."
Understanding sources of variation is important so that we are not misled.
Rely on Interdisciplinary
It takes a village to raise a child. It takes a team to put man on the moon. Team work
is necessary for completing complex tasks. Changing organizations, even simple changes,
are difficult to accomplish and require team work. Working with teams means that you will
take time to socialize with each other, to bring each other up to par concerning the
process improvement project, to accept solutions that may not agree with your intuitions.
Change by fiat, change because I told you so, will not work. Team work means team members
can participate in selecting what to work on, in gathering data and in suggesting
solutions. TQM suggests that not only problems
should be solved through team work, but also that teams should be composed of
people from different disciplines. Nurses and physicians should talk to each
other about how the system should change. For sometime now, Clinicians have
worked in teams to care for patients. Clinicians are familiar with team
work. What is unusual about TQM is that for the first time it puts managers and
clinicians in the same team: solving patient problems. This gives clinicians a
role in management. It also gives managers a role in clinical care. It creates a
new environment, where clinicians and managers begin to share a common insight
into the life and attitudes of the patient. Instead of divergent and conflicting
point of views, the patient experience is the common thread that brings
inter-disciplinary teams to common perspectives.
Onetime I was teaching a class on TQM to a group of nurses, physicians and managers.
Obviously, I expected that there would be conflict among the nurses and the physicians
concerning autonomy and limits of practice. Contrary to my expectations the biggest
conflict was between managers and the physicians in the class. The conflict did not center
around the typical issues that budgets interfere with patient care. No, the conflict was
much more deeper. The clinicians felt, and the physicians among them strongly articulated,
that good management was not a science. They felt that anyone can become a manager. Good
management did not need schooling. They believed what they did was scientific and
extensive schooling was necessary to succeed in it. In other words, the clinicians under
valued what it takes to prepare as a manager and over valued their own professional
preparation. We entered into a heated discussion, where each profession argued on his/her
own behalf. When managers reviewed their training and reviewed with class the experimental
data behind their training, the clinicians came around with more interest. In the end, we
came to an interesting compromise. The class accepted that team work did not mean that we
should act like each other. Physicians were not managers nor were managers making clinical
decisions. But every profession needed to accept the legitimacy of the other professions
in helping to solve the problem at hand. In the end, it was the patient experiences that
brought the team together. Despite the conflict among them, they agreed that what counts
is who can make the patient experience better and healthier. Any profession that can do so
is welcomed and appreciated. Managers can take many steps that affects patient clinical
experiences. Physicians can take many decisions that affect organization wide management
issues. What resolves the conflict and the practice boundaries is the effect of these
decisions on the patient experiences. I thought that the class had arrived at a mature
decision concerning what really matters. Instead of fighting with each other about turf,
they were focused on the customer.
Relying on teams make sense
- We all have experiences about how committee meetings, group projects, and team work have
been frustrating. Later in this course, I teach about how to avoid pitfalls of group work.
But assuming that we can have effective team work, why should we do it. Why should we not
rely on individual initiative and effort instead of the much harder group work? Teams are
more effective than individuals because:
- The more the number of people involved, the higher the pool of ideas available for
decision making. When more ideas are around, the chance of premature closure of problem
solving effort is reduced. Team members question each others assumptions. They act as a
check a balance against each other's idiosyncrasies. Organizations are so large that few
individuals have detailed understanding of the entire process. When interdisciplinary
teams are involved, more perspectives and experiences are brought to bear on the problem.
Interdisciplinary teams are more aware of the nuances of the problem than any one
individual in the team. Thus, effective teams may have better judgments than an
- Team work facilitates communication. People in the team need to discuss issues and
convince one another. These communications are the prelude of what is going to come when
change is implemented through out the organization. In essence, communication among the
team members is a microcosms of what is needed for an organization-wide change.
Individuals, in contrast, often know something but do not know how they come to know it.
They are not aware of their own reasoning. They just know intuitively that something is
right. When it comes to explain their ideas to others and to convince them, they fall
short. Because individuals do not need to communicate their ideas to themselves, the
communication effort does not start early. And, there is not as much experience with it.
As a consequence of poor communication, ideas emerging from individuals may be less likely
to be implemented.
- More hands on deck. Teams can do more because they have more people in them. This is an
instance that more is better. Tasks can be allocated to more individuals. This is
important in accomplishing tasks. It is also important in implementing the team's decision
afterwards. Each team member becomes an agent for change. Individual works limits the
number of people around to change the rest of the organization.
This principle has several interpretations. First, it means
that everyone can help the improvement process. From the CEO to
the janitor, all employees can help the TQM process. Quality
improvement is not limited to a department. It is what everyone
should do everyday at their work. A second interpretation of this principle is that everyone can
improve -- even the best among us. Other approaches, like
Physicians Review organizations, are focused on finding the
"bad apples." TQM tries to improve the average
employees. The focus is not on a few statistically abnormal cases
but the entire group of employees. The intent is to improve the
average health worker's job. Involving everyone makes sense
- Involving everyone in the change, reduces resistant to change.
- Focusing on the good and the bad apples, helps move the average performance higher.
- Implementation is easier when many organizational members have been involved in the change process.
Step3: Allocate Funds
Organize Resource Center
It is quite possible to conduct an organization-wide improvement without creating a new
Department and a new expense for the organization. After all, employee participation in
TQM does not require additional pay. Most employees are asked to volunteer their time.
Sometimes, this is time after work. Given TQM's emphasis on employee participation as part
of their current work, why should the organization pay for a TQM resource center and its
staff? In addition, given TQM's claim that it wants to improve communication across
departments and break down barriers, why should the TQM resource center be organized as a
department? Could it not just be part of an existing function? In TQM employees are organized in
problem solving teams. These are autonomous self-governing teams. These teams
design studies, collect information, and report their findings. In order to
facilitate the team meetings, the data collection, the data analysis and the
preparation of story boards, a facilitator often helps each team. The role of a
facilitator is to help the team to achieve its goals, not to actively
participate in the team's deliberation. While most employees participate in TQM
processes without pay, the facilitator needs to be paid. Of course, it is possible to conduct meetings without a facilitator. But such meetings
inevitably run into problems because of the group skills of the chair of the meeting.
Imagine a group of manager and clinicians conducting a TQM process. Managers will hesitate
taking a leadership role in order not to offend the egos of others present. Clinicians may
not wish to facilitate the meeting as they want to actively participate in the meetings
and may not have the time in between meetings to collect data and analyze it. A paralysis
may emerge. The presence of the facilitator changes the equation. There is no longer a
need for a chair and therefore difficulties of establishing who is in charge. There is no
longer a need for worries of who will collect data and analyze it. The group can more
effectively focus on the job at hand.
Because TQM team members come from different departments, the budget for the TQM
resource center needs to be set by the top management. Otherwise, a squabble emerges over
which functional unit of the organization should pay for the facilitator? In addition,
because top management must show commitment to TQM, because top management must hold the
TQM group responsible to addressing central organizational issues and not minor issues,
and because top management should be involved in encouraging adoption of TQM findings, it
is important that the TQM resource center reports directly to top management. Organizing a TQM resource center requires selecting TQM staff. Because these staff are
agent of change within the organization it is important that the TQM department has
appropriate authority and prestige. Diverse experience in implementing various projects is
necessary. Success is more likely when the TQM leader is respected by the rest of the
organization. The TQM staff need group facilitation expertise. They need statistical
analysis expertise. They need to know about effective methods for sampling and data
collection. Beside an experienced staff, the resource center also needs appropriate
equipment and software. More recent group ware (software that helps groups of people work
together) may be useful. Gadgets, back drops and flip charts needed for conducting
meetings may be necessary. Computers for data analysis may be necessary. Because TQM often
reports to the all employees about successes inside the organization, often the company
newsletter originates from this office. Equipment to design and prepare story boards is
necessary. Use of technology to tell the story of improvement projects, e.g. video tapes,
is also useful and may be necessary.
Step 4: Gather Data and
It is best not to identify "the bad
apples" among the providers. Any measurement should be used for improving
everyone and not for focusing on select few.
Data are needed to track improvement
efforts and to verify that implemented changes have adequately addressed the
problem at hand. Prior to wide spread use of process improvement, outcomes
were measured to identify poor performing providers, usually following these
- Measure outcomes such as mortality, morbidity, patient satisfaction or health status.
- Stratify subgroup data
- Identify individual providers that are organizational outliers.
- Identify poor care provided by outliers.
- Determine corrective action.
When it comes to improvement efforts,
this is not a reasonable course of action because it focuses on poor performing
providers. Real process improvement should not blame anyone but seek
system wide changes. In process improvement data is used in an
entirely different way. Data is used to document customer's experience and compare the organization's experience with other
organizations. When improvement team implement system wide changes, data is also
used to trace whether
the change has led to improvement and the problem has been solved.
Step 5: Assign Teams to Problems
French WL, and Bell CH write in their book Organization Development (Prentice Hall,
Fifth Edition, 1995):
Teams are important for a number of reasons. First, much individual behavior is rooted
in socio-cultural norms and values of the work team. If the team, as a team, changes those
norms and values, the effects on individual behavior are immediate and lasting. Second
many tasks are so complex they cannot be performed by individuals; people must work
together to accomplish them. Third, teams create synergy, that is, the sum of the efforts
of members of a team are far greater than the sum of the individual efforts of members of
the team working alone. Fourth, teams satisfy people's needs for social interaction,
status, recognition, and respect -- teams nurture human nature.
We will also discuss the advantages of inter-disciplinary team work when we discussed
the principles of and the environment of TQM.
For each problem identified by the top management as a significant organization
problem, the management should invite a team of individual to address it. A key question
is what should be the composition of this team. The composition of the group is an
important and generally controllable aspect of problem solving groups. The facilitator
could choose group members based on whether they are an expert in the field, an employee
intimately familiar with the process, or an employee representing an interest group,
profession, or perspective affected by the judgment. The essential requirement is that
they be people whose expertise is strong and preferably recognized by people who use the
model. Some authors believe that some meetings should be staffed by people from the
outside of the organization rather than from the inside. If the co-worker is an expert in
the subject and well respected, there is no reason to ignore him/her in favor of an
external expert. Representatives of particular perspectives are best used when acceptance
of the decision is the prime criterion. Often management does not ask clinicians to
participate in TQM teams. Partially, because many clinicians do not report to the
management, are paid on the basis of fee for service and not salary. This is a mistake.
Teams should be composed of all relevant professions. If necessary, individuals from
outside of the organization should also be asked to participate. The following is a set of
principles that we have found useful in assigning employees or outsiders to teams"
- Assign the individuals close to the process to the team. They know more of what is
really going on and their cooperation is most needed in carrying out the team's
- Assign all relevant professions to the team. The more the pool of knowledge the less
likely that relevant information is not considered.
- The number of members of the team should depend on the team's environment. Experiments
with groups of various size have shown that if the quality of the group's solution is of
considerable importance, it is useful to include a large number of members (e.g., seven to
nine) so that many inputs are available to the group in making its decision. If the degree
of consensus is of primary importance, it is useful to choose a smaller group (e.g., five
to seven) so that members can have their opinions considered and discussed (Cummings,
Huber, and Arendt, 1974, and Manners, 1975). It is a general rule of thumb that the group
size should not be smaller than five or domination will occur; and it should not be larger
than nine when size prevents some group members from participating.
- Heterogeneity of the group's background is closely related to the size of the group and
is another important aspect of design of successful groups. A necessary, though not
sufficient, requirement for accurate group judgments is to have an appropriate knowledge
pool in the group. Since no one person is an expert in all aspects of a problem, diverse
backgrounds and expertise are imperative for achieving this heterogeneity. Difference in
background and knowledge could, however, accentuate the conflict between the group members
and, if neither originality nor quality are criteria for evaluating the team's work,
select group members to minimize differences in their backgrounds.
- Getting people to devote their time to a meeting is difficult. Many remember wasted
efforts in other meetings and avoid new meetings. Some clinicians are paid per service and
see TQM meetings as not part of their job. There are a number of steps to increase
participation. First, examine the purpose of the meeting. If it is difficult to obtain
participation, perhaps the problem assigned is not important. Invited group members will
participate if the meeting addresses a problem they consider important. Show how the
team's recommendations will be followed. An important problem is tied to action. Show what
resources are available to the team. Give examples of how clinicians and others have in
the past addressed similar problems in other institutions.
In the coming lectures you will learn more about how to run effective meetings. There
is considerable research on what makes teams successful. We will review the studies and
give you specific actions for effective meetings.
Steps 6 through 8: Plan, Do, Check & Act Cycles
The quality improvement unit assigns a problem to a cross-functional team.
The team meets and through a series of steps solves the problem and improves the organization. Details of these steps are explained
in section titled "PDCA Cycles."
Step 9: Celebrate Success
Organization leaders can make a difference in performance of employees by noticing and
celebrating small successes. This may be accomplished through electronic media (e.g.
emails) or a newsletter report. It could also be accomplished through visits. The important message to convey is that the top leadership of the company understands
the achievements and the frustrations of the employees. We always knew that success brings optimism. What was not known until recently
was that both optimistic and pessimistic people tend to have failures. But the
optimistic employee sees the failure as a function of the system and the success as a
function of his/her skills. In contrast, pessimistic employees see failure as a
function of their own efforts. Optimistic employees are more likely to bring about
change because they try more often and stick to it more often. Organizational
leaders can celebrate successes and underplay failures. They can play a pivotal role
in allocating the blame for failure to the system and the environment and to praise
successes to employees efforts. In this fashion they can help create more optimistic
employees, who are more likely to try to bring about change.
Step 10: Spread Improvement
important to leverage success in one unit of the organization to change other units.
Details of how to do so are provided in steps 6 through 8.
What you know?
Advanced learners like you, often need different ways of understanding a
topic. Reading is just one way of understanding. Another way is through writing
about what you have read. The enclosed
assessment is designed to get
you to think more about the concepts taught in this session.
- Why is it important to create a positive environment for change?
- List what continuous quality improvement suggests should be the culture within the organization so that change can succeed?
- Two to three year old children play differently than older children. These children, while in the same room, do not interact with
each other. They may be playing with parts of the same toy but not with each other. The concept is known as parallel play. Do you think that interdisciplinary
work is parallel play or is it something more?
- I prefer to work individually. I know the effort I am putting in, and I get rewards proportional to what I put in. How can you convince me that I should work in a team. What
benefits will I get from team work that I cannot have through individual work?
- Is TQM a bottom up approach, top down approach or both?
Please send an email to your instructor with your responses to the above questions. Make sure that the email subject line includes the course number, topic name and
your name, otherwise it will not get to the right place. If you wish to receive a receipt that the instructor has received your email, you may request
the receipt from your email program. Please respond to all of the questions within the same email. Keep a copy of all your emails to the
instructor till the end of the semester. Email►
Throughout quality improvement projects, you would be repeatedly asked to
examine data and plot charts. In later sections of this course, you are
asked to analyze data. In preparation for our anticipated needs, we ask
you to get oriented to data analysis using Excel.
- Plot the following data, where the X axis is the time periods, the
Y-axis shows the observed value, the upper control limit and the lower
control limits. Distinguish between the first seven data periods as
these were collected pre-intervention. Remaining data points were
collected post intervention. Title the chart. Create a
legend that defines the name for various lines. Make sure that the
observation line has markers and the control limits have no markers.
Make portion of Upper and Lower limit lines that are post intervention
dashed. Make portion of the line that is pre-intervention straight
line. Make all Upper and Lower limit lines red. If you
have no experience in using Excel you may wish to
start with an Introduction to Excel.
Table 2: Data for Plotting
Email your instructor and obtain his email. Then send an email to
him with your Excel file attached. For full credit of your work,
in the subject line include the course number and your name. For
example, subject line could be: "Joe Smith from HAP 586
analysis of data in
Leading Change" Please submit one file. Please note
that all cell values must be calculated using a formula from the data.
Do not enter values in any calculated cells. Calculate each cell using
Excel formulas. Make
sure that legend, the X-axis and the Y-axis are appropriately labeled in the
Keep a copy of all assignments till end of semester.
To assist you in reviewing the material in this lecture, please see
the following resources:
- Lecture on leading change Slides► Listen►
- Russian translation of lecture on leading change Slides► Listen►
- Lecture on characteristics of a typical improvement effort Slides► Listen►
Narrated lectures require use of Flash Download►
92 improvement efforts
Studies of impact of quality improvement
Impact of quality on cost of care
Role of top management in successful implementation of innovations
Empowerment has its limits
Overcoming barriers to organizational change
Leading improvement systems
Institute for healthcare improvement
This page is part of the course on Quality Improvement, the lecture on Leading Change.
This page was last edited by Farrokh Alemi, Ph.D.. ęCopyright Protected.