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 development." 
   

• 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 groups, respectively."
   

• 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:

• Correctly implemented.

• Over long time periods.

• Focused on significant problems.

10 Steps to Successful Improvements

 We present the content of continuous quality improvement through 10 steps:

The first five of these steps are addressed in this lecture.

Step 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 the innovation.

• When implementation is sponsored by organizations, innovations are more likely to succeed.

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:

• Motivate change

  1. Create readiness for change by highlighting the discrepancies between now and the future.

  2. 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.

  1. Statement of the vision. Management gives a picture of the future.

  2. What are the valued outcomes. Give tangible goals.

  3. What are the valued conditions. Clarify what are valuable responses to the environment.

  4. What are the mid point goals. Show to get there from here.

• Develop political support.

  1. Assess the change agent power and acknowledge that the process is sanctioned at the highest level of the organization.

  2. Identify key stakeholders that may be affected by the change, both inside and outside the organization.

  3. Influence stakeholders to see in broad terms why change is necessary.

• Manage the transition

  1. Plan for key activities including the specification of sequence of activities to take place, and when will we know if we have succeeded.

  2. Plan for commitment. Get the support of key people concerning specific activities.

  3. 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

  1. Provide resources for change.

  2. Build a support system for change agents. Without emotional support, change agents may burn out from their early failures.

  3. Develop new competencies and skills. Allow for acquisition of skills missing.

  4. 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 following steps:

1. Rely on customer's experiences

2. Avoid Blame

3. Rely on data

4. Rely on teams

5. Involve all

Each of these are discussed below.

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.

Avoid blame

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 escape."

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 teams

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 because:

• 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 individual.

• 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.

Involve all

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 because:

• 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 Select Problems

How would we know if change is an improvement?

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 steps:

• 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 recommendations.

• 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."  More►

Step 9: Celebrate Success

Have fun

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

It is important to leverage success in one unit of the organization to change other units.  Details of how to do so are provided in the section titled "PDCA Cycles."

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.

1. Why is it important to create a positive environment for change? 

2. List what continuous quality improvement suggests should be the culture within the organization so that change can succeed? 

3. 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?

4. 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?

5. 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►

Analyze Data

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.

1. 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.  Excel► Show me► 

Time	Observed value	Upper limit	Lower Limit
1	30	52.5	12.5
2	0	52.5	12.5
3	25	52.5	12.5
4	30	52.5	12.5
5	35	52.5	12.5
6	40	52.5	12.5
7	50	52.5	12.5
8	45	52.5	12.5
9	31	52.5	12.5
10	20	52.5	12.5
11	40	52.5	12.5
12	60	52.5	12.5
13	45	52.5	12.5
14	60	52.5	12.5
15	45	52.5	12.5
16	32	52.5	12.5
17	50	52.5	12.5
18	60	52.5	12.5
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 chart.   Keep a copy of all assignments till end of semester.  Email►

 

Presentations

To assist you in reviewing the material in this lecture, please see the following resources:

1. Lecture on leading change  Slides► Listen►

2. Lecture on characteristics of a typical improvement effort  Slides►Listen►

Narrated lectures require use of Flash  Download►

 

Recently Asked Questions

Ask a question and we will answer it within the next 48 hours.  If you have no questions, please review the answer to the questions asked by others: 
 

Question: Thank you for the detail on plotting the graph in the initial exercise. Even with using EXCEL on a regular basis, the plotting functions aren't always used on a regular basis.  Answer: You are welcomed  This question was asked on 2/5/2008 11:14:53 PM and answered on 2/5/2008 11:25:06 PM.

Question: When we create charts in the future, for clarification, would you like us to keep the legend or will that information be given to us depending on the assignment?  Answer: No please always include a legend unless you have designed the chart with added explanations within the chart figure.  This question was asked on 2/5/2008 10:27:37 PM and answered on 2/5/2008 10:35:01 PM.

Question:  I wanted to know if there is any way to Pause or Stop the slide show in Excel because sometimes I need to listen again to a particular slide? Other than this I noticed I needed to select ALL the data in the "range" part for the chart to graph correctly, however I think you asked us to select only up till row E in the "show me" slides, (The data include row F as well"  Answer: Unfortunately, we do not have the pause in these early videos, we are in the process of changing them and within a few months we will post a different set. Too late to serve your needs but perhaps we can serve the needs of future students by adding more pause options. Later videos in the course do have this option. Also please note that there is an error in the video and it should say row F.  This question was asked on 2/5/2008 3:16:19 PM and answered on 2/5/2008 7:52:23 PM.

Question: It is evident to me form the lecture and from the personal improvement project, that team work and setting the positive environment for that team is necessary to produce the positive change, However is TQM possible in the light of an individual lacking the team in his or her environment? Simply put for those of us who lead a solitary life is there a way we could bring about quality improvement?  Answer: When people do not have a process owner that shares the environment with them, they tend to think that all changes are a function of their effort and motivation. In these circumstances it is important to distinguish between actions that can be done today but will have an impact on the person days later. for example, today's shopping can have an impact in tomorrows dinner. Now that you live alone, it is important that you remain vigilante about system change. One way to do so is to notice how your own actions affect you over time.   This question was asked on 2/5/2008 3:02:17 PM and answered on 2/5/2008 7:49:37 PM.

Question: If TQM is a Top Down approach how effective can this be with an organization with 0ver 7,0000 employees?  Answer: I have not seen any data that TQM is less effective in larger organizations, I do not see why it would not work on an organization with that size.  This question was asked on 2/5/2008 12:22:47 PM and answered on 2/5/2008 12:28:44 PM.

Question: when I ask a question here is it supposed to appear on this page once i close the window or refresh the screen..b/c i asked a question an hour ago and had a confirmation and it also mentioned to close the window but I don't see my question.  Answer: It will appear on this page once it is answered.   This question was asked on 2/5/2008 12:47:07 AM and answered on 2/5/2008 7:59:06 AM.

Question: for the excel I tried selecting the data range B2:E19 as the demo tell us but ended up w/ one solid line but when I tried B2:F19 i got the desired results..  Answer: Good point. This maybe an error in the video.  This question was asked on 2/4/2008 10:58:02 PM and answered on 2/5/2008 7:58:33 AM.

Question: In the analyze data exercise the following statement is made: “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.” Can I assume since the data for the exercise has already been calculated for this exercise you are referring to our projects and not this particular “home work assignment?” Thank you for clarification.   Answer: Yes, in this assignment there were no calculated values and therefore there were no need to use formulas, in future assignment this will not be the case  This question was asked on 2/4/2008 9:46:26 PM and answered on 2/5/2008 7:56:10 AM.

Question: In plotting the dat, the lower time line remains a solid line and will not allow me to break it up. Have I entered the data wrong perhaps?  Answer: Right click on the line and re-format the line. Make sure that the dashed line is not over written with another solid line from a different column of data.  This question was asked on 2/4/2008 2:36:07 PM and answered on 2/4/2008 5:51:17 PM.

Question: The lesson discusses not placing blame. But sometimes you have a team member who will not commit to goals, nor give a productive contribution. When can you stop TQMing and just remove the team member?  Answer: You can stop TQM at anytime, but it is much harder to start it up again. Once people see that their jobs maybe lost they are less likely to believe that they will not be blamed for customer's experiences and will be more defensive.  This question was asked on 2/4/2008 1:56:38 PM and answered on 2/4/2008 5:49:49 PM.

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More & References

1. Alemi and colleagues study of 92 improvement efforts found that improvement projects self-reported changes in a number of organizational variables.

2. Goldberg and colleagues conducted  a randomized controlled trial of CQI teams and academic detailing.

3. Curley, McEachern and Speroff  randomly assigned patients to a group receiving continuous quality improvement and another not receiving this process.  In this fashion they were able to examine impact of continuous quality improvement.

4. Impact of quality on cost of care. 

5. Continuous Quality Improvement is a process of change that starts from the top and empowers employees to bring about change.  If you want to implement this approach you need to start from the top.  A first step could be providing information to top executives regarding the potential of continuous quality improvement.   For a list of reading in this area, click here.  An excellent review of what it takes to prepare an organization for process improvement can be found in a recent report.  For more on organization development and change through culture, click here. 

6. Gustafson and Hundt  reviewed studies examining the role of top management in successful implementation of innovations.

7. If you are interested in examples of real improvement efforts, you may want to look at work of researchers who solicited nominations for successful examples of clinical quality improvement teams from quality leaders in the network.  After collecting data from the nominees (e.g., team reports, storyboards, charts, graphs, and bibliographies), the researchers developed a  report, with 15 case studies. Other examples of use of Plan, Do, Check and Act (PDCA) model can be found in published literature. 

8. Projects may  focus all of their time on measurement and proving that something is not working.  They never get to improvement.  Surely this is not advisable.  The point of measurement is to improve and not to merely prove something.  Furthermore, if the environment is defensive, people will work on meeting what is measured but avoiding the spirit of the measurement.  For example, if we are measuring blood pressure as an indication of adherence with preventive medicine guidelines, in a defensive environment employees may increase the frequency of measuring blood pressure but fail to do more with the information or keep up with other preventive medicine guidelines.  Berwick argues that barriers to measurement are not just in the lack of uniform, meaningful, simple and reliable tools but also in the preparedness of the organization and individuals being measured.  See barriers to measurement are not just in the lack of uniform, simple, and reliable measurements.  He argues that organizations and individuals need to be prepared to accept, without acting defensively, the results.  See Berwick, Donald M. MD,. James, Brent MD, Coye, Molly Joel MD Connections Between Quality Measurement and Improvement. Medical Care. 41(1) Supplement:I-30-I-38, January 2003

9. It is important to think of how the customer experiences our services.  For example, if you have to make a point in a meeting, it is important to video tape an interview with a client complaining about a service and to play this video tape.  Let the customer speak with his own voice instead of paraphrasing the customer in management rhetoric.  To understand how a customer experiences our services it may be useful to conduct focus groups and ask the customer.  Research shows that customers tend to look at quality of health care services through 11 attributes.  These attributes are (1) tangibles, (2) reliability, (3) responsiveness, (4) competence, (5) courtesy, (6) communication, (7) access, (8) understanding the customer, (9) collaboration, (10) caring and (11) patient outcomes.  The first 8 have been identified in research on service organizations in general.  The last three seem to be specific to health care.  The dimension of "Collaboration" refers to coordination of care among providers.  "Caring" implies a personal, human involvement in the service situation, with emotions approaching love for the patient. The dimension of "Outcomes" reflected relief from pain, saving of life, or anger or disappointment with life after medical intervention.  For more detail see  Jun, Minjoon. Peterson, Robin T.. Zsidisin, George A.. The Identification and Measurement of Quality Dimensions in Health Care: Focus Group Interview Results. Health Care Management Review. 23(4):81-96, Fall1998.

10. It does not seem practical to involve all in a change.   A recent article by Argyris provides a very good answer to the question of whether widespread participation of emplyees if for real or for a show.  He writes: "Everyone talks about empowerment, but it's not working. CEOs subtly undermine empowerment. Employees are often unprepared or unwilling to assume the new responsibilities it entails. Even change professionals stifle it. When empowerment is used as the ultimate criteria of success in organizations, it covers up many of the deeper problems that they must overcome. To understand this apparent contradiction, the author explores two kinds of commitment: external and internal. External commitment--or contractual compliance--is what employees display when they have little control over their destinies and are accustomed to working under the command-and-control model. Internal commitment occurs when employees are committed to a particular project, person, or program for their own individual reasons or motivations. Internal commitment is very closely allied with empowerment. The problem with change programs designed to encourage empowerment is that they actually end up creating more external than internal commitment. One reason is that these programs are rife with inner contradictions and send out mixed messages like "do your own thing--the way we tell you." The result is that employees feel little responsibility for the change program, and people throughout the organization feel less empowered. What can be done? Companies would do well to recognize potential inconsistencies in their change programs; to understand that empowerment has its limits; to establish working conditions that encourage employees' internal commitment; and to realize that morale and even empowerment are penultimate criteria in organizations. The ultimate goal is performance."  For more details see Argyris C.  Empowerment: the emperor's new clothes. Harvard Business Review 1998 May-Jun;76(3):98-105. 

11. Who is Deming?   William Edwards Deming was born in Sioux City, Iowa on 14 October 1900.   In 1917, he enrolled in the University of Wyoming at Laramie.  In 1921 he graduated with a B.S. in electrical engineering.  In 1925, he received an M.S. from the University of Colorado and in 1928, a Ph.D. from Yale University.  Both graduate degrees were in mathematics and mathematical physics.  Dr. Deming lived in Washington, D. C. from 1936 till June 1993, when he passed away.  Dr. Deming served as an international consultant to several governments and international firms.  His work popularized the use of statistical process control tools in improving quality of products.  He also articulated management principles based on continuous quality improvement.  After wide popularity among Japanese firms, many United States firms began applying his ideas to improving their products.  Click here for more details about Dr. Deming and his biography or accomplishments.  

12. Click here to see the definition of the word "principles."

13. Continuous Quality Improvement starts with a change of organization's culture.  But how does culture make a different in organization's change?  Amartya Sen, recipient of the 1998 Nobel Prize for Economics, discusses the role of culture in addressing development.  Professor Richard Price, from Institute for Social Research University of Michigan, presents three stories of how culture affects organizational innovation.  Donna Deeprose discusses why culture matters and what is its impact on the organization.  Shortell and colleagues discuss impact of culture on continuous quality improvement.  See also Shortell, Levin, O'Brien, and Hughes for a review.

14. Argyris, C. Knowledge for Action: A Guide to Overcoming Barriers to Organizational Change.  San Francisco: Jossey-Bass, Inc. Publishers, 1993. -- Argyris describes in detail his consultation with a firm seeking to overcome its own obstacles to learning.  The description highlights the difficulty of maintaining consistency in leaders’ ability to reconcile their espoused theory and theory in use in daily work.

15. Deming WE.  The New Economics.  Cambridge, MA:  Massachusetts Institute of Technology, Center for Advanced Engineering Study; 1993. --  From one of the founders of CQI, a book published just before his death.

16. Garvin DA.  Building a Learning Organization.  Harvard Business Review.  July-August 1993, 78-91. --  A practical guide to the creation of an organization which is "skilled at creating, acquiring, and transferring knowledge, and at modifying its behavior to reflect new knowledge and insights." See summary.

17. Kotter JP.  Leading Change:  Why Transformation Efforts Fail.  Harvard Business Review.   March/April 1995, pp 59-67.

18. Langley GJ, Nolan KM, Nolan TW, Norman CL, Provost LP.  The Improvement Guide: A Practical Approach to Enhancing Organizational Performance.  San Francisco: Jossey-Bass Publishers, 1996.  -- A superb new guide to an overarching model of improvement that combines the best of  “CQI”, “TQM”, “reengineering”, etc.  Excellent reading for the beginner and the expert.

19. Senge, PM.  The Fifth Discipline:  The Art and Practice of The Learning Organization.  New York:  Doubleday, 1990.  The "textbook" on systems thinking for any group or organization that wishes to have the IQ of the group exceed the IQ of the individuals.

20. Batalden PB and Stoltz PA-C.  A Framework for the Continual Improvement of Health Care:  Building and Applying Professional and Improvement Knowledge to Test Changes in Daily Work.   Jt Comm Jl  Qual Improv, 1993;19:424-452. -- An important article describing how "knowledge for improvement" plus "discipline-specific knowledge" stimulates continual improvement.

21. Berwick, DM.   Continuous Improvement as an Ideal in Health Care.   NEJM 1989;320:53-56. -- A classic article that argues for CQI as a more powerful way to improve health care than looking for "bad apples."

22. Berwick DM, editor.  Eye on Improvement.  A twice-monthly journal which publishes abstracts on continual improvement in health care from a wide range of formal and informal sources.  Reviewers are interdisciplinary and include representatives from medicine, nursing, and health administration. Published by the Institute for Healthcare Improvement, Boston. 

23. Berwick DM.  A Primer on Leading the Improvement of Systems.  British Medical Journal.  1996;312:619-622. -- A guide to how to make change successfully, citing common pitfalls and how to avoid them.            

24. Blumenthal, D.  Total Quality Management and Physicians' Clinical Decisions.  JAMA 1993;269:2775-2778. --  Describes industrial quality management science, with special attention to statistical quality control.  Illustrations include improving the accessibility of large amounts of clinical data, as in the intensive care unit and interpreting outcomes over time, as in the management of chronic disease.

25. Chassin MR.  Part 3: Improving the Quality of Care.  NEJM 1996;335:1060-1063. -- Argument for clinicians to be actively involved in measuring and improving quality of care.

26. Headrick LA, Neuhauser D.  Quality Health Care.  JAMA.  1995;273:1718-1720.  --  Brief review of progress to date in applications of CQI to clinical medicine.

27. Kritchevsky SB, Simmons BP.  Continuous Quality Improvement:  Concepts and Applications for Physician Care.  JAMA.  1991;266:1817-1823. --  One of the first articles describing CQI in health care to be published in a "major" journal.

28. Leading Clinical Quality Improvement.  Healthcare Forum Journal, July - August, 1994: 18-54 -- This issue contains five articles devoted to Leading Clinical Quality Improvement.   James L. Reinertsen, in “The Tyranny of Piecework” addresses the question,  “Does your system have enough central nervous system and backbone to be able to suboptimize one part so you can optimize the whole?”  Eugene C. Nelson and John H. Wasson contend  that each patient care episode is an opportunity to learn and improve present and future care in “Using Patient-Based Information to Rapidly Redesign Care.”  Lee H. Newcomer presents  “Six Pointers for Implementing Guidelines.”  H. Gary Pehrson shares lessons from Intermountain Health Care in his article, “Give it Time,” which emphasizes the need to make a long term commitment to attain lasting improvements.  A fifth article is the special insert on “Outcomes Measurement.”

29. McLaughlin CP, Kaluzny AD.  Continuous Quality Improvement in Health Care:  Theory, Implementation, and Applications, 2^nd ed.  Gaithersburg, MD:  Aspen Publishers, 1999. --  For those who wish to dig deeper, this recent, well-written book is a good overview of the state-of-the art in continual improvement in health care.

30. The President’s Advisory Commission on Consumer Protection and Quality in the Health Care Industry.  Quality First:  Better Health Care For All Americans. Washington, D.C.:  U.S. Government Printing Office, 1998.  Available by writing the printing office, Superintendent of Documents, Mail Stop:  SSOP, Washington, D.C.,  20402-9328.  ISBN 0-16-049533-4.   – Recommendations to improve the U.S. health care system  “to continuously reduce the impact and burden of illness, injury, and disability and to improve the health and functioning of the people of the United States.”  

31. Agency for Health Care Quality and Research fact sheet on Improving Health Care Quality. Quality problems are reflected  today in the wide variation in use of health care services, the under-use and overuse of some services, and misuse of others. Improving the quality of health care and reducing medical errors are priorities for the Agency for Healthcare Research and Quality.

32. American Society for Quality, Health Care Division.

33. Institute for Healthcare Improvement

34. National Coalition on Health Care (NCHC)

35. National Institute of Standards and Technology (NIST) on Health Care

36. Baldrige National Quality Award

37. American National Standards Institute's Healthcare Informatics Standards Board (ANSI HISB)

38. VA National Center for Patient Safety

39. Barriers to implementation of continuous quality improvement

40. Read more about outcome measurement and benchmarking. 

Suggestions for Improving Lecture on "Leading Change"

Add your own suggestions or read below suggestions made by others regarding how to improve this session:

Suggestion: The tips on plotting and EXCEL were very helpful.   This comment was left on 2/5/2008 11:15:56 PM.

Suggestion: This lecture was easy to navigate!   This comment was left on 2/5/2008 10:45:39 PM.

Suggestion: Great introduction to the concept of organizational change.   This comment was left on 2/5/2008 8:45:26 PM.

Suggestion: I really liked this lecture! It was easy to move through the slides.   This comment was left on 2/5/2008 7:29:56 PM.

Suggestion: Class was fine   This comment was left on 2/5/2008 4:31:39 PM.

Suggestion: Dr. Alemi, May I request if we could please reserve the last 20 - 30 minutes of the class. This may reduce distractions and so we can concentrate on the lecture. Thanks.   This comment was left on 2/5/2008 4:11:02 PM.

Suggestion: the overall lecture was very well organized and easy to understand   This comment was left on 2/5/2008 12:54:06 AM.

Suggestion: Provided multiple media forms (video, slides, and a transcipt) make it easier to gather the important parts of a lecture. The written notes can be approved by placing them in Word or PDF files, so that less paper is used to print off the notes.   This comment was left on 2/4/2008 1:54:06 PM.

Suggestion: I really enjoyed the tutorial for plotting the data. I am fairly comfortable with Excel, but until the tutorial did not know how to work with before/after intervention situations. Thank you for the clarification!   This comment was left on 2/4/2008 8:01:58 AM.

Suggestion: Course material on Leading Change is outlined and presented well and can be used to guide personal project but there seems to be a disconnect on what is needed for group project.   This comment was left on 2/3/2008 10:00:33 PM.

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This page is part of the course on Quality / Process Improvement, the lecture on Leading Change.   This page was last edited on 09/29/2008 by Farrokh Alemi, Ph.D..  ©Copyright protected.