Leading Change by Using Continuous 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 about leadership:
For another example, Kotter in his book titled "Leading change, Harvard Business Review 1996" lists eight steps in successful efforts to change organizations:
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.
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:
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:
We present the content of continuous quality improvement through 10 steps:
The first five of these steps are addressed in this lecture.
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:
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:
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:
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.
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:
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]:
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.
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.]:
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:
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:
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.
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:
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.
French WL, and Bell CH write in their book Organization Development (Prentice Hall, Fifth Edition, 1995):
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"
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.
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►
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.
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."
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.
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.
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►
To assist you in reviewing the material in this lecture, please see the following resources:
Narrated lectures require use of Flash Download►
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.
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.