Principles of Quality Management
Organizations that focus on quality rely on the same basic management principles for success, no matter what kind of product or service they provide (79, 245, 262). These principles are:
* Strengthen systems and processes. By viewing an organization as a collection of interdependent systems and processes, managers can understand how problems occur and can strengthen the organization as a whole.
* Encourage staff participation and teamwork. Every employee can help assure good quality if managers empower staff members to solve problems and recommend improvements.
* Base decisions on reliable information. By collecting and analyzing accurate, timely, and objective data, managers can diagnose and solve organizational problems and measure progress.
* Improve communication and coordination. Different units, facilities, and management levels can work together to improve quality if they share information freely and coordinate their activities.
* Demonstrate leadership commitment. When top leaders are committed to good quality, employees accept it as a guiding principle for their own work.
Strengthen Systems and Processes
“Systems thinking” can help improve the delivery of family planning and other health care services. A systems perspective sees an organization as a collection of interdependent systems and processes (403). Because the work of an organization crosses the boundaries of different hierarchical levels, functional departments, and geographic units, many problems can be understood and solved only in the context of the whole organization.
From a systems perspective, the weakest subsystem in an organization determines its overall performance, just as the weakest link in a chain determines the overall strength of the chain (80). For example, if the supply of contraceptives is not reliable, improvements in counseling will be undermined.
Human and technical systems. Human systems organize people. They include salaries and incentives, management and supervision, staff training and development. Technical systems are specific to the work of an organization, for example, the service delivery system in health care. In any organization, problems can be caused by weaknesses in either the human system, such as poor motivation caused by inadequate salaries, or by technical systems, such as lack of supplies resulting from poor logistics. Each system affects the other, as when failures in the technical system frustrate workers’ efforts to do a good job and sap their motivation (79, 92, 113). At the same time, such employee problems as interpersonal conflicts, poor communication, and fear can cripple the technical systems.
In most organizations fixing flawed processes helps to improve staff performance (92, 324). Even the most conscientious employees cannot do a good job if the systems they depend on are deficient–for example, if employees lack training, equipment, supervision, or a clear idea of their responsibilities (343). Once managers see poor employee performance as a symptom of failure, rather than its cause, they stop blaming employees for problems. Employees then stop feeling defensive and can focus on finding and correcting the real causes of poor performance.
Structures and processes. Avedis Donabedian, an early leader in defining the quality of health care, divides health care organizations into structures, processes, and outcomes (93). Structures are the inputs that make care possible. They include the organization’s staff and other physical and financial resources, such as facilities, equipment, supplies, training, payroll, and operating budgets. Processes are the tasks–such as counseling, contraceptive ordering, and supervision–that transform these inputs into products and services (113). Together, structures and processes determine clinical outcomes.
Adequate structures–that is, appropriate staffing, equipment, and funding–are necessary to provide good-quality services, but they are not sufficient. Well-designed and implemented processes also are crucial.
It might seem easier to strengthen structures–by buying more equipment or paying for a training course, for example–than to improve processes (394). Most quality improvement approaches, however, focus on improving processes in order to use resources more efficiently, although they also address structures and outcomes. For example, defects in the contraceptive logistics process might best be cured by revising the process of ordering, storing, and distributing the supplies to minimize wastage and ensure timely delivery, rather than by purchasing more supplies. Indeed, front-line supervisors and middle managers usually have focused their quality improvement efforts on processes because they have little authority over program inputs; that is, they cannot hire more workers or buy more equipment, no matter how important these might be.
Encourage Staff Participation and Teamwork
Staff members’ knowledge and experience are among an organization’s most important resources. The employees who perform a task daily know best what may go wrong and why. They also may have the most practical ideas about how to improve the process. To improve quality, top managers must recognize and value the knowledge and experience of staff members at every level. They must give staff members the authority and responsibility to improve quality (169). Thus empowered, staff members often can solve problems and improve quality quickly and effectively.
For example, when rising demand for measles vaccinations overwhelmed a rural health center in Niger, the limiting factor was the capacity of the center’s refrigerator to make freezer packs. Without more freezer packs, the staff could not safely transport vaccines to surrounding villages each day. The problem was solved when the head nurse took matters into her own hands and rearranged the interior dividers in the refrigerator so that more packs could fit inside. A quality improvement initiative gave her the authority and confidence to act (314).
Workers who participate in decision-making typically feel committed to making the proposed course of action work (113, 129, 219). Participation generates enthusiasm and increases workers’ motivation (44, 70, 113). Solving problems, even small or simple problems, gives staff members a sense of achievement and boosts their self-confidence (119, 219, 265).
Crossfunctional teams. Crossfunctional teams, sometimes called “quality circles” in industry, are a common technique to encourage people from different departments to work together (81). By bringing together all the people who are involved in a process, crossfunctional teams can assemble a complete picture of what is happening, examine weaknesses throughout a system, and generate a wide variety of ideas about the possible causes of a problem and its solutions (113, 119, 129). Crossfunctional teams also can help overcome barriers caused by differences in employees’ power, status, attitudes, and values (216).
These teams are important because a single person, or even a single department, rarely controls or understands an entire process. For example, many workers contribute to preventing infection in a clinic, including the providers who practice no-touch technique, the assistants who clean and sterilize or disinfect the equipment, the custodians who clean the facility, and the administrators who order the necessary supplies. Many family planning programs have used crossfunctional teams and team problem-solving to help improve the quality of services.
Base Decisions on Reliable Information
Reliable information forms the foundation of every quality improvement effort. Managers need accurate, up-to-date information to assess an organization’s strengths and weaknesses, diagnose problems, develop improvement strategies, and measure progress (113, 127). In particular, good information on clients’ needs, perceptions, and satisfaction is needed for a client-centered approach (344).
Often, however, family planning managers operate without reliable information about service delivery (258). Service statistics often are forwarded to higher levels, aggregated, and reported in ways that are not useful for decision-making (65, 127). For example, in Ghana in the late 1980s not more than 10% of the health information entered on 27 different client cards, registers, and tally sheets (and collated in 38 different reporting forms) was ever used to improve management in any meaningful way (65).
In the absence of accurate, relevant information, decisions are based on assumptions, intuition, and anecdotal information that may be incorrect or biased (65). In The Gambia, for example, managers commonly thought that all health facilities were understaffed–a problem too big for them to tackle. After district health teams collected and analyzed data on staffing, attendance, and workloads, however, they found that only certain facilities needed additional staff. Using these data, the teams successfully lobbied the Ministry of Health to add staff to the facilities with the greatest need (70).
A good way to ensure that information is useful and used is for the front-line managers and service providers who collect information also to analyze it, interpret it, and make decisions based on it (127, 344, 364). Then staff are more likely to understand why they are gathering the data and have more incentive to be accurate. Also, local managers can check accuracy immediately (36).
Often, front-line managers must first be trained in basic data analysis, such as calculating rates or making charts, and shown how to interpret and act on their findings (36, 65, 127). In Tanzania family planning workers in an AVSC International program are learning these skills and have begun to examine service delivery statistics that previously were forwarded to headquarters without discussion (43).
For quality improvement, data collected should reflect the quality of services rather than just their quantity (33, 127). Substantial progress has been made recently in identifying new indicators of quality in family planning programs (see p. 22) and in developing methods to track these indicators.
Improve Coordination and Communication
Coordination is crucial for family planning and other health care organizations, both within a service unit and between service delivery approaches, such as clinics and community-based distribution. Effective coordination should be built into an organization. The starting point is a set of standardized procedures, guidelines, operating manuals, and job descriptions (216). Training also helps staff members work together by giving them a common body of knowledge and skills. Managers should stay alert to coordination problems and correct them as they arise.
Communication is important. Managers must share information as widely as possible, both across departmental lines and throughout all levels of the hierarchy (216). Effective communication helps staff members understand how their jobs and their units fit into the larger organization and contribute to meeting its objectives (403). In contrast, when information is restricted, individuals and units cannot appreciate the “big picture” and tend to work independently, often in conflict with one another.
To prevent misunderstandings, the Asociaci6n Hondurena de Planificaci6n Familial (ASHONPLAFA), the major family planning provider in Honduras, made all internal communication campaign the first priority when the organization’s strategy changed to attract paying, middle-class clients (69, 77). The campaign was designed to reduce workers’ fear that they would lose their jobs, to eliminate confusion caused by conflicting rumors, and to inspire workers with the program’s new mission.
To encourage effective communication, organizations must overcome the many obstacles that block, filter, and distort messages. Hierarchical organizations tend to promote only vertical flows of information, from top managers to supervisors to workers. Providing information horizontally, across units, is crucial for coordination, however (216). For example, health care providers may not even know how to refer patients for other services within their own facility.
To encourage internal referrals and coordination, AVSC International’s “inreach” approach orients all staff of a health facility to family planning and creates links between family planning units and other departments. An inreach project at two Kenyan hospitals dramatically increased the percentage of prenatal, postpartum, and child welfare clients who were informed about family planning services (220). Similarly, cross-training in a quality improvement initiative in Russia, assisted by the Family Planning Service Expansion and Technical Support Program (SEATS), helped increase contraceptive use among new mothers (163).
The Zimbabwe National Family Planning Council (ZNFPC) undertook a 4-year effort to strengthen internal coordination and communication so that all staff–nurses, community-based distributors (CBDs), and supervisors–understood their roles in the referral system. ZNFPC decided on this step after a provincial nursing officer found that CBDs rarely referred family planning clients to clinics, as they were supposed to. In fact, CBD agents and clinic staff saw themselves as separate programs rather than as parts of the same, larger organization. The internal coordination effort included revising nurses’ training, holding joint workshops for CBDs and nurses, retraining supervisors, and publicly recognizing CBDs for high referral rates. Improved coordination led to more referrals. It also increased understanding and confidence among CBD agents, supervisors, and clinic staff (60).
Also, an organization’s leaders must value receiving accurate information, no matter how negative or unpleasant. Otherwise, employees naturally tend to report only good news to their supervisors. They may even falsify reports for fear they might be punished for bad results (202).
Demonstrate Leadership Commitment
Top managers must be actively involved in any quality improvement initiative if it is to succeed. Leaders’ personal and professional example demonstrates institutional commitment, helps overcome workers’ natural resistance to change (36, 81), and helps convince the staff that quality is important (36, 129, 245, 337). Successful quality initiatives usually have a quality champion, that is, a respected leader who is personally identified with and dedicated to the initiative (88). Without strong leadership, the staff may be confused about what is expected of them, question what the top leaders really want, and put off action (61, 106).
The most powerful way to change everyday practices is for top managers themselves to practice what they preach–that is, to do what they are asking other staff members to do. Such leaders provide a positive example, encourage others to think about new approaches themselves, and reinforce new values (36, 81, 179, 279). Top managers must fully understand and be committed to quality improvement, however, to demonstrate such personal commitment (245). In fact, they may feel threatened by a quality initiative because it changes the standards applied to them and their programs. Also, they may not appreciate the need for change as much as their subordinates because they are further from the front lines of service delivery (154).
Middle managers and front-line supervisors also play important roles in quality improvement (323). Even without a program-wide quality initiative, they can improve the quality of care by addressing such problems as long waiting times or poor record-keeping and by encouraging their staff to be sensitive to clients’ needs (219, 242). Their example may influence the whole organization and pave the way for larger initiatives (154).
COPYRIGHT 1998 Department of Health
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