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• Section 1. Achieving and Maintaining Quality Performance

Chapter 40 Sections

• Section 3. Obtaining and Using Feedback from Participants
• Section 4. Establishing Oversight Mechanisms
• Section 5. Creating Formal Public Reporting Processes

• Main Section

Why is quality important to you?

What are the basic principles of tqm, what is tqm and its relevance to your organization, how do you achieve quality performance, using tqm and other principles, how do you maintain quality performance, the fourteen points.

W. Edwards Deming, a businessman who was influential in American industry during World War II and Japanese industry afterwards developed successful management principles based on quality. These principles encouraged the development of a flexible, dynamic system which involved everyone in a company in the production of goods that exactly met the customer's needs, did precisely what they were supposed to do as effectively as possible every time at the best possible price, and were constantly being improved. His ideas are often referred to as Total Quality Management (TQM), and they have led to a number of similar theories of management and numerous innovations in businesses around the world.

Why is quality important for you?

Exactly what does quality mean in the context of advocacy, community development, health, or human service organizations or initiatives.

A quality program:

• Responds as effectively as possible to the needs it was designed to meet
• Is totally consistent with the mission and philosophy of the organization or group carrying it out
• Is sensitive to the needs and culture of the target population
• Is a model of ethical behavior

But why is quality important for a grass roots organization?

• Quality makes a group more effective at meeting the needs it's concerned with
• Quality adds strength and credibility to your organization or initiative
• Ethically, you're bound to provide the absolute best quality of service or advocacy you can
• Quality is always more economical in the long run

Developing a "culture of quality" can have a number of positive effects on your organization itself

• If staff members and volunteers know that they and the organization are doing the best job possible, it builds their morale and makes them proud of themselves and the organization
• Striving for quality helps to develop organizational and individual competence, thus continually improving the organization
• A quality program continually increases its performance level and improves its service delivery, which gives your organization credibility and ultimately benefits your target audience

(Much of the following discussion is based on material contained in Introduction to Total Quality: Quality Management for Production, Processing, and Services, 2nd Edition. Full source citation can be found under Resources .)

There are some basic assumptions that underlie the idea of TQM. In this section, we'll look at how they might relate to your organization or initiative.

Key elements of total quality

• Customer Focus : Everything an organization does should have the needs of the customer as its starting point. In your work, the "customer" is the target population or the community that will benefit from what you are offering or doing. What are the needs to which you are responding? How can you meet those needs effectively, appropriately, and with respect for the people you're intending to serve?
• Obsession with Quality : Quality has to be something that's considered from the very beginning and built into everything a business or organization does. Planning carefully, monitoring your work, and constant reevaluation and adjustment are all extremely important. You don't ensure quality by catching mistakes before they reach the customer; you ensure it by setting up a system in which you don't make the mistakes to begin with. Everyone in the organization must understand and adopt this point of view if the organization is truly going to have quality performance.
• Continual Improvement of Systems : The work of an organization must be viewed as a process that is never finished. Any program can always be improved, and must be changed as the needs of the community or the target population change.
• Unity of Purpose : In order for quality to be achieved, everyone in an organization or business has to work together toward common goals. That means mutual support throughout the organization , not turf battles, not jealousy, not unnecessary competition. All interactions among people in the organization should be mutually helpful and aimed at achieving the best possible performance of the organization as a whole.
• Teamwork : Working in teams, rather than individually, people make better connections with their colleagues and the organization, and create better results. Teamwork removes performance pressure from the individual and usually coaxes better performance from everyone.
• Employee Involvement : If everyone in an organization is to be committed to quality performance, then all staff members should have the ability to contribute to its achievement. That means that people must have enough control over their own jobs to do them effectively, and that everyone's opinions and ideas must be respected and taken seriously.
• Education and Training: Achieving quality requires constant learning for everyone in an organization, and that learning needs to be part of the organizational culture. Not only should staff members be learning from others in the organization, but they should also be encouraged to take courses, to attend organization-sponsored trainings and workshops, to visit other organizations, etc., to continually learn more about their work, and to get new ideas and perspectives on it.
• Scientific Approach : For grass roots and community-based organizations, this means using the best research available, as well as the experience of others, to construct an effective program or initiative. That approach is much more likely to result in success and high quality than relying only on intuition or on what seems politically correct.

The founders of a Massachusetts community-based adult literacy program, with backgrounds in both developmental psychology and reading theory, based their program on the best available research in both areas. They made sure that the educational and support elements of the program fit together properly, and trained staff with that in mind. Initially, since it was doing something that hadn't been done with adults before, the program was severely criticized by others in the field. The founders were accused of cheating their students by not using a strict, phonics-based approach to reading, and by paying too much attention to other matters - students' concerns, community issues, etc. As time went on, however, and the program's drop-out rate remained extremely low and its students' success rate extremely high, others began experimenting with similar ideas. 15 years later, the program is a model for the state, but it keeps changing, responding both to student needs and feedback and to new research findings.

• Long-Term Commitment:  The best work in the world is ultimately useless if it's not maintained. Quality is a long-term concept: you have to keep striving for its improvement, even after you've achieved an acceptable level of performance. "Acceptable" is never good enough. In fact, you're never really at an endpoint, because the level you're trying to reach is "the best that can possibly be."

The Deming Cycle

The assumptions above underlie the "Deming Cycle," which is really a process for creating and selling a quality product. We'll revisit the Deming Cycle later to examine how it can be used in an advocacy, community development, health, or human service context.

• Plan - conduct consumer research and use it for planning the product
• Do -  produce the product
• Check - check the product to make sure it was produced in accordance with the plan
• Act - market the product
• Analyze - analyze how the product is received in the marketplace in terms of quality, cost, and other data

It is important to note that the principles of TQM were designed for the business sector, so while some aspects are relevant to organizations concerned with advocacy, community development, health, and human services, other aspects may be contrary to the goals of those organizations.

Some elements of TQM that would work toward quality in any environment include:

• The need for careful planning, monitoring, evaluation, and adjustment
• Teamwork and the empowerment of all in the organization
• Constant education and training for all staff
• Attention to the needs of the target population and to the results for them
• Identifying and changing what doesn't work well
• Encouraging and rewarding, rather than discouraging, new ideas
• Developing an organization-wide culture of quality
• Keeping at it over the long term

Some elements which may not work toward quality for your organization are those that assume that the goal is the success of a business, such as:

• The emphasis on products and production, which may take the focus off the human needs and consequences your organization is concerned with
• The assumption of a hierarchical structure where those in authority "let " others have a say in the achievement of quality, and where leadership always comes from the top, which may conflict with the way your organization operates
• The definition of everyone as either a supplier or a consumer/customer, which may provide the wrong metaphors for grass roots work where everyone is, on some level, a participant

Using the Deming Cycle while keeping some of the basic TQM principles in mind can help you design, deliver, refine, and maintain an effective program or initiative.

Conduct consumer research and use it for planning the product. The "product" here is the actual program you intend to conduct, and the "consumer research" is an examination of actual needs of the target population, the community, and others who will be affected.

Thus, the "Plan" part of the cycle might include the following:

• Conducting a needs assessment , involving everyone concerned
• Deciding what the desirable outcomes are, from the perspectives of the target population, the organization, and the larger community
• Determining ways to reach those outcomes that are feasible, consistent with the guiding principles of the organization, inclusive (respectful of all and beneficial to as many people and groups as possible), and consistent with the needs and culture of the target population
• Developing indicators to show when you have reached either outcomes themselves or significant points on the way to reaching those outcomes
• Inviting all stakeholders to participate in the development of the plan

Produce the product. The "production" part of the process is the actual design of the program, outreach effort, treatment strategy, etc. that will meet the need determined in the "Plan" part of the cycle. Much of the actual work here depends not only on TQM principles (teamwork, employee involvement, scientific approach, obsession with quality, and customer focus), but also on common sense and organizing principles.

The following are important elements of designing an effective program:

• Finding out what has already been tried in the community, and how well it worked
• Discovering whether there's any residual bad feeling attached to certain methods or approaches -- or people -- which may resurface if they're proposed again
• Using as examples other communities that have successfully mounted similar programs, while remaining aware that not everything that works in one place will work in another
• Consulting the research to see what has worked in this situation
• Involving all stakeholders in the development of the program or initiative, especially the people who will do the actual work
• Taking care of the logistics: a place to operate, equipment and supplies, the proper staff and/or volunteers on board, etc.

Check the product to make sure it was produced in accordance with the plan. Compare the details and overall shape of the program or initiative to the plan. Does it align with the needs assessment? Does it look like it will address the desired outcomes in desired ways? Is it inclusive? Was everyone involved in its development? Is it feasible? Is it ready to go?

Market the product. "Marketing the product" here means actually running the program or initiative that you've planned.

If it's going to work well, there are some non-TQM standards that need to be applied:

• Everyone involved should understand the process that led up to this program, as well as the philosophy, concept, and workings of it
• Everyone involved should be committed to making every effort to bring about success. A program or initiative should never fail because people don't follow through or do their jobs. (This doesn't mean that you shouldn't expect mistakes; it means, rather, that mistakes shouldn't happen just because people weren't trying, or because they simply didn't bother to do something they knew they had to do.)
• All the planning in the world is useless if everyone involved doesn't go into the experience expecting to do their best, and if there aren't good people implementing the functions of the organization

Analyze how the product is received in terms of quality, cost, and other data. Analysis in this context - looking at what you're doing, evaluating it, and trying to improve it - needs to be conducted on the basis of the original plan, with discussions among participants, staff, and others.

• Does the program or initiative actually address the identified needs? Are these needs the same as when the original assessment was conducted?
• Does the program or initiative reach, or help participants reach, the desired outcomes? Were those outcomes the right ones to aim for, or do they need to be changed? (Looking at the indicators you've developed should help you answer both these questions.)
• Is the plan in fact feasible? Can the program or initiative be run with the time, resources, and personnel available? Is it accessible to participants? Are staff and volunteers able to do their jobs without having to work to exhaustion, or beyond reasonable expectations? Is the program or initiative accepted by the community and other organizations?
• Is the program or initiative consistent with the vision, mission, philosophy and guiding principles of the organization (and are those still the same as when the plan was formulated)? Does what actually goes on in the program or initiative -- working conditions, empowerment, relations among staff, participants, volunteers, and the community -- mirror its desired effect on the community and society?
• Is the program or initiative inclusive and respectful of the target population and the community?
• Is the program or initiative ethical? Are you skirting your own principles in any way? Are you ignoring basic principles of fairness, honesty, civility, democracy, or responsibility for your actions?

Although the two are usually congruent, ethical is not always exactly the same as legal. The exercise of civil disobedience may be profoundly ethical, while being, at the same time, inarguably illegal. The civil rights marches and actions led by Martin Luther King and others during the 1950's and 60's often fell into this category.

Restart the cycle

Your analysis should naturally lead into a new planning sessions, and where necessary, lead to rethinking and reworking the program or initiative, or even the task of the organization itself.

While the maintenance of quality is, to some extent, built into the Deming Cycle, it requires some particular commitments and action.

Institutionalization of dynamism

An organization needs to be dynamic , always moving and always seeking continued improvement, and to institutionalize its dynamic character.

This means:

• An assumption of dynamism needs to be part of the organizational culture, with everyone understanding and buying into it.
• Encouraging and providing support -- to staff, volunteers, and participants -- for learning.

Organizational support for education includes providing, or coordinating with another organization's provision of, professional development or university courses, training, certification, etc., that help staff and volunteers to build their skills. If financial resources are not available, other means of institutional support -- release time or leave time, special recognition, a library for the organization, study circles or reading groups, etc. -- need to be considered. Everyone in the organization, including administrators and Board members, should be encouraged to take advantage of learning opportunities and to model learning behavior.

• Listening to and carefully evaluating ideas from everyone.
• Encouraging openness to change and experimentation with new ideas and strategies

Administrators and Board members need to model such openness by being willing to reexamine and change procedures, policies, etc. when needed. Staff and volunteers should be given room to try out even things that others may be skeptical about, as long as they can justify the attempt ("It worked elsewhere" and "I learned about it in a course" are both reasonable justifications.). If such an attempt is honestly carried out, it should be seen as a positive even if it fails: it provided new information, and is another building block in the construction of a quality program.

• Never being complacent and always being open to the idea that the work could be done differently -- and better.
• Incorporating constant reevaluation, including feedback and ideas from the target population.
• Always being aware of the original mission, but not being afraid of change. While the mission itself may change as the community and circumstances do, it should nonetheless remain consistent with the principles and philosophy upon which the organization was founded.

Long-range strategic planning

To maintain quality, an organization needs to continually look at itself over and for the long term.

It needs to ask some questions about its role and its future:

• Is it meeting an ongoing need effectively? If not, what does it need to do to become more effective?
• Have community needs changed? Are they likely to? If so, how can the organization regroup to meet new needs?
• Are there more or different things it should be doing? Does it need to expand its present activities to meet current or projected community needs?
• Does it need more resources, or will it in the future? What are some likely sources?
• Is its structure appropriate to what it's doing, and consistent with its mission and guiding principles? (An organization dedicated to empowerment, for instance, may not be consistent if its internal structure is hierarchical and authoritarian.)
• Are its goals, vision, and philosophy still relevant to the realities of the community and in keeping with its organizational mission and guiding principles?

SWOT Analysis

One way to explore these questions is through the use of another device partially borrowed from TQM: SWOT analysis . SWOT stands for Strengths, Weaknesses, Opportunities, and Threats. Each of the questions above can be examined in the light of SWOT analysis. What are the strengths and weaknesses of your organization in regard to each question? What opportunities exist for the organization in each area of its functioning? And what threats or challenges will the organization have to overcome if it is to continue to be successful, and to maintain quality performance?

Strengths and weaknesses : Strengths and weaknesses may be trends, rather than specifics. A level of service that is currently appropriate, for example, is not a strength if it is more or less than will be needed in a year. A new program that's not ready to implement yet is not a weakness if it's unready because the developers are taking the time necessary to make it effective.

By the same token, strengths and weaknesses don't necessarily lie only in the success of programs or the skills of staff members, but in such areas as relationships, contacts, and reputation. An organization running a great program may still be have serious weaknesses because it lacks some of these other features, no matter how well it carries out its day-to-day activities.

Opportunities: Opportunities can take many forms.

• An organization may be able to meet other needs with its current structure. For instance, an organization that publicizes and provides prenatal care to pregnant teens could be in an excellent position to also publicize and provide vaccinations, nutrition information, and help with parenting skills after the babies are born.
• It may be possible to expand into other areas of service, or into a larger arena (another town, another county, national instead of just one state).
• Increased funding may be available from new sources, or because of changed circumstances. A new census, for example, can result in an increase in federal funds to a region, or an economic downturn may bring a demand -- and increased funding -- for adult education or retraining.
• Collaboration with other groups , leading to increased resources, may become a prospect.
• Invitations or awards offered to your organization or staff members or good press may lead to your organization being viewed as more "legitimate."

Taking advantage of any opportunity can have both positive and negative consequences for your organization, so it's important to analyze the situation carefully before committing yourself.

Threats (Challenges): Some of the challenges that go along with any opportunity can be truly daunting if they're not thought through carefully. Many of the opportunities above require some sort of organizational restructuring or growth, processes that are always difficult, and require a lot of planning. Some even represent rethinking the purpose of the organization, which may become a different organization in the process. In becoming larger or more accepted, for instance, an organization may forget its roots or its guiding principles, and lose much of its effectiveness.

Other threats may come unaccompanied by opportunity. Your organization may experience difficulty finding -- and keeping -- ongoing funding and other resources, including competent staff; sustaining continued effort in all areas of functioning (advertising, recruitment, public relations, programming, evaluation, etc.); dealing with controversy; and addressing antagonism from individuals, other groups, or the community.

Applying SWOT analysis to all the areas your organization has to deal with makes it easier both to anticipate and prepare for the negative, and to remember to identify and build on the positive.

Other facets of the planning process

Some specific areas that long-range strategic planning needs to address at regular intervals:

• Reexamining the organization's vision, guiding principles, and mission statement . Are they still relevant to what the organization does, and are they still what the organization believes? Do they need to be restated or redefined?
• Reexamining the goals of the organization . Are they still relevant to the needs they were originally meant to address? Are they consistent with the vision and mission statement?
• Reexamining the current strategies of the organization for meeting those goals . Are current methods effective? Are they consistent with the organization's vision, mission statement, and guiding principles? Are they feasible? Do they play well in the community? Are they inclusive and respectful? Are they ethical?

Keeping at it

The single most important thing to understand about maintaining quality performance -- or maintaining an organization, for that matter -- is that you can never stop working at it. No effort at maintaining quality will work any longer than it is applied. No matter how institutionalized dynamism becomes, no matter how good your planning process is, they take constant care.

The Fourteen Points Deming used the key elements listed above in "Basic principles of TQM" to define the "Fourteen Points," fourteen things that he felt businesses needed to do in order to achieve quality performance. Create constancy of purpose toward the improvement of products and services in order to become competitive, stay in business, and provide jobs. Adopt the new philosophy. Management must learn that it is a new economic age and awaken to the challenge, learn their responsibilities, and take on leadership for change. Stop depending on inspection to achieve quality. Build in quality from the start. Stop awarding contracts on the basis of low bids. Continuously improve the system of production and services to enhance quality and productivity, and thus constantly to reduce costs. Institute training on the job. Institute leadership. The purpose of leadership should be to help people and technology work better. Drive out fear so that everyone may work effectively. Break down barriers between departments so that people can work as a team. Eliminate slogans, exhortations, and targets for the work force. They create adversarial relationships. Eliminate quotas and management by objectives. Substitute leadership. Remove barriers that rob employees of their pride of workmanship. Institute a vigorous program of education and self improvement. Make the transformation everyone's job and put everyone to work on it.

Achieving and maintaining quality performance is important to the target population, to funders, and to the community.

Using some TQM principles and, specifically, the Deming Cycle ( Plan, Do, Check, Act, Analyze ) can be helpful in getting to a high level of quality and continuing to improve.

In general, achieving and maintaining quality is a result of:

• Careful planning
• Program or initiative development that adheres to that planning
• Implementation that takes quality into account
• Constant reevaluation of implementation and of the organization
• An assumption of the dynamic character of the organization, and a willingness to change continually in striving for a better way to accomplish goals
• Keeping at it indefinitely

If you can carry out and institutionalize these steps, especially the last, success is in your grasp.

Online Resources

ASQ: The Global Voice of Quality  is a global community of people passionate about quality, who use the tools and their ideas and expertise to make our world work better.

The International Organization for Standardization (ISO)  publishes International Standards which ensure that products and services are safe, reliable and of good quality. For business, they are strategic tools that reduce costs by minimizing waste and errors and increasing productivity. They help companies to access new markets, level the playing field for developing countries and facilitate free and fair global trade.   ISO 9000 WWW Pages , provided by  Simply Quality , lists websites that provide information on ISO 9000. The ISO 9000 family of standards is related to quality management systems and designed to help organizations ensure that they meet the needs of customers and other stakeholders while meeting statutory and regulatory requirements related to the product. ISO 9000 deals with the fundamentals of quality management systems.

Little-Bitty Quality Steps  is an article on small steps to quality on the website of Bacal & Associates, management and training consultants to the public sector in Canada.

Publich Health Quality Improvement Exchange (PHQIX)   allows people to submit short explanations of their initiatives and observations/lessons-learned.

Total Quality Management  provides a dictionary of TQM terms.

Print Resources

Deming,  E. Out of the Crisis . (1986). Cambridge, MA: Massachusetts Institute of Technology, Center for Advanced Engineering Study.

Deming,  E. Quality, Productivity, and Competitive Position . (1982). Cambridge, MA: M.I.T., Center for Advanced Engineering Study.

Goetsch, D., & Davis, S.  Introduction to Total Quality: Quality Management for Production, Processing, and Services , 2nd Edition. Merrill, an imprint of MacMillan Publishing Co.

Hunt, D. (1992).   Quality in America: How to Implement a Competitive Quality Program . Homewood, IL: Business One Irwin.

Latzko, W., & David, M. Four Days with Dr. Deming: A Strategy for Modern Methods of Management . (1995). Reading, MA: Addison-Wesley Publishing Co.

Sashkin, M., & Kenneth, J. (1993).  Putting Total Quality Management to Work . San Francisco: Berrett-Koehler.

The Key Strategies for Measuring Employee Performance in Companies: A Systematic Review

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• v.367; 2019

Quality Improvement

How to improve healthcare improvement—an essay by mary dixon-woods.

As improvement practice and research begin to come of age, Mary Dixon-Woods considers the key areas that need attention if we are to reap their benefits

In the NHS, as in health systems worldwide, patients are exposed to risks of avoidable harm 1 and unwarranted variations in quality. 2 3 4 But too often, problems in the quality and safety of healthcare are merely described, even “admired,” 5 rather than fixed; the effort invested in collecting information (which is essential) is not matched by effort in making improvement. The National Confidential Enquiry into Patient Outcome and Death, for example, has raised many of the same concerns in report after report. 6 Catastrophic degradations of organisations and units have recurred throughout the history of the NHS, with depressingly similar features each time. 7 8 9

More resources are clearly necessary to tackle many of these problems. There is no dispute about the preconditions for high quality, safe care: funding, staff, training, buildings, equipment, and other infrastructure. But quality health services depend not just on structures but on processes. 10 Optimising the use of available resources requires continuous improvement of healthcare processes and systems. 5

The NHS has seen many attempts to stimulate organisations to improve using incentive schemes, ranging from pay for performance (the Quality and Outcomes Framework in primary care, for example) to public reporting (such as annual quality accounts). They have had mixed results, and many have had unintended consequences. 11 12 Wanting to improve is not the same as knowing how to do it.

In response, attention has increasingly turned to a set of approaches known as quality improvement (QI). Though a definition of exactly what counts as a QI approach has escaped consensus, QI is often identified with a set of techniques adapted from industrial settings. They include the US Institute for Healthcare Improvement’s Model for Improvement, which, among other things, combines measurement with tests of small change (plan-do-study-act cycles). 8 Other popular approaches include Lean and Six Sigma. QI can also involve specific interventions intended to improve processes and systems, ranging from checklists and “care bundles” of interventions (a set of evidence based practices intended to be done consistently) through to medicines reconciliation and clinical pathways.

QI has been advocated in healthcare for over 30 years 13 ; policies emphasise the need for QI and QI practice is mandated for many healthcare professionals (including junior doctors). Yet the question, “Does quality improvement actually improve quality?” remains surprisingly difficult to answer. 14 The evidence for the benefits of QI is mixed 14 and generally of poor quality. It is important to resolve this unsatisfactory situation. That will require doing more to bring together the practice and the study of improvement, using research to improve improvement, and thinking beyond effectiveness when considering the study and practice of improvement.

Uniting practice and study

The practice and study of improvement need closer integration. Though QI programmes and interventions may be just as consequential for patient wellbeing as drugs, devices, and other biomedical interventions, research about improvement has often been seen as unnecessary or discretionary, 15 16 particularly by some of its more ardent advocates. This is partly because the challenges faced are urgent, and the solutions seem obvious, so just getting on with it seems the right thing to do.

But, as in many other areas of human activity, QI is pervaded by optimism bias. It is particularly affected by the “lovely baby” syndrome, which happens when formal evaluation is eschewed because something looks so good that it is assumed it must work. Five systematic reviews (published 2010-16) reporting on evaluations of Lean and Six Sigma did not identify a single randomised controlled trial. 17 18 19 20 21 A systematic review of redesigning care processes identified no randomised trials. 22 A systematic review of the application of plan-do-study-act in healthcare identified no randomised trials. 23 A systematic review of several QI methods in surgery identified just one randomised trial. 56

The sobering reality is that some well intentioned, initially plausible improvement efforts fail when subjected to more rigorous evaluation. 24 For instance, a controlled study of a large, well resourced programme that supported a group of NHS hospitals to implement the IHI’s Model for Improvement found no differences in the rate of improvement between participating and control organisations. 25 26 Specific interventions may, similarly, not survive the rigours of systematic testing. An example is a programme to reduce hospital admissions from nursing homes that showed promise in a small study in the US, 27 but a later randomised implementation trial found no effect on admissions or emergency department attendances. 28

Some interventions are probably just not worth the effort and opportunity cost: having nurses wear “do not disturb” tabards during drug rounds, is one example. 29 And some QI efforts, perversely, may cause harm—as happened when a multicomponent intervention was found to be associated with an increase rather than a decrease in surgical site infections. 30

Producing sound evidence for the effectiveness of improvement interventions and programmes is likely to require a multipronged approach. More large scale trials and other rigorous studies, with embedded qualitative inquiry, should be a priority for research funders.

Not every study of improvement needs to be a randomised trial. One valuable but underused strategy involves wrapping evaluation around initiatives that are happening anyway, especially when it is possible to take advantage of natural experiments or design roll-outs. 31 Evaluation of the reorganisation of stroke care in London and Manchester 32 and the study of the Matching Michigan programme to reduce central line infections are good examples. 33 34

It would be impossible to externally evaluate every QI project. Critically important therefore will be increasing the rigour with which QI efforts evaluate themselves, as shown by a recent study of an attempt to improve care of frail older people using a “hospital at home” approach in southwest England. 35 This ingeniously designed study found no effect on outcomes and also showed that context matters.

Despite the potential value of high quality evaluation, QI reports are often weak, 18 with, for example, interventions so poorly reported that reproducibility is frustrated. 36 Recent reporting guidelines may help, 37 but some problems are not straightforward to resolve. In particular, current structures for governance and publishing research are not always well suited to QI, including situations where researchers study programmes they have not themselves initiated. Systematic learning from QI needs to improve, which may require fresh thinking about how best to align the goals of practice and study, and to reconcile the needs of different stakeholders. 38

Using research to improve improvement

Research can help to support the practice of improvement in many ways other than evaluation of its effectiveness. One important role lies in creating assets that can be used to improve practice, such as ways to visualise data, analytical methods, and validated measures that assess the aspects of care that most matter to patients and staff. This kind of work could, for example, help to reduce the current vast number of quality measures—there are more than 1200 indicators of structure and process in perioperative care alone. 39

The study of improvement can also identify how improvement practice can get better. For instance, it has become clear that fidelity to the basic principles of improvement methods is a major problem: plan-do-study-act cycles are crucial to many improvement approaches, yet only 20% of the projects that report using the technique have done so properly. 23 Research has also identified problems in measurement—teams trying to do improvement may struggle with definitions, data collection, and interpretation 40 —indicating that this too requires more investment.

Improvement research is particularly important to help cumulate, synthesise, and scale learning so that practice can move forward without reinventing solutions that already exist or reintroducing things that do not work. Such theorising can be highly practical, 41 helping to clarify the mechanisms through which interventions are likely to work, supporting the optimisation of those interventions, and identifying their most appropriate targets. 42

Research can systematise learning from “positive deviance,” approaches that examine individuals, teams, or organisations that show exceptionally good performance. 43 Positive deviance can be used to identify successful designs for clinical processes that other organisations can apply. 44

Crucially, positive deviance can also help to characterise the features of high performing contexts and ensure that the right lessons are learnt. For example, a distinguishing feature of many high performing organisations, including many currently rated as outstanding by the Care Quality Commission, is that they use structured methods of continuous quality improvement. But studies of high performing settings, such as the Southmead maternity unit in Bristol, indicate that although continuous improvement is key to their success, a specific branded improvement method is not necessary. 45 This and other work shows that not all improvement needs to involve a well defined QI intervention, and not everything requires a discrete project with formal plan-do-study-act cycles.

More broadly, research has shown that QI is just one contributor to improving quality and safety. Organisations in many industries display similar variations to healthcare organisations, including large and persistent differences in performance and productivity between seemingly similar enterprises. 46 Important work, some of it experimental, is beginning to show that it is the quality of their management practices that distinguishes them. 47 These practices include continuous quality improvement as well as skills training, human resources, and operational management, for example. QI without the right contextual support is likely to have limited impact.

Beyond effectiveness

Important as they are, evaluations of the approaches and interventions in individual improvement programmes cannot answer every pertinent question about improvement. 48 Other key questions concern the values and assumptions intrinsic to QI.

Consider the “product dominant” logic in many healthcare improvement efforts, which assumes that one party makes a product and conveys it to a consumer. 49 Paul Batalden, one of the early pioneers of QI in healthcare, proposes that we need instead a “service dominant” logic, which assumes that health is co-produced with patients. 49

More broadly, we must interrogate how problems of quality and safety are identified, defined, and selected for attention by whom, through which power structures, and with what consequences. Why, for instance, is so much attention given to individual professional behaviour when systems are likely to be a more productive focus? 50 Why have quality and safety in mental illness and learning disability received less attention in practice, policy, and research 51 despite high morbidity and mortality and evidence of both serious harm and failures of organisational learning? The concern extends to why the topic of social inequities in healthcare improvement has remained so muted 52 and to the choice of subjects for study. Why is it, for example, that interventions like education and training, which have important roles in quality and safety and are undertaken at vast scale, are often treated as undeserving of evaluation or research?

How QI is organised institutionally also demands attention. It is often conducted as a highly local, almost artisan activity, with each organisation painstakingly working out its own solution for each problem. Much improvement work is conducted by professionals in training, often in the form of small, time limited projects conducted for accreditation. But working in this isolated way means a lack of critical mass to support the right kinds of expertise, such as the technical skill in human factors or ergonomics necessary to engineer a process or devise a safety solution. Having hundreds of organisations all trying to do their own thing also means much waste, and the absence of harmonisation across basic processes introduces inefficiencies and risks. 14

A better approach to the interorganisational nature of health service provision requires solving the “problem of many hands.” 53 We need ways to agree which kinds of sector-wide challenges need standardisation and interoperability; which solutions can be left to local customisation at implementation; and which should be developed entirely locally. 14 Better development of solutions and interventions is likely to require more use of prototyping, modelling and simulation, and testing in different scenarios and under different conditions, 14 ideally through coordinated, large scale efforts that incorporate high quality evaluation.

Finally, an approach that goes beyond effectiveness can also help in recognising the essential role of the professions in healthcare improvement. The past half century has seen a dramatic redefining of the role and status of the healthcare professions in health systems 54 : unprecedented external accountability, oversight, and surveillance are now the norm. But policy makers would do well to recognise how much more can be achieved through professional coalitions of the willing than through too many imposed, compliance focused diktats. Research is now showing how the professions can be hugely important institutional forces for good. 54 55 In particular, the professions have a unique and invaluable role in working as advocates for improvement, creating alliances with patients, providing training and education, contributing expertise and wisdom, coordinating improvement efforts, and giving political voice for problems that need to be solved at system level (such as, for example, equipment design).

Improvement efforts are critical to securing the future of the NHS. But they need an evidence base. Without sound evaluation, patients may be deprived of benefit, resources and energy may be wasted on ineffective QI interventions or on interventions that distribute risks unfairly, and organisations are left unable to make good decisions about trade-offs given their many competing priorities. The study of improvement has an important role in developing an evidence-base and in exploring questions beyond effectiveness alone, and in particular showing the need to establish improvement as a collective endeavour that can benefit from professional leadership.

Mary Dixon-Woods is the Health Foundation professor of healthcare improvement studies and director of The Healthcare Improvement Studies (THIS) Institute at the University of Cambridge, funded by the Health Foundation. Co-editor-in-chief of BMJ Quality and Safety , she is an honorary fellow of the Royal College of General Practitioners and the Royal College of Physicians. This article is based largely on the Harveian oration she gave at the RCP on 18 October 2018, in the year of the college’s 500th anniversary. The oration is available here: http://www.clinmed.rcpjournal.org/content/19/1/47 and the video version here: https://www.rcplondon.ac.uk/events/harveian-oration-and-dinner-2018

This article is one of a series commissioned by The BMJ based on ideas generated by a joint editorial group with members from the Health Foundation and The BMJ , including a patient/carer. The BMJ retained full editorial control over external peer review, editing, and publication. Open access fees and The BMJ ’s quality improvement editor post are funded by the Health Foundation.

Competing interests: I have read and understood BMJ policy on declaration of interests and a statement is available here: https://www.bmj.com/about-bmj/advisory-panels/editorial-advisory-board/mary-dixonwoods

Provenance and peer review: Commissioned; not externally peer reviewed.

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Essay on Total Quality Management TQM Total Quality Management system and the Enrichment of Customer requirements

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iaeme iaeme

In present scenario of globalization and economic slowdown, survival of organizations has become a challenging task for the management. Customers expect high product quality along with low cost, timely deliver and best service. In such a situation, total quality management in the organization is very relevant. This paper has tried to explore different issues affecting implementation of TQM, effect of TQM on performance and circumstances under which TQM fails. One hundred twenty research papers, mainly from referred international journals are reviewed to identify thrust areas of research. On the basis of review, gaps are identified and research agenda is proposed. This paper has identified certain gaps from literature on issues related with TQM such as development of framework for evaluating effectiveness of TQM, prioritization of critical success factors, comparative study of TQM and effect of TQM on performance of organizations from supply chain perspective etc on which further study can be conducted

Gangaram Biswakarma, PhD

In this 21st century, globally quality is the foremost emphasized in any sector, whether it is manufacturing or service sector. It leads to the competitive advantage to an organization. In this front, TQM implementation gives a cutting edge to the organization. In Nepalese context there is an increasing interest in TQM in service sector including hospitality, for providing company with a competitive advantage. A sample of 250 employees of hospitality sector in Nepal was taken with convenience sampling techniques, returned 226 questionnaires. It can be concluded in results that TQM is an important tool to manage organization successfully. TQM focuses strongly on the importance of the relationship between customers and as well as employee. It is practiced moderately. The dimensions of TQM - top management commitment & leadership, continuous improvement, quality planning, customer focus, service design, supplier relationship and employee management are equally vital and contribute to the instatement of TQM in hospitality industry. All the dimensions have positive correlation with effectiveness of TQM. Likewise, all dimensions have their impact over the effectiveness of TQM; employee management has the strongest impact on effectiveness of total quality management.

Canadian Institute for Knowledge Development (CIKD)

International Journal of Organizational Leadership (IJOL)

There are many skeptics about the contributions of Total Quality Management (TQM) to education because of its roots in the world of business. TQM says nothing about actual production but stresses the process of management and collaboration within the system to reach quality output. Any quality-conscious organization, despite the nature, should understand this. This paper will not present any innovative ideas but will define TQM and focus on its influence on the various facets of an institution of higher education. TQM helps to provide better services to its primary customers-students and the community. Moreover, TQM focuses on continuous improvement and growth that can offer an enhanced and challenging learning environment for all involved. Thus, a more effective and efficient corporate culture emerges.

Bala Salisu

Objective: The objective of this review is to spotlight, based on contextual fit, the essence of the Total Quality Management (TQM) concept, advance the context-specific tools for its adoption, and suggest Critical Success Factors (CSFs) researchers and management practitioners should consider when considering any TQM initiative. Method/ Analysis: The traditional narrative review design was used. Based on the authors' extensive readings, a number of TQM tools and CSFs reflective of Lee's conception of the paradigmatic shifts in management practice were identified from the extant literature. A synthesis of a selected set of TQM tools and CSFs form the paper's argument. Findings: The results show that when conceptualised to reflect the appropriate management context (mechanical, biological , or social), TQM can impact organisational outcomes based on intervention in six areas. Five management tools and a set of three foundational CSFs form the operational grid for a typical TQM programme. Novelty: Against the backcloth of the five revolutions in management, this paper presents a set of five management tools that could be used across industry groups in implementing TQM programmes based on the pedestal of three foundational CSFs.

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IDOSI Publications

Ain Zakinuddin

The main purpose of this article is to propose a framework on the relationship between Total Quality Management (TQM) and Customer Relationship Management (CRM). In the relevant literature, many theories have focused on TQM dimensions like as leadership, strategic planning, customer focus and information analysis. TQM practices seems to become benefit to all types of organization in which it is applied. Like as TQM, organization will get a better chance to become successful if implementing CRM strategies in their organization with the help from flexibility and reconstruction of the organizational structure, organization wide commitment of resources and human resources management.

IOSR Journals publish within 3 days

Abstract: Total Quality Management (TQM) is a management philosophy which focuses on customer satisfaction by improving the organisation performance through co-ordination of various processes in all the business units. The purpose of TQM is to provide quality product or service to the customer which inturn provides increased productivity at low cost. TQM is applicable to all manufacturing and service industries. It operates on the principle that cost of prevention is less than the cost of correction. This study focuses on TQM development, performance and sustenance in service industries through effective communication, critical success factors and market orientation. It examines the quality improvement through effective employee communication and the relationship between CSFs and company performance. The study suggests Deming’s Plan-Do-Study-Act (PDSA) cycle based approach to develop and sustain TQM. It articulates the relationship between TQM and market orientation, in terms of both elements (practices) and performance. The study investigates the reasons for TQM failures and proposes guidelines for successful implementation of TQM. Keywords: Critical Success Factors (CSFs), Effective Communication, Market Based Quality, PDSA, TQM Failures, and TQM Implementation

hahid hakim

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Ng Kim-Soon

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