Quality Improvement: A
Front Line View
In many industries and business sectors there has been an evolution over the past fifteen years and a distinct shift from the "quality assurance" approach to the broader, more encompassing "quality improvement" concept.
In spite of the broad recognition and adaptation to quality improvement, there continues to be a challenge within organizations to fully integrate this newer approach with the work of front line staff. This article identifies some of the factors that contribute to these barriers, and suggests some proven strategies for overcoming them.
Quality Management by Management Staff
Departmental managers then take the information and quality initiatives back to their individual departments. Front line staff may be involved at this point, but often their role is in implementation of new strategies that they have had very little involvement in developing. Understandably, the success rate of these initiatives is often limited. If front line staff are not fully aware of the rationale and do not feel that they are responsible for the outcome, their degree of involvement in the implementation may be superficial or worse, there may be resistance to the changes resulting from the quality initiative.
Whose Job is it Anyway?
Barriers in the System
Budgeting and financial control are not linked to outcome or objective performance measures. Some organizations have succeeded in building balanced scorecards, that demonstrate a link between quality, client satisfaction and financial outcomes; but these examples are few in number. The lack of a clear linkage between quality indicators and financial outcomes is a major barrier. This results in low levels of management commitment to allocating resources that enable the involvement of a wider range of front-line staff in special projects or initiatives related to quality improvement.
The functional approach to service delivery, which may, in part, be related to the previous comments regarding workload pressures, is another barrier in and of itself. While more client-focused models have been reported in the literature and implemented in varying degrees in many organizations, a functional approach to client service still exists in a lot of the day-to-day operations in many other organizations. Cross functional teams do exist in more settings than in the past, but often the front line team members are still not completely involved in developing quality initiatives from the ground up. This can reinforce a narrow rather than systems-view of problem solving and improvement initiatives. A lack of attention to the interconnections of the various teams within the organization may then limit the success of such initiatives.
Fear of change is also a barrier to wider involvement in quality initiatives and one that must be dealt with in any planning that takes place. Pacing, timing and sequencing are important factors in the degree of resistance that may be encountered when undertaking quality improvement initiatives.
Strategies to Overcome the Barriers
Getting the right people involved in capturing the voice of the customer can be achieved using creative methods that need not entail extra time set aside for scheduled meetings. One such approach involves having front line staff capture information and ideas as they go about their daily duties. This information is then arranged on multi-colored post-it notes on a bulletin board in the staff room. Different shifts and/or departments can also be asked to respond to "Key Brainstorming" questions/issues in this manner. In response to the issues, each staff member can be challenged to come up with 3-5 different ideas. The process can be continued by having staff then affinitize* the responses (group the ideas they have come up with into natural clusters). The team can then vote using techniques such as multi-voting or nominal group technique to whittle down or prioritize the ideas and preferences for action. All of this can be achieved on the fly, that is, during the course of day-to-day work with very minimal meeting time! The process is also fun and the anonymity encourages hearing from those staff members who are reluctant to speak up in groups or more traditional meeting settings.
Education based on the principles of adult learning is a critical strategy to gaining staff understanding of the importance of their involvement. Linking the learning to real life practical applications as above enables staff to become aware of how they can contribute to successful improvements. It can also support the development of new models of service based on best practices and evidence-based decision-making. Education and training of leaders in the use of quality management tools and techniques, group facilitation and project management is also critical in supporting successful improvement planning and implementation.
In addition to hearing from staff about what matters most to clients, leaders also need to hear directly from the clients themselves. A combination of several methods of documenting client comments and complaints is generally supported in the literature on customer satisfaction measurement. The use of formal surveys, questionnaires, focus groups, client councils, and complaint management systems are several of the most frequently used methods. These require careful thought and planning to ensure valid and reliable information is obtained in order to use this information most effectively in the context of a team based management system. It is important to consider how the results of formal or structured satisfaction surveys/questionnaires can be incorporated into this management system. This approach provides the organization with a built in means of evaluating the outcomes of their improvement initiatives using pre and post survey results. By doing this, the cycle of improvement becomes truly continuous.
"Think Big, Start Small" is an adage with a great deal of wisdom. Organizational improvement initiatives often fail because they attempt to do too much, too soon. It is much more gratifying to front line staff to have early successes with small improvements/early wins than to fail at over-ambitious attempts at great sweeping changes. A key component to this strategy is to identify the whole game plan in advance and then proceed in an incremental fashion so that each small improvement links to an overall larger change. In short, a whole-systems approach to managing change that acts as an umbrella to many smaller changes.
Judy Worrell, R.N., BSc.N. has over 20 years experience working in the continuing care (community care, public health and facility based) sector and is a principal in Affinity Consulting. In her most recent role as the Director of Consulting Services for Extendicare (Canada) Inc., she was actively involved in direct facility consultation, development and delivery of educational programs and workshops, project coordination, and policy and procedure development. This work involved coordinating program implementation and evaluation within a multi-site environment. She can be contacted at firstname.lastname@example.org .
*You can download a FREE copy of the instructional text The Affinity Diagram by going to www.affinitymc.com .