BACKGROUND
Much has been said previously about the definition of quality and the fact that the customer defines quality. The way the customer normally does that is through a process of purchase or neglect. While market assessments are often done to determine the customers preferences, the bottom line is that if the customer purchases a product and returns to purchase it again, we can assume that the customer is satisfied with the quality of the product at least to the extent that price does not prohibit another purchase. One may be satisfied with Ford quality at the price expended, but prefer the Lincoln quality, but not be able to afford the price. Thus, quality includes the parameters of affordability.
Public human services are generally speaking a not for profit business, at least to the extent that the primary purpose for which human services are extended are not intended and should not be for reasons of profit. In this environment the customer [buyer] is not the customer [end user or client] and therefore the normal buying habits or market test are not a factor in meeting the test of satisfaction. If the end user is not satisfied with the services s/he is usually a) limited as to whether there is even another option, and b) often unable to change the situation. This varies, of course, by the degree of restrictiveness in the services being offered with prisoners having the least leeway followed closely by ‘patients’. There are, however, end users who argue that they would rather be in the corrections system to achieve more freedom.
This is one of the greatest moral dilemmas in providing human services. In fact, the human services organization must be very clear about whom it intends to satisfy. We have indicated this dilemma elsewhere and will reiterate only that the primary goal of human service organizations should be to improve the quality of life of the end user and that the way to identify what is a quality of life in the eyes of that end user is to ask what changes they would like to see occur – in other words, what hurts? Constraints would include a) the fact that the client’s desire for change can only be within him/herself since they have no control over anyone else except as their own behavior generates improved responses, and b) the moral constraints identified through philosophic discussion in the organization and consensus. Individual philosophical constraints aren’t valid.
In following such a pattern of client determined quality, we would expect to find that clients will generally seek an ‘everyday’ life with fewer problems in living and more control over prediction and outcomes of life experiences. An individualized plan of change can be created using such preferences and specific outcomes can be determined through a proper assessment process. But what is a proper assessment process? How does this process contribute to or hinder the substantive outcomes defined by the client? Who decides what this process should look like and how it is carried out. Or for that matter, who decides how any of the processes of assessment and human service delivery and facilitation are carried out.
Production workers are the final determinants of quality enhancement, and their willing and informed involvement in the quality effort is essential. One approach to achieving involvement of these and other workers in a formal way is through the institution of quality circles.
Quality circles are problem solving teams consisting of 5 to 12 volunteers from different areas of a department or assigned to the same process. The team identifies problems, analyzes data, and proposes solutions. Their effectiveness and productivity is, to a large extent, dependent upon management’s implementation of the recommended solutions. Don’t give a vote if you do not intend to follow it.
Problems solving in continuous quality improvement is undertaken by groups of people who usually have different perspectives of the problem. We have referred elsewhere to the Zen master who with sixty three [63] self reflecting mirrors provides a view to Paradise and have suggested that if we could see all sixty three perspectives we would be much better able to make choices about how to behave. The problem is that, as individuals, we usually see only one perspective – our own. And since that one perspective is so ‘real’ to us, we tend to ignore other perspectives which seem to contradict our own. Quality Circles will not ensure that an individual will be able to obtain different points of view – only ensure that they may hear them. However, Quality circles also ensure that the person will hear such differences publicly, which has some merit in helping the person to accept difference on a different level of consciousness. Most of us are ready to at least accommodate differences of opinion publicly, which allows for an opportunity to maintain them in consciousness long enough to analyze them – leading, perhaps to assimilation.
Following this principle, total quality management approaches seek to form discussion groups which are constituted of people who a) are familiar with the process under discussion, and b) bring potentially different occupational as well as personal perspectives on the issue. In order to ensure differing occupational perspectives, different levels of the hierarchical organization are included in the circle. Since managers, administrators, supervisors and direct service workers tend to have increasingly narrow perspectives of events that occur in the organization, this enhances the potential for differing perspectives. In order to ensure that these perspectives are focused on the same issues, the circle will usually concentrate on a specific logical process – such as assessment. A flow chart, popularized by computer programming, can be developed in discussion ensuring that it follows precisely the steps of a process from the inputs, through the process, to the outputs – and then determines the impact of those outputs on the client’s quality of life – identifying outcome.
The difference in hierarchical perspective undertakes to see the process from all perspectives within the organization and may include both a client and the client’s personal support network or “community of (private) interest”, to include both different additional perspectives and important quality considerations. Such a model is similar the restorative practices conferencing models which is becoming popular in corrections and justice programs. In these cases multiple perspectives of the community of (private) interest are used to help the victim and trespasser come to a common agreement of what took place and how it must be corrected.
In a similar fashion, it has been recommended that a Community Assessment/Support Team [CA/ST] be used in the assessment process. Such a group can reliably provide all perspectives of a human service process, including as it does the child/ family and all child managers. Assuredly, the child does not see the process the same way as the teacher and there may well be differences in perspective between the home adults, school adults and clinical adults as well. The community of interest and the staff hierarchy would provide multiple perspectives of a common process.
Imagine, if you will, the perspective of the waiting room and the time spent there from the points of view of the client, the client’s family, the secretary, the direct service worker, the financial administrator and the manager. The likelihood of achieving consensus on what is the appropriate setting and the appropriate amount of time to wait, without extensive dialogue and extensive negotiation are virtually zero. But this is the essence of quality improvement which seeks to end defects and diminish the time cycle.
Quality circles are typically said to have originated with Deming in Japan in the 1960s but some have argued that the practice started with the United States Army soon after 1945 with the Japanese then adopting and adapting the concept and its application. Regardless of origin, the use of Quality Circles and flow charting can increase pertinent communication across the system and support continuous quality improvement at the service delivery level.
WHAT IS A QUALITY CIRCLE?
A quality circle consists of a small group of people who are related to the same jobs or tasks. This group meets voluntarily, on a regular basis, to discuss problems, seek solutions, and cooperate with management in the implementation of those solutions. Traditional quality circles operate on the principle that employee participation in decision-making and problem-solving improves the quality of work. Quality of human services is of a different order, and the client and his/her circle of interested parties should be an essential part of the quality process. Through the circle, members generate mutual respect and trust as they work on solutions to common, on-the-job problems.
A review of the literature shows that quality circles have several defining characteristics.
- First, participation in a quality circle is strictly voluntary.
- Second, members of the circles set their own rules and priorities and select the problems that are to be discussed.
- Third, decisions are made by consensus; open communication is encouraged and negative criticism is discouraged.
- Finally, quality circles utilize organized approaches to problem-solving, including brain-storming and cause-and-effect diagramming; persons who act as circle leaders need to be familiar with these and other participative management techniques.
Ideally, then, quality circles are not hampered by members who are not personally committed to the process; in addition, the organized approach to problem solving prevents quality circles from holding unproductive rap sessions. The circle is empowered to promote and bring the quality improvements through to fruition. The use of the flow chart to examine specific processes enables the organization, child/family and all other stakeholders to determine a) what actually occurs, b) what everyone thinks occurs, and c) what might better occur. Better is defined in terms of meeting client expectations or improving quality. Best is not used, because any time the organization decides that the process is “the best that it can be”, quality improvement stops.
The adoption of quality circles (quality improvement teams) has a social focus. There must be commitment from senior management, unit management and supervision, other staff and of course the circle members. A team of people need to participate freely together, to challenge assumptions and existing methods, examine data and explore possibilities. They need to be able to call in expertise and ask for training. They need a skilled team leader who works as a facilitator in support of team efforts.
The circle needs to have a very good approach to
- analyzing the context of the process and its situation
- defining just exactly what occurs and the relationship between its component parts.
- negotiating perspectives, particularly around decision points – a) is there a decision to be made here and b) who’s decision is it?
- how it identifies and verifies that the decision &/or actions are indeed the causes of failure to meet outcome expectations.
- The goals of the quality circle are clear to – improve outcome through the reduction of deficits and of cycle time
- Problem definition requires quantitative measurement and often a consensus of qualitative judgement. The impact of the “problem” – if it continues – must be comprehended. Where is it affecting other parts of the “problem system”?
Quality circles need to understand the quality objectives to be achieved and evaluate the resources that can be brought to bear on the problem and possible solutions. Objectives relate to both what must be done and what we would like to do – if only everything else will fit into place.
In the classical “functional, problem analysis” cycle, solution generation involves conceiving what might be done. We can typically develop options from do nothing to do everything. The options (MAX / MIN, optimistic / pessimistic, high / low budget etc.) are all models to be tested against objectives and constraints. The objectives are steps or benchmarks towards the achievement of outcome, which can be defined is the positive impact of outputs on the client’s quality of life. Since the outputs of human services are usually defined as the number of service units [e.g., educational, clinical hours], this is not the performance test of the organization. The organization’s performance test is related to how salient the impact of those hours are on the substantive issues which diminish or enhance an ‘everyday’ [quality] life as defined by the client.
A ‘functional problem analysis’ of the assessment process is irrelevant except as improvement are made in reducing ‘deficits’ – 1) clients who come through the process and still have the same or increased problems in living, or 2) the organizations time cycles – the amount of time that it takes to meet the outcome expectations – remain consistent or lengthen. Since the assessment process is only one part of a multipart process [assessment, service delivery, service facilitation, etc.] the quality circle members will need to determine how this component contributes to the overall outcome expectations of the cumulative clients – i.e., organizational outcome expectations. In continuous quality improvement, the goal is ALWAYS zero defects. Thus no client should be able to go through the assessment, service delivery and service facilitation processes within or in less than the specified time without meeting or exceeding their outcome expectations and each person who fails to attain full satisfaction and/or gratification with life after the provision of services opens up new possibilities for improvement.
Quality attainment is something like perfection. Perfection has been described in terms of as a continuum which is halved over and over again. No matter how many time you reduce defects by fifty [50%] percent there is still half the distance to the goal. One can never get to the end of the line. In human services, the outcome expectation is even more ambiguous since it is not only the actual outcome, but the client’s perception of the outcome which is to be meet – and clients will have differing perceptions as will all other stakeholders. While we would certainly emphasize the need to meet the outcome expectations of the client – it is necessary as well to meet the outcome expectations of the management, the board, the community at large and the funding source – each of whom may perceive quality differently. The first step, in Quality Management therefore, is to negotiate as closely as possible a precise summon bonum or greater good, so that all of the stakeholder are at least using the same measuring stick in measuring quality. Overtime, the vast majority of individual quality expectations should begin to create some vortex of quality which can then be incorporated as the system’s quality expectations.
But reaching outcome expectations is not the only dimension of quality. The customer [in this case the end user] must be satisfied and gratified. Because of this and other societal factors, value constraints are added. Slavery is not an acceptable form of employment. While traditional observations of constraints include resources [human, financial, etc.] these constraints are not the ones of most interest for human services. Of predominant interest should be the constraints imposed by the individual clients themselves. Resistance and indication of a constraint which must be identified – as the client is saying, this offering of services is in some way unacceptable to me. And since it is unacceptable, outcomes will not be met – therefore, the delivery of service must change.
The question is whether we spend the resources wisely [do they trend towards meeting outcome expectations?]. We must recognize also that there are tensions between resource constraints and solutions and the imagining processes of solution development. In traditional models, these must then be elaborated and grounded in detailed planning and operational implementation. For purposes of human services, they should be ignored by the quality circle participants – it is not their problem. The issues that they must address are embodied in the process of doing what they do and how that hinders or enhances outcomes. They seek the best possible solution for the moment [until they can improve upon it] and the constraints of resources must be addressed by governance if they seek to provide quality services.
The expectation is that the outcome of the quality circles will cause the organization to reevaluate its posture on financial expenditure away from – we do the best we can – to – we must find ways to do better. Implementation planning and management of the change/operational program involves decision making, scheduling, work allocation, capacity management, communication, development of information monitoring systems and overall coordination and control of the solution program. Quality circle members will need training and support to apply these to the context and issue they are experiencing.
Management have to believe in the quality team process, listen to proposals and enable feasible solutions to be developed through pilot stages and into full operation. Open-mindedness and a desire to avoid blocking is essential. It is a useful philosophy to realize that experimentation enables learning.
The primary quality relationships are housed in the process that occur within the inputs and the outputs. These processes or activities are housed within a frame of reference. There will be some people who will take on an attitude that ‘nothing will ever change’, no matter what I do. This is a ‘learned helplessness’ which can only be overcome by demonstration, not by moralizing.
Process Flow Charts
A computer must be replaced, an insurance claim must be dealt with, a cognitive behavior protocol must be followed and an intake must be completed.
Each of these a ‘transformations’ involves an arrangement of people and facilities (machines, desks, computers, ovens, mixing equipment, high-speed packaging and cutting gear). The arrangement is a combination of attitudes, methods/rules and technology. It can be simple or complex, machine oriented or people-oriented. Human ingenuity integrates tools and methods with skills, effort, knowledge and decisions to make complex things.
Outcome expectations
The first thing to be determined is, of course, what is intended? Human services are fraught with ambiguous intentionality, we intend to do something? What is it? Can everyone around the table agree on what the intent of the intake process is? What outcome expectations do each of us have? How are these intentions modified by the need to have clients, make money, stay employed? How are they modified by a rote process which leads to an inevitable end. Since my only tool is a hammer, every client looks like a nail?
Next, we need to determine what actually takes place? How are these people, methods, rules, attitudes, skills and tools used to accomplish the purpose? Does the assessment require quantitative measurement and or a consensus of qualitative judgement. If quantitative measure is involved, how does it take place? Is there qualitative judgement intermixed with the quantity being measures – in, for example, an IQ test? Is this quantitative score really quantitative?
The frame of reference is important as well, in assessing, do we want to ‘rule out’ disability or are we seeking to document it? This is based on the primary assumption going in – a) there is nothing wrong with this kid and I can prove it! Or – there is something wrong with this kid and I can prove it? How much do self fulfilling prophecies play a role?
What are we doing now?
Assuming we can find consensus on the outcome expectations, which by the way, is a lot harder in human services than when a baker has a goal of baking biscuits [output], which are then deemed as ‘good’ by the people who eat them [outcome]. It also should be noted that the ‘good’ biscuits are then likely to be purchased again by the same people who enjoyed them – while the ‘good’ client [the product of human services] will hopefully never need to purchase the services again1.
From an initial idea as to how an operation can be carried out, we build a pilot or prototype as a test bed. More is learned. Improvements are secured.
- a re-arrangement of machines and sequences
- a new tool or technique
- an increase in scale
- routinization of tasks
- people replaced by machines
Operations
Operations are designed, often incrementally, based on the first arrangement we imagine and construct. Trial and error is a natural human activity. “If it works don’t change it” – is often a sensible piece of advice. However the current method may be obsolete and inefficient. If you were to re-design an operation from scratch, the new operational design would reflect experience with the old – tools and methods, etc. Existing systems represent investments of money and experience. A complete re-design of a system (business process re-engineering) involves re-investment.
In many organizations, work systems are not systematically designed nor are the prevailing “designs” documented. They exist, are taken for granted and just work [although they may be more ‘satisficing’ than gratifying]. Those who set up the methods have often long since departed. Current operators may merely accept “what is” without evaluating how it could be improved and changed for the better (quicker, cheaper, more reliable, safer, better quality, more accurate). Human services, particularly that which is called ‘mental health’, are notorious for a lack of protocol in service delivery and often the direct service worker does his/her ‘own thing’, which may or may not achieve intentional outcomes. We tend to believe that we are ‘good’ people and therefore will do ‘good’ things. Yet any evaluation of public human service delivery indicates repeated failure in the most significant cases.
New factory, warehouse and office layouts and processes taking place in them are usually custom-designed by architects, engineers or facilities specialists using known methods and techniques. Continuous quality improvement requires a conscious design and scrutiny of processes. For an effective quality management, layouts and process have to be defined so that critical success factors can be controlled.
A process flow chart visually records the steps, decisions and actions of any process (old or proposed) – manufacturing or service. The chart is an “abstraction” – it defines the process/system; its key decision points, activities and role performances. For a new process – the chart is a “model” – a blue-print. We can imagine [visualization techniques] the process working before spending on building and training. The chart/model is an important project development and documentation tool.
A process flow chart depicts a process sequence succinctly i.e.
- first A is done
- then B
- then if X is present, do C OTHERWISE
- move to D
- check E and when E is complete inspect F.
The chart can be
- a process outline (operations and inspections only). This is a “first-cut” chart useful for initial investigations and can be elaborated. Often this outline is the one used to allow the differing perspective to react – and the process elements come under fire at least from some of the perspectives, thus requiring adjustment.
- a material flow process chart – operations, inspections, transport/movement, storage and delays. This charts work on an object, its movements to and from the operation , when it is inspected/tested, when stored and when delayed/queued. Remember, in human services that object, may be a client who moves through a process of presumed improvement to become the product [improved client] at the end of the process.
- a worker process chart – operations, inspections, transport/movement, delays. An individual worker needs a personal quality checklist – quality improvement is not just an institutional assignment, it is a daily personal priority obligation [Roberts & Sergesketter].
Narrative English versus a Chart
A process could be recorded as an essay but essays suffer from problems of vague and convoluted English. Narrative can have omissions and complex relationships can be hard to follow. A diagram/chart enables the process (if not overly large) to be seen more clearly. We can draw the chart using standard symbols either by hand, using a template or using flow-charting software.
Basic symbols for method study are:
- Start/end – marks the start and end of a process. As each symbol can be given a number code, the end symbol can be a connector to the start symbol of the next process or the next page if the process is to big to fit on one page
- Operation – DO operations – perform work on/with client, material or equipment. Add value to the item by changing/transforming it in some way. ANCILLARY operations – prepare, put away, clean. The circle is annotated with a label/description of the process.
- Decision – decision points are critical to the flow of any process. It is not only necessary to outline the options of yes/no, but also to indicate who’s decision it is. How often do these decisions belong to the client, but are made by a worker?
- Transport – the movement of worker, materials or equipment to and from the process.
- Storage – permanent storage points. The material is put away/stored e.g. placed in or issued from a store.
- Delay – points of temporary delay or waiting until work can be performed
- Inspection – a point in a process where the material must be inspected or worker perform and inspection/test. Thus we can record what the test is
Tips on Drawing a Flow Chart
Drawing the first process flow chart is not easy. Talk through the process’s sequence identifying what is done at each step. Sketch the flow chart in rough – don’t worry about errors. Go back to the process and verify against the job in operation. At every stage consult with experienced operators [practitioners] and managers. Observe, re-draft, verify, and change to
- improve understanding of the process
- clarify and challenge the ‘taken for granted’ aspects
- secure client confirmation
- identify redundancy and unnecessary steps/efforts in the process
- note the quality critical points if zero defects are to be achieved
- identify the inspection and testing routines for each step
- identify the control data to be recorded or confirmed (use exception reporting) at key points.
Who draws the Flow Process Chart?
Flow process charts can be researched and drafted by quality improvement teams. They do not have to be drawn up by separated specialists or consultants. Of course training is needed. But the team’s synergy and ability to walk-through (talk-through) the chart should enable devolution of responsibility for documenting and up-dating their own activities. They can always call on the expertise of an clinical technician if needed. Some processes can be extremely complex (and process charts can be too unwieldy) and safety critical. For the too complex processes, break it down into parts which can be worked on individually.
Process Charts and Quality Specifications
A process chart is a key item in the specification for each process in quality management. It gives the opportunity for a cognitive process of awareness, attention, analysis, alternative development and adaptation to occur in a public arena. With the chart the operation can be more easily reviewed and evaluated. It provides a potential for change. Process modifications require charts to be up-dated – hence the value of using a computer package. The quality manual can then reference the file name. The software package should offer the facility of attaching version numbers to charts and recording who last up-dated it and why.
When re-evaluating a process, we can identify
- the amount of physical movement and double-handling
- redundant operations
- points of inspection and quality monitoring
- etc
The questions of method study and work measurement can be applied to the evaluation of the process.
WHAT ARE SOME PROBLEMS ASSOCIATED WITH QUALITY CIRCLES?
The number one reason for quality circle failure is inadequate training. A lack of understanding of quality circle technique may cause management to be reluctant to initiate circles, act upon circle suggestions or, eager for easy solutions, may implement quality circles recommendations too quickly. Circle members may be unsure of their purpose, reluctant to believe that participation is truly voluntary or, may simply lose interest. As mentioned earlier, training in quality technique is necessary to keep the circle productive and to prevent gripe sessions. Furthermore circle implementation must be well thought out and introduced as an on-going process, and not oriented toward a single problem (Ladwig, 1983).
Quality circles in human services face special problems. Many practitioners view such services as an intangible, and so, not applicable to the productivity-boosting techniques employed by industry. Furthermore, they tend to emphasize individual achievement and personal importance, which may run contrary to group participation. Highly educated circle members tend to become over philosophical about the purpose of the circle and may hamper circle progress.
Human services are of a different order than business and industry. The client [end user] is also the product and usually the customer [buyer] is a third party payer. One must use the abstractions of the cognitive behavior management process through the quality circle to orient towards outcomes, not simply outputs.
Though originally intended for industry, the quality circle clearly has uses in human services. Organizations seeking to improve employee and client morale through participative management techniques may well wish to learn more about the quality circle, its uses, and its effects.