Quality Improvement: A Front Line View «

Quality Improvement: A Front Line View


Introduction

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 continuous quality improvement, there continues to be a challenge within organizations to fully integrate this 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

Roles and responsibilities in many industries still tend to follow somewhat traditional models. There are organizational charts that illustrate a departmental structure consisting of departmental managers aligned in the stovepipe manner. In a structure such as this, the managers work as a leadership team distinct from the front line staff and participate in traditional managerial roles that include responsibility for managing risk and the quality of the service within the organization as a whole.

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?

Gaining full participation in quality initiatives by front line staff is a change in
itself and will be successful if approached using proven change management approaches. In order for there to be a shift in ownership, front line staff must be comfortable with bringing their ideas for improvements forward and then seeing that something happens as a result of their suggestions. A quality improvement atmosphere where everyone shares in the responsibility becomes part of the culture of the organization.

Barriers in the System

Resource constraints, both economic and human, have been frequently cited as large barriers when attempting to be more inclusive in participation in quality improvement initiatives. In addition to limitations in the use of extra dollars and staff hours, pressing workloads and resulting routinization to get the work done, makes it difficult to schedule. It takes time to get groups together to provide input and to plan quality improvements as well as to allow those groups to function effectively in this new team-based context.

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

Creative scheduling to enable participation of front line workers is one way of minimizing this barrier. Sometimes thinking “outside” the box in terms of when meetings are held may prove helpful. Holding meetings at change of shift time, doing mini-meetings and hosting dinner meetings are ways of inexpensively accommodating the time required for meetings and planning sessions. In one organization renowned for its approach to continuous improvement, the authors observed how communication, particularly about the status of changes and improvements was greatly enhanced by the use of a 15 minute mini-meeting at shift change over. Another approach that we have seen in action is to provide someone from the management team to cover while staff attends team meetings. This approach has the added bonus of showing concrete support for wider involvement and enabling staff to attend and be worry free about the possibility of work piling up during their absence.

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.

 

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