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13th June 2011

Quality Assurance de-mystified

Face to face discussions with providers and managers and questions coming into the helpline, point to quality assurance being an area where people feel uneasy about their understanding of the issues. Often, QA is assumed to be one or more of: extremely complex, mysterious, beyond the scope of front line staff, bureaucratic, a “big deal”, a paper exercise having no effect on “real” quality, or an imposition by the regulator. Note that none of these often-met opinions is positive.

In reality, QA is positive, developing, motivating, non-bureaucratic, and above all, and surprisingly to many people, cost-saving.

Holistic Quality & Efficiency - Reduce Waste and Save Money

An ice-breaker analogy often used by the author in QA seminars is: "imagine 3 factory production lines producing ornamental plaster statues".

Line 1 is staffed by workers who are trained to do their work and they work hard and produce statues as fast as they can, and at the end of the line they are boxed up and sent to the customer.  The customer sends back any statues which they do not think are acceptable, and the factory destroys them.

Line 2 produces the same way as Line 1, with similar staff, but places a Quality Inspector at the end of the line, who checks each statue as it arrives, places the acceptable ones in a box for despatch, and throws the unacceptable ones in a skip.

Line 3 dispenses with Line 2’s inspector, and each member of staff on the line is trained to check the quality of the statue at their work station, having been given a specification for quality at that stage, and given the authority to fix or reject any duds on the spot.  At the end of each shift all team members get together and discuss their rejects, why they happened, and arrange to change what they do to reduce or eliminate them.

Line 1 produces no quality at all, except by accident.

Line 2 produces quality because it executes Quality Inspection, or Quality Monitoring.  The advantage over Line 1 is that the customer does not receive unacceptable stock, does not have to return it, and is happier because they do not have to inspect incoming stock so vigorously and therefore have more confidence in the producer.

Line 3 executes true Quality Assurance.  Quality is specified at each stage, staff inspect their own work and are empowered to fix or reject poor quality, and feed back their developing skills into the production process to continuously improve it. Line 3 also runs cheaper than Line 1 and 2.  Rejects are made earlier, with lower material and labour content.  The cost of a specific Quality Inspector is dispensed with, rejects are fewer and over-time eliminated/reduced, because all production staff are interested in quality, know what it is, and adjust their working practices to improve it.


Iterative Quality and Collaboration

The lessons of this experiment is that QA involves everyone, not just managers and/or quality inspectors, it requires specifications of work quality, specification of the structures (equipment, buildings etc.) and processes which are required to carry out the work and the training of all staff in their part in achieving that quality, and crucially, a discussion forum and time for all staff to examine their own and other’s working practices and how they can be changed to improve quality.

How can these lessons be applied to a care setting?  A useful model of QA is the Deming approach, which is mentioned specifically in the Care Quality Commission publications on QA.  The Deming approach, stripped to its bare but very effective minimum, promotes the Plan-Do-Check-Act cycle of management.  The cycle is just that; it is never ending.

The 'Plan-Do-Check-Act' Cycle in Practice

The Plan is the specification of the work; structures (equipment, buildings), processes (policies, procedures and work instructions).

Between the Plan and the Do is training.  All staff must be fully trained in the Plan, and their part in achieving it.

Then the staff Do what they are trained to do.

As the “Do-ing” is happening, checks (audits) are carried out to check that the result of the Do is, as per the Plan.  These audits are best carried out by the individual employee, who needs to be trained to audit, and to be realistic and self-critical.

The audits are then analysed, again preferably with everyone involved.  A useful forum for this activity is a Quality Circle and Quality Forum.  Another variation is the Professional Team, a group of specialists in the work area under examination.  Whatever forum is used, the forum will produce a list of Areas for Improvement.  In a care setting, the full, continuous and consistent involvement of the service user in the checking and feedback process is vital and expected of any competent service provider, and all staff must understand this principle and how it affects the way they work.  For instance, it is front line workers who will hear, and must take account of, the informal feedback which service users give on a minute-by-minute basis as they experience the service.  No formal manager-led auditing process will pick this up with any consistency.

Then results of the audit examination must then be put in front of an authoritative body or person, preferably a body, for the final Act.  The Act element is the execution of whatever needs to be done to put into effect the Improvements.  By definition, the Improvement has to be executed by either changing the Plan (equipment, instructions etc.) or re-training the worker to carry out the existing Plan. Interestingly, and counter-intuitively to most people, Dr Deming’s research shows that 94% of all problems identified for improvement are a consequence of a fault in the Plan, and not the people.  If you include training within the Plan element, then this is more understandable.  The lesson is, most problems are caused by Managers, not the workers!  Managers have control of the Plan.


Consequences and Common Piftalls

Looking through the 4 stages of the cycle, one can see that none of the 4 elements imposes any additional work over and above what the average competent care business already does, with the possible exception of providing adequate time for all staff to reflect on their practice with a view to improving it.

What does make a difference is the management’s dedication to making sure that the Check and Act, particularly the Act part, actually happens, all the time.  Any Quality Assurance assessor, particularly those concerned with the Business Excellence (EFQM) model, such as the author, will tell you without hesitation that firms consistently score well on Plan, slightly less well on Do, less again on Check, and usually very poor on Act.  That is, the firms operations are stuck in a rut because the information which is freely available to spell out areas for improvement is not effectively gathered and acted on, therefore consistent improvements do not happen.

What are the effects of this lack of completion of the cycle?  Frustration is the main effect - managers and workers alike all know something can be done, but no-one knows what.  Costs also inexorably rise over time.  In the absence of effective planning and improvement, everyone tends to throw additional money at the problem - money which can be saved by properly executing QA.  Staff turnover increases, mainly through frustration, with the consequent loss of all that Plan training, which has to be expensively replaced in the incoming staff.


Adoption Among Regulatory Authorities

This overall process is now an integral part of Regulation Authority inspection models.  With the reduction in resources for hands on inspection, the regulators are looking for care services which have their own robust internal quality development processes, but more importantly the final element of Act-ing is required, because they know that without continuous improvement, back-sliding is far more likely.

An additional, but important benefit of an effective working QA process is risk management.  At both a micro (for instance, care planning ) and macro (for instance, overall health and safety management) level, a reflective process focussed on continuous improvement will identify and alleviate risks well before a less well managed service, with consequent reductions in risks posed to the service user, and regulatory and financial risk to the provider.

The QCS Management System was designed originally as a Deming Total Quality Management System, and has been maintained as such throughout its long life.  Invisible to the user, but nonetheless highly important, are features such as the consistency of approach between the care policies and the HR policies.  Deming, and many others, noted long ago that workers will interact with customers in a similar manner to that which their employer interacts with their workers.  It is no coincidence then, that the HR section of the QCS system is based on the same human rights principles that the employee is expected to show towards the service user. For more details see our page on Quality Assurance/Control.


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