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Manage Better - Using Quality Tools


There are the traditional forms of management, which most of us grew to hate as we endured our supervisors and their enlightened whims. We all can relate to the plight of Dilbert, the cartoon engineer, who constantly fights a losing battle with his thickheaded boss.

For most of us, there has been an occasional good manager who helped us grow. Most of the less good management styles are the result of a lack of training for the manager. This leads to fear, “protect one’s backside,” and other psychosis. It would be better for the manager, and much better for his/her subordinates, to have a scientific approach to management. This approach is un-burdened by emotional, “knee jerk reactions,” and historical, “we have always done it that way!” barriers to progress. A scientific method is based on quality tools used to gather factual data upon which the decisions can be made. It requires input, and therefore, involvement by the “troops.” This builds “espirit de corps” or teamwork.

The focus is on processes, productivity, quality, and waste. The manager worries less about personalities or trying to manage them. It advocates self-management with leadership.

Quality tools found in Total Quality Management (TQM), Continuous Quality Improvement (CQI), and even basic Quality Control (QC) can all be used by a manager to manage better. By their nature, they create leaders, not dictators. They develop teamwork and consensus. They foster a happy, positive work environment.

The objective of this course is not to teach you how to use the various quality tools, but to show how they can be used to help you manage better and how to become a better manager.

CHAPTER ONE: Traditional Forms of Management

Positive Management Styles

“Promote your workers” was used successfully by the DuPont Company. The manager was charged to develop his/her subordinates and help them succeed to the point where they can be given more responsibility. The more successful the team was, the sooner the boss got promoted. Besides, if the team was successful, then sales were up, productivity was up, waste down, and expense accounts were on or under budget, etc. One cannot have a successful business without successful personnel. This approach showed the worker that he/she was an important, valued employee. It also offered opportunity in the future to both the manager and the worker. Perhaps the flaws in this approach were minor, but they existed. Some managers did not believe in the system, even though it helped them. Others did not care; they were happy where they were and did not care about advancement.

“Everyone is a worker, no bosses.” This has been used by the W. L. Gore Company (maker of Goretex fabrics) from its inception. No one is the “boss” over another person. There is a president and other officers, but this is for legal reasons. There are no preferred parking spaces or lunch rooms. Scientists and engineers bid on projects and then must sell the idea to others. The other workers have to see the purpose and the potential goal of the project. They look at the team and decide whether or not to leave their current team, or their own team, and join this new team. Mr Gore developed these concepts while an employee at DuPont.

“Delegation of Authority” simply means the workers participate in the manager’s s job. Sometimes this is exciting and enjoyable, as everyone likes a challenge and a little diversity. The problem with the system is that a manager can dump all his jobs on one or two workers. This generates resentment. Some jobs are inappropriate, such as performance reviews or budget forecasting.

“Walkabout” has grown in favor over the years. The manager makes his/her rounds, stopping to observe and chat with various workers. In effect, this is a mini-audit. It does help the manager keep on top of problems and to keep more actively involved in the operation. Besides, it is often easier for the worker to talk in his/her environment than in the boss’s office.

There are many books and training programs on how to manage, and others on management styles, such as “The Peter Principle.” The managers who take the time to learn a skill often blend styles with their experience. In modern quality based styles, the manager is more a facilitator or guide than a boss. He/she is a true leader and a part of a larger team. The manager is the quarterback of the team, but, also, is like a playing coach. Great managers know that they are part of the team and that their success comes from the team. They let the team know this also.

Negative Management Styles

1. The “do as I say, not as I do!” This was first uttered by your first manager, a parent. This is negative leadership because it implies there is a dual standard: One for the boss and another for the subordinate.

2. Taking the above a step further, we have the “do as I say!” dictatorial style. No one likes to be told what to do. This system cuts off lines of communication. It artificially increases the status of the supervisor and demeans other workers as second-class citizens.

3. Perhaps one the more frustrating approaches is the “not invented here” (NIH) system. If the manager does not think of the idea, it does not exist and will not work. Sometimes a manager refuses to make changes because this is “the way it has always been done.” There’s no desire to invent anything new. This stifles internal inventiveness, creativity, and motivation.

4. Along with the above NIH style is the TWILI system: “…the way I learned it.” The boss is so insecure that he/she continues doing business exactly as he/she learned it. One hears “I understand your point, but TWILI.” This is related to the “Do you know how long I have been doing this?” style.

5. “I am the boss” is certainly egotistical, and that is okay, because we all are to some degree. But, in this case, one has to work extra hard to sell an idea to the boss and convince him/her that it was their idea. Most workers lack the energy to play this game. This is one level higher than the dictator. The “dictator” might try new ideas, but the “I am the boss” person does not want to hear ideas and expects complete servitude to the old ways. In modern terms this is a paradigm approach. They have always done it “this way” therefore it must be the one and only correct way. There is no need to look for improvement.

6. Even the most positive approaches have the problem of “cliques.” These are, to use Continuous Quality Improvement (CQI) tool, an “affinity group.” A group of workers who like each other, think alike, etc. They can also be a boss and a few workers. They can be several bosses. Everyone responds negatively to cliques. People waste energy trying to join a clique, to belong. These are the wrong types of teams because they are self-serving.

7. The “Peter Principle” states employees are promoted to one level above their competency. Generally, this is a managerial position. It often leads to inept managers who are not trained or do not know what to do. It can lead to a self-serving type also. This type is very insecure about the job and therefore always does things to make himself or herself look good. Everything is his/her idea.

Related to many of the above managerial styles is the boss who yells at everyone with the rhetorical question “what’s the matter with you?” The worker is berated, belittled, and put on the defensive. The manager has established his/her superiority, and once again de-motivates a valued employee. Continuous Quality Improvement (CQI) uses audits to evaluate policies, programs, or processes. It never evaluates people. Therefore, a positive approach, using a quality tool, would be for the manager to ask, quietly, “what happened?” This is followed by “what do you think we should do to correct the problem, or do to keep it from happening again?” The process failed; not the person. The person closest to the process is asked for input to improve the process. The person/worker is truly valued, and that is often more valuable than wages.

Negative styles are very common and they stifle progress, cooperation, and communication. They de-motivate with the result that production and quality suffer. This costs the business money/profit.

Positive styles are just the opposite. They motivate people to do more. Most people, especially workers, realize that they are the most knowledgeable people regarding their area of work. They have ideas. Some of them are very good and can lead to system improvements.

Dr Deming developed fourteen quality issues or points he felt were necessary to operate a business efficiently. Of course, the fourteen points can be used as a management style. One of the points is to not be managed by objectives. Management by objectives is one of the oldest styles. A boss is given a quota and the boss gives each worker a quota. Deming pointed out that this style limits productivity and acts as a barrier to progress. Eliminating objectives opens up a world of possibilities. The worker is asked to do more, not 10% more, and not 110 pieces per hour instead of 100. The worker is challenged to develop other procedures or tools that will allow increased productivity. Workers manage their own jobs.

One must be aware that all quality initiatives are economic tools. That is, simple Quality Control (QC), TQM, or CQI, and their tools and processes, exist for one reason only: to improve profit. They function by identifying and reducing sources of waste. Profit can increase by increased volume (economy of scale) or by decreased waste or rising prices. Waste is decreased as the level of control of quality is increased.

Using quality initiatives, tools, practices, and procedures is a very positive management style. It delegates authority, creates teams, and promotes teamwork. It evolves on group consensus. Everyone contributes something to progress. The work focus is switched to quality issues and away from the volume issues. The “quality approach” to management relies on positive management styles. It rejects or minimizes the negative styles noted above.


1. Management styles cover a wide range.

2. Positive styles promote teamwork, and progress.

3. Negative management styles are used to protect and insulate the manager.

4. Negative management styles stifle creativity.

5. Quality control is an economic tool, and thus, is a management style.

CHAPTER TWO: A Better Way Based on Data and Quality Tools

In Deming’s fourteen points we find many ideas that can be directly used to manage a department, unit, or team. Dr. Juran developed his seven points later. They are essentially a regrouping of Deming’s fourteen points. Other quality gurus have reworked both Juran’s and Deming’s ideas. The important point is to read them to learn how they can help to manage more efficiently, better, or more friendly, etc. Management is a job, just like any other job. It should have specific and general goals, attitudes, objectives, checkpoints, etc. It can be audited like any job.


1. Create constancy of purpose toward improvement in product and service.

2. Adopt a new philosophy: take the challenge, learn responsibilities, take on leadership.

3. Stop relying on inspection to achieve quality: build quality in.

4. Do not award business based on price. Minimize total cost. Develop single loyal suppliers of quality goods.

5. Constantly improve the system of production and of service.

6. Institute training on the job.

7. Institute leadership on the job.

8. Drive out fear.

9. Break down barriers between departments.

10. Eliminate slogans, exhortations, and targets for the work force.

11. a. Eliminate numerical quotas for the work force (management by objectives).

Eliminate numerical goals for people in management.

12. a. Remove barriers that deplete pride in workmanship.

Remove barriers that deplete people in management, engineering, research of pride in workmanship.

13. Institute a vigorous program of education and self-improvement.

14. Put everyone in the company to work to bring about a quality transformation.

Juran’s Objectives for Breakthrough

1. Obtain or hold leadership.

2. Improve profit by improving “fitness for use” (product quality).

3. Teach competitiveness.

4. Reduce the highest level problems.

5. Effect internal cost reductions.

6. Improve the internal poor image of customers, vendors, public, and other groups.

7. Improve worker morale, motivation, and reduce internal dissension.

Building Consensus

This does not mean everyone agrees to an idea. It means a majority, by vote, believes the idea is worth trying. It may turn out to be a bad idea. In may turn out to “sort of work.” The important step here is that, within a group of peers (which can include the boss under certain restrictions) on a team, the majority has given direction. The first step in this process is to form a team (what used to be called a committee). This can be interdisciplinary, and should be. It can be the whole department, but usually is a part of the department, such as a sub-process or work unit. Depending on the size of the department there might be one or a dozen teams. Some teams tackle similar problems. Others tackle different problems. Committees have meetings; teams take action.

The next step is for the team to create a list of problems to be addressed. All problems are listed! Everyone votes on all problems to derive the top three problems. Next, everyone offers ideas to solve the number one, agreed upon problem. All ideas are listed. Everyone votes on the top three to six ideas the group wishes to try. Understand, some of these ideas will be around the concept of measurement; gathering more data so a better decision can be made. Finally, everyone is given jobs to do, relative to the ideas generated.

As a management style, you delegated authority. But, you did not dictate: “Bill, calculate the patient bed time average in…..” Bill does not want this job, does not understand the job, and knows it is extra work that will help his boss, not him. In CQI, as noted above, the team thinks, and agrees by consensus that there is a need to better understand patient bed time. The group may even decide that all patient conditions should be tabulated, not just the obvious one or two conditions. Because a group voted on this plan of action, Bill is not upset with his boss. The team asks for volunteers to do the study. Perhaps Bill volunteers, even though he did not vote for the idea, because he sees the group believes it is worthwhile and he has an interest in the survey or already has some data. Those who are not part of the majority had their chance to disagree. They were not removed from the group and cast out of the “clique.” As a matter of fact, the minutes of the meeting only records a consensus vote and never who votes or how large the vote was. What value is there in knowing the vote was 3-2 or 6-1? Incidentally, teams should always be odd numbered, about five to seven members, not including the facilitator, who acts as a nonvoting guide to the process.

The whole exercise of recording problems and ideas is called “brainstorming.” One person’s ideas stimulate others. The goal is to tap into the experiences, observations, and brain power of five to seven people immediately involved in some work activity. A report is made to the boss as to what the team has decided. This is a priority list, and timetable along with who is doing what (GANTT Chart). The boss might have been a part of the team and may have voted against the project. He was not in the majority. His single vote has the same weight as anyone else’s. A smart boss will accept the report and monitor the progress as if it was his or her own idea. When he/she hands out praise for a job well done, it goes to the team and not to the individual members.

There are dozens of important jobs that can be handled this way: bench marking, internal audits, risk management, facility design, equipment upgrades, patient surveys, customer identification, etc.

Strategic Versus Tactical Planning

A piece of equipment breaks down. A repair service is called. Patients are moved to another area, sent home, or other action taken. This is a barrier, a bottleneck to productivity. It is a quality issue. How does the manager handle the situation? Typically, the manager gives permission to call a repair person and agrees to authorize payment for service and parts. This gets the equipment fixed and the status quo is reestablished as soon as possible. This is often called “a knee jerk reaction.” The “bad incident” is put behind everyone and they return to their normal routine. This is tactical planning: “What is needed to get us back on track?”

There is a better approach called strategic planning. It asks: “How do we prevent this from ever failing again?” The quality control person’s job is not to control quality for quality’s sake, but to prevent, reduce, minimized, and/or eliminate failures, or loss of quality. And, a 95% accuracy rate means a 5% failure rate. This translates into 50,000 failures per 1,000,000 units (patients, tests, etc.) or 50,000 parts per million (ppm)! A good level would be 5 ppm. How long does it take your department to produce a million units?

Strategic planning involves first assessing the number of failures in the past (increasing or decreasing?), types and causes of failure (the same one or different ones?), an estimate of lost productivity (units per hour times worker average hourly rate in dollars), total cost for repairs over a year, over past five years (increasing or decreasing?), and other indications of increased failure. It will take some work, by team, to answer these and other questions. When all the data is gathered the team decides whether to overhaul the equipment, replace the equipment, or purchase a second unit to reduce load on the first unit, and to provide a backup. Further research will show how cost-effective it is to take each of these actions. Finally, a report is prepared for management. Management has asked for a long-range plan to correct this problem. A simple cost analysis will show cost relationships and can be generated using CQI tools.

The beauty of the strategic plan is that it is well thought out based on facts or, at least on information available at the time. It was developed by a team. It is a consensus document. It should be a lot easier for the manager to approach his/her supervisor with this report.

Management Team Concept

Teams are set up by the manager; the manager asks each worker to be on at least one of the teams. The manager can be a member of one team, but not all teams. As a member, he/she cannot be the elected team leader. He/she is treated with the same respect as any other member, no more, no less. He/she is not allowed to dominate, no one is. If the manager sits in as a guest on a team, he/she cannot input ideas. If asked a specific question, the manager can serve only as a resource and nothing more. This is true of the facilitator and other “experts” that teams call to help them do their job.

Within a given business or department there is a manager. There might be 3 sub-managers or supervisors, or lead people. Under each of these there can be 5 to 50 workers. The structure is typically drawn as a pyramid with the workers at the bottom and a single manager at the top. In CQI, the pyramid is turned upside down. Everything balances on the point, the manager. Now information flows by gravity, more easily from the multitude of customers to workers to supervisors and to the manager. The manager has an easier job and can do a better job because of this natural input.

A better way to visualize this is that the business, as a whole, is a large circle. Inside the circle is a manager and a bunch of small circles. Some circles overlap (“cross functional”) because of similar jobs, and related activity, or dependency in the flow of work. Each circle is a group of workers, not as a subgroup of the whole, but as a management team. All teams are of equal value, similar size, and operate similarly. All of these teams compose and make up the whole. Everyone is a part of their team and the overall team. Each team is self-managed and works as a manager, to better manage some aspect of the business. Does this mean the manager is not needed? No, the manager is like the Ring Master of a three-ring circus. He/she directs the activity, but does not participate. The individual performers do their own act. Everyone works together. Everyone wants everyone else to be happy and to succeed. How can the high wire act inspire awe if the Clowns down below are not funny?How can a technical person make a patient feel at ease if the receptionist has caused the patient to feel totally frustrated?

Within each smaller team there is a facilitator to help the team stay focused and on track to a purpose. The facilitator is not a member of the team, makes no comments other than things like “that is a good idea to talk about but it is not a part of your current discussion, you are going astray.” The group might decide, by vote, to abandon the primary issue and resolve this issue. The facilitator is usually a member of another team.

The manager acts as the overall facilitator for all the teams. If a team is non-productive, work cannot get started, or has a bad mix of personalities, the manager makes adjustments. This is done in private. The manager knows that the most cantankerous, loud, angry worker may have the best ideas. Then again, maybe not. But, one has to give the person a chance. It is common to have a worker, shy by nature and perhaps of a lower rank, who never contributes anything. Ask the worker to place his ideas in writing. To keep the playing field equal, all team members are asked to also write down their ideas on a particular subject. This is nonverbal brainstorming called, in TQM terms, “brain-writing.”

J. L. Alloway in “Be Prepared with an Affinity Diagram,” offers a simple plan:

1. Each worker/team member records, on individual index cards, problems (patients, equipment, procedures, etc.) they have experienced in the past six months

2. The cards are sorted by major problems (affinity).

3. Those problems most common are then used to ask the workers for input.

4. Each worker lists, individually on index cards, ideas of how to solve a specific problem.

5. The cards are sorted by common ideas (affinity).

…and so on.

Sharing ideas identifies common problems and binds workers together. Look for common threads in problems and in cures. Realization by workers that they are part of a team, with similar experiences and ideas, will amplify the results.

Most managers observe, or are told by workers, that some groups and some sub-processes get along better than others. Actually, it works the other way around: “we just cannot work with that department!” Affinity studies, matrix studies, tree diagrams, etc, are all common TQM tools that can be used to identify relationships. Instead of looking for quality barriers, the same quality tools are used to look for barriers in the interrelationships of workers, teams, and groups. They help the manager better understand these relationships. This can be a valuable tool.

Training is required by most codes. This is often a nuisance to the manager so it gets delegated. A time is selected and everyone is “herded” into the classroom. The subject may only be of value or of interest to 30% of the attendees. Using TQM tools, such as a simple survey, the manager learns what subjects the workers want to hear about and the level of presentation. The manager learns that it is not much work to hold several different training sessions for different groups, with specific lectures. Employees want to know: “What is in it for me?” If they are asked for input, they know it will be beneficial to them. As a manager you have to provide training. As an employee you want meaningful, useful training. Therefore, the manager seeks input from employees, who are more motivated to attend and to participate. It is a win-win situation. For general subjects, such as fire preparedness or other emergency situations where everyone has to attend, split the training. Half of the lecture applies to everyone. Then, breakout into small groups that have special needs and duties. For instance, moving patients out of the area is one job. Others, like the response team, discuss their responsibilities. A third group may focus on shutting down equipment, closing doors, securing narcotics, and records. It is a team effort and a quality issue. There cannot be mistakes! It is exactly like running the day-to-day business.

Many Administrators, like all workers, keep running into roadblocks. If they could only get “a little slack” they could do a better job. A common barrier is cost of goods and quality. Dr Juran calls this “Objectives for breakthroughs.” Managers are working toward the breakthrough to something better. A purchasing agent can get “cheaper” goods. The manager, with the help of employees, documents problems with the cheaper product. Compensation for low product quality directly affects overall quality. This is documented and costs are assigned. If the new cheap gloves cost 15% less, but 30% of them tear when put on, this should convince the purchasing apartment that they need to buy better gloves. Maybe the workers need training on how to put the gloves on so they will not tear. Maybe this really is a good product. Remember to cost out the training activity.

The objective, as in all quality issues, is to define the product, process, or program and monitor it. From this activity comes data from which decisions can be made. Data, once analyzed, can be used to generate specifications. The purchasing agent was not provided specifications, so why would they look for any feature other than price?

Managers, contrary to popular belief, do not “know it all.” The wise ones gather data and input and are constantly learning. One of the best methods to learn is to use quality tools. These include Quality Control (QC), Total Quality Management (TQM), Continuous Quality Improvement (CQI). Within TQM and CQI there are “tool boxes” with dozens of tools. The product is management. It has a level of quality. It has a consistency level (level of quality control), and it can be improved, continuously.


1. Total Quality Management (TQM) means management of quality found in all aspects of the business, including management.

2. Delegation of authority is best achieved by creating teams to help define processes/policies and to offer suggestions for improvement.

3. Strategic planning is long-term; tactical is short term.

4. TQM helps workers to see their role in the overall operation. They are valued for their input. They are members of management.

5. Managers learn more and work less by delegating authority to teams.

6. Simple affinity diagrams can be useful management tools to identify problems, organize possible solutions, or to set up more meaningful training programs. Quality Control (QC) as a Management Tool

Many departments and medical facilities have been doing “quality control” for years. It is required by JCAHO, MQSA, etc. The problem is that much of what is done is solely to satisfy the requirement and not to implement improvement. For instance, quality control can be applied to one sub- process, or the entire process. Seldom is it applied to all processes. However, it is a fact that quality control is an economic tool, so why should it not be applied to everything, as anything in the process could affect the final quality. If the product is “scrapped,” there is not only a loss of anticipated income but a loss of the initial investment in raw materials. A worker normally does 4 products per hour. If he/she has to redo one, the productivity is reduced to three units per hour, or a 25% reduction. This increases the cost of all the other products.

In medicine, what is the product? For the records room, it is maintaining records. For the receptionist, it is a friendly, prompt response. For most health care workers, the product is a healthy patient. A radiologic technologist produces a radiograph for the radiologist, who interprets for the surgeon, who uses the information to help the patient. Communications with the patient are just as important as making the “x-ray” film. The film, like the patient, is a product with defined quality parameters. At the same time the patient is a “customer.” The radiologist is also a customer. CQI requires, and shows how one can define customers, suppliers, and producers/workers. It uses affinity diagrams, cause and effect diagrams (“fish bone”), tree or block diagrams, etc, to show how groups interact. It defines the business! Once defined, it can be better controlled to reduce waste, which means improved profit. Once controlled (and, only then) the process can be improved.

In the realm of QC, a process is monitored. Typically, tests are performed over time and the resulting numbers are analyzed. Walter Shewhart showed that all processes fluctuate, no matter how well you control them. He found that there were two groups of variables that caused fluctuations: 1) major or assignable variables that directly affect the process, such as time, temperature, etc. (controllable) 2) minor or unassignable causes that indirectly affect the process, such as room temperature, time of day, etc. These are on uncontrollable variables. The beauty of Shewhart’s work is that it helps a manager focus on those items that are controllable and have a direct effect on the bottom line. Typically, most people do not like to analyze numbers so they create charts. Shewhart Charts are called trend charts or average charts or run control charts. A target is simply the average value (“mean”) derived from prior sampling. This chart shows fluctuation around the average line. It becomes a limit chart if upper or lower limits are calculated. These are usually three sigma (3 s) or three standard deviation units (3 StD). Once a worker or manager masters analyzing charts, they easily move to analyzing data and forgo the charts.

Another tremendous tool is Pareto Analysis. It is sometimes called “Pareto’s Law of Maldistribution.” It is best explained this way: “the majority of the problems are caused by minority of the factors.” A manager, might read “the majority of absenteeism is caused by a minority number of workers.” The obvious conclusion is to identify the minority and work to improve their performance. This is also called the “80/20 Rule:” 80% of the waste is cause by 20% of the workers/assignable causes/parts/etc. Statistically it might be 74% to 26% or whatever. The key is that a “few” cause the majority of problems. Fix the “few,” not the majority. Pareto analysis can be applied to virtually any situation:

80% of complaints from workers will come from 20% of all workers. 80% of new ideas will come from 20% of all workers (usually a different group than complainers). 80% of the patient complaints will come from 20% of those polled. 80% of your boss’s complaints about you will cover 20% of your duties.

With simple, powerful quality tools like these (Pareto or Shewhart) one can more easily and efficiently manage anything.

Most managers learn rapidly that every decision has an effect for better or worse, on the operation. What seemed like a great idea can end up costing money and creating new problems. Some of the problems are worker confusion, frustration, alienation, etc. So how can one structure improvements to win? Firstly, understand that there is a fundamental difference between the words “change” and “improvement.” Secondly, improvement can only be instituted after there is a period of control (consistency). To control something requires defining the process and monitoring the process routinely to generate data that can be analyzed. The third factor one must acknowledge, is that medicine or health care, is a business. All businesses operate with budgets (income/out go or expenses) and a profit/loss statement. The objective of the business is to stay in business. To do this requires a profit. Profit is achieved as income over and above expenses. In a high-volume business the profit margin may be small, such as $1.00 per unit profit but a 1,000,000 unit production. In a low volume, higher quality business perhaps the profit is $100.00 per unit but only 100,000 units are produced. In either company, waste increases costs and this reduces profit. The waste is an out-of-control product. Thus, QC exists to achieve consistency, not quality. QC minimizes waste, to maximize profit. There will always be waste. Anyone operating a QC program without some waste simply has set up parameters that are too wide. It is an illusion if they report no waste. Customers will eventually avoid the product because they will find rejects mixed in. If it costs $10.00 in time and materials to produce a radiograph or pill, and the patient pays $50.00, this results in a $40.00 gross profit. If a product is wasted and a second product is substituted, then the patient pays $50.00, as usual, but the cost of production is $10.00 for the first product (scrapped) plus $10.00 for the second product, plus $50.00 lost revenue for a total of $70.00. The sale results in a loss of $20.00.

Managers need to work with purchasing agents and administrators to know exactly what supplies, raw materials, labor, and infrastructure (institutional) costs are. They need to know what is being charged for their “products.” These are numbers and numbers can be analyzed. Should you buy a new $500,000.00 device? Does it only treat 5% of the patients? Will it take five years to pay for itself while other devices only take two years? Will it contribute to better patient care, or quality, or otherwise contribute to the profit line? This is beginning to sound like a business plan; a plan for running the business. Decisions are made on “factual” numbers and not on emotional whims. These factual numbers may be in error, or not of high quality, but they are of quality level that is superior to emotional input. A manager can ask some workers to work up a proposal. This involves the workers, and teaches them about the business. When done, they may prove something is a good idea or convince themselves it is a bad idea. In either case, the workers are involved and are a part of the process. One of the saddest issues in modern health care involves the design of new facilities. An architect is hired and the owner/administrator/manager provides a list of specifications without consulting with the workers. Assuming there are ten workers and one manager, it would seem that ten minds can generate more ideas than one manager. After the facility is built, one often hears of expensive corrections needed and some voice saying: “I could have told them that wouldn’t work, but they didn’t ask.”

In addition to getting input from all workers, input is needed from customers, patients, suppliers, and other department heads.

Some of the causes of high cost (low profit), low quality, and low morale are:

  • Lack of information from managers to workers
  • Lack of ideas: take the first idea rather than getting many ideas and analyzing them
  • Band-Aids instead of permanent cures: doomed to repeat mistakes
  • Resistance to change: usually caused by ignorance
  • Habits and attitudes: we all have them and we can learn to change

Facilities, processes, and sub-processes must be designed around cost factors, environmental (intrinsic and extrinsic) values, and human factors, including gender, senses, mental, and physical capabilities/limitations.

It all comes down to “quality.” A quality operation has a high profit, low-cost operation because everything, including management, is consistent (in control). This quality institution may actually produce a slightly lower quality product, but they do it consistently. The “better” institution has some good days and some bad days and no one can predict the bad days. Thus, it lacks control; it has a higher level of costs. As the nursery rhyme states, to paraphrase: “…when it is good it is very good; when it is bad, it is horrid.” To which institution would you send your mother? Which type of institution do you manage? Which would you like to manage? Unfortunately, many managers cannot answer the last two questions because they lack a complete understanding of their operation.

Everything is quality defined. We often described something we do not like as “lousy quality.” We miss the point that, as bad as it is, it still has quality. That level for us is described as “lousy.” Quality can be measured. Numbers that result can be analyzed. Decisions can be made based on the analysis. Better decisions usually mean better economics. One thing to consider is the fact that what we consider to be lousy quality may be very good quality or acceptable quality to someone else. We must also recognize that what we consider, today, to be good quality or ideas or values may change and new quality levels will be established. It is the manager’s job, with help from workers, to define the quality levels and to look for new and better definitions of quality.

Audits are a way to see how well something is working. They look at processes, or sub- processes, programs, policies, etc, but not the worker. Audits have a high level of emotion because people do not like to be observed or criticized. But an audit should be a very pleasant and positive process. Consider the management style called “walkabout.” Every morning the manager spends an hour walking the halls. He/she stops to talk to various workers. During their discussion the manager gets to know the worker better. He/she learns about problems in general or specific to the worker, equipment, process, sub-process, etc. Ideally, the manager would retreat to his/her office and record these observations. An audit has just been done and no one complained or was upset.

Audits are usually done by outside authorities. They can be done internally also. The added benefit is that if a nurse audits the pharmacy (at the request of the pharmacy manager), the nurse gets a better understanding of the pharmacy. The pharmacy personnel know the nurse will not play “favorites.” In larger departments, equals from the same department, but from different locations, can be used to do internal audits.

An audit is basically a checklist. It is based on a standardized, written procedure, just like a cookbook recipe. The auditor simply watches the worker go through his/her routine and sees how this matches the written procedure. From this activity will be learned where the procedure fails and, thus, where it can be strengthened. The procedure may say something about preliminary steps with the patient prior to another step, but in practice the worker may find it more efficient to switch this sequence. The procedure might require something that cannot be accomplished, so it does not get done. The manager must decide if it is really needed, if a correction to the process is needed, and how to write it so it can be done. Remember the audit never audits the worker, only the guiding procedure. If the worker makes a “mistake” it is the fault or weakness in the procedure. This is even true when the audit concludes a worker is poorly trained or motivated, or has a bad attitude. The procedure needs to address this through training programs. Of course, one of the best motivational tools, as well as quality tools, is to have the worker involved in rewriting the procedure. The conclusion of most audits is that there is compliance with all steps except one or two (80/20 rule?). There are many steps in the procedure and this generates numbers. For instance, 42% of the time (four out of ten) the worker had difficulty with step 4. With a little work on step 4, one might get this reduced to 20% or 10% or even zero. This is progress and it is call quality improvement!

Simple numbers can be analyzed and decisions made. Sophisticated statistical analysis is not required although many functions can be carried out on a $10.00 scientific calculator. Audits are an economic tool. They indicate a level of consistency. They indicate areas for improvement. They are an excellent way to objectively analyze written procedures and to gain insight into how things are really done in the department. Internal audits prepare the staff for external audits.

Third-party audits such as JCAHO, FDA-MQSA (Mammographic Quality Standard Act), OSHA, or EPA are done to support licensure. Many departments wait until they are notified before they begin to prepare their records. Total Quality Management (TQM) and Continuous Quality Improvement (CQI) are exactly what they say. Everything must be identified and controlled so there can be effort to improve. This is the basis of the JCAHO regulation. A well-managed department will always be ready for an audit.

The third-party audit begins by reviewing training records. This is a great source of information. It shows attitude and involvement. If there is no ongoing formal (planned) training, the workers cannot perform at peak levels of safety and efficiency. Next, auditors look at general QC records to see if they are organized, neat, professional, etc. These two steps are the most important. Often, if there is a failure at this point the audit is terminated. When doing an internal audit, try to make these two steps prominent.

Benchmarking is a key TQM/CQI tool that works to better understand product quality. For instance, you cannot decide which brand of whole wheat cereal to buy. You buy three different boxes/brands. You compare the price, price per ounce, ease of opening and closing the packaging, the taste, texture, how soggy it gets, nutritional claims, and even which has nicer graphics to look or games to play on the back. Based on this “data,” you judge the cereal as A=1, C=2, B=3. You not only know why cereal “A” is number one, but you know what characteristics make it number one and what the deficiencies are in boxes “B” and “C.” If you wish to make further comparisons, perhaps brand “D,” you would compare it to your standard, brand “A.” Perhaps a few months later you’re not sure you still like “A,” so you re-benchmark a new box of “A” against the standards and find that the manufacturer has made a change.

Bench marking is another wonderful quality tool. However, it is virtually impossible to do in the health care field. One cannot pose as a surgery patient and check into several hospitals to evaluate them. However, a manager can get information from former employees or patients. Never ask a specific question such as “how was the food at…?” Rather, use more general and open-ended questions, such as, “in other hospitals, how did you find the food quality, preparation, service, menu, etc.?” Thus, it is possible, albeit difficult, to benchmark health care. The main problem is that it takes time to generate sufficient inputs. This can be reduced if the manager has sufficient confidence to attend meetings with peers from other institutions and openly discuss options. A better way is to internally benchmark. Based on written procedures, create a questionnaire. This is written in the form of expectations and is given to the patient as they “signed in.” As they leave, they are asked to answer another set of similar questions that indicate fulfillment levels. From this information a specification list can be generated:

1. Open at 8:30 AM, fully prepared for first patient

2. First patient arrives at 8:35 AM, on average

3. Average patient waiting time fifteen minutes, monitor waiting time, assess patient discomfort level

4. Be aware if the doctor is tied up in rounds or if an emergency comes in, that causes delays

5. Keep patients informed

When this checklist is created, an auditor simply does a check once a month to see how well the department is performing versus its “benchmark standard.” From this data will come indications of “soft” areas that require action to correct or strengthen. Where an audit monitors a process benchmark analysis compares today’s production to a predetermined standard. In medical laboratories, they benchmark thermometers and other equipment against National Institute for Standards & Technology (NIST) standards. They have “standardized” thermometers, weights, etc to test against. Image quality in radiology is defined as sensitometric values and these are calculated as density variations. Densitometers, that measure density, must be calibrated using a NIST standard gray scale. Benchmarking is a great tool to involve workers and to educate them in understanding their jobs and the overall business. Eventually, department managers will see the value of benchmarking outside their departments and will share their information with other managers in other institutions. The result will be improved health care for all patients.


1. The process by which we establish and meet standards is called “control.”

2. Bench marking helps to establish standards.

3. Audits can be internal, external, or third party.

4. Audits analyze how well a written procedure works.

5. Audits never analyze personnel performance.

6. Quality Control is an economic tool. Quality Control means consistency.

7. Managers can manage better using quality tools like Pareto Analysis and Shewhart Charts.

CHAPTER FOUR: Total Quality Management (TQM)

First and foremost, this is a quality tool. The premise is simple: Identify every factor that affects the quality of the product and control (manage) them.

However, because TQM can be applied to all processes, it can also be applied to the management process. Identify all parts of a manager’s job and apply a quality value for each part. For instance: what do managers do?

  • They make decisions that affect patients, customers, and workers.
  • They handle crisis by making decisions.
  • They plan for the future.
  • They create and control a budget.
  • They supervise personnel.
  • They are responsible for safety and meeting all regulations, whether imposed by local, state, or federal regulations.

Your assignment is to write down all the jobs you do as a manager. Start with the written job description, if it exists. You will have trouble placing things like “meetings” into categories. You make decisions at meetings, but you also give and receive information. Communications is a big part of the job, so list it. List the jobs you hate and avoid. Try not to embellish the jobs you like.

Most managers are surprised at the length of the list. Next, try to group items together. This is called looking for “affinity groups of similar characteristics.” It can also be called “list reduction” if you find you can now create larger categories. Next, list your tasks in order of priority (then ask your boss to do the same.) Then assign percentages based on time factors to each item. If the most important job takes 10% of your time and a less important job receives 35% of your time (Pareto Analysis?), there is a need for change, if you are to survive. This change should result in an increase in quality, within the management job.

Now that you have an idea of what you are supposed to do, what about each worker? Have each of them do the same exercise. When they are done, compare the worker’s perception of their job versus their job description. Incidentally, this is one of the best ways to write a job description. You will find that of five workers doing the same job, there are four different perceptions and ways to do the job. It is reasonable to assume that some of the steps are better than others. Therefore, incorporate the better steps and eliminate the less good steps. You will find that some workers understand the project while others are confused by it. You will find that you need to be more careful in defining or describing jobs, tasks, and duties (all of which should be listed separately).

The next step is to have section leaders or volunteers put together cards to describe all the functions of an area. For instance, a receptionist’s job is to greet patients and answer questions. The function of the reception area is to greet patients and coordinate their processing, provide entertainment (music, magazines, newspaper, TV), gather information in the form of forms to be filled in, and other functions. Areas are placed on a card and the cards are laid out so they touch to show flow between areas. The patient goes from reception to a change room or to the laboratory then a change room, etc. From this is drawn a flow diagram of the entire business. Overlook no area. Include porters, service personnel, shipping and receiving, billing, guards, etc, because all of these people, jobs, and departments not only effect your quality, but also your business. The electrician may not be on the department’s payroll. If there is an electrical short, you need his/her help, but you do not pay him. He is overhead, part of the infrastructure, which is paid from departmental profits. So indirectly he is your employee also, just not a full-time employee. Show a flow diagram for full time employees and another for part time employees. Try to create, with the help of workers, a list of all other employees of the institution who enter the department in a month. This will demonstrate new relationships. List all non-employees starting with the patients. Do they have family members or aides to assist them? On average, how many? Physicians, therapists, and nurses not from the hospital may visit the patient. Perhaps clergy. What you do for these people is one issue, but first you must acknowledge their presence.

Total Quality Management is concerned with today. Most managers use a negative style of management simply because they do not know the business. With detailed maps of the business one can more easily allocate time in a more efficient manner. It is easier to understand and to manage personnel. It is easier to develop and manage budgets. Many managers were former assistants and had some idea about what the manager’s job entailed. However, they were seldom exposed to the total picture. Certainly, as an assistant, they did not have total responsibility, exempt for, perhaps, a small unit. Thus, when they were promoted they found that they no longer managed one of twelve units, but all twelve units. This is a big responsibility regardless of the size of the business. Thus, one needs a road map. Diagrams, like maps, show you the way and the most efficient way.

In summary, TQM as a quality initiative that states one must fully uncover and understand all aspects of the business because any one aspect can influence the quality of the final product. It is not uncommon to have a cranky, hard to work with patient. Perhaps a patient is obnoxious, angry, frustrated, challenging, etc. The reason may have nothing to do with your department; perhaps he/she could not find a parking place or got lost in the halls. While TQM is designed to understand all aspects of quality so they can be measured, the same skills can be used to manage. After all, the manager wants to provide quality management. The manager wants to have quality workers, not just workers who control quality. Everything learned in doing a TQM study can be applied to management style, as well as to technical quality management.

Now that you are thinking positively and proactively, consider paradigms. Paradigms are things that are believed to be true, based on past history and/or experiences. What is one to believe? Human nature will cause one to believe in what one knows. A good manager, or worker, will be receptive to change and, thus, will grow. An example of a paradigm is the story of a US Navy captain of a huge battleship, on a foggy night, who sends a signal to a distant “light” to change course. The “light” responded: “I suggest you change course.” The captain was irate because of his rank, power, size of his vessel, etc, which he explained to the “light.” The “light” responded: “I am a lighthouse.” The captain was wrong. He did not have the right of way. His experience and education failed him. Indeed, he was forced, as the manager, to make a paradigm shift.

Most of us have said: “That is the way I learned it” or, “In my former job, all we did was….” as if past ways of doing things are always correct and true. If we choose a new way, how do we know it will not become a paradigm that we need to shift in the future? We do not. That is why we must always challenge what we do and how we do it, and be receptive to change. There is no shame in doing something wrong. The shame is continuing to do it wrong in light of new evidence.

Part of the TQM process is to uncover paradigms and to look for new methods. Thomas Edison, owner of a thousand patents, once said something like “there’s a better way of doing everything, just find it.” Another example is of a time management professor who fills a jar with rocks and asks his students if the jar is now full. They all agree. He then pours in sand, to the top, and asks if the jar is now full. The answer is a little less certain: “probably not.” The professor proceeds to fill the jar with water. The points of this demonstration were, one, do not be too quick to jump to conclusions, wait till you have all facts. In management, if you do not put the rocks in first, they will never fit. The rocks are your major problems and top priorities.

Basic TQM tool box:

  • Bench marking: compare against the standard
  • Diagrams

Block diagram: defines major work groups

Flow diagrams


Fishbone: cause and effect



  • Brainstorming/brain writing

List reduction: vital few


  • Surveys

Written questionnaires

Interviews (verbal)

  • Force Field Analysis: what currently exists that helps or hinders progress

Restraining forces

Counter forces to force field analysis (CFFFA)

  • GANTT: who does what, when, why, how
  • Statistical analysis



Scattergram Run control charts (Shewhart)

  • Strategic planning

As with any tool box, there are a variety of tools available. Some tools are used more frequently than others. Some are more useful or more user friendly, or we just like them better. Some tools are seldom or never used. That is the beauty of the toolbox. Again, while TQM is designed to understand quality issues, it can also undercover and understand management issues. It is a powerful process. One of the more important aspects of TQM is to find who is who. For instance, the patient in radiology is a product, a raw material to be worked with, and a customer. The patient is an unknown thing. The technologist must position the product in order to produce a quality radiograph. Technologists are producers or workers to the patient. The film was not made for the patient/customer, it was made for the radiologist/customer. The radiologist takes the film, as a raw material/product supplied by technologist/producer, and interprets it. He/she prepares a report for the referring physician, his customer.

We are all suppliers of something to someone else. We are all producers or workers. We are all customers of someone else. In the above example, how the technologist fares with the patient may be directly related to how the receptionist or porter interfaced with the patient. It is important for managers to understand these relationships. Several years ago, a manager got his team together and announced costs were out-of-hand and that all spending would cease. His biggest budgetary item was labor, as it is in most medical units. It was suggested that he layoff a third of the employees. “But, then we cannot handle as many patients as we do now, and we would lose income,” he complained. It would have been better to have employed some TQM tools, such as brainstorming, with the workers, to try to find a better way to cut costs and still maintain the same level of service. Who are the customers of the manager? His boss. The workers are suppliers and the raw materials. This type of thought process brings a whole new light to management. It forces one to look at each worker as a multifaceted person, not just a worker. The worker is someone’s customer and all customers expect to be treated with respect and consideration.


1. TQM is a quality tool. It can help produce a quality management style.

2. Affinity, fishbone, block, and flow diagrams are simple tools to help educate the new manager in the structure of his/her business.

3. Paradigms block progress. Everyone has them.

4. TQM tool box holds a variety of tools to help define and understand a process.

5. TQM uncovers and defines where we are today, so we can plan better for tomorrow.

6. Identify suppliers, workers/producers, customers for each a small step in any process.

CHAPTER FIVE: Continuous Quality Improvement (CQI) as a Way of Business Life

Continuous Quality Improvement (CQI) is a quality process. The concept is: whatever your quality is today, you plan to improve it in the near future. You and your staff are continually looking for improvements. Normally, this is improved product quality. However, it can also be improvement in the quality of management or services or employee efficiency or anything. It is interesting to note that if a manager motivates his/her staff to produce better and better products, at lower cost (reduced wasted), with higher productivity, then the manager will be thought of as an excellent manager. Thus, improving quality improves the business, and the manager gets the credit, which is shared with the workers.

Previously we discussed the fact that quality control is an economic tool. Quality control (QC) controls quality, regardless of level, and thus, is another name for consistency. How can one be continuously improving, mean changing, quality, and have control or consistency at the same time? In CQI, a process or sub-process is defined and controlled. One factor is changed. Careful controls you use to see if the change is an improvement, or simply a change. Next, testing verifies that the improvement is controllable. If it cannot be controlled, no matter how good it is, than it is deleted until more is learned and the process is returned to its original quality state.

Whatever your current management style is today, it can be improved upon. Working toward product CT is the same for management. While TQM defines where we are (product or service or management), CQI plans where we want to go (product or management or service).

The tool box of TQM is essentially the same in CQI. The primary difference is that TQM defines the current state; where we are. CQI questions what might happen if we change flow between sub-processes on the block, affinity, or flow diagrams. CQI looks at cause and effect diagrams (fishbone) for ways to streamline, reduce bottlenecks, etc.. Because it is a little more scientific, the process delves deeper into various relationships. TQM may have detailed how a nurse transitions at the beginning of a shift and specifically, how narcotic products are controlled. CQI wants to know more about each step and asks, constantly: why? Of course, this reveals many paradigms, which is a good result. Consider the following dialog: Question: “Why do you do that?” Answer: “Because, it is in the written protocol/procedure.” Question: “Do you feel it is a reasonable flow pattern?” Answer: “No, I would suggest….”

This is not unlike an audit (except audits do not ask for input), a survey, or brainstorming. One can manage what exists today or work to find a better way to manage and a better process (department or unit) to manage. In the above example, the worker provides input. The worker, the most knowledgeable person in the workings of his/her part of the total process, is given value and recognition. Based on a variety of inputs, that give direction for the future, a plan is developed. Tactical plans are for the near term (“Band-Aids”). Strategic planning is for the future, over the next 1 to 5 years. Input comes from workers organized in small groups or teams. Based on prior input, under TQM, specific problems are identified and listed by priority. Next, the most critical problems are addressed. Everyone is asked for idea, and the ideas are all recorded. There are no bad ideas. Indeed, a poorly thought out idea may stimulate others to expand on the idea until it is crystal clear. The dialogue and “what-ifs” are more valuable than actually solving a problem, which will also happen. The entire list is voted on in an effort to reduce the list to a “vital few.” These 2 or 3 ideas, or plans of action, are implemented, as an experiment. It is an approach that can be used in organization, planning, operation, and/or management of the department.

Federal Environmental Protection Agency (EPA) charge manufacturers of hazardous products to be responsible for the product “from cradle to grave.” This includes transportation, storage, selling, even disposal of the product after someone else has purchased and used it. In the same way, the managers are responsible for everything in the department. Involving everyone in CQI is a simple way to delegate authority and to share responsibility. It makes everybody a part of the management team. Obviously a manufacturer cannot afford to station a trained expert in the customer’s place of business. The manufacturer can afford to train a customer, provide literature, keep them informed, and solicit their ideas of how they can better service the customer.

Dr Juran discusses in his “Objectives for Breakthrough” that a formal plan should have these components:

  • Force people to think things through, to challenge, to seek out paradigms.
  • Convert all problems into recorded knowledge. The greatest waste is repeated waste.
  • Optimize overall departmental process performance, in preference to individual sub-processes.
  • Empower employees.
  • Clearly define responsibilities.
  • Foster an environment of self-control.

To bring these things about one needs to motivate workers to participate so they have ownership of change. Technological cultural baggage (paradigms) should be minimized or removed, or at least employees should gain agreement on common elements. Reduce the effect of change by incorporating it into a larger change. Treat people with dignity and try to see things from their perspective. Workers need to be motivated to do their jobs and also to undertake planning for change. Workers, and everyone, have physiological and psychological attitudes and attributes. As a manager, you need to spend time learning what these are through one-on-one interviews or in small groups. Consider the new boss who was raised and trained in a very large city, trying to understand his new team of workers in a small rural farm community. In the same way, while we are all customers, we tend to believe we provide “perfect” health care to our customers: the patient is happy with the service they receive. Is this your opinion or do you have data to prove it? Did you ask them questions important to you or important to them? Measuring customer service on a factual scale is difficult. The only way is to develop some simple, meaningful surveys and ask customers to fill them out. That is an indirect approach. A direct approach is to ask questions (interview) and record the answers. Also, try to record the reactions and their questions and concerns and suggestions, because they will have them. A very good approach is to survey the customers to find out what they want to talk about, rather than simply supplying questions you are interested in. Which is really important: getting the answers you think you want or getting answers the customers want to give? Which are more useful to you? When you last went to a restaurant did the host, or wait staff ask you: “How was the food?” Did you give a complete answer? Did they listen intently? Did you feel they could care less? Or, perhaps, regardless of the quality, you stated: “Everything is fine.” Whether it is in a restaurant or hospital, it sounds like the relationship between customer and producer should be one of mutual respect and dependency. In CQI we are all customers. We are all suppliers. We are all producers. We are all part of the process.

In “On Leaders and Leadership” (Quality Progress, October, 1999) the authors summarize several points as: “…leadership is we, not me…” A good leader is focused on the business and all its aspects, not on the one sub-process, one worker, or on themselves.

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