Leadership, measurement, and change in improving quality in healthcare.

SANDRA POTTHOFF, PH.D. I OFTEN HEAR cynicism from practitioners and academics; they bemoan the plethora of techniques for improving quality in healthcare-continuous quality improvement (CQI), Six Sigma, rapid-cycle improvement, lean manufacturing systems, Balanced Scorecard, Baldrige-because they are viewed as yet one more "fad" in the search for the holy grail of quality. The articles by Sister Mary Jean Ryan and Glen Barton provide a framework for understanding that all are important tools that work in tandem to achieve quality results. Furthermore, regardless of the tools used, the articles show that quality is created in healthcare by the following: * Leadership * Quality measures that are transparent through their public availability * Organizational know-how to turn benchmark and performance data into actionable knowledge Both articles demonstrate that systematic and sustained improvements in quality require leadership that is willing to step up to the plate, provide resources to get the job done, and hold people accountable for results. In studying quality management practices in long-term care, my colleague Doug Olson and I posited and measured four leadership practices based on the Baldrige leadership criteria and assessed their relationship to quality management practices, as follows: 1. Focused visionary sets the future agenda for the organization and targets the vision on the core set of initiatives that will focus the organization to improve. 2. Supporting change encompasses encouraging individual growth and learning as well as organizational innovation. 3. Effective communication entails motivating communication and creating a climate of sharing information across the organization. 4. Visible presence provides support with visible behavior and practices throughout the organization. SANDRA POTTHOFF, PH.D., IS ASSOCIATE PROFESSOR AND DIRECTOR FOR THE MASTER OF HEALTHCARE ADMINISTRATION PROGRAM AT THE CARLSON SCHOOL OF MANACEM ENT AT TH E U N IVERSITY OF MIN NESSOTA IN MINNEAPOLIS. Using employee satisfaction as the dependent variable, analysis using a statistical approach called structural equation modeling (Maruyama 1998) revealed that these leadership practices work hierarchically on Baldrige quality areas from the strategic (strategy development and deployment) to the operational (process management) to the tactical (staff focus) (Olson 2000). Being a focused visionary directly affects the organization's ability to develop and deploy strategy, supporting change directly affects organizational process management, and communication directly affects staff focus. Staff focus most directly affects employee satisfaction, although strategy works through process management, and, in turn, process management works through staff focus to indirectly affect employee satisfaction. The direct statistical association of visible presence on employee satisfaction was weak, although this could have been because there was less variation in that practice across the 60 facilities that were in the study. The experiences described by Ryan and Barton also demonstrate that leadership must work across multiple levels to effect meaningful improvements in quality. Ryan describes focusing a vision on quality, first through more general CQI approaches and then using the Baldrige framework as a tool to build a common vision across all the operating units to drive rapid improvement. Barton describes Caterpillar Inc.'s targeted efforts both through policy activism and through collaborating with networks of caregivers, most recently using Six Sigma methods. Both describe the attention to process management, including the use of data, that must be implemented and nurtured to sustain meaningful and timely gains in quality, and both highlight the extensive amount of communication required to engage employees in change efforts in meaningful ways. Measurement is shown in the Baldrige framework as the foundation on which performance excellence rests (NIST 2004). …