QUALITY STANDARD IN HEALTH CARE ORGANIZATIONS IMPROVING PERFORMANCE

Presented to Dr. Betty T. Polido Faculty of the College of Nursing Central Philippine University

In Partial Fulfillment for the Requirement in the course N 414- F

By Solinap, Lady Juelaine M. Somongcad, Denevieve P. July 10, 2012

OBJECTIVES:
The report is about improving performance in health care organizations specifically it aims to: identify important events and people in the history of quality care; describe factors influencing performance of health workers and strategic performance; discuss about ineffective performance and factors related to it; determine the influence of motivation as a performance indicator identify strategies that influence, competence and responsiveness among health care organizations; compare the benefits and drawbacks of performance appraisal describe what is Total Quality Management (TQM); explain the relevance of TQM in Quality of Health Care.

INTRODUCTION
Quality is a more complicated term than it appears. Dictionary definitions are usually inadequate in helping a quality professional understand the concept. It seems that every quality expert defines quality somewhat differently, and there are a variety of perspectives that can be taken in defining quality. This report focuses in improving

performance of health care provider organizations in quality standard.

Improving performance is a very relevant topic in the health care organization since our clients deserve the best quality of care. We, as the providers

have to be fully equipped with knowledge, skills and attitude in order to be considered
as competent in our field.

The quality movement can trace its roots back to medieval Europe, where craftsmen began organizing into unions called guilds in the late 13th century. Until the early 19th century, manufacturing in the industrialized world tended to follow this craftsmanship model. The factory system, with its emphasis on product inspection, started in Great Britain in the mid-1750s and grew into the Industrial Revolution in the early 1800s. In the early 20th century, manufacturers began to include quality processes in quality practices.

After the United States entered World War II, quality became a critical component of the war effort: Bullets manufactured in one state, for example, had to work consistently in rifles made in another. The armed forces initially inspected virtually every unit of product; then to simplify and speed up this process without compromising safety, the military began to use sampling techniques for inspection, aided by the publication of military-specification standards and training courses in Walter Shewharts statistical process control techniques. The birth of total quality in the United States came as a direct response to the quality revolution in Japan following World War II. The Japanese welcomed the input of Americans Joseph M. Juran and W. Edwards Deming and rather than concentrating on inspection, focused on improving all organizational processes through the people who used them.

By the 1970s, U.S. industrial sectors such as automobiles and electronics had been broadsided by Japans high-quality competition. The U.S. response, emphasizing not only statistics but approaches that embraced the entire organization, became known as total quality management (TQM). By the last decade of the 20th century, TQM was considered a fad by

many business leaders. But while the use of the term TQM has faded somewhat,
particularly in the United States, its practices continue. In the few years since the turn of the century, the quality movement seems to have matured beyond Total Quality. New quality systems have evolved from the

foundations of Deming, Juran and the early Japanese practitioners of quality, and
quality has moved beyond manufacturing into service, healthcare, education and government sector (http://asq.org/learn-about-quality/history-ofquality/overview/overview.html).

FACTORS INFLUENCING PERFORMANCE OF HEALTH WORKERS AND STRATEGIES FOR IMPROVEMENT

Poor performance of service providers leads to inaccessibility of care and inappropriate care, which thus contribute to reduced health outcomes as people are not using services or are mistreated due to harmful practices. Poor performance results from too few staff, or from staff not providing care according to standards and

not being responsive to the needs of the community and patients. As Hughes et al.
state: Most performance problems can be attributed to unclear expectations, skills deficit, resource or equipment shortages or a lack of motivation (Hughes et al., 2002). These causes are rooted in a failing health system, low salaries, difficult working and living conditions and inappropriate training.

Figure 1. Framework for Analysis

This framework was designed using a systemic approach to health worker performance: situational analysis, intervention (input/process), outputs, effects, outcome and impact. The framework shows that determinants of health workers behavior (in the workplace) are rooted in factors relating to:

macro level, or the overall health system, such as resources allocation, planning
and deployment of health workers, current regulatory framework, communication and decision-making processes, and accountability mechanisms. These can be influenced by

policy-makers and planners in the health sector, as well as other stakeholders at

national level, such as the ministry of finance, ministry of education, professional associations, civil society groups and funding agencies (health systems level).

 micro level, or the workplace itself (district or facility, etc.), such as availability of
equipment, drugs and supplies, teamwork and human resources management activities.
In principle these can be influenced by local managers, colleagues, patients and other local partners (health facility level)4. individual characteristics and living circumstances, such as living in conflict areas or being a woman or a newly graduated professional. These require specific group

strategies and can be developed locally by managers or nationally by policy-makers and

planners together with other stakeholders (individual level).

Interventions are designed based on an analysis of the determinants that

influence health workers performance. Implementation of these interventions (inputs

and process) provides outputs (expected results) in terms of improved working conditions, improved motivation, improved staff retention, etc. These, in turn, result in the effects of the intervention in terms of measurable improvements on availability, productivity, competence and/or responsiveness of health workers. The effects positively influence performance, i.e. the outcome of the intervention, for which the intervention is not totally accountable. Improved performance in turn contributes to improved health status.

There is no linear relationship between determinants and outputs, between

outputs and effects, and between effects and outcomes. Health worker performance is
a complex issue to address, as a variety of determinants influence staff behaviour at different levels. Various authors have regrouped the determinants (Rowe et al., 2005; Hongoro & Normand, 2006; WHO, 2006), suggesting four main areas:

health worker characteristics (individual level)

health system and facility characteristics (macro and micro levels) characteristics of the wider political and socioeconomic environment (contextual

factors)
community/population characteristics (contextual factors) (www.who.int/hrh/resources/improvinghw-performance.pdf).

INEFFECTIVE PERFORMANCE
Job performance is ineffective when productivity falls below a standard considered acceptable at a given time. Ineffective performers consume considerable managerial time. The causes of poor job performance can be rooted in the employee, the job, the manager, or the organization. Usually ineffective performance is caused by

a combination of several factors.

Factors contributing to ineffective performance Employees are or become ineffective performers for many different reasons. The cause of poor performance can be rooted in the person, the job, the manager, or the company.

FACTORS RELATED TO THE EMPLOYEE:

Insufficient education Insufficient job knowledge Job stress or burnout Low motivation and loafing Technological obsolescence Absenteeism and tardiness Emotional problem or personality disorder mental ability and Alcoholism and drug addiction Tobacco symptoms Conducting outside business on the job Family and personal problems Physical limitations Preoccupying office romance Fear of travelling, especially flying addiction or withdrawal

FACTORS RELATED TO MANAGER :

Inadequate communication about job responsibilities Inadequate feedback about job performance Inappropriate leadership style Bullying or intimidating

FACTORS RELATED TO JOB:

Ergonomics problems and repetitive motion disorder Repetitive, physically demanding job Built-in conflict Night-shift work assignments Substandard industrial hygiene A sick building

FACTORS RELATED TO THE ORGANIZATION:

Organizational culture that tolerates

poor performance
Poor ethical culture Counterproductive work environment

Negative work-group influences

Intentional threats to job security Violence or threats of violence

Sexual harassment

APPROACH IN IMPROVING INEFFECTIVE PERFORMANCE:

Define performance standards.

Detect deviation from acceptable

performance Define and assess the cause Communicate with the substandard

performance
Set improvement goals Select and implement an action plan Reevaluate performance after a time interval Continue or discontinue the action plan (Dubrin, 2006).

MOTIVATION AS PERFORMANCE INDICATOR

Understanding why people do the things they do on the job is not an easy
task for the manager. All important work behaviors are motivated. Managers need to motivate employees to join and remain in the organization and to exhibit high attendance, job performance, and citizenship. Motivation refers to forces that energize, direct, and sustain a persons efforts. All behavior, except involuntary reflexes like eye blinks is motivated. A highly motivate person will work hard toward achieving performance goals. With adequate

ability and understanding of the job, such a person will be highly productive (Bateman,
2007).

THEORIES IN MOTIVATION

The Nature of Motivation. Motivation encompasses the psychological forces within a person that determine the direction of the persons behavior in an organization, the persons level of effort, and the persons level of persistence in the face of obstacles. Mangers strive to motivate people to contribute their inputs to an organization, to focus these inputs in the direction of high performance, and to ensure that people receive the outcomes they desire when they perform at a high level.

THEORIES IN MOTIVATION
Expectancy Theory

According to expectancy theory,

managers can promote high levels of motivation in their organizations by taking steps to ensure that expectancy is high (people think that if they try, they can perform at a high level, they will receive certain outcomes) and valence is high ( people desire these outcomes).

THEORIES IN MOTIVATION
Need Theories
Need theories suggest that to motivate their workforces, managers should determine what needs people are trying to satisfy in organizations and then ensure that people receive outcomes that satisfy these needs when they perform at high level and contribute to organizational effectiveness.

Equity Theory
Managers can promote high levels of motivation by ensuring that people perceive that there is equity in the organization or that outcomes are distributed in proportion to inputs. Equity exists when a person perceives that his or her own outcome-input ratio equals the outcome-input ratio of a referent. Inequity motivates people to try to restore equity.

THEORIES IN MOTIVATION
Goal-setting Theory Suggests that managers can promote high motivation and performance by ensuring that people are striving to achieve specific, difficult goals. It is important for people to accept the goals, be committed to them, and receive feedback about how they are doing.

Learning Theories.
Operant conditioning theory suggests that managers can motivate people to perform highly by using positive reinforcement or negative reinforcement. Managers

can motivate people to avoid performing dysfunctional behaviors by using extinction

or punishment. Social learning theory suggests that people can also be motivated by observing how others perform behaviors and receive rewards, by engaging in selfreinforcement, and by having high levels of self-efficacy.

Pay and motivation

Each of the motivation theories discussed

alludes to the importance of pay and suggest that pay should be based on performance. individual,Merit group-, plans or can be

organizational

based and can entail use of

increases or bonuses (Jones, 2006).

salary

STRATEGIES TO INFLUENCE PRODUCTIVITY, COMPETENCE AND RESPONSIVENESS

Various strategies have been developed to improve productivity, competence

and responsiveness of health workers: these range from specific interventions (such as
the provision of performance-related allowances) to more comprehensive approaches that combine aspects such as training, supervision and the provision of drugs and guidelines. Success depends not only on identifying and addressing root causes but also on the process of implementation. Although there was no conclusive evidence, single interventions often had limited success (Rowe et al., 2005).

The following framework (Figure 2) has been developed to analyze improvements in productivity, competence and responsiveness. This framework is based on Figure 1.

Figure 2. Analytical Framework for Retention

PERFORMANCE APPRAISAL: PROS AND CONS

A performance appraisal (PA) or performance evaluation is a systematic and periodic process that assesses an individual employees job performance and productivity in relation to certain pre-established criteria and organizational objectives. A central reason for the utilization of performance appraisals (PAs) is performance

improvement (initially at the level of the individual employee, and ultimately at the level of the
organization). Other fundamental reasons include as a basis for employment decisions (e.g. promotions, terminations, transfers), as criteria in research (e.g. test validation), to aid with

communication (e.g. allowing employees to know how they are doing and organizational
expectations), to establish personal objectives for training programs, for transmission of objective feedback for personal development, as a means of documentation to aid in keeping

track of decisions and legal requirements and in wage and salary administration.)

PERFORMANCE APPRAISAL: PROS AND CONS

Additionally,

Performance

Appraisals can aid in the formulation of job criteria and selection of individuals who are best suited to perform the required organizational tasks. A

Performance Appraisal can be part of guiding and monitoring employee career development (www.wikipedia.com).

PERFORMANCE APPRAISAL: PROS AND CONS

Potential Benefits of Conducting Performance Appraisals

Facilitate communication Enhance employee focus by promoting trust Goal setting/reinforcement of desired behavior/performance Performance improvement Determination of training needs

Drawbacks of Formal Performance Appraisals

Detrimental to quality improvement Negative perceptions Errors Legal issues Performance goals Derail merit pay or performance-based pay

POTENTIAL BENEFITS OF CONDUCTING PERFORMANCE APPRAISALS

Facilitate communication:
- recognized as an important skill for managers and leaders in organizations (Kikoski,

1999). -help reduce employee uncertainty, while promoting more effective communication between supervisors and subordinates (Spinks, Wells, and Meche, 1999; Wells and Spinks, 1999). -absence of feedback leaves employees to play a guessing game concerning whether to continue on the current path of workrelated behavior or to chart another course. -encouraging employees to continue on a positive trajectory or to guide employees in improving problem areas.

POTENTIAL BENEFITS OF CONDUCTING PERFORMANCE APPRAISALS

Enhance employee focus by promoting trust: The existence or the lack of trust among organizational members and structures affects performance (Argyris, 1964). Behaviors, thoughts, or issues that distract the employee from the work task reduce task performance (Kanfer and Ackerman, 1989, p. 659). Their reasoning suggested that issues that consume an employees limited capacity to focus would necessarily lessen the employees ability to focus on activities that contributed to the achievement of organizational goals. Performance appraisals,properly structured and applied, can be used to help minimize environmental distractions (Mayer and Gavin, 2005), promoting an increased level of trust within the organization.

Goal setting/reinforcement of desired behavior/performance:

Ideally, organizations strive to match individual goals and performance to the overall objectives of the organization. This may help reduce uncertainty about jobrelated expectations (Pettijohn et al., 2001). Performance appraisals also provide a forum for collaboration in setting goals for the employee (Kikoski, 1999). This collaborative effort in goal setting is desirable because it results in greater acceptance and satisfaction with appraisal results (Cawley, Keeping, and Levy, 1998).

POTENTIAL BENEFITS OF CONDUCTING PERFORMANCE APPRAISALS

Performance improvement:
Performance appraisals are an important tool for communicating with employees about how well their job-related performance meets organizational expectations (Spinks et al., 1999). Well structured appraisals should directly relate to noted improvements in any weak areas (Broady-Preston and Steel, 2002). At the organizational level, numerous studies have reported positive relationships between human resource management (HRM) practices, including performance appraisal and organizational performance (e.g., Arthur, 1994; Delery and Doty, 1996; Guthrie, 2001; Juselid, 1995; MacDuffie, 1995).

POTENTIAL BENEFITS OF CONDUCTING PERFORMANCE APPRAISALS

Determination of training needs:

Employee training and development are crucial components in helping an organization achieve strategic initiatives (Twomey and Harris, 2000). Seldon et al. (2001) argue that the key to an effective performance appraisal system is providing individuals with an opportunity to pursue training and development directly related to problem areas identified in the appraisal. Appraisals systems can serve as an effective conduit for identifying training needs, particularly for new employees (Broady-Preston and Steel, 2002). Further, performance appraisals may be useful in establishing and monitoring employees career goals (Spinks et al., 1999) (www.asq.org.).

DRAWBACKS OF FORMAL PERFORMANCE APPRAISALS

Despite all the potential advantages of formal performance appraisals (PAs), there are also potential drawbacks. It has been noted that determining the relationship between individual job performance and organizational performance can be a difficult task. These includes:

Detrimental to quality improvement:

It has been suggested that the performance appraisal systems of organizations are an impediment to the pursuit of quality (Soltani, 2005). Kikoski (1999) acknowledged the belief among some scholars and practitioners that total quality management eliminates the need for formal performance appraisals.

DRAWBACKS OF FORMAL PERFORMANCE APPRAISALS

Negative perceptions:
Deming (1986), advocated that organizations take steps to create an organizational environment that was free from fear, thus enhancing the overall quality of performance. Quite often, individuals have negative perceptions of performance

appraisals (Pettijohn et al., 2001). Indeed, receiving a performance appraisal can be an

unnerving and even frightening experience for some employees (Spinks et al., 1999). Performance appraisals can also create tension between supervisors and subordinatesm(Jenks, 1991). This could be why some managers dread or even avoid conducting them (Kikoski, 1999).

DRAWBACKS OF FORMAL PERFORMANCE APPRAISALS

Errors:
Performance appraisals should be based on a pre-established set of criteria directly related to the employees job assignments (Amsterdam, Johnson, Monrad, and Tonnsen, 2005). Thus, the ratings should provide an accurate reflection of the

employees performance. However, supervisors often give employees ratings that

exceed their true performance to avoid conflicts or avoid other unpleasant consequences. Inflated ratings are a common malady associated with formal performance appraisals (Martin and Bartol, 1998).

DRAWBACKS OF FORMAL PERFORMANCE APPRAISALS

Legal issues:
Performance appraisals that are not done well by supervisors can be costly to
organizationsfrom a legal standpoint (Jenks, 1991). This is important since performance appraisals are becoming increasingly important tools in organizations disciplinary programs (Spinks et al., 1999). Ratings on performance appraisals may also be used by some organizations as a basis for promotion decisions. If the appraisals are not donecorrectly, the resulting decisions may have negative effects on employees, thus leading to legal action.

DRAWBACKS OF FORMAL PERFORMANCE APPRAISALS

Performance goals:
Performance or outcome goals are often used in conjunction with performance appraisal systems. When performance or outcome goals are too challenging or overemphasized at the expense of ethics, legal requirements, or quality, this can have negative consequences for organizations (Loomis, 2003; Schweitzer, Ordonez, and Douma, 2004). Furthermore, specific challenging performance goals have a deleterious effect on employees effectiveness in the early stages of learning (Kanfer and Ackerman, 1989). Therefore, in organizational situations where the acquisition of knowledge and skill

is the primary focus, performance goals may be detrimental to performance (Seijts and
Latham, 2005). Learning goals, rather than performance goals would be more appropriate in these situations.

DRAWBACKS OF FORMAL PERFORMANCE APPRAISALS

Derail merit pay or performance-based pay:
Some researchers argue that failure of merit-based pay and performancebased pay can been associated with problems inherent in performance appraisal systems (Selden, Ingraham, and Jacobson, 2001). As Milkovich and Newman (2005) note, performance measurement and performance management are the oil that lubricates the human resources (HR) engine. To determine if HR efforts are working, accurate performance appraisals are needed (http://asq.org/qualityparticipation/2007/03/human-resources/critical-examination-performance-

appraisals.pdf).

The TQM concept was developed by a number of American management consultants, including W. Edwards Deming, Joeseph Juran, and A.V. Feigenbaum. Originally, these consultants won few

converts in the United States. However, managers in Japan embraced their ideas enthusiastically and
even named their premier annual prize for manufacturingexcellence after Deming.

Total Quality Management is a philosophy or approach to management that is grounded on three core

principles:
1. 2. 3. A focus on the customer. Participation and teamwork Continuous Improvement

These principles are supported and implemented by an integrated organizational infrastructure, a set of management practices, and a wide variety of tools and techniques, which all must work together and support each other .

Figure 3. The Scope of Total Quality Management

CUSTOMER FOCUS

The modern definition of quality

centers on meeting or exceeding customer expectations. Thus, the customer is the

principal judge of quality. Perceptions of

value and satisfaction are influenced by many factors throughout the customers

overall purchase, ownership and service

experiences.

PARTICIPATION AND TEAMWORK

When managers give employees the tools to make good decisions and the freedom and encouragement to make contributions, they virtually guarantee that better quality products and production processes will result. Employees allowed to participateboth individually and in teams- in decisions that affect their jobs and the customer can make substantial quality contributions. In any organization, the person who best

understands his or her job and how to improve both the product and the process is the
one performing it. By training, employees think creatively and rewarding good suggestions, managers can develop loyalty and trust. Another important element of total quality management is teamwork, which

focuses attention on customer-supplier relationships and encourages the involvement of

total workforce in attacking systemic problems, particularly those that cross functional boundaries.

TQM requires horizontal coordination between organizational units.

Poor quality often results from breakdowns in responsibility that occurs when
an organization focuses solely on vertical structures, and fails to recognize the horizontal interactions. Vertical structures lead to internal competition rather than promoting the good of the whole organization. Partnerships are an additional way of promoting teamwork.

Partnerships between a company and organized labor and between customers and suppliers are common among companies practicing TQM.

CONTINUOUS IMPROVEMENT
Continuous Improvement has its roots in the industrial revolution. In the early 1900s, Frederick

Taylor,

often called

the

Father

of

Scientific

Management, believed that management had a responsibility to find the best way to do a job and train workers in the appropriate procedures.

Continuous improvement is an integral

part of processes. the management of all systems and however, Under TQM framework

responsibility for quality lies with the individual

worker and teams of workers and quality is the

principal focus. The process of continuous improvement requires systematic planning, execution, and evaluation.

Improvement is a critical aspect of all operations and of all work unit

activities of a company. Improvements may take any one of several forms:

Enhancing value to the customer through new and improved products and

services
Reducing errors, defects and waste Improving productivity and effectiveness in the use of all resources Improving responsiveness and cycle time performance

Seven important principles of Total Quality

Management as a foundation for all your activities

1. Quality can and must be managed 2. Processes, not people, are the problem 3. Dont treat symptoms, look for the cure 4. Every employee is responsible for quality 5. Quality must be measurable

6. Quality improvements must be continuous

7. Quality is a long-term investment (http://managementhelp.org/quality/total-quality-management.htm).

APPLICATION OF TQM IN QUALITY OF HEALTH CARE

Total quality management (TQM) is originally a concept of manufacturing management. It is first used in the enterprise management, and considerrd as one of effective methods of managing in the management field because a good result is achieved on TQM. One of the content of its core is based on the course of the total quality management. The total quality management thinking applied to the management of hospital care is to focus on the hospital care management, improve work-related activities, and establish apatient-centeredconcept of care, so that the management of all hospital care forms a complete network of services, which will ensure and enhance the quality of care. Hospital care is an important component of the overall curative work. The quality of care reflects the

work level of hospital care and the quality of hospital management, and directly relates to the
patients life and health, impacts the satisfaction degree of the patient on the care, and even plays a vital role in the development of the hospital (http://www.res-medical.com/clinicalmedicine/81208).

LESSONS LEARNED
Achieving quality care and improving performance is not an instantaneous job to do. This two requires endless effort to be achieved. Before achieving that certain level of excellence in patient care there are certain factors to consider. In improving performance, various factors influencing staff retention and mobility can be distinguished such as personal and lifestyle-related factors, including living circumstances; work-related factors, related to preparation for work during pre-service education; health-system related factors, such as human resources policy and planning; and job satisfaction, influenced by health facility factors, such as financial considerations, working conditions, management capacity and styles, professional advancement and safety at work. providers depends on the political, socioeconomic and cultural environment. As elements influencing performance are intricately related to each other, interventions must be comprehensive and multifaceted and must take place simultaneously and at different levels of the health system. While experiments have taken place using different types of interventions to improve performance of health workers, substantive evidence of their effectiveness is still limited.

BIBLIOGRAPHY
Books
Bateman, Thomas S (2007). Management: leading & collaborating in a competitive world . The McGraw-Hill Companies, Inc., 1221 Avenue of the Americas, New York,NY,10020 : p. 427-428 DuBrin Andrew J. (2006). Essential of Management, Seventh Edition . Thomson Higher Education 5191 Natorp Boulevard Mason, OH 45040 USA: p. 513, 538 Evans James R., Lindsay William M. (1996). The management and control of quality ,West Publishing Company 610 Opperman Drive P.O. Box 64526 St. Paul, MN 55164-0526: p.105-109 Jones,Gareth R (2006). Contemporary Management , The McGraw-Hill Companies, Inc., 1221 Avenue of the Americas, New York,NY,10020: p.484

Electronic Resources
www.who.int/hrh/resources/improvinghw-performance.pdf (07-8-2012) http://asq.org/learn-about-quality/history-of-quality/overview/overview.html (07-8-2012) http://asq.org/quality-participation/2007/03/human-resources/critical-examination-performanceappraisals.pdf (07-8-2012) http://www.res-medical.com/clinical-medicine/81208. (07-8-2012)