Professional Documents
Culture Documents
QUALITY
Definition of quality
In simple terms quality can be defined through the voice of the customer. It can be said that a
product is of satisfactory quality if it satisfies the customer’s needs. A customer will buy a
product if it meets the minimum expectations. Therefore, quality refers to the ability of a
product or service to consistently meet or even exceed customer needs and expectations.
Several aspects about quality clearly stand out from this definition;
1. Customer determination- it is only customers who can decide if and how well a
2. Actual experience- the customer will judge the quality of a product or a service based
stated or unstated, conscious or merely sensed. The product or service must meet the
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5. Entirely subjective- aspects of the product or service may be interpreted in the
Dimensions of quality
1. Performance – the most essential aspect of quality is whether the product does what
quality; for example, when buying a car, performance would mean acceleration,
2. Aesthetic properties- such as appearance, feel, smell, taste or sound may form
important aspects of quality. The saying goes that the best goods are not the most
sophisticated, rather the most appealing and that the market belongs not to the highly
3. Reliability – is the ability of a product to continue to be fit for the intended purpose
(i.e. continued fitness for purpose) or function. Reliability measures how consistently
4. Durability- durability measures how long the product performs until repair is needed
entails the ease of repair of the product. Other important aspects include the training
offered to customers in order to use the product, the assistance available, the
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6. Special features- customers are normally interested in extra features in the product.
customers’ perception of the product is very important. Customers rely heavily on the
past performance and the reputation of the firm producing the product, hence
products.
purpose/use, performance, safety and reliability, with economic factors, which include price
and availability.
Quality is a strategic factor that works through virtuous cycle to enhance a company’s
sustainable competitiveness as illustrated in Figure 1.1. In the present time, every company is
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1. It increases customer satisfaction
services which enables the firm to charge high prices for the value differentiation that
it offers
3. It lowers cost- process improvement have a direct bearing on cost because defects are
not free, rather someone is paid to make them, resources are used and opportunity for
5. It enhances competitiveness
6. It enhances staff morale- poor quality is demoralizing for staff because they spend
time coping with complains and are frustrated when nothing seems to be done to
relieve them
government or pressure from activities groups. Studies have shown that while a
satisfied customer is likely to tell a few people about their experiences, a dissatisfied
customer will tell an average of nine others. It is also important to note that people
rarely complain directly to the company for poor quality but more often switch to a
to faulty designs or poor workmanships, for instance a surgeon may be held liable for
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negligence during a patient’s operation. liability for poor quality has been well
3. Reduced productivity- productivity and quality are closely related. Poor quality
Deming’s philosophy
Diming’s initial approach, largely rejected by the American industry was based on this
causes of variability in manufacturing process. According to him, there are two main causes
of quality problems. ’Common’ and ‘special’ causes. Special causes are those relating to
particular operators or machines and requiring attention to the individual causes while
common causes are those which arise from the operation of the system itself and are the
responsibilities of management.
Deming believed in the use of statistical process control (SPC) charts as the key methods for
identifying special and common causes and assisting in the diagnosis of the quality problems.
His aims were to identify quality problems relating to special causes and remove them
through training, improved machinery and equipment among others. SPC enabled the
remained were considered to be related to common causes i.e. they were inherent in design of
Deming believed in a systematic approach to problem solving and promoted the widely
known Deming, shewhart or PDCA cycle. Plan, Do, Check, Action as illustrated below:
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ACT
CHECK
PLAN
DO
The Plan- stage entails identifying and recognizing opportunities for improvement. Since
customer’s satisfaction is the focal point, the degree of difference between customers’ needs
and process performance is analyzed. Customers’ needs can be obtained through market
survey and customer research while process performance may be obtained from the feedback
information
The Do stage involves implementing the course of action that is intended to satisfy the
customer needs on a small scale while the CHECK stages will involve auditing the Do stage
The ACT stage entails making a decision regarding the implementation. If the result of the
check stage is positive, then the proposed plan is adopted. Customers and process feedback
will again be obtained after a full- scale implementation. However, if the check stage shows
no significant improvement alternative plans must be developed and the cycle continues
The PDCA cycle is a universal quality improvement methodology, the ideas being to
constantly improve and thereby reduces the differences between customer requirement and
PDCA cycle is about learning and ongoing improvement learning what works and what does
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Deming philosophy of total quality assurance can then be stated as follows;
“To ensure total quality the next person in a chain or process must be treated as a personal
One of Deming’s recruits and spokesmen a slogan about quality which later came to be
referred to as “the lotus quality ethic, it stated that “a stricter emphasis on quality leads to
higher standards”
Deming illustrated seven fundamental beliefs which he referred to as “seven deadly sins or
diseases” about bad management practices which he considered must be eliminated before
initiative as follows:
Top management must always aim at long term goals and formulate operational strategies to
achieve them. The management must walk their talk because constancy of purpose insures
and assures survival. A healthy organization provide a sense of security to its workers, hence
when employees see that the company has a long-term vision and sees daily demonstration of
this vison, they see stability. The mission vision and goals of the organization must be
propagated through all levels of the organization and interpreted and understood by all. The
management should create a culture where the emphasis is on the process and not the end
result.
b) A short-term orientation:
Deming was particularly worried by the emphasis of short-term goas and objectives. Such
short-term aims are meant to satisfy shareholders. Short-term goals such as increased profits,
increased quarterly production, increased sales may give birth to the culture of manipulation;
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for example, to reflect an increased profit training and education costs may be curtailed.
Although such an action may show an increased short-term profit, the long-term effects may
be devastating. Other actions that promote short-term goals include linking executive pay on
profit figures.
Performance appraisal and merit rating can be devastating for organization because it may
promote rivalry and internal competition hence reducing the spirit of cooperation and team
work that may have existed. Performance appraisal encourages counterproductive behavior
among workers since rivalry within weakens rivalry without. For an organization to be
competitive, a concerted effort must be made to ensure that everyone works as a team.
Effective team work is achieved when employees share a common goal of authorizing
organizational performance.
d) Job-hopping:
may not get to learn the real problems and requirements of an organization. Getting
acquainted with and accustomed to a quality culture requires a major paradigm shift and it
promotion from within, instituting job enrichment programs and practicing job relation.
Organizations should also demonstrate their concern for their advancement by investing in
management trainings and seminars geared towards responsibilities. Similarly, there is need
Deming argued that management by numbers such as monthly productivity, amount shipped,
sales made, profits, among others do not present an accurate picture of the state of
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organization because numbers are prone to manipulation. There are cases when management
cut down a research, training and education costs to report an increased profit. Deming argues
that “he who runs the company on visible figures alone will in time have neither the company
nor the figures.” The management should select statistical data, unbiased and as objective as
Deming criticized the practice of incurring excessive costs in medical programs arguing that
it paralyzes competitiveness.
He was also not supportive of the way American organizations incur excessively in legal
costs because it would also affect its competitiveness. He noted that the last two deadly
sins/diseases were common among the American organizations, but may be a foretaste of
Deming came up with four principal quality approaches, including the PDCA cycle. The
others are:
process is considered to be under control, which is stable when the random variation falls
within the determined upper and lower limits. At this point the process is seen to have
achieved a position where the special causes of failure have been eradicated. Events that fall
outside the normal variation limits are considered “special” and should prove traceable to
individual diagnosis and treatment. events falling without the two limits are considered to
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have common causes and hence a product of the organization and require treatment at the
system level. Accordingly, Deming estimates that 94% of quality problems belong to the
system and are the responsibility of management, while 6% are due to special causes and are
worker controllable.
According to Deming, a major proportion of the problems can be solved by management and
hence cannot “pass the buck”. He argued that 94% of the problems can be solved by
what must change fundamentally is the style of management and corporate culture inherent in
the organization. His argument revolved around the fact that without management,
commitment, the adoption and implementation of total quality system will not succeed. It is
the management that invests in the processes. It is management that creates corporate culture,
and it is also management that selects suppliers and develops long-term relationships.
Deming was convinced that management must be provided with a sense of direction as
This point stresses that there is need to create long-term plans that will steer the company in
obligation that management should accept as first priority and hence allocate resources for
planning. To create constancy of purpose, a “team” type of environment is required where all
work together towards a common goal. It calls for management to make a commitment to
achieve ever improving quality as a primary objective of the organization. Therefore, there
should be a consistent message about quality throughout the organization which should not
vary by department, time or customer. A clear statement is required from the management
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that merely meet the competition is not a long-term strategy; rather the company must focus
on customers’ satisfaction.
The new age of quality requires commitment to continuous improvement. We can no longer
live with commonly accepted levels of delay, mistakes and defective workmanship.
Declaring any level of defects to be acceptable promotes the belief that defects are
acceptable. The new philosophy of no defects must be adopted. Quality consciousness must
be everything to everyone and management must accept that the responsibility for developing
and achieving quality is theirs. They need to recognize that workers are not to blame for
quality deficiencies.
Design quality into their product at the development stage instead of inspecting quality into
the product. Inspection merely separates the acceptable from the unacceptable. It does not
address the root cause of the problem. The output from the process is inspected and a good
product is shipped, while defective one is reworked or scrapped. Such an approach can
actually keep what is shipped defect free but the method is not a good one because; it is
expensive in terms of inspection and rework and secondly, the part of the process causing the
defect is never fixed. A firm should therefore, move away from defect detection to defect
prevention, inspect the process rather than the product, insist that the same quality standard
acknowledging that processes cannot function correctly or that specifications made no sense
in the first place (Deming 1982). It focuses on the negative aspect without offering alternative
means of improving quality of the product. It is a waste of time and effort to simply check
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4. End the practice of awarding business on the basis of price
Many organizations, including government, award contracts to the lowest binders as long as
they satisfy certain specifications. This practice should cease and review be based on the
quality conformance, for instance what quality assurance do the bidders use? What methods
do they use to improve quality? What is the attitude of the management towards quality?
Answers to those questions along with price may be used to select vendor because low bids
do not necessarily guarantee quality. To remedy this situation, there is need to reduce the
number of suppliers and move towards a single supplier for any item, if necessary, the
supplier should be appropriately train in quality techniques and partnership. The uses of
single supplies invariably result in less variation otherwise caused when different supplies are
used and reduces inspection costs. Supplier selection should be based on quality assurance
According to Deming, organizations should move away from defect detection to defect
prevention and continue with process improvement to meet and exceed customer requirement
Employees are the organization’s most valuable assets. When employees are hired, they
should be properly oriented in the company’s goals in clear-cut terms. Employees must have
a clear understanding of what is to be done and its importance in the entire process. The
management must not only train on the way things are done but provide employees with the
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The responsibilities of supervisors must change from sheer numbers to quality. Because they
form the link between employees and top management, they need to understand both the
problem of the workers and top management’s goals. Communicating top management’s
effective leaders they must adopt a style of coaching and support. They must no longer think
positively, rather they must think in terms of helping workers to do a better job. They also
The fear of failure and being exposed inhibits our willingness to do the correct difficult thing.
dictated by the behavior patterns that will please management, rather than those that meet
organizational goals.
Remove any departmental barriers that impede quality improvement. Poor communication is
always the main cause of barriers. Similarly, a fear ridden atmosphere builds barriers as well
as lack of cross functional teams. Every individual from every department must work hand in
Avoid the use of slogans which demand zero defects, doing right the first time and new level
of excellence without providing the means and the method. Deming suggests that such
practices act more to vet the staff rather than to encourage them, and may at the extreme
generate frustration and resentment. Numerical goals set arbitrarily by management have
demoralizing effect. Management should provide a road map to help in accomplishing the set
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improvement. Rather than providing slogans they should describe clearly what they are doing
to implement this long-term goal to employees. The goal or standard setting should bottom-
up where employees are involved in setting the quality standards. Deming argues that most
causes of poor quality are systemic and are beyond the power of the work force.
numerical goals.
Work standards are normally established by someone other than those who perform the job
and such standards are based on quantity and without regard to quality. They encourage poor
workmanship in order to meet the quotas. According to Deming, settling such work standards
guarantees inefficiency and increases cost. Management therefore, should replace quotas with
There are several factors that impede worker pride. Such factors include management
inability to treat workers with dignity, lack of proper communication of the company’s goals
and objectives to all employees. Management may blame employees for failing to meet
company goals while in the real sense the fault lies with management; for instance,
inadequate provision of training, punitive supervision and inadequate or ineffective tools and
equipment provided to perform the tasks. Workers always want to do a good job and be
proud of it, but it may be difficult if no quality tools are provided, no adequate documentation
Deming observed that if you give the workforce a chance to work with pride, the 3% that
The performance appraisal system also robs workers of their pride in workmanship because
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should be replaced by proper leadership; communication and counselling whose main
Deming recommended that there is need to abolish the merit rating system because it affects
teamwork, fosters mediocrity and focuses on the short-term. He argued that merit rating is a
subjective method without a statistical basis which attempts to justify the fact that an
employee depends on the personal opinion of the manager. Similarly, merit rating may cause
internal competition and isolation which kills the team spirit and reduces initiative and risk
taking.
Because of the value attached to human resource in an organization, it is vital that its people
be motivated and adequately trained. The management must commit resources for education
and training in terms of time and money because well-educated and trained workers are likely
the people must continuously improve. He argues that future competitive advantage will be
achieved through knowledge, an observation that is hard to dispute. Secondly, education and
training enable the company to inform the employees on the goals and objectives of the
organization; thirdly, continuously training programs keeps workers up-to-date with new
machinery and other innovative technologies. Lastly, education and training discourage job-
hopping. By investing in the workers through seminars, workshops and technical training the
organization gains workers’ loyalty and normally loyal employees stay with the organization
longer. It should be noted that without adequate training there is no guarantee to innovation
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A full transformation must be put in place for forms to implement the 13 points. More
specifically, a structure has to be created and maintained for the dissemination of the
concepts outlined in the 14 points. The onus for creating this structure lies with top
management. The management must be visionary, knowledgeable and set long-term goals.
Without full management belief and support, progress in quality will not succeed even if it
has a full backing of the people below. Deming argues that quality is made in the boardroom;
however, limitations on quality also emanate from the same room. The management therefore
should put everyone to work to achieve the transformation. This will require a strong and a
unified culture within the organization with absolute commitment from top to bottom. Such
which is perhaps best interpreted as statements about what to do, rather than the more
i. Management must agree on the meaning of the quality program, its implication and
ii. Top management must accept and adopt the new philosophy.
iii. Top management must communicate the plan and the necessity for it to the people in
the organization.
iv. Every activity must be recognized as a step in a process and customers of that process
identified.
v. Each stage must adopt the “Deming” or Shewhart cycle – plan, do, check and act- as
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vi. Team working must be engendered and encouraged to improve inputs and outputs;
vii. An organization for quality must be constructed with the support of knowledgeable
statiacans.
Deming advocated key companchart that are necessary for the journey towards
According to Deming, effective leaders must have an appreciation of the systems that
work together to create their organization’s product and services. Management need
systems where the stakeholder’s needs may not be satisfied. Management which has
ana appreciation for a system aligns their customers’ needs, requirements and
expectation to the system that produces products and services, and their organizations
goal.
According to Deming all processes exhibit variation which may be caused by either
special causes or common causes. Special causes of variation are normally external to
the system and it is the responsibility of the technical people to eliminate, whereas
common causes are due to design and structure of a system and is their management’s
responsibility to eliminate.
control. Deming suggests that significant process improvement comes from obtaining
knowledge about process through charting, the study of variation and collection and
analysis of data.
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3. Exposure to the theory:
Knowledge provides a basis of making predictions and such predictions are based on
observed outcome is compared to the predicted value. Thus, experience and intuition
are not valuable to management unless they can be interpreted and explained in the
problem solving where data is collected and analyzed to ascertain results which help
4. Knowledge of psychology:
one another and with the environment. He argues that it helps us understand each
understanding people, their interaction and their motivation, management can make
informed decisions.
control activities not only ensure the quality of industrial products but also contributes
to the organizational overall business. Ishikawa defines quality as “not only the
quality of the product but also of after sales service, quality of management, the
company itself and the human beings.” According to Ishikawa everyone involved or
affected by the company and its operations should be involved in the quality program.
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His approach to participation emphasizes greater worker involvement and motivations
attitude.
the use of his tools for problem solving. He believed in simplicity and using the
language of the shop floor in order to have an empowering effect. Since training is
given to all levels of employees, a common quality language is spoken by all which in
turns aid and enhances communications. Therefore, three principal strands can be
initiatives.
as embracing all departments and functions. Secondly, the use of quality circles is
are composed of between four and twelve workers from the same area of activity
problems and recommend solutions. Ishikawa suggested that quality circles should
be an integral part of the quality effort and shot an isolated approach. Quality
circles have met with both success and failures which in Japan, many quality
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circles have collapsed, usually because of management’s lack of interest or
excessive interventions.
tools of quality control”. Such tools are sets of pictures of quality representing in
diagrammatic or chart form the quality status being reviewed. He suggested at all
staff should be trained in these seven tools of quality control. These quality
3. Stratification; this is a layer chart which place each set of data successively
on top of the previous one. It describes how the data is made up.
values of a quality.
7. Control charts; they are used in statistical process control which shows
He believed these seven tools should be known by everyone in the organization and used to
analyze problems and develop improvements because they form a powerful tool box as far as
quality control is concerned. Therefore, Ishikawa’s approach contains both quantitative and
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While overall Deming can be said to have been very successful in his achievements, there are
both success and failures. The principle strength in Deming’s approach in the systematic
logic in his thinking, particularly the idea of the internal customer- supplier relationships and
secondly his emphasis on management leadership and bias in statistical approaches are
amazing. However, Deming’s work lacked a well-defined methodology and his work is not
adequately grounded in human aspects. Some have even criticized his work as essentially
success. He is best known for the fishbone diagram and similarly, the success of the
ii. His emphasis on participation especially of people at all levels in the organization is
of enviable value.
iii. The choice of a mixture of methods and tools which are both quantitative and
iv. The quality control circles are relevant to all sectors of the economy, be they
i. Quality control circles depend on management support. It has been observed hat
quality control circles is often used as a device for allowing workers to feel they are
involved but with little real commitment for managers. This is according to old adage
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ii. The linear view of problems proposed by the fishbone diagram is in limited use. It
would be better to recognize that problems are often interacting and far more complex
iii. Participation is highly valued in Ishikawa’s work and the idea of training everybody
in the same tools and technologies is a sound method to encourage this; however, the
come by.
iv. There does not emerge from Ishikawa’s work a methodology which bonds together
and integrates all the different strands of his thinking. While man of the tools and
vi. Ishikawa’s work may be seen as undervaluing or underestimating the people in the
organization in a assuming that they can only cope with simple concept and methods.
In reality, majority of the people deal extremely well with a highly complex
environment.
CROSBY’S PHILOSOPHY
product that consistently reproduced its design specifications was of high quality.
Another powerful idea associated with Crosby is the idea that “quality is free”. This
idea is remised on the fact that savings from quality improvements programs pay for
themselves. He argues that the real cost of quality is the nonconformance which
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results in scrap, rework, test and inspection. His philosophy is encapsulated in his five
organizations manufacture what they can rather than what customers demand,
then there will be perennial quality problems since customers’ requirements are
never met. This fundamental belief was based on the fact that quality is a
are met.
poor management is the source of quality problems. Such problems do not create
the management process has inherent quality, then a quality product will be
produced. He also believed that the management has a fundamental role to play in
3. Absolute 3: It is always cheaper to do right first time- Crosby has made clear
that inspection is a cost and that quality needs to be designed into a product rather
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developing a quality process with no expectation of failure. He strongly opposed
the use of inspectors whose job is to catch the errors made by the workers. He
argued that we are conditioned to expect errors in the workplace and not other
does not expect mistakes; where errors are not expected or inevitable (Beckford,
2002). His believe agrees with the saying prevention of error is better than cure or
believes that the cost of quality is measurable; for instance, the cost of rework,
warranty costs, rejects, scrap, among others. Such costs comprise the cost of
concept as a way of making management believe that it does not have to accept
standard to aim for thorough sound processes, product design and continuous
the idea that there will always be some level of defectives because any level of
defect is too high, and that management must install programs that help the
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believe that it is alright to make errors through such common sayings as “to err is
serve to justify the lack of conformance to quality. Crosby suggested that top
management must make commitment to zero defects and have zero defects as a
training in quality, quality councils and even setting aside a zero defects day to
Crosby’s principal approach is his 14-step plan to help business implement a quality
For quality improvement to take place, commitment must start at the top. Management must
demand on the management to consistently behave in a manner oriented towards quality . the
emphasis on defect prevention ha to be communicated and a quality policy that states the
developed.
Crosby puts emphasis on the need to form multi-disciplinary teams which may comprise
representatives for each department or division. The team members act as spokesperson for
each group they represent. The team members are responsible for ensuring that suggestions
are brought too action. This means that managers and other staff must take a break out of
their comfort zones and relinquish some of the expert and position ponker that goes with a
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functional organization. An initiative from the quality department alone will not be successful
Measurements are necessary to determine the level of quality of a product or service, hence is
a precursor to evaluation. Measurement defines areas that need corrective action and where
amenable to measurement; hence way has to be designed to measure all aspects e.g design,
manufacturing, delivery, etc. the results of measurements are placed in visible charts for all to
see.
The cost of quality consists of such things as the cost of things going wrong; scrap, rework,
having to be things of an inspection and testing costs among others. It is important to be able
to identify the costs of quality and put a value on them as this will result in saving for the
company.
The result of the cost of nonconformance to quality should be shared with all employees and
management because getting everybody involved with quality enhances a quality attitude and
culture. This quality awareness program is normally undertaken through the training of
managers and supervisors, through communications such as books and videos and by
This is the point where the entire organization must “walk the talk”. If the numbers generated
through measurements are used to humiliate the staff, then the effort is unlikely to prove
helpful. The numbers must be used to provide guidance and support to the action taken and
the actions must in harmony with the words spoken. Open communication and active
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discussions of problems creates feasible solutions because such discussions may also expose
other problems not identified previously and hence determine a procedure to eliminate them.
The concept of zero defects must be communicated clearly to all the employees and everyone
must have an understanding that the achievement of zero defects goal is the company’s
group to develop ways to initiate and implement a zero defects program. This committee
gives credibility to the quality program and demonstrates a commitment of top management.
Management at all levels must be made aware of the steps needed to implement a quality
improvement program in order that they can explain it in turn to their subordinates. This
practice of “train the trainer” is a powerful instrument for culturally embedding the behavior
To ensure a uniform understanding of the concept of zero defects, a one-day event should be
buttons and balloons. The management has the sole responsibility of explaining the program
to employees and they should describe the day as signifying “new attitude”.
Employees and management should set specific and measurable goals with predetermined
time span for achievement. Goals are of course of no value unless they are related to
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appropriate time scale for their achievement. The goal setting process creates a favorable
The employees should be encouraged to report on obstacles that derail their quality efforts.
They should be asked to identify reasons that prevent them from meeting the zero defects
goal, but not to make suggestions on how to address them. It is task of cross functional teams
This process enables those facing problems to report them and more importantly, it places
necessary so that both groups can work together to achieve zero defects.
Crosby considers that those who contribute to the quality program should be rewarded
recognition rather than money and should identify those employees who have either met or
exceeded their goals or have excelled in other ways. Recognizing and rewarding the
contributors to the program is a device for reinforcing among the entire staff a particular kind
These are essentially forums comprised of quality professionals and team leaders allowing
them to communicate and determine action plans for quality improvement. The quality
council should meet on a regular basis to keep everyone up to date on quality progress. Such
meetings provide a fertile ground for new ideas on quality improvement. The establishment
of quality councils seen as institutionalizing the quality program and making it part of the
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This is a reminder that quality improvement never stops and that achievement of quality is an
ongoing process. Therefore, any quality program may overtime lose the impetus and drive
because perhaps the leadership will have achieved the objectives which they had set for
new energy into the organization by way of appointing new people and the establishment of
new objectives.
Similarly, people who are engaged in doing the work can recognize the root cause of
the problems. This argues with the saying that it is the shoe wearer who knows where
it pinches.
ii. His rejection of a tangible quality problem and the conception that all quality issues
reinforcing behavior and attitudes which ensure that they never will be.
iii. The clarity and simplicity of Crosby approach and in its 14-point implementation
program.
iv. Crosby’s 14-step program is very extensive. It is not simply a motivation effort, but
i. Crosby’s does not believe that workers should take prime responsibility for poor
quality. He argues that you have to get management straight first because quality
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initiatives come from the top. The problem however, may rest on how the massages
are translated by the managers in the middle level and how competent they are to
transmit them.
ii. Crosby considered only one goal of the organization and that its zero defects. He
however neglected to address workers perception of their own values needs. It must
be understood that the requirement for quality is being driven from the environment
iii. His misinterpretation of “zero defect” as meaning the avoidance of risk is another
weak link. There will always be an element of risk involved in change of behavior or
cultural environment where risk can be calculated and minimized and where learning
iv. Crosby’s assumption that people will work in an open and conciliatory manner may
many management writers concur that an element of politics and coercion is present
individual in an organization and that having a fully open and conciliatory atmosphere
Feigenbaum’s philosophy is found in his early idea of the “total” approach to quality which
quality process and that quality should be built into the product rather than failure being
inspected out. He defined quality as “best for the customer use and selling price” and quality
control as “an effective system for integrating quality development, quality maintenance and
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quality improvement effort of the various groups within an organization so as to enable
production and service at the most economical levels which allows full customer
satisfaction.”
His definition of quality emphasized “customer use” and “selling price”. While customer use
selling price was entirely a new idea. Feigenbaum perceives that for any given price, there are
every need to manage from systematic perspective while recognizing and dealing with
interaction across internal and external organizational boundaries as well as with supplies,
Feigenbaum recognizes that organizations do not only manufacture products, but also design
and develop them. This means that quality problems can be addressed right from the
on designing for quality and involving all the functional areas, including recognition of and
QUALITY APPROACH
Feigenbaum’s quality approach can be distilled into a four-step approach which is intended to
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He proposed participation as a means of harnessing the contribution of people and
“operating quality costs” which he categorized into four groups; internal failure costs,
external failure costs, appraisal costs and prevention costs. His thinking was that by
measuring quality at its critical stage, the total costs of running the organization will be
reduced.
The systematic concept of “total quality” i.e. running throughout the organization from its
inputs, transformation process and output has immense. Feigenbaum’s work has the
following strengths;
The focus on his work was on industrial activities and has little value for service-based
organizations.
There are more clear methods and instructions on what to do and how it should be done.
Although Feigenbaum accepts the value of a participative approach, the question that remains
A process is a means of converting inputs into the intended outputs. Waste is an outcome of
an event, process or item /resource which is, less than the total amount of input(s) invested.
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PROCESS MODEL SUMMARY
Definition
Process
Inputs internal Outputs
actions
Equipment/Facilities Training/Knowledge
PROCESS APPROACH
This is the management of all value adding activities within the organization.
1. Following strictly the process recipe for the various process-steps of leather
manufacture. For instance, soaking of dry hides need two soaking steps as follows;
Pre-soak
Main soak
200-300% water (with the addition of wetting agent and a biocide or antiseptic
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2. Ensuring that all the enablers for all the various process-steps are available (i.e. in
3. Ensuring that the various sections of the tannery are manned by qualified technical
personnel.
4. Ensuring that the suppliers of raw materials for leather processing supply materials of
5. Ensuring that there is minimum wastage in both material resources and time as well as
good environmental practice and occupational health safety measures during leather
processing.
QUALITY AUDIT
Quality audit is merely the actions of checking and verifying whether or not an organization
is operating in accordance with the requirements of their own documented quality system. i.e.
policies, procedures, etc. to ensure that such a system complies with a national/international
standard.
The cost of quality is the amount of money that has to be spent as a result of quality problems
within the organization. It aims at quantifying in financial terms all activities involved in the
prevention and rectification of defects. These are costs associated with the discovery of
failure, and the cost of preventing poor quality. The American Society of Quality Control
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iv. Preventions Costs
it wrong. They are considered as internal failure cost if the defective item is detected within
the organization before delivery to the final customer. Internal failures may occur due to
variety of reasons such as defective materials from vendors, faulty equipment’s and
machines, incorrect methods, carelessness, faulty materials handling procedures and incorrect
Downtime: this is the cost of idle personnel and facilities when production is halted to
Scrap: these are defective products which cannot be repaired, used or sold
Waste: the activities associated with doing unnecessary work or holding stocks as a
Cost of investigation: include the cost of all the activities required to establish the
Nobody wants to take responsibility for the high proportion of defectives; hence one
department or an employee may shift the blame to another which eventually affects
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Inventory safety stocks: cost of extra safety stocks held specifically to guard against
Excess capacity cost: cost of excess capacity that must be maintained to make up for
the capacity lost from making defective products. This include the cost of extra
facilities and equipment above those that would be needed if the production were
defects free
Defects generated overtime costs; additional cost of having employee work overtime
to meet delivery deadline for orders that were late because defective items have to be
reworked
These are cost incurred when the products fail to perform satisfactorily after being transferred
long period of time. Poor quality has a negative impact on the reputation and image
and impinges directly on the future prospect for sale. Re- establishing a lost goodwill
is a difficult task.
Warranty charges: failed products within the warranty time may have to be replaced
under guarantee
Liability cost: these are costs of defending law suits and compensating customers for
the injury death and business losses and even change of contracts
investigation of the rejected products, replacing shipping and handling or any price
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Complaint costs; these include all cost incurred with servicing customer complaints
such as cost of investigation and adjustments, cost of receiving and handling the
complaints
Before the fate of the quality profession can be determined, the functions, jobs and tasks it
includes must be established. In the past, the profession encompassed quality auditors, quality
control inspectors and quality engineers, who ensured that design documents contain
necessary and sufficient quality assurance and control criteria, that in-process or finished
products met specific and measurable criteria and that organizations established appropriate
procedural controls. These quality disciplines resulted from regulated mass production
The heavily regulated commercial nuclear industry of the 1970’s helped solidify quality
professional’s role in business and government and as overseas competition for manufactured
goods increased. American business began to adopt this quality disciplines in an attempt to
survive. More recently, however, manufacturing has changed. The world economy has
levelled the playing field in which the United States was once the dominant player. An
example of this is the switch from mass customization and from stable, long-term services to
constantly changing and niche services. Mass customization can be seen everywhere from
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coffee and blue jeans to automobiles and health insurance. Short production runs, customer
input, short product life cycles and innovations in computer controlled and robotized
Attempts to quantify the value added by traditional quality disciplines have produced
unflattering results. General belief is that traditional quality roles (inspection, process audit,
document review etc.) add costs that are seldom recovered. This is largely due to many
addition, responsibilities and ownership of the processes are assigned to the quality
departments. The quality professional has responded by shifting its emphasis from audit and
inspection to preventive methodologies. This shift is positive, but it won’t be sufficient if the
intent is merely to create another discipline such as total quality engineering or total quality
management department. It doesn’t dispel the notion that organisations need a central area
responsible for quality. This shift has caused an upheaval among quality professionals. Many
including inspectors, auditors and other quality department employees, still cling to the
US businesses will survive by using TQM, continuous improvement and business process re-
engineering as management tools and principles - not as job titles, departments or disciplines.
Those that rely on audit and inspection will die, as more forward-thinking business innovate,
reduce costs and gain market share. The unrelenting change facing businesses demands that
managers and employees work in teams to ensure that customer expectations are exceeded
and that product and services delight rather than merely satisfy.
Redefining quality
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Business need to change their understanding of quality: it is no longer a department, a
business. There is no acceptable level of quality-products and services either delight or they
are doomed. Workers must take back control of their processes to feel ownership and
responsibility for their contribution and their perception of the customer must shift from the
Business and organization need to make the transition from the oversight to ownership. To do
that they must understand the trade -offs required. For example, if quality control inspectors
are pulled from the line without any other changes being made, unsatisfactory product will
end up in customers’ hands.one way to begin the transition process is to look at what would
happen if traditional quality function disappeared. What would happen if the compliance
audit department vanished? People would be responsible for policing themselves and would
Are empowered knowledgeable workers capable of following written policies and directions
on their own? What about inspectors? Can line workers be trusted to do excellent to do
excellent work or must they be subject to persistent QC inspection and oversight? The answer
will most likely depend on the company’s culture and the worker’s attitudes. Responsible
leadership must rely on self-assessment rather than independent oversight. Business results
must be directly linked with process and will be the measure of effectiveness. Worker’s
perceptions of themselves must change from labor components to process owners. This will
require attitude changes on the part of workers, management and the organization. In other
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An organization’s attitude about quality must be evident in both its implicit and explicit
behavior and must be congruent with stated or written philosophy. More thought must go into
planning, developing values and principles and creating a mission statement that is lived by
shareholders, directors, employees and communities. When all stakeholders are considered in
the vision and operating and management systems are designed to realize that vision,
departments such as quality assurance not only become unnecessary, but detrimental.
Formal quality assurance and quality control departments perpetuate the idea that
conformance or compliance is the objective rather than customer delight. Instead, companied
must educate stakeholders on the vision and the philosophy of the company, each
stakeholder’s contribution and what to expect from living that philosophy. Everyone must
have a genuine desire to live the philosophy. This desire is created when policy and behavior
are congruent, when all participants know their rules and value and when all share visibly in
the organisation’s success. This doesn’t mean that those with the word ‘quality’ or
‘compliance’ in their job title should be fired. New roles must be found for these people and
those currently working in traditional quality roles must create their own future. There is
plenty of work to be done as businesses make the transition from mass production to mass
customization.
Traditional quality professionals can work to give responsibility back to the workers and they
can help in the education process necessary for this reassignment. But, when the initial
transition is complete, they must fill new roles. Those who cannot or will not change will no
longer be needed. Auditors and inspectors (most of whom have considerable knowledge of
the processes they audit or inspect) can become doers rather than watchers. Change has
affected, and will continue to affect, workers and businesses. The age of the specialist is
giving way to the age of the adaptive team. The cold science of industrial engineering is
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being blended with the art and pride of the craftsman. Loggers, autoworkers, textile workers,
miners and quality professionals will survive in better, more productive roles or they will go
Loyalty levels
satisfaction levels are not close to the 100% level, disloyalty is a given. Shopping around
pays. Today, you do not have to pay more for less; with little effort, you can get more for
less. So, where does this leave you as manager? How can you become more competitive?
What should you do to improve your service levels? Where do you begin?
As the accompanying diagram shows, business involves an exchange between two value
systems. The “value demand system” is the customer’s world. The “value delivery system” is
yours.
Partnerships Psychographics
Positioning etc.)
Processes Experience
Resources Competence
Options
Resources
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Context
The more closely you can connect them, the better for both you and your customers.
Customers are valuable because they provide the revenue you need to survive and grow. But
equally important, and often overlooked, is the fact that they also provide the information and
insights that let you rejuvenate your organization and its offerings. Without these, all the
money in the world is of limited worth. It will not be long before you loose touch with what
customers want and need, and cut off the flow of their funds.
to begin in the mind of the customer. You have to understand what drives him or her. This is
the starting point for any re-engineering effort, or for the shift to learn production. All too
often, companies start this improvement processes in the wrong place. Their transformations
are planned from an internal rather than an external perspective. Little wonder that so many
Customer knowledge
Two broad categories of customer knowledge are needed. Firstly, there are demographic
factors such as age, education, income, geographic location- and yes even race. In the case of
business buyers, demographics would include information about when and how they place
orders, order quantities and value, usage, and so on. Secondly. There are softer psychographic
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facts about their needs, wants, values, beliefs, and assumptions. Yes, even industrial buyers
are human.
But there is more you need to know. What is your customer’s experience with products like
yours, or with others, that might impact on his behavior? Is that experience positive or
negative? What has customers learnt that they might make them more discriminating? What
competencies do they have that will affect how they buy and use your product? Can they be
easily sold? What support might they require? And what options do they have- either directly
competitive products, or substitute sources of value? How easily can they avoid you? What
else could they buy that would satisfy them? Then, naturally, there is the question of
resources. Can customers afford your product? Can they use it? Do they have appropriate
systems, tools, skills? Thus armed, you can begin to design your company’s value delivery
Purpose. Why does your firm exist? What is your reason for being- your overall
Philosophies. What are your guiding principles? What do you believe about every
aspect of your business, including service level and policies, human sources
like?
People. What kind of people should you hire? How will you induct, develop, manage
Partnerships. Which stakeholders must you win to your side? What do you expect
from them? How can they help you? How should you communicate with them? What
is in it for them?
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Products. What products should you sell? Why do they matter to customers? How will
Positioning. What should your products promise to set them from others? Why are
Processes. Consider everything you do, and the way you do everything. The first
question to ask is not, “how can we improve this process?” but rather, “why do we do
As with the factors in the customer’s value demand system, all of these are underpinned by
your resources, finance, capabilities, and skills you can call upon. Do you have what you
need? Can you acquire o develop it? Can you compete in spite of deficiencies? How might
you compensate for what you lack? Customer service is a perception in your customer’s
mind. No matter how rationally you try to measure it, you ultimately are dealing with
feelings, impressions, opinions, and other-soft issues which change literally from moment to
moment. But to win against your competition- and to sustain your advantage – you need to
Difficult customers
There is no arguing that attitude is a vital element in superior service. Front line people
should be carefully selected for their people skills. After all, customers can be demanding,
rude, irrational, and even crooked. Some personality types are simply more suited to dealing
with them. Your customer team should also be thoroughly trained, and retrained as often as
needed. But no matter how well you select your sales and service staff, and no matter how
well you train them, you still have to support them in a way that lets them excel.
You have to see service as organizational design. You have to be willing to create a service
organization, not just try to shape a service culture. This is an important insight. Most efforts
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to improve service begin and end with stabs at changing culture. Managers talk about the
need to improve attitudes. There are many theories about how to do it. Any number of gurus
But the results are dismal. All evidence points to the simple fact that changing culture is
harder than anyone knows – and no one really knows how to pull it off.
Where most attempts go wrong is in trying to alter behavior by altering minds. In fact,
psychologies have long known that the way to change minds is to change behavior. This,
then, is where customer service must begin. Attention must focus on the organizational
Every company I know talks of empowering its people. Yet the fact is, almost all of them
systematically disempower their people. They expect breakthrough performance, yet prevent
it. They set high standards, yet get in the way of them. They spend like crazy on badges,
buttons, posters and parties, yet skimp where it counts – IT systems, product design and
Customers must obviously be the focal point of every company’s attention and efforts. Their
needs and wants determine what a firm must do, how, and when. To think that you can
improve service levels with a few superficial waves of a wand is ridiculous. To underestimate
As service levels continue to rise, companies will face growing pressure to change faster and
more radically. If the past is any guide, managers will flail about in search of silver bullets
that might save them. Management fads will stay attractive. And we will see many more
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Customers’ service is not something you tag on to the tail of a business. It is the reason
businesses exists. It should drive every aspect of competitive strategy and every corporation:
reengineering, quality, IT, training, rewards, or whatever. Set it out into the future with
customers in mind, and you have a good chance of designing an organization that will survive
and thrive in the tough years ahead. Start elsewhere – trying to satisfy your own needs first,
or relying on smiles to save you – and you will pay dearly. Your costs will rise, inefficiencies
will be assured, and your customers will defect. Get this simple fact right, and you win. Try
Reducing a company’s non-value creating costs-the cost of poor quality-is one of the best
many businesses from releasing the benefits. In the second of a two-part report on research
among some of Sweden’s largest companies, Lars Sorqvist describes some of the more
There is much talk these days about the cost of poor quality. As competition become stiffer,
more companies and organizations are trying to reduce their non -value creating costs as a
means of increasing their competitiveness. Public bodies are being forced to make cutbacks
and savings to balance national budgets. At the same time awareness is building on how high
Swedish company managers estimate that on average the cost of poor quality corresponds to
about a quarter of sales, according to a recent survey. The real cost of poor quality would be
probably be even higher if it were possible to calculate the value of the effects poor quality
often has on the market in the form of bad will and loss of customers.
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It is important for a company to know how high its poor-quality costs are in order to motivate
all parties to make systemic improvements. Drawing attention to the often-large costs reveals
the potential for improvement on which investment decisions on corporate and product
The introduction of a monetary unit into the quality measurements also helps to create a
simple means of comparing and prioritizing between different problems. The cost of poor
quality can also be used to monitor trends in quality over a period of time. Many companies
have tried to calculate the cost of poor quality, but have come up against serious problems. A
high proportion of the costs have proved difficult to measure and have thereby remained
hidden.
Attempts to measure these costs have been most successful on the production side which has
sometimes led to sub optimization with improvement work being concentrated (wrongly) on
production. The accuracy of the measurements is not always what it might be which has
resulted in misleading comparisons. Problems arise from difficulties in getting the personnel
Moreover, there is often much disagreement over which costs should be regarded as being
associated with poor quality. But over the past few years Sweden’s Royal Institute of
Technology, inn collaboration with some of the country’s top companies, has developed
The project, which began in 1993, moved from general studies to more detailed case studies.
As well as companies such as Scania, Ericson, Volvo, SAAB, Sandvik, SAS, Telia, Teli and
the Swedish Post Office, the study was supported and advised by several international
experts, among them Blanton Godfrey, Frank Gryna and William Golomski.
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Clarifying what is meant by the cost of poor quality requires a clear and comprehensive
definition. A suitable one is costs which would be eliminated if a company’s products and the
processes in its business were perfect. To apply this usually to a particular company, the
individual parameters which reflect the cost of poor quality have to be identified.
At a general level, these could include rework, scrap, complaints or lost sales. These should
then be broken down further until specific activities are reached. The cost of poor quality is
usually divided into internal and external failure costs and appraisal costs. Prevention costs
were once included, but these should rather be classed as an investment in quality and not as
There is little need to measure them, as the information available is never sufficient to make
an optimization analysis possible. The problems which cause poor quality costs may be
divided into sporadic and chronic problems. Sporadic problems are those which occur in an
acute situation and cause disturbances while chronic problems tend to be hidden and
accepted. In many cases, the chronic problems are very costly, but also require more detailed
Measurement
There are two general methods for measuring the cost of poor quality in an organization.
Either a measuring system is built up to enable employees to report the quality defects and
faults which occur or an assessment is performed in which a team analyses the business as a
Traditionally most companies have tried to introduce permanent measuring systems- often
without realizing that there are alternatives and without questioning their choice. Experience
shows that company-wide measuring systems are difficult to use successfully as they require
far reaching changes in attitudes and corporate culture. The time required can also vary
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widely since a measuring system may take several years to build whereas a study can usually
ASSESSMENT
An assessment to mark the quality status becomes simple and systematic if the analysis is
made sequentially along the process in the business. By starting the study with external
customers and moving back to external suppliers, valuable information can be obtained from
later stages in the process on problems in earlier stages. Such studies consist of four phases:
Preparation
The scope of the assessment and the breakdown level required are established. This decision
represents a balance between the accuracy of the study’s result and the time taken. The
project team which is to carry out the assessment is appointed. It should be cross-functional
in character so that the team is well informed about all aspects of the business. The financial
and quality functions can make a valuable contribution. The team is then given training to
Planning
The purpose of the assessment is stated in detail. A time table for the work is drawn up,
giving clear final and subsidiary targets. The necessary resources are allocated. The methods
for the work are established. An inventory is made up of what secondary data are available.
Performance
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The work can be carried out in accordance with two principles. According to the first,
‘deviation analysis,’ existing defects and faults are listed, their frequency is determined and
their cost are estimated. The second principle, ‘best- in- class analysis,’ involves determining
the best possible way of running the business and then comparing with the current situation to
establish the cost of poor quality. The latter method is usually more complicated to use, but
has a better chance of identifying problems of a chronic nature. Collecting data for the
deviation analysis begins with existing information from the accounting system, the
Information can also be obtained with relative ease by identifying individual and units which
are concerned wholly or partly with activities which gives rise to poor quality costs. Such
complicated situations a simple assessment of the cost of poor quality can be obtained by
estimating a unit’s quality costs from its failure rate. When the documented and readily
available data have been collected, the study continues with interviews of the personnel
concerned. Interviews can vary in scope, from a general one with management to detailed
They can take the form of individual interviews, group interviews or questionnaires. A good
way of beginning the interview is with an information and motivation phase in which the
necessary background is provided. This is followed by the data collection phase, where
questions are asked about existing problems, defects and faults, together with estimates of
their frequency. Another way of obtaining this information is to carry out a survey in the
form of a measurement of limited duration. This can be performed using a simple report form
on which employees can make daily notes of the faults and problems that occur.
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In a best-in-class analysis, the best practice can be established by making a theoretical
analysis of the process, carrying out practical studies and comparisons or through a
combination of both methods. A theoretical analysis can be made by surveying and studying
the process. A practical study can be carried out in the form of interviews, where employees
make assessments of how their work would be done under ideal conditions or in the form of
benchmarking in which different situations are compared and most suitable methods are
identified. Benchmarking can be carried out internally at various levels, from individual to
Processing
Analyzing the data obtained. Proposals for improvement projects are established. Reports are
drawn up for management and the units concerned. The assessment is evaluated and
MEASURING SYSTEMS
Measuring systems can be useful for monitoring the quality level over a period of time.
reflect the entire business. The task is complicated and a high level of maturity is required
among both management and personnel. Many have failed in the attempt. Measuring systems
should instead be focused on a few costs or a selected area with readily available information
used, the measured data will be accurate. The work of developing a measuring system can be
PHASE 1
PROOF OF NEED
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PHASE 2
DEVELOPMENT
PHASE 3
TRAINING
PHASE 4
IMPLEMENTATION
PHASE 5
MEASUREMENT
The company’s management must first decide on whether a measuring system should be
introduced. The reason for this is that it is essential for the functioning of the system that
management gives it priority and constantly asks for and uses the information it provides.
Developing this support may require training courses and seminars for company
management. It is also useful to present the results of earlier assessments of the costs of poor
quality.
Phase 2: Development’
This work is most appropriately done as a project. A cross-functional group is formed and the
scope of the measuring system established. It is important not to be over-ambitious as this can
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lead to difficulties. It is often a good idea to begin on a small scale and them expand.
Available sources of information (for instance, accounting and other measuring systems) are
studied. A model for a measuring system is then created. This could be an integrated
component of an already existing system or a separate system. the former is often preferable.
Detailed parameters for the cost of poor quality are established. Procedures for reporting are
developed. A comprehensive pilot test should then be carried out to adapt the system to the
specific conditions of the business. During the development stage, it is important that as
many employees as possible feel they are fully involved in the work.
Phase 3: Training
Before the system can be implemented, all users need to be given the appropriate training.
The objective of the training is to impart skills in the use of the measuring system and to
bring out a change of attitude among employees. This change of attitude has proved to be
Phase 4: Implementation
The measuring system is not implemented until the pilot test show positive results and the
skills and attitudes of the employees are judged to be adequate. If there are any doubts, then
implementation should be delayed and development and training should continue as a failure
always makes further attempts more difficult. When the measuring system has been
Phase 5: Measurement
Procedures should be established and responsibility decided for supervision and maintenance
of the measuring system, analysis of the data obtained, design and distribution of reports and
When the cost of poor quality is being measured the method used should be decided in the
light of the purpose of the study. If the primary purpose is to motivate long-term
improvement work and make the quality concept more tangible, it is important to use a
measuring method accepted in the organization so that the results will not be questioned.
Where the purpose is to identify problem areas and priorities among them, the measuring
method must be consistent so that the entire organization is analyzed in the same way and sub
optimization is avoided. If the purpose is to monitor the organization’s quality level, the
measuring method must first have a good capability. A suitable way of working on the cost of
poor quality is to begin with a simple survey mainly using accepted parameters for poor
quality costs, to make the quality concept more tangible and to create understanding at
management level.
This survey is then expanded to identify and prioritize suitable improvement objectives. The
improvement work is begun and then followed up using a simple measuring system which
methods can be developed for certain key quality costs such as rejects in production and
complaints.
An organization is a system- it functions as a whole through the interaction of its parts. The
overall results you get are determined by the structure of the system-how the parts relate. The
whole is more than the sum of its parts. A business is more than the sum of its different
functional departments. The relationship between them-how they work together-is what
produces results. To analyze a system into its component parts does not help to understand
how it works overall. Systems thinking cease beyond one-way relationships of cause and
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effect. In a system what is an effect of one change can be the cause of another or feedback to
modify what caused it in the first place. Systems thinking sees chains and circles of cause and
effect rather than straight lines. Systems thinking focuses on the relationship between the
Reinforcing feedback is when the effects of an action return to amplify the change
and lead to more change in the same direction. The principle of reinforcing feedback
is the more you do it, the more you get. Example: compound interest on a bank
Balancing feedback is when the effects of an action return to oppose the original
change and so dampen the effect. It leads to less of an action that is creating it.
Balancing feedback leads to stability. The principle of balancing feedback is the more
you do it, the less you need to it. Example: customer care.
Feedback is not always obviously connected to what caused it. There may be a substantial
time delay between the cause and the effect. Systems are sustained by the beliefs and values
of the people within them. Change in the beliefs and values will create change in the system.
ORGANIZATIONAL PUZZLES
Actions intended to increase understanding and trust often have the opposite effect. There is a
surprising gap between what is intended and the actual result. Nobody wants
misunderstanding and yet it frequently happens. Sometimes others do not seem to act
reasonably, even when it is in their best interest. What seems reasonable from one person’s
perspective looks different to others and different again from an organizational point of view.
People are blamed for poor decisions, yet from their point of view they did the best they
could in the system they were in. to avoid risk and blame people may then adopt a safety-first
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way of working. This leads to organizational inertia. Initiating and improvements can be
risky. (‘If it isn’t working, do it twice as hard, twice as careful and twice as fast’). Defensive
routines and unofficial channels proliferate. Sometimes the only way to effectively act is to
bypass the established and recommended way. How do procedures that are designed to be
Direct actions and decisions designed to solve a problem often have no effect or even seem to
make it worse in the long run. What worked last year probably may not work this year.
Results are not proportional to effect. Small changes can produce large results and it is hard
to know what those changes might be. It is easy to get bogged down in details of a complex
system and forget the larger picture. (‘When you are up to your knees in crocodiles, it is hard
to remember you went in to drain the swamp’). It is hard to connect cause and effect when
the effects may happen months or years afterwards. We have act now, but do not see the
One widely used way of analyzing and dealing with an issue or problem is to make a list of
key factors involved. The factors put in order of importance and have resources allocated to
them.
Each factor may be dealt with, the different elements may improve and progress, yet the
overall results may be disappointing. Also, when resources are moved, the problem may
return. This is sometimes called ‘laundry list’ thinking as it does not take the relationships
between the factors into account. Systems thinking looks at how the factors relate and so
Group exercise
Starting with the top factor, aim to increase a self-reinforcing loop. Ask: what would
lead to this factor growing and being self-sustaining? How does it link to other factors
Look at the loops and see if they can be connected into one diagram. Identify the
overlapping factors.
Explore any side effects of these loops that might work against the project.
Consider the possible negative side effects that could result from the loops you have
constructed.
Solutions that work in the short-term may not work in the long-term. Because of the complex
that are made to solve it. In the short-term the problem may disappear only to appear again in
a worse form later. This is because there is a delay while the feedback has an effect on the
In the example in Diagram 2, cost cutting improves profits in the short-term, but may also
lead to loss of staff, low morale, a decline in the quality of work and a downturn on profits
which leads to more cost cutting. This pattern solves yesterday’s difficulties by creating
tomorrow problem.
Types of learning
Diagram 3 represents simple learning and problem solving. We learn through feedback.
There is a gap between what we know and what we want to know. We take action to close
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that gap. The results are feedback, increased knowledge or skills. A problem is a difference
between where we are and where we want to be. When we engage in a problem, we try
The results are feedback we use to narrow the gap between where we are and where we want
to be. Solving the problem is closing the gap. In simple learning and problem solving, this
takes place within a boundary of assumptions and beliefs about what is possible and
necessary. These assumptions may limit us and blind us to certain types of feedback.
Diagram 4 illustrates what is known as double loop learning- it brings our beliefs and
assumptions about the issue into the feedback loop. Feedback from our actions leads us to
question our assumptions. Double loop learning is generative. The basic questions to ask for
Diagram 1
SKILLED PEOPLE
POLICY
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INCREASED REVENUE
Diagram 2
TIME DELAY
STAFF MORALE
Diagram 3
PROBLEM
A DIFFERENCE BETWEEN WHERE
YOU ARE AND WHERE YOU WANT TO BE
DECISION
FEEDBACK
THE RESULT OF YOUR ACTION
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ACTION
Diagram 4
PROBLEM
A DIFFERENCE BETWEEN WHERE YOU
ARE AND WHERE YOU WANT TO BE
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FEEDBACK DECISION
THE RESULT OF
YOUR ACTION
ACTION
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