1. South African Quality Institutes latest news

    July 17, 2015 by ahmed

    South African Quality Institute (SAQI) http://www.saqi.co.za is the national body that co-ordinates the Quality effort in South Africa. Their monthly newsletter is an excellent source of information to keep up with the latest quality issues in South Africa.


    • Deming, Zen and Mathematics Education, by Ansie Harding
    • Need a quick profit boost?, by Ed Hatton
    • The lean report: lean news, notes and know-how, by Javed Cheema
    • Economic crime in South Africa: fact or fiction, by Terrance M. Booyen
    • Quality in Schools, by Richard Hayward

    Click here to download this newsletter.








  2. Stop Selling: 5 Mindful Ways to Engage Others in Fixing A Process

    July 5, 2015 by ahmed

    Originally posted on GoLeanSixSigma by Elisabeth Swan

    How often have you worked on fixing what seemed like an obvious problem but found yourself frustrated with how much time you had to spend convincing others it was worth solving? Have you ever sponsored a Black Belt, a Green Belt or a Lean practitioner in solving a process issue only to see the effort languish for lack of buy-in? Even with seemingly simple ideas, this can be a huge waste of energy.

    What Is Process Improvement And Who’s Buying It?

    Process improvement necessarily involves others. You need them to provide you with data, change what they do and generally expend some effort. But other people don’t necessarily see the effort through your eyes. They may not understand the point of what you’re trying to do or they may not be sold on the way you’re going about it. They may just not like you, but that’s an issue for another day!

    When conducting process improvement work the all-important buzzword is “buy-in.” Everybody stresses the importance of getting buy-in from leadership, buy-in from stakeholders and buy-in from other departments. At some point while trying to “sell” my ideas to others, a wise person explained to me that “buy-in” isn’t the same as “ownership,” and that’s the problem.

    “Buy-in” isn’t the same as “ownership,” and that’s the problem.

    Asking for someone’s “buy-in” indicates that you have an idea that you didn’t involve them in or discuss with them, but you want them to embrace it anyway. And on the flipside, “ownership” is what people feel around an idea, improvement or decision because they’ve been part of the process of coming up with it on some level, at some point. The key when doing process improvement work is increasing others’ of ownership of an idea. How do you pave the way for others to become part of the process?

    What’s great about this is that the tools and techniques of continuous improvement provide an easy answer. They key is to use the tools with others. This way you get critical assistance with fixing process problems and the people you include get the satisfaction of ownership.

    Share the A3 or Project Charter

    The first thing people need to understand is why you’re doing what you’re doing. Back in early days of Six Sigma at GE the mantra was, “Satisfy customer needs profitably.” Most of our efforts are focused on doing just that whether we’ve made it clear or not. People generally don’t rally around, “Decrease the hours it takes to make a whirligig”, or “decrease the cost of a whatsit.” So when you declare that you’re decreasing or increasing something, it’s helpful to answer the question, “for the sake of what?”

    So when you declare that you’re decreasing or increasing something, it’s helpful to answer the question, “for the sake of what?”

    Include a description of how this is enabling the organization to have a positive impact on customers. Once people are clear on the purpose of the work they’re generally more engaged than they were with the goal of raising or lowering a given number.

    Conduct a Process Walk

    The next opportunity to engage others is the Process Walk, which also goes by the name Gemba Walk. This refers to the act of taking a small, core group of people to walk a process and interview process participants. At each step the process walkers learn the actions involved along with sources of pain. It’s group education. This accomplishes two things at once, Number one, it educates the process walkers on what exactly happens in the creation of the output. And two, it allows the process participants to speak their minds. It may have been a long time since anyone asked them for their opinions. By joining in this exchange both the interviewers and the interviewees are engaged in discovery. They are now part of the improvement effort as opposed to observers or victims.

    They are now part of the improvement effort as opposed to observers or victims.

    Build a Process Map

    This should always be a group activity. It’s a great follow-up to the Process Walk since you just spent time learning the process. Do this with sticky notes so you can edit as you go. Post it on a wall somewhere and invite others to come see it and add what they know. Ask them to use pink sticky notes to point out pain points. This advances the project and engages the process participants. Even if you already have a map due to ISO efforts or Standard Operating Procedures, you can involve others in verifying that the recorded process steps reflect reality. You’ve just on-boarded a new set of owners and completed essential process work!

    Stakeholder Analysis

    This is generally a team activity and it starts with brainstorming all the people who might be impacted by a particular process effort. It isn’t always obvious where the ripple effects of an effort might extend. Having a diverse group of minds thinking through all the touchpoints uncovers more potential owners. When reaching out to stakeholder groups and individuals consider how you plan to engage with them. Will you ask them for input? This is a great start point and a source of true connection. Don’t get in “transmit only” mode when dealing with stakeholders – invite them to participate on some level.

    Don’t get in “transmit only” mode when dealing with stakeholders – invite them to participate on some level.

    Fishbone Diagram

    This last example provides an opportunity to expand the network once again. This is one of those essential tools for project work. It points to where you might go to get data and to discover what potential root causes to examine. The key is to consider all potential sources of issues. Invite a crowd and make this a Fishbone Party. You want a good spread of brains in the room so you can think about the process from as many angles as possible. Process participants from all levels of a process get an opportunity to give you input and your project gets valuable information. Another task done, more forward momentum and a new group of owners. Everybody wins.

    This is such obvious synergy but many project leaders choose to go it alone. Stop wasting so much time selling and start asking others to join you. Reach out and lighten your load.

    Do you have a favorite tool that helps you engage others? Tell us about it! We’d love to hear what works for you.

  3. South African Quality Institutes latest news

    June 16, 2015 by ahmed

    South African Quality Institute (SAQI) http://www.saqi.co.za is the national body that co-ordinates the Quality effort in South Africa. Their monthly newsletter is an excellent source of information to keep up with the latest quality issues in South Africa.


    • Deming, Zen and Mathematics Education, by Ansie Harding
    • Quality checks for your business plan, by Ed Hatton
    • Happy birthday Magna Carta, by Paul Naysmith
    • Jacob Zuma asks Africa: Why are their citizens not in their countries and are in South Africa, by Joseph Mwamsa
    • Corruption: Strong Governments and Ethical Leaders bring Sustainability, by Terrance M. Booysen
    • Quality in Schools: Protecting the rainbow of our Rainbow Nation, by Richard Hayward

    Click here to download download this newsletter.








  4. The Top 5 Reasons Why You Need to Adopt ISO 9001:2015 Now

    May 28, 2015 by ahmed


    Originally posted on Cavendish Scott

    By way of introduction, it must be said that the recent vote on whether to accept the DIS version of the ISO 9001:2015 standard included a rejection from the United States. While they publish and justify their reasoning, this is not made widely available and more than likely includes much political positioning as it does technical concerns. It remains to be seen if the overall vote (the US does not have any more voting power than other countries) is approved or rejected. If there is rejection it will cause delay to the publication of the new standard by at least 6 months as the rejection reasons are quantified and a new draft attempts to account for them. We shall see in the coming weeks.
    However, irrespective of what happens next or even finally with the standard, the content in the current DIS give us some great direction which we should all adopt anyway.

    Leadership and Full Integration

    It was always intended that ISO should be adopted and integrated into an organization. It was never envisaged as something that would cause a manual to be written and have someone maintain it with the main emphasis being that it does not interfere too much with the operation of the company. Sadly many organizations ended up with this approach. Management perhaps did not believe in or understand the principles of a QMS or that ISO is only that – a model for a QMS.
    Without the integration you don’t get the deliberate success out of your ISO that a QMS intends. No/limited management commitment, no/limited fact based management, maybe financial metrics (maybe not) but not/limited quality related, leading indicators of success.

    Any major change in a standard would be an opportunity to change things with an established system but this new standard goes out of its way to press for true leadership, and full integration of the system into the workings of the organization. The pressure to assure certification may make management more committed and supportive of integration. A lowly and abused management representative now has some more teeth to implement a more effective system. Obviously you don’t get management commitment and supportive leadership just because a standard asks for it. However, it’s a start to open discussion and an opportunity to develop a more appreciative understanding. Once started, the need for certification should drive management to the right place with the appropriate coaxing. Integration of the system is a different manner. If the system is not currently being truly used in the organization then it is likely to need some resources to get there. These will need to be quantified in order to justify the resources to management but there are also cost reductions and tangible benefits which should support the case.
    To be really successful, you need to manage your organization deliberately. Full integration will bring that. You also need real leadership from top management. ISO now provides a supporting hand to get you there.

    Process Approach

    The process approach was always advocated by ISO. Officially it first showed up in the 2000 standard but even earlier standards explained they did not advocate any particular approach. Many organizations needed ISO for a customer or contract and somebody was told “go get us ISO”. They got the task because they weren’t particularly doing much and they weren’t doing much because they weren’t very good. Management didn’t understand what it was; they just knew they needed it so it was a simple task allocation. Our new ISO guy read the standard and decided the easiest way to get ISO was to basically address each section of the standard in a procedure. Further, the procedure would use basically the same language. That way, how could it be wrong? It was wrong because although it reflected the requirements of the standard very well, it did not reflect what was going on in the organization. Hence the new “system” was not integrated; most people did what it said they had to and went back to what they were doing to run their department. Management quickly saw no value in this, labelled it as unhelpful and basically ignored it. They didn’t challenge it because they didn’t know any better.

    ISO is about a QMS which is about being successful by design and not accident. A QMS is the activities (combined into processes) that start with a customer order and progress to delivery of product or service and ultimately the satisfaction of the customer. Any procedures should have defined the processes in the organization and not been based around a standard. Based around a standard, they need to be changed every time the standard changes. If they adopt the standard requirements numbering, they tend to adopt the structure and content of the standard. Obviously this helps to get ISO but it doesn’t help assure the running of the organization.
    The new standard pushes quite hard for a process based approach. The current requirements are not totally mandating or explicit but it pushes a lot further than it has in the past. This provides significant motivation to convince other personnel in your organization to change the system to make it more integrated and more process based (it is almost impossible to have an integrated system without a processed based approach). Not only that, it will be useful, meaningful, drive improvement and be easier to maintain.

    Annex SL

    Less of a direct reason for you to adopt the 2015 version of ISO 9001 but certainly a good idea, is the inclusion of what is known as Annex SL in the 2015 standard. What ISO decided is that management system standards, like ISO 9001 and ISO 14001, that apply to the operations of an organization, have a lot of common processes. They decided to define a common structure, terminology and content for all standards that relate to organizations’ operations. Whether you are trying to achieve environmental superiority, information security or superb quality, you need management commitment, competency, documentation and records to do it. Consequently for every common activity, process or overlapping element ISO wrote the requirements for those areas in Annex SL. All the management requirements, resources, planning, support processes, measurement and improvement are all independent of the varied operations goals of different standards. This leaves the ISO 9000 committees to focus on quality and not have to worry about how to control documents. In practice the committees are allowed to change the Annex SL language if they have a compelling case. But the changes tend to be small. The net effect for you, the user, is that your standard is less and less likely to change (after this time when it is adopted) for the 70-80% of the standard that Annex SL addresses. Greater consistency, simpler changes, more common understanding and if you have more than one standard to adopt, even easier to combine multiple standards.


    The new standard has abandoned preventive action. The wording in the old standard was not completely clear but it did ask organizations to proactively look for opportunities for preventive action. Unfortunately in most cases organizations just adopted a system that was the same as their corrective action system which is designed to be reactive. It’s easier to design a system for reaction because you are reacting to something that happened or exists. A proactive system requires stopping your very profitable activity to try to come up with something that doesn’t exist or hasn’t happened….yet. So most people didn’t. They simply waited for their ISO audit and then they filled in some preventive action forms with the actions that they took during the year, in a way that appeared proactive. Really what ISO 9001:2008 was asking for (and the 87, 94 and 2000 versions) was some risk assessment and management.
    The new standard makes it clear. You will do risk assessment and management. While this will be “new” for most ISO systems, risk is a tremendous tool. It is common in most best practices and business models and is designed to avoid and mitigate problems before they occur. It does require some effort and there is no guarantee that the problem will actually occur but management will be in a much better position to make decisions, allocate resources and, it will make them accountable. Small organizations will take a “smaller” approach to it. Simple short reviews, quick updates, limited documentation. Larger enterprises might have individuals permanently assigned. The foresight it will bring to organizations will be tangibly beneficial.

    …and Opportunity

    ISO 9001 has always required continual improvement and this standard is no different. However, in addition to having improvement built into the processes (by taking a PDCA cycle for your process based approach) this standard takes advantage of the fact that you are going to be looking for potential problems (in a structured manner) because of the need to address risk, and it “suggests” you use that process or occasion (or define a completely separate process) to look for opportunities for improving performance. While it could be a completely separate process, it is likely to be more successful to have a similar process structure, but perhaps different content, and focus on where things are not bad, probably won’t get worse, but might be better. For instance, if your risk process was a team meeting where each process activity is reviewed for potential failures, the opportunity process might be a meeting where each important metric is reviewed for how its performance might be enhanced. This is a tangible improvement focus that 2015 will bring to organizations.


    There are a lot of good things in the new version of ISO 9001:2015 and you don’t have to wait. It’s all too easy to moan about the difficult terminology or the weakening of the requirements. So don’t! Adopt all of the good things about the new standard now.

  5. The Problem With Satisfied Patients

    May 27, 2015 by ahmed

    Originally posted on the Aatlantic by Alexandra Robbins

    When healthcare is at its best, hospitals are four-star hotels, and nurses, personal butlers at the ready—at least, that’s how many hospitals seem to interpret a government mandate.

    When Department of Health and Human Services administrators decided to base 30 percent of hospitals’ Medicare reimbursement on patient satisfaction survey scores, they likely figured that transparency and accountability would improve healthcare. The Centers for Medicare and Medicaid Services (CMS) officials wrote, rather reasonably, “Delivery of high-quality, patient-centered care requires us to carefully consider the patient’s experience in the hospital inpatient setting.” They probably had no idea that their methods could end up indirectly harming patients.

    Beginning in October 2012, the Affordable Care Act implemented a policy withholding 1 percent of total Medicare reimbursements—approximately $850 million—from hospitals (that percentage will double in 2017). Each year, only hospitals with high patient-satisfaction scores and a measure of certain basic care standards will earn that money back, and the top performers will receive bonus money from the pool.

    Patient-satisfaction surveys have their place. But the potential cost of the subjective scores are leading hospitals to steer focus away from patient health, messing with the highest stakes possible: people’s lives.

    The vast majority of the thirty-two-question survey, known as HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) addresses nursing care. For example, in a section about nurses, the survey asks, “During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted it?”

    This question is misleading because it doesn’t specify whether the help was medically necessary. Patients have complained on the survey, which in previous incarnations included comments sections, about everything from “My roommate was dying all night and his breathing was very noisy” to “The hospital doesn’t have Splenda.” A nurse at the New Jersey hospital lacking Splenda said, “This somehow became the fault of the nurse and ended up being placed in her personnel file.” An Oregon critical-care nurse had to argue with a patient who believed he was being mistreated because he didn’t get enough pastrami on his sandwich (he had recently had quadruple-bypass surgery). “Many patients have unrealistic expectations for their care and their outcomes,” the nurse said.

    In fact, a national study revealed that patients who reported being most satisfied with their doctors actually had higher healthcare and prescription costs and were more likely to be hospitalized than patients who were not as satisfied. Worse, the most satisfied patients were significantly more likely to die in the next four years.

    Joshua Fenton, a University of California, Davis, professor who conducted the study, said these results could reflect that doctors who are reimbursed according to patient satisfaction scores may be less inclined to talk patients out of treatments they request or to raise concerns about smoking, substance abuse, or mental-health issues. By attempting to satisfy patients, healthcare providers unintentionally might not be looking out for their best interests. New York Times columnist Theresa Brown observed, “Focusing on what patients want—a certain test, a specific drug—may mean they get less of what they actually need. In other words, evaluating hospital care in terms of its ability to offer positive experiences could easily put pressure on the system to do things it can’t, at the expense of what it should.”

    As a Missouri clinical instructor told me, “Patients can be very satisfied and dead an hour later. Sometimes hearing bad news is not going to result in a satisfied patient, yet the patient could be a well-informed, prepared patient.”

    * * *

    How far will a hospital go to satisfy a patient? Recently, some have rushed to purchase extra amenities such as valet parking, live music, custom-order room-service meals, and flat-screen televisions. Some are offering VIP lounges to patients in their “loyalty programs.”

    And because almost every question on the survey involves nurses, some hospitals are forcing them to undergo unnecessary nonmedical training and spend extra time on superfluous steps. Perhaps hospitals’ most egregious way of skewing care to the survey is the widespread practice of scripting nurses’ patient interactions. Some administrators are ordering nurses to use particular phrases and to gush effusively to patients about both their hospital and their fellow nurses, and then evaluating them on how well they comply. An entire industry has sprouted, encouraging hospitals to waste precious dollars on expensive consultants claiming to provide scripts or other resources that boost satisfaction scores. Some institutions have even hired actors to rehearse the scripts with nurses.

    In Massachusetts, a medical/surgical nurse told The Boston Globe that the scripting made her feel like a “Stepford nurse,” and wondered whether patients would notice that their nurses used identical phrasing. She’s right to be concerned. Great nurses are warm, funny, personal, or genuine—and requiring memorized scripts places a needless obstacle in their path.

    The concept of “patient experience” has mischaracterized patients as customers and nurses as automatons. Some hospital job postings advertise that they are looking for nurses with “good customer-service skills” as their first qualification. University of Toledo Medical Center evaluates staff members on “customer satisfaction.”

    By treating patients like customers, as the nurse Amy Bozeman pointed out in a Scrubs magazine article, hospitals succumb to the ingrained cultural notion that the customer is always right. “Now we are told as nurses that our patients are customers, and that we need to provide excellent service so they will maintain loyalty to our hospitals,” Bozeman wrote. “The patient is NOT always right. They just don’t have the knowledge and training.” Some hospitals have hired “customer-service representatives,” but empowering these nonmedical employees to pander to patients’ whims can backfire. Comfort is not always the same thing as healthcare. As Bozeman suggested, when representatives give warm blankets to feverish patients or complimentary milkshakes to patients who are not supposed to eat, and nurses take them away, patients are not going to give high marks to the nurses.

    More disturbing, several health systems are now using patient satisfaction scores (likely from hospitals’ individual surveys) as a factor in calculating nurses’ and doctors’ pay or annual bonuses. These health systems are ignoring the possibility that health providers, like hospitals, could have fantastic patient satisfaction scores yet higher numbers of dead patients, or the opposite.

    * * *

    On the nursing blog Emergiblog, one nurse reported that at a hospital that switched its meal service to microwaved meals, food-service administrators openly attributed low patient scores to nurses’ failure to present and describe the food adequately. It is both noteworthy and unsurprising that the hospital’s response was to tell the nurses to “make the food sound better” rather than to actually make the food better.

    This applies to scripting, too: It does not improve healthcare, but makes it sound better. The University of Toledo Medical Center (UTMC) launched an entire program based on patient satisfaction, iCARE University, which mandated patient satisfaction course work and training for every university student and employee. “Service Excellence Officer” Ioan Duca told a publication sponsored by Press Ganey, a company that administers the surveys for hospitals, “I am really focused on creating a church-like environment here. We want a total cultural transformation. I want that Disney-like experience, the Ritz Carlton experience.”

    But hospitals, too, can offer poor care and still get high patient-satisfaction ratings, and an alarming number of them do. I examined Medicare’s provider data for thousands of hospitals—the data on every hospital in the country that the agency makes publicly available. I found the hospitals that perform worse than the national average in three or more categories measuring patient outcome. These are hospitals, in other words, where a higher number of patients than average will die, be unexpectedly readmitted to the hospital, or suffer serious complications. And yet two-thirds of those poorly performing hospitals scored higher than the national average on the key HCAHPS question; their patients reported that “YES, [they] would definitely recommend the hospital.”

    UTMC is a good example of how an emphasis on patient satisfaction does not make for better care. At the time of this writing, according to government data on hospitals’ rates of readmissions, complications, and deaths, UTMC appeared to be among the worst performers in the state, if not the country. UTMC has higher than average rates of serious blood clots after surgery, accidental cuts and tears from medical treatment, collapsed lungs due to medical treatment, complications for hip/knee replacement patients, and, more generally, “serious complications.” In addition, UTMC made headlines in 2013 when, during a transplant operation, hospital staff threw away a perfect-match kidney that a patient was donating to his sister.

    Many hospitals seem to be highly focused on pixie-dusted sleight of hand because they believe they can trick patients into thinking they got better care. The emphasis on these trappings can ultimately cost hospitals money and patients their health, because the smoke and mirrors serve to distract from the real problem, which CMS does not address: Patient surveys won’t drastically and directly improve healthcare.

    But research has shown that hiring more nurses, and treating them well, can accomplish just that. It turns out that nurses are the key to patient satisfaction after all—but not in the way that hospitals have interpreted.

    A Health Affairs study comparing patient-satisfaction scores with HCAHPS surveys of almost 100,000 nurses showed that a better nurse work environment was associated with higher scores on every patient-satisfaction survey question. And University of Pennsylvania professor Linda Aiken found that higher staffing of registered nurses has been linked to fewer patient deaths and improved quality of health. Failure-to-rescue rates drop. Patients are less likely to die or to get readmitted to the hospital. Their hospital stay is shorter and their likelihood of being the victim of a fatigue-related error is lower. When hospitals improve nurse working conditions, rather than tricking patients into believing they’re getting better care, the quality of care really does get better.

    Instead, hospitals are responding to the current surveys and weighting system by focusing on smiles over substance, hiring actors instead of nurses, and catering to patients’ wishes rather than their needs. Then again, perhaps it’s no wonder that companies are airbrushing healthcare with a “Disney-like experience,” a glossy veneer. One of the leading consulting companies now advising hospitals on “building a culture of healthcare excellence” is, oddly enough, the Walt Disney Company.