Culture of Quality and Change Management
Change management is essential to sustaining a culture of quality. Quality improvement (QI) is about designing system and process changes that lead to operational improvements, and an organizational culture of quality is one in which concepts of quality are ingrained in organizational values, goals, practices, and processes. In the context of quality, change could be something as discrete as a revised contracts approval process resulting from a QI project, or it could be something as transformational as a complete shift to an organizational strategy and culture that embraces quality. In both cases, structural and process changes are introduced and change management is key to facilitate employee transition to the new state.
The Process and Human Sides of Change
For successful organizational change, attention must be given to both the “process” and “human” sides of change. The “process” side involves the specific project management related activities required for moving from the current to desired state (e.g., develop plans, build the infrastructure, change processes or systems, redefine job roles). In the example of a revised contracts approval process, the “process” side of change may involve budgeting for new technology, a revised contracting process map, or redefined employee responsibilities. The “human” side of change involves strategies to help employees impacted by the change understand and adopt it as a part of their jobs (e.g., alleviate staff resistance, meet training needs, secure buy-in). In the contracting example, employees engaged in any aspect of contracting must understand the urgency for a revised process, have input into the new process, and be trained in the new process.
Both aspects of change should be integrated and occur simultaneously for successful change, however, the change leader(s) may need to think of the “process” and “human” changes distinctly when assessing and addressing roadblocks. For example, an organization may have full employee buy-in for a particular change initiative but adequate resources and planning efforts have not been put in place to support the change. Alternatively, appropriate structures and processes may be in place but employees remain resistant to the initiative.
The Roadmap to a Culture of Quality: A Change Management Tool
NACCHO’s Roadmap to a Culture of Quality (the Roadmap) is a tool for change management as it offers guidance on transformational change from the current organizational culture to one that fully embodies quality. Because the scope of a transformational change initiative is so large, the Roadmap integrates the “process” and “human” considerations and strategies necessary to build a culture of quality into each of the six foundational elements, and across the six phases, of a culture of quality. Table 1 below summarizes how the Roadmap addresses the “process” and “human” sides of change within each foundational element. Please note that Table 1 is not a comprehensive representation of the content offered in each of the Roadmap phases.
||“Human” Side of Change
||“Process” Side of Change
- Is there senior leadership and middle management buy-in to QI?
- Are leaders trained in change management and quality management?
- What is the organizational leadership style?
- How does leadership communicate about QI?
- Do leaders serve as good QI role models and mentors for employees?
- Do leaders continuously assess and address employee resistance to QI?
- Is there a process to hold employees accountable to QI?
- Are adequate resources dedicated to building a quality culture?
- Do leaders have a clear vision for the future culture of quality?
- Do leaders engage in data driven decision making?
- Have leaders adopted organizational policies and plans that support a culture of quality?
- What are sources of employee resistance against QI?
- Do employees have the necessary knowledge, skills, and abilities (KSAs) to engage in QI?
- Do employees understand why quality is important to public health and their job specific duties?
- Are employees incentivized and rewarded for QI activities?
- How do employees account for time dedicated to QI?
- Is QI incorporated into position descriptions?
- Is QI incorporated into the employee performance appraisal process?
- Do employees have the necessary autonomy or authority to make process improvements?
- Is there a process for employees to formally nominate and/or initiate QI projects?
- Do staff value the customer and understand the importance of ensuring customer satisfaction?
- Do staff have the KSAs to meet customer needs?
- Is there a process for assessing customer needs and satisfaction?
- Is customer satisfaction data collected and used for process improvements?
- Are customer needs appropriately considered during decision making?
|Teamwork & Collaboration
- Do employees feel comfortable collaborating within teams/programs and across departments/divisions?
- Are individual team member voices valued and respected within organizational teams?
- Are teams effective at conflict resolution?
- How often to employees convene for the purposes of problem solving and innovation?
- Are formal and informal mechanisms in place for employees to collaborate and share?
- Is the organization’s physical space conducive to collaboration?
- Is there a process to form and disband teams, as needed?
- How is team performance monitored?
- Are employees engaged in the development of a performance management system?
- Do employees understand how their work and performance measures link to the strategic plan?
- Do employees have the KSAs to monitor and track performance?
- How is organizational performance being measured?
- What is the organizational QI planning process?
- Are organizational plans aligned (e.g. CHIP, strategic plan, QI plan, operational plans)
- What technology is used for performance management?
|Continuous Process Improvement
- Do employees have the KSAs to implement QI projects?
- Do employees have a voice in the QI nomination/selection process?
- Are QI successes recognized and celebrated?
- Do employees continuously question how processes can be improved?
- How are QI projects selected?
- What QI methods are used in the organization?
- How are QI projects documented?
- How are improvements monitored and sustained?
Managing Change to Build a Culture of Quality
Several change management frameworks exist and specific components of each framework vary but most models describe the change process along three general phases: preparing for change, transitioning, and institutionalizing change. Each phase is described in more detail below.
Preparing for Change
Prior to any change initiative, it is important to understand the context (e.g. current culture, readiness, environment) in which the transition will occur. During this stage of the change process, leaders must define the vision for the future desired state, conduct assessments, and identify change leaders.
- Define the change – Developing a clear vision of the desired state at the onset will avoid confusion among employees and help to understand the scope and size of the initiative, and who will be impacted.
- Conduct assessments – Every organization has a culture, or beliefs and values that shape formal and informal policies and procedures. An understanding of this culture and the degree to which quality is already present will inform the progress toward a sustainable culture of quality. Learn how to conduct an assessment and determine which phase of a quality culture your organization falls.It is also useful to assess organizational and employee readiness by collecting data on employee satisfaction, available resources (e.g. technology, staff), history of change, perceived success rate, degree of resistance, internal strengths and weakness, and external threats and opportunities. Potential data collection methods include employee satisfaction or feedback surveys, environmental scanning process (e.g. SWOT analysis), focus groups or employee interviews, financial data, or other existing assessment tools. Also consider other change initiatives already occurring as introduction of an additional change initiative (e.g. relocating physical office space, restructuring organizational hierarchy) can be disruptive.
- Identify change leaders – Change processes require a range of leadership and support. For transformational change, it is very important to have a highly visible and fully committed executive leader. Executive leaders often delegate oversight of change processes to a change management team (e.g. QI governing body). These leaders can support change by staying visible throughout the transition, serving as roles models for staff, empowering others to act, and communicating updates to staff. However, the executive leaders must remain fully engaged, visible, and transparent throughout the process.
In this phase of the change process, the change leaders will develop the change management plans which should include key milestones, goals, and objectives; training plans; delegation of responsibilities; resource allocation; and communication strategies. When developing a culture of quality, the QI plan will be a key component of the change management planning efforts, as it includes specific objectives related to quality, including addressing training and communication needs.
It is also very important to assess and manage resistance on an ongoing basis. In the “transitioning” phase of change, many sources of employee resistance are the result of anxiety around either not having the skills to implement QI projects or a fear of blame placing or punishment over poor performance.
- Communication & Resistance Management – A strong communications plan is essential to successful uptake of quality. Employees must know that the change is happening, why it is happening, the intended outcomes, their role in implementing the change, and how the change will affect them. Leaders should develop a communication strategy early, employing multiple open communication channels, reducing misinformation, and disseminating targeted messaging segmented for particular audiences (e.g. frontline staff, middle managers, executive leaders, governing entity) based on levels of influence and involvement. Key messaging should be delivered based on the phase of the change process. For example, in the early stages it is crucial to create a sense of urgency and awareness for the change to generate buy-in among employees. Initial communications may focus on consequences of not changing and benefits of adopting the change. Refer to Table 2 below for communication and change management strategies to address common sources of employee resistance to QI at each stage of the process.
- Planning & Implementation – To facilitate the change process, the steering team should develop an implementation plan that includes the budget and step-by-step action plans and timelines. Special consideration should be given to communication, contingency planning, monitoring, dissemination, and institutionalization. An essential element of the process is attending to the needs of the staff. Consider the necessary knowledge, skills, and awareness of your staff. It is especially important to ensure staff receive the training and support they need to successfully adjust to the change.
- Training & Coaching – Provide employees the knowledge and skills necessary to adopt the change. Training and resources should be offered to employees based on their level of involvement with quality. For example, frontline employees may need to be trained in how to use certain QI methods and tools while those responsible for leading QI projects may need training in how to facilitate a QI project. Additionally, managers and supervisors are key in the uptake of QI and managing change as they have the most direct influence over their employees. In addition to training in QI concepts and methods, they need change management tools to actively gain and maintain buy-in from their direct supervisees.
Once the change management and/or QI plan(s) have been implemented, leaders should evaluate progress, understand where there are gaps in progress, and determine next steps for sustaining progress and corrective action. At this stage, the change should become a part of both the formal and informal culture (e.g. adopt official policies around quality, incorporate into performance appraisal process, hold ongoing events to celebrate successes).
Table 2 below summarizes how the Roadmap phases align with steps in a change management process, and offers strategies for combatting common forms of staff resistance against QI. Please note that Table 2 is not a comprehensive representation of the strategies offered in the Roadmap phases.
|Change Management Phase
||Employee Reactions to QI
||Change Management Steps
|Preparing for Change
- Phase 1: No Knowledge of QI
- Phase 2: No QI Activity
- QI is a passing phase
- QI is confused for quality control or quality assurance
- QI is not relevant to PH practice
- Assess current culture and readiness for change
- Establish urgency for change, i.e. consequences of not changing
- Highlight QI successes in the field
- Phase 3: Informal/Ad Hoc QI
- Phase 4: Formal QI in Some Areas
- No time to implement QI
- Fear that QI results in blame placing or could lead to job loss
- Anxiety due to limited QI knowledge/skills
- Frustration when results are not immediate
- Train employees
- Create messaging that emphasizes QI is about the process, not the people
- Mentor and coach employees
- Celebrate small successes
- Incentivize use of QI
- Phase 5: Formal Agency-Wide QI
- Phase 6: Culture of Quality
- Employees embrace QI
- QI is viewed as a way to do work better
- QI is the norm
- Adopt formal QI policy and protocols
- Incorporate quality in to official documents (e.g. strategic plan)
- Establish formal methods of quality control and accountability