Max Moullin's presentation from Open Forum Events' second annual Continuous Improvement conference

1. Continuous Improvement:
Change for the Better
Manchester Conference Centre, May 2015
Creating a quality culture
Max Moullin, Public Sector Scorecard Research Centre
www.publicsectorscorecard.co.uk

2. Quality - have we
lost the plot?
What definition of quality do most
organisations use in practice ?
Conforming to the specifications of
head office (or central government)
A.
Q.

3. So what is Quality in
the public sector ...
“Meeting the requirements and
expectations of service users
and other stakeholders while
keeping costs to a minimum”
Moullin, 2002

4. Insurance Claims Example
• Insurance company has an average call
waiting time of 12 minutes in its claims
department - up to 25 minutes at busy
times. Many complaints.
• The manager is considering four options:
A. employ 2 extra staff
B. reduce average call time by 25%
C. divert most enquiries to the internet or
D. share services with another company.
What would you recommend?

5. "Don't just do something,
stand there"
The White Rabbit
(Disney's Alice in
Wonderland movie, 1951)
… and do some
systems thinking

6. Systems Thinking: Insurance Claims
Reason
for
phone
call
%
How
to
address
Chasing
up
due
to
non-­‐
response
22
Process
claims
on
6me
Don't
understand
claim
form
16
Produce
clearer
form.
Help
on
web
site.
Disagree
with
decision
20
Give
clear
reasons
Mistake
in
processing
claim
12
BeFer
training
to
prevent
errors
Informing
company
about
details
of
claim
25
Adds
value.
But
check
that
all
stages
needed.
Other
5
Inves6gate
further
Two stages: analyse data. Take action!

7. In
addi'on
you
are
told
that
28%
of
calls
have
to
be
re-­‐
directed
as
they
come
through
to
the
wrong
person,
while
5%
of
calls
are
re-­‐directed
twice.
18:58

8. Developing a quality
culture - some pointers …

9. ©Max Moullin 9
Pointer 1: Focus on outcomes, not activity
"Effective commissioning must
focus on outcomes. Only then
will we achieve the high quality,
value for money public services
that people deserve"
Sir Stuart Etherington,
Chief Executive, UK National
Council for Voluntary Organisations

10. Pointer 2. Manage performance
across organisational boundaries
• For example, research on teenage pregnancy
showed that 71% of young women between
16 and 18 who were NEET* for > 6 months
were parents by 21
• Therefore if you run a team aimed at
addressing teenage pregnancy, working
together with local colleges and employers is
absolutely vital.
* Not in education,
employment or training

11. Moullin, 2006
©Max Moullin 11
Pointer 3: Integrate risk management
'identifying and addressing key risks
are essential for any high-performing
organisation and therefore any
evaluation of performance without
considering risk is incomplete'

12. 4. Take account of the cost of measurement
"Public sector organisations spend up to
20% of time on form-filling, auditing,
measuring and reporting performance
but only a fraction of this is ever used to
gain relevant and new insights or lead
to performance improvements."
Professor John Baillie
Chair of Audit Scotland

13. 5. Develop a performance
management culture focussed
on continuous improvement,
innovation, and learning - and
not a top-down blame culture …
©Max Moullin 13
Pointer 5: Focus on CI

14. "All performance
targets are flawed,
some are useful"
Max Moullin, "What's the Score",
Public Finance, 22 May 2009
with due acknowledgment to the quality
management guru Deming who said:
"all models are flawed, some are useful"

15. COMPLACENCY
TUNNEL
VISION
DATA MIS-
REPRESENTATION
MEASURE
FIXATION
GAMING
MYOPIA
Concentrating
on short-term
Emphasis on 5 A-C
GCSEs. Schools focus
on those on C-D margin
13 week target for
planning applications
'led to more rejections'
% of offences brought to
justice target led to more
efforts on easy to solve
crimes
Follow-up appts for
ophthalmology delayed to
meet targets for new ones
3.5 hour wait for
A&E is OK
Based on Brooks
(2007), Ch 3.
UNINTENDED
EFFECTS
Auditors found 12 NHS
Trusts had adjusted
waiting lists
‘inappropriately’
© Max Moullin,

16. Performance management culture
“Once we accept that all targets are
flawed, it is clear that the priority is to
develop a culture focussed on
continuous improvement, innovation
and learning - and not a top-down
blame culture”
... but targets can be useful too
Max Moullin, 2009, What’s the Score, Public Finance

17. Hospital waiting times in England–thousands
of people waiting a number of months
©Max Moullin 17
Source: Dept of Health
0
50
100
150
200
250
300
350
400
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
Thousands
>6 months
> 9 months

18. Pointers for creating a quality culture …
6. Use the Public Sector
Scorecard to help you ...

19. ©Max Moullin 19
The Public Sector Scorecard
OUTCOMES
PROCESSES
CAPABILITY
The Public Sector Scorecard is
an integrated performance
management framework for the
public and third sectors
“The Public Sector
Scorecard
is groundbreaking”
Bob Penna, former Director of
Research and Communications,
New York Senate

20. ©Max Moullin 20
The Public Sector Scorecard
What are the outcomes we
really want to achieve for our
service users and stakeholders?
How effective are our processes
in achieving these outcomes?
How can we improve them?
How can we best support our
people and processes to
achieve the outcomes required?
OUTCOMES
PROCESSES
CAPABILITY

21. ©Max Moullin 21
SERVICE USER/
STAKEHOLDER
FINANCIAL
OPERATIONAL
EXCELLENCE
INNOVATION
& LEARNING
STRATEGIC
key performance
outcomes
The Public Sector Scorecard
OUTCOMES
LEADERSHIP
PEOPLE,
PARTNERSHIPS
& RESOURCES
PROCESSES
CAPABILITY

22. Clarifying
outcomes
Identifying process
& capability outputs
Strategy
mapping
Integrating risk
management
Re-designing
processes
Addressing
capability
Developing
performance
measures
Learning from
performance
measures
How the Public Sector Scorecard works

23. ©Max Moullin 23
Strategy maps
• Kaplan and Norton (2001) say a strategy
map ‘describes how shareholder
value is created from intangible
assets’
• However with the PSS, it can be defined
more simply as showing the
relationships between capability,
process and outcome elements
• They are the vital link between strategy
and performance measurement

24. Health
&
Wellbeing
of
people
with
LTCs
Effec=ve
use
of
resources
Reduced
unnecessary
acute
bed
days
In
control
of
their
health
Reduced
isola=on
&
anxiety
Reduced
cost
of
unscheduled
care.
Sustainability
Effec=ve
personal
&
self-­‐care
Improved
mental
health
Reduced
A&E
admissions
for
non-­‐A&E
pa=ents
Integrated
LTC
&
mental
health
care
Reduced
admissions
to
care
homes
Consistent
good
quality
care
in
care
homes
Accessible
shared
records
Reduced
delays
Carers’
needs
met
Removal
of
non-­‐VA
ac=vi=es
Re-­‐design
flow
systems
Reduce
unwarranted
treatment
varia=on
Focus
on
resource
-­‐
intensive
pa=ents
BeNer
sharing
of
informa=on
Emphasis
on
preven=on
&
early
diagnosis
More
joined
up
working
in
H&SC.
Change
public
percep=on
re
hospital
care
Simpler
financial
flows
&
risk
sharing
Less
duplica=on
of
assessments
Integrated
H&SC
teams
More
independence
Reduced
hospital
admissions,
length
of
stay
&
outpa=ent
aNendances
OUTCOMESPROCESSESCAPABILITY

25. Feedback on the PSS
'The strategy map is really useful as it
simplifies a complex issue with a
complex response into an orderly
understandable approach'
Executive Director for Children, Young
People, and Families, Sheffield City Council
©Max Moullin 25

26. 'The SLC4L Strategy Map visually told
the story of SLC4L, what we were trying
to achieve and how.
It helped all those involved understand
the outcome and process measures the
programme was trying to achieve, and
therefore being evaluated against.'
Programme director
Sheffield Let’s Change4Life
©Max Moullin 26

27. How the PSS reduces the impact
of perverse incentives
• Measures user satisfaction
• Focus on outcomes, not activity
• Works across organisational boundaries
• Involves staff, users and other
stakeholders in developing measures
• Much more selective approach to targets,
not top down
• No blame culture – appraisal model
©Max Moullin 27

28. Key features of the PSS
• Focuses on outcomes and evidence-based
drivers of outcomes
• Provides a link between strategy, service
improvement and performance measurement
• Incorporates service re-design, organisational
culture and resource issues
• Ideal for use across organisational
boundaries
• Integrates risk management
• Culture of improvement, innovation &
learning, not a blame culture

29. Creating a quality culture:
Recommendations
1. Make sure you focus on the outcomes that
matter to users and other key stakeholders
2. What about your processes? Can they be more
effective in delivering these outcomes
3. How can your organisation improve its capability
to support its people and processes in meeting
the outcomes required
4. Develop your performance measures around
desired outcomes, processes and capability
5. Develop a culture of innovation and continuous
improvement and not a blame culture
6. Use the Public Sector Scorecard to help you

30. Recommendations (continued)
7. Performance measures and targets, where
appropriate, should be developed jointly with the
organisations that are being held to account.
8. If measures are not directly related to outcomes
or evidence-based drivers of those outcomes,
then they should be scrapped.
9. If performance is below a target, then
organisations or departments should be able to
offer an explanation of any exceptional
circumstances that have affected performance.
10. Public and third sector organisations need to
develop their own integrated service improvement
and performance measurement frameworks.

31. MAIN REFERENCES
1. Moullin, M and Copeland, R (2013) Implementing and
evaluating behaviour change programmes with the Public
Sector Scorecard. National Health Executive, Jul-Aug 2013,
pp.16-18
2. Moullin, M. and Copeland, R. (2012) Strategy Mapping for
Behaviour Change with the Public Sector Scorecard. British
Academy of Management Annual Conference Winner of
'best paper' prize.
3. Moullin, M. (2009) What's the score? Feature Article, Public
Finance, 21 May Chartered Institute of Public Finance and
Accountancy, London.
4. Moullin, M. (2009) Lean and Six Sigma – Can they really be
applied to the public sector? Public Sector Executive, May /
Jun 2009
5. Moullin, M. (2004) Eight essentials of performance
measurement International Journal of Health Care Quality
Assurance. 17:3. Winner of International Literati Prize

32. Contact details:
Max Moullin, BSc (Soc.Sc.), MSc, FORS, FCQI, CQP
Director, Public Sector Scorecard
Research Centre
Visiting Fellow, Sheffield Business School
e-mail: max@publicsectorscorecard.co.uk
Web site: www.publicsectorscorecard.co.uk