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Bernie Dana and Cheryl Maitland - National Association of State ...
Bernie Dana and Cheryl Maitland - National Association of State ...
Bernie Dana and Cheryl Maitland - National Association of State ...
Bernie Dana and Cheryl Maitland - National Association of State ...
Bernie Dana and Cheryl Maitland - National Association of State ...
Bernie Dana and Cheryl Maitland - National Association of State ...
Bernie Dana and Cheryl Maitland - National Association of State ...
Bernie Dana and Cheryl Maitland - National Association of State ...
Bernie Dana and Cheryl Maitland - National Association of State ...
Bernie Dana and Cheryl Maitland - National Association of State ...
Bernie Dana and Cheryl Maitland - National Association of State ...
Bernie Dana and Cheryl Maitland - National Association of State ...
Bernie Dana and Cheryl Maitland - National Association of State ...
Bernie Dana and Cheryl Maitland - National Association of State ...
Bernie Dana and Cheryl Maitland - National Association of State ...
Bernie Dana and Cheryl Maitland - National Association of State ...
Bernie Dana and Cheryl Maitland - National Association of State ...
Bernie Dana and Cheryl Maitland - National Association of State ...
Bernie Dana and Cheryl Maitland - National Association of State ...
Bernie Dana and Cheryl Maitland - National Association of State ...
Bernie Dana and Cheryl Maitland - National Association of State ...
Bernie Dana and Cheryl Maitland - National Association of State ...
Bernie Dana and Cheryl Maitland - National Association of State ...
Bernie Dana and Cheryl Maitland - National Association of State ...
Bernie Dana and Cheryl Maitland - National Association of State ...
Bernie Dana and Cheryl Maitland - National Association of State ...
Bernie Dana and Cheryl Maitland - National Association of State ...
Bernie Dana and Cheryl Maitland - National Association of State ...
Bernie Dana and Cheryl Maitland - National Association of State ...
Bernie Dana and Cheryl Maitland - National Association of State ...
Bernie Dana and Cheryl Maitland - National Association of State ...
Bernie Dana and Cheryl Maitland - National Association of State ...
Bernie Dana and Cheryl Maitland - National Association of State ...
Bernie Dana and Cheryl Maitland - National Association of State ...
Bernie Dana and Cheryl Maitland - National Association of State ...
Bernie Dana and Cheryl Maitland - National Association of State ...
Bernie Dana and Cheryl Maitland - National Association of State ...
Bernie Dana and Cheryl Maitland - National Association of State ...
Bernie Dana and Cheryl Maitland - National Association of State ...
Bernie Dana and Cheryl Maitland - National Association of State ...
Bernie Dana and Cheryl Maitland - National Association of State ...
Bernie Dana and Cheryl Maitland - National Association of State ...
Bernie Dana and Cheryl Maitland - National Association of State ...
Bernie Dana and Cheryl Maitland - National Association of State ...
Bernie Dana and Cheryl Maitland - National Association of State ...
Bernie Dana and Cheryl Maitland - National Association of State ...
Bernie Dana and Cheryl Maitland - National Association of State ...
Bernie Dana and Cheryl Maitland - National Association of State ...
Bernie Dana and Cheryl Maitland - National Association of State ...
Bernie Dana and Cheryl Maitland - National Association of State ...
Bernie Dana and Cheryl Maitland - National Association of State ...
Bernie Dana and Cheryl Maitland - National Association of State ...
Bernie Dana and Cheryl Maitland - National Association of State ...
Bernie Dana and Cheryl Maitland - National Association of State ...
Bernie Dana and Cheryl Maitland - National Association of State ...
Bernie Dana and Cheryl Maitland - National Association of State ...
Bernie Dana and Cheryl Maitland - National Association of State ...
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Bernie Dana and Cheryl Maitland - National Association of State ...

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  • It is a leader’s choice. Do you settle for being pretty good, or do you strive for performance excellence – the place that our customers really expect us to be. Have everyone stand, put hand on heart, and spin in circle one time When you fill out evaluation of this session remember that I: brought you to your feet. touched your heart and turned you around Please don’t be shy about coming up to front with any questions you may have.
  • 10
  • Poor process results can come from strategic problems (poor allocation of resources, inadequate supplies, etc.) Poor process results may contribute to achieving strategic goals Teams take 5 minutes to read and discuss briefly each example (1-2 and 1-3)
  • Why not Who - essential to removing blame from organization’s culture and creating environment where employees contribute to problem solving. Why X 5 - Ask in sequence, like pealing an onion. Keep asking why until you get to the root cause. Drives us past the temptation to react to symptoms or stop at the apparent cause. Use only facts from investigations as the basis for root cause analysis. Causes assigned by those involved or affected by the problem may be clouded by emotion or responsive to only one view.
  • Transcript

    • 1. Pathway to Performance Excellence NASVH 2009 Summer Conference – Asheville, NC <ul><li>Bernie Dana, LTC Management Consultant & Associate Professor of Business, Evangel University, Springfield, MO; [email_address] </li></ul><ul><li>Cheryl Maitland, Administrator, Oregon Veterans Home, The Dalles, OR; [email_address] </li></ul><ul><li>Melissa Temkin, American Health Care Association, Washington, DC; [email_address] </li></ul>
    • 2. About AHCA <ul><li>A non-profit federation of state affiliates that represent more than 10,000 non-profit and for-profit nursing and assisted living facilities that care for more than 1.5 million elderly and disabled individuals nationally, including veterans. </li></ul><ul><li>AHCA currently represents 25% of state veterans homes nationwide. </li></ul><ul><li>AHCA represents the largest number of not for profit nursing facilities nationwide: over 2,500 facilities. </li></ul><ul><li>2nd largest health care PAC at average $1 mil per year. </li></ul>
    • 3. AHCA Support: State Veterans Homes <ul><li>Legislative and Regulatory Advocacy </li></ul><ul><li>In-depth education: Annual convention and other events </li></ul><ul><li>National Quality Recognition </li></ul>
    • 4. Legislative and Regulatory Advocacy <ul><li>Over 80 full-time regulatory, legislative, research and other staff based in Washington, D.C. </li></ul><ul><li>5 full-time lobbyists </li></ul><ul><li>VA liaison works on issues that affect state veterans homes and civilian homes that serve VA beneficiaries </li></ul><ul><li>Not for Profit Council: NASVH is a member </li></ul><ul><li>Committee structure addresses the broad spectrum of LTC issues: quality, HIT, life safety, disaster preparedness, etc. </li></ul>
    • 5. Educational Opportunities <ul><li>Annual Convention: </li></ul><ul><ul><li>Over 70 sessions in 13 focus areas, including quality, care practice, workforce and leadership issues </li></ul></ul><ul><ul><li>Keynotes: Cal Ripken, Jr. and Dr. Bob Arnot </li></ul></ul><ul><ul><li>October 4-7, McCormick place in Chicago </li></ul></ul><ul><li>Annual Quality Symposium: February 9-10, 2010 at the Marriott Baltimore Waterfront </li></ul><ul><li>Congressional Briefing: June 8-9, 2010 </li></ul>
    • 6. Pathway to Performance Excellence <ul><li>Bernie Dana </li></ul><ul><li>Cheryl Maitland </li></ul>
    • 7. Program Objectives Understand the Need and Opportunity Philosophical Principles Quality Tools Quality Models Pathways to Performance Excellence
    • 8. The Need and the Opportunity <ul><li>Rising costs cannot be fully offset by increasing revenue </li></ul><ul><li>Regulatory compliance does not increase customer satisfaction </li></ul><ul><li>Inconsistent performance causes employee dissatisfaction </li></ul><ul><li>Traditional management systems are reactive rather than proactive and visionary </li></ul><ul><li>Person-centered culture change will not be sustained without systems change </li></ul>
    • 9. There is a Better Way! <ul><li>Act on a vision for what can be </li></ul><ul><li>In all situations, lead by example </li></ul><ul><li>Let customer expectations define the quality standard </li></ul><ul><li>Engage and empower employees </li></ul><ul><li>Develop a quality management system to sustain a focus on performance </li></ul><ul><li>Develop a structure to fulfill the quality journey </li></ul><ul><li>Commit to continuous learning and growth </li></ul>Source: “Mapping the Road to Quality Results,” Olson, Dana, and Ojibway, Provider , Apr 2005
    • 10. Leadership and Culture Change <ul><li>Create a vision for performance excellence </li></ul><ul><li>Change to systems thinking: </li></ul><ul><ul><li>It’s the system – how organizations approach getting things done </li></ul></ul><ul><ul><li>Does caring and compassion trump system thinking? </li></ul></ul><ul><ul><li>Systems create behaviors </li></ul></ul><ul><ul><ul><li>“ My people won’t do what your people do” </li></ul></ul></ul><ul><ul><ul><li>85% of “people” problems are systems problems </li></ul></ul></ul>
    • 11. Sharing the Right Vision <ul><li>Grasp your current reality </li></ul><ul><li>Commit to innovation </li></ul><ul><li>Vision sharing takes time and new system </li></ul><ul><ul><li>New language </li></ul></ul><ul><ul><li>New tools </li></ul></ul><ul><ul><li>Engage all in CQI </li></ul></ul><ul><li>LTC research found common theme – they chose to act on a vision for what can be. </li></ul><ul><li>Paradigm shift needed – compliance vs. customer </li></ul>
    • 12. How Vision Developed <ul><li>New leadership – young or from other professions </li></ul><ul><li>Education programs </li></ul><ul><li>Pioneer Network, Eden Alternative, etc. </li></ul><ul><li>Quality award program and similar models </li></ul><ul><li>Never from regulatory change or survey enforcement </li></ul>
    • 13. “ Get a Vision” Exercise <ul><li>3 minutes total </li></ul><ul><li>Work individually or as a group from the same facility </li></ul><ul><li>Develop a headline that you would like to see about your “community” in 5-7 years </li></ul><ul><li>Headline should reflect a measurable result (i.e. Veterans Home staff satisfaction at 96% -- highest in nation) </li></ul><ul><li>Write on handout </li></ul>
    • 14. The Philosophical Principles of Quality Management <ul><li>Quality is meeting or exceeding customer expectations. </li></ul><ul><li>Quality is everyone’s job. </li></ul><ul><li>Quality is systems and statistical thinking. </li></ul><ul><li>Quality is continuous learning and improvement. </li></ul><ul><li>Quality requires effective leadership. </li></ul>CULTURE
    • 15. Definition of LTC Quality Is... <ul><li>“ The totality of service features and characteristics that meet or exceed customer needs and expectations .” 1 </li></ul><ul><li>Requires the provider to: </li></ul><ul><ul><li>Comprehend individual and collective expectations </li></ul></ul><ul><ul><li>Provide services and facilities that meet expectations </li></ul></ul><ul><ul><li>Achieve a high level of performance and reliability in systems and processes used to deliver services </li></ul></ul>1 Source: “Defining Quality in Long Term Care,” Dana, Provider , Aug 2004
    • 16. An Essential Measure of Quality Is… <ul><li>Customer Satisfaction </li></ul><ul><li>Customers may not always know what is best for them; but they have right to be fully informed, respected, and in control of decisions regarding their service. </li></ul>
    • 17. Customer <ul><li>External Customer: Ultimate user of the service </li></ul><ul><li>Internal Customer: Anyone we hand off work to within the organization </li></ul>
    • 18. Customer’s View of Quality (Kano) <ul><li>What comes first? </li></ul><ul><li>Shift in expectations </li></ul>HIGH SATISFACTION - DELIGHTED QUALITY PERFORMANCE PRESENT Expected Quality (must-haves) : Routine expectations; Not meeting it creates dissatisfaction One Dimensional Quality: Depends on exact conformance to need or want; Can be moment by moment <ul><li>Exciting Quality : </li></ul><ul><ul><li>Unexpected feature or service </li></ul></ul>LOW SATISFACTION - DISGUSTED QUALITY PERFORMANCE ABSENT
    • 19. Customer: Realization & Challenges <ul><li>We care a lot, but then assume we know what is best </li></ul><ul><li>Learn to differentiate key customer groups </li></ul><ul><li>Empower staff to respond </li></ul><ul><li>Recognize every encounter as a quality moment for the customer </li></ul>
    • 20. Remove “Blame” from the System <ul><li>Get the right people on the bus </li></ul><ul><li>Believe that everyone wants to do a good job and have fulfillment from their work </li></ul><ul><li>Write personnel policies to encourage your best rather than to control your worst </li></ul><ul><li>Confront poor performance when it happens rather than at the annual evaluation </li></ul><ul><li>Build trust by response, fairness, & transparency </li></ul><ul><li>Learn to ask “why” instead of “who” when something goes wrong </li></ul><ul><li>Train staff how to continuously improve their work </li></ul>
    • 21. Empowerment <ul><li>Parameters and Empowerment </li></ul>Parameters set by vision, goals and resources to maintain the focus on improvement and alignment with organizational purpose <ul><li>Employees are EMPOWERED when they: </li></ul><ul><ul><li>Know what is expected of them </li></ul></ul><ul><ul><li>Have the skills and resources to meet expectations </li></ul></ul><ul><ul><li>Receive continuous feedback to know how they are doing </li></ul></ul><ul><ul><li>Can adjust work processes to achieve desired result </li></ul></ul>Empowerment
    • 22. “ Most Important” Exercise <ul><li>2 minutes total </li></ul><ul><li>Meet with someone next to you </li></ul><ul><li>Identify the three most important individuals or groups of employees </li></ul>
    • 23. The Managers <ul><li>Gallup research: People leave managers, not organization </li></ul><ul><li>Managers not effective – employees not effective </li></ul><ul><li>LTC managers selected from ranks for work skills, loyalty, and compliance </li></ul>
    • 24. Managers Need Development <ul><li>Basic management skills </li></ul><ul><li>Communication styles </li></ul><ul><li>Conflict resolution </li></ul><ul><li>Performance evaluation </li></ul><ul><li>Coaching </li></ul><ul><li>Team meeting skills, idea generating tools, consensus building tools, process management, improvement tools </li></ul>
    • 25. Systems View of Quality Design Quality Performance Quality Judged by customer Satisfying features Minimize work errors Improve price and market share Reduce waste, rework, & failures Superior customer value Higher revenues Lower cost
    • 26. Cost of Quality <ul><li>Prevention Cost - Activities designed to prevent poor quality </li></ul><ul><li>Appraisal/Inspection Cost - Assessing conformance to a standard </li></ul><ul><li>Failure Cost - Correcting non-conformance to a customer’s requirement </li></ul><ul><li>Cost increases as problem gets closer to customer </li></ul>$ $$ $$$
    • 27. Does Inspection Work? Do both of the lines have an equal amount of bend in them? <ul><li>Dependent on the inspectors and their paradigms </li></ul><ul><li>Managers add inspection steps when something goes wrong </li></ul>
    • 28. Classifying Work <ul><li>Value-Added Work - External customer sees benefit </li></ul><ul><li>Required Work - Needed to keep organization operating </li></ul><ul><li>Rework - Something was not done properly the first time </li></ul><ul><li>Wasted Work - Not required and no value </li></ul><ul><li>No Work - Authorized leave/waiting time </li></ul>20% 15% 30% 10% 25%
    • 29. Do We See the Opportunity? <ul><li>Waste and Rework Cost </li></ul><ul><li>Number of full-time equivalent employees 100 </li></ul><ul><li>Average annual hours worked by each employee 1,950 </li></ul><ul><li>Total hours worked annually </li></ul><ul><li>Estimated rate of waste and rework (20%) .2 </li></ul><ul><li>Total waste and rework hours </li></ul><ul><li>Average hourly pay rate (including benefits) $12.00 </li></ul><ul><li>Total cost of waste and rework </li></ul>195,000 39,000 $468,000
    • 30. Process and System <ul><li>Process - Interrelated work activities producing a specific outcome </li></ul><ul><li>System - A combination of related processes </li></ul><ul><li>Process characteristics: </li></ul><ul><ul><li>Can be divided into a series of tasks </li></ul></ul><ul><ul><li>Tasks can be put into order </li></ul></ul><ul><ul><li>Performance can be measured </li></ul></ul><ul><li>Need standardized process </li></ul>
    • 31. Variation <ul><li>Two Basic Kinds of Variation: </li></ul><ul><li>Common Cause Variation: </li></ul><ul><ul><li>predictable and inherent in all processes </li></ul></ul><ul><li>Special Cause Variation : </li></ul><ul><ul><li>not predictable; </li></ul></ul><ul><ul><li>often unsatisfactory; </li></ul></ul><ul><ul><li>assignable to a cause – should be investigated </li></ul></ul>
    • 32. Example of Process Variation <ul><li>Sample food temperatures of meal entrees over a 10 day period from two facilities </li></ul><ul><li>Average is the same…are both processes performing the same? </li></ul>
    • 33. Organize for Quality <ul><li>Performance accountability continues with day-to-day leadership structure </li></ul>
    • 34. Process Management Cycle Establish Process Control Process Improve Process Hold the Gains
    • 35. Selecting a Process to Improve Team?
    • 36. Keep Score that Matters <ul><li>Performance is everything </li></ul><ul><ul><li>Efforts will earn you sympathy </li></ul></ul><ul><ul><li>Compassion doesn’t cover up poor results </li></ul></ul><ul><ul><li>If not getting results, change something </li></ul></ul><ul><li>Know key success factors, then </li></ul><ul><li>Learning to measure quality is not easy </li></ul>BHAGs  Strategies  Action Plans  Feedback
    • 37. Principles of Measurement <ul><li>Measure the process, not the person </li></ul><ul><li>Measure to improve, not to blame </li></ul><ul><li>Keep simple, understandable, believable, accurate, and useful </li></ul><ul><li>Measure performance against a customer-focused standard </li></ul><ul><li>Measure the key process indicators </li></ul><ul><li>Make comparisons meaningful (best, not average) </li></ul>
    • 38. Is Alarm Disconnected? “ We have disconnected the alarm on chronic quality failures because the failures are so familiar and expected that we no longer are surprised or even offended by them.” Dr. Joseph Juran
    • 39. The Tools of Quality Management 1. Root cause analysis <ul><li>CQI Methodology </li></ul><ul><li>Data analysis tools </li></ul>
    • 40. Nature of Problems <ul><li>Problem: Any situation/issue that separates you from your mission, vision, and goals </li></ul><ul><li>Two primary categories: </li></ul><ul><ul><li>Strategic problems - organizational performance gaps </li></ul></ul><ul><ul><li>Process problems - work process failures </li></ul></ul><ul><li>Responsibility for problems: </li></ul><ul><ul><li>Management responsible for all strategic problems and all process problems if: </li></ul></ul><ul><ul><ul><li>process handed down or “tweaked” by management </li></ul></ul></ul><ul><ul><ul><li>employees are not empowered to correct </li></ul></ul></ul>
    • 41. Key Root Cause Concepts <ul><li>Ask “why” rather than “who” </li></ul><ul><li>Ask “why” at least five times </li></ul><ul><li>Investigate the facts </li></ul>
    • 42. Find the Root Cause <ul><li>Problem 1: Resident and daughter upset that expensive slip purchased for mother had returned from laundry in frayed condition. </li></ul><ul><li>Symptoms: - Clothing damaged </li></ul><ul><li>- Laundry chemical costs increased </li></ul><ul><li>Why: Expensive booster chemical being added to every load </li></ul><ul><li>Why: Laundry staff feel it is need to prevent rewash </li></ul><ul><li>Why: Laundry supervisor directed </li></ul><ul><li>Why: Vendor had not provided training. </li></ul><ul><li>Why: Administrator did not include laundry supervisor in </li></ul><ul><li>decisions and got too busy to schedule training </li></ul><ul><li>Solution: Provide training, develop measurements, empower </li></ul>
    • 43. Develop a CQI Methodology <ul><li>Helps create objectivity </li></ul><ul><li>Can be adjusted to fit your QMS </li></ul><ul><li>Provides a roadmap to solving problems </li></ul><ul><li>Requires discipline to follow steps </li></ul><ul><li>Everyone needs to be trained to use it </li></ul>
    • 44. Sample CQI Methodology <ul><li>Identify the process and the customers’ requirements </li></ul><ul><li>Collect and analyze process data </li></ul><ul><li>Describe the current process (flowchart) </li></ul><ul><li>Select opportunities to improve and determine root causes </li></ul><ul><li>Develop and implement potential solutions </li></ul><ul><li>Hold the gains </li></ul>
    • 45. PDSA Cycle of Improvement PLAN ACT DO STUDY 1. What are you trying to change? What idea are you testing? What will you measure? Plan your change. 2. Pilot your test. What were the results? Document the results. 3. What happened? Summarize what you learned. 4. Revise plan/retest. Spread/expand test. Implement change on a larger scale
    • 46. Display and Analysis <ul><li>Learn to use the right tools to measure, analyze information and data </li></ul>
    • 47. Models of Quality Management <ul><li>Baldrige National Quality Award Program </li></ul><ul><li>State Quality Awards </li></ul><ul><li>Six Sigma, Lean Enterprise, Etc. </li></ul><ul><li>AHCA/NCAL National Quality Award Program </li></ul>
    • 48. Organizational Profile: Environment, Relationships, and Challenges (6) Process Management (7) Results (5) Workforce Focus (3) Customer Focus (1) Leadership (2) Strategic Planning (4) Measurement, Analysis, and Knowledge Management
    • 49. Steps Toward Mature Processes <ul><li>Characterized by activities mostly responsive to immediate needs or problems rather than by processes </li></ul><ul><li>Goals are poorly defined </li></ul>(1) Reacting to Problems Strategic and Operational Goals
    • 50. Steps Toward Mature Processes <ul><li>Beginning stages of using operating processes with repeatability, evaluation, improvement, and coordination </li></ul><ul><li>Strategy and quantitative goals are being defined </li></ul>(2) Early Systematic Approaches Strategic and Operational Goals
    • 51. Steps Toward Mature Processes <ul><li>Systematic processes in place that are regularly evaluated for improvement </li></ul><ul><li>Learning from processes shared </li></ul><ul><li>Organizational units are coordinated </li></ul><ul><li>Processes address well defined strategies and goals </li></ul>(3) Aligned Approaches Strategic and Operational Goals
    • 52. Steps Toward Mature Processes <ul><li>Systematic processes in place that are regularly evaluated for change and improvement in collaboration with other affected organizational units </li></ul><ul><li>Efficiencies across units sought and achieved through analysis, innovation, and sharing </li></ul><ul><li>Processes and measures track progress on key strategic and operational goals </li></ul>(4) Integrated Approaches Strategic and Operational Goals
    • 53. AHCA/NCAL Quality Award <ul><li>Step 1 - Commitment: Organizational Profile with mission and demonstration of ability to improve (5 pages; met/not met; no IJ) </li></ul><ul><li>Step 2 – Achievement: Address how core values of quality are embraced with good results (18 pages; team of examiners; No IJ and 3 year weighted average above state) </li></ul><ul><li>Step 3 – Excellence: Address all of Baldrige criteria with superior results; 55 pages; team of master examiners, No IJ and 3 year weighted average above state) </li></ul>
    • 54. Benefits of Quality Award Model <ul><li>Develops providers’ ability to improve services and internal processes </li></ul><ul><li>Peer and public recognition as a quality champion </li></ul><ul><li>Examiner feedback identifies strengths and opportunities for improvement </li></ul><ul><li>Creates disciplined learning curve </li></ul><ul><li>Webinars and other support resources available </li></ul>
    • 55. Benefits of Quality Award Pathway <ul><li>Begins change in thinking </li></ul><ul><li>Gives focus to the real customer </li></ul><ul><li>Requires continuous learning at all levels </li></ul><ul><li>Creates pride/celebration in achievement Requires long term commitment </li></ul><ul><li>Creates shift in management style </li></ul>
    • 56. QUESTIONS?
    • 57. Resources <ul><li>Multiple resources for quality improvement listed at AHCA website: http://www.ahcancal.org/quality_improvement/quality_first_initiative/Pages/QF_ToolsResources.aspx </li></ul><ul><li>Developing a Quality Management System: The Foundation for Performance Excellence in Long Term Care , Dana, AHCA revised 2008 (Order through AHCA bookstore – listed at above website) </li></ul><ul><li>Guidelines for Developing a Quality Management System (Free download) http://www.ahca.org/quality/qf_qms_guidelines.pdf </li></ul><ul><li>A Guide to Nursing Facility Performance Measures (also for MR/DD providers) (Free download) http://www.ahca.org/quality/qf_nf_perform_measure.pdf </li></ul><ul><li>Good to Great , Collins, HarperCollins, 2001 </li></ul><ul><li>First, Break All the Rules , Coffman and Buckingham, Simon and Schuster, 1999 </li></ul><ul><li>Zapp! Empowerment in Healthcare , Bynam, Random House, 1993 </li></ul><ul><li>The Deming Management Method , Walton, Perigee Books, 1986 </li></ul>

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