1. Leadership though Compliance,
Quality, & Process Improvement
Bobby D. Scott, MPA
PI & Compliance Administrator

2. Definitions
• Compliance: activities the organization does to
ensure it adheres with all applicable laws,
regulations, standards, contractual obligations,
ethical standards, etc.
• Examples: Policies & Procedures,
Internal/External Auditing, Corrective Action
Plans (CAPs)

3. Definitions (Continued)
• Quality: a measure of excellence or a state of
being free from defects, deficiencies and
significant variations.

4. Definitions (Continued)
• Performance Improvement: Systematic and
continuous actions that lead to measurable
enhancement in health care services and the
health status of targeted patient groups.

5. Visuals…Measurement
0
10
20
30
40
50
60
70
80
90
100
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
Percent
What Does Each Approach Look Like???
Quality/Standard
Compliance
Performance Improvement

6. Quality as a Standard for
Leadership
• Edward Deming: 14
Points
• https://www.youtube.
com/watch?v=tsF-8u-
V4j4

7. Deming 14 Points Revisited
• Create Constancy of Purpose
• Adopt the New Philosophy
• Cease the dependency upon inspection
(Compliance) to achieve quality
• Total Cost reduction
• Improve constantly & forever…

8. Deming 14 Points Revisited

9. Deming 14 Points Revisited
• Institutionalize on the Job Training…Mentorship
or Apprenticeship
• Leadership, Leadership, Leadership
• DRIVE OUT FEAR
• Break down barriers between departments (silos)
• Eliminate slogans/targets

10. Demings 14 Points Revisited
• Remove barriers/Empower hourly staff to take
pride in their work
• Institutionalize education & self improvement
• Put everyone to work to make the
transformation…
• Example…Janitor at NASA

11. A Picture is worth a thousand words...

12. So what’s the Point?
• Culture Trumps Strategy…
• Deming’s 14 Points are all about creating an
organizational environment (Culture) where
people want to work hard, smart, and where
creativity is a highly sought after commodity

13. Reality Check…
• Unfortunately Compliance Activities will be with
us for a while…but they don’t have to be our
core activities…
• Breaking down Silos sounds good, but it is hard
work...
• Giving up quality targets, or performance targets
is even harder…Deming example/legend…

14. Let’s Circle Back to Measurement…
• Why do we measure?
• What are the basics?
– Keep it positive
– Keep it simple
– Percentages/error
rates/counts/checklists
• Example…GPS
0
10
20
30
40
50
60
70
80
90
100
1 3 5 7 9 11 13 15 17 19
Percent
What Does Each Approach Look
Like???
Quality/Standard
Compliance
Performance
Improvement

15. Step One: Know where you are
now…
• Establish a baseline
(measurement)
• Communicate
transparently,
honestly, with
INTEGRITY
• Build the case for the
future state
(VISION/MISSION)

16. Step Two: Bring a Map
• Experience
• Best Practices
• Performance
Improvement
• Lean/Six Sigma
• Creative Staff
• Teamwork
• Start with the END IN MIND
• Build the CULTURE
• EVERYONE
COUNTS…TEAM
• Celebrate wins & learn from
failures…(3 cycles)
• Trust the process…

17. Sample Data…

18. Another way of looking at the data…

19. Still another …
• Averages by year
– 2013 40.00
– 2014 29.25
– 2015 25.42 A net 15 ↓
• Soooooo….
– Look at the date critically
from many different
angles before you decide
if the improvement is
actually an improvement
and if it is permanent.

20. Data Driven Decision Making
• Using Mission oriented data collection and
analysis to drive the decision process and make
it more objective.
• Business Intelligence/Analysis
• Quantitative Analysis
• Largely becoming dependent upon databases
and very large and multiple spreadsheets…

21. Six Sigma’s DMAIC Process
• DEFINE: What is the problem?
• MEASURE: How is the problem effecting the
customer/staff?
• ANALYZE: How big is the problem?
• IMPROVE: Are the intended outcomes
occurring? Rule of three…
• CONTROL: Can we sustain & spread these
results?

22. DEFINE: What is the Problem?

23. MEASURE: How is the problem effecting
the customer/staff?

24. ANALYZE: How big is the problem?
• Can this be addressed by my team?
• Do we need to bring in other departments?
• Is it going to cost money to fix?
• Is it costing us money not to fix?
• Is it a patient safety issue?
• Is your current measurement adequate to the
task?

25. IMPROVE: Are the intended outcomes
occurring?
• Make the change(s)
• Determine quickly if the changes are having the
intended effect
• Rule of Three
• Be prepared to make alterations as needed to
adjust to learning during the implementation or
in some serious cases, stop the project entirely.

26. CONTROL: Can you sustain & spread
these results
• Sustaining & Spreading results are the most
difficult aspect of any PI Project.
• They require great documentation and the
ability to transfer the knowledge to different
environments.
• Remember Deming referring to the word
“Institutionalize” several times during his
presentation. The control phase is where you
would codify and control the behaviors and
system.

27. Why DMAIC? Is it really worth it?
• Isn’t this a lot of extra work?
• Measurement is a hassle…
• What if you measure the wrong thing?
• Leadership doesn’t think it is important…
• My co-workers will think I’m weird
• What if it doesn’t work?

28. Why DMAIC?
• YES this a lot of extra work, but it is proven to
work!
• Measurement is a hassle, but once in place it
provides routine feedback on performance.
• You will most likely measure the wrong thing…If
at first you don’t succeed…
• Leadership doesn’t think it is important…prove
them wrong…

29. Why DMAIC (Continued)?
• My co-workers will think I’m weird…
– Be a Leader, not a follower…
– Example…Disease Management
• What if it doesn’t work?
– Rule of Three
– If at first you don’t succeed
– You learn more from failure anyway…

30. Lather, Rinse, Repeat…
• Find your true calling
because once you hit
that one milestone,
it’s time to set new
goals and start all
over again…

31. The Choice…
• A job that energizes you • Or a job that well…