self assessment for quality improvement

1. Leadership QI Self-Assessment:
Group Discussion and Scoring

2. Objectives
• Outline a process for assessing our QI culture
• Engage in facilitated group discussion around our culture of
quality
• Administer the QI SAT through group scoring

3. • Comprehensive assessment
• Based on the 6 foundational
elements (14 sub-elements)
• Aligned with QI Roadmap
• Links results with transition
strategies
• Scoring Summary Sheet
Organizational Culture of Quality
Self-Assessment Tool (SAT)

7. Interpreting the Leadership SAT
Scale
Roadmap Phase
SAT
Scale
Rating
SAT Scale Interpretation
Phase 1: No
knowledge or
awareness of QI
1 The respondent feels that the statement never occurs in the
company.
Phase 2: Not
Involved in QI
Activities
2 The respondent feels that the statement rarely occurs in the
company.
Phase 3: Informal
or Ad Hoc QI
3 The respondent feels the statement occurs inconsistently or on an
informal or ad hoc basis in some areas of the company.
Phase 4: Formal QI
in Specific Areas of
the company
4 The respondent feels the statement occurs informally in some areas
and formally in other areas of the company.
Phase 5: Formal
company-wide QI
5 The respondent feels the statement occurs formally in all areas of the
company.
Phase 6: QI Culture 6 The respondent feels the concept in the statement is fully integrated
into the company culture.

8. QI Self-Assessment Process: Next
Steps
[Adapt this slide to reflect the assessment process you have designed].
1. Staff complete [online/paper] assessment by DATE
2. QI Committee will collectively complete the assessment for a leadership score by
DATE
3. QI Committee staff will prioritize NACCHO transition strategies to select strategies
for addressing QI gaps DATE
4. Strategies are selected and prioritized by DATE
5. Strategies are incorporated into QI plan and presented to staff by DATE

9. Assessing our QI Culture:
Leadership Group Discussion &
Scoring

10. Foundational Element 1: Staff
Empowerment
Staff are empowered to use QI in their daily work through:
• Trainings, coaches, and resources
• Clear expectations
• Opportunities to implement QI
• Autonomy to make improvements
• Performance feedback systems
• List the company’s specific staff empowerment efforts

11. Staff Empowerment
Sub-Element 1.1: Enabling Performance
• Have we clearly articulated expectations around QI across all
staff?
• Do staff have access to needed resources to do their jobs? To
learn and implement QI?
• Are skilled QI and other job related mentors available to staff?
• Have staff been given a voice in the company’s QI process (e.g.
nominate or select projects? Authority to make
improvements)?

12. Staff Empowerment
Sub-Element 1.1: Enabling Performance
[Placeholder slide to facilitate scoring of Sub-Element 1.1:
Enabling Performance.]

13. Staff Empowerment
Sub-Element 1.2: Knowledge, Skills, and Abilities (KSAs)
• To what extent are our workforce development processes and
plans addressing gaps in performance and workforce
competencies and KSAs?
• Are sufficient employee performance tracking or appraisal
processes in place to support meaningful growth?
• Are sufficient QI and other workforce training opportunities
and resources readily available to all staff?

14. Staff Empowerment
Sub-Element 1.2: Knowledge, Skills, & Abilities
(KSAs)
[Placeholder slide to facilitate scoring of Sub-Element 1.2:
Knowledge, Skills, and Abilities.]

15. Foundational Element 2:
Teamwork and Collaboration
Create effective team performance by:
• Defining team expectations
• Carefully selecting team members
• Holding teams accountable
Break down silos through:
• Communication of lessons learned
• Formal/informal learning and problem solving groups
• Eliminating redundancies and creating alignment
• List opportunities for collaboration in the company.

16. Teamwork & Collaboration
Sub-Element 2.1: Collaborative Sharing and Improvement
• What formal or informal mechanisms exist for staff to
collaborate and share successes and lessons learned across
teams?
• What external opportunities are staff engaged in to enhance
knowledge and expertise around QI other job functions?

17. Teamwork & Collaboration
Sub-Element 2.1: Team Performance
[Placeholder slide to facilitate scoring of Sub-Element 2.1:
Collaborative Sharing and Improvement.]

18. Teamwork & Collaboration
Sub-Element 2.2: QI Team Performance
• Do teams have processes in place to support success (e.g.
effective communication mechanisms, opportunities to meet,
methods for tracking goals)?
• What accountability mechanisms are in place to ensure that
teams meet their goals?
• Are QI teams being held accountable and prioritized in daily
work?

19. Teamwork & Collaboration
Sub-Element 2.2: QI Team Performance
[Placeholder slide to facilitate scoring of Sub-Element 2.2:
Strategic Planning.]

20. Foundational Element 3:
Leadership Commitment
• Dedicate financial and human resources to QI
• Communicate the vision and urgency for QI
• Empower staff to engage in QI
• Hold staff accountable
• Exhibit visible support for QI
• Add leadership commitment to date (e.g. dedicated resources,
$$, QI committee)
• Add leadership expectations of staff

21. Leadership Commitment
Sub-Element 3.1: Culture
• Has leadership defined and communicating a clear and
inspiring vision for QI and its urgency?
• How has QI been integrated into company policy, plans, and
procedures?
• How do leaders model behaviors in support of QI, as they
expect from staff?

22. Leadership Commitment
Sub-Element 3.1: Culture
[Placeholder slide to facilitate scoring of Sub-Element 3.1:
Culture.]

23. Leadership Commitment
Sub-Element 3.2: Resourcing & Structure
• Does the company have sufficient funding and resources
allocated for QI?
• Does the company have a high functioning QI Committee?
• Do leaders have the necessary KSAs necessary to drive and
sustain QI?

24. Leadership Commitment
Sub-Element 3.2: Resourcing & Structure
[Placeholder slide to facilitate scoring of Sub-Element 3.2:
Resourcing and Structure.]

25. Foundational Element 4:
Customer Focus
• A customer focus is part of the company’s core values and
vision
• Programs understand and respond to customer needs
through stakeholder engagement
• Customer satisfaction data is collected
• Customer data drives decision making and improvement
efforts
• Employees are empowered to exceed customer
expectations
• Add current efforts to collect and use customer data.

26. Customer Focus
Sub-Element 4.1: Understanding the Customer
•How well do product and service development
continuously engage with stakeholders to understand
needs of different customer groups?
•How well do administrative work units with internal
customers (e.g. Human Resources, Finance)
understand needs of staff?

27. Customer Focus
Sub-Element 4.1: Understanding the Customer
[Placeholder slide to facilitate scoring of Sub-Element 4.1:
Understanding the Customer.]

28. Customer Focus
Sub-Element 4.2: Meeting and Exceeding Customer
Expectations
•How do we collect customer satisfaction data
cross the company?
•To what extent is internal and external customer
input and satisfaction data used to drive
improvement efforts?
•How are staff empowered to resolve customer
issues?

29. Customer Focus
Sub-Element 4.2: Meeting and Exceeding
Customer Expectations
[Placeholder slide to facilitate scoring of Sub-Element 4.2:
Meeting and Exceeding Customer Expectations.]

30. Foundational Element 5: QI
Infrastructure
Components of a strong QI infrastructure:
• Alignment with strategy
• Performance management system
• QI governing body
• QI Plan and/or policy

31. QI Infrastructure
Sub-Element 5.1: Strategic Planning
• How well do we operationalize an company strategic
plan?
• What processes are in place to link department-wide
programs and services to strategic goals?
• Does the strategic plan guide resource allocation?

32. QI Infrastructure
Sub-Element 5.1: Strategic Planning
[Placeholder slide to facilitate scoring of Sub-Element 5.1:
Strategic Planning.]

33. QI Infrastructure
Sub-Element 5.2: Performance Measurement and Use of
Data
 Is there an effective company-wide process for
developing meaningful performance metrics in all
products, services and departments?
 How do we ensure a mix of meaningful process and
outcome performance measures that link activities to
outcomes?
 Do products, services, and work units link performance
measures to company level measures?

34. QI Infrastructure
Sub-Element 5.2: Performance Measurement
[Placeholder slide to facilitate scoring of Sub-Element 5.2:
Performance Measurement and Use of Data.]

35. QI Infrastructure
Sub-Element 5.3: Quality Improvement Planning
 How is performance data being used to identify and
implement improvements?
 Are unmet strategic goals prioritized for QI?
 How well do we operationalize our QI plan?

36. QI Infrastructure
Sub-Element 5.3: Quality Improvement Planning
[Placeholder slide to facilitate scoring of Sub-Element 5.3:
Quality Improvement Planning.]

37. Foundational Element 6: Continuous
Process Improvement
• Also called Continuous Quality Improvement
(CQI)
• Common methods are Lean, Six Sigma, and
Plan-Do-Check-Act (PDCA) or Plan-Do-Study-
Act (PDSA) cycles.
• Elaborate on the department’s QI process
here
• Add how staff can nominate or get engaged
with QI projects.

38. Continuous Process Improvement
Sub-Element 6.1: Improving Standardized Work
• Do staff have access to a library of standardized work processes or
procedures?
• Are they consistently followed?
• How well do we formally apply QI method(s) to improve work
processes?

39. Continuous Process Improvement
Sub-Element 6.1: Improving Standardized Work
[Placeholder slide to facilitate scoring of Sub-Element 6.1:
Installing Standardized Work.]

40. Continuous Process Improvement
Sub-Element 6.2: Planning for QI Projects
•Do our QI projects adhere to formal QI methods?
•How clearly do we scope QI projects with Aim
statements and baseline data?
•How well do we investigate root causes of a
problem?
•Are best or promising practices considered for
potential improvements to test?

41. Continuous Process Improvement
Sub-Element 6.2: Planning for QI Projects
[Placeholder slide to facilitate scoring of Sub-Element 6.2:
Planning for QI Projects]

42. Continuous Process Improvement
Sub-Element 6.3: Testing, Studying, and Acting on Potential
Solutions
•Are tests done on a small scale and gradually scaled up
once improvements are demonstrated?
•How are we documenting results and lessons learned
from QI projects? Are standardized work processes
updated accordingly?
•How often do QI projects result in measurable
improvements?
•How frequently are we sustaining improvements?

43. Continuous Process Improvement
Sub-Element 6.3: Testing Proposed Solutions
[Placeholder slide to facilitate scoring of Sub-Element 6.3:
Testing Proposed Solutions.]

44. Next steps
[Insert next steps for scoring, selecting transition strategies, and updating the QI plan
per company’s process.

45. THANK YOU!
Questions?