J. M. Juran
The Meanings of “Quality” of the many meanings of the word “quality,” two are of critical importance to managing for quality:

“Quality” means those features of products which meet customer needs and thereby provide customer satisfaction. In this sense, the meaning of quality is oriented to income. The purpose of such higher quality is to provide greater customer satisfaction and, one hopes, to increase income. However, providing more and/or better quality features usually requires an investment and hence usually involves increases in costs. Higher quality in this sense usually “costs more.”

“Quality” means freedom from deficiencies—freedom from errors that require doing work over again (rework) or that result in field failures, customer dissatisfaction, customer claims, and so on. In this sense, the meaning of quality is oriented to costs, and higher quality usually “costs less.”

IHI Framework for Leadership for Improvement

Innovation Series: Seven Leadership Leverage Points for Organization-Level Improvement in Health Care (Second Edition). IHI. 2008

Leadership models and frameworks can provide a roadmap for leaders to think about how to do their work, improve their organizations, learn from improvement projects, and design leadership development programs. The core of the comprehensive IHI (Institute for Healthcare Improvement) strategic improvement framework is Will, Ideas, and Execution3: in order to get organization-level results, leaders must develop the organizational will to achieve them, generate or find strong enough ideas for improvement, and then execute those ideas—make real improvements, spread those improvements across all areas that would benefit, and sustain the improvement over time. And when this Will-Ideas-Execution framework is fully fleshed out with the addition of two other core components, “Set Direction” and “Establish the Foundation,” 24 specific elements emerge into an overall leadership system for improvement called the IHI Framework for Leadership for Improvement (see below).


Leaders can be daunted by the breadth and depth of this sort of comprehensive model. Even though the 24 individual elements are quite clear, many of them are still fairly broad in scope (e.g., “Plan for Improvement” or “Review and Guide Key Initiatives”). So leaders often look at comprehensive models such as this and ask questions such as “But how exactly do I ‘Plan for Improvement’ or ‘Review and Guide Key Initiatives’?”

Performance Improvement Methodology

by Thada Bornstein, MEd, Deputy Training Director, Quality Assurance Project

Performance Improvement (PI) is a methodology for improving the quality of institutional and individual performance. Performance improvement is helping to change the widespread notion that all performance problems are best addressed by training. Traditionally, management viewed poor performance as a lack of knowledge or skills, without regard for a variety of internal and external determinants of performance, such as motivation, incentives, environmental factors, resources, feedback, coaching, supervisory support, and others. This mentality leads managers to think that workplace performance problems can be “fixed” by training, so training became a panacea for those problems but rarely solves them. Even when training is required, it alone is often insufficient to improve job performance (“training transfer”). Without certain supports present in the workplace, performance may improve for a short period following training, and then erode.

PI addresses human performance within organizations at the individual, process, and organizational levels. It uses a systematic method that has five stages: (a) getting agreement on the project goal from the clients, stakeholders, and PI practitioner; (b) conducting a performance needs assessment (identifying performance gaps and their root causes); (c) designing the interventions to close the gap; (d) implementing the interventions, and (e) evaluating the change in the performance gap.

Performance Improvement Process

U.S. industrial models of performance factors differ from these and include categories such as Capacity, which refers to individual capability and aptitude for the job, as well as selection of the right person for the job, and Incentives, which encompasses adequate pay and non-pay incentives made contingent upon performance, clear consequences for performance, and absence of disincentives, such as rewarding poor performance or negatively rewarding good performance.

Five Tips for Publishing Your QI Work

By IHI Open School | Wednesday, February 10, 2016

Quality improvement work isn’t done until you’ve shared it.
So says Dr. Greg Ogrinc, a foremost expert in QI publishing, who helped establish the Standards for Quality Improvement Reporting Excellence (SQUIRE) guidelines. Dr. Ogrinc, Director of the Quality Literature Program and Senior Associate Dean for Medical Education at Dartmouth Medical School, presented his tips for publishing QI work to IHI Open School students on a recent Global Chapter Call. You can access the full recording here.

Here are a few of Dr. Ogrinc’s tips for sharing (and doing) QI work:
  1. The goal of publishing your QI work is to help others apply the learning to their settings. It’s different from reporting the results of a randomized trial. For example, one of the most famous QI projects, known as the Keystone project or the Michigan Study, reported incredible results in reducing catheter-related bloodstream infections (CLABSIs) using a simple checklist with five steps known to reduce such infections. However, the report wasn’t clear about the process for implementing the checklist, so it was difficult for others to replicate the change. Like the checklist implementation, most QI projects require a socio-technical change in a complex system. Remember that when you publish your QI work, you’re trying to help other people understand what you did to get results — not just the results themselves.
  2. Use a clear theoretical model to frame your QI work. Sharing your method — whether it’s the Model for Improvement, Lean, or Six Sigma — isn’t as important as the theory behind why you chose that model. Why did you think certain changes would result in improvement? What was the system that you wanted to change? How were various components interacting in the system?
  3. Describe the context as clearly as possible.The goal of improvement is to make care better in your own local setting, so readers will be thinking about their context as they read about your work. This isn’t just the care setting — it’s also all the internal and external factors that are affecting the outcome. It’s also helpful to describe how the context evolved over the course of your work — Did the culture change? Did new technology become available? Did you find leadership support?
  4. It’s very important to have strong data analysis. You don’t need the depth of data that you would for a typical randomized trial; however, showing data over time using run charts is essential.
  5. Qualitative data matters, too. Where possible, use quotes and representative stories to help readers understand how your results unfolded. For example, you might consider listing the drivers of change and how each of your tests related to those drivers. Tell the story of your work.

Quality Improvement

The Model for Improvement is a simple, yet powerful approach to achieving rapid and significant improvements in care delivery and outcomes. It has been used very successfully by hundreds of health care organizations in many countries to improve many different health care processes and outcomes.