…. and why being clear about each matters
This post is a catch up from week 17 where we had a spontaneous discussion about the relationship between quality and requirements and why improving the grade of a product or service will normally add cost, but improving quality will normally reduce cost.
The idea that increasing quality reduces costs seems counter-intuitive, but that is only because we’ve not understood what “quality” is, and importantly, how it is distinct to “grade”. So here are some definitions of each from ISO9001, as defined by the International Standards Organisation (ISO):
Requirement: A need or expectation that is stated, generally implied or obligatory.
Quality: The degree to which a set of inherent characteristics of an object fulfils requirements.
Grade: The category or rank given to different requirements for an object having the same functional use. For example, the class of airline ticket and category of hotel in a hotel brochure.
-Thanks to the International Standards Organisation (ISO) for the definitions. (https://www.iso.org/obp/ui/#iso:std:iso:9000:ed-4:v1:en)
And for clarity, “Object” is defined as:
“An object is any entity that is either conceivable or perceivable. Objects can be real or imaginary and could be material or immaterial. Examples include products, services, systems, organisations, people, practices, procedures, processes, plans, ideas, documents, records, methods, tools, machines, technologies, techniques, and resources.” http://www.praxiom.com/iso-definition.htm#Object
Given that we are using ISO9001 definitions, I suppose it’s only right to explain a little about what it is.
“The ISO 9001 standard provides a framework of globally recognised principles of quality management, including: customer focus, leadership, involvement of people, process approach to management, continual improvement, factual approach to decision making and mutually beneficial supplier relationships. These are also known as the eight key principals of quality management.” – http://certificationeurope.com/what-is-iso-9001/
These definitions of Quality and Grade are applied across the world in the discipline of Quality Management. In manufacturing, services, agriculture and pretty much anything. Some industries have specific variants on the base standard, for example I was involved in managing an AS/EN9100 Quality Management System (QMS) when I worked in the aerospace design and advanced engineering sector, but that standard is essentially ISO9001 with some industry specific variations.
ISO9001 isn’t perfect, but it’s pretty good
It’s not all good news with these standards. They can be bureaucratic to administer and whilst that’s fine for a stable organisation in a relatively stable market, for a more dynamic organisation in unstable markets, it can be difficult, if not impossible to maintain all company procedures appropriately documented and audited, as certification requires.
That was certainly my experience later when playing a leading role in transforming a construction company into a primarily logistics oriented one as a result of the highly unstable market conditions that existed post the 2008 financial crash; and the need for us to develop new services for new customers to stay in business. The idea of maintaining a fully compliant ISO 9001 QMS in that situation is hard to square away. Similarly, it shouldn’t be allowed to constrain any positive change or transformation in an organisation. It is not intended to, but through it’s (inappropriate) application, that can be problem.
So, it’s not without it’s problems, but at it’s heart it is a sound approach. For our purposes, what I think is really useful and important is how it defines Quality and Grade. To reiterate the definitions above;
- Quality is about the degree to which requirements are fulfilled.
- Grade is about what the requirements actually are compared to the requirements for other products in the same category.
- Quality is independent of Grade!
Do we mean grade rather than quality then?
People often confuse the two, or simply don’t know there is a distinction. I’ve foud this to often be the case in healthcare. In a sense, that’s fair enough. Industries can use whatever terminology they like to mean whatever they like. However, if “quality” means “grade”, then what word is used to refer to “quality”, or rather, services that don’t fully satisfy requirements? I’m not aware there is one.
In practice, I think they’ve been merged into a single concept. And maybe that’s ok. After all, we are offering a standard service to all. A single grade I suppose. The difficulty, is that it’s not entirely clear that we’ve formally defined, recorded and agreed the requirements or purpose of our services and systems. We found it hard to do this for a GP practice if you cast your mind back, and we weren’t aware of a Requirements Document we could refer to. How do we know if we are fulfilling requirements if we haven’t defined and documented them?
It’s not unusual to hear people in our and other industries say “we can’t afford to provide a higher quality service.” or similar. This might be a problem though. If we understand quality to be about the degree to which requirements are satisfied, rather than what the requirements are, then we can see that ultimately we can’t afford not to increase quality. Why is this?
If the basic requirement of a car is to get the driver from A to B in comfort, and there is an aspect of it, a leaking door seal perhaps, that prevents it from doing that, then the car will be returned to the manufacturer to be repaired. Or the problem may be picked up by “Quality Control” before it leaves the plant and repairs are made at that point. There are costs associated to this. The costs of identifying the problem, and then fixing it. These costs are specifically associated to poor quality. You have to fulfil requirements. There are no two ways about it. You have to. And if you don’t, you will have to pay to correct the problem.
Providing it satisfies the requirements of a typical buyer, a brand new Dacia without a leaky window is actually a higher quality car than a brand new Rolls-Royce with a leaky window. Presuming both sets of buyers have a requirement to arrive at their destination dry. Of course, the Rolls-Royce is a far higher “grade” of car though. It will have all sorts of additional requirements on it the Dacia doesn’t, such as speed, comfort, the degree to which it impresses your mates, etc. Quality and Grade are independent of one another.
Increase Quality to reduce cost
In health services, there will be a myriad of requirements on any service, but for the sake of argument, let’s assume a basic and fundamental requirement on all health services is to diagnose and cure, or treat as far as is medically possible (given NICE sanction) a presented condition. Ultimately, this has to be fulfilled, or patients will unnecessarily die, or live with unnecessary suffering. They and their relatives will know this, and so they will keep presenting, or be passed around different parts of the health service until the requirement is satisfied (assuming it can be).
This is all the cost of low quality. And worse than that, if the requirement isn’t fulfilled quickly, their health can worsen, and ultimately cost more to put right. I have personal family experience of this, and sadly, I imagine many others do too.
So, increasing quality in a health service is about identifying and treating conditions as quickly and appropriately as we can, whilst treating people as individually and kindly as possible and it is not about “gold plating”. That would be “Grade”. When we talk about “getting things right first time”, this is what we are talking about, Quality.
A tough job in public services
I don’t underestimate how difficult this is to do in public services though. I think one particular challenge we have is defining the requirements and in turn the grade of the service we should offer. We all have individual personal expectations and requirements for all things that we buy and consume. Ideally, all products and services would be produced for us individually. This would not be economical though. To get around this, companies will segment their customers into groups, generalise requirements for each of those groups and produce offerings for each and importantly, charge accordingly.
If we think about laptop computers, manufacturers will produce a wide variety of models, each aimed at a different category of customer. The medium performance, but robust build quality for the person who needs it for work, the cheap and cheerful basic machine for the home user on a budget, the high performance machine for those who work with graphics, and the good performance in a shiny, slim package, for the trendy person who wants to impress their mates. Each of the options described will be priced differently to reflect it’s grade.
One difficulty we have in public services is that we need to offer a standardised service for all. We can’t “charge accordingly”. It’s not possible to do this, and satisfy everyone’s requirements, and so there is a lot of compromise and accommodation going on along the way and effort to try to provide services that more or less satisfy most people’s requirements. A kind of service for the “average” patient.
For health services, the core functional requirement of making people better will be the same irrespective of grade, but there will be decisions made around waiting times, length of time it takes to treat, and other service elements like comfort of facilities, and where services are provided (hospital, GP practice, or at home) etc. i.e. Non-Functional System, Non-Functional Implementation and Non-Functional Performance Requirements.
It seems to me that all of this requires debate at national and local levels between patients, taxpayers, government, commissioners, providers, suppliers, lobbyists, activists and probably others too, to come to an accommodation over what the grade of services should be. This is no mean feet! There are a lot of stakeholders to accommodate in public services. It’s a much bigger job than a manufacturer has when categorising customers and defining their requirements.
This does beg the question how one goes about defining the concept of “Value” in health services, but let’s leave that for another day. There’s also the question of the role “Outcomes” play in all of this. A central one. We should also need remember what Jean Boulton had to say about the things that really matter often can’t be easily measured quantitatively. How does that fit with this approach to Requirements and Quality. Lots of swirling questions for us to keep in mind as we continue this journey.
Does it really matter?
Why does all of this matter to we Systems Thinkers. Well, as we’re discovering, “Requirements” are a very close relation to a system’s “Purpose”. So quality is about the degree to which something is “fit for purpose”. Before we can determine whether a product of service is fit for purpose, we need to have a clear understanding of exactly what it’s “purpose” is, and that is exactly what we have been doing in this group. You may not have realised you were learning about “quality” as well as problem solving and design, but you are.