From Rules & Regulations
to
Continuous Improvement
Presented by:
Elaine Griffin, PhD, MHA, MBA, FACHE
Lipscomb University
Nashville, Tennessee
And the benefits of CQI…

Improved learning outcomes of
the educational process (student
learning outcomes)

Increased student satisfaction

Increased faculty and staff
satisfaction

Improved organizational
performance

Improved financial strength
Objectives for this session…
At the conclusion of this session, you will be able to:
 Answer the question, “Why quality?”
 Discuss the philosophy of CQI with its components:
- Customers and requirements
- Process focus
- Continuous improvement
 Describe and explain the process focus of:
- Quality planning
- Quality measurement and reporting
- Quality improvement
- Cultural changes
I.
Philosophy of CQI
Customers and
requirements
Continuous
improvement
Process focus
II. Process focus and continuous quality
improvement (CQI)
Quality planning
Quality
measurement and
reporting
Cultural changes
Quality
improvement
We’re going to spend our time on CQI

Quality planning

Quality measurement
and reporting

Quality improvement

Cultural changes
But first, let’s note some pressures on
education…

Competition for students

Increased awareness by
customers of educational quality

Cost of education

Continuous changes in job skills
requirements to meet
stakeholders’ needs

Regulatory agencies and
accrediting bodies
More pressures…

Pressure from all constituents
to lower educational costs

Pressure from all constituents
to improve quality
How do you define quality?
Our definition:
Customers (students) define
what quality is for them. The
product or service is quality if it
meets the customer’s expectations
or requirements
Customer requirements for education

Learning outcomes

Service requirements

Cost requirements
Continuous improvement is a journey




The goal is to provide services that meet our
customers’ expectations
It cannot be accomplished overnight
It is accomplished over time by measuring the
performance of our processes (everything is a
process)
We must take actions to improve our processes
The journey requires…






Identifying our current level of performance
Setting goals for improvement
Identifying new ways to improve work processes
Pursuing goal achievement
Celebrating
Setting new goals to continuously improve
Four components
I.
Quality planning
II.
Quality measurement
and reporting
III. Quality improvement
IV. Cultural changes
I.




Quality planning
Purpose of planning: to define a corporate-wide strategy
to meet customer needs and achieve the vision
Provides framework for innovation and creation of new
services
Concept of customers and requirements is further
developed and put into action for organization as a whole
Starts with mission, vision, values, and goals
1.
Organization’s mission, vision, values,
goals




Mission: purpose for existence
Vision: where organization
wants to be in the future
Values: principles by which
organization conducts business
Goals: what organization needs
to accomplish in short run to
achieve the vision
2. Department mission


Each department adopts a mission, vision, values, and
goals which contribute directly to the organization’s
mission, vision, values, and goals
Example:
- University mission: To provide an undergraduate
liberal arts education for any student, regardless of
race, age, political preference, or religious preference
- Department of Management mission: To educate
students in the art and science of management and to
prepare them for positions in the profession of
management
Another way to look at it…
Organization mission,
vision, values, goals
Departmental mission,
vision, values, goals
Departmental mission,
vision, values, goals
Departmental mission,
vision, values, goals
Your turn to participate …

Corporate vision: to become a
premier nationally recognized
university

Finance:

Student enrollment:

Computer Center:

Your department:
Write the mission for your department

Mission

Vision

Values

Goals
3.
Let’s summarize quality planning

Integrates departmental
operations into corporate mission
and vision (alignment)

Results: corporate-wide strategy
on how to meet customer
requirements

Achieves vision of organization
II. Quality measurement and reporting
Includes:

Performance measurement: indicators and goals

Alignment of goals

Department continuous improvement plan
1.
Performance measurement:
indicators and goals




Must manage by facts
Information obtained allows
decisions based on objective data
Indicators are used to measure
performance
Quality indicator measures the
performance of a process which
meets customer requirements
Examples of indicators

Student achievement

Accurate billing

Student registration process

Retention rate

Student satisfaction
How do you select indicators?

Guiding principle #1:
MEASURE WHAT MATTERS

Guiding principle #2:
SET PRIORITIES
- Required by agencies (legal,
accreditation, state, strategic plan)

Guiding principle #3:
BE REASONABLE
And next?

When the measurement of an indicator
demonstrates that a process needs
improvement, then a goal may be established

Goals give us a target or milestone at which to
aim
2. Department continuous improvement
plan (CIP)

The departmental plan contains indicators for
the end results or outcomes important for the
department to measure, and goals for those
outcomes where customer requirements are not
being met
3. Let’s develop a plan…
Answer these questions:
 What is my mission?
 How am I organized?
 Who are my stakeholders/constituents/students?
 With whom am I affiliated?
 Products and services offered (courses)
 How do I conduct my business (meetings, etc)?
 What have I promised (mission) and what are the major program
outcomes/learning objectives for my stakeholders?
 What are the indicators used to determine performance?
 What is my current performance at meeting their expectations
(program outcomes)?
 What is my goal for continuous improvement on this
performance?
Write your own plan…
YOUR UNIVERSITY
CONTINUOUS IMPROVEMENT PLAN
I.
II.
III.
IV.
V.
VI.
VII.
VIII.
IX.
X.
DATE:
DEPARTMENT:
MISSION:
ORGANIZATION:
CONSTITUENTS:
Internal constituents:
External constituents:
AFFILIATIONS:
MEETINGS:
STANDING COMMITTEES:
PROGRAM OUTCOMES:
PERFORMANCE INDICATORS:
1. Strategic plan
2. Continuous improvement
3. Other
A little review…
UNIVERSITY MISSION
AND VISION
UNIVERSITY INDICATORS/GOALS
(CORPORATE CIP)
DEPARTMENT INDICATORS/GOALS
(DEPARTMENT/MAJOR CIP)
Bachelor of Arts in Accounting
Learning Objective or Outcome
Quality
Present (2006)
For Each Major
Indicators
Performance
CQI goal
1. Recognize, understand, and develop skills to
perform and interpret accounting principles
MFT
CPA exam
GSS
Internal exams
95th percentile
Etc.
Etc.
98th percentile
2. Recognize, understand, and develop skills to
perform and interpret managerial accounting
principles
MFT
CPA exam
GSS
Internal exams
87th percentile
98th percentile
3. Recognize, understand, and develop skills to
perform and interpret auditing principles and
processes
MFT
CPA exam
GSS
Internal exams
89th percentile
98th percentile
4. Recognize, understand, and develop skills to
perform and interpret cost accounting principles
MFT
CPA exam
GSS
Internal exams
85th percentile
98th percentile
5. Recognize, understand, and develop skills to
perform and interpret federal income tax
principles
MFT
CPA exam
GSS
Internal exams
82nd percentile
98th percentile
Percentile
Major Field Test Scores
100
90
80
70
60
50
40
30
20
10
0
Acc P
Mg Ac P
Aud P
CA P
FIT P
2002 S
2003 S
2004 S
2005 S
2006 S
Semester
Legend: Acc P = Accounting Principles; Mg Ac P = Managerial Accounting Principles; Aud P = Auditing Principles;
CA P = Cost Accounting Principles; FIT P = Federal Income Tax Principles
Percent of accounting graduates
Job upon graduation
100
95
90
85
% w Job
80
75
70
2002 S
2003 S
2004 S
Semester
2005 S
2006 S
Percent satisfied with advising
Student satisfaction with advising
(Graduating Senior Survey: GSS)
100
90
80
70
60
50
40
30
20
10
0
Sat/advis
2003 S 2003 W 2004 S 2004 W 2005 S 2006 S
Semester
CIP Worksheet
YOUR UNIVERSITY
CONTINUOUS IMPROVEMENT REPORT
DEPARTMENT: Department of Accounting
OPPORTUNITY FOR IMPROVEMENT: Student achievement (Accounting Principles – Acc P)
INDICATOR: Major field test (MFT)
PRESENT LEVEL OF PERFORMANCE: 80th percentile (2002 S)
GOAL: Incremental improvement until 98th percentile
TEAM MEMBERS: Department of Accounting faculty, students, alumni, business representatives
Date
initiated
Plan of action
Internal or
external
constituent
Source of data
Resources
required
Estimated
completion date
Measure of
effectiveness
May 2003
Review curriculum
Internal
Accounting
Curriculum
Budgeted
August 2003
Improved Acc P
scores if
successful
Dec 2003
Identify root cause of
low Acc P MFT scores
Internal and
external
Students, scores,
curriculum,
faculty, teaching
methods, etc.
NA: budgeted
May 2004
Improved Acc P
scores if
successful
Make appropriate
changes as determined
Summary Form
Degree
Learning Objectives/
Outcomes
How Measured
Bachelor of Arts
in Accounting
Recognize, understand, and develop skills to
perform and interpret accounting principles
MFT, CPA exam, GSS, Internal exams
Recognize, understand, and develop skills to
perform and interpret managerial accounting
principles
MFT, CPA exam, GSS, Internal exams
Recognize, understand, and develop skills to
perform and interpret auditing principles and
processes
MFT, CPA exam, GSS, Internal exams
Recognize, understand, and develop skills to
perform and interpret cost accounting principles
MFT, CPA exam, GSS, Internal exams
Recognize, understand, and develop skills to
perform and interpret federal income tax principles
MFT, CPA exam, GSS, Internal exams
Use of results: Describe how you used the data to make changes in the teaching process that
ultimately led to increased student learning and improved scores
Verbs for stating general instructional
objectives
Analyze
Compute
Interpret
Perform
Translate
Apply
Create
Know
Recognize
Understand
Appreciate
Demonstrate
Listen
Speak
Use
Locate
Think
Write
Comprehend Evaluate
Verbs for stating specific learning outcomes
(Complex, Logical, Judgmental Behaviors)
Analyze
Conclude
Deduce
Formulate
Plan
Appraise
Contrast
Defend
Generate
Structure
Combine
Criticize
Evaluate
Induce
Substitute
Compare
Decide
Explain
Infer
Verbs for stating specific learning outcomes
(Language Behaviors)
Abbreviate
Edit
Punctuate Speak
Tell
Accent
Hyphenate
Read
Spell
Translate
Alphabetize
Indent
Recite
State
Verbalize
Articulate
Outline
Say
Summarize Whisper
Call
Print
Sign
Syllabify
Capitalize
Pronounce
Write
Verbs for stating specific learning outcomes
(Mathematical Behaviors)
Add
Derive
Group
Number
Square
Bisect
Divide
Integrate
Plot
Subtract
Calculate
Estimate
Interpolate Prove
Tabulate
Check
Extrapolate
Measure
Reduce
Tally
Compute
Extract
Multiply
Solve
Verify
Count
Graph
4.





In education, indicators frequently
measure the following…
Student achievement/effectiveness of educational process
- was a planned, successful outcome achieved?
Appropriateness of programming/curriculum
- was the curriculum appropriate for desired outcomes?
Student satisfaction
- were students satisfied with advising, etc.?
Retention rates
- were retention rates acceptable?
Graduation rates
- were graduation rates acceptable?
More education indicators…




Customer (students, parents, community) satisfaction
- were customers satisfied with products/services and outcomes
of educational process?
Enrollment management
- did enrollment meet planning goals?
Campus climate
- does campus climate meet mission/goals for LU?
Resource utilization
- was product/service delivered in cost-effective manner?
- was product/service a good value for the cost?
- was product/service affordable?
5.





Summary of quality measurement
and reporting
Uses objective data for continuous improvement purposes
Provides opportunity to know and manage current
performance
Identifies opportunities to improve
Prioritizes attention
Requires departmental continuous improvement plan (CIP)
- measures operational and management indicators
- establishes departmental goals that support corporate
goals
- reports on progress towards goals
III. Quality improvement



Includes actions taken to improve processes that deliver
products/services to customers
Actions can be efforts of individuals or quality
improvement teams/departments
Here’s what we will discuss:
- action for improvement
- faculty/staff involvement
- continuous quality improvement teams/departments
1. Action for improvement

Here’s the process:
- identify the opportunity to improve
- analyze the problem
- take action to resolve problem
- actions can be made by individuals and teams
- requires skills that may be new to many faculty
and staff
Skills and required concepts…

Understanding stakeholders
and their requirements

Measurement by facts

Process definition and
analysis

Root-cause identification

Plan-Do-Check-Act on-going
improvement cycle
Plan-Do-Check-Act cycle
(PDCA)
1. Plan what to do
4. Act to improve what
you did
Act
Check
3. Check the results
Plan
Do
2. Do what you planned
2. Faculty/staff involvement in CQI





Invaluable resources
Know and use the processes/deliver
the product and service
Know how best to improve the
processes
Closest to the “customer”
Need to know:
- CQI philosophy
- Department CIP plan
- Problem solving skills
- Customer relations skills
3.
Quality improvement teams (QITs)

Groups of faculty/staff who
analyze problems and
recommend actions to resolve
problems

Two kinds of teams:
- functional (one department)
- cross-functional (from
different departments)
4.
Summary of quality improvement


Individuals or teams can make improvements
Problem-solving skills include:
- managing by facts
- process analysis
- root-cause identification and elimination
- PDCA (plan, do, check, act)
IV. Cultural changes
Here are our topics for this one:
 Management commitment
and leadership in process
 Organize for CQI
 Education and training
 Communication
 Our professional attitude and
behavior
 Recognition
Paradigm shift…


The shift is from one of
looking for assessment
activities (narrow) to one
of pursuing continuous
improvement (inclusive)
opportunities
Requires a “higher”
approach to the process
1.
Management commitment and
leadership responsibilities







Knowledge of CQI
Encourage innovation and
risk-taking
Remove barriers
Speak about CQI and process
Encourage participation
Provide necessary resources
Become a role model
Let’s exercise…

1.
2.
3.
List some barriers to CQI
in the organization and in
your area of responsibility
2. Organize for CQI
Organize so everyone will know:
1. Who will develop the plan
2. Who will oversee implementation
3. How employees will be involved in development and
implementation
4. What will be the responsibilities of:
- the board
- executive staff
- deans/department directors
- front-line employees
5. Communication channels
3. Education




Management education
CQI awareness training
Problem-solving skills
- management by facts
- process analysis
- root cause identification
- PDCA
Tools for CQI
Tools and techniques…










Brainstorming
Multi-voting
Selection matrix
Checklist
Graphs
Pareto diagram
Process flow chart
Histogram
Cause-and-effect diagram
Problem statement
Brainstorming

Technique used to generate a large quantity of
ideas in a short time

It is useful because it encourages participation
and contributions from all team members

There is a right way and a wrong way
Benchmarking




Benchmarking is a process of comparing one’s
performance on a specific achievement with that of
another department/organization, etc.
Usually compares one’s own performance with a
“best in class”
Can be useful in setting and reaching realistic goals
Can be harmful if you select one that is just a
mediocre department/company
Check-sheet
Sept
Oct
Nov
Dec
Jan
Feb
Wrong
Question
#1
Question
#2
Question
#3
Etc.
A check-sheet is an easy-to-use form for collecting and processing data. It is used
by teams to collect data and help identify and quantify problems.
Checklist
Registration checklist
Yes
No
Student ID
Admission number
Meal plan
Housing location
Adviser assigned
A checklist is a list of items or steps to be checked off or referred to in completing
a process. It provides an organized way of proceeding.
Bar graph
90
80
70
60
50
East
West
North
40
30
20
10
0
1st Qtr
2nd Qtr
3rd Qtr
4th Qtr
Bar graphs visually represent comparisons among groups of data. Quantities are
shown by means of uniform-width bars (rectangles) whose length is proportional to
the number being represented.
Line graph
100
90
80
70
60
East
West
North
50
40
30
20
10
0
1st Qtr
2nd Qtr
3rd Qtr
4th Qtr
A line graph is a way to visually display data for trends or comparisons.
Histogram
20
18
Admissions in 000’s
16
14
12
10
Admissions
8
6
4
2
0
2001-02
2002-03
2003-04
2004-05
A histogram is another type of bar chart. It is a graphic representation of the distribution of
a set of data. It displays patterns that are difficult to see in a simple table of numbers.
Pie chart
20.4
20.4
27.4
Section
Section
Section
Section
90
A pie chart is used to visually show relative relative proportions or frequency of items.
It can be used to show real numbers or percentages.
1
2
3
4
Pareto chart
Number of complaints
80
70
60
50
40
30
20
10
0
Santa
overslept
Sleigh
broken
Wrong toy
Wrong
address
Reindeer
ill
Pareto analysis is a ranked comparison of factors that make up the subject being analyzed. It helps a team
focus on the vital few problems or causes of problems that have the greatest impact on what the team is
trying to improve. The 80-20 rule: 80% of the problems result from 20% of the causes
Cause-and-effect diagram
Machine
Man
Night technician
Mean machine
Day super
Problem statement
Floors are dirty
Cleaning sol
Process for cleaning
Mops
Materials
Methods
This technique is used to generate, organize, and display the factors that might
contribute to a problem. Lines and arrows show relationship between problem and
potential causes
Process flow chart
Registered for class
Arrived on campus
Picked up packet
Found dorm room
Went to class
Confirmed student
identity
A process flow chart is a graphic representation of the sequence of steps in a process.
It also helps clarify the relationship between steps.
Problem statement
It must:
 Be measurable
 Be specific
 State the pain of how customers are affected
It must not:
 Imply blame
 Imply solutions
Problem statement says in specific and concrete terms what the data have revealed
and what the team will now focus on improving
10 – 4 exercise





Used to quickly determine priorities among
issues and/or ideas
Each member given 10 points to “spend”
Can vote on ideas as desired, but upper limit
is 4 points on any particular item
Ideas getting the most points are declared
winners
Top numbers established in advance, i.e., top
5, top 10, etc.
4. Communication

Varied – newsletters,
bulletin boards, e-mail, etc.

Wide-spread

Frequent

Timely
5.






Our professional attitude and
behavior
We have been working “in” our
profession
We must begin working “on” our
profession
We are responsible for the success
of (fill in the blank) University
Stakeholders expect the very best
from us
We are a million dollar business
unto ourselves
If this were your business, would
you manage it differently?
6. Recognition

Spontaneous and planned events

Individual and team recognition

Small wins and large wins

CQI efforts and successes
7. Summary of cultural changes

Management’s actions demonstrate leadership

Organization’s structure must support CQI

New skills are needed for faculty and staff to participate

Information must be communicated

We must manage our business as though it were our business

Recognition should reinforce continuous improvement activities
Summary of CQI process

Quality planning

Quality measurement and reporting

Quality improvement

Cultural changes
And the benefits of CQI…

Improved outcomes of the educational
processes (student learning outcomes)

Increased student satisfaction

Increased external stakeholder
satisfaction

Improved organizational performance

Improved financial strength
Questions…
Verbs for stating specific learning
outcomes (Creative Behaviors)
Alter
Paraphrase
Reconstruct Rephrase
Rewrite
Ask
Predict
Regroup
Restate
Simplify
Change
Question
Rename
Restructure
Synthesize
Design
Rearrange
Recognize
Retell
Systemize
Generalize
Recombine
Reorder
Revise
Vary
Verbs for stating specific learning outcomes
(General Discriminative Behavior)
Choose
Detect
Identify
Match
Place
Collect
Differentiate
Indicate
Omit
Point
Define
Discriminate
Isolate
Order
Select
Describe
Distinguish
List
Pick
Separate
Verbs for stating specific learning outcomes
(Social Behaviors)
Accept
Communicate Discuss
Invite
Praise
Agree
Compliment
Excuse
Join
React
Aid
Contribute
Forgive
Laugh
Smile
Allow
Cooperate
Greet
Meet
Talk
Answer
Dance
Help
Participate
Thank
Argue
Disagree
Interact
Permit
Volunteer
Verbs for stating specific learning outcomes
(Study Behavior)
Arrange
Compile
Itemize
Mark
Record
Categorize
Copy
Label
Name
Reproduce
Chart
Diagram
Locate
Note
Search
Cite
Find
Lock
Organize
Sort
Circle
Follow
Man
Quote
Underline
Verbs for stating specific learning outcomes
(Music Behavior)
Blow
Compose
Hum
Pluck
Strum
Bow
Finger
Mute
Practice
Tap
Clap
Harmonize
Play
Sing
Whistle
Verbs for stating specific learning outcomes
(Physical Behaviors)
Arch
Bend
Catch
Climb
Float
Bat
Carry
Chase
Face
Grab
Grasp
Kick
Pull
Skip
Swim
Grip
Knock
Push
Somersault
Swing
Hit
Lift
Run
Stand
Throw
Hop
March
Skate
Step
Toss
Jump
Pitch
Ski
Stretch
Walk
Verbs for stating specific learning outcomes
(Arts Behaviors)
Assemble
Dot
Illustrate
Press
Stamp
Blend
Draw
Melt
Roll
Stick
Brush
Build
Drill
Fold
Mix
Mold
Rub
Sand
Stir
Trace
Carve
Color
Form
Frame
Nail
Paint
Saw
Sculpt
Trim
Varnish
Construct
Hammer
Paste
Shake
Wipe
Cut
Handle
Pat
Sketch
Wrap
Dab
Heat
Pour
Smooth
Verbs for stating specific learning outcomes
(Drama Behaviors)
Act
Display
Express
Pass
Show
Clasp
Emit
Leave
Perform
Sit
Cross
Enter
Move
Proceed
Start
Direct
Exit
Pantomime Respond
Turn
Verbs for stating specific learning outcomes
(Laboratory Science Behaviors)
Apply
Demonstrate Keep
Prepare
Specify
Calibrate
Dissect
Lengthen
Remove
Straighten
Conduct
Feed
Limit
Replace
Time
Connect
Grow
Manipulate Report
Transfer
Convert
Increase
Operate
Reset
Weigh
Decrease
Insert
Plant
Set