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Jump-Starting A Quality Program With A Self Assessment

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Jump-Starting A Quality Program With A Self Assessment

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There are plenty of organizations that hire expensive teams of consultants to manage all aspects of assessment, strategy, planning, and implementation of a Quality program. There are others, who decide to try and figure out how to get started on there own. Here's how.

Many organizations have turned to the selection criteria of the Malcolm Baldrige National Quality Award (MBNQA) as a guide to assessing their organizational strengths and areas for improvement. But once the self assessment is complete, what do you do with the information? How do you know which areas are more important, which structures need to be put in place first, what efforts will get you moving? This article looks at how to do a Baldrige self assessment, what to do once you have the assessment results, and when and how to leverage an affordable amount of consulting to help you get started.

Conducting the Assessment
The first step is to conduct a self assessment using the Baldrige criteria. There are other criteria available, such as the Presidential Quality Award available to Government agencies, but the MBNQA criteria are the most generic and the most easily available. The pamphlet[1] contains complete explanations of the criteria, the scoring methods, and interpretation of results.

Forming a team to do the self assessment is key. The self assessment is the first step in a coordinated process of Focusing on the problem, Analyzing the opportunity, Developing a plan for improvement, and Evaluating the results of using the plan (FADE).[2] The self assessment team will share knowledge and come to common understandings during the assessment that will be key to the work of analyzing the results, agreeing on improvements to try, and committing to work together to implement and evaluate the plans.

It is critical that all parties who will be involved in implementation and evaluation of improvement actions be represented on the team. Team products are the result of a largely political process of balancing the aspirations, goals, and concerns of various parties to find a mutually-agreeable solution. At the moment that a concern not represented during the team process is allowed to impact the team solution, the work becomes useless and the valuable time and energy put into it is lost forever.

It is especially important that the individual with the final approval authority for improvement actions be on the assessment team. Otherwise they will not be a party to the early consensus building and will be able to destroy the valuable and costly efforts of the team by second guessing the hard-won agreements the team will come to. This is not common practice in most organizations. In the name of "hearing what the people have to say," "not influencing the outcome," and "maintaining objectivity," most managers will try to stay removed from team process. Understanding the dysfunctional nature of this conventional practice is a the first step in understanding Quality Management. It cannot be overemphasized that the members of the assessment team must be able to make and follow through on a commitment to each other to work together to understand the problem, decide on what improvement efforts they are going to try, and evaluate the outcomes of their efforts. Putting together the correct self-assessment team is the first challenge of creating a Quality program.

At this point, a few days of training in the criteria and conducting the self assessment from an experienced Quality consultant will pay for itself many times over by helping your people climb the learning curve. Otherwise you will pay a high cost in false starts and non-productive discussions of what the criteria really mean and how they interrelate. A certain amount of this discussion is necessary for the self-assessment team to work together. However, a consultant can facilitate and guide this discussion to speed consensus building and maximize the value of the time spent.

After all the team members understand the criteria, a self-assessment strategy should be developed. In most of the scoring items, getting accurate scores will require researching policies, interviewing people, or collecting other pertinent data. A plan and schedule for this data gathering will determine when the team can get back together to do their scoring. Whether the planning and scoring should be done with the help of a consultant will depend on how well people in your organization work as a team. One caution here: most organizations that do uniformly badly at forming and working on teams do not recognize how bad they are. True team performance is characterized by the production of team work products that are not just a collection of individual products, and could not be produced by individuals.[3] If this kind of performance is not commonplace among teams in your organization, you should consider having a facilitator or Quality consultant guide the planning and scoring meetings.

Evaluating the Assessment

The self assessment will provide the organization with three essential products: a numerical score on a scale of 1 to 1000, a list of strengths for each criteria, and a similar list of areas for improvement. Most organizations that are "well managed" by conventional standards will score between 150 and 300, with closer to 150 being more common, and will usually have a fairly balanced list of strengths and areas for improvement, usually about 3 to 10 of each for each criteria.

Most organizations tend to focus on their areas of improvement, starting immediately to categorize, affinitize, and prioritize them for addressing in a gap closing effort. This is the conventional way of addressing identified deficiencies from any sort of assessment, survey, or audit. One of the talents of traditional managers is this method of simultaneously saying "There never was a real problem" and "We have fixed the symptoms" without seeming to contradict themselves. This brings us to the second understanding needed to start a Quality program: fixing the symptom never changes anything. Systems thinking tells us that wrong behaviors usually result from systemic problems, and the system must be fixed before the behavior can be addressed.[4]

Do not be so quick to leave consideration of your numerical score. It is an indication of the kind of change that is required in your organization. Change management experts have a deceptively clear and concise taxonomy of kinds of changes: required change can either be major or minor. The need for major change is characterized by a large number of people needing to make drastic changes in their behavior and/or high resistance to change inherent in how the organization currently does business.[5] Major change is also indicated by a low numerical score. The band 0 to 250 includes the comment "Important gaps exist in most Categories." If that is the case, then there are systemic problems that prevent people from looking at important aspects of how the organization does business, justifying their behavior by saying "That's how we do things around here." If you're in this band, then you need Major Change. Use your numerical score to determine if you have what is fundamentally a good Quality organization with some flaws or if you have an organization designed for the needs of the 50s that has just about reached its peak performance. If you have a score below 200, you need to rethink some major structures and beliefs in your organization.

At the same time, do not overlook the strengths found in the self assessment. The strengths are included for more than just keeping the organization from saying "You didn't give us credit for our XYZ system." Any organization undertaking a change effort, and especially a major change effort, must start from a solid foundation. The only thing you have going for you, the only resource available to you in making change, is your current strengths. Study what the assessment says you do well; later you will want to build on these in your improvement efforts.

Planning Your Improvement

If your numerical score is 350 or greater, somewhere in the "Systematic approach to the purposes of most items" range or better, then you can start working directly on the areas to improve from your self assessment. But major change requires addressing the whole system of your organization. This is complicated by the multidimensional nature of organizations. Viewing your organization as a system, there are several perspectives that can be taken. These are not different pieces of the puzzle, these are different directions from which all the same pieces can be viewed, different threads running throughout the whole of the organization. Stated another way, nearly everything in the organization is affected by the leadership, and nearly everything affects the people. So in attempting to improve your score in leadership or human resources, nearly everything in the organization will have to be considered from the leadership or the human resources perspective. Conversely, when working on the leadership dimension, changes throughout the organization must be considered from the human resources (an all other) perspectives to keep from making those dimensions worse.

If your organization needs major change, it is likely that one or more of the key dimensions are out of alignment with the goals and objectives of the organization. Planning for improvement means finding the misaligned dimensions and focusing improvement efforts on learning about and aligning those dimensions. Some of these dimensions are reflected in the seven criteria of the Baldrige award, such as leadership, human resources, information resources, results focus, and customer focus. But the Baldrige criteria are purposely not prescriptive, and therefore cannot address other key dimensions that affect results. Dimensions of the organization not covered by Baldrige but affecting the overall Quality management include corporate structure, job structure, reward structure, the performance ethic,[6] and the mental models that exist within the climate and culture of the organization. While no one structure or culture can be pointed to as "good" or "bad," a high-performing organization is characterized by an alignment of all it's dimensions.[7] An organization whose hierarchical structure is out of alignment with it's vision of being "fast and flexible" will not achieve high performance.

Part of the message of Baldrige and the basis of the criteria is that improvement should be data driven: use the data to find out what is working and what isn't, then fix what isn't. But if nothing is working well, where do you start?

You start by looking at the primary source (or sources) of what is not working well. The Baldrige criteria ask three basic questions:

1) How are you doing in addressing what matters to the organization? Are customers satisfied with what we do for them (criteria 7)? Are you making money (profit company) or achieving your desired outcomes (not-for-profit or public sector) (criteria 6)?

* Are you helping or hurting yourselves in the process? Do your processes have a good return on investment, a good "give to get ratio," or do you suck up too much time and energy for what you get back (criteria 5)?
* Are people used as a rare and precious resource or used up in an attempt to show activity without spending money (criteria 4)?
* Is there a plan for moving forward based on a clear vision of where we need to be and what obstacles must be overcome to get there and what strengths can be counted on along the way (criteria 3)?
* Is information used effectively to avoid decisions based solely on "management intuition" and "conventional wisdom" ("that"s the way we do things around here") (criteria 2)?

3) Is top management providing leadership in addressing what matters (criteria 1)" Or do people in leadership positions provide bad administration, worse management, and almost no leadership"

Which of these processes is working badly? Which is there a lot of energy being spent around fixing, but little improvement to show for it? These are all indicators of dimensions of the organization that are out of alignment, of resistance to the vision, goals, and objectives residing in the structure, behavioral norms, and common practices.

Obtaining Alignment

The key dimensions of the organization must each be considered in figuring out where to make adjustments. Just as aligning a piece of equipment must proceed in the correct order to result in satisfactory performance, so to must your organization be aligned in the proper order. For many organizations, the following three dimensions are a good place to start.

Information Resource Management

You can't make data-driven decisions if you don't have data. Most organizations in the 0 to 250 score band have little or no real data on how they are doing with their customers, with their employees, and with their suppliers. And organizations that are not profit based often have a similar lack of real data on how they are doing on their key outcomes.

The first step is to get real data. Care must be taken to balance hard and soft data, formal and informal methods, and internal and external sources. Care must also be taken to make sure that preconceptions and paradigms do not influence data gathering or interpretation. There was once a psychological researcher working with rats: if the rat didn't perform the way the researcher's theory said it should, he threw the rat up against the wall with a loud German oath. Expect to hear bad news and have your beliefs shaken: you might be pleasantly surprised, but you won't be fooled.

If the climate has not been open and trusting, then confidentiality must be enforced if you want to hear the truth. Be patient. It may take people a long time to figure out that you really want to know what's going on, not receive the usual "no worries" coverup.

Performance Ethic

Most organizations will talk about an emphasis on performance, but many lack a balanced picture of what that means. High performance organizations have a three-pronged approach to achieving performance. They focus on customers, people, and results. Results are why you exist, but results come from customers (profit) or are measured by them (not-for-profits). And it is people who satisfy those customers and achieve those results. These are like the three legs of a stool: pull out any one leg and the stool falls over. Each aspect of performance requires nearly equal focus: too much focus on one, and eventually one of the others will let you down.

This focus has to be more than lip service or a sense that everything is going okay. If you're not constantly terrified about what might be happening to you in any and all of these three areas, then you're not taking them seriously enough. You must be constantly gathering hard and soft data from formal and informal methods about how you are doing, how your customers think you are doing, and how your people are coping with the demands for their time and energy and the perceived benefit to the organization and themselves from their effort. You must have a formal method for using the information to drive substantive improvements in each area. And you must be ready to throw out cherished assumptions about how things should be done if the data says they are causing problems in one of the key areas.

Culture and Climate

The culture and climate of your organization can really screw up your attempts to institute a Quality program, to achieve high performance. Are managers expected to know what to do, or are they expected to ask customers and employees what needs to be done? Are they expected to have all the answers, or are they expected to constantly and visibly seek data and act upon it? Are all projects expected to succeed, or are people rewarded for recognizing early that a path will not yield results and abandoning it, with adequate documentation of lessons learned?

Is conflict valued as a source of strength and new ideas, or is conformity expected? Is diversity valued, or can anyone of any gender, color, and heritage work here as long as they think like a white male? Is there a perceived necessity to cling to traditional forms of structure, authority, job design, and reward even in the face of hard data that they are out of alignment with the vision, goals, and objectives of the organization?

Closing the Gap

This article is too short to talk about all the methods, techniques, concerns, and pitfalls associated with making changes in the alignment of the critical dimensions of an organization. Each of the dimensions mentioned here and many others besides have had volumes written about them. Your best bet is to identify the dimension that most needs realignment, then get consulting help in working on that dimension. However, there are a few basics to keep in mind.

Multidimensional Change

First, remember that your organization is multidimensional and therefore change will be multidimensional. Even if you are focusing on only one dimension, it will pull the other dimensions a little out of alignment. Try to find a change consultant that is not too single minded in fixing what you are working on, and constantly second guess her or him as to whether enough attention is being paid to the rest of the organization.

Stages of Change

Change is a three-stage process. It is not a single step of stopping one thing and starting another. All change involves an ending, a beginning, and a place of uncertainty in between. Each of these stages has its own requirements.

Any change involves giving up something. Even if the change is obviously for the better for all concerned, there are certain habits, assumptions, and familiar routines involved in the old that will be missed. Ending is a little death, and to a certain extent must be grieved the same as Big Death. Expect the phases of denial, bargaining, anger, depression, and acceptance,[8] even if the change is as small as moving people's offices. Acknowledging the endings, maybe even celebrating the accomplishments of what is coming to a close and then ritually shutting it down, can help with this step.

The place of uncertainty is sometimes called "the neutral zone." [9] In the neutral zone, groups and individuals are finding their new path in the changed landscape of the organization. They are finding what works and what doesn't, what they care about, what they have energy for and where they can best apply that energy. Job descriptions and roles and responsibilities have never been as important as we believed: they lose even more of their importance as the organization becomes more flexible and responsive to achieve higher performance. Change of any sort, alignment of any of the dimensions, will make people rethink the best match of their skills, interests, and opportunities. This process cannot be rushed. If it is forced to premature conclusion, it will have to be repeated as people realize they have made choices that were not right for them.

During the neutral zone, performance will be lower than it was with the old system. People will grumble and grouse about going back to the old ways, especially if they were not allowed to grieve the ending. If some people in the Soviet Union want to go back to communism and many Israelites during the 40 years in the desert wanted to go back to slavery in Egypt, it should not surprise you that people will get tired of the neutral zone and want to go back to the old system. Keep the faith, stay the course, don't change horses in the middle of the stream, and invoke any other clich you must to get the organization through this time.

Finally you will get to the beginning. People are settling in, work is getting done, things seem to be ticking along. Now it is time to think about the next change.

Real Change vs. Surface Change

The last thing to remember about gap closing is that, if your organization is like most, people have seen a lot of flavor-of-the-month change fads come and go. If you are not persistent, consistent, and insistent in your change efforts, they will wait you out. Some ways to make sure change "takes" have already been discussed: look for the need to realign, not just change the surface; look for ways in which the culture and climate have to change to overcome the resistance of "the way we've always done things;" build on the organization's strengths; pay attention to the multidimensional nature of change. Other keys include:

Change the reward systems: teams will never really catch on in an environment of individual rewards, and early identification and abandonment of failure will never become the norm when all rewards go to successes.

Change the mental models; institute the practices of systems thinking and personal mastery that are fundamental to a learning organization -- no organization can change if it cannot learn.

Look for the leverage points: not everything has to be fixed for things to get better. Look for the key things that are holding you back and the strengths that can move you forward. A word of caution: forces that hold you back tend to increase in reaction to increases in forces that move you forward: it is critical to remove some restraining forces as well as increase some supports (rewards are a good example).

Understand the new system: don't just read one Harvard Business Review article or attend one half-day seminar. If this is the new way of doing business, it is your new way of doing business: read, study, discuss, and understand everything you can get your hands on.

Another approach is to use the conscious change model.

The Conscious Change Model

The conscious change model recognizes seven distinct stages involved in all real change.[10] The first stage is the form: what we are doing now. The second stage is the challenge: what we are doing doesn't seem to be working any more. We wonder why. We begin to see things in what we are doing that seem dysfunctional and counterproductive. This is the desired result of the self assessment.

The third stage is resistance. This is when all the years of following the old form, when all the conventional wisdom, all the things we were told by our parents or our mentors or the old gurus, all our fear of change, all the vested interests of those who will lose from the change, all the fears of little death, tell us that the old form worked for a long time and there is no need to change it. Or we use the old form to try and change the outcomes: we go about fixing things uncovered by the self assessment the way we have always fixed things. This resistance must be overcome by the forth stage, the Aha. The Aha occurs when we see that the truth we were working under lay deeper than the surface of the old form: that while the objectives were right, the things we were doing to get there were just a surface form that worked for awhile. The universal truth is in the objective, not the practice. Based on seeing reality just a little deeper, we see how we can change the form and still be true to the goals and nature of the organization. We can align structure, policies, and culture to our vision, goals, and outcomes[11] without losing what we are about.

If the Aha is powerful enough to create a vision of a new form, then the fifth stage is commitment to that new form. But the commitment we make is not to the whole new way: it is a commitment to begin the three-phase process of ending, neutral zone, and beginning. During the ending and the neutral zone, there will be the sixth stage, the trial by fire. All the devils of grieving through the ending and uncertainty about the path through the neutral zone assail us and try to get us to turn back. If we stay the course, we reach the seventh stage: the beginning, the integration of the change into the form of our organization, our community, or our self. Then we sharpen our awareness to look for the next challenge to our current form.

We have talked about several "Ahas" required for Quality management in this paper, including how we form work groups and respond to their products, how we do teams, and how we address deficiencies in the old form. There may need to be more than one cycle of conscious change involved in implementing Quality Management -- the culture and processes may have to change a little at a time. The first step is changing how things are changed -- understanding the nature of major change and learning how to throw away old structures and processes to achieve alignment with objectives and values. As we make the commitment to use this new way of changing things, we will begin to create the environment for Quality management. The trial by fire will be holding on during the slow process of using a better way of making change to obtain real process improvement, and waiting while those improved processes produce measureable improvement in results.

Conscious change is hard, and still may not produce the desired results. Gather your data, try something, evaluate your progress, make small or big corrections to your initiatives, and start the cycle again. Keep your eye on the goal: continuous, data-driven improvement in all three aspects of performance.



* Throughout this paper, Quality with a capital "Q" will be used to denote management practices based on the concept of Quality management or Total Quality Management (TQM) or programs aimed at instituting such practices. Quality with a capital "Q" is differentiated from the word "quality" with a lower-case "q," the later denoting those characteristics and properties of goods and services that result in a perception of usability, value, or satisfaction in the eyes of customers and consumers. Thus good management may be quality management but may not be Quality management.


[1] The Malcolm Baldrige National Quality Award 1996 Award Criteria (updated annually), administered by: United States Department of Commerce, Technology Administration, National Institute of Standards and Technology, Route 270 and Quince Orchard Road, Administration Building, Room A537, Gaithersburg, MD 20899-0001

[2] The United States Coast Guard Process Improvement Guide for Teams and Individuals, Petaluma, CA: The Quality Center, 1993

[3] Katzenbach, Jon R. And Douglas K. Smith, The Wisdom of Teams: Creating the High-Performance Organization, New York: Harper Business, 1993

[4] Senge, Peter, The Fifth Discipline: The Art and Practice of the Learning Organization, New York: Doubleday Currency, 1990

[5] Katzenbach et. al, op. cit.

[6] , Edward, "Facilitating for High-Performance Teams," 1997, Unpublished

[7] Mohr, Bernard J., "Theory, Method, and Process: Key Dynamics in Designing High Performance Organizations from an Open Socio-technical Systems Perspective," The Emerging Practice of Organizational Development, Sikes, Drexler, and Gant, eds., San Diego: NTL Institute for Applied Behavioral Science and University Associates, 1989

[8] K'bler-Ross, Elisabeth, On Death and Dying,New York: Macmillan, 1969

[9] Bridges, William, Transitions:Making Sense of Life's Changes, New York: Addison-Wesley, 1980

[10]Karpinski, Gloria, Where Two Worlds Touch, New York: Ballantine, 1990

[11] Mohr, op. cit.

This Article is authored / contributed by ▸ Edward R. who travels from Waterford, United States. Edward is available for Professional Consulting Work both Virtually and In-Person. ▸ Enquire Now.

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