Public Health Nursing Vol. 8 No. 3, pp. 190-195 0737-1209/91/$5.00 0 1991 Blackwell Scientific Publications, Inc.
Quality Circles in the Public Health Sector: Implementation and Effect June A. Schmele, R.N., Ph.D., Mary E. Allen, R.N., Ph.D., Sandra Butler, R.N.C., M.S., and Deborah Gresham, R.N.C., M.S.
Abstract Although the quality circle (QC) process has been used in health care, there is a conspicuous gap in the literature about its use in community health nursing. The purpose of this service/education project was to implement QCs in the public health nursing sector throughout a southern central state. The major objective was to provide QC training to approximately 250 supervisors and staff nurses so that this participative group problem-solving approach might be used as a systematic method of dealing with concerns related to quality of care. Evaluation tools, such as the Science Research Associates' attitude scale and the quality management maturity index, were used to determine whether or not the implementation of the QC program influenced the level of morale and quality management maturity. The data obtained reflected positive changes and favorable supervisory responses.
Many challenges face community nurses and community nurse administrators in today's rapidly changing health care environment. One of them is to increase, or at least maintain, the quality of nursing care while attempting to minimize personnel costs. The purpose of this joint service and education project was to address this issue by implementing the participative management practice of quality circles (QCs) as a strategy to deal with problems and issues relating to quality of care. The practice component was to prepare all public health nurses in the state of Oklahoma to use the QC process. The project objectives were to implement the QC process in the Public Health Nursing Department throughout the state and to explore the relationship between it and the evaluation components of morale and quality management maturity. As part of the evaluation process answers to the following questions were sought: 1. Is there an increase in morale as measured by the
Science Research Associates' attitude scale (SRA) after the implementation of QCs? 2. Is there an increase in quality management maturity as measured by the quality management maturity index (QMMI) after the implementation of QCs?
CONCEPTS June A . Schmele. R . N . . P h . D . , and Mary E . Allen. R . N . , P h . D . . Lire with the University of Oklahoma College of Nursing. Sandra Butler, R . N . C . , M . S . is with Carter County Health Depurtment, Ardmore. Oklahoma and Deborah Gresham, R .N . C . , M . S . is with Oklahoma State Department of Health. Oklahoma City. Okluhoma. Address correspondence to June A . Schmele, University of Oklohoma Colleae P.O. E o x 2 6 9 0 / . Oklahoma City. OK .. ofNursina, 73190.
Quality Circles The theoretical foundation for quality circles is based on several well-established motivational and management theories ( M ~ ~1954; I ~~ ~ , ~M ~~& snyder~ ~ ~ man, 1968; McGregor, 1960; McClelland, 1951). More recently Ouchi (198l) promulgated theory z as a participative management approach in which workers and
b~
Schmele et al.: Quality Circles
managers have a shared responsibility for decision making. Goldberg and Pegels (1984) suggested that a worker’s basic social and psychologic needs are most satisfied in environments that are open and supportive of opportunities for self-determination and job satisfaction. The concept of QCs emerged in Japan in the postWorld War I1 era when Deming, who was a Harvard professor and statistician, was consulted with respect to rebuilding Japanese productivity (Rehder, 1981). Further development of the QC concept was done by Juran in 1954 (Crocker, Charney, & Chiu, 1986). These experts recognized the value of participative problem solving and decision making to increase productivity. Ishikawa (1985) is recognized as the founding father of the Japanese QC movement, which has been widely recognized as a successful management approach. Honeycutt (1989) identified the three major determinants of QC effectiveness as administrative support, member training, and voluntary participation. Currently QC movements have been gaining popularity in North America, being used successfully in several large companies in the U.S. and Canada (Crocker et al, 1986). The movement has been recognized and used in the health care sector during the last 20 years (Goldberg & Pegels, 1984; Helmer & Gunatilake, 1988), but has evolved only recently in nursing services (National League for Nursing, 1982). Nelson Associates (1981) developed a modular training approach to implement it in nursing, using the definition of QC as “. . . a problem solving group, consisting of 6-12 people. The Circle meets together during work time for an hour each week to identify problems, recommend solutions, and implement solutions” (p. 5). Nelson Associates, in collaboration with the National League for Nursing (NLN), presented the approach to health care personnel throughout the country. The model used, as well as the author’s project, is shown in Figure 1. Most reports in the literature about QCs in nursing deal with its use in the acute-care setting (Turner, 1986; Tinello-Buddle, 1986; Fiedler, 1987; O’Brien, 1988; Eason & Lee, 1988). Characteristics of the setting such as physical proximity, unit team practices, common patient care objectives, and participative management practices may facilitate the development of QCs. Although the public health sector shares the characteristics of team focus, participative management, and common objectives, it is recognized that major differences are found in organizational structures, lack of geographic proximity of work groups, and the largely autonomous practice with client groups and populations. Although the authors were unable to find literature dealing with the use of QC specifically in community health, it was recognized that programmatic goals and the need
191
t
3. COLLECTBASEUNEDATA
\
I
4.
ANALYZE&-
/’
Figure 1. The quality circle process. Adapted from Nelson Associates.
for multidisciplinary and interdisciplinary collaboration in the public health sector lend themselves to the formation of QCs. Since t h e literature strongly substantiated their value in nursing and health care, this project was prompted to explore their implementation and subsequent value in community health nursing, and more specifically in the public health sector. Synthesis of the literature clarifies the QC concept as a group problem-solving method, which in turn evolves into a long-term participative management approach. The approach is based on the management belief that workers have creative abilities and valuable ideas that can be used to solve problems that affect their own work. It is widely accepted that the main attribute of QCs is its focus on participation in problem solving, for example, in quality of patient care, staff retention, productivity, and multidisciplinary collaboration. Quality Management Maturity
The second concept addressed was quality management maturity. Crosby, who is considered a guru of quality in industry today, developed the quality management maturity grid that can be used to show where an organization is on a continuum. This continuum of “uncertainty” to “certainty” is measured in the following areas: .management understanding and attitude, organization, problem handling, cost of quality, quality improvement actions, and the summation of the organization’s posture toward quality (Crosby, 1979, pp. 32-33). Previous work by Schmele and Foss (1989) described the use of the grid in the health care setting. For this project, quality management maturity was defined as the stage of perceived organizational readiness to deal with quality matters as measured by paper and pencil responses to the QMMI.
192 Public Health Nursing
Volume 8 Number 3 September 1991
Morale
strument has established reliability and validity. It contains 78 items on which subjects respond to a modified The literature substantiates, although implicitly, the Likert scale of “agree” to “disagree.” The I5 subscales idea that staff participation has value in maintaining and are scored separately, with favorable responses receivimproving morale. Morale is frequently referred to in ing a score of I and nonfavorable responses receiving a the literature but it is seldom defined (Shires, 1984; score of 0. Sbordone. 1983). Webster’s dictionary defines it as “the level of individual psychological well-being based on such factors as a sense of purpose and confidence in the IMPLEMENTATION future” (Woolf, 1974, p. 748). Although the literature lacks conceptual clarity, the value of high morale in The idea for the project was initiated by the Nursing health care settings is strongly identified, and its rela- Quality Assurance Committee of the Oklahoma State tionship to productivity and quality of care was made Department of Health. The author was invited as facquite clear by Haw and associates (1984). For this proj- ulty consultant to participate in exploring the feasibility ect, morale was defined as the level of psychologic well- of such a project on a statewide basis. After the initial being as measured by paper and pencil responses to the planning meeting with the chief of nursing and the Quality Assurance Committee, the decision was made to faSRA. cilitate a centrally located, one-day workshop for all the district nursing supervisors, to familiarize them with the SETTING concept of QCs and demonstrate its use for quality asThe Oklahoma State Health Department consists of 77 surance purposes. The supervisors’ feedback after the counties. Although not all of them have local health de- workshop was, with few exceptions, very positive. partments, some may have more than one site. A total Based on this evaluation, the decision was made by the of 84 sites are divided qmong 19 district nursing super- chief nurse and the Quality Assurance Committee to imvisors. All county health departments are accountable plement the QC process on a statewide basis. At a joint to implement federal and state directives regarding pro- meeting of nursing administration, the Quality Assurgrams and nursing protocols, and each county is auton- ance Committee, and the faculty consultant, it was deomous in the implementation process. One large met- cided that nine identical one-day workshops would be ropolitan area opted not to participate in this project. held at various regions throughout the state to show that Since each county is an individual unit, the dynamics administration valued the nurses’ time and energy, may be quite complex for programs originating from the which would not have to be spent in traveling. In addistate or district level. Differences among districts in- tion, some of the quality issues and concerns could be clude size of population served, services delivered, specific to a particular geographic area. number of nurses, and personal characteristics of nursIn general, the supervisors and nursing staff were reing supervisors and local administrators. For example, ceptive to the workshop, probably due to strong adminwithin each of the 16 districts the number of nursing istrative support. The participants were 250 registered personnel varies from I 5 to 52. public health nurses who were employees of the Public Health Department and who functioned at the local TOOLS county unit level. Prior to beginning each six-hour Objective preevaluation and postevaluation measures workshop, the pretests (SRA and QMMI) were adminwere chosen to determine if the implementation of QC istered to all the participants. The workshop consisted influenced the morale and the quality management ma- of four major parts: turity. The QMMI measures the organizational readiness for quality improvements and is based on Crosby’s 1. Didactic (overview, QC model) quality maturity grid (1984). This short instrument, 2. Large group process (experience with model) which the first author developed, consisted of six major 3. Small group processes (use of model) questions. Using a multiple-choice format, respondents 4. Summary and evaluation check the item in each section that best represents their Administrative guidelines for the implementation perception of the organization with regard to quality. Previous studies by the investigator yielded a reliability phase were that each district nursing supervisor was expected to hold at least one QC per quarter in his or her alpha for the QMMI of 0.76 (Schmele & Foss, 1989). The SRA, developed by the Employee Attitude Re- district, a summary report of the QC meeting was to be search Group of the Industrial Relations Center at the sent to central office twice a year, and the reports were University of Chicago (Miller, 1977), measures em- to be shared by all district nursing supervisors. During the first six months each supervisor solicited ployee attitudes toward the work environment. The in-
Schmele et al.: Quality Circles
local administrative support, as well as authorization to travel to a regional site to meet together, since most counties did not have a large enough staff to hold QC meetings at their site. These geographic differences resulted in increased cost of travel and time, as well as the drawback of attempting to organize people who work great distances apart. In spite of these drawbacks, similar problems surfaced and creative solutions were derived. For example, one district supervisor held a QC with members from four counties. They identified common issues and problems, and subsequently divided into three interest groups, each working on resolving a particular problem: clinic efficiency, development of patient education tools for sexually transmitted diseases, and program development to increase the number of breast-feeding mothers. At the central office level the monitoring of the QC reports led to identification of other common problems such as lack of a systematic approach to client tracking. As a result, a central committee redesigned an improved tracking system that would benefit the local level.
193
TABLE I . PretestIPosttest Comparisons of M e a n Scores for SRA Attitude Scale ( N = 91) ~
~~
~
~
Subscales
Pretest
Posttest
Job demands Working conditions Pay Employee benefits Friendliness, cooperation Supervisor-employee relat ions Confidence in management Technical competence Effectiveness of administration Adequacy of communications Security of job Status and recognition Identification with the organization Opportunity for growth Reactions to the attitude survey
3.52 4.11 I .56 2.74 2.97
3.30 3.82 I .26 2.96 2.88
5.30 4.22 4.05
4.86 3.87 4.05
2.79 3.60 3.97 4.56
2.71 3.52 3.41 4.22
3.11 2.43
3.07 2.24
I .09
.78
EVALUATION The majority of supervisors held QC meetings as directed. Six months after the intervention phase began, the respondents were again asked to complete the same instruments. Ninety-one (37%) group participants returned the matching SRA and QMMI pretests and posttests. The majority were women, between ages 31 and SO years, with nursing experience 10 years or more. Four to 10 years of this experience was in the health department. The participants were fairly evenly divided among diploma, associate, and baccalaureate degrees, with the highest percentage being diploma prepared. Question 1
Is there an increase in morale as measured by the SRA after the implementation of QCs? The mean scores of the 15 subscales of the SRA were computed. The pretedposttest comparison table of means is read horizontally to note changes in the mean (Table I). The mean scores for the majority of the subscales were less in the posttest than in the pretest. The only exceptions to this were “friendliness and cooperation,” which increased 0.09 and “technical competence,” which stayed the same. A f test for paired comparisons showed no statistically significant increases in any of the subscales. There may be several explanations for this unanticipated finding. Perhaps the most plausible is that other uncontrolled variables were also affecting staff morale. Some incident. may have occurred that had negative affects on morale, washing out any positive effect of the QC intervention. For example, the respondents showed
unfavorable responses to the subscale “response to the survey.” It would appear that there may have been a low level of trust, and that the QC intervention may have been viewed as just another approach that was not likely to yield results. Narrative comments on the questionnaire would support this. This finding also may offer some further explanation for the low response rate brought about by the lack of matching identification numbers on the pretest and posttest. Question 2
Is there an increase in quality management maturity as measured by the QMMI after the implementation of QCs? In contrast to the SRA. the QMMI mean scores showed an increase in all pretedposttest scores for the individual items as well as the summed score, which showed an increase of 1.72 (Table 2). The greatest increases were for items dealing with “boss attitude,” “agency approach,” and “quality improvement. ’’ Although there was a visible increase in all the individual scores between the pretest and posttest, using the r test, it was not statistically significant in the summed score. However, the raw scores of the QMMI suggest that after participating in QC the respondents perceived increased organizational readiness to deal with quality matters. It seems self-evident that the large administrative investment of resources (time and money) would indicate to the nursing staff that management was indeed serious about solving such problems.
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Volume 8 Number 3 September 1991
TABLE 2. Comparison of PretestlPosttest M e a n Scores for QMMI ( N = 91) ltems
Pretest
Posttest
Boss attitude Agency approach
4. I6 2.83 3.54 I .29 3.43 3.70 18.86
4.70 3.29 3.63 I .30 4.10 3.76 20.58
Problem handling
Quality costs Quality improvement Agency position QMMI total
Follow-Up Survey A survey evaluation of the QC program by the nursing
supervisors was recently sent to each of the 17 district nursing supervisors. All 17 responded and reported that they were using the QC process, with most describing multidisciplinary involvement. The supervisors' narrative comments were favorable, indicating in general that they perceive QCs to be valuable in involving staff in problem solving related to quality issues, and that the quality of care had indeed improved. Because of the possible value in long-term assessment of the perceived effects of QC. a survey is currently being conducted with both managers and staff nurses.
DISCUSSION The major objective of the project, which was to prepare nurses to use the QC process, was clearly met. From a practice standpoint, district nursing supervisors do indeed continue to implement the QC program and report it as successful and effective for dealing with quality assurance concerns. The implementation process was strengthened by the fact that the district nursing supervisors played a major part in the original decision to adopt QCs as a problemsolving mechanism and were also the first group to be instructed. Strong administrative and supervisory support was evidenced by the nursing service goal, which addressed the implementation of the QC process over three years. Further administrative endorsement at the local level, as well as multidisciplinary collaboration for mutual problems, has strengthened and enriched the approach. One supervisor emphasized the importance of giving it a high priority. Her experiences revealed that the results have been effective problem solving, improved quality of care and documentation, improved efficiency of service delivery, and increased employee motivation. Suggestions for improving implementation include the formulation of clear guidelines and expectations based on the critical aspects of QC. For example, it may
strengthen the process to define proactively the guidelines of topics, volunteerism, leadership, and frequency of meetings. Also, the continuous development of local administrative support and subsequent multidisciplinary collaboration for common concerns to be handled in a QC presents a worthwhile challenge and goal.
CONCLUSION From a practice perspective, the statewide QC program yielded positive results, and it continues to be used by public health nurses as a participative approach to deal with problems related to quality. in addition, collaboration between the service and academic settings brought about by planning and implementation resulted in the forming of effective working relationships. In conclusion, QCs appear improve the quality of public health nursing since many nursing problems involve various disciplines. As this process lends itself to a concerted effort through multidisciplinary use, it has much potential for implementation in the public health sector.
ACKNOWLEDGMENTS The authors express appreciation to the nursing administrative and field staff of the Oklahoma State Department of Health for their participation in this project. Gratitude is also expressed to research assistant Margo MacRoberts for her assistance.
REFERENCES Crocker. 0. L.. Charney, S., & Chiu. J . S. L. (1986). Quality circles. New York: New American Library. Crosby. P. B. (1979). Quality is free. New York: New Arnerican Library. Eason. F., & Lee, B. (1988). Quality circles-A summation for inservice education: Using circles to increase staff nurse participation in problem solving. Journal uf Nursing StaffDevelopment, 4(3). 131-132.
Fiedler, I. G. (1987). Quality circles-an approach to health care. Journalof Nursing StaffDevelopment, 3(3), 118-1 19. Goldberg, A. M., & Pegels, C. C. (1984). Quality circles in health care facilities. Rockville, MD: Aspen. Haw, M. A., Claus, E. G . , Durbin-Lafferty, E., & Eversen, S. M. (1984). Improving nursing morale in a climate of cost containment. Part I. Journal of Nursing Administration, l 4 ( I I). 10-15.
Helmer. F. T., & Gunatilake, S. (1988). Quality circles: A supervisor's tool for solving operational problems in nursing. Health Care Supervisor, 6(4), 63-71.
Herzberg, F.. Mauser, B., & Snyderman, B. (1968). The mutivafion to work. New York: John Wiley & Sons. Honeycutt, A. (1989). The key to effective quality circles. Training and Development Journal, 45(5), 8 1-84. control? Englewood
Ishikawa, K. (1985). What is total quality Cliffs, NJ: Prentice-Hall.
Schmele et al.: Quality Circles
Maslow, A. (1954). Motivation and personality. New York: Harper & Row. McClelland, D. C. (1951). Personality. New York: William Sloan Associates. McGregor. A. (1960). The human side of enterprise. New York: McGraw-Hill. Miller, E. D. (1977). Handbook of research design and social measurement (3rd ed.) (pp. 358-363). New York: Longman. National League for Nursing. (1982). Quality circles in nursing service. New York: Author. Nelson Associates. (1981). Quality circles in health care. Cedar Rapids. IA: Author. O'Brien. B. (1988). QA: A commitment to excellence. Nursing Management. 19(1 I ) , 33-40. Ouchi. W. G . (1981). Theory Z . Reading, MA: AddisonWesley. Rehder. R. R. (1981). What Americans and Japanese man-
195
agers are learning from each other. Business Horizons, 2 4 Marc h-April), 68. Sbordone, R. J . , and Sterman, L. T. (1983). The psychologist as a consultant in a nursing home: Effect on staff morale and turnover. Professional Psychological Research Practice, 14(2), 240-250. Schmele, J . A., and Foss, S. J. (1989). The quality management maturity grid: A diagnostic method. Journal of Nursing Administration, 19(9), 29-36. Shires, B. (1984). Accentuate the positive, improving morale is everyone's job. Nursing Lge, 4(5), 26-27. Tinello-Buddle. N. (1986). Quality circles: A management strategy that works. Nursing Success Today, 3(4), 9-1 I . Turner, S. (1986). The hurnerous joint commission and burns and bones: Quality control circles on orthopaedic surgery divisions. Orthopaedic Nursing, 5(2), 19-22, 31. Woolf. H . B . (Ed.). (1974). Webster's new collegiate dictionary. Springfield, MA: G . & C. Merriam.
Quality Circles in the Public Health Sector: Implementation and Effect June A. Schmele, R.N., Ph.D., Mary E. Allen, R.N., Ph.D., Sandra Butler, R.N.C., M.S., and Deborah Gresham, R.N.C., M.S.
Abstract Although the quality circle (QC) process has been used in health care, there is a conspicuous gap in the literature about its use in community health nursing. The purpose of this service/education project was to implement QCs in the public health nursing sector throughout a southern central state. The major objective was to provide QC training to approximately 250 supervisors and staff nurses so that this participative group problem-solving approach might be used as a systematic method of dealing with concerns related to quality of care. Evaluation tools, such as the Science Research Associates' attitude scale and the quality management maturity index, were used to determine whether or not the implementation of the QC program influenced the level of morale and quality management maturity. The data obtained reflected positive changes and favorable supervisory responses.
Many challenges face community nurses and community nurse administrators in today's rapidly changing health care environment. One of them is to increase, or at least maintain, the quality of nursing care while attempting to minimize personnel costs. The purpose of this joint service and education project was to address this issue by implementing the participative management practice of quality circles (QCs) as a strategy to deal with problems and issues relating to quality of care. The practice component was to prepare all public health nurses in the state of Oklahoma to use the QC process. The project objectives were to implement the QC process in the Public Health Nursing Department throughout the state and to explore the relationship between it and the evaluation components of morale and quality management maturity. As part of the evaluation process answers to the following questions were sought: 1. Is there an increase in morale as measured by the
Science Research Associates' attitude scale (SRA) after the implementation of QCs? 2. Is there an increase in quality management maturity as measured by the quality management maturity index (QMMI) after the implementation of QCs?
CONCEPTS June A . Schmele. R . N . . P h . D . , and Mary E . Allen. R . N . , P h . D . . Lire with the University of Oklahoma College of Nursing. Sandra Butler, R . N . C . , M . S . is with Carter County Health Depurtment, Ardmore. Oklahoma and Deborah Gresham, R .N . C . , M . S . is with Oklahoma State Department of Health. Oklahoma City. Okluhoma. Address correspondence to June A . Schmele, University of Oklohoma Colleae P.O. E o x 2 6 9 0 / . Oklahoma City. OK .. ofNursina, 73190.
Quality Circles The theoretical foundation for quality circles is based on several well-established motivational and management theories ( M ~ ~1954; I ~~ ~ , ~M ~~& snyder~ ~ ~ man, 1968; McGregor, 1960; McClelland, 1951). More recently Ouchi (198l) promulgated theory z as a participative management approach in which workers and
b~
Schmele et al.: Quality Circles
managers have a shared responsibility for decision making. Goldberg and Pegels (1984) suggested that a worker’s basic social and psychologic needs are most satisfied in environments that are open and supportive of opportunities for self-determination and job satisfaction. The concept of QCs emerged in Japan in the postWorld War I1 era when Deming, who was a Harvard professor and statistician, was consulted with respect to rebuilding Japanese productivity (Rehder, 1981). Further development of the QC concept was done by Juran in 1954 (Crocker, Charney, & Chiu, 1986). These experts recognized the value of participative problem solving and decision making to increase productivity. Ishikawa (1985) is recognized as the founding father of the Japanese QC movement, which has been widely recognized as a successful management approach. Honeycutt (1989) identified the three major determinants of QC effectiveness as administrative support, member training, and voluntary participation. Currently QC movements have been gaining popularity in North America, being used successfully in several large companies in the U.S. and Canada (Crocker et al, 1986). The movement has been recognized and used in the health care sector during the last 20 years (Goldberg & Pegels, 1984; Helmer & Gunatilake, 1988), but has evolved only recently in nursing services (National League for Nursing, 1982). Nelson Associates (1981) developed a modular training approach to implement it in nursing, using the definition of QC as “. . . a problem solving group, consisting of 6-12 people. The Circle meets together during work time for an hour each week to identify problems, recommend solutions, and implement solutions” (p. 5). Nelson Associates, in collaboration with the National League for Nursing (NLN), presented the approach to health care personnel throughout the country. The model used, as well as the author’s project, is shown in Figure 1. Most reports in the literature about QCs in nursing deal with its use in the acute-care setting (Turner, 1986; Tinello-Buddle, 1986; Fiedler, 1987; O’Brien, 1988; Eason & Lee, 1988). Characteristics of the setting such as physical proximity, unit team practices, common patient care objectives, and participative management practices may facilitate the development of QCs. Although the public health sector shares the characteristics of team focus, participative management, and common objectives, it is recognized that major differences are found in organizational structures, lack of geographic proximity of work groups, and the largely autonomous practice with client groups and populations. Although the authors were unable to find literature dealing with the use of QC specifically in community health, it was recognized that programmatic goals and the need
191
t
3. COLLECTBASEUNEDATA
\
I
4.
ANALYZE&-
/’
Figure 1. The quality circle process. Adapted from Nelson Associates.
for multidisciplinary and interdisciplinary collaboration in the public health sector lend themselves to the formation of QCs. Since t h e literature strongly substantiated their value in nursing and health care, this project was prompted to explore their implementation and subsequent value in community health nursing, and more specifically in the public health sector. Synthesis of the literature clarifies the QC concept as a group problem-solving method, which in turn evolves into a long-term participative management approach. The approach is based on the management belief that workers have creative abilities and valuable ideas that can be used to solve problems that affect their own work. It is widely accepted that the main attribute of QCs is its focus on participation in problem solving, for example, in quality of patient care, staff retention, productivity, and multidisciplinary collaboration. Quality Management Maturity
The second concept addressed was quality management maturity. Crosby, who is considered a guru of quality in industry today, developed the quality management maturity grid that can be used to show where an organization is on a continuum. This continuum of “uncertainty” to “certainty” is measured in the following areas: .management understanding and attitude, organization, problem handling, cost of quality, quality improvement actions, and the summation of the organization’s posture toward quality (Crosby, 1979, pp. 32-33). Previous work by Schmele and Foss (1989) described the use of the grid in the health care setting. For this project, quality management maturity was defined as the stage of perceived organizational readiness to deal with quality matters as measured by paper and pencil responses to the QMMI.
192 Public Health Nursing
Volume 8 Number 3 September 1991
Morale
strument has established reliability and validity. It contains 78 items on which subjects respond to a modified The literature substantiates, although implicitly, the Likert scale of “agree” to “disagree.” The I5 subscales idea that staff participation has value in maintaining and are scored separately, with favorable responses receivimproving morale. Morale is frequently referred to in ing a score of I and nonfavorable responses receiving a the literature but it is seldom defined (Shires, 1984; score of 0. Sbordone. 1983). Webster’s dictionary defines it as “the level of individual psychological well-being based on such factors as a sense of purpose and confidence in the IMPLEMENTATION future” (Woolf, 1974, p. 748). Although the literature lacks conceptual clarity, the value of high morale in The idea for the project was initiated by the Nursing health care settings is strongly identified, and its rela- Quality Assurance Committee of the Oklahoma State tionship to productivity and quality of care was made Department of Health. The author was invited as facquite clear by Haw and associates (1984). For this proj- ulty consultant to participate in exploring the feasibility ect, morale was defined as the level of psychologic well- of such a project on a statewide basis. After the initial being as measured by paper and pencil responses to the planning meeting with the chief of nursing and the Quality Assurance Committee, the decision was made to faSRA. cilitate a centrally located, one-day workshop for all the district nursing supervisors, to familiarize them with the SETTING concept of QCs and demonstrate its use for quality asThe Oklahoma State Health Department consists of 77 surance purposes. The supervisors’ feedback after the counties. Although not all of them have local health de- workshop was, with few exceptions, very positive. partments, some may have more than one site. A total Based on this evaluation, the decision was made by the of 84 sites are divided qmong 19 district nursing super- chief nurse and the Quality Assurance Committee to imvisors. All county health departments are accountable plement the QC process on a statewide basis. At a joint to implement federal and state directives regarding pro- meeting of nursing administration, the Quality Assurgrams and nursing protocols, and each county is auton- ance Committee, and the faculty consultant, it was deomous in the implementation process. One large met- cided that nine identical one-day workshops would be ropolitan area opted not to participate in this project. held at various regions throughout the state to show that Since each county is an individual unit, the dynamics administration valued the nurses’ time and energy, may be quite complex for programs originating from the which would not have to be spent in traveling. In addistate or district level. Differences among districts in- tion, some of the quality issues and concerns could be clude size of population served, services delivered, specific to a particular geographic area. number of nurses, and personal characteristics of nursIn general, the supervisors and nursing staff were reing supervisors and local administrators. For example, ceptive to the workshop, probably due to strong adminwithin each of the 16 districts the number of nursing istrative support. The participants were 250 registered personnel varies from I 5 to 52. public health nurses who were employees of the Public Health Department and who functioned at the local TOOLS county unit level. Prior to beginning each six-hour Objective preevaluation and postevaluation measures workshop, the pretests (SRA and QMMI) were adminwere chosen to determine if the implementation of QC istered to all the participants. The workshop consisted influenced the morale and the quality management ma- of four major parts: turity. The QMMI measures the organizational readiness for quality improvements and is based on Crosby’s 1. Didactic (overview, QC model) quality maturity grid (1984). This short instrument, 2. Large group process (experience with model) which the first author developed, consisted of six major 3. Small group processes (use of model) questions. Using a multiple-choice format, respondents 4. Summary and evaluation check the item in each section that best represents their Administrative guidelines for the implementation perception of the organization with regard to quality. Previous studies by the investigator yielded a reliability phase were that each district nursing supervisor was expected to hold at least one QC per quarter in his or her alpha for the QMMI of 0.76 (Schmele & Foss, 1989). The SRA, developed by the Employee Attitude Re- district, a summary report of the QC meeting was to be search Group of the Industrial Relations Center at the sent to central office twice a year, and the reports were University of Chicago (Miller, 1977), measures em- to be shared by all district nursing supervisors. During the first six months each supervisor solicited ployee attitudes toward the work environment. The in-
Schmele et al.: Quality Circles
local administrative support, as well as authorization to travel to a regional site to meet together, since most counties did not have a large enough staff to hold QC meetings at their site. These geographic differences resulted in increased cost of travel and time, as well as the drawback of attempting to organize people who work great distances apart. In spite of these drawbacks, similar problems surfaced and creative solutions were derived. For example, one district supervisor held a QC with members from four counties. They identified common issues and problems, and subsequently divided into three interest groups, each working on resolving a particular problem: clinic efficiency, development of patient education tools for sexually transmitted diseases, and program development to increase the number of breast-feeding mothers. At the central office level the monitoring of the QC reports led to identification of other common problems such as lack of a systematic approach to client tracking. As a result, a central committee redesigned an improved tracking system that would benefit the local level.
193
TABLE I . PretestIPosttest Comparisons of M e a n Scores for SRA Attitude Scale ( N = 91) ~
~~
~
~
Subscales
Pretest
Posttest
Job demands Working conditions Pay Employee benefits Friendliness, cooperation Supervisor-employee relat ions Confidence in management Technical competence Effectiveness of administration Adequacy of communications Security of job Status and recognition Identification with the organization Opportunity for growth Reactions to the attitude survey
3.52 4.11 I .56 2.74 2.97
3.30 3.82 I .26 2.96 2.88
5.30 4.22 4.05
4.86 3.87 4.05
2.79 3.60 3.97 4.56
2.71 3.52 3.41 4.22
3.11 2.43
3.07 2.24
I .09
.78
EVALUATION The majority of supervisors held QC meetings as directed. Six months after the intervention phase began, the respondents were again asked to complete the same instruments. Ninety-one (37%) group participants returned the matching SRA and QMMI pretests and posttests. The majority were women, between ages 31 and SO years, with nursing experience 10 years or more. Four to 10 years of this experience was in the health department. The participants were fairly evenly divided among diploma, associate, and baccalaureate degrees, with the highest percentage being diploma prepared. Question 1
Is there an increase in morale as measured by the SRA after the implementation of QCs? The mean scores of the 15 subscales of the SRA were computed. The pretedposttest comparison table of means is read horizontally to note changes in the mean (Table I). The mean scores for the majority of the subscales were less in the posttest than in the pretest. The only exceptions to this were “friendliness and cooperation,” which increased 0.09 and “technical competence,” which stayed the same. A f test for paired comparisons showed no statistically significant increases in any of the subscales. There may be several explanations for this unanticipated finding. Perhaps the most plausible is that other uncontrolled variables were also affecting staff morale. Some incident. may have occurred that had negative affects on morale, washing out any positive effect of the QC intervention. For example, the respondents showed
unfavorable responses to the subscale “response to the survey.” It would appear that there may have been a low level of trust, and that the QC intervention may have been viewed as just another approach that was not likely to yield results. Narrative comments on the questionnaire would support this. This finding also may offer some further explanation for the low response rate brought about by the lack of matching identification numbers on the pretest and posttest. Question 2
Is there an increase in quality management maturity as measured by the QMMI after the implementation of QCs? In contrast to the SRA. the QMMI mean scores showed an increase in all pretedposttest scores for the individual items as well as the summed score, which showed an increase of 1.72 (Table 2). The greatest increases were for items dealing with “boss attitude,” “agency approach,” and “quality improvement. ’’ Although there was a visible increase in all the individual scores between the pretest and posttest, using the r test, it was not statistically significant in the summed score. However, the raw scores of the QMMI suggest that after participating in QC the respondents perceived increased organizational readiness to deal with quality matters. It seems self-evident that the large administrative investment of resources (time and money) would indicate to the nursing staff that management was indeed serious about solving such problems.
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Public Health Nursing
Volume 8 Number 3 September 1991
TABLE 2. Comparison of PretestlPosttest M e a n Scores for QMMI ( N = 91) ltems
Pretest
Posttest
Boss attitude Agency approach
4. I6 2.83 3.54 I .29 3.43 3.70 18.86
4.70 3.29 3.63 I .30 4.10 3.76 20.58
Problem handling
Quality costs Quality improvement Agency position QMMI total
Follow-Up Survey A survey evaluation of the QC program by the nursing
supervisors was recently sent to each of the 17 district nursing supervisors. All 17 responded and reported that they were using the QC process, with most describing multidisciplinary involvement. The supervisors' narrative comments were favorable, indicating in general that they perceive QCs to be valuable in involving staff in problem solving related to quality issues, and that the quality of care had indeed improved. Because of the possible value in long-term assessment of the perceived effects of QC. a survey is currently being conducted with both managers and staff nurses.
DISCUSSION The major objective of the project, which was to prepare nurses to use the QC process, was clearly met. From a practice standpoint, district nursing supervisors do indeed continue to implement the QC program and report it as successful and effective for dealing with quality assurance concerns. The implementation process was strengthened by the fact that the district nursing supervisors played a major part in the original decision to adopt QCs as a problemsolving mechanism and were also the first group to be instructed. Strong administrative and supervisory support was evidenced by the nursing service goal, which addressed the implementation of the QC process over three years. Further administrative endorsement at the local level, as well as multidisciplinary collaboration for mutual problems, has strengthened and enriched the approach. One supervisor emphasized the importance of giving it a high priority. Her experiences revealed that the results have been effective problem solving, improved quality of care and documentation, improved efficiency of service delivery, and increased employee motivation. Suggestions for improving implementation include the formulation of clear guidelines and expectations based on the critical aspects of QC. For example, it may
strengthen the process to define proactively the guidelines of topics, volunteerism, leadership, and frequency of meetings. Also, the continuous development of local administrative support and subsequent multidisciplinary collaboration for common concerns to be handled in a QC presents a worthwhile challenge and goal.
CONCLUSION From a practice perspective, the statewide QC program yielded positive results, and it continues to be used by public health nurses as a participative approach to deal with problems related to quality. in addition, collaboration between the service and academic settings brought about by planning and implementation resulted in the forming of effective working relationships. In conclusion, QCs appear improve the quality of public health nursing since many nursing problems involve various disciplines. As this process lends itself to a concerted effort through multidisciplinary use, it has much potential for implementation in the public health sector.
ACKNOWLEDGMENTS The authors express appreciation to the nursing administrative and field staff of the Oklahoma State Department of Health for their participation in this project. Gratitude is also expressed to research assistant Margo MacRoberts for her assistance.
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