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What Does It Mean to Rethink Quality?

Why It Matters

"Whole system quality takes a holistic approach to quality activities across three domains: quality planning, quality control, and quality improvement."

Building on the ideas of quality movement pioneers, the Institute for Healthcare Improvement (IHI) has published Whole System Quality: A Unified Approach to Building Responsive, Resilient Health Care Systems, a white paper proposing a holistic approach to quality management. In the following interview, one of the white paper’s co-authors, IHI Research Associate Bhargavi Sampath, MPH, describes how whole system quality was developed to “refocus quality on meeting customer needs.”

The IHI white paper on whole system quality defines quality as “the endeavor of continuously, reliably, and sustainably meeting customer needs.” Why did you and your co-authors use this definition?

We went back to the work of some of the early quality thinkers and looked at their understanding of quality. We appreciated how [Joseph] Juran defined quality as “fitness for use” (see Figure 1 below). This concept comprises two components: meeting customer needs and freedom from deficiencies.

Juran's definition of quality

Figure 1. Joseph Juran’s definition of quality

In recent decades, a focus on eliminating defects has driven a lot of quality efforts while customers have largely been forgotten. We saw an opportunity to re-center quality around the idea of meeting customer needs. With that in mind, we developed an approach called whole system quality to outline a journey toward a customer-oriented quality strategy.

What is whole system quality?

Whole system quality takes a holistic approach to quality activities across three domains: quality planning, quality control, and quality improvement. (See Figure 2 below.)

Relationship Between Quality Planning, Quality Improvement, and Quality Control

Figure 2. Relationship Between Quality Planning, Quality Improvement, and Quality Control

Whole system quality has two components to it: a set of management practices and a set of leadership principles. The management practices outline the way in which every part of the system helps to advance the organization toward its quality goals, and the leadership principles describe behaviors to bring those activities to life by embedding purpose, inquiry, and learning into the culture. (See Figure 3 below.)

Whole System Quality Practices and Principles

Figure 3. Whole System Quality Practices and Principles

When we say leaders, it’s important to note that we don’t just mean executives or those sitting at the senior levels of an organization. A leader is anyone who is trying to shift the status quo of the organization and in the process mobilizes others toward a shared goal. Anyone at the organization — from the front line to the executive team — can be a leader.

What leadership behaviors support whole system quality?

We’ve outlined four whole system quality leadership principles:

  • Build a shared sense of purpose — Building a shared purpose around quality means cultivating a vision of what is possible together. This ensures that quality is a collective, enterprise-wide commitment, not just the responsibility of a particular team.
  • Practice systems thinking — By appreciating the interdependence and interconnectedness of a system, we can begin to uncover the strengths of an organization, the drivers of persistent challenges, and focus on addressing root causes rather than only symptoms.
  • Engage in collective learning and dialogue — New ideas and generative thinking emerges from an environment where a community of learners can ask questions, challenge orthodoxies, and explore new ways of working. By creating spaces where the workforce can surface challenges and opportunities — with candor, compassion, and humility — true dialogue, collaboration, and collective learning can take place.
  • Practice personal inquiry and reflection — We all come with assumptions and deeply held beliefs that influence our thinking and our judgment. It’s important to sometimes pause to reflect and recognize the ways in which our thinking and assumptions can be influenced and explore new ways of seeing the world.

In the whole system quality approach, who is considered a customer?

In the white paper, we talk about primary customers and secondary customers. The primary customers are those most impacted by quality work. This includes the patients, the larger community that the health system serves, and the workforce who engage in quality activities. The secondary customers include payers, regulators, partners, and others who make it possible to deliver quality continuously, reliably, and sustainably.

Would you describe an example of an organization that puts whole system quality into practice?

There is a large health system in the UK that has a very clear commitment to centering quality around the customer. They define quality by bringing together the patients, populations they serve, and the frontline staff to identify their strengths and persistent quality gaps. They pursue quality projects and initiatives that prioritize the needs that are most urgent and important. They also put effort into embedding quality within their larger organizational strategy. Quality is not a part of their system priorities; quality is the purpose of the enterprise.

How do you hope people use the whole system quality white paper?

The COVID-19 pandemic shows us how important it is to be aware of a changing context and emergent challenges in delivering quality. Whole system quality is intended to create a level of sensitivity to the urgent, persistent, and evolving needs of customers.

I hope that an organization that approaches quality with the spirit outlined in this paper would adapt quickly and be resilient. Learning how to learn is at the center of whole system quality. Appreciating the dynamic environment within which the system operates and evolving to meet any challenge would be the ultimate demonstration of putting these ideas into practice.

What does it mean to learn how to learn?

This is a field unto itself, but we define learning around two key components: adaptive learning and generative learning. Adaptive learning requires an organization to appreciate the system and environmental context within which it operates. By seeking to understand the forces within and around the system that drives customer needs, an organization can be resilient and responsive to an evolving context while having clarity of purpose. Generative learning enables a system to engage with new ideas and explore new possibilities to deliver on the promise of quality. By fostering continuous reflection, personal inquiry, and honest dialogue, organizations can cultivate a workforce that is curious, compassionate, and committed to learning and improvement. This process can produce an environment where everyone has the ability to suspend their assumptions, explore new ways of seeing the system, and develop new ideas and mental models. In many ways adaptive and generative learning go hand in hand. And they both require a culture of humility and a commitment to purpose.

Can whole system quality build on past or current quality work?

Whole system quality doesn’t require a blank slate, but it does require orienting the organizational purpose around customers. Instead of merely thinking about an organizational strategy in terms of a financial bottom line or quality as meeting certain regulatory requirements, whole system quality offers an opportunity to build one unified enterprise strategy: to meet the needs of patients, providers, and the community continuously, reliably, and sustainably.

Editor’s note: This interview has been edited for length and clarity.