Improvement Tip: "Quality" Is Not a Department

​"Your organization will only make meaningful and sustainable quality improvements when people at every level feel a shared desire to make processes and outcomes better every day, in bold and even imperceptible ways.”

Robert Lloyd, Executive Director of Performance Improvement at the Institute for Healthcare Improvement, offers some tips for improving quality within your organization.


If your hospital, medical practice, or health system has a Quality Improvement Department, congratulations. If the general assumption is that this is the place where quality improvement resides and is performed, however, you’ve got work to do. Quality is not a program or a project; it isn’t the responsibility of one individual or even those assigned to the Quality Department. The Quality Director is basically the coach, facilitator and cheerleader. His or her job is to instill principles of quality at all levels, helping everyone in your organization — every employee, executive, caregiver, and consultant — feel driven to achieve excellence.

This fundamental lesson is at the heart of successful quality improvement, and often the most challenging and hardest for an organization to grasp. After all, everyone believes they perform at a high level of quality — it’s the American way, it’s written in slogans, posters, even billboards. “We care,” “We’re number one,” “We’re the quality leader,” and so on.  And when your organization's Quality Department is diligently taking steps to comply with quality directives from external review or accrediting bodies, it is easy to feel complacent. But this is only part of the story. Your organization will only make meaningful and sustainable quality improvements when people at every level feel a shared desire to make processes and outcomes better every day, in bold and even imperceptible ways.

I often make this point with a story. It’s short and sweet, no doubt part real and part legend, retold again and again at quality events. In 1969 when the US was planning a trip to the moon, the major TV networks had crews stationed at NASA headquarters in Houston, Texas, to cover the lead up to the launch. One day the reporters and camera crews had some down time while waiting for the NASA officials to arrive at the press room. As they passed the time milling about the halls, someone noticed a janitor coming toward them with a broom and thought, “Well, nothing else to do, why don’t we film some ‘B’ footage to have on hand.” A reporter happened to have a microphone handy, so he said to the approaching janitor: “So, what’s your job at NASA?”

As the story goes, the fellow paused, leaned on his broom, looked thoughtfully into the camera and said, “My job is to help us get to the moon.” He then picked up his broom and went on his way. Whatever the apocryphal elements may be, I tell people: There in a nutshell is "quality." This is a man who sees himself not as a janitor but as part of a team helping people get to the moon.

All too often health care organizations I have worked with will tell me, “Oh yes, we believe in quality. We’ve got 40 projects going on, just talk to so-and-so down the hall who runs the Quality Department.” Or they’ll show me their high satisfaction ratings on this or that survey, or nice brochures announcing the corporate commitment to quality. But the truth is, quality is a way of thinking about work, how you approach work every day for yourself personally and for those that you serve. It’s not about the right turn of phrase or staff titles.

When organizations tell me how many teams they have assigned to quality projects, I ask them: “But what are the teams really doing? What have they done to make something better for your doctors, nurses, patients and their families?” Quality is about making change, getting results. Activity doesn’t equal accomplishment.

This approach is not always easy to embrace. Health care providers and administrators I have worked with sometimes see it as idealistic; they feel so swamped with daily commitments and duties that they see quality improvement as an added burden. It’s more work, extra work, over and above their ‘real’ job. But if they tell me that, I’ll ask them: “Well, if quality isn’t your job, what is?”

This reflects a fundamental shift in perspective — a cultural, almost philosophical evolution — that some organizations have to attain in order to really understand quality and be able to achieve it. Quality has to be connected to an organization’s mission, its strategic vision. It has to be part of the work and weave, the very fabric of the organization.

I often tell another story to illustrate this point, a health care example that I can attest is true. I once worked with a small inner-city hospital that served a low-income community in a neighborhood plagued with crime — gangs, drugs, violence, you name it. This place had so much going against it, so many challenges; you might imagine the science of quality improvement wouldn’t get a lot of attention. But quite the contrary: the hospital was full of spirit and energy — I loved going there.

One day the emergency department (ED) was backed up. The hospital’s CEO learned of the problem during regular check-ins and review of bed flow charts and such. What did she do? Make a few phone calls to put someone to work finding staff? No. She got up, left her office, and went down to the ED and started registering patients. Before long she was getting patients in wheelchairs and transporting them to the lab, to radiology, or to their assigned unit.

This woman understands what quality and service are all about. It’s not that she’s just generous enough to take on extra work. She is able to connect the dots, see the bigger picture, instead of saying, “I’m the Administrator,’ or ‘I’m in HR,’ ‘I’m in the finance department.” She is someone who — like our mythic NASA janitor — understands that it’s these little moment-to-moment interactions that, once accumulated, become the overall quality of what we do. Quality is personal — and it begins with you!

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