A TQM SELF-EVALUATION
1. Do you include Continuous Quality Improvement as a key area in every manager’s performance evaluation?
2. Do you include Continuous Quality Improvement as a key area in every employee's performance evaluation?
3. Do you have organization-wide improvement goals? If so, does everyone (employees, doctors, board members) know what the goals are? Are run charts and control charts used for the top five goals? Does everyone know where the organization is (right now) relative to the goals?
4. Do all levels and all players (employees, doctors, board, etc.) have a role? Do they know their roles and responsibilities relative to Continuous Quality Improvement?
5. Do you have a plan to develop manager skills that promote teamwork and continuous improvement? If so, how much of the plan has been implemented?
6. Do you have a systematic approach to obtaining employee ideas for improvement? If so, how many ideas were submitted last month/last year? How many were implemented last month/last year? What was the impact of the implemented ideas? For example, how much money was saved, how much was waiting time reduced, how were error rates reduced, etc.?
7. Do you have departmentally based improvement teams? If so, how many and in what departments? Can you identify (quantify) results? How many employees are involved? Percent and total number?
8. Do you have cross-organizational teams? If so, how many? What issues are they looking at? What measurable impact have they had?
9. Do you know what your customers think of your services? Have you used physician and patient surveys, focus groups, etc.? Do you have other systems in place to track customer satisfaction? What trends do you see in patient satisfaction?
10. Do you know the facility's market share in primary and secondary markets? If so, do you know how it has changed over time?
11. Do you know what your employees think of the organization?
12. Have you used surveys, focus groups, and other data to track employee perceptions? How have employees' attitudes changed over time?
13. Do you know in what areas your quality of service is excellent? How do you know; what data do you have? What other organizations have you compared yourself to?
14. Do you have a systematic method of reporting quality improvement projects to the entire organization?
15. Do you have an accepted, uniform, organization- wide problem-solving approach? If yes, is it used by all teams? How do you know?
16. Do you recognize success and/or movement to- ward improvement goals? How? What informal recognition processes are in place? How many of your teams are recognized each year?
17. Do you create win/win situations or pit individuals or teams against one another?
18. Do you show that Continuous Quality Improvement is one of the top goals of the organization? How?
19. Do you understand the difference between common causes and special causes as they relate to variation?
20. Do all managers understand the differences between common causes and special causes as they relate to variation?
21. Do you know in a formal, measurable way where you stand relative to your competitors?
22. Do you know the average cycle time for key processes such as admitting, or scheduling, lab and x-ray results, etc.? If so, what trends have you observed? Are things getting better or worse? How do you compare with other area providers? How do you compare with world class providers?
23. Do you have an organization where all senior managers work as a team toward a common vision? What is that vision? Are board and patient care staff leaders included?
24. Do you have measures of the process itself? If so, do you measure the number of ideas? The number of meetings? The number of cross-organizational groups?
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