Summary The Health Care Quality Book Essay Example for Free

Summary The Health C ar lumber Book EssayChapter 1 science and familiarity foundation twain notable contributions to the industry from the Journal of American Medical Association 1. Assessment of the state of forest sincere and widespread woodland problems 2. Categorization of three defectsa. Underuse some scientifically sound exerts argon not employ as often as they should be b. Overuse can be seen in argonas such as imaging studies for diagnosis in acute asymptomatic low back pain or prescription of antibiotics when not indicated for infections. c. Misuse when the proper clinical explosive charge mathematical operate is not executed appropriately, such as giving the incorrectly drug to a patient roles. To Err Is Human publication that shows the severity of the eccentric problems in a way that captured the attention of all recognize stakeholders for the first prison term this report spoke about the negative, not how it should be improved. Crossing the prize c hasm provided a blueprint for the future that classified and unified the components of quality through six aims for proceeds, chain of effect and saucer-eyed rules for redesign of health anxiety.Six dimensions of quality (Berwick) take measures and goals (IOM) = Institute of Medicines SafePercentage of overall mortality rates/patients experiencing adverse events or harm Effective science and indorse should be use and practise as the standard for delivery of tutelage. How sound argon evidence based practices followed? Percentage of time diabetic patients receive all recommended direction at each doctor visit.. Efficient C are and service should be cost effective, and waste should be removed. Analyzing the costs of burster by patient, presidential term, provider or community Timely no waits or delays in receiving careMeasured by waits and delays in receiving needed care, service, and test solvings. Patient centered system should wrap around the patient, respectits prefer ences and put the patient in control Patient or family satisfaction with care and serviceEquitable Disparities should be eradicated.Examining differences in quality measures by race, gender, income or other factors.The underlying framework for achieving these aims depicts the health care system in four levels Level A what happens with the patientLevel B the micro system where care is delivered by small provider squads Level C organizational level the macro system or aggregation of the Microsystems and backup berths. Level D external environment where payment mechanisms, policy and regulatory factors re incline (verblijven)Chapter 2 Basic concepts of health care qualityThe following attributes relevant to the definition of quality of care are important Technical effect refers to how well current scientific medical exam knowledge and technology are applied in a given situation (it is usually assessed in terms of timeliness and accuracy of the diagnosis, appropriateness in of the rapy) Management of the interpersonal comparisonship refers to how well the clinician relates to the patient on a human level.The quality of this relationship is important because By establishing a good relationship with the patient the clinician is able to fully cut through the patients concerns, reassure the patient and relieve the patients suffering It can affect technical performance the clinician is better able to protract from that patient are more than complete and accurate medical history, which can result in a better diagnosis Amenities (voorzieningen) refers to the characteristics of the come downting in which the encounter between patient and clinician takes place, such as comfort, convenience and privacy. Amenities are valued both in their own right and for their effect on the technical and interpersonal aspects of care. Amenities can yield (opleveren) benefits that are more indirect.Access refers to the degree to which individuals and groups are able to obtain needed services. Responsiveness to patient preferences respect for patients values, preferences and expressed needs affects quality of care as a factor in its own right. Equity the amount, type or quality of health care provided can be related systematically to an individuals characteristics, particularly race and ethnicity, rather than to the individuals need for care or healthcare preferences, get hold of heightened concern about equity in health care. Medicine does not fulfill its function adequately until the like perfection is indoors the reach of all individuals. Efficiency refers to how well resources are used in achieving a given result. Cost-effectiveness how much benefit, typically measured in terms of approach in health status, the intervention yields for a particular level of expenditure.For each stakeholder in health care, quality can be differently outlined summon 30 + 31. These definitions have a great deal in common Each definition emphasizes different aspec ts of care Definitions conflict only in relation to cost-effectivenessAll evaluations of quality of care can be classified in terms of one of the three aspects of caregiving they measure Structure when quality is measured in terms of structure, the counselling is on the relatively static characteristics of the individuals who provide care and of the prunetings where the care is delivered. These characteristics involve the education, training and certification of professionals. Process refers to what takes place during the delivery of care, in addition can be the basis for evaluating quality of care. Outcomes Outcome measures, which capture whether healthcare goals were achieved, are another way of assessment of quality of care. Outcome measures have to include the costs of care as well as patients satisfaction with care. Which one is better to use? none of them, all depends on the circumstances.To assess quality utilize structure, process or outcome measures, we need to know w hat constitutes good structure, good process and good outcomes. We need criteria and standards we can apply to those measures of care Criteria = specific attributes that are the basis for assessing quality Standards = express quantitatively what level the attributes must reach to satisfy preexisting expectations about quality. For example type of measurestructure and focus on primary care group practice Criterion percentage of board-certified physicians in inbred or family medicine Standard 100% of physicians in the practice must be board certified in internal or family medicine.Optimal standards denote the level of quality that can be reached under the surmount conditions, typically conditions similar to those under which efficacy is determined useful as reference invest.Structural measures are well suited to detecting lack of electrical condenser to deliver care of acceptable quality. They are also only as good and useful as strength of their relation to coveted processes and outcomes. To evaluate structure, process and outcome measures criteria and standards are prerequisite. Whereas the formulation of criteria is expected to be evidence driven (efficacy). The setting of standards is not similarly tied to scientific literature. The decision to set standards at a minimal, ideal or achievable level is most meaningful if driven by the goals behind the specific quality of care evaluation for which the standards are to be used.Chapter 3 Variation in medical practice and implications for qualityVariation the difference between an observed event and a standard or norm. Without this standard, or best practice, measuring of transition offers little beyond (biedt niet meer dan) a description of the observations. Random variation = physical attribute of the event or process, adheres to the laws of hazard and cannot be traced to a root cause. (houdt zich aan de wetten van waarschijnlijkheid en kan niet worden herleid tot een oorzaak). It is not worth to st udy it in detail.Assignable variation = arises from a single or small set of causes that are not part of the event or process and thence can be traced, identified, and implemented and eliminated subject to potential misapprehend because of complexity of design and interpretation. 1. Process variation = the difference in procedure throughout an organization (use of various screening methods for colorectal cancer) Technique multitude of slipway in which a procedure can be performed within the realm of acceptable medical practice. 2. Outcome variation = difference in the result of a single process (mostly focus on this measure) the process yielding optimal results outcomes research 3. Performance variation = the difference between any(prenominal) given result and the optimal ideal result. This threshold or best practice is the standard against which all other touchstones of variation are compared. Performance variation tells us where we are and how far we are from where we wan t to be, and suggests ways to achieve the desired goal.Variation can be desirable? a boffo procedure that differs from other, less(prenominal) successful procedures is by definition variation. The objective then for quality improvement is not simply to identify variation but to determine its value. How can the variation be eliminated or reduced in the ways that focus on the variation rather than on the people involved? So, understanding the implications for quality of variation in medical practice is not simply learning how eliminate variation but learning how to improve performance by identifying and accommodating good or suboptimal variation from a predefined best practice.Variability plays a role in identifying, measuring and reporting quality indicators (effective, efficient, equitable..) and process-of-care improvements.Some hospitals are reluctant to use quality improvement measures (they perceive them as biased towards academic medical research centers or large health care organization) untrue Quality improvements efforts can be and have been successfully applied to small organization and practices.The size of an organization also effects the ability to disseminate (verspreiden) best practices. Large organization course to have rigid frameworks or bureaucracies deviate is slow and requires perseverance (doorzettingsvermogen) and the ability to make clear to skeptics and enthusiasts the value of the young procedure in their group and across the system.An organization s commitment to paying for quality improvement studies andimplementation is equally affected by its size and infrastructure, but there are some minimum standard levels of quality and linked reimbursement schemes to achieving goals established by the Joint Commission, CMS and Medicare all organizations obligated to meet these standards.Quality improvement effort must turn organizational mind-set, administrative and physician world thoughts, and patient knowledge and expectations. Phys ician buy-in is critical to reducing undesired variation or creating new and succesfull preventive systems of clinical care, therefore training physician champions and inciting (aanzetten) them to serve as models, mentors and motivators and it reduces the risk of alienating (vervreemden) the fall upon participants in quality improvement efforts.Patient education in quality of care is equally subject to variation patients are aware of the status of health care providers in terms of national rankings, public news of quality successes and so on. Educating patients about a health care organization and its commitment to quality makes variation and process-of-care measures available to the public.Organizational mind set organizational infrastructure is an essential component in minimizing variation, disseminating best practices and supporting a research agenda associated with quality improvements. Economic incentives may be effective in addressing variation in health care by awarding monetary bonuses to physicians and administrators who meet quality targets or withholding bonuses from those who do not. Goals of incentives to help people understand that their organization is serious about implementing quality switchs and minimizing unwanted variation to ensure conjunctive with national standards an directions in quality of care and to encourage them to use the resources of the organization to achieve this alignment .Chapter 4 Quality improvement the foundation, processes, tools and knowledge transfer techniquesDifferent shooters of quality improvement systems pageboy 63 67Quality improvement approaches (derivatives and models of the ideas and theories substantial by thought kick the bucketers) PDCA/PDSA, Associates for Process Improvements Model for Improvement, FOCUS PDCA, Baldrige criteria, ISO 9000, Lean, Six Sigma.PDCA/PDSA cycleBasis for stick outning and directing performance improvement efforts. 1 PlanObjective what are you trying to accomplish? Wh at is the goal? Questions and predictions What do you think bequeath happen?Plan to carry out the cycle Who? What? When? Where?2 DoEducate and train staffCarry out the plan (try out the change on a small scale)Document the problems and unexpected observations? jump analysis of the cultivation3 Study/CheckAssess the effect of the change and determine the level of success as compared to the goal/objective canvass results to predictions follow what changes need to be made and what actions testament be taken next 4 ActAct on what you have learnedDetermine whether the plan should be repeated with modifications or a new plan should be created Perform necessary changesIdentify remaining gaps in process or performanceCarry out additional PDCA/PDSA cycles until the agreed-upon goal or objective is metAPI improvement modelSimple model for improvement based on Demings PDSA cycle. The model contains three fundamental questions that form the basis of improvement What are we trying to accomp lish?How will we know that a change is an improvement?What change can we make that will results in improvement?FOCUS/PDCA modelBuilding on de PDCA cycle the FOCUS PDCA model is created more specific and defined approach to process improvement. The key feature of this model is the preexistence of a process that needs improvement. The intent of this model is to maximize the performance of a preexisting process, although the comprehension of PDCA provides the option of using this model for new or redesign process. F FIND a process to improveO ORGANIZE a team that knows the processC CLARIFY current knowledge of the existing or redesigned process U UNDERSTAND the variables and causes of process variation within the chosen process S SELECT the process improvement and identify the potential action for improvement Baldrige criteriaThe criteria can be used to assess performance on a wide range of key indicators health care outcomes patient satisfaction and operational, staff and financial i ndicators. The Baldrige healthcare criteria are built on the following set of interrelated core values and concepts (page 70). The criteria are organized into seven interdependent categories LeadershipStrategic planningFocus on patients, other customers, and marketsMeasurement, analysis and knowledge managementStaff focusProcess managementOrganizational performance resultsBaldriges scoring system is based on a 1000 point scale. Each of the seven criteria is assigned a maximum value ranging from 85 to 450 maximum points. The most heavily weighted criterion is the results menage (450). The weight of this category is based on an emphasis Baldrige places on results and an organizations ability to demonstrate performance and improvement in the following areas Product and service outcomes, customer-focused outcomes, financial and market outcomes, workforce-focused outcomes, process effectiveness outcomes, lead outcomes.ISO 9000The international Organization for Standardization (ISO) iss ued the original 9000 series of voluntary technical standards in 1987 to facilitate the development and precaution of quality control programs in the manufacturing industry. In 2000, ISO made major changes to the standards to make them more relevant to service and health care settings. Focused more on quality management systems, process approach, and the role of top management, the most recent standards include eight common quality management principles Customer-focused organizationLeadership interest of peopleProcess approachSystem approach to managementContinual improvementFactual approach to decision qualificationMutually beneficial provider relationshipsLean thinkingLean to describe production methods and product development that, when compared to traditional mass production processes, begin more products, with fewer defects, in a shorter time. The focus of Lean methodology is a back to basics approach that places the needs of the customer first through the following five f lavors 1. pin down value as determined by the customer, identified by the providers ability to deliver the right product or service at an appropriate price. 2. Identify the value stream the set of specific actions required to bring a specific product or service from concept to utmost 3. Make value added move flow from beginning to end4. Let the customer pull the product from the supplier, rather than push products 5. Pursue perfection of the processSix sigmaThe aim of six sigma is to reduce variation (eliminate defects) in key business processes. By using a set of statistical tools to understand the mutation of a process, management can predict the expected outcome of that process. Six sigma incluses five steps, commonly known as DMAIC Define Identify the customers and their problems. Determine the key characteristics important to the customer along with the processes that support those key characteristics. Identify existing output conditions along with process elements. Measure Categorize key characteristics, verify amount systems and collect info Analyze Convert raw information into entropy that provides insights into the process.These insights include identify the fundamental and most important causes of the defects or problems. Improve rebel solutions to the problem, and make changes to the process. Measure process changes and judge whether the changes are beneficial or another set of changes is necessary. Control If the process is performing at a desired and predictable level, monitor the process to ensure that no unexpected changes occur. The primary tool of six sigma is that focus on variation reduction will lead to more uniform process output. Secondary effects include less waste, less throughput time and less inventory.Quality tools three categories (also six categories distinguishing on page 74) Basic quality toolsControl chart upper and lower control boundaries that define the limits of common cause variation. It is used to monitor and anal yze variation from a process to determine whether that process is stable and predictable or unstable and not predictable HistogramCause-and-Effect/Fishbone diagram the problem is stated on the right side of the cart, and likely causes are listed around major headings that lead to the effect. It can help organize the causes contributing to a complex problem. Pareto chart 80% of the variation of any characteristic is caused by only 20% of the possible variables. Management and planning tools (75)Affinity diagram a list of ideas is created, and then individual ideas are scripted on small note cards. Team members study the cards and group the ideas into common categories. The affinity diagram is a way to create order of a brainstorm session. Matrix diagram helps us to answer two importantquestions when sets of data are compared Are the data related? How strong is the relationship? Priorities intercellular substance uses a series of planning tools built around the matrix chart. Other qua lity toolsBenchmarking compares the processes and successes of you competitor of similar top-performing organizations to your current processes to define, through gap analysis, process variation and organizational opportunities for improvement. Benchmarking defines not only organizations that perform better but also how they perform better. Failure mode and effect analysis examines potential problems and their causes and predicts undesired results. FMEA normally is used to predict product failure form past part failure, but it also can be used to analyze future system failures both in patient safety toolbox. 5S is a systematic program that helps workers take control of their workspace so that is actually works for them instead of being a neutral or, as is quite common, competing factor. Sort centre to keep only necessary itemsStraighten means to arrange and identify items so they can be easily retrieved when needed. Shine means to keep items and workspaces clean and in working ord er Standardize means to use best practices consistentlySustain means to maintain the gains and make a commitment to continue the first four S.Theory of Transfer of Learning page 77Rapid cycle interrogation/improvementDeveloped by IHI, rapid cycle testing/improvement was designed to create various small tests involving small sample sizes and using ninefold PDSA cycles that build on the lessons learned in short period while gaining buy-in from staff involved in the change. It is designed to reduce the cycle time of new process implementation from months to days.Read 78/79/80/81Chapter 5 milestones in the quality measurement excursionMany health care providers struggle to address the measurement mandate proactively, which leads organizations to assume a defensive posture when external organizations release the data. In such encases, the provider usually responds in one of the following ways data are old, data are not stratified and do not demo appropriate comparisons, our patien ts are sicker than those in other hospitals. A more proactive posture would be to develop an organization-wide approach to quality measurement that meets both internal and external demands. This approach is not a task, but a journey that has many potential pitfalls and detours. Key milestones exist that mark your progress and chart your direction.Milestone 1 Develop a measurement philosophy (strategic step) What is/should be the role of performance measurement in the organization? Should it be done periodically or a day-to-day function? The first step toward this milestone should be the creation of an organizational statement on the role of measurement. Three simply questions should be explored when developing a measurement philosophy 1. Do we know our data better than anyone else does?2. Do we have a balanced set of measures that encompasses clinical, operational, customer service and resource allocations? 3. Do we have a plan for using the data to make improvements?Milestone 2 Ide ntify the concepts to be measured (types and categories of measures) (strategic and operational step)The second milestone consists of deciding which concepts the organization wishes to monitor. There are three basic categories of measures structure (s) represents the physical and organizational aspects of the organization processes (p) every activity, every job, is part of a process. outcomes (o) structure combine with processes to produce outcomes. The relationship between these categories usually is shown as follows s + p = o Another categorization that can be made is (more specific) according to the six aims for improvement 1 Safe, 2 Effective, 3 Patient centered, 4 Timely, 5 Efficient, 6 Equitable Regardless of the method used, an organization must decide which concepts, types, or categories of measures it wishes to track.Milestone 3 Select specific measuresWhat aspect of (patient safety) do we want to measure?What specific measures could we track?Choose a specific indicatorIn t his step you need to specifying what aspect of for example patient safety you intend to measure and the actual measures. Within the patient safety, you could focus on medication wrongdoings, patient falls, wrong site surgeries etc. Within the medication error you can measure different things number of medication orders that had an error, total number of errors caught each day, percentage of orders with an error etc.Milestone 4 Develop operational definitions for each measure An operational definition is a description, in quantifiable terms, of what to measure and the specific steps needed to measure it consistently. A good operational definition Gives communicable meaning to a concept or an ideaIs clear and unambiguousSpecifies the measurement method, procedures and equipmentProvides decision-making criteria when necessary andEnables consistency in data collectionThe problem created by poor operational definitions should be obvious if you do not use the same operational definition each time you record and plot data on a chart, you will either miss a true change in the data or think a change has occurred when in fact one has not. Using the same operational definition becomes even more critical if you are trying to compare several hospitals or clinics in a system.Milestone 5 Develop a data collection plan and gather data (giving special consideration to stratification and sampling) Direct start with data collection may cause teams to collect the wrong data in the wrong amounts. The data collection phase consists of two partsPlanning for data collection what process will be monitored? What specific measures will be collected? What are the operational definitions of measures?.. The actual data gathering how will you collect the data? Will you conduct a pilot study? Who will collect the data? (page 94) Once you have resolved these issues, the data collection should go smoothly. Sometimes improvement teams do not spend enough time on data collection plans. This can lead to the following problems (1) collect too much, or too little data (2) collect the wrong data (3) become frustrated with the entire measurement journey. Consequences can be the team tends to (1) distort (verdraaien) the data (2) distort the process that is produced the data or (3) kill the messenger. two key data collection skills stratification and sampling enhance any data collection effort. Stratification = the separation and classification of data into reasonably alike categories. The objective of stratification is to create strata, or categories, within the data that are mutually exclusive and facilitate discovery of patterns that would not be observed if the data were aggregated. Stratification allows understanding of differences in the data caused by different factors (page 95). If you do not think about how these factors could influence your data you run the risk of making incorrect conclusions and having to filter out the stratification effect manually after you hav e collected the data. consume (steekproef) the most important thing you can do to reduce the amount of time and resources spent on data collection. There are four conditions for developing a sampling plan accuracy, reliability, speed and economy. Sampling consists of a series of compromises and trade-offs. The basic purpose of sampling is to be able to draw a limited number of observations and be reasonably confident that they represent the bigger population from which they were drawn.There are two basic approach to sampling Probability sampling techniques based on statistical probability (systematic sampling, simple random sampling, stratified random sampling, stratified proportional random sampling) Non-probability sampling techniques should be used when estimating the reliability of the selected sample or generally applying the results of the sample to larger population is not the principal concern. The basic objective is of this type of sampling is to select a sample that the researchers believe is typical of the larger population. (conveniencesampling, quota sampling and perceptiveness sampling) 99-102Milestone 6 Analyze the data using statistical process control methods (especially run and control charts) Translate data into information.Milestone 7 map the analytic results to take action (implement cycles of change, test theories and make improvements)Chapter 6 Data collectionQuality measurements can be grouped into four categoriesClinical qualityFinancial performancePatient satisfactionFunctional statusTo report on each of these categories, several spate data sources may be required. The dispute is to collect as much data as possible from the fewest sources with the objectives of consistency and continuity in mind.Retro prospective data collection involves realization and selection of a patients medical record or group of records after the patient has been discharged. Prospective data collection relies on medical record review, but it is completed during a patients hospitalization or visit rather than retrospectively. Disadvantage time consuming and can cark nurse from their direct patient care responsibilities, expensive method, mostly full time data analyst needed.Source for data for quality improvementsAdministrative databases are information collected, processed and stored in automated information systems. Excellent source of data for reporting on clinical quality, financial performance, and certain patient outcomes.Advantages less expensive source of data, they incorporate transaction systems, moest of the code sets embedded are standardized, the database are staffed by individuals who are skilled, the volume is great, data reporting tools are available.. Disadvantages some argue that these data is less reliable than data gathered by chart review. Patient surveys especially when teams are interested in the perceptions of patients, either in terms of the quality of care or the quality of service provided. A team can des ign the survey itself, hire an expert to design a survey, or purchase an existing survey/survey service. Functional status surveys usually measured before and at several points following the treatment or procedure. (for example a baseline before the knee procedure and then assessments are made at regular intervals after the surgery) Health plan databases dainty source of data for quality improvement projects, particularly projects that have a population health management focus.These databases are valuable because they contain detailed information on all care received by health plan members. It provides a comprehensive record of patient activity and can be used to identify and select patients for enrollment in disease management programs. Used properly rich source of data for population management, disease management and quality improvement projects. Health plan databases limitations considerations include accuracy, detail and timeliness. Recoding may make some data inaccurate, they do not contain detailed information on outcomes of care . Patient registries powerful source of quality improvement data. Advantages rich source of information because they are customized, can collect all the data that the physician or health system determines are most important, can be used for quality improvements, they are not subject to the shortcomings of administrative or health plan databases, collection techniques can be combined to provide a complete picture of the patient experience. They are versatile and flexible. Example case study in clinical reporting page 123-127Conclusion there are many sources and data collection approaches from which to choose. Rarely does one method serve purposes, so it is important to understand the advantages and disadvantages of all methods. A combination is also possible. Knowledge of different sources and techniques will help you to use data more in effect and efficiently in your clinical improvement effort.Chapter 7 Statistical tools for quality improvementThree fundamental purposes for performance measurementAssessment of current performance identify strengths and weaknesses of current processes Demonstration and verification of performance improvementAnd control of performancePerformance measurement benefits organizations in several ways provides factual evidence of performance, promotes ongoing organization self-evaluation and improvement, illustrates improvement, facilitates cost-benefit analysis, helps to meet external requirements and demands for performance evaluation, may facilitate the establishment of long-term relationships with various external stakeholders. May differentiate the organization from competitors, may contribute to the awarding of business contacts and fosters organizational survival. ..Chapter 13 Leadership for qualityLeadership = working with people and systems to produce needed change. Individual leadership = this set of leadership is about what people must be and what they must know how to do, if they are to influence others to bring about needed changes. Both being and doing are needed, especially when the changes required for quality improvement involve reframing core value or remaking professional teams. Many improvements in health care will require these kinds of deep changes in values. These changes are sometimes labeled as transformational changes to distinguish them from transactional changes, which do not require changes in values and patterns of behavior.Organizational leadership = about creating a supportive organizational environment in which hundreds of capable individual leaders work can thrive (groeien). One way to view this level (system-of-leadership level) is as a complex set of interrelated activities in five broad categories Set direction every organization has a smell out of direction, a future self-image. A leader should set that direction. Establish the foundation leaders must prepare themselves and their leadership teams with the knowledge a nd skills necessary to improve systems and lead change (and reframe values) Build will to initiate and sustain change takes will, which seem to be highly sensitive to discord and often grind to a halting because of one loud voice opposing change therefore making logical and quantitative links should be made between improvement and key business goals. Generate ideas quality challenges require innovation.Page 313Implementing quality as the core organizational strategyImplementing a culture that has quality improvement at its core is an important goal for providers who want to serve patients better, gain the support of healthcare providers, stay ahead of government regulation, meet consumers demand for transparent information on quality and costs, an gain a competitive advantage in the marketplace. Recent history many efforts have not resulted in the sustainable quality improvements that the leaders hoped to see.Quality improvement strategy should start with leadership from the boar d of trustees, the CEO and the executive team, but it is a challenge for health care organizations because of the many internal competing agendas, the rapidly changing environment, employees and so on.First step to establish an organizational culture that will support the hospital on their journey to quality starting point leadershipKaplan Norton Balanced Scorecard this approach includes the perspective of the patient and family, internal processes such as clinical pathways, learning and increment opportunities that focus on employees and financial performance. Role of leadership leaders ask financial questions about market share, margins and quality implications. They raise questions related to the satisfaction of their internal and external customers and the way in which business processes must change to improve and sustain quality. Primary focus on creating a culture of quality.Baldrige National Quality ProgramCreating the change towards quality starts with leadership.Road ma p for changeEight stage change process, modified form Kotters seminal work (Leading exchange 1996) serves as a realistic and viable framework to guide leaders who are managing a change to quality 1. Unfreezing the old cultureThis is the most intemperate step because of cultures influence on employee behavior and some employees to desire to resist change and impede progress. 2. Forming a powerful steer coalition3. Developing a vision and strategy4. Communicating a vision and strategy5. Empowering employees to act on the vision and strategy6. Generating short-term wins7. Consolidating gains and producing more change8. Refreezing new approaches in the cultureView as multi-pages