CHAPTER 19
Quality in the Professions and Vocations
The perception, regulation, and achievements of quality in the professions and vocations are varied and complex and need careful investigation and presentation.
There are perfectly straightforward case studies of classical application of quality principles with resounding success1 among many other contrasting stories and themes.2
Education
Education quality is a top priority for the world’s leading bodies.
Education transforms lives and is at the heart of UNESCO’s mission to build peace, eradicate poverty and drive sustainable development.
UNESCO believes that education is a human right for all throughout life and that access must be matched by quality. The Organization is the only United Nations agency with a mandate to cover all aspects of education. It has been entrusted to lead the Global Education 2030 Agenda through Sustainable Development Goal 4. The roadmap to achieve this is the Education 2030 Framework for Action (FFA).3
Aims and Objectives
UNESCO summarizes the progress toward quality in its goal of universal primary education having earlier identified the two main characteristics of quality education:
Two principles characterize most attempts to define quality in education: the first identifies learners’ cognitive development as the major explicit objective of all education systems. Accordingly, the success with which systems achieve this is one indicator of their quality. The second emphasizes education’s role in promoting values and attitudes of responsible citizenship and in nurturing creative and emotional development. The achievement of these objectives is more difficult to assess and compare across countries.4
Key Issues for Education
Following a consideration of the benefits the report mentions the key issues in education and looks at what policies for better learning must focus on:
• Teachers.
• Learning time.
• Core subjects.
• Pedagogy—teaching styles
• Language.
• Facilities.
• Leadership.
In 2000 the Dakar Framework for Action report affirmed that:
quality was “at the heart of education”—a fundamental determinant of enrolment, retention and achievement. Its expanded definition of quality set out the desirable characteristics of learners (healthy, motivated students), processes (competent teachers using active pedagogies), content (relevant curricula) and systems (good governance and equitable resource allocation).5
Foundations and Curricula
In 1996, the report to UNESCO of the International Commission on Education for the Twenty-First Century entitled “Learning: the treasure within” stated that there were four pillars to education:
• Learning to know acknowledges that learners build their own knowledge daily, combining indigenous and “external” elements.
• Learning to do focuses on the practical application of what is learned.
• Learning to live together addresses the critical skills for a life free from discrimination, where all have equal opportunity to develop themselves, their families and their communities.
• Learning to be emphasizes the skills needed for individuals to develop their full potential.
And that:
“This conceptualization of education provided an integrated and comprehensive view of learning and, therefore, of what constitutes education quality” (Delors et al., 1996).6
The Scottish Curriculum for Excellence has four capacities
to be:
And expands on this:
They will demonstrate this by becoming more independent and successful in their learning, by having greater knowledge and more secure understanding, and by being able to use the knowledge that they have more effectively. They will be able to process new information more easily and apply knowledge in different contexts from those in which the knowledge was acquired. They will be able to learn more independently.
Figure 19.1 The purpose of the curriculum—the four capacities
They will be more confident in tackling new and more challenging tasks and dealing with new situations and will have a better understanding of their responsibilities within society.
They will be more able to control their own lives and to be active in society, particularly in contributing to the economy, but also in their awareness of wider issues that affect them.8
Both UNESCO and the Scottish Curriculum for Excellence outline the objectives for education without which it will be impossible to define and manage quality achievement.
Our very first example—“What is education here to provide and enable,” confirms that setting objectives and expectations for a service is fundamental to defining and achieving quality.
Defining Quality in Education
UNICEF takes the whole topic to another big step in a paper on “Defining quality in education” and has the following introduction that lays the foundation for the paper and the case studies with which it concludes:
Quality education includes:
• Learners who are healthy, well-nourished and ready to participate and learn, and supported in learning by their families and communities;
• Environments that are healthy, safe, protective and gender-sensitive, and provide adequate resources and facilities;
• Content that is reflected in relevant curricula and materials for the acquisition of basic skills, especially in the areas of literacy, numeracy and skills for life, and knowledge in such areas as gender, health, nutrition, HIV/AIDS prevention and peace;
• Processes through which trained teachers use child-centred teaching approaches in well-managed classrooms and schools and skilful assessment to facilitate learning and reduce disparities;
• Outcomes that encompass knowledge, skills and attitudes, and are linked to national goals for education and positive participation in society.
• This definition allows for an understanding of education as a complex system embedded in a political, cultural and economic context. … It is important to keep in mind education’s systemic nature, however; these dimensions are interdependent, influencing each other in ways that are sometimes unforeseeable.9
We can now look at the educational system as a whole and see how and where quality applies within it having put the whole system in context—which is what the international standard on quality management10 puts first.
Learning and Education
Education is also about lifelong learning and includes vocational and technical training—
The Lifelong Learning Programme: education and training opportunities for all. The European Commission’s Lifelong Learning Programme enables people at all stages of their lives to take part in stimulating learning experiences, as well as helping to develop the education and training sector across Europe.11
Organizational learning is one important aspect and encouraging learning-oriented organizations is implicit in the benefits of a thorough going application of management best practice.12
The importance of careful definition of the goals of any lifelong learning is very well illustrated by the paper on the “Design of Cross-Cultural Training” where Roger Harrison focused on how to deliver more effective training for those going overseas as part of the Peace Corp program in the USA based on the recognition of the interpersonal skills needed to deliver and succeed with no other resources to turn to. Two tables expressed the different goals of academic and specific overseas interpersonal skills education (Table 19.113).
And the contrasting meta goals provide the context for the main goals (Table 19.2)14.
He sums up the different goals as follows:
The meta-goals also differ profoundly along the dimension of freedom. It is here that the inappropriateness of traditional educational systems for overseas work is most evident. The high degree of control and dependence upon authority common in the college classroom does not lead to the development of a learning style facilitative of success in an overseas environment. This is not just because freedom is a good thing and everyone ought to have a lot of it. It is because so much external control implies a dependency on experts and authorities for direction, information, and validation. When the learner is deprived of these sources of support, as he is almost certain to be in the overseas environment, he is in an uncomfortable and sometimes emotionally crippling situation. He not only must solve new problems in a new setting, but he must develop a new learning style, quite on his own. This experience—not knowing how to learn without traditional supports—may be productive of a good deal of the anxiety and depression grouped under the rubric, “culture shock.” It is certainly responsible for much individual failure, even when it does not lead to chronic depression and anomie.
Table 19.1 Contrasting educational goals of university and overseas education
Communication. To communicate fluently via the written word and, to a lesser extent, to speak well. To master the languages of abstraction and generalization, for example, mathematics and science. To understand readily the reasoning, the ideas, and the knowledge of other persons through verbal exchange. |
Communication. To understand and communicate directly and often nonverbally through movement, facial expression, and person-to-person actions. To listen with sensitivity to the hidden concerns, values, and motives of the other. To be at home in the exchange of feelings, attitudes, desires, and fears. To have a sympathetic, empathic understanding of the feelings of the other. |
Decision-making. To develop critical judgment, the ability to test assertions, assumptions, and opinions against the hard facts and the criteria of logic. To reduce susceptibility to specious argument and to be skeptical of intuition and emotion. To search for the best, most rational, most economical, and most elegant solution. |
Decision-making. To develop the ability to come to conclusions and take action on inadequate, unreliable, and conflicting information. To be able to trust feelings, attitudes, and beliefs as well as facts. To search for the possible course, the viable alternative, the durable though inelegant solution. |
Commitment. Commitment is to the truth. It requires an ability to stand back from ongoing events in order to understand and analyze them and to maintain objectivity in the face of emotionally involving situations. Difficult situations are handled by explanations, theories, and reports. |
Commitment. Commitment is to people and to relationships. It requires an ability to become involved, to give and inspire trust and confidence, to care and to take action in accordance with one’s concern. Difficult situations are dealt with by staying in emotional contact with them and by trying to take constructive action. |
Ideals. To value the great principles and ideals of Western society: social justice, economic progress, and scientific truth. To value the sacrifice of present rewards and satisfactions for future advancement of these ideals and to find self-esteem and satisfaction from one’s contribution toward distant social goals. |
Ideals. To value causes and objectives embedded in the here-and-now and embodied in the groups and persons in the immediate social environment. To find satisfaction, enjoyment, and self-esteem from the impact one has directly on the lives of others. To be able to empathize with others who live mostly in the present and to work with them toward the limited, concrete goals which are important to them. |
Problem-solving. A problem is solved when the true, correct, and reasonable answer has been discovered and verified. Problem-solving is a search for knowledge and truth. It is a largely rational process, involving intelligence, creativity, insight, and a respect for facts. |
Problem-solving. A problem is solved when decisions are made and carried out which effectively apply people’s energies to overcoming some barrier to a common goal. Problem-solving is a social process involving communication, interpersonal influence, consensus, and commitment. |
Table 19.2 Contrasting meta-goals of university classrooms and cross-cultural training
Source of information. Information comes from experts and authoritative sources through the media of books, lectures, and audio-visual presentations. “If you have a question, look it up.” |
Source of information. Information sources must be developed by the learner from the social environment. Information-gathering methods include observation and questioning of associates, other learners, and chance acquaintances. |
Learning settings. Learning takes place in settings designated for the purpose, for example, classrooms and libraries. |
Learning settings. The entire social environment is the setting for learning. Every human encounter provides relevant information. |
Problem-solving approaches. Problems are defined and posed to the learner by experts and authorities. The correct problem-solving methods are specified, and the student’s work is checked for application of the proper method and for accuracy, or at least for reasonableness of results. The emphasis is on solutions to known problems. |
Problem-solving approaches. The learner is on his own to define problems, generate hypotheses, and collect information from the social environment. The emphasis is on discovering problems and developing problem-solving approaches on the spot. |
Role of emotions and values. Problems are largely dealt with at an ideational level. Questions of reason and of fact are paramount. Feelings and values may be discussed but are rarely acted upon. |
Role of emotions and values. Problems are usually value- and emotion-laden. Facts are often less relevant than the perceptions and attitudes that people hold. Values and feelings have action and consequences, and action must be taken. |
Criteria of successful learning. Favorable evaluation by experts and authorities of the quality of the individual’s intellectual productions, primarily written work. |
Criteria of successful learning. The establishment and maintenance of effective and satisfying relationships with others in the work setting. This includes the ability to communicate with and influence others. Often there are no criteria available other than the attitudes of the parties involved in the relationship. |
Education for cross-cultural applications should train the individual in a system of learning operations that is independent of settings, persons, and other information sources not found in the overseas environment. If the trainee can be educated to be an effective and independent learner, he need not be filled with all the information he can contain before going into his new job. He will have the capacity to generate his own learning as needed. Indeed, he will have to generate his own learning in any case, whether he is trained to do this or not, for the simple reason that no training agency can train for every exotic contingency, for every aspect of life and work in another culture.15
He provides a case study and associated papers touch on “classroom innovation,” “developing autonomy, initiative, and risk taking,” “self-directed learning,” and “steps toward the learning organization.”16
Components and Requirements of Quality Management
The issue of the importance of context, scope, interested parties, expectations, and objectives is highlighted in a recent article on the UK Government Inspectorate of Schools—Office for Standards in Education, Children’s Services and Skills (Ofsted) entitled—“Ofsted inspections to focus on “quality of education” over performance data.”17 You get what you measure and if your measurements are too narrow you will skew and bias the whole system to what you focus on. Performance data needs to reflect all the processes and the whole system and build than on understanding what and who the system is there to serve, and why and how, with a set of measurable objectives and a clear system definition with well-delineated processes. This is the essential foundation.
The whole set of quality tools and techniques we have outlined is potentially applicable with care and sensitivity including benchmarking and experimentation as well as more classical structured improvement.18
Nations see the performance of their society in its ability to perform and contribute and based on their understanding and their recognition of the need to improve.19 Grasping the whole system and applying the best practice quality tools with the involvement of all the stakeholders has then real traction.20
Quality, Life, and Service
A quality professional noticed that his teacher wife was unconsciously excelling at customer care, service, and satisfaction. To her “to teach is to touch a life” and this includes
not just standing in front of a class and teaching or lecturing. “She gets involved in the lives of her students—not just their school lives but also their home lives, as much as the students are willing to share. Her involvement often consists of being compassionate, listening to problems, counselling, and giving affection or encouragement to students who will not turn to anyone else.”21
This also includes mutual respect, complete absence of stereotypes, and no labeling of individuals. The regular peer reviews to which she is subject always show up as excellent!
We shall see these themes again, and again, in the very best of quality in health care and medicine, and many, many places in quality—in fact everywhere potentially.
Medicine and Health Care
Quality in Health Care
When we come to medicine and health care, we need to be sensitive to cultural differences. For instance, in the USA Health Care is “an industry,” as an article entitled “Finding Solutions To Quality Issues That Affect The Healthcare Industry”22 shows, even though the file name reflects the global reach, the article seeks—“finding-solutions-to-quality-issues-that-affect-all-aspects-of-healthcare-across-the-globe.pdf.”
The introduction to the new direction in quality in the UK NHS contrasts with this:
The NHS is organising itself around a single definition of quality: care that is effective, safe and provides as positive an experience as possible. This simple, yet powerful definition that arose out of the NHS Next Stage Review has now been enshrined in legislation. It lies at the heart of the first ever NHS Outcomes Framework and continues to help unite the ambitions and motivations of staff with the hopes of patients and the expectations of the public. It is also inherent in the related Outcomes Frameworks for public health and adult social care.
But quality must never become some abstract concept or theoretical pursuit. A relentless focus on quality means a relentless focus on how we can positively transform the lives of the people who use and rely on our services. In contrast, a failure to focus on quality and to make it our primary concern can result in lasting emotional and physical damage to patients and even death. The appalling failures at Mid Staffordshire NHS Foundation Trust23 and at the independent hospital, Winterbourne View,24 provide stark reminders that when we fall short on our responsibilities in respect of quality, the consequences for patients, service users and their families can be catastrophic.25
A UK health care definition then is “Quality: care that is effective, safe and provides as positive an experience as possible”. Thankfully, although cost is always an issue the definition focuses on “possibilities” rather than “affordability.” The links with issues of failure of quality we pick up in Chapter 21—Quality—unifying and correcting, along with other failure issues.
The Scottish NHS definition of quality is
Mutually beneficial partnerships between patients, their families and those delivering healthcare services which respect individual needs and values and which demonstrate compassion, continuity, clear communication and shared decision-making. There will be no avoidable injury or harm to people from healthcare they receive, and an appropriate, clean and safe environment will be provided for the delivery of healthcare services at all times. The most appropriate treatments, interventions, support and services will be provided at the right time to everyone who will benefit, and wasteful or harmful variation will be eradicated.26
It included six dimensions of quality (Figure 19.2) recommended by the Institute The IHI has adapted the US Institute of Medicine’s six dimensions of quality … into a “no needless” framework,… which aspires to promote: “no needless deaths—no needless pain or suffering—no helplessness in those served or serving—no unwanted waiting—no waste—no one left out.”27
Figure 19.2 The dimensions of quality28
It is also at the heart of the quality improvement approach by the UK Healthcare Foundation29:
The conception of improvement finally reached as a result of the review was to define improvement as better patient experience and outcomes achieved through changing provider behaviour and organisation through using a systematic change method and strategies.
The key elements in this definition are the combination of a “change” (improvement) and a “method” (an approach with appropriate tools), while paying attention to the context, in order to achieve better outcomes.
The improvement context is:
Quality improvement draws on a wide variety of methodologies, approaches and tools. However, many of these share some simple underlying principles, including a focus on:
• understanding the problem, with a particular emphasis on what the data tell you
• understanding the processes and systems within the organisation—particularly the patient pathway—and whether these can be simplified
• analysing the demand, capacity and flow of the service
• choosing the tools to bring about change, including leadership and clinical engagement, skills development, and staff and patient participation
• evaluating and measuring the impact of a change.30
The Health Foundation lists and outlines the use of the following tools and techniques for quality improvement, which we have already covered in this work, applied in a system context:
• Business process reengineering
• Experience-based co-design
• Lean
• Model for improvement (including PDSA)
• Six Sigma
• Statistical process control
• Theory of constraints
• Total quality management (TQM)31
Quality is a journey and Ham32 outlines that journey for the UK NHS in the headings of “Improving quality in the English NHS—A strategy for action”:
• Competing beliefs on how to improve quality
• The need for a coherent and integrated strategy
• Where next?
• Expect NHS organisations to build in-house capacity for quality improvement
• Support NHS organisations through shared learning and regional support
• Establish a modestly sized national centre of expertise
• Integrate work on quality improvement with work on leadership development
• Ensure that national bodies provide unified, co-ordinated support to the NHS as full participants in a single strategy
• Involve frontline clinical leaders and the leaders of NHS organisations in developing the strategy
• Ensure the voice of patients and the public is sought and heard in the design and implementation of the strategy
• Be open to learning from other organisations at home and abroad
• Work with organisations and experts outside the formal structures of the NHS
The journey that Ham33 reviews finds echoes in Becher.34
Health Care Quality Management Systems
This is a journey on which the USA has traveled further than many and has articulated with a model quality management system for health care and a maturity model for applying it.
The inner circle of patient experience can be expressed by the patient as “Make me better, and don’t hurt me,”35 see Figure 19.3, but the often conflicting requirements of “Exceptional quality, safety and patient outcome”—see equivalent inner circle in Figure 19.4, requires that communication between patient and the clinical team is carefully defined and agreed that with the patient.
Figure 19.3 A high-level conceptual representation of the health care QMS36
Source: Peiffer, Susan E., Pierce B. Story, and Grace L. Du, “The Impact of Human Factors on a Hospital-Based Quality Management System”, The Journal for Quality & Participation, October 2016, pp 19 – 23, http://asq.org/quality-participation/2016/10/quality-man
Reprinted with permission from the Journal for Quality and Participation © 2016 ASQ, www.asq.org
All rights reserved. No further distribution allowed without permission.
Figure 19.4 The ASQ QMD-HCD hospital-based health care QMS model37
Source: Peiffer, Susan E., Pierce B. Story, and Grace L. Du, “The Impact of Human Factors on a Hospital-Based Quality Management System”, The Journal for Quality & Participation, October 2016, pp 19 – 23, http://asq.org/quality-participation/2016/10/quality-man
Reprinted with permission from the Journal for Quality and Participation © 2016 ASQ, www.asq.org
All rights reserved. No further distribution allowed without permission.
Before proceeding to the building of the care delivery supported by a management system founded on quality assurance best practice expressed in health care sympathetic terminology, we need to look at the issues facing health care worldwide.
Peiffer et al. point out that though many health care institutions—hospitals, institutions, teams, and others, engage in quality improvement; the long-term success from embedding short-term gains into a sound system approach is elusive, and they consider the issues.38
The pressures that staff are under and the shortage of resources to make the transition to a supportive system environment are suggested, and considered. The challenges and opportunities and the application of “equity” rather than “equality” to patient populations and national situations are considered as vital issues to be faced in making the transition to a fully supported system approach.39
The system elements of the outer ring are fully explained in the exposition of the health care model. The application of the 10 system elements is fully explored in the model.40
To complement the model, there are suggested approaches to implementation fully supported with stages in the implementation of the QMS model (Figure 19.5),
• along with process maps and self-assessment instruments.41
• Stage 1—QMS model adoption. The organization officially adopts the QMS model as the relevant framework for its system.
• Stage 2—Alignment of existing processes against 10 QMS elements. The organization determines how its existing processes align with the 10 QMS elements, where there are redundant efforts, and where gaps exist.
• Stage 3—QMS pilot. The organization selects a department, function, clinic, location, or other subsidiary work units as a pilot site for implementing the complete QMS model. Applicable existing processes are improved or supplemented as necessary to fulfill the QMS model’s intentions completely. Initial metrics and performance targets are adopted to track results. Learnings from the pilot are used to improve the QMS model’s application in the initial work unit.
• Stage 4—QMS expansion. The organization develops a comprehensive expansion plan that applies the QMS across all work units. Processes associated with the 10 QMS elements are customized as appropriate to meet specific patient and business needs. Appropriate metrics and performance targets are adopted to track results for each work unit. Learnings are monitored and used to improve the QMS model’s application in each work unit.
• Stage 5—Consistent application of the comprehensive QMS model. The organization’s focus moves beyond determining if means and proportions of processes’ adopted metrics are on target. More attention is given to consistent application by monitoring variances of the metrics.
• Stage 6—Understanding QMS drivers and interdependencies. The organization’s comprehension of relationships among the QMS model’s levels are understood deeply. Continual improvement and innovation efforts associated with the 10 QMS elements not only enhance attainment of target performance (for both means/proportions and variances) but also ensure sustainable performance of the organization’s highest-level outcomes.42
Six sigma (see Chapter 16, six sigma) is again part of the tool set that can be deployed in the QMS.43
The NHS improvement hub provides support for the application of a wide range of quality, service improvement, and redesign (QSIR) tools and shows how they can be deployed in appropriate stages of the patient pathway.44
Care Quality Commission
No consideration of quality in health care would be complete in the UK without touching on the Care Quality Commission (CQC)—particularly because of its role in revealing poor quality care (see Chapter 22 Quality—unifying and correcting) (Figure 19.6).
Figure 19.5 QMS maturity model45
Source: Duffy, Grace L., Susan Peiffer, and Pierce Story, “Healthcare QMS Self-Assessment Based on a Maturity Model”, The Journal For Quality & Participation, April 2019, on-line only pp 1 - 22, http://asq.org/quality-participation/2019/04/best-practices/how-well-is-your-healthcare-quality-management-system-performing.pdf
Reprinted with permission from the Journal for Quality and Participation © 2019 ASQ, www.asq.org
All rights reserved. No further distribution allowed without permission.
Figure 19.6 CQC’s overall operating model46
The CQC focuses on the following and carries out inspections to confirm compliance: -
• Person-centred care
• Dignity and respect
• Need for consent
• Safe care and treatment
• Safeguarding service users from abuse and improper treatment
• Meeting nutritional and hydration needs Regulation
• Premises and equipment Regulation
• Receiving and acting on complaints
• Good governance Regulation
• Staffing
• Fit and proper persons employed
• Duty of candour
• Requirement as to display of performance assessments.47
The Heart and Science of Health Care Quality
Again, the personal interaction can transform the whole experience of medicine and health care. Sister Jean Ryan quotes a physician Rachel Naomi Remen:
The ways and means by which people serve may vary from time to time and from culture to culture, but the nature of service has not changed since our beginnings. No matter what means we use, service is always a work of the heart. There are times when the power of science is so seductive that we may come to feel that all that is required to serve others is to get our science right, our diagnosis, our treatment. But science can never serve unless it is first translated by people into a work of the heart
to illustrate the intimate and the caring compassion that transformed her experience of recovery from chronic lymphocytic leukemia. This she felt exemplified “our mission statement in action: ‘Through our exceptional health care services, we reveal the healing presence of God’.”48
Public Sector
The themes affecting the professional and vocational sectors are already visible from the sections on education, medicine, and healthcare, and Becher,49 although simplistic in the assessment of assurance and control, looks at the following professions—medicine, pharmacy, law, accountancy, architecture, and structural engineering, and adds these issues from many in-depth interviews:
• A belief that QA and QC focus on easily measured but shallow and misleading data instead of professional capability.
• Concern about the appropriateness and legitimacy of QA and QC in the face of need for creativity, freedom from straight jacket, market being the best judge, professional quality easy to judge.
• Beliefs that clients are incapable of assessing and practitioners wrongly focus on easy parameters.
• The effects of dwindling resources and increasing workloads.
• Professions have an emphasis on internal vigilance over professional conduct.
• Provision of existing individual and course or qualification approval mechanisms.
• Current site and trainer inspection and accreditation incapable and inappropriate to extend.
• Low to no enthusiasm for adopting the management system accreditation approach believed to be at the root of BS 5750 (early predecessor of ISO 9001) and shown in some sectors (architecture and engineering) at around a quinquennial level.
Becher notes the present reliance on individual accreditation and the growing requirement for individual re-accreditation and the related dependence on evidence of continuing professional development. He also notes that these procedures—peer group review and observation of practice, submission, and scrutiny of documentary evidence, are common features of inspection and monitoring regimes. Notes are included on the use of audit, peer review, and appraisal.50
A sizable British Institute of Management survey showed that although organizations in the public sector were involved with quality and TQM and were catching up, they were the least likely to have sought certification to the international quality management standard and the experiences of the champions of quality of taking it forward were among the most lonely and difficult.51
The local government in the UK has been under considerable pressure for many years and “best value” is one of the ways—radical process re-engineering is another, is one of the ways of driving performance improvements alongside budget reductions.52 Council responses to improve quality in response have included not only ISO 9001 and awards like the EFQM award but also related schemes such as Investors in People53 and The Charter Mark Award.54
The summary and conclusions outline the picture at the end of the 1990s with the expectation of continued uptake of these programs.
“Many local government services have, or are in the process of, implementing one or more quality standards. This is being done in order to improve services and provide better value for money. However, the cost of implementing such standards can be high and so service providers need to ensure that the benefits accrued from such standards are worthwhile. Unfortunately, the services studied have not measured the benefits of the standards in financial terms so were unable to tell if the standard implemented was cost-effective or not.”
“Conclusions”
“Local government services are being driven down the path of continuous improvement by a central government keen to get as much as possible for the taxpayers’ money. Severe budgetary constraints have already led to a reduction in the number of local government employees from 300,000 to 290,000 in the past two years. Therefore, the maintenance of service levels will require more efficient use of available resources. To enable this to happen, the central government has introduced its best-value policy. In order to comply with the best value’s requirements, local council service providers will have to implement various quality standards and may find it useful to measure their performance against the criteria of the EFQM business excellence model. The model offers a framework for both the integration of a number of standards and an aid to meeting the requirements of best value. The field interviews found that those services that had already implemented one or other of the standards had reaped some benefits, although in relation to continuous improvement, there is as yet no empirical data on whether the improvements to services have been cost-effective or not. Improvements in services, whether through reduced customer complaints or faster throughput of customers, have to be measured in monetary terms as evidence of improved value for money services. The choice of which standard to implement has so far had more to do with personal preferences, past experiences, and good luck than as part of an integrated quality improvement strategy. This is where the framework of the EFQM model will have an important task to perform. For example, only one of the services studied had implemented more than one standard, yet each has something different to offer. The model will allow senior management to see the overall strategy as regards continuous improvement and offer guidance on those areas where more effort is required so that scarce resources can be best utilized.”55
To these initiatives can be added a more recent summary of initiatives—“TQM in the Oregon Judicial Department, Florida’s Fourth District Court of Appeal, and the Texas Department of Mental Health and Retardation, benchmarking their initiatives and outlining the importance of leadership commitment as it relates to TQM success.”56 Very telling and valuable insights are provided:
Without clear, decided direction, a TQM initiative is likely viewed as a short-term program or “flavor of the month.” Undoubtedly, this leads to scepticism and inhibits real cultural transformation. A clearly articulated and cohesive purpose is essential to success and “Courts embarking on TQM must be aware of the stamina required for a transformation to a ‘real’ TQM management culture.” This important statement summarizes an often-ignored concept; TQM is not a program or a project but is a management philosophy requiring leadership, commitment, a central purpose, and education to generate an organization-wide cultural transformation. Failing to lay this critical foundation returns marginal results and can create cynicism.
Where the leadership was present in other initiatives there was much more success. And part of the leadership commitment was to the personal transformation it required.57
Lewis points out that implementing TQM is a response to the “demand for improving governmental performance in services, cost-effectiveness, and general overall efficiency as a result of the general squeeze on incomes.” She identifies potential obstacles such as “bureaucratic and political resistance to change, changing or expanding paradigms, garnering program support, and funding of resources.”58 Federal quality initiatives, and the awards provided to support them, are reviewed along with state-level initiatives, which apply as much or more to the local private sector, and municipal and local area initiatives.
The classical barriers to TQM are considered. The need to customize the language and presentation to government mirrors what happened with the health care quality management system model—see Health care quality management systems. The contribution reviews the dynamics of change and best practice in implementing TQM in the public sector.
The way in which hidden political agendas can be perceived, or included, in the use of quality in the public sector is considered by Kirkpatrick.59
Law
Users of the law can find it difficult to judge quality was a key finding of a survey:
It was also clear that they felt largely unable to judge such quality, for a number of reasons:
• using a solicitor is a relatively rare event, so individuals don’t have much of a benchmark against which to judge them;
• the legal world is felt to be above most consumers’ heads;
• the nature of legal services is that their value is often in the long-term rather than short-term context;
• there is felt to be minimal public or regulatory information to refer to;
• consumers are relatively inactive in terms of comparing different firms’ offers.60
The expectations of users were revealing in that they stopped short of anything to do directly with the knowledge and competence of the person they were dealing with:
• Empathy—treating the consumer as an individual, not just another file, understanding their situation and relating to it.
• Efficient processes—ensuring things progress smoothly and on time.
• Outcomes—e.g. completing on a property on time, delivering a will or achieving the desired outcome in a divorce/separation.
• Clarity and de-mystification—unravelling the mystery of the legal world with clear explanations (no jargon), clear signposting of what should happen and when, and clear guidance on charges.
• Proactively using their knowledge—explicitly suggesting alternative options, tailoring advice to individual circumstances or challenging the client’s assumptions.
• Professional presentation—both personally in terms of dress and appearance, but also in terms of the physical office environment.61
All solicitors were assumed to be technically competent— It was not that technical knowledge was not important to consumers, but more a function of two background issues. Firstly, consumers generally assumed that all lawyers have an acceptable level of legal knowledge, and have all passed sufficient qualifications. Secondly, there is a common belief that the law is relatively black and white (at least in terms of wills and conveyancing, though less so with divorce/separation), and that since all lawyers work from the same legal framework, the quality of advice offered will not vary significantly across firms.62
Regulators were expected to ensure technical quality standards— The general assumption that nearly all solicitors were “competent” was based on the common standard for qualifying, and respect for the “professions,” rather than any knowledge of active regulation. Awareness of a legal services regulator was minimal—though most did “assume” there was someone—and although a minority of consumers knew of the Law Society, they considered it mainly in the context of reactively handling complaints rather than any wider regulatory activity (no-one in the groups mentioned the Solicitors Regulation Authority, although the organisation was only established a few years ago).63
Which all points up the need for society and regulators—and the professional bodies to both ensure competence on qualifying, see that it is maintained, and ensure the organizations work within a management system framework that assures quality on an ongoing basis.
The Law, and other professions, do present schemes offering assurance to users. The Law Society in the UK has a scheme called “Lexcel.” The scheme is “Designed especially for providers of legal services, Lexcel sets out required rules and guidelines to help raise standards and promote a quality management approach to practice management and client care.”64
It is a voluntary standard but with annual external accreditation:
• Lexcel is a voluntary standard designed especially for the legal sector.
• Lexcel sets out required rules and guidelines to raise standards and promote a quality management approach for client service and how to manage a legal practice.
• Annual re-accreditation against the Lexcel Standard by independent assessors and mandatory training help ensure continued compliance and competence.65
Farming and Fishing
Farming and fishing quality is firstly today about safety and the environment at a regulatory level, and though quality is the sense of taste and flavor, health benefits are still central for many people; for most it is about affordability even at the risk of health risks.
There are standards and regulations, including ISO 22000,66 which ISO also presents as relating to quality,67 but the major and predominant emphasis for 22000 and all the related standards is on safety. Surak points out the similarities between ISO 22000 and ISO 9001 but highlights the key differences among which is the much clearer emphasis on risk management, in this case using Hazard Analysis & Critical Control Point (HACCP).68 This transition to more specific risk management for a sector-specific standard is quite common as we have seen before with ISO 13485 for medical devices. The commonality with ISO 9001 probably has as much more to do with the Annex SL management system foundation than anything pointing toward quality per se. Surak also lists other global food safety schemes.
The Red Tractor scheme,69 for a wide range of foodstuffs, and Quality Meat Scotland70 and Farm Quality Assured—the Northern Ireland Beef and Lamb Farm Quality Assurance Scheme, and the Marine Stewardship Council71 all offer closely related schemes for food safety, including traceability and related issues.
The importance of careful “proof of concept” including a consideration of all the potential negative aspects of a food innovation are highlighted by Merrill.72
Humane slaughter affects the quality of fish carcasses,73 as well others and as well of protecting our humanity. The care of all creatures has effects at all levels.
Performing Arts
Training and Competence
The system of exam grades for music enables a clear understanding of competence and allows orchestra leaders to put together musicians who with moderate rehearsal time will be able to turn out a creditable and enjoyable performance. Portfolios of art and experience and/or musical exam grades enable presentation for many roles and opportunities.
The development of competence and the system of training and exams for music is very well known and practical. To put together a performance that will rejoice the listener, you can start with specifying the musical grade level you need in the instrumentalists you want to assemble. Auditions are a searching means of demonstrating competence based on training and experience. The benchmark for many other areas of competence, experience, education, and training could be readily found here.
Demonstrating competence in the arts is a matter of the assembled portfolio and the ability to present that as needed.
Mastery
The development of mastery is another keystone of the performing arts. Entering and winning competitions—whether music for piano, voice, or other instruments, or to exhibit at the Royal Academy of Arts requires commitment and devotion above and beyond the ordinary.
“How is mastery achieved? Achieving mastery in any skillset generally requires accumulating thousands or tens of thousands of hours of deliberate practice, which can take decades.”74 Deliberate practice is the mental and emotional (and sometimes physical) struggle—spent mostly in solitude—completing practice activities just beyond the practitioner’s current capabilities. What about talent? “Achieving mastery doesn’t happen faster for people who are born with superior learning abilities. Most practitioners who invest the time in deliberate practice will see the resulting improvements. The level of progress toward mastery often depends on the time the practitioner spends on deliberate practice activities.75 More advanced learning activities, better feedback and improved mental representations can help speed the process.”76
And again, this sets a benchmark for mastery of any area of life, profession, and service. The issue of motivation and the contrast with seeing achievement of an objective as a contribution based on intrinsic motivation—an inner drive, rather than some extrinsic reward is a major theme in achieving mastery.77
Communicating at the Deepest Levels
The criterion that differentiates between the good and the excellent in art is to communicate at the deepest levels through the performance of the piece. Convincing the audience that you are giving of yourself at the deepest level provokes a response.
Touching Lives
The arts touch lives. People come out from performances and presentations not just full of the experience but in many ways changed often from the draining experiences of everyday life, sometimes for good in every respect. The impact that our deep, deep commitment and loving service have on others is clear from so many angles.
1See C.B. Montano and G.H. Utter. August 1999. “Total Quality Management in Higher Education—An Application of Quality Improvement in a University,” Quality Progress, pp. 52-59. http://asq.org/data/subscriptions/qp/1999/0899/qp0899montano.pdf.
2See T. Becher. 1999. “Quality in the Professions,” Studies in Higher Education 24, pp. 225-235. doi:10.1080/03075079912331379908.
3See UNESCO. “Education for All: The Quality Imperative; EFA Global Monitoring Report, 2005,” ISBN:978-92-3-103976-8, 92-3-103976-8. https://unesdoc.unesco.org/ark:/48223/pf0000137333 and http://www.unesco.org/education/gmr_download/chapter1.pdf.
4See p. 15 in Ibid.
5See p. 29 Ibid.
6See p. 30 ibid.
7See Scottish Government. 2008. Curriculum for Excellence: Building the Curriculum 3: A Framework for Learning and Teaching: Key Ideas and Priorities, ISBN: 978-0-7559-5711-8. https://www2.gov.scot/resource/doc/226155/0061245.pdf and https://www2.gov.scot/Publications/2010/06/02152520/1.
8Ibid.
9See UNICEF. 2000. Defining Quality in Education (New York: United Nations Children’s Fund). http://www.oosci-mena.org/uploads/1/wysiwyg/Quality_Education_UNICEF_2000.pdf.
10See ISO 9001:2015. “Quality Management Systems—Requirements.”
11https://www.europatrainingltd.com/LLP/index.cfm/Introduction/39.
12See clause 7.1.5 in ISO 9001:2015. “Quality Management Systems—Requirements,”
13See and part four, Chapters 18-24 in R. Harrison. 26 May 1995. The Collected Papers of Roger Harrison (San Francisco, CA: Jossey-Bass Publishers), ISBN-10: 0787900834, ISBN-13: 978-0787900830.
14Ibid
15See p. 300 in R. Harrison. 26 May 1995. The Collected Papers of Roger Harrison (San Francisco, CA: Jossey-Bass Publishers), ISBN-10: 0787900834, ISBN-13: 978-0787900830.
16Chapters 21, 22 and 24 in R. Harrison. 26 May 1995. The Collected Papers of Roger Harrison (San Francisco, CA: Jossey-Bass Publishers), ISBN-10: 0787900834, ISBN-13: 978-0787900830.
17See G. Jozwiak. 15 January 2019. “Ofsted Inspections to Focus on ’Quality of Education’ over Performance Data,” Children and Young People Now. https://www.cypnow.co.uk/cyp/news/2006260/ofsted-inspections-to-focus-on-quality-of-education’-over-performance-data and UK Gov Ofsted. “Ofsted Is Changing How It Inspects Schools.” https://www.gov.uk/government/news/ofsted-is-changing-how-it-inspects-schools.
18See B. Bergman, E. Cudney, P. Harding, Z. He, and P. Saraiva. January 2019. “Global Perspectives on Quality in Education,” The Journal for Quality & Participation. http://asq.org/quality-participation/2018/07/global-quality/global-perspectives-on-quality-in-education.pdf and www.asq.org/pub/jqp.
19See K. Bemowski. October 1991. “America 2000—The Revolution to Change the US Education System by the Year 2000 has begun,” Quality Progress, pp. 45-48.
20See T. Kelly. October 1991. “Elementary Quality,” Quality Progress, pp. 51-56, J.E. Horine, W.A. Haley, and L. Rubach. October 1993. “Transforming Schools,” Quality Progress, pp. 31-38, J.E. Horine, W.A. Haley, and L. Rubach. October 1993. “Shaping America’s Future,” Quality Progress, pp. 41-60, F.P. Schargel. October 1993. “Total Quality in Education,” Quality Progress, pp. 67-70, V.R. Salmon. October 1993. “Quality in American Schools,” Quality Progress, pp. 73-75, J.A. Hittman. October 1993. “TQM and CQI in Postsecondary Education,” Quality Progress, pp. 77-80., K.A. Sharples, M. Slusher, and M. Swaim. May 1996. “How TQM Can Work in Education,” Quality Progress, pp 75-78. http://asq.org/data/subscriptions/qp/1996/0596/qp0596sharples.pdf.
21See L.J. Caldwell. November 1993. “To Serve a Customer Is to Touch a Life,” Quality Progress, pp. 117-118.
22See S. Peiffer, G. Kollm, C. Graham-Clark, R. Denis, G.L. Duffy, V. Araujo, and P. Story. January 2018. “Finding Solutions to Quality Issues That Affect The Healthcare Industry,” The Journal for Quality & Participation, pp. 1-11. http://asq.org/quality-participation/2018/01/best-practices/finding-solutions-to-quality-issues-that-affect-all-aspects-of-healthcare-across-the-globe.pdf.
23See UK Gov Publications. “Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry.” https://www.gov.uk/government/publications/report-of-the-mid-staffordshire-nhs-foundation-trust-public-inquiry.
24See UK Gov Department of Health. “Transforming Care: A National Response to Winterbourne View Hospital—Department of Health Review: Final Report, Mental Health, Disability and Equality Department of Health. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/213215/final-report.pdf and UK Gov NHS Transforming Care and Commissioning Steering Group. “Winterbourne View—Time For Change—Transforming the Commissioning of Services for People with Learning Disabilities and/or Autism.” https://www.england.nhs.uk/wp-content/uploads/2014/11/transforming-commissioning-services.pdf.
25See D. Nicholson. January 2013. “Quality in the New Health System—Maintaining and Improving Quality from April 2013,” Final Report. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/213304/Final-NQB-report-v4-160113.pdf.
26See Scottish Government. 2010. “The Healthcare Quality Strategy for NHSScotland,” ISBN: 978-0-7559-9323-9 (web only). https://www2.gov.scot/resource/doc/311667/0098354.pdf.
27See p. 244 in Institute of Medicine (IOM). 2001. Crossing the Quality Chasm: A New Health System for the 21st Century (Washington, DC: The National Academies Press). doi:10.17226/10027. Paperback: 978-0-309-46561-8, Hardcover: 978-0-309-07280-9, Ebook: 978-0-309-13296-1.
28See The Health Foundation. August 2013. Quality Improvement Made Simple—What Everyone Should Know About Healthcare Quality Improvement, 2nd edition, ISBN 978-1-906461-47-8. https://www.nes.scot.nhs.uk/media/3604996/qualityimprovementmadesimple.pdf.
29The Health Foundation. August 2013. Quality Improvement Made Simple—What Everyone Should Know About Healthcare Quality Improvement, 2nd edition, ISBN 978-1-906461-47-8, https://www.nes.scot.nhs.uk/media/3604996/qualityimprovementmadesimple.pdf
30Ibid.
31Ibid.
32See C. Ham, D. Berwick, and J. Dixon. February 2016. “Improving Quality in the English NHS—A Strategy for Action,” The Kings Fund, https://www.kingsfund.org.uk/sites/default/files/field/field_publication_file/Improving-quality-Kings-Fund-February-2016.pdf.
33See Ibid.
34See T. Becher. 31 July 1999. Professional Practices: Commitment and Capability in a Changing Environment (London: Routledge); 1st edition, ISBN-10: 1560004142, ISBN-13: 978-1560004141, T. Becher. 1999. “Quality in the Professions,” Studies in Higher Education 24, pp. 225-235. doi:10.1080/03075079912331379908.
35See S.E. Peiffer, P.B. Story, and G.L. Du. October 2016. “The Impact of Human Factors on a Hospital-Based Quality Management System,” The Journal for Quality & Participation, pp. 19-23. http://asq.org/quality-participation/2016/10/quality-management/the-impact-of-human-factors-on-a-hospital-based-quality-management-system.pdf.
36Ibid.
37S.E. Peiffer, P.B. Story, and G.L. Du. October 2016. “The Impact of Human Factors on a Hospital-Based Quality Management System,” The Journal for Quality & Participation, pp. 19-23. http://asq.org/quality-participation/2016/10/quality-management/the-impact-of-human-factors-on-a-hospital-based-quality-management-system.pdf.
38Ibid.
39Ibid.
40See T. Motschman, C. Bales, L. Timmerman. April 2016. “Improving Healthcare Monograph Series: A Hospital-Based Healthcare Quality Management System Model,” Healthcare Technical Committee. http://asq.org/2016/04/quality-management/a-hospital-based-healthcare-quality-management-system-model.pdf.
41G.L. Duffy, S. Peiffer, and P. Story. April 2019. “How Well Is Your Healthcare Quality Management System Performing?,” The Journal For Quality & Participation, pp. 12-18. http://asq.org/quality-participation/2019/04/best-practices/how-well-is-your-healthcare-quality-management-system-performing.pdf.
42Ibid and G.L. Duffy, S. Peiffer, and P. Story. April 2019. “Healthcare QMS Self-Assessment Based on a Maturity Model,” The Journal for Quality & Participation, pp. 1-22. http://asq.org/quality-participation/2019/04/best-practices/how-well-is-your-healthcare-quality-management-system-performing.pdf.
43See L. Duncan and S. Luchs. July 2017. “Down With Silos—Offering Better Value and Achieving Better Patient Care with Lean Six Sigma,” Quality Progress, pp. 22-29. http://asq.org/quality-progress/2017/07/six-sigma/down-with-silos.pdf and J. Bossert. April 2019. “Implementing Healthcare Quality,” The Journal for Quality & Participation. http://asq.org/quality-participation/2019/05/basic-quality/implementing-healthcare-quality.pdf.
44See J.R.A. Taylor, S. Reid, and A. Tweed. 2017. “Quality, Service Improvement and Redesign (QSIR) tools,” NHS Improvement. https://improvement.nhs.uk/resources/quality-service-improvement-and-redesign-qsir-tools/.
45See G.L. Duffy, S. Peiffer, and P. Story. April 2019. “How Well Is Your Healthcare Quality Management System Performing?,” The Journal For Quality & Participation, pp. 12-18. http://asq.org/quality-participation/2019/04/best-practices/how-well-is-your-healthcare-quality-management-system-performing.pdf.
46See Care Quality Commission (CQC). 2015. “Guidance for Providers on Meeting the Regulations.” https://www.cqc.org.uk/sites/default/files/20150324_guidance_providers_meeting_regulations_01.pdf.
47See Care Quality Commission (CQC). 29 May 2017. “The Fundamental Standards.” https://www.cqc.org.uk/what-we-do/how-we-do-our-job/fundamental-standards.
48M.J. Ryan. 2016. “The Heart and Science of Health Care Quality,” IAQ General Meeting in Helsinki, Finland on June 3, 2016. https://img1.wsimg.com/blobby/go/f9efea8c-f34b-41d8-a64d-aac8dd7f72ca/downloads/1cpkoibv1_179495.pdf?ver=1572443644267.
49See T. Becher. 1999. “Quality in the Professions,” Studies in Higher Education 24, pp. 225-235. doi:10.1080/03075079912331379908 and T. Becher. 31 July 1999. Professional Practices: Commitment and Capability in a Changing Environment (London: Routledge); 1st edition, ISBN-10: 1560004142, ISBN-13: 978-1560004141
50See T. Becher. 1999. “Quality in the Professions,” Studies in Higher Education 24, pp. 225-235. doi:10.1080/03075079912331379908.
51See A. Wilkinson, T. Redman, E. Snape. Winter 1995. “New Patterns of Quality Management In The United Kingdom.” Quality Management Journal. http://asq.org/data/subscriptions/qmj_open/1995/february/qmjv2i2wilkinson.pdf.
52See C. Brennan and A. Douglas. “Striving for Continuous Improvement: The Experience of U.K. Local Government Services,” ASQ’s 53rd Annual Quality Congress Proceedings, pp. 414-422. http://asq.org/articles/aqc-proceedings/public_proceedings/53_1999/10853.pdf.
53See https://www.investorsinpeople.com/our-story/.
54See https://publications.parliament.uk/pa/cm200708/cmselect/cmpubadm/411/41106.htm now replaced with Customer Service Excellence—https://www.customerserviceexcellence.uk.com/.
55See C. Brennan and A. Douglas. “Striving for Continuous Improvement: The Experience of U.K. Local Government Services,” ASQ’s 53rd Annual Quality Congress Proceedings, pp. 414-422. http://asq.org/articles/aqc-proceedings/public_proceedings/53_1999/10853.pdf.
56C. Kluse. “TQM and the Government—The Importance of Leadership and Personal Transformation,” pp. 27-31. http://asq.org/quality-participation/2009/10/total-quality-management/case-study-tqm-and-the-government-the-importance-of-leadership-and-personal-transformation.pdf.
57Ibid.
58See C.J. Lewis. 1995. “Implementing Total Quality Management in The Public Sector,” Theses Digitization Project. 1106. https://scholarworks.lib.csusb.edu/etd-project/1106 and https://pdfs.semanticscholar.org/8612/950e65ad75155508bc9ea2dbb5e3ec0bdf9a.pdf.
59See I. Kirkpatrick and M.M. Lucio. 1995. The Politics of Quality in the Public Sector (London: Routledge), ISBN 0-415-10665-6 (hbk), ISBN 0-415-10666-4 (pbk).
60See Legal Services Panel. September 2010. Quality in Legal Services (London: Legal Services Panel). https://www.legalservicesconsumerpanel.org.uk/publications/research_and_reports/documents/VanillaResearch_ConsumerResearch_QualityinLegalServices.pdf.
61Ibid.
62Ibid.
63Ibid.
64See The Law Society, Lexcel—The Legal Practice Quality Mark (London: The Law Society). https://www.lawsociety.org.uk/for-the-public/quality-marks/legal-practice/.
65Ibid.
66See ISO 22000. “ISO 22000:2018 Food Safety Management Systems—Requirements for any Organization in the Food Chain,” ISO. https://www.iso.org/iso-22000-food-safety-management.html and https://www.iso.org/standard/65464.html.
67ISO. 2017. “ISO and food.” https://www.iso.org/publication/PUB100297.html and https://www.iso.org/files/live/sites/isoorg/files/archive/pdf/en/iso_and_food_en.pdf.
68See J.G. Surak. March 2013. “Apples to Oranges? Clearing up the differences between ISO 22000 and ISO 9001 standards,” Quality Progress. http://asq.org/quality-progress/2013/03/food-safety/apples-to-oranges.html.
69See Red Tractor. “Red Tractor Assurance.” https://assurance.redtractor.org.uk/.
70See QMS. “Whole Chain Assurance,” Quality Meat Scotland, Ingliston, Newbridge.
71See MSC. “The MSC Fisheries Standard,” Marine Stewardship Council, Marine House, London. https://www.msc.org/standards-and-certification/fisheries-standard.
72See P. Merrill. March 2012. “Seize the Opportunity Who Will Improve Food Safety?,” Quality Progress, pp. 44-45. http://asq.org/quality-progress/2013/03/innovation/seize-the-opportunity.pdf.
73See Fishcount.org.uk. “Quality Benefits.” http://fishcount.org.uk/fish-welfare-in-commercial-fishing/quality-and-animal-welfare.
74See A. Ericsson and R. Pool. 21 April 2016. Peak: Secrets from the New Science of Expertise (London: Bodley Head), ISBN-10: 1847923194, ISBN-13: 978-1847923196
75Ibid.
76See S. Kachoui. April 2018. “Personal Improvement—Becoming a Master—Do You Have What It Takes To Achieve Mastery?,” Quality Progress, pp. 38-43. http://asq.org/quality-progress/2018/04/career-development/becoming-a-master.pdf.
77Ibid.