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Unit 4 Improve organisational performance | International Board for Quality in Healthcare IBQH

Unit 4 Improve organisational performance



Unit Code - J/600/9795
Level - 7
Credit Value – 10

Learning Outcome - The learner will: Assessment Criteria - The learner can:
1. Be able to examine the existing culture in relation to performance.

1.1 Critically evaluate the existing culture within own organisation.
1.2 Evaluate the impact of the culture on organisational performance.

2. Be able to evaluate performance in own organisation.

2.1 Develop a system for collecting and analysing data.
2.2 Analyse and benchmark performance of own organization against competitor organisations.

3. Be able to identify opportunities for organisational improvement and develop a communications strategy.

3.1 Identify opportunities for improvement in line with organizational objectives.
3.2 Define key success criteria for organisational improvement.
3.3 Consult with key stakeholders.
3.4 Develop a communications strategy for organisational improvement.
3.5 Implement a communications strategy highlighting organizational improvements to all key stakeholders.

4. Be able to support continuous improvement in organizational performance.

4.1 Develop processes to support continuous improvement.
4.2 Agree support requirements with stakeholders in own organisation.
4.3 Implement continuous improvement in line with organisation’s objectives.

5. Be able to evaluate the impact of performance improvement.

5.1 Critically evaluate organisational
performance against key success criteria.
5.2 Communicate recommendations for ensuring continuous improvement.


Learning outcome 1

1. Be able to examine the existing culture in relation to performance

1.1 Critically evaluate the existing culture within own organisation

The candidate should be able to evaluate the existing culture that operates in the organisation.

Evidence: Literature review and evidence of role types.

Further information and guidance:
The candidate should be able to classify their organisation against classic cultural types such as a role culture, task culture, club culture, coercive culture. Note that most large organisations are role cultures where the individual's power and authority comes from their role but there might also be features of other cultural types. Candidates should be able to relate the organisational culture to the quality issues within the organisation. In healthcare there is often a tension between “systems” culture and “people” culture. Candidates are encouraged to explore these issues. The candidate should be able to reviewing critical events related to culture and learn from these. Interdependencies between teams and individuals and the degree of cooperation will all be important factors. Staff absence and turnover within the organisation statistics and information stemming from exit interviews can all provide evidence of the cultural type.
1.2 Evaluate the impact of the culture on organisational performance

The candidate should be able to evaluate the effect of the culture in terms of its effect on the organisational performance through an analysis of strengths and weaknesses.

Evidence: Clear analysis of performance linked to culture.

Further information and guidance:
The candidate should be able to establish the performance indicators such as staff absence and turnover statistics as a means of measuring impact of particular cultural conditions.

Learning outcome 2

2. Be able to evaluate performance in own organisation

2.1 Develop a system for collecting and analysing data.

The candidate should be able to develop a system for collecting data about the organisation including financial data, throughputs, employee attitudes and values, and comparison with similar organisations.

Evidence: Data collection instruments in their portfolio

Further information and guidance:
The candidate should determine the type of data, size of sample, accuracy and validity of data and whether there are uncontrolled variables that will affect the confidence in any results.

2.2 Analyse and benchmark performance of own organisation against competitor organisations

The candidate should be able to use key performance indicators common across the industry to make objective comparisons between the performance of their own organisation and that of competing organisations.

Evidence: Structured reports using comparative data across organisations.

Further information and guidance:
The candidate can work with colleagues to acquire the necessary data but they should perform the analysis and make the judgements themselves. There should be clarity as to the aspects of performance that are being measured and objectivity about different contexts of different organisations. Examples might be the number of a particular operation completed in a week, lengths of waiting lists, average waiting time in casualty or the ratio of the operational cost of a hospital ward to the number of beds. It is not necessary to benchmark every possible measurable item but candidates should choose perhaps three that give a good indication of overall performance and treat these with some rigour.

Learning outcome 3

3. Be able to identify opportunities for organisational improvement and develop a communications strategy

3.1 Identify opportunities for improvement in line with organisational objectives.
The candidate should be able to identify opportunities for improvement in line with organisational objectives and prioritise them.
Evidence: Research and rationale leading to prioritised improvements in their portfolio

Further information and guidance:
The most important improvements are those likely to have the biggest impact for the least cost. Candidates can use historical data, customer complaints, focus groups and surveys as sources of evidence to underpin their choice of priorities. The importance of establishing the causes and effects of problems and practical strategies to solve them is emphasised.
3.2 Define key success criteria for organisational improvement
The candidate should be able to define the key success criteria for organisational improvement leading on from identifying and prioritising opportunities to improve.

Evidence: Statement of the success criteria for identified improvements.

Further information and guidance:
The candidate should select the key success criteria for an organisational improvement project which aligns with the strategic plan.

3.3 Consult with key stakeholders

The candidate should be able to communicate and consult with stakeholders to identify opportunities for improvement including them in the process where appropriate.

Evidence: of consultation with key stakeholders.

Further information and guidance:
The candidate should be able to consult and take feedback from stakeholders either by focus group, interview, survey or any appropriate method.

3.4 Develop a communications strategy for organisational improvement
The candidate should be able to develop a communication plan to be used during the organisational improvement activities.

Evidence: Fully developed strategy available in portfolio.

Further information and guidance:
The candidate should consider the impact of organisational improvement needs on individuals and teams within the organisation. The communications strategy should encourage and motivate those charged with its implementation to achieve its desired outcomes. This will be more important to quality than the means of making the communication but candidates should also consider the right media for the right circumstances. Face to face meetings will be important where improvement needs complex explanation, e-mail is useful for straightforward factual and non-emotive issues.

3.5 Implement a communications strategy highlighting organisational improvements to all key stakeholders

The candidate should show the practical competence of implementing a communications strategy.

Evidence: commentary and feedback documented from stakeholders.

Further information and guidance:
This should be a natural follow on from 3.4.

Learning outcome 4

4. Be able to support continuous improvement in organisational performance

4.1 Develop processes to support continuous improvement
The candidate should be able to develop a process to support and manage continuous improvement activity.

Evidence: Documented processes to support continuous improvement.

Further information and guidance:
The candidate should be able to develop processes to support and manage continuous improvement activities such as Kaizen or PDCA. Whatever method is adopted, systematic staff development and lifelong learning should be part of the process in people intensive services. This will involve the candidate consulting with and involving stakeholders in developing the new processes.
4.2 Agree support requirements with stakeholders in own organisation.

The candidate should be able to develop a process to get agreement on the support requirements of their organisation.

Evidence: Commentary on process for achieving agreement.

Further information and guidance:
The candidate should use appropriate methods to gain agreement on support activities that will improve or maintain quality standards in a cost-effective way.
4.3 Implement continuous improvement in line with organisation’s objectives.
The candidate should be able to implement continuous performance improvement processes as developed in 4.1
Evidence: Commentary on implementation in their portfolio

Further information and guidance:
The process should align well with organisation goals and the strategic plan for quality.

Learning outcome 5

5. Be able to evaluate the impact of performance improvement.
5.1 Critically evaluate organisational performance against key success criteria.

The candidate should be able to evaluate performance against pre-determined criteria with quantitative and qualitative methods.

Evidence: Evaluation report.

Further information and guidance:
The candidate should be able to objectively evaluate organisational performance identifying key strengths and weaknesses in performance using key indicators.

5.2 Communicate recommendations for ensuring continuous improvement.
The candidate should be able to communicate clear recommendations to stakeholders in a way that makes them likely to be accepted.

Evidence: Reported recommendations and rationale with feedback from stakeholders.

Further information and guidance:
Recommendations need to be underpinned by clear evidence that could be sourced from other aspects of the course.