The Evaluation, Quantification And Management Of Quality

Preface In The Form Of A Synopsis

	In contemporary society there is, I believe, a trend that is inclined to perceive and re-write traditional categories of value determination through the lens of a superficial philosophical naivete in which the richness of the life-world is subjected to an hermeneutical narrowing and lack of overall focus. Usually, various phenomenologically distinctive modes of experience are inappropriately re-translated solely in terms of a pragmatic bias, often under the economic influence of various forces in society that seek, and benefit from, a quantification of that particular phenomenon. In this paper the concept of `quality' as invoked in either `quality assurance' or `quality management' programmes will be critically investigated.

Introduction

	The title of this paper is misleading, in keeping with the very nature of a title. Being `about' a text it cannot, in this regard, be purely textual per se. Although this paper is ostensively about `the evaluation, quantification and management of quality' in the performance, or `delivery,' of a service in general, and in the medical field in particular, that objective is the final, unrealized aim of this paper. Like a typical phenomenologist this paper is more correctly an `introduction' to this subject rather than a finished product that needs only to be unwrapped and presented.
	This paper begins with a few quotations from a book on Quality Management recently circulated in the hospital where I work. The title of this technical volume is Managing Quality: A Guide to Monitoring and Evaluating Nursing Services, co-authored by Jacqueline Katz and Eleanor Green.
	With some reason, as I hope to show in this paper, I am philosophically suspicious when the quality of a service is discussed through the lens of a business model or metaphor, is calculated in terms of dollars saved, invokes so called `scientific methods' for the determination of the same, and in the final analysis appears to have a firm belief in the universal and accurate quantification of the essentially qualitative. Under the rubric of "Managing Quality" various strands of meaning involved in the apparent use of the expression `quality' appear to be rather loosely woven together whilst other strands we would, or perhaps should expect to find present in such an expression, are effectively absent or merely overlooked in passing. 
	To phenomenologically structure this appreciation of what might be meant by the complex expression of `quality' I shall propose a certain, relatively simple, hermeneutic-heuristic device. Although I shall briefly argue for its phenomenological grounding in an interpretation of our experience of the judgment of value my emphasis will be more interested in the use of this device and the point that such an exercise has in the relative clarification of some of the complexities entailed in the general concept of quality. Using this same model I will also briefly enter into a discussion of the interaction between distinctive types of value and attempts at a quantification of value in general.
	To complete this paper I would like to re-iterate some of the more important conclusions that, I believe, pertain to a critical appreciation and realization of quality in regards to its evaluation, quantification and management.

The Need For A Rectification Of Names

	Recently, in my job as a nurse, in an endeavour to attain `a culture of quality,' I have found myself having to learn a new language and therein translate old expressions into a new, more precise manner of expression. In the hospital we no longer have `patients' we now have `clients' or `customers,' `consumers of a service' `delivered' no longer by `nurses' and `doctors,' etc., but rather by `care-givers,' `care-professionals,' etc. Into this linguistic milieu the term `quality' is bandied about in such a manner that we assume that we all know what is being talked about when, more often than not, quality is the last thing that we should truthfully say indeed comes to mind for in its place `dollar signs' and `the forever pervasive hand of the accountant' can be seen to be that not too far away! Such an influence often lurking in the background manipulating and re-directing the lives of people, and in my estimation, often to the detriment of both institutions and their personnel! Such well intentioned, but badly mis-directed, attitudes not only affecting the delivery of medical services but also our schools and universities, other service industries, the spheres of business and manufacturing, the appropriate functioning of government, and, contaminating even the very way we think itself.  
	Although this paper is a critique of contemporary conceptions of `quality' and its `evaluation, quantification and management' it is not my intention to deride the pursuit of excellence that all individuals and institutions should, quite naturally, aim for. Rather, in this critique, I hope to expose the intrinsic poverty and the consequential bankruptcy realized through the use of key-metaphor currently utilized in the distortion of this subject. A distortion arising through an imperfect, incomplete understanding of the nature of value. Hopefully, by giving this topic a certain degree of phenomenological-hermeneutical focus, I can make some contribution to a recognition and reversal of this seemingly non-controversial trend for a narrow pragmatic reading of certain practices currently set loose upon, and cutting into, the functioning fabric of our society!

A Series Of Characteristic Quotations From Managing Quality

	In this text various positive and negative definitions of value are noted, e.g., on page 4 we are told:

One of the important challenges facing health care today is to define "quality." Individual definitions are numerous, and one can easily be confused by the verbiage. Ask any nurse what is meant by the term and he or she may have difficulty putting the concept into words. Describe for the nurse a patient situation, however, and he or she can easily point out the factors that indicate quality care or the lack of it.

	On page 5 we are told:

In 1951, Fiegenbaum defined quality straightforwardly as the capability of a product to fulfil its intended purpose, produced with the least possible cost.

	In the next paragraph an amplification of this definition is proffered:

Philip Crosby acknowledges the importance of the relationship of quality and cost but broadens the definition to include conformance to requirements; that is, quality is achieved through compliance with defined specifications or standards... "Quality is an achievable, measurable, profitable entity once you have commitment and understanding and are prepared for hard work."

	Immediately under the heading "Applying Business Concepts To Health Care" on pages 6 to 8 we are told:

The emphasis on quality in industry is evident in the number of theories about it. Although the primary focus of each theory may differ, there appear to be similarities in all the theories that have application to health care.

	These similarities are now listed under the following six classifications:

The first is that quality can be defined and measured... 

Second, quality is dynamic - it is not simply achieved and then disregarded...

Third, quality involves a competitive edge...

Fourth, quality has to do with doing the "right" thing right...

Fifth, quality relates to outcome...

Sixth, quality is everyone's responsibility...

	It should be obvious, from these fragments of text quoted so far, that the technical meaning given to the word `quality' is considerably more narrow than its more commonly understood range of meanings. The nature of this re-definition of `quality' being set up to entail a pragmatic approach with an emphasis on a competitive, business-like methodology wherein standards are described and outcomes are measured in terms of the success such ideals are realized. This idea is iterated many times, e.g., on page 8 we read:

The quality of care which is expected from a health care facility is made explicit by written standards that direct the way the service is to be provided and the results that should be achieved from that service. Standards, therefore, define quality.
	A standard is a written value statement of rules, conditions, and actions in a patient, staff member, or the system that are sanctioned by an appropriate authority.

	But we have also just been told that:

The pursuit of an all-embracing definition of quality has been elusive...

	Moreover:

It does not appear that a universal definition of quality is forthcoming. Nevertheless, even in the absence of a formal definition, a patient or provider can certainly identify its absence - substandard care or less-than-optimal results.

	It appears that the "universal, formal definition" of quality has now taken a rather negative theological-like turn. But that twist in meaning doesn't exclude it from being determined through "scientific" methods. On page 143 we are told:

"The core of quality improvement methods is summed up in two words: scientific approach." A scientific approach is simply a systematic, planned, organized method for problem solving that is understood and followed by all employees.

	It is my belief that the evaluation, quantification and management of value cannot be a "simple" reduction to some universally adopted method, a set of rules, written standards, etc. To demonstrate this let me first outline a `simple' hermeneutic-heuristic model of the types of value determination that need to be distinctly demarcated and indicate that, normally, an appreciation of quality involves a complex evaluation of a number of different types of value determination along with a recognition of the variations of value exercised within each type (proportionally appropriate to the priorities that should be entertained in accordance with the nature of that situation under examination).

An Hermeneutic-Heuristic Model Of Value Determination

	It is almost a truism to state that in intentional consciousness there is an involvement with `some form of an intentional object,' a `something' there for consciousness. Equally, and likewise not to be treated in an hypostatized, absolutist, reified manner, it could be argued that it is a truism to state that in intentional consciousness there must also be `some form of an intentional ego.' Lastly, invoking a gestalt conception and modeling of consciousness, we might like to add that in intentional consciousness there is also some sense of `an intentional context, field, background or sense of world.' 	
	In these tri-polar terms of reference meaning being seen as `that generated through the mutual co-thematization of an intentional sense of an object-pole, an ego-pole and a world-pole.'
	Now, I would like to argue that, given this gestalt frame of reference, all relatively distinct forms of intentional meaning are generated between these three poles and that through forms of polar suppression we can generate the following distinct types of value:

1.	Suppression of the sense of `world' and the sense of `ego' gives us a phenomenological-like focus on the intentional `object' (as a text) with a corresponding (logical-like) interest in its general classification and specific characterization (along with logical forms that involve the potential or actual manipulation of the same). 
2.	On the other hand a double suppression of `world' and `object' defines the sense of `ego'-relations and hence a sense of the ethical. 
3.	Then, a double suppression on the poles of `ego' and `object' give us a complex sense of the `world' and therein a sense of hermeneutical value, how a certain text is (meta-textually) conventionally situated inter-textually.
4.	In contrast to a double suppression of these polar modalities the concentration of focus on a suppression only of the `world'-pole realizes a sense of the aesthetical - the relationship between an `object' and an `ego.' 
5.	In a similar fashion a suppression of the `ego'-modality gives us a sense of the factual, i.e., a sense of the determination of how an `object' is found `in' the `world' (with a non-Aristotelian emphasis on the semblance of the actual over the potential).
6.	Lastly, the suppression of the `object'-pole realizes the sense of the `ego' in the `world,' in other words a sense of how the `ego' functions in the `world,' i.e., the sense of the pragmatic.

The Hermeneutic Application Of This Heuristic Model

	Later in this paper the phenomenological grounding of this schema will be important for showing how distinct types of value might interact, and, how qualitative forms of value, e.g., the ethical, aesthetical, pragmatical and hermeneutical, might be able to be quantitatively evaluated, albeit indirectly. 
	Putting these last comments to the side, let us now forget the phenomenological grounding of this schema. Re-ordering this list of six distinct types of value let our heuristic device be quite simply the question does the particular nature of the value under examination entail one or more of the following types of value-judgment, namely, factual, essential, aesthetical, ethical, pragmatical and/or hermeneutical forms of value determination?
	In the rhetorical form of these six questions this simple heuristic device can now be used to hermeneutically reflect upon the type of value, the type of quality, that might be entailed, or should be expected to be found, in a certain situational-type under investigation. Returning to the delivery of nursing care it now becomes obvious that the complex type of quality that should be entailed, that we would normally expect to find, must be something above and beyond the merely pragmatic. To begin with the factuality, or reality, of our diagnostic procedures must be correctly noted in conjunction with the accurate determination of relevant quantitative forms of essential evaluation. Next, the element of the aesthetical should not be absent. It is my belief that a beautiful environment enhances the therapeutic environment! Then, because the delivery of medical services and nursing care is centered on both the patient and the relationship between them and the providers of that care it is vital that an ethical dimension in its broadest sense also be present. If the person is not treated as a `person,' and merely as some disease, medical condition or syndrome, then no matter the excellence of the quality of the so called care given that environment, through alienation of the person, is not going to function therapeutically or successfully in any other form be it pragmatically, ethically, aesthetically, realistically, etc. Then, in a narrow pragmatic mode, if the delivery of care is too conscious of costs alone then it would obviously be cheaper in those terms of reference to have no patient, no hospital in the first place and today many services, or rather their lack thereof, seem to be driven in that direction. And, lastly, how are these first five forms of value to be determined and evaluated other than in hermeneutical terms of reference. The evaluation of quality must involve an hermeneutical dimension! The very act of evaluation necessitates the presence of texts and the appropriate treatment of such involves the necessary hermeneutical treatment of the same. Hence I would argue that, in general, the quality of a service, e.g., must involve these six distinct dimensions of value determination and that their absence or too narrow involvement will damage, indeed must damage, the delivery of that service. 
	With reference to our text of Managing Quality, and asking these six rhetorical questions concerning the presence or absence of factual, essential, aesthetical, ethical, pragmatical and hermeneutical forms of value in regards to the positive and negative definitions of quality defined therein, it is obvious that for all practical purposes quality is defined purely in pragmatic terms of reference and then in a very restricted vision of what should be entailed in the normally understood sense of the `pragmatic.' Saving money in the performance of a particular service is not necessarily beneficial. Perhaps more money should be spent? Of course the wasteful expenditure of limited resources means that other services, actual and/or potential, will be compromised. Moreover, the critical evaluation of the pragmatic cannot itself be determined in pragmatic terms of reference! Only an hermeneutical position, with an eye on all other forms of value, is going to be able to do this for us given that such treatment is critically exercised. 

Applying this Heuristic Model To Managing Quality

	Where in such expressions and metaphors as quoted from this text Managing Quality do we find much else other than a restricted sense of the pragmatic. E.g., let me list some of these expressions, etc:

The capability of a product to fulfil its intended purpose, produced with the least possible cost; conformance to requirements; that is, quality is achieved through compliance with defined specifications or standards; quality is an achievable, measurable, profitable entity once you have commitment and understanding and are prepared for hard work; applying business concepts to health care; that quality can be defined and measured, is dynamic, involves a competitive edge, doing the "right" thing right, relates to outcome, is everyone's responsibility...

	But this restricted sense of quality does a gross injustice to the way this term is used in everyday parlance. Quality is not just a measurable, pragmatic property, etc., and expressions like the `"right" thing,' `responsibility,' etc., are going to ensure that when this text is leaned upon, actually exercised, overlooked and made to apply to the real world, that these blinkered attitudes are going to quite quickly deconstruct and fall apart. And thank goodness for that! As a patient it is bad enough being treated as a disease or as a medical problem, but to be treated as a cost too doesn't do too much for one's self esteem, especially in this age of endemic budgetary inflation. Indeed, it is my belief, that to truly control costs in the medical field, e.g., or any other professional field for that matter, one must take one's scalpel to a much deeper level of institutional organization! That is, to those institutional forces that ensure a year by year inflation of costs; those professional rorts that ensure that excessive and inappropriate services are directed by those professionals that directly benefit financially from such organizational decisions; the collectively adverse influences of insurance, legal concerns as currently practiced; lack of oversight in those areas that generate goodwill; excessive degrees of bureaucratic duplication, inadequate degrees of attention to standards, organization, personnel and customers, etc. Saving a few cents here and there, a few minutes in this and that procedure, is not going to solve the constitutional costs incurred in these deeper, levels of natural, human functioning; practices that need to be counter-balanced by adequate forces to check and hold the motivational processes that, in small doses, are necessary for the efficient and successful functioning of our institutions. Forces, that, if not counter-balanced and checked, when left to their own devices lead to the inevitable decline and non-renewal of those institutions along with their impaired performance. 

The Implicit Interaction Between Distinct Types of Value

	Another issue that needs to be addressed is that of the overall role played by the interaction of different forms of value upon each other. As, in accordance with this heuristic model (itself a more detailed examination of the `hermeneu-tic circle') there is this demand for the mutual co-thematization of these three poles, it is implied that to some degree all forms of value, through having this same experient-ial ground, must be potentially inter-translatable, i.e., in terms of this deeper structure, must be commensurate. 
	Applying this insight to the question of quality, e.g., the quality of the performance of some service, we should be able to ask ourselves what role does the aesthetical have with all other forms of value as found present in a certain situation, what role does the ethical have with all other forms of value as found present in a certain situation, etc? This question on the interaction of distinct types of value in essence recognizes that, although types of value are distinctive phenomenologically, on a deeper level there can be no ultimate, absolute sense of distinction. Thus, in this light, it is indeed most appropriate to ask how various strands of value enfranchise or dis-enfranchise various other strands of value? But let me end here merely with some observations in this regard. E.g., I am sure an aesthetic work that involves a profound ethical breakdown of values is not going to be able to mutually establish a sense of the aesthetic. Could you knowingly enjoy a snuff movie even if it were performed in the form of an impeccably enacted ballet, e.g? Could a door be directly experienced as beautiful if it cannot be found to function properly? Could the saving of money in a manner actually detrimental to the delivery of a particular medical service be regarded as `a service delivered in a culture of quality?' 
	Needless to say the phenomenological and hermeneutical evaluation of the interaction of relatively distinct types of value is an extremely complex affair and not one that could be reduced to mere specifications in a written statement of values. This does not imply that there is no role for the specification of standards but that one must be cautious and vigilantly suspicious that their over zealous instantiation is not detrimental to any outcomes thought initially desirable or re-defined as desirable in the undergoing of that on-going process. Standards should be treated as `principles of intent,' ideals that are there to help us realize those intentions without being instruments that actually thwart the realization of those intentions.

The Quantification Of The Qualitative

	Finally, one more issue needs to be addressed and that is the problem "how, or if, quality can be quantitatively evaluated?" Correctly, only essential forms of value can be directly quantitatively evaluated. E.g., this morning, at home, I saw three, and not four, apples in the fruit bowl, and, that they were very red and ripe looking, etc. Such a report has numerically estimated the number of the denominated logical subjects perceived as present and relatively determined the equivalent degree of directly proportional redness and ripeness also felt to be present.
 	But, it could be argued in the phenomenological light of my heuristic model, that, if all forms of intentional meaning are realized through the mutual co-thematization of these three poles of `object,' `ego' and `world,' and, if the practice of quantification can be made to apply to one field of distinct value, then, why cannot all such fields of value also be so treated to some process of quantification, if not directly at least indirectly? In this we can find some form of intuitive justification. E.g., the Mona Lisa is considered by many people to be a `great' painting. In this regard the intensity of the aesthetic experience, when appropriately attended to in a manner commensurate with the essential nature of that phenomenon, can be considered indirectly to be both relatively quantifiable and universally recognizable, rightly or wrongly. In a similar fashion we can talk about ethical propriety, pragmatic utility, hermeneutic successfulness, degrees of factual certainty, etc. In this exercise of our intuition there seems to be some recognition of the degree the state and value of that under examination compares with another pre-evaluated state or standard of evaluation. But, here, such forms of evaluation should be recognized as indirect in their quantification in so far as what is subject to that state of quantification is `the experiential reflection upon the same' and not the subject matter of that state of experience per se.
	Moreover, the aspectival nature of phenomena and the complex nature of phenomena, as already indicated through this heuristic analysis of quality, and, the fact that experience is generated through this tri-polar process of mutually dependent co-thematization, it follows that our experience of reality in practice cannot conform to the simplicity of ideal standards, etc. Only in the hermeneutic simplification of our reading of a certain type of situation can this simplicity be taken for granted once established and all relevant measures are correctly put in place and put in play. Even then our control over that simplified environment cannot always be perfectly executed. Hence, although standards can be usefully constructed, such ideal patterns in reality cannot find an absolute coincidence in practice other than in provisionally treated situations that trivialize the complexity of such phenomena. Moreover, in reference to the direct input of the person it is the existential nature of the human being, in their freedom, to be able to exercise, through their acts and non-acts of choice, their conformance or non-conformance to expected patterns of behaviour. And it is this very element of indeterminacy that defines the human individual, an existential fact that must be both accepted and recognized!

Conclusion

	The title of this paper was The Evaluation, Quantification and Management of Quality. Under these three headings let me provisionally conclude this paper by re-iterating the following points.
	That the evaluation of complex forms of quality in practice can never be merely the simple evaluation of a distinct type of value, and, certainly not one that is subject to narrow forms of restriction within that defined sense of type. That such an exercise can only be provisional, and, only exercised in practice with the open expectation that the richness of reality never conforms to mere ideality. Complex forms of evaluation demanding complex forms of provisional treatment.
	That the quantification of complex forms of value, e.g., anticipations of quality, can only be conducted in an indirect manner through the form of appropriately treated indicators, which, correctly, can only be evaluated metaphorically and non-literally although relatively objective inter-subjective degrees of consensus can be recognized.
	That the management of quality is an existential affair! An existential process that must take into account all forms of phenomenologically distinct type, an overall appreciation of their provisional quantification and interaction, and, those conditions that, in effect, allow the self-instantiation of appropriate forms of qualitative refinement, the self-rectification and self-management of that `culture of quality' and its ongoing sense of self-advancement! Critical hermeneutic reflection upon the textualized traces of such events helping us to establish the qualitative nature of those processes of transformation.
	Hence, there is this critique of the post-modernist condition, in this regard, that, in the evaluation, quantification and management of quality, what entitles the person, as a person-in-this-world-of-life, is their sense of humanity in all its unexpected richness, and, that an openness to this richness is called for in the qualitative enhancement and realization of the person as a person able to respond with an appropriately attuned sense of responsibility in this world-of-life. That, in the final analysis, it is w.r.t. the transcendental dimension of the life-world that questions of quality, and its transformation, should be primarily addressed!

						  Noël Tointon, Sydney, 9.8.95

Appendix I: Representation In The Form Of A Diagram 
Of The Three Phenomenological Poles 
And Their Six Transcendental Fields Of Cognitive 
Value Determination

Ethical

[EGO]
.

	Aesthetical					Pragmatical

		  .			              .

	[Object]							[World]

  Phenomenological						 Hermeneutical

Factual

Appendix II: Heuristic Device For The Determination Of Value

	Does the particular nature of the value under examination entail one or more of the following types of value-judgment, namely, factual, essential, aesthetical, ethical, pragmatical and/or hermeneutical forms of value determination?