Integrating Elegance into Quality Systems: The Third Dimension of Excellence

Quality systems often focus on efficiency—doing things right—and effectiveness—doing the right things. However, as industries evolve and systems grow more complex, a third dimension is essential to achieving true excellence: elegance. Elegance in quality systems is not merely about simplicity but about creating solutions that are intuitive, sustainable, and seamlessly integrated into organizational workflows.

Elegance elevates quality systems by addressing complexity in a way that reduces friction while maintaining sophistication. It involves designing processes that are not only functional but also intuitive and visually appealing, encouraging engagement rather than resistance. For example, an elegant deviation management system might replace cumbersome, multi-step forms with guided tools that simplify root cause analysis while improving accuracy. By integrating such elements, organizations can achieve compliance with less effort and greater satisfaction among users.

When viewed through the lens of the Excellence Triad, elegance acts as a multiplier for both efficiency and effectiveness. Efficiency focuses on streamlining processes to save time and resources, while effectiveness ensures those processes align with organizational goals and regulatory requirements. Elegance bridges these two dimensions by creating systems that are not only efficient and effective but also enjoyable to use. For instance, a visually intuitive risk assessment matrix can enhance both the speed of decision-making (efficiency) and the accuracy of risk evaluations (effectiveness), all while fostering user engagement through its elegant design.

To imagine how elegance can be embedded into a quality system, consider this high-level example of an elegance-infused quality plan aimed at increasing maturity within 18 months. At its core, this plan emphasizes simplicity and sustainability while aligning with organizational objectives. The plan begins with a clear purpose: to prioritize patient safety through elegant simplicity. This guiding principle is operationalized through metrics such as limiting redundant documents and minimizing the steps required to report quality events.

The implementation framework includes cross-functional quality circles tasked with redesigning one process each quarter using visual heuristics like symmetry and closure. These teams also conduct retrospectives to evaluate the cognitive load of procedures and the aesthetic clarity of dashboards, ensuring that elegance remains a central focus. Documentation is treated as a living system, with cognitive learning driven and video micro-procedures replacing lengthy procedures and tools scoring documents to ensure they remain user-friendly.

The roadmap for maturity integrates elegance at every stage. At the standardized level, efficiency targets include achieving 95% on-time CAPA closures, while elegance milestones focus on reducing document complexity scores across SOPs. As the organization progresses to predictive maturity, AI-driven risk forecasts enhance efficiency, while staff adoption rates reflect the intuitive nature of the systems in place. Finally, at the optimizing stage, zero repeat audits signify peak efficiency and effectiveness, while voluntary adoption of quality tools by R&D teams underscores the system’s elegance.

To cultivate elegance within quality systems, organizations can adopt three key strategies. First, they should identify and eliminate sources of systemic friction by retiring outdated tools or processes. For example, replacing blame-centric forms with learning logs can transform near-miss reporting into an opportunity for growth rather than criticism. Second, aesthetic standards should be embedded into system design by adopting criteria such as efficacy, robustness, scalability, and maintainability. Training QA teams as system gardeners who can further enhance this approach. Finally, cross-pollination between departments can foster innovation; for instance, involving designers in QA processes can lead to more visually engaging outcomes.

By embedding elegance into their quality systems alongside efficiency and effectiveness, organizations can move from mere survival to thriving excellence. Compliance becomes an intuitive outcome of well-designed processes rather than a burdensome obligation. Innovation flourishes in frictionless environments where tools invite improvement rather than resistance. Organizations ready to embrace this transformative approach should begin by conducting an “Elegance Audit” of their most cumbersome processes to identify opportunities for improvement. Through these efforts, excellence becomes not just a goal but a natural state of being for the entire system.

Microfeedback for Adjusting Behaviors

Previously I’ve talked about defining the values and behavior associated with quality culture. Once you’ve established these behaviors, a key way to make them happen is through microfeedback, a skill each quality professional, supervisor, and leader in your organization should be trained on.

We are all familiar with the traditional feedback loop: you receive feedback, reflect on it, make a plan, and then take action. This means feedback is given after a series of actions have taken place. Feedback addresses a few key observations for future improvements. In a situation when actions and sequences are quite complicated and interdependent, feedback can fail to provide useful insights to improve performance. Micro-feedback potentially can be leveraged to prevent critical mistakes and mitigate risks, which makes it a great way to build culture and drive performance.

Micro-feedback is a specific and just-in-time dose of information or insights that can reduce gaps between the desired behavioral goals and reality. Think of it as a microscope used to evaluate an individuals comprehension and behavior and prescribe micro-interventions to adjust performance and prevent mistakes.

Microfeedback, provided during the activity observed, is a fundamental aspect of the Gemba walk. These small tweaks can be adapted, and utilized to provide timely insights and easy-to-accomplish learning objectives, to drive deep clarity and stay motivated to modify their performance.

Where and when the microfeedback happens is key:

1. Task–based microfeedback focuses corrective or suggestive insights on the content of a task. To provide higher impact focus micro-feedback on the correct actions rather than incorrect performance. For example “Report this issue as an incident…”

2. Process-based micro-feedback focuses on the learning processes and works best to foster critical thinking in a complex environment. For example, “This issue can be further processed based on the decision tree strategies we talked about earlier.”

3. Self-regulation-based micro-feedback focuses on giving suggestive or directive insights helping individuals to better manage and regulate their own learning. For example, “Pause once you have completed the task and ask yourself a set of questions following the 5W2H formula.”

For microfeedback to be truly successful it needs to be in the context of a training program, where clear behavorial goals has been set. This training program should include a specific track for managers that allows them to provide microfeedback to close the gap between where the learner is and where the learner aims to be. This training will provide specific cues or reinforcement toward a well-understood task and focus on levels of task, process, or self-regulation.

During change management, provide positive micro-feedback on correct, rather than incorrect, performance. This can be very valuable as you think about sustainability of the change.

Leveraged sucessful, but well trained observers and peers, microfeedback will provide incremental and timely adjustments to drive behavior.

Flow Chart

The flow chart is a simple, but important, graphic organizer. Placing the states or steps of an event or process into the correct sequence allows you to reach conclusions and make predictions.

However, its simplicity means we don’t always work to be consistent and can benefit from a little effort to ensure users are aligned.

I am a huge fan of including flow charts in all process and procedure documents.

Steps for Building a flow chart

Capture

Capture the events or steps of the process. Resist the urge to arrange them sequentially and concentrate on capturing the events/steps only.

Cull

If there are more than eight steps in a flow chart we start creating cognitive overload. If a process or procedure has more than eight steps you need to:

Ensure the steps are at the right level, sometimes we have substeps represented and we can cull that. Ensure they are all on the same level of process/procedure/task.
Decide we need to break the procedure into multiple documents. This is a great way to decide what work instructions are necessary.
Look for opportunity for process improvement.

Sequence the events and draw the flow chart

The focus now shifts to temporal relations. The correct sequential arrangements of steps or events helps to reach conclusions about past events and prepare for future events.

Example

I’m writing the procedure for my mornings, I capture the following:

Eat breakfast
Take shower
Take dog out
Get dressed
Decide on tea
Heat water
Drink tea
Read for 30 minutes
Deal with morning email
Snuggle with dog

Taking a look at the list I realize that not everything is on the same level of process/procedure/task and end up with a shorter list.

Breakfast
Take shower
Take dog out
Get dressed
Read for 30 minutes
Deal with morning email
Snuggle with dog

Notice how I combined all the tea stuff into a breakfast category. When brainstorming my list I put a lot of weight on tea, because it is important to me (yes I have been using tea as a training example since 2005, I just love tea).

I can then put them in sequence:

When I was making things sequential I realized that two of my activities (read and dog snuggle) were concurrent, so I combined them as one step.

Interviewing

One of the great tools of root cause analysis, planning, process improvement and knowledge management is the interview. Properly used the interview allows one to gather a great deal of information and perspective and ferret out hidden information.

For interviews to be truly effective, we have to understand how the function and apply a process. Cognitive Interviewing, originally created for law enforcement and later adopted during accident investigations by the National Transportation Safety Board (NTSB), provides an effective framework. I was first introduced to this at my previous company, where it has become a real linchpin, so I share it here.

The two principles here are:

Witnesses need time and encouragement to recall information
Retrieval cues enhance memory recall

Based on these two principles there are four components:

Component	What It Consists of
Mental Reinstatement	Encourage the interviewee to mentally recreate the environment and people involved.
In-Depth Reporting	Encourage the reporting of all the details, even if it is minor or not directly related to the purpose of the interview. This is intended to improve the detail and accuracy of memory. For example, if investigation a computer error, you would encourage the interviewee to discuss everything they were doing around the event. You would hold the interview at the station the error happened, ideally using the computeras much as possible.
Multiple Perspectives	Ask the interviewee to recall the event from others’ points of view. For example, the person upstream or downstream, or a partner or observer.
Several Orders	Ask the interviewee to recount the timeline in different ways. Beginning to end, end to beginning.

Four Components of Cognitive Interviewing

A key part of this is that retrieval cues access memory. This is why doing the interview on the scene (or Gemba) is so effective.

The basic behaviors you want to bring to bear are:

Recreate the original context; have them outline and walk you through process to explain how they work.
Tell the the witness to actively generate information and not wait passively for the interviewer to ask questions.
Adopt the witness’s perspective; ask eyewitness-compatible questions.
Perform the interview at the Gemba, the place where the work happens.
Listen actively, do not interrupt, and pause after the witness’s response.
Ask open-ended questions, utilize short phrases when possible.
Encourage the witness to use imagery. Explicitly request detailed descriptions.
Follow the sequence of the cognitive interview major components.
Bring support materials such as attachments, procedures, and copies of relevant documents.
Establish a connection with the witness; demeanor has a big impact.
Remember, active listening.
Do not tell the interviewee how they made the mistake, blame, or assume.

Active listening is key here.

At the mouth of the funnel we begin with an ‘open’ question. This question is intended to give the interviewee the widest possible scope for responding. Sometimes it may be necessary to repeat or rephrase this question to give the interviewee more thinking time and further opportunities to raise information. Working down the narrowing body of the funnel we use a series of probing questions to draw out further specific information and help complete the picture. Closed questions then have their place to draw out, check or confirm specific pieces of information, or to get the interviewee to commit on a point more precisely. This then brings us to the bottom of the funnel where we clarify, using a short summary, what we have got out of the discussion, aiming to check our understanding of the main points. The question sequence might go something like this:

‘Tell me how you went about…?’ (open)
‘How did you prepare?’ (open – secondary)
‘What was your starting point?’ (probe)
‘So, what happened next?’ (probe)
‘Who else was involved?’ (probe)
‘And how did they respond?’ (probe)
‘What were your thoughts at that stage?’ (probe)
‘What were the main outcomes?’ (probe)
‘So, that took a total of 30 minutes?’ (closed – clarifying)
‘And the task was completed?’ (closed – clarifying)
‘So, let me see if I’ve followed you…’ (checking – summary)

A good interview requires preparation. Have opening questions ready, ensure you have all the right props and the right people involved. That extra hour or two will pay dividends.

Here is a helpful worksheet.

Self Awareness and Problem Solving

We often try to solve problems as if we are outside them. When people describe a problem you will see them pointing away from themselves – you hear the word “them” a lot. “They” are seen as the problem. However, truly hard problems are system problems, and if you are part of the system (hint – you are) then you are part of the problem.

Being inside the problem means we have to understand bias and our blind spots – both as individuals, as teams and as organizations.

Understanding our blind spots

An easy tool to start thinking about this is the Johari window, a technique that helps people better understand their relationship with themselves and others. There are two axis, others and self. This forms four quadrants:

Arena – What is known by both self and others. It is also often referred to as the Public Area.
Blind spot – This region deals with knowledge unknown to self but visible to others, such as shortcomings or annoying habits.
Façade – This includes the features and knowledge of the individual which are not known to others. I prefer when this is called the Hidden. It was originally called facade because it can include stuff that is untrue but for the individual’s claim.
Unknown – The characteristics of the person that are unknown to both self and others.

The original Johari Window (based on Luft, 1969)

An example of a basic Johari Window (my own) can be found here.

Users are advised to reduce the area of ‘blind spot’ and ‘unknown’, while expand the ‘arena’. The premise is that the lesser the hidden personality, the better the person becomes in relating with other people.

The use of Johari Window is popular among business coaches as a cognitive tool to understand intrapersonal and interpersonal relationships. There isn’t much value of this tool as an empirical framework and it hasn’t held up to academic rigor. Still, like many such things it can bring to light the central point that we need to understand our hidden biases.

Another good tool to start understanding biases is a personal audit.

Using the Johari Window for Teams

Teams and organizations have blind spots, think of them as negative input factors or as procedural negatives.

The Johari Window can also be applied to knowledge transparency, and it fits nicely to the concepts of tacit and explicit knowledge bringing to light knowledge-seeking and knowledge-sharing behavior. For example, the ‘arena’ can simply become the ‘unknown’ if there is no demand or offer pertaining to the knowledge to be occupied by the recipient or to be shared by the owner, respectively.

The Johari Window transforms with the the four quadrants changing to:

Arena – What the organization knows it knows. Contains knowledge available to the team as well as related organizations. Realizing such improvements is usually demanded by network partners and should be priority for implementation.
Façade – What the organization does know it knows. Knowledge that is only available to parts of the focal organization. Derived improvements are unexpected, but beneficial for the organization and its collaborations.
Blind Spot – What the organization knows it does not know. Knowledge only available to other organizations – internal and external. This area should be investigated with highest priority, to benefit from insights and to maintain effectiveness.
Unknown – What the organization does not know it does not know, and what the organization believes it knows but does not actually know. Knowledge about opportunities for improvement that is not available to anyone. Its identification leads to the Façade sector.

We are firmly in the land of uncertainty, ignorance and surprise, and we are starting to perform a risk based approach to our organization blind spots. At the heart, knowledge management, problem solving and risk management are all very closely intertwined.