ISO 9001 for Nonprofits: Is It Worth the Expense?
By Mick Stimpson, CPO (UK)  Many prosthetic and orthotic service providers in
the industrialized world have realized the benefits of achieving
ISO 9001:2000 accreditation. Until now, this has not been
replicated in the developing world.
When Carson Harte, the international director of the Cambodia
Trust (CT) told me at the end of 2000 that he was considering
working towards ISO accreditation, I had to ask myself if the
expense is worthwhile for an organization which provides free limbs
and orthotic devices to the people of Cambodia, one of the poorest
countries in the world. CT's production costs for a transfemoral
prosthesis are typically less than $100. Also, the service will be
eventually transferred to the Cambodian government, which has
little money to provide any service at all and will certainly not
want to fund the extra expense of maintaining an international
quality standard.
My own experience with ISO in both the O&P and aircraft
industries convinced me that the improvements that an organization
undergoes with ISO implementation should not be ignored. The
creation of a quality management system (QMS) would benefit the
service provided in rehabilitation centers and could easily be
upgraded to ISO 9001 later. The drawback of a "standalone" QMS is
that the standard is to an extent defined by the experiences of
those implementing it.
ISO 9000 series quality standards are a set of rules defining
practices that are internationally recognized. They were originally
a replica of British Quality Standards BS5750, which were adopted
from standards and practices used in the defense and arms
industries. Since their 1987 founding, ISO 9000 series have
themselves undergone significant changes. The current standard, ISO
9001:2000, focuses on setting quality objectives which encourage
continuous improvement and ultimately, customer satisfaction.
One prerequisite clearly stated in the quality standard is
senior management commitment. Without it, any attempt at
implementation would wither and die. The ISO QMS also focuses on
"consensus management," which is widely understood to mean that
ideas and changes are agreed to by employees as well as management.
People welcome responsibility and like to use their creativity to
solve problems. When management truly believes and encourages this
philosophy, it leads to better cooperation and morale within the
organization.
ISO: Aiding 'Cambodianization'
The government of New Zealand agreed to fund a project to
develop the capacity within the Cambodian Trust of staff members
who are Cambodian nationals, with a view to localization of the
Cambodian operations by 2005.
ISO 9001:2000 accreditation is an integral part of this project,
which has directly led to the whole of the Cambodia Trust
rehabilitation service being managed and operated solely by
Cambodian nationals. The Cambodian School of Prosthetics and
Orthotics (CSPO) will follow when staff members become more
experienced.
Like many small nongovernmental organizations (NGOs), the
Cambodia Trust began by trying to fulfill a desperate need in a
war-ravaged country, initially with only a couple of expatriates
and a few local staff. Practices and procedures tended to be
committed to memory. Very little was ever written down. Policies
and procedures frequently changed with the arrival of new
management. In the meantime the organization grew to provide
services in three clinics, operate an International Society for
Prosthetics and Orthotics (ISPO) Level II prosthetic and orthotic
school and employ almost 100 staff members.
The first and probably the biggest hurdle for the implementation
process was to get the staff to take ownership of the project.
Developing trust and allowing staff members to speak openly were
facilitated with the formation of small meeting groups. Khmer staff
members were encouraged to chair and take minutes for their own
meetings.[Editor's note: The Khmer people comprise about 90 percent
of Cambodia's population, and the Khmer language is spoken by about
95 percent of the people. Thus, the Cambodian people and language
are often referred to as "Khmer."] Monthly appraisal meetings began
to be held to promote two-way communication between staff and
supervisors. Khmer staff members were trained to be quality
managers and auditors. Being given this responsibility helped to
involve their hearts and minds in the project and in their
work.
A necessary part of the implementation process was staff
training. All staff members now have a job description written in
their native tongue and can explain how their job contributes to
the quality of service to the patient.
The Khmer staff members were highly enthusiastic and keen to
prove that they could achieve international standards and be judged
by them, which is why I feel that implementation of ISO 9001:2000
is better than adopting a homemade quality system.
In late August 2001, ISO auditors from BM Trada, a certifying
organization, swooped in from Thailand, armed with clipboards and
wearing no-nonsense expressions, for a pre-audit check. Despite the
best preparations, some serious nonconformities were highlighted.
After a further three months of work, the implementation team felt
that more work was still required to meet the standard. The final
audit was rescheduled from mid-December 2001 to March 2002.
Positive Results
The focus on continuous improvement provided some positive
results early on in the implementation process. For example,
spoilage of polypropylene when draping dropped to almost nil in
provincial clinics. Even in the Phnom Penh clinic, where third-year
students from CSPO conduct their internships, the technical
supervision of students improved and the number of aborted drapes
decreased to only one per month per student. These statistics are
collected by the workshop staff themselves and a month-to-month
running total is displayed on a whiteboard. This visible example of
continuous improvement provides staff with motivation because they
can see that the quality system is showing results.
Building Confidence, Saving Money
Increasing efficiency and cost effectiveness of the organization
is essential. The terrorist attacks of September 11, 2001, have
diverted attentionand funding from countries which have become very
reliant on donors in affluent countries. This factor, combined with
recent corruption scandals in Cambodian managed projects, has made
the situation more acute. Donors now demand value for money, so it
is necessary for organizations to be transparent and accountable.
The ISO quality system provides a convenient vehicle for this
openness. The aim to reduce costs and increase efficiency must be
realized by all staffinstead of being just a slogan liberally
bandied by managers worried about budgets. With a funding shortfall
of US $250,000 this year at the Cambodia Trust, real strain is put
on people's jobs. If any kind of service is to survive once it is
in the hands of the government, operating costs must be reduced
much further.
The road to implementation of ISO 9001:2000 in any country,
developed or developing, is not quick, easy, or stress-free. The
system can be intensely paperwork-heavy. The Cambodia Trust is one
of the first organizations in the not-for-profit sector to achieve
this accreditation. Where most organizations use the system to make
money, CT is hoping that it will help make the little they have
last longer and instill confidence in potential donors. With a
moderate financial investment combined with hard work, total
commitment, and self-belief, the CT has found its Cambodianization
objectives about 18 months further along than originally expected.
Staff members at all levels are much more motivated, aware, and
interested in how the organization works. There is a collective
sense of achievement. All of these, I imagine, are bonuses far
exceeding the expected reward seen in Carson's initial vision of
gaining accreditation.
The Next Challenge
The next big challenge to the staff is to maintain their quality
system. According to Rob Kantner, author of the ISO Answer Book,
this is more difficult and stressful than achieving it. The staff
must now live by those quality objectives written months before and
show evidence of continuous improvement when the auditors come
calling again.
A question remains to be answered: What about the financial
sustainability of an ISO QMS in the developing world? In Cambodiaa
country with perhaps the highest percentage of disabled people in
the worldthis is about more than money.
For more information about ISO international quality standards,
visit www.iso.ch 
Table Of Contents - February 2003
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