Thursday, December 24, 2009

Healthcare, Quality and Deming

I reread Deming's book over the summer and scanned the fourteen points as adopted for healthcare as part of a discussion on leadership in my masters program this fall. As someone who came from manufacturing to healthcare, one thing that strikes me is that the "quality revolution" seems to have missed healthcare. I think that this will change, with the quality reporting requirements that are a part of ARRA's meaningful use definition. As Yogi Bera said, "It's like deja vu all over again." I'm hearing some of the same arguments that I heard twenty years ago.

So, here they are: Deming's fourteen points as adopted for health care.

From Out of the Crisis by W. Edwards Deming --

Adaptation of the 14 points to medical service. The 14 points of Chapter 2 apply to a service organization with little modification. For example, my friends Dr. Paul B. Batalden and Dr. Loren Vorlicky of the Health Services Research Center, Minneapolis, have written the 14 points for medical service:

1. Establish constancy of purpose toward service.

a. Define in operational terms what you mean by service to patients.

b. Specify standards of service for a year hence and for five years hence.

c. Define the patients whom you are seeking to serve - those here, those that you seek, those that have been here only once.

d. Constancy of purpose brings innovation.

e. Innovate for better service for a given cost; planning for the future will require the addition of new skills, training, and retraining of personnel, satisfaction of patients, new treatments, new methods.

f. Put resources into maintenance of equipment, furniture, and fixtures; new aids to production in the office.

g. Decide whom the administrator and the chairman of the board are responsible to and the means by which they will he held responsible for working for constancy of purpose.

h. Translate this constancy of purpose to service into patients and to the community.

i. The board of directors must hold on to the purpose.

2. Adopt the new philosophy. We are in a new economic age We can no longer live with commonly accepted levels of mistakes, materials not suited to the job, people on the job that do not know what the job is and are afraid to ask, failure of management to understand their job, antiquated methods of training on the job, inadequate and ineffective supervision. The board must put resources into this new philosophy, with commitment to in-service training.

3a. Require statistical evidence of quality of incoming materials, such as pharmaceuticals, serums, and equipment. Inspection is not the answer. Inspection is too late and is unreliable Inspection does not produce quality. The quality is already built in and paid for.

b. Require corrective action, where needed, for all tasks that are performed in the hospital or other facility, ranging all the way from bills that are produced to processes of registration. Institute a rigid program of feedback from patients in in regard to their satisfaction with services.

c. Look for evidence of rework or defects and the cost that may accrue as a result - an incorrect bill, an incorrect or incomplete registration.

4. Deal with vendors that can furnish statistical evidence of control. This will require us to examine generic lowest-price buying; it will cause us to ask more penetrating questions about prospective colleagues regarding their interactions and the track record of their interactions with patients and with colleagues.

We must take a clear stand that price of services has no meaning without adequate measure of quality. Without such a stand for rigorous measures of quality, business drifts to the lowest bidder, low quality and high cost being the inevitable result. We see this throughout the United States industry and government by rules that award business to the lowest bidder.

Requirement of suitable measures of quality will, in all likelihood, require us to reduce the number of vendors. The problem is to find one vendor that can furnish statistical evidence of quality. We must work with vendors so that we understand the procedures that they use to achieve reduced numbers of defects.

5. Improve constantly and forever the system of production and service.

6. Restructure training.

a, Develop the concept of tutors.

b. Develop increased in-service education.

c. Teach employees methods of statistical control on the job.

d. Provide operational definitions of all jobs.

e. Provide training until the learner's work reaches the state of statistical control, and focus the training to assist the learner to achieve the state of statistical control.

7. Improve supervision. Supervision belongs to the system and is the responsibility of the management.

a. Supervisors need time to help people on the job.

b. Supervisors need to find ways to translate the constancy of purpose to the individual employee.

c. Supervisors must he trained in simple statistical methods for aid to employees, with the aim to detect and eliminate special causes of mistakes and rework. Supervisors should find causes of trouble and not just chase anecdotes. They need information that shows when to take action, not just figures that describe the level of production and the level of mistakes in the past.

d. Focus supervisory time on people that are out of statistical control and not those that are low performers. If the members of a group are in fact in statistical control, there will be some that are low performers and some that are high performers.

e. Teach supervisors how to use the results of surveys of patients.

8. Drive out fear. We must break down the class distinctions between types of workers within the organization-physicians, nonphysicians, clinical providers versus nonclinical providers, physician to physician. Discontinue gossip. Cease to blame employees for problems of the system. Management should be held responsible for faults of the system. People need to feel secure to make suggestions. Management must follow through on suggestions. People on the job can not work effectively if they dare not inquire into the purpose of the work that they do, and dare not offer suggestions for simplification and improvement of the system.

9. Break down barriers between departments. Learn about the problems in the various departments. One way would be to encourage switches of personnel in related departments.

10. Eliminate numerical goals, slogans, and posters imploring people to do better. Instead, display accomplishments of the management in respect to assistance to employees to improve their performance. People need information about what the management is doing on these 14 points.

11. Eliminate work standards that set quotas, commonly called also measured day work. Work standards must produce quality, not mere quantity. It is better to take aim at rework, error, and defects, and to focus on help to people to do a better job. It is necessary for people to understand the purpose of the organization and how their jobs relate to the purpose of the organization.

12. Institute a massive training program in statistical techniques. Bring statistical techniques down to the level of the individual employee's job, and help him to gather information in a systematic way about the nature of his job. This kind of training must be married to the management function rather than to the personnel function within the organization.

13. Institute a vigorous program for retraining people in new skills. People must be secure about their jobs in the future, and must know that acquisition of new skills will facilitate security.

14. Create a structure in top management that will push every day on the above 13 points. Top management may organize a task force with the authority and obligation to act. This task force will require guidance from an experienced consultant, but the consultant can not take on obligations that only the management can carry out.