More Reflections on Philip Crosby’s Reflections on Quality.

The quality improvement process is progressive.  One doesn’t just go from awful to wonderful in a single bound 

Crosby’s book on reflections contains a spectrum of trite such as “Anything that tastes good is bound to be bad for you (110)”, which is the all too common moan of the perpetual dieter, or inane “Once you put on a suit, no one tells you the truth anymore (83)” – I’m sure there is a grumbling story behind this.   

And there there are some very insightful, such as “The quality improvement process is progressive.  One doesn’t just go from awful to wonderful in a single bound.”  (234).  

I am intrigued by this reflection, not because it is so insightful (which it is) but that it comes from the mind of Philip Crosby.  

I never got to meet Crosby, but I have read his books.  He seems in writing to be a pretty black-and-white sort of guy.  “Do it right the first time” or “Anything caused can be prevented” or “The Performance Standard is Zero Defects” and “Zero Defects means doing what we agreed to do when we agreed to do it.  It means clear requirements, training, a positive attitude, and a plan.”   

This is all pretty absolute and without any wiggle room.  And none of that sounds even remotely aspirational.  You either did it Right or you did it Wrong.  

And it is a terrible message.

There have been few messages that have had so much resonance as DIRFT, or has spawned more corollaries.  “Why is there so little time available to do it right the first time, and so much time allocated to repeat it”.  “You can’t do it right the first time, unless you know what right is”  “You can’t do it right the first time, unless you know what it is”, “if you don’t have the time to do it right, when will you have the time to do it over”, and my personal favorite “it takes less time to do a thing right, than it takes to explain why you it wrong”.   

Almost all of these have the ring of bon mots; tone without substance.

In the medical laboratory and I suspect in a lot of other jobs and positions, nobody wants error, and nobody wants to make mistakes, and given a choice we “always” avoid error. But most error is human derived, some systemic, but a huge amount personal, and mostly silent or subtle;  distractions, slips, mis-interpretations, mis-understandings, errant keystrokes.  And while these still lead to errors and consequences, finger wagging about zero defects, does not make things better, it makes thing worse.  

It’s like when you mom or teacher or coach berated you with “you have to try harder”.

The quality challenge is to aspire to no errors, but to be vigilant in looking out, and diligent in catching as soon as possible.  In some situations, we can reduce error through inserting  some effective poke yokes (error blocking) tools and techniques such as required daily and in-run (real-time) quality controls, preventative maintenance, and error-reducing software and providing sufficient time-outs to allow reducing focus and stress.  More diligent attention to internal audits and proficiency testing can definitely help. 

But not always.

So that is why I was so pleased to see that Crosby also had a progressive side which acknowledged that nothing in reality is so cut and dry as zero defects, and that an organization needs to have enough tolerance and patience to accept a planned process of little steps, that allow time to reach a point approaching fewer mistakes and maybe even “zero defects” at least for a little while. 

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On a related but different topic, work on our October Quality Conference is coming together nicely.  We have a working group that has come up with a number of very good topics, and some potential speakers.  One topic of special interest is a debate (Is Patient Centered Care in the Medical Laboratory Even Possible?),

We have our location, and assurances from a number of sponsors.  I expect that we will be able to post our first advert on time.  In the meantime,

Save the Date

POLQM October Quality Conference.

October 1-3, 2017

Vancouver BC Canada

Quality means never having to say you are sorry ... TWICE

Jim writes a very contributory comment about Quality.  It is consistent with the Crosby view of Quality (Do it Right the First Time). 

Quality is the doc ordering the right test and the lab drawing the right specimen on the right patient.  The test result is right (correctly reflects what is going on in the patient) and is sent to the right person. And the price/cost is right (we're spending taxpayers money). 

It is completely consistent with the Four Absolutes that the definition of Quality is conformance to requirements, and that the system of Quality is prevention.  The performance standard for Quality is zero defects and the measurement of Quality is the price of non-conformance.

My problem is that this is all about the ideal, and not the real world.  Slips happen and mistakes happen.  They don’t happen all the time or even at regular or predictable intervals. They annoyingly occur like atrial fibrillation, irregularly irregular.

 And as our laboratories have become more consolidated and more complex and with more highly sensitive and intricate equipment, they happen faster and in ways that many never get detected until it is far too late.  Remediating early errors is often an easy fix.  Detecting and fixing downstream errors is ALWAYS a pain.
Every day the nonconformities happen; and they never seem to stop.  Fortunately, the vast majority of nonconformances are minor and don’t affect patient care or management or result in poor outcomes.

That is not to say we should be untroubled about error, but I think that Crosby was excessive in defining Quality by the ideal.  Deming was about 20 years older than Crosby but was still very active in the 70’s which was Crosby’s heydays.  Demining wrote extensively on hazards of slogans and the anxiety they raised. He was very unimpressed by the notion of Doing it Right the First Time.

I think Deming was closer with his sense of Continual Improvement.  It is not only about putting out fires, but catching them early before they get out of control and sorting out why they happened and fixing that.  When I look at reports of patient error, if you knock out the repeat problems the total number of errors drops ... dramatically.  

So I am going to argue the following:

Since errors happen often silently and beyond your control, the effective measure of Quality is the prevention of and the rapid detection of errors in order to avoid or at least reduce customer inconvenience and harm.

Quality is never making the same mistake twice.