Deming and the diversity of healthcare Quality

Deming and the diversity of healthcare Quality

I am going through a personal evolution in my Quality career.  It is starting to get very complicated.  

In many ways I am very typical of people of my age and era in that given the opportunity to get involved, my first instinct is always to say “Yes!”  Part of this reflects my personal interest in the Quality process, part of it my ego that still leads me to believe that I can do everything and do it all very well.  And part of it is a protection strategy; given a choice between having to deal with a standard that someone else has written and having the opportunity to inject my own beliefs, I would rather fight the battle early rather than fight it late.  This strategy has stood me more in good stead than bad over the years, although it does take a certain toll on my time.

But as I get closer to thinking about going to the next phase, I do reflect on what I do and what it says about Quality.  The reality is that most of what I do is done on a volunteer or a small honorarium basis.  Most of it does not generate direct revenue.  Most of it exists because I have a position that provides me with an income base and a fair amount of flexible time.  It all keeps me very busy, but not of it is “busy work”.

As far as income generating activities, I have a faculty position at a university and as part of that position I operate a proficiency testing program that works across Canada and provides international training to personnel in developing countries so that they can learn how to develop similar PT programs in their own country.  I also teach an on-line course in medical laboratory Quality.  Both these activities   can take a lot of time.  I have learned that a program or a course that stands still and rests of success and laurels is a dead program or course, soon to become very obsolete and mowed over by competition.  Operating both of these activities has allowed me to develop and hone my innovation chops in order to stay one step ahead, or at least not two steps behind.   

But in order to support these two programs I have become directly involved with a variety of Quality Partner activities, primarily in the standards development and the educator/communicator arenas.  I sit on a variety of standards development technical committees on both the national and international level, in part developing documents which my programs are intimately involved with.  In my opinion I know of no better way of knowing exactly what and why a standard requires certain expectations than being involved in the writing.  

I also get a lot of opportunities to get involved in networking through education/communicator process.  Over the years we have trained and certified near 300 people as medical laboratory quality managers, many of whom have remained in contact, and some have remained close.  We regularly put on Quality oriented conferences which brings me together with the former group and creates connections with new and interesting speakers.  Of interest we are now in the planning phase for our next conference which will occur next year, and I have already got a collection of speakers who will be new and unique to our audience community.  

In addition I have just finished one book chapter and I have been asked to write a new book as part of a series focused on medical laboratory Quality and patient safety which will create potentially a broader audience for  the conference.   

And next week I get to travel internationally to a meeting on Excellence in Medical Laboratory Quality and give a presentation which likely will help foster both meeting attenders and course takers.   

My point is not to blow my own horn about how busy I am (well maybe a little bit), but rather to make a few points: 

1. First and foremost the arena of medical laboratory Quality is very alive and very busy.  If you are bored with what you are doing, you aren’t trying.
2. Second, if you want to have success in this arena you have to keep new and fresh and diversified but with clear links to your foundational base.   

And lest you miss the point, all of this is totally consistent with Deming and 5 of his 14 absolutes:

• Create constancy of purpose for improving products and services.
• Improve constantly and forever every process for planning, production and service.
• Adopt and institute leadership.
• Institute a vigorous program of education and self-improvement for everyone.
• Put everybody in the company to work accomplishing the transformation.

I always have thought that if W.E.D. had taken the opportunity to adapt his list of absolutes he would have included “Plan for success by getting busy and staying busy”.

Reflections on achieving organizational Quality

In a previous post, I commented on a “Notable Quote” printed in the ASQ’s November 2013  Quality Progress magazine.  It was reportedly a quote ascribed to Deming. 

Not entirely by coincidence, I was going through a number of books for our Certificate Course in Laboratory Quality Management and I came across a little book first published in 1996 entitled “Philip Crosby’s Reflections on Quality”.  It is basically a book of 295 quotations written and authored by Crosby.  I suspect by the very design of the book it was intended to be both a compilation of Crosby’s most influential comments on Quality and an homage to the book genre of the 1966 The Little Red Book: Quotations for Chairman Mao Tse-tung.  I mention this second point because while the two are in vastly different spheres, one can see common seeds between the Cultural Revolution and the Quality Revolution.  But that is a topic for a future posting.

What I want to focus on is Crosby’s absolutes, in particular his first “the definition of Quality is conformance to requirements”, his second “the system of Quality is prevention”, his third “the performance standard is zero defects” his fourth “the measurement of Quality is the price of non-conformance”.  

I was in a conversation with a colleague last week and the question came up about, at what point can you say that you truly run a Quality laboratory?  It is a fair question because we all tend to be goal oriented and labels are important.  

If I read Crosby as I think he intended, Crosby had a rather strict view on Quality and was that a Quality organization meets all requirements and has no defects or no nonconformities.  If that is a correct reading, I think that Crosby was of the opinion that the state of Quality is aspirational and a valued ideal, but is not truly or sustainably unachievable.  Quality is the ethereal end to the journey that begins with a single first step (homage to Confucius). 

I know that Crosby and Deming knew each other, but I don’t know if he had met James Reason, the expert on organizational error.  Current risk management is predicated on the concept that bad things happen, most often as the consequence of simple mistakes or distractions.  Many of these will be invisible or benign or seemingly innocuous but some of them will lead to very bad outcomes.  They are for all intents and purposes inevitable.  As long as we have working humans or machines, we will have defects.

But in today’s world recognition and public relations are important to organizations, especially in healthcare.  Top management needs to be able to point to evidence that their efforts to improve the organization are working.  Top management needs to be able to have some markers along the path to which they can honestly refer, and be able to say that the organization is moving well along the path to Quality and success.

So I present some markers that indicate they your organization is moving in the right direction, and at a certain point deserve to call yourself a Quality organization

1: A good start.
Perform your first Gap Analysis against your measureable goal, and develop a process by which you can and will close the gaps.

2: You are Making Progress.
Your first accreditation is always an achievement of which you can be pleased, but it is far more important what you do next.  The first is an achievement, the second is an accomplishment. The third is a demonstrated record.

3: Quality is your middle name.
You still have errors and defects, but now you have a system that detects them quickly and remediates their impact on your customers.  More importantly your system allows you to learn from your errors and put in corrective actions that make it unlikely that you will repeat that error.

4: Your name is Quality.
Your system works.  You know it works, your staff knows it works, your customers know it works, your colleagues know it works, your competition knows it works.  But you are still looking for continuous tweaks for improvement.

Allowing your staff to do their best

I was perusing my November 2013 copy of ASQ’s Quality Progress magazine and the article “Words to Work By” caught my eye.  Not so much an article, it was a collection of Quality quotes submitted by other readers.  Some were predictable (“Quality is never an accident…”) and some were pretty iffy (“There is more than one way to skin a cat … but it matters to the cat”).  

But there was one that caught my eye.  It was ascribed to Deming, and maybe that is true: ”It’s not enough to do your best.  You must first know what to do, and then do your best”.  

First off let me say that in a quick peruse of the internet, many ascribe the words to Deming, so I guess I will have to believe it.  But I also will say it is pretty inconsistent with his own 14 points, specifically the one about “eliminate slogans, exhortations and targets for the workforce” and the other about “remove barriers that rob people of pride of workmanship”.  Somehow I have my doubts.  What Deming probably said was something more like “if your worker’s best doesn’t measure up to what you expected or wanted, perhaps it is because you didn’t tell them what you wanted.”  Don’t blame the worker, look more closely at yourself.  

All my career I have seen folks write job descriptions which gets read, signed off, and then put in a file where is sits forever, provided that it doesn’t get lost.  The job changes over and over, but the document remains written in stone which progressively becomes as immutable as granite.  As new tasks come on stream, there may be efforts to train workers, but in many situations the process of learning is one of self-discovery.  

It seems to me that if our organizations wants people to know what they are supposed to be doing, so that they can then “do their best”, what we have to do is start seeing their job descriptions as living documents that documents each change that gets implemented.  

There are many advantages in ensuring that job descriptions remain current.  First, the description becomes the foundation for ensuring that appropriate training and confirmation and follow-up competency assessment occur.   Second, it becomes a foundation for task ownership.  Third it becomes the foundation for management to know what exactly they are expecting their staff to be responsible for.  Fourth it provides a foundation for ensuring that when the job becomes vacant, the next person in can be made aware of all the tasks they will be expected to address.   

Let me focus on one of the above foundation statements, specifically management awareness.  

Has this happened at your place?  It certainly has in mine.  Over time, the number of tasks required incrementally increases, commonly at a rate that is faster than revenue generation.  We can always hire more people, so we tack the new tasks on to existing personnel.  Research and development, or provision of new programs sometimes requires what seems to be just a few more hours per week to get a new service or program established; at least that is what you estimate.  But the task becomes a little bigger than you anticipated or takes longer than you thought.  Now your staff are incrementally busier than before.  Then another “small change” gets added in, and then another.  Nobody says anything, but after a while the signs of stress and distraction start to show up.  Mistakes start happening.  People seem angry, or worse, burned out.  All of a sudden, a key person quits.  Now you and your program are in trouble.  Unchecked persistent incremental change all too often leads to precipitous crisis.  

The problem wasn’t that people stopped doing their best; the problem was that you let the operation get out of control.  Management dropped the ball by not keeping an eye on what you were expecting of your staff.  

So here is the solution.  May sure that the job description is kept as a living document which is checked regularly and often.  If you know what you are asking people to be responsible for, and you monitor that list to ensure that it is feasible, then and only then can you count on your staff meeting expectations.

You hired your staff because you saw their strengths and merits.  Good management provides the opportunities that allow them prove your judgement and assessment was right. 

Doing it Right or Doing it Wrong?

Doing it Right

Recently I was reading the recent (August 2013) edition of ASQ’s Quality Progress and came across an opinion article by Bob Kennedy who jumped into the fray between W. Edwards Deming and Philip Crosby and said that in his opinion that Crosby’s first essential, Do it Right the First Time (DIRFT) was wrong on every level.  The foundation of his argument was that Deming proscribed against slogans and therefore Crosby and DIRFT was wrong.

 I have to say that Crosby was NOT wrong, and that DIRFT was NOT wrong.  I am not sure that Deming’s concerns about sloganism was meant to include concepts like DIRFT, but if they were, then in all due respect, in this circumstance, I would have to side with Crosby.  Even a pioneering genius like Deming could not always be correct all the time. 

When is comes to concepts like DIRFT, Crosby was spot on, and Deming should have acknowledged it.

First off, let me put some context around my opinion.  I understand Deming’s point of view.  There are some slogans that I think are unhelpful.  “There is no such thing as an Accident” .  “Accidents poison to our organization”.  “Time is money – time loss kills growth and progress”.  These are not slogans, they are less than idle threats that lead people to hide slips and simple mistakes.  There is little place for threats in the workplace.

But DIRFT is not a threat, and indeed makes sense.  Given the alternative I would hope that a neurosurgeon makes triplely sure he does it right the first time.  And by the same token, the same goes for the airplane pilot.  Even the woodworker says, “Measure twice and cut once”. 

DIRFT is in fact a reiteration of a concept that Deming was so proud to adopt, even if he did not state it, “PLAN DO CHECK ACT”.  (For the origins of PDCA see Deming did not create PDCA.  [ http://www.medicallaboratoryquality.com/2012/06/deming-did-not-create-pdca.html ] .

What DIRFT was intended to mean was before you do something, make sure that you have organized your thoughts before you put a plan into action.  It is the essential corollary to PDCA.  Think before you do. 

In the medical laboratory we have tons of examples where things don’t work that way.  Tests get implemented without proper validation.  Tests are done and reported before checking the Quality Control results.  Reports are sent to the wrong person before confirming who was truly was the intended receiver.  These happen all the time and in every instance they result in external failures with potential false reports, misleading information, loss of confidentiality and huge cost of poor quality.  And most of them were pointless and preventable. 

A few seconds or at most minutes of thought and planning could prevent most of these problems, and save the laboratory from embarrassment or potential liability, and save the patients from inconvenience or harm.

Perhaps in Deming’s time, folks were very aware and sensitive to threats in the form of slogans.  Labor protections, either under the umbrella union protection or workplace legislation either did not exist, or were in their infancy.

That is not the world in which we live today.  Today we live with 40 character headlines and 140 character tweets, and thirty second commercials.  We live in a slogan society, and we by-and-large put them into a more current context.  We may see slogans as jargon and trite or sophomoric, but we don’t see them as threats.

Personally I see DIRFT as rather aspirational.  I fatigue of avoidable errors, or repeated mistakes.  I embrace the notion that doing things RIGHT is better than doing things WRONG, and believe that many errors result from automaton-like behaviour.  I absolutely support “Plan before you do; Prevent the avoidable error”  and even more importantly, “Learn from mistakes; support continual improvement”.

So to Bob Kennedy I think with respect it is OK to relax on the absolute adherence to Deming’s word.  It is time to embrace context and circumstance, and to acknowledge that it is also possible to acknowledge that both Deming and Crosby were giant contributors to our current concepts of Quality. 

Deming did not create PDCA

Thanks to Google there is a fun game for entertainment and insight.  Create a sentence in English, and pass it through Google Translate and convert it to another language, and then retranslate it back to English and compare what you started with and what you got.  Sometimes the results take an interesting twist.  Recently I heard about a company that has a commercial interest  in the phrase “come alive!”.  Unfortunately when that phrase was translated into Japanese it became “may you ancestors return from the dead”.  Gives a whole different tone to your soft drink pleasure.  Another is the German translation of “knapsacks” or “fanny packs” in “body bags”, or In Italy, a campaign for Tonic Water translated the name into Toilet Water.  It reminds me that we are not all that far away from the biblical Tower of Babel.  

But if you think that translations always go from good to bad, there seems to be an important Quality story that suggests the contrary.  The source for this comes from Ronald Moen and Clifford Norman who wrote an interesting article “Evolution of the PDCA Cycle”.  You can find it on the web.  It was originally published as Circling Back in Quality Progress in November 2010.

According to these two well informed Qualitologists, when Shewhart first raised the notion of a structured quality cycle in 1939, it was in a manufacturing framework.  The notion was that first one creates the Specification, and then creates the product by Production based on the specification and then tests the product through Inspection.  

By the time Deming adopted this and took the concept to Japan in 1951, Shewhart’s three phase cycle evolved to four phases:  first there is a product Design which is followed by Production to the design.   Then the design and product are studied through the customer’s response at the time of Sales.   If the customer is not happy and registers a complaint, then the process from design to sales (or release) is Researched, and if necessary revised to improve customer satisfaction.  One can see that this clearly has the flavour of the current cycle.

What happened next is the point of my story.

According to Imai (through Moen and Norman) Japanese executives, taking Deming’s notes from his lecture with the Japanese Union of Scientists and Engineers (JUSE) and translated Design-Produce-Sales-Research (see above) as PLAN-DO-CHECK-ACT.  So while the concept may have come from Shewhart and Deming, the words came from the English-Japanese-English translation. 

This is a perfect example of innovation [see: http://www.medicallaboratoryquality.com/2012/04/invention-and-innovation-and-new.html] which in this case may have been a consequence of intent (if the executives knew the potential power of going from the manufacture specific language to more generalized terms) or serendipity (if they did not). 

Either way, the creation of a generalizable science concept for Quality contributed largely to the wide application of PDCA in education, service, and health, and government in a way that the Shewhart or Deming manufacture specific language could not. 

Of interest the first place that Deming actually published the use of the term PDCA (which he subsequently changed to PDSA) was not until he published his book Out of Crisis in 1986, over 30 years later.  

I am not trashing Deming or Shewhart.  Both were clearly  leaders in expressing Quality in scientific terms.  But the term PDCA cycle was not their invention, it was the creation of the Japanese executives responsible for the translation.  And I think that we do history a disservice to continue to attribute the cycle as we do.

  I think my son Steven has said it best.  Life loves a good story.  While mythology needs to have heroes and clean stories,  history rarely works out that way.  

Sometimes you have to decide what you want - the story or the fact.  

Deming did not create PDCA.  Deal with it.