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Quality Transformation: It’s the System!

System-caused problems can affect returns to hospital, increase potential for more pain

Quality Transformation With David Schwinn
Tue, 01/09/2018 - 11:03
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I was recently reminded of a fundamental statement about continual improvement. In Out of the Crisis (Massachusetts Institute Center for Advanced Engineering, 1986), W. Edwards Deming stated, “I should estimate that in my experience, most troubles and most possibilities for improvement add up to the proportions something like this: 94 percent belongs to the system (responsibility of management).”

A couple of weeks, ago, I went into the hospital for a hernia repair, one of the most common surgeries there is. The plan was to have the surgery, go home the same day, and recover at home in a few weeks. According to the surgeon, the surgery went fine. That still seems to be true. However, the morning after surgery, I woke barely able to stand, with severe body aches as well as nausea and vomiting.

 …

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Comments

Submitted by Alan Metzel on Tue, 01/09/2018 - 11:39

The System

Amen! As Pogo so aptly stated, "We has met the enemy, and he is us!"

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Submitted by Bill Sproat on Wed, 01/10/2018 - 07:29

5 Whys pitfall

Enjoyed the article and it got me thinking about a root cause analysis pitfall that I have witnessed (and committed) over the years.  When drilling down the 5 whys, we need to provide evidence for the cause/effect relationships identified.  Too often we assume that our cause is true when in fact, it is just an opion or guess.  Providing evidence for each 'why' forces the root cause analysis to validate the cause/effect relationships or acknowledge that it must be tested and validated.  Root cause analysis is an effective tool when used properly but can lead to a false sense of discovery when guesses or opinions are not validated.

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