Evolving Beyond Platitudes to Holistic Improvement

Effective improvement people will never be out of work

Published: Monday, December 17, 2012 - 13:03

The 24th Institute for Healthcare Improvement (IHI) Annual Forum took place on Dec. 9–12, 2012. It is probably the leading health care improvement event in the world. I have presented there for 20 consecutive years and watched it evolve from barely 1,000 attendees to well over 5,000. What’s changed during these past 24 years?

Here are two quotes from past plenary speeches of the always-inspiring Donald Berwick, M.D., its former CEO. See if you can guess how old they are. Even if you’re not in healthcare, they are applicable to any industry, but I would ask you to think about your recent healthcare experiences, and those of your families:

1. “Now, in healthcare, among the people at this forum, we have made the needed preparations for change. Our preparations are sufficient. We have studied enough. We have reviewed our cultures enough. We have spent the time we needed, enough time, in training and planning and filling our kit with new and useful tools and methods. We know how. Now, we must remember why....”

2. “I want to see healthcare become world-class. I want us to promise our patients and their families things that we have never before been able to promise them... I am not satisfied with what we give them today.... And as much respect as I have for the stresses and demoralizing erosion of trust in our industry, I am getting tired of excuses....”

“To get there we must become bold. We are never going to get there if timidity guides our aims.... Marginal aims can be achieved with marginal change, but bold aims require bold changes. The managerial systems and culture that support progress at the world-class level... don’t look like business as usual [Emphasis is mine]:
• Bold aims, with tight deadlines
• ‘Improvement’ as the strategy
• Signals and monitors—providing evidence of commitment to aim, giving visible evidence of strategy via management of monitors
• Idealized designs
• Insatiable curiosity and incessant search
• Total relationships with customers
• Redefining productivity and throughput
• Understanding waste
• Cooperation
• Extreme levels of trust.”

Quote No. 1 is from 1993, Quote No. 2 is from 1997, and the past 15 years have just been “more of the same.” I am reminded of one of Brian Joiner’s favorite expressions, “Vague solutions to vague problems yield vague results.” During the past 30 years, improvement has gone through total quality management (TQM), continuous quality improvement (CQI), Six Sigma, Toyota Production System (TPS), lean, and lean Six Sigma. So what’s truly changed during the 15 years since the second quote?

As many of you have no doubt discovered, a single method does not work for all problems. It’s time to move the focus from “method” to “improvement.” Ron Snee, a respected statistical colleague, calls it, “Holistic improvement: A system that can successfully create and sustain significant improvements of any type, in any culture, for any business.”

Snee coined this term in 2009. Can you consider how your improvement efforts have transitioned during the past three years toward this needed view?

Lessons still not learned

Quality professionals have made huge strides in speaking the language of senior management. However, in many organizations, senior management still does not know the fundamental lessons of quality and, frankly, shows no interest in learning them. (Other than, “Get to the punchline and give me the 10-minute overview.”) Poor use of data remains rampant—and tolerated by improvement professionals. Promotions self-perpetuate the status quo. Could it be that few quality managers make it into senior management positions because senior management does not really believe in the quality concepts?

Snee lists six common mistakes that continue to be made despite what has been learned the last 30 years:
• Failing to design improvement approaches that require the active involvement of top management
• Focusing on training rather than improvement
• Failing to use top talent to conduct improvement initiatives
• Failing to build the supporting infrastructure, including personnel skilled in improvement and management systems, to guide improvement
• Failing to work on the right projects—those that deliver significant bottom-line results
• Failing to plan for sustaining the improvements at the beginning of the initiative

Where are you?

As the roles of supervisors, managers, and executives evolve, Jim Clemmer talks about the skills at which they now must excel. He summarizes them in this chart:

Would it be safe to say that many organizations are still stuck in “Increasing participation,” with some token efforts at creating a high-performance culture… by retrofitting it onto the current culture? Is improvement is still treated as “bolt-on” rather than “built-in?”

Resolution for 2013: Evolve beyond the tired, arbitrary numerical goals approach

As your management inevitably sets goals for the coming year, here is some wisdom I once heard at a conference: A good goal should be based in research and also called a “fact of life.” Apply this test: Could you say to people, “If we don’t attain this result, we don’t survive. What part of that don’t you understand?”

Many of my past articles have talked about huge chunks of time wasted in meetings accounting for performance vs. achieving goals via special-cause strategies. And have you noticed (your culture surely has) that even if most goals are not attained, business as usual somehow always manages to continue... as do these meetings. What could be done with all that time? (Hint: Create a high-performance culture as a driving context for all of your hard project work.)

Improvement methods may come and go, but the need to improve business performance and the bottom line never goes out of style. Even innovation and growth will eventually create waste and inefficiencies, but effective improvement people will never be out of work.

I hope this gives you some ideas as you plan your improvement strategy in 2013. Resolve to improve your improvement process.

About The Author

Davis Balestracci

Davis Balestracci is a past chair of ASQ’s statistics division. He has synthesized W. Edwards Deming’s philosophy as Deming intended—as an approach to leadership—in the second edition of Data Sanity (Medical Group Management Association, 2015), with a foreword by Donald Berwick, M.D. Shipped free or as an ebook, Data Sanity offers a new way of thinking using a common organizational language based in process and understanding variation (data sanity), applied to everyday data and management. It also integrates Balestracci’s 20 years of studying organizational psychology into an “improvement as built in” approach as opposed to most current “quality as bolt-on” programs. Balestracci would love to wake up your conferences with his dynamic style and entertaining insights into the places where process, statistics, organizational culture, and quality meet.