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Davis Balestracci

Health Care

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:

Traditional management Increasing participation Leading a high-performance culture
Direct people Involve people Develop self-motivating people
Get groups to understand ideas Get groups to generate ideas Get diverse groups to carry out their own ideas
Manage one-on-one Encourage teamwork Build teams that manage more of their work
Maximize the performance of the department Build relationships with other departments Champion cross-functional process improvements
Implement change Initiate change Sponsor innovation to meet needs

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’s picture

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.


Managing Change and Maintaining the Gain

Good article. I agree we should be measuring the right things right.

I am not sure there is enough trust for truly “high performance cultures” as defined by Jim Clemmer’s chart in many regulated organizations. A good governance structure and change management process can help senior management let go a little and enable them to get comfortable with “self-directed” teams with “proper oversight”. It also provides for better senior management immersion in improvement initiatives, controls the amount of change that the organization is permitted to assimilate, and with senior management involvement improves change enculturation to better help maintain the gain. In regulated environments, hybrid systems where diverse groups are enabled to carry out their own ideas but with change control and management oversight is better than traditional management or “increasing participation” modalities, but perhaps is perhaps a bit more stifling than freewheeling high performance cultures. A side benefit may be that improvements are better retained with senior management embedded, especially with appropriate measures and tracking, than in freewheeling cultures because people are less likely to go back to their old ways of doing things when the improvement project is over. This has been a plague of six sigma project failures in many companies and could be a way of improving the success rate.

Lack of SoPK strikes again

I loved the lead-in to this article; Davis provides superb context to the problem. I have little doubt that you could take comments from just about any Quality leader at any Quality-related keynote in the past 30 years and find similar themes and statements.

As is my wont, I go back to Deming; he warned that if management continued to be ignorant of what he called the System of Profound Knowledge, organizations would continue to stumble along. Twenty years after his death, I see very little evidence that anyone has learned much. Most businesses (and some hospitals) are more concerned with creating value (money) for shareholders rather than creating value for customers. Waste is everywhere, and it is especially egregious in high-margin, hostage-customer enterprises like healthcare. Most business statistics courses still teach nothing but enumerative studies; managers remember statistics as a confusing math course with a lot of weird double-triple-negative language around something called "hypothesis testing." Control charts are just "too complex" for these managers, so if any metrics are tracked, it's usually in a red-green idiot light dashboard. Everyone gets a t-shirt when it's green, wrist slaps for red. The line for green and red is usually some arbitrary goal, without any consideration of Davis's question--usually just some number picked to satisfy the CFO's hunger for predictions of growth.

As for holistic or systems thinking, it has unfortunately become--in many ways--politicised. Trying to manage any part of the healthcare system as a system runs you into the danger of being accused of advocating socialism, usually by someone who can't define socialism beyond its tenuous association with Stalin. Healthcare insurance is, undeniably, an inherently socialistic enterprise, though; the young and healthy subsidize the old and feeble. The fact that the young and healthy have little appreciation for how quickly you end up old and feeble should have nothing to do with how the system is managed. To optimize the system you need to have everyone in it, so that record-keeping can become consistent and portable, so that knowledge can be quickly shared and diffused throughout the system, and so that the universal risk pool minimizes insurance premiums. These are just facts, knowable to anyone with a modicum of understanding of variation and general systems theory. Whether or not we SHOULD run healthcare (and education) as a system should not be debatable...HOW we do that should be the subject for discussion. But that statement requires that most people have a modicum of understanding...

Holistic Health

Well said, Mr. Balestracci: Ron Snee's Holism agrees with Ed Rickett's Non-Teleological thinking, that I am fighting for. For too long we have been accustomed to the ants' swarm eating an elephant bite by bite: instead of viewing the ants' swarm and the elephant as systemic bodies, we saw the meal as a systematic process, which is a totally different vision. You may probably know that I live in Italy, where Healthcare can be rated from null to ten, not necessarily from South to North: Lombardy - Milan is a notorious reference - is considered a Healthcare Champion in the whole European Union; if that is a truth, I would never wish anybody living in Lombardy to fall ill, unless affordable for private care. But it's just the same as Education: there is something basically wrong in the governmental management practices of so crucial social services. No management TECHNIQUE will ever help, unless management COMMITMENT equals the ants' swarm hunger for an elephant. Not for the swarm itself ... Thank you.

It's time to stop admiring the problem!

In one of his comedy routines, comedian Jeff Foxworthy said: "My family has been in this country for over 300 years; why don't we own anything?"

I'd like you to consider that the same is true of quality, especially in healthcare. Quality improvement has been around since the 1920s when Shewhart worked at Western Electric. Why don't we see control charts, Paretos and histograms everywhere?

The IHI exhibits improvement posters from all over the country. Few, if any, show signs of using quality tools.

Meanwhile, the Institute of Medicine (IOM) estimates that $750 Billion of healthcare spend is for waste and rework. According to the Wall Street Journal, a 20% reduction in these costs would pay for healthcare reform. A 100% reduction would cut the U.S. deficit in half.

It's time to stop admiring the problem, set BHAGs for improvement and start driving healthcare toward zero defects.