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Davis Balestracci

Health Care

A New Conversation for Quality Management

It’s time to move beyond passionate lip service

Published: Tuesday, August 2, 2011 - 11:18

Finally, the medical industry is putting aside its “We’re medicine; we’re different” mindset and taking a more practical look at quality improvement. Bravo! Although an element of physician culture remains convinced that improvement is all about outcomes and double-blind clinical trials, the executive culture at least has become so well-versed in quality jargon they can now use it to disguise a cost-cutting program. They’ve caught up with the rest of American management.


For those of you who perhaps didn’t read my last column because “health care” was in the title, let me repeat a quote from 1993 made by Donald Berwick, M.D., head of the Centers for Medicare and Medicaid Administration, that is applicable to all improvement:

“[W]e 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....”

And the “why” is not cutting costs and meeting “tough” goals and standards.

Berwick got it—in 1993—when Six Sigma was barely a blip on the radar screen. Quality improvement via passionate lip service and calls to action continues to be the norm—as long as quality doesn’t interfere too much with the “real” work.

How do we move beyond this to get quality hardwired into organizational DNA? Two issues must be addressed.

1. Where are the improvement professionals in the C-suite?

I believe quality professionals have made huge strides toward 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. Moreover, current promotions “processes” are perfectly designed to self-perpetuate this status quo.

Could it be that few quality managers make it into senior management positions because senior management doesn’t really believe in the quality concepts?

Quality professionals are hardly blameless in this picture. Unfortunately, in their zeal many “qualicrats” don’t help matters by inflicting Japanese buzzwords and “death by statistics and tools” on executives. As Tripp Babbitt says, “Your native tongue will suffice.”

2. It’s time to own glacial progress and create new conversations.

It’s time for a conversational moratorium on statements and topics like the following:
• “It’s important to have the support of top management.”
• “Workers do not want to be empowered.”
• “Leaders need to provide a good role model.”
• “How do we hold people accountable?”
• “How do we get people on board and aligned?”
• “We need to be customer-focused.”
• “How do we do things faster and cheaper?”
• “How do we give more choice to the people close to the customer?”
• “We need a clear and common vision.”
• “We need to have ground rules for dialogue, consensus, teamwork, decisions, and feedback.”
• “It is important for us to understand systems thinking and whole system change.”
• “We need servant leaders and the end of command and control.”
• “We need to commit to continuous improvement.”

As management expert Peter Block says, “All of these points are true. It is just that they have become useless to talk about. They have become habitual language, and we have become anesthetized to their meaning and depth. These words, because of their popularity, now belong to someone else, not to us. The phrases get used for persuasion and political advantage, not for their capacity for human connection. They have become the party line and evoke unconsciousness and keep us frozen in the comfort of routine.”

If these are issues in your culture—and they are—consider this wisdom from management consultant Jim Clemmer:

“Many organizations induce learned helplessness. It’s like the strange pumpkin I once saw at a county fair. It had been grown in a four-cornered Mason jar. The jar had since been broken and removed. The remaining pumpkin was shaped exactly like a small Mason jar. Beside it was a pumpkin from the same batch of seeds that was allowed to grow without constraints. It was about five times bigger. Organization structures and systems have the same affect on the people in them. They either limit or liberate their performance potential.”

Ask yourself, “So, what am I going to do about it?”

Stop confusing activity with impact

I was talking with a friend the other day, and she was frustrated. She worked at a college and registered students for a particular summer session that involved community teachers being aware of potential scholarship money for their students. The process was rife with poor communication and many paperwork mistakes, including missing information, which caused a lot of rework behind the scenes.

This resulted in a poor image of the college, but more important, it was a missed opportunity for deserving students. My friend had a very innovative idea for eliminating the paperwork and improving communication; however, that fell on deaf ears in the administration.

In Fourth Generation Management: The New Business Consciousness (McGraw-Hill, 1994), which I believe is still the best overall book on improvement, author Brian Joiner talks about three levels of fix.

Level 1: Fix the incident (damage control)

Many times, as in the case of a serious complaint or angry customer, this must be done; however, if one stops here or thinks that it’s just a matter of “finding the guilty,” the incident—i.e., undesirable variation—has been treated as a special cause.

In my friend’s case, this would involve taking action on every paperwork mistake or angry teacher who wasn’t aware of the scholarship opportunity, and doing her best, she actually did this very well.

Level 2: Fix the process producing the incident

From what I see, this is where Six Sigma has gotten seriously mired. There is no doubt that many, many processes are seriously broken and do indeed need to be fixed.

Here is where my friend had an innovative solution to fix the process. If she had been supported and empowered to do so, she no doubt would have been nominated for, and received, an internal quality award.

What’s wrong with that, you may ask? Frankly, despite the excellent work, in the scheme of things, it would have been the proverbial drop in the bucket.

How about considering it from an even larger perspective?

Level 3: Fix the system that has allowed the process

In other words, is my friend’s process just symptomatic of an overall organizational problem that tolerates wasteful, cumbersome paper processes, which in turn causing poor communication and image? What is that cost to the organization?

Such an effort would indeed affect a “big dot” (an indicator in the board room) and be a worthwhile organizational commitment on which to focus everyone’s energy.

So, until Joiner’s level-three fix becomes the norm, the Six Sigma belt training mill will continue. Its graduates will continue to be gainfully employed. The quality profession will continue to confuse activity with impact. Quality professionals will continue to talk about how underappreciated and busy they are, using the statements above. Employing some conventional wisdom here, “When you realize you’re in a hole, stop digging.”

Change the conversation

How many of you spend a lot of time delivering internal education and training seminars? So tell me: How is it all contributing to a “big dot” in the boardroom? Do your executives still demand to know what the “payback” is for all this training and threaten it with the first cutbacks when a cost-cutting season inevitably arises? Well, then: Stop it all right now.

That would be drastic, but you would precede making this bold move by:
1. Looking at every project in progress to see whether it is firmly connected with organizational “big dots”
2. Temporarily stopping those that aren’t connected to the big dots, and when possible, applying a level-three fix to them
3. Seeing whether alleged saving from past projects did indeed move a “big dot” as claimed by using…
4. … data plotted over time as a run or control chart

Regarding No. 4, here is another Berwick quote (from 1995) that is relevant to all improvement:

“Plotting measurements over time turns out, in my view, to be one of the most powerful devices we have for systemic learning.... Several important things happen when you plot data over time. First, you have to ask what data to plot. In the exploration of the answer, you begin to clarify aims, and also to see the system from a wider viewpoint. Where are the data? What do they mean? To whom? Who should see them? Why? These are questions that integrate and clarify aims and systems all at once.... When important indicators are continuously monitored, it becomes easier and easier to study the effects of innovation in real time.... If you follow only one piece of advice from this lecture when you get home, pick a measurement you care about and begin to plot it regularly over time. You won’t be sorry.”

That ought to get some new conversations started, don’t you think?


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.