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Davis Balestracci

Quality Insider


Yet another blinding flash of the obvious

Published: Monday, May 18, 2015 - 13:24

In the past couple of weeks, I have stumbled onto three things that triggered this column. Two of them came from academic-type healthcare journals, one of which shall remain nameless. This type of journal is still trying to make a formal case for improvement. Article after article belabors the obvious in stilted, arcane academic language and models that won’t motivate anyone to do anything. I know what these articles are talking about and even I get confused!

It must be because it went through this process:

Image source

Now there is an aggressive movement encouraging and teaching healthcare quality professionals to prepare their projects for publication in such journals. Isn’t there far too much real work to do to make things easier for the front-line staff and patients instead of spending precious time learning how to jump through hoops to deal with such pretentious nonsense?

A friend who is an editor for one of these journals asked me to referee an article on run charts. Given my reputation, she should have known better, but I accepted the challenge. Reading the paper literally gave me a headache (it was already in the form above!). Why does simply plotting data over time have to be so profound? The author took offense at my practical suggestions, so I recommended not publishing it, which was overridden because “We need papers on run charts in refereed journals so that it can gain credibility as a technique.” A technique no one will care to use?

My dear readers, do you need such convincing?

The same journal came out with a tweet this past week touting a service they are now selling: “Want to undertake quality improvement without disruption to the day-to-day running of services?” [My emphasis]

What planet are they on? As Deming said, “Any theory is correct in its own world. But does it make contact with this world?”

I then encountered this freshly published article in another academic journal, which made these profound conclusions:

As the abstract states, “This perspective discusses 12 key facts derived from 50 years of health services research and argues that this knowledge base can stimulate innovative thinking about how to make healthcare systems safer, more efficient, more cost-effective, and more patient-centered, even as they respond to the needs of diverse communities.”

50 years? Take a look at my newsletter from almost five years ago quoting Dr. Donald Berwick’s similar observationsfrom 20 years ago!


Healthcare improvement is currently driven by the “obvious”—a plethora of platitudes and “vague” solutions to “vague” problems that, if one looks at the past 20 years, are ultimately getting “vague” (and, in many cases, mostly temporary) results. I’ll say it again: Put focused attention on anything and it will improve—for awhile.

In 1999, Peter Block had some sage comments about how the process of an enthusiastic call to action almost predictably hardens into a set of platitudes—by addressing the very barriers why it doesn’t happen, which happen to form yet another set of platitudes:

“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.”

What is it going to take to overcome this? Wait for it... leadership (yet another platitude).

I also found this site, on which the goals and generosity are nothing short of admirable. I would ask anyone in healthcare improvement to look at it for some helpful free resources worth considering.

That said, they do re-tread a lot of the ground of the last 25 years since healthcare got the improvement bug. I bet you that some semblance of “The Leader's Credo” has been developed at hundreds of executive retreats, and I can already hear your groans as you read it.

I’m reminded of one of my all-time favorite Dilbert sequences:

His company wanted to improve morale, so they put the entire culture on anti-depressants.
• One woman was so depressed, she took all of the pills.
• The group was frantic: “We’ve got to get her to vomit. What should we do?”
• Someone said: “I’ve got it! Go to the board room and get the mission statement. We’ll read it to her.”
• They all vomited.

Much to his credit, the founder of this site issued this very challenging call to action—in 2009—to show how to bring The Leader’s Credo to life. As do my book, Data Sanity (Medical Group Management Association, 2009) and Quint Studer’s Hardwiring Excellence (Fire Starter Publishing, 2003).

A test of your organization's leadership: Which level are you?

If one of your executives once again demonstrates “passionate lip service” about the need to improve, ask yourself:
1. Is it safe to engage the leader in dialogue about what such an ambiguous statement means in terms of specific results, both clinically and as an organizational culture?
2. Is it safe to point out inconsistencies between executives’ walk and talk when behaviors are observed that aren’t in line with those desired results? (Or does the mission statement still induce vomiting in the front line?)
3. Is the existence of such ambiguity and inconsistencies undiscussible?
4. Is the fact that the existence of ambiguity and inconsistencies is undiscussible also undiscussible?

I worked for two organizations where passionate lip service abounded—with toxic “level four” cultures as seen above.

If you tolerate it, it’s culture

What are you tolerating?

As Jim Verzino has said: “Any good quality management system is the sum of the decisions made within it.... Each time we choose to sacrifice the good of the system for one person, or allow an ineffective, outdated legacy practice to continue, we take small steps toward lower and lower standards. When we have a culture that puts quality and environmental attainment at a lower priority than feelings and keeping the status quo, slowly we make the hundreds of decisions that eat away at total performance. Over time, harmless little decisions can derail a quality management system.”


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.


Health Care Quality

Health Care has been admiring the problem.

According to Press Ganey, ED turnaround times are four hours, unchanged for a decade.

The 1999 To Err Is Human report found that 99,000 people a year died unnecessarily; better measurement has shown that it's closer to 500,000/year.

It's not hard to improve health care, but as I wrote in Lean Six Sigma for Hospitals, it requires persistence and a couple of hours a week.

Start with Lean to reduce delays and movement. Add Six Sigma to eliminate defects, mistakes and errors.

Stop admiring the problem. Start improving.