Quality Transformation: It’s the System!

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.

We called an ambulance, and I spent most of the day in the emergency room having tests run. They concluded that I had pneumonia. I was admitted to the hospital and filled with antibiotics. My pain medication was changed, and I was discharged after another day with the new pain medications, antibiotics, and an incentive spirometer with instructions to use it and to breathe deeply and cough. After two days with continuing, but not as severe, digestive problems, I went to my primary care physician, who told me to stop all medications except my regular prescription medication. Then, I began to slowly heal.

My wife, Carole, remembered that I had been given a spirometer and similar instructions with previous surgeries I’ve had. I received none of that immediately following this outpatient surgery. Seeing an opportunity for improvement, Carole contacted the hospital president and CEO, who quickly responded that “right at this time [we are] working on post-operative respiratory issues. Data shows that this is a significant challenge nationally and we want to use benchmark data as well as studies of best practices which improve outcomes to make sure that our results are at the highest levels.”

Our own research suggests that this is a common problem that can be ameliorated by pre-operative, as well as post-operative, breathing exercises. The hospital’s president and CEO also promised to advise us of the results of their work.

Although we have not yet seen the results of the work, it seems likely that there is a policy of providing an incentive spirometer with instructions to use it and to breathe deeply and cough with surgeries that require the patient to stay in the hospital overnight, and not provide the spirometer and related instructions with surgeries when the patient is expected to go home the same day as the surgery. That would be a system-caused problem. It was probably caused by a well-intended but barely informed management decision.

Although I never expect to see this in writing, based on my work in all kinds of other organizations and sectors, I can imagine that what happened was that someone realized that the spirometer and related instructions helped prevent post-operative respiratory issues in serious surgeries, but assumed that it was not necessary for simpler surgeries and saw an opportunity to save some money. I doubt that it was a conscious, informed decision, but nearly all organizations, whether they are for-profit or nonprofit, are driven by profit or, at least, the need to keep revenues above costs. That makes sense, but sometimes that culture drives decisions that result in the kind of pain, inconvenience, customer (or patient) dissatisfaction, rework, and extra cost that this decision apparently caused.

The reason that Deming’s estimate is so important, I think, is that we all tend to default to thinking the cause of any problem is the person on the front line–even if that person is our self. I’m not sure why that occurs, but it seems to me to be a most common default response everywhere. By acting as if the person is the cause of a problem, we generally waste time, alienate people, engender a culture of fear, and frequently make matters worse.

Let’s assume, first, that the system is the primary cause.

This is a simple, but potentially profound change. The 5 Whys approach to root cause analysis has been around for quite a while. I personally like to combine it with the use of a cause-and-effect diagram. By starting with a cause and effect diagram and continuing to “ask why five times,” the teams I’ve worked with usually get to a common system problem along several different paths in the cause-and-effect diagram. When that happens, everyone is usually convinced that they’ve really found the cause, and they are generally correct.

This seems like such a simple approach to continual improvement and one that I imagine many of you already use. I hope, however, that some of you find this reminder useful.

As always, I look forward to your comments and questions.

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