Along my learning journey, I’ve studied with several management greats—among them Dr. W. Edwards Deming (famous statistician, now deceased) and Dr. Paul Batalden (formerly at HCA, now at Dartmouth’s Institute for Health Policy). Both taught me that deep understanding of systems is critical to developing change strategies. Here are some of the lessons they’ve taught me about making quality improvements that will last.
1. Think About Your Larger Purpose
One Saturday morning in the early 1990s, I remember a learning session on systems diagrams with Dr. Batalden. He helped us, as Belmont University stakeholders, discover some of our big-picture goals. We used what we knew about our students and other stakeholders to discover the university’s larger purpose. From then on, that knowledge helped us map out our change initiatives in a dramatic way. Up until that point we had been making changes at the perimeter, or picking the easiest, “low-hanging fruit” types of changes. As we went forward, we began to change at the core, altering the processes that most directly impacted students and their futures. We began new curricula that added global perspectives. Our tagline even changed: “Belmont: From here to anywhere!” While we had been focused on eliminating waste on the edges and in our administrative processes, we then began change initiatives and focused on preventing waste at the core of our system.
2. Take Steps Toward Prevention
Remember the “1-10-100” rule? It’s the “ounce of prevention is worth a pound of cure” rule that says by spending one dollar on prevention, we save $10 on correction costs and $100 on failure costs. In healthcare, if we design a medication error prevention step (the “1”) that prevents the nurse from having to correct a medication error before the drug is given to the patient (the “10”), we will prevent the 100-fold cost of the error of the wrong drug being given to a patient. We all know it’s much less costly to prevent a defect than to correct one.
If you go back to the core of why you are in business, then the tools of improvement make sense. It doesn’t really matter which tools you use as long as you are working on improvement and change at the core.
When your managers are searching for improvements that have the most impact, remember to go back to system knowledge. In your system, what are the things that can go wrong that will have the most impact on your organization’s larger purpose? Think beyond the budgets, the revenue cycles, the number of dollars you must cut. Instead, ask “What’s our aim?” and “What’s our purpose?” Then quantify the likelihood of success and/or mistakes happening at the core. What’s the risk and how can you put steps in place that prevent the 100-times cost of error?
You can make estimates about what those failures would cost your organization, but as Dr. Deming said, “The real cost of [poor] quality is unknown and unknowable.” While you can figure out the actual cost of a medical device malfunctioning and the associated repair, potential lawsuits, etc., you have no way of calculating the human cost of a defective lead in a pacemaker or the cost of an infection that resulted from a caregiver’s poor hand hygiene. Doing what’s right for the patient is always the No. 1 goal of any change process in healthcare.
If you go back to the core of why you are in business, then the tools of improvement make sense. It doesn’t really matter which tools you use as long as you are working on improvement and change at the core. All of the new systems for quality improvement—such as Lean Six Sigma, Baldrige Criteria for Performance Excellence, traditional CQI tools—will work as long as you recognize that real quality enhancement involves preventing errors, eliminating waste and designing changes for improvement at the core of the system.
3. Seek Out Others’ Lessons
Paul Batalden recommends we ask what others have learned and then listen to those lessons. The words of Toyota Chairman Fujio Cho, “Go see, ask why, show respect” are now basic Lean principles. The Lean world says “go to the gemba”—or the place where value is added—then learn from each other. It’s there on the front lines where work is happening—and where waste is most visible. That’s where change can start.
If you observe colleagues leading change initiatives, borrow from their hard-won lessons. Ask, “What have you learned that you can share with me?” Then listen deeply and reflect on how you might use that knowledge. Networking and sharing knowledge to create a stronger, better system makes it less of a daunting task.
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