In 2012, there were estimates of waste in US healthcare amounting to $750 billion per year, or approximately 30% of overall spending. The leading causes of waste are broken out in the Table, with low value services, excess administrative costs, and process inefficiencies reflected as the top three contributors. Since 2012, some pundits estimate that more than one-half of healthcare organizations have initiated quality improvement (QI) programs.
However, even when organizations adopt QI methods, they sometimes do so in ways that undermine QI, and result in failure. We will discuss three common implementation mistakes: seagulls, cakes, and beatings.
“The Seagull Flyby”
Many organization employ external consultants to educate staff on QI principles and methods, initiate QI projects, or manage QI deployments. In many of these, a QI expert flits in, declares almost everything to be “Muda” (waste), showers the bewildered staff with sage advice, and leaves in a flurry of handouts and anecdotes.
Staff are often left bewildered and soon forget the intervention. The books, process manuals, and glossy handouts join dusty piles of previous clever improvement ideas.
No QI program can survive on just a flashy kickoff. QI programs need long-term commitment to develop champions from within the staff and become part of “how we do business.” A key aspect of effective QI is that external experts can be used to perform scheduled audits; help to resolve specific issues, or perform training sessions, but daily management and strategic QI direction must come from within the organization.
“Let Them Eat Cake”
Some organizations do engage staff in QI once the external experts have left but then abandon junior management and general staff to a DIY hell. In many cases, there is no tangible leadership involvement other than exhortations to do better, with less, and faster.
Staff may form quality circles or improvement forums but often have to fight for time out and basic supplies for QI initiatives. Management may signal their lack of priority for QI efforts in subtle but easily interpreted ways. For example, managers may push quality groups out of their meeting rooms if there is a clash with an operational meeting, cancel QI briefings when “real work” conflicts for that time, or cut the funding for food and stationary used by QI teams. These actions signal to everyone in the organization that QI is for show only and not a priority.
Making QI a leadership priority is straightforward: mentions, money, and meetings. QI language must be in everything that senior leadership says, it must be budgeted for specifically, and if there is a clash for a meeting room or a slot in the calendar, QI needs to win at least half the time. Anything else broadcasts that QI is not really seen as important.
“Beatings Will Continue Until Morale Improves”
The most harmful and atrocious approach to QI is, however, using it as an enforcement weapon. If QI is used by management as a means of punishment, it loses credibility, employee acceptance, and any hope of being useful. Quality metrics should never be used to judge individual performance or to deny or grant bonuses and raises. A punitive approach to error results in abandonment of organizational learning, because near misses are ignored, and quality failures are hidden instead of used to learn and change.
Number eight of Deming’s list of 14 Points for Quality Management underscores that QI should address faulty policies, processes, or methods, be used to revise and improve metrics, and never be used as an instrument for punishing individuals.