The CQI and the NHS

There have been a number of memorable moments in my career, but the buzz in this week's meeting of healthcare quality folk is something particularly special.

Under the auspices of the Chartered Quality Institute, we met to hear presentations on the state of quality in the NHS and the state of quality improvement training. I found the view from NHS Tayside particularly encouraging. They have been working with the Institute for Healthcare Improvement for 8 years to train staff in quality improvement methodology; they are aiming to have 0.5% of staff as QI experts; 10-15% QI facilitators; and the rest familiar with QI methodology. Doing so should allow ground-level QI projects to be run quickly and easily, but also robustly with data, without needing to go through bureaucratic approval processes.

(Needless to say, the organization still needs an aim and the leadership to maintain constancy of purpose!)

The purpose of the meeting was also to create a Healthcare Special Interest Group (SIG) for the CQI, to provide an industry-standard quality voice for the NHS. I believed that it made sense for the first chair to be a CQI member (MCQI) and a Chartered Quality Professional (CQP) - that is, a demonstrable expertise in QI - rather than just someone who merely had an interest in quality. To that end, I was delighted when Philip Carroll was elected as the founding chair. I will attempt to assist as his deputy. Our first action has been to prepare a response to the draft document from the English Department of Health's National Quality Board on maintaining and improving quality from April 2013. This is a good start, but I think it needs more work to fulfil its potential.

The National Quality Board: options for hope

Following Martin Bromiley's comments, I have been looking at the website of the NHS's National Quality Board under the chairmanship of Sir David Nicholson, the Chief Executive of the NHS. From October 2011, he has also become the first Chief Executive of the NHS Commissioning Board.

The NQB describes itself as "a multi-stakeholder board established to champion quality and ensure alignment in quality throughout the NHS. The Board is a key aspect of the work to deliver high quality care for patients."

The NQB has issued a draft document recently, "Quality in the new health system – Maintaining and improving quality from April 2013". The invitation to comment on this as a draft is a welcome one, and I hope that other organizations such as the BMA, the Health Foundation and CQI will take the opportunity to respond and that the NQB will listen.

Human Factors

I have long admired Martin Bromiley of the Clinical Human Factors Group. His experiences around the death of his wife could have led him to sue the hospital where she died. Instead he used his background as an airline pilot to help the hospital and to set up a group to develop an awareness of human factors in healthcare.

Martin Bromiley believes that "Healthcare culture often inadvertently conceals systemic problems and in the past has laid the 'blame' on certain individuals.  But to me this is fundamentally flawed thinking.  It wasn’t the clinicians that failed; it was the system and training that failed them."

This understanding has been fuelled by a profound understanding of human factors. Dr Ken Catchpole, a human factors expert who has done much work in healthcare, defines clinical human factors as: “Enhancing clinical performance through an understanding of the effects of teamwork, tasks, equipment, workspace, culture, organisation on human behaviour and abilities, and application of that knowledge in clinical settings.”

From that background, I was delighted to see that the CHFG had contributed to the 'DH Human Factors Group Interim Report and Recommendations for the NHS', chaired by Sir Stephen Moss.

Then I read his blog on the Health Foundation website.

"Firstly, I’m particularly cautious of that old question often asked at the top of the NHS: ‘What’s the one thing we could do that would make the difference or gives us the biggest bang for our bucks?’ I hate that question because, to my mind, it misses the point. Culture change isn’t about doing one thing – it’s about doing lots of little things consistently and with purpose (whilst maintaining coordination).

"Secondly, we’re concerned that we’ll be seen as talking about a minority interest. The National Quality Board will say ‘nice presentation, now let’s get on with the real business of improving efficiency and saving money’. But of course, this is about the real business."

These are desperately sad comments. If true, they suggest an attitude at the Department of Health suggestive of Taylor's attitude. with thinking that could jeopardize the push for quality care that we should strive for. I hope the National Quality Board will listen instead to quality professionals.

Taylor, Ford & management

If you cast your minds back to the early twentieth century, there was one company and one product that was about to revolutionize transport and communications: Henry Ford's Model T.

I have heard it said that Henry Ford was influenced by the ideas of Frederick Winslow Taylor, the first of the management consultants. Taylor's theories on "scientific management" have become the foundation of many Masters in Business Administration (MBA) courses. But why does this concern those interested in healthcare?

Taylor believed that a worker playing sport would "[strain] every nerve to secure victory for his side" but that "[when] that same workman returns to work on the following day, instead of using every effort to trn out the largest possible amount of work, in a majority of cases this man deliberately plans to do as little as he safely can - to turn out far less work than he is well able to do - in many instances to do not more than one-third to one-half of a proper day's work". In this, Taylor seems to believe in the fundamental laziness of workers - and indeed, the laziness of all but the most senior of managers; it becomes the role of management to drive the workforce with incentives, slogans and managment-by-objectives (MBO).

Nelson & Deming believed that this view had created a prison limiting both the senior management and the rest of the workforce, with "comments overheard in the prison compound" such as:
* "Computerize everything, let's eliminate people"
* "Let's appraise performance and get rid of those below average"
* "Don't tell me how you do, just do it"
* "Just give me the bottom line"
* "With a good MBO system we only need to set targets for people"

Therefore, if management can just set up a series of procedures and ensure that all follow them, quality will ensue. Particularly in service organizations - such as the NHS - there is the (unstated) assumption that there are fully defined and followed procedures. Unfortunately this is often not the case.

Often we compound the problem with inspection - generally 'dependent' inspection, reviewing work after it has been completed. This in less effective than one might imagine. It also puts the emphasis in the wrong place: work on improving the process instead.

So what is the alternative? What can we learn from successful companies? (Worth listening: saying "our (healthcare) problems are different" may limit what we can do.)

One of the pople who attended Deming's lectures in Japan after World War II was Konosuke Matsushita, the founder of Panasonic. Reflecting on the difference between Japan

“We are going to win and the industrial west is going to lose: there’s nothing much you can do about it, because the reasons for your failure are within yourselves. Your firms are built on the Taylor model; even worse, so are your heads. For you, the essence of management is getting the ideas out of the heads of the bosses into the hands of labour. We are beyond the Taylor model : business, we know, is now so complex and difficult, the survival of firms so hazardous in an environment increasingly unpredictable, competitive and fraught with danger, that their continued existence depends on the day-to-day mobilisation of every ounce of intelligence. For us, the core of management is precisely this art of mobilising and pulling together the intellectual resources of all employees in the service of the firm. We know that the intelligence of a handful of technocrats, however brilliant and smart they may be, is no longer enough. Only by drawing on the combined brain power of all its employees can a firm face up to the turbulence and constraints of today’s environment”

Further reading:
Latzko WJ & Saunders DM (1995) "Four Days With Dr Deming"
Labovitz, G, Rosansky, V & Chang, YS (1993) "Making Quality Work: A Leadership Guide for the Results-driven Manager"

Smokefree - Plymouth Hospitals

Fifty years ago this week, on 7th March 1962, the Royal College of Physicians of London published its seminal report "Smoking and Health". This was the first major review that linked smoking with lung cancer and with 'chronic bronchitis' (better known now as chronic obstructive pulmonary disease (COPD)). The report also recommended restrictions on the sale of tobacco and increasing taxation as means of limiting tobacco use. Many of the recommendations are now commonplace.

The benefits of stopping smoking in terms of reducing the risk of heart attack or COPD are well known. Less well known are the facts that stopping smoing before surgey will improve wound healing, reduce the pain experienced and shorten the time to recovery.

Next week, Plymouth Hospitals NHS Trust will take the next step and will become a smokefree site. The Board are to be congratulated for this bold move. Other hospitals in the UK such as Blackpool NHS Trust have successfully gone smokefree. Now with funding from Smokefree Southwest and in collaboration with Smokefree Plymouth, Plymouth Hospitals will contribute to the improving the city's health and reducing health inequalities. We will also demonstrate what can be achived by a large employer in the city. There will be some special guests tomorrow for final preparations. If you are in Plymouth and want to prepare yourself, look here for information or call Smokefree Plymouth on 01752-314040. If you're trying to stop, I hope it goes well for you.

Deming's "deadly diseases"

While Dr W. Edwards Deming drew out 14 points for industry, he also identified several commonly held wrong beliefs that he called the "deadly diseases". Some of these (such as the first) are direct corollaries to his 14 points; some less so. Of the seven diseases, Deming felt that the first five were generally applicable and that (at the time of writing) the last two were more associated with the USA.

The "Seven Deadly Diseases" include:
   1. Lack of constancy of purpose
   2. Emphasis on short-term profits: this includes trying to meet quarterly / annual financial targets
   3. Evaluation by performance, merit rating, or annual review of performance
   4. Mobility of management: this includes management moving round / being moved (restructuring....)
   5. Running a company on visible figures alone: a real problem - and ignoring what you don't know / can't see / can't measure
   6. Excessive medical costs: the cost of medical insurance in the USA was becoming such a problem in industry (even in the 1980s) that for one company, the cost of medical insurance for staff outweighed the cost of raw materials
   7. Excessive costs of warranty, fueled by lawyers who work for contingency fees

Deming also identifed what he felt were a real but "A Lesser Category of Obstacles", including
   1. Neglecting long-range planning: what Deming called "hope for instant pudding": that is, "an expectation of quick results without effort and without sufficient education to do the job"
   2. Relying on technology to solve problems: the "supposition that solving problems, automation, gadgets, and new machinery will transform industry": it won't, but getting the workers involved in quality improvement (and encouraging & equipping them) will
   3. Seeking examples to follow rather than developing solutions: "no number of examples of success or failure in the improvement of quality and productivity would indicate to the enquirer what success his company would have. His success would depend totally on his knowledge of the 14 points and of the diseases and obstacles, and the efforts that he himself puts forth."
   4. Excuses, such as "our problems are different" - because we are doctors/nurses/astronauts/...: different, perhaps, but with similar principles
   5. Obsolescence in school that management skill can be taught in classes: people not being properly numerate (esp. those with MBAs), not understanding right statistics
   6. Reliance on quality control departments rather than management, supervisors, managers of purchasing, and production workers
   7. Placing blame on workforces who are only responsible for 15% of mistakes where the system desired by management is responsible for 85% of the unintended consequences
   8. Relying on quality inspection rather than improving product quality

By now, you may recognize some of these in the organizations you may have observed (I'm sure none of the ones we work for would ever do these...); I hope they set you thinking about what we might do differently in UK health care.

What is the purpose of a hospital?

During World War II, workers in a parachute factory had to stitch material for hours at a time. This was repetitive and tedious work. However, each morning they were reminded just how important their work was and that it might savev the lives of their husbands, sons and boyfriends. In this way, the purpose of the factory (to make high quality, functioning parachutes) was kept in clear focus for everyone.


So: "what is the purpose of a hospital?"
That may sound like a very simple question, with a really obvious answer, but I have heard some less obvious ones during my time in NHS hospitals. For me, the answer that took the prize was "Our main purpose is to make money" from a hospital chief executive.

I suspect that CEQ had not read Deming's points for improvement and in particular not point 1: "Create constancy of purpose toward improvement of product and service, with the aim to become competitive and to stay in business, and to provide jobs."

I have suggested before what the ideal state might be for a healthcare organization:
* To deliver what the patient wants & needs, defect free
* ...one by one, customized to each individual patient
* ...on demand, exactly as requested
* With an immediate response to problems or changes
* With no waste
* In an environment safe for patients, staff & clinicians: physically, emotionally & professionally

This should be the main focus - the object of constant purpose - for a hospital or similar body, as it is for the staff dealing with patients daily.

But what of the constituent departments? What is the purpose of the finance department or of human resources? I suggest the answer is still the same. While how they do that differs between departments, the purpose of these departments is to deliver what the patient wants and needs. It remains the responsibility of senior management to help maintain that focus throughout the hospital, to ensure continual improvement in the effectiveness of services we deliver for our patients.

14 points for health care

The "14 points" stuff is all very well - but how does it apply to those of us who work not in business but in health care? Fortunately, in "Out of the Crisis" (1986), Dr Deming cited an adaptation of the 14 points to medical service, written by Dr. Paul B. Batalden and Dr. Loren Vorlicky of the Health Services Research Center, Minneapolis:

1. Establish constancy of purpose toward service.
    a. Define in operational terms what you mean by service to patients.
    b. Specify standards of service for a year hence and for five years hence.
    c. Define the patients whom you are seeking to serve - those here, those that you seek, those that have been here only once.
    d. Constancy of purpose brings innovation.
    e. Innovate for better service for a given cost; planning for the future will require the addition of new skills, training, and retraining of personnel, satisfaction of patients, new treatments, new methods.
    f. Put resources into maintenance of equipment, furniture, and fixtures; new aids to production in the office.
    g. Decide whom the administrator and the chairman of the board are responsible to and the means by which they will he held responsible for working for constancy of purpose.
    h. Translate this constancy of purpose to service into patients and to the community.
    i. The board of directors must hold on to the purpose.

2. Adopt the new philosophy. We are in a new economic age We can no longer live with commonly accepted levels of mistakes, materials not suited to the job, people on the job that do not know what the job is and are afraid to ask, failure of management to understand their job, antiquated methods of training on the job, inadequate and ineffective supervision. The board must put resources into this new philosophy, with commitment to in-service training.

3a. Require statistical evidence of quality of incoming materials, such as pharmaceuticals, serums, and equipment. Inspection is not the answer. Inspection is too late and is unreliable Inspection does not produce quality. The quality is already built in and paid for.
b. Require corrective action, where needed, for all tasks that are performed in the hospital or other facility, ranging all the way from bills that are produced to processes of registration. Institute a rigid program of feedback from patients in in regard to their satisfaction with services.
c. Look for evidence of rework or defects and the cost that may accrue as a result - an incorrect bill, an incorrect or incomplete registration.

4. Deal with vendors that can furnish statistical evidence of control. This will require us to examine generic lowest-price buying; it will cause us to ask more penetrating questions about prospective colleagues regarding their interactions and the track record of their interactions with patients and with colleagues.
We must take a clear stand that price of services has no meaning without adequate measure of quality. Without such a stand for rigorous measures of quality, business drifts to the lowest bidder, low quality and high cost being the inevitable result. We see this throughout the United States industry and government by rules that award business to the lowest bidder.
Requirement of suitable measures of quality will, in all likelihood, require us to reduce the number of vendors. The problem is to find one vendor that can furnish statistical evidence of quality. We must work with vendors so that we understand the procedures that they use to achieve reduced numbers of defects.

5. Improve constantly and forever the system of production and service.

6. Restructure training.
     a. Develop the concept of tutors.
     b. Develop increased in-service education.
     c. Teach employees methods of statistical control on the job.
     d. Provide operational definitions of all jobs.
     e. Provide training until the learner's work reaches the state of statistical control, and focus the training to assist the learner to achieve the state of statistical control.

7. Improve supervision. Supervision belongs to the system and is the responsibility of the management.
     a. Supervisors need time to help people on the job.
     b. Supervisors need to find ways to translate the constancy of purpose to the individual employee.
     c. Supervisors must he trained in simple statistical methods for aid to employees, with the aim to detect and eliminate special causes of mistakes and rework. Supervisors should find causes of trouble and not just chase anecdotes. They need information that shows when to take action, not just figures that describe the level of production and the level of mistakes in the past.
     d. Focus supervisory time on people that are out of statistical control and not those that are low performers. If the members of a group are in fact in statistical control, there will be some that are low performers and some that are high performers.
     e. Teach supervisors how to use the results of surveys of patients.

8. Drive out fear. We must break down the class distinctions between types of workers within the organization-physicians, nonphysicians, clinical providers versus nonclinical providers, physician to physician. Discontinue gossip. Cease to blame employees for problems of the system. Management should be held responsible for faults of the system. People need to feel secure to make suggestions. Management must follow through on suggestions. People on the job can not work effectively if they dare not inquire into the purpose of the work that they do, and dare not offer suggestions for simplification and improvement of the system.

9. Break down barriers between departments. Learn about the problems in the various departments. One way would be to encourage switches of personnel in related departments.

10. Eliminate numerical goals, slogans, and posters imploring people to do better. Instead, display accomplishments of the management in respect to assistance to employees to improve their performance. People need information about what the management is doing on these 14 points.

11. Eliminate work standards that set quotas, commonly called also measured day work. Work standards must produce quality, not mere quantity. It is better to take aim at rework, error, and defects, and to focus on help to people to do a better job. It is necessary for people to understand the purpose of the organization and how their jobs relate to the purpose of the organization.

12. Institute a massive training program in statistical techniques. Bring statistical techniques down to the level of the individual employee's job, and help him to gather information in a systematic way about the nature of his job. This kind of training must be married to the management function rather than to the personnel function within the organization.

13. Institute a vigorous program for retraining people in new skills. People must be secure about their jobs in the future, and must know that acquisition of new skills will facilitate security.

14. Create a structure in top management that will push every day on the above 13 points. Top management may organize a task force with the authority and obligation to act. This task force will require guidance from an experienced consultant, but the consultant can not take on obligations that only the management can carry out.


I think the ideas here apply to the NHS. Above all, the need for senior management to adopt and maintain constancy of purpose and to take responsibility for making the cultural changes: leadership, not fear; data, not slogans; continual improvement and training to enable everyone to do their job better.

And if we do, our patients will get a better, more effective, less wasteful service. But why does there seem to be a tendency for people not to think in terms of quality & systems? For that, I think we need to go a little further back, to the home of the Model T: Ford.

Dr W. Edwards Deming and the 14 points

Dr W. Edwards Deming was an American engineer-turned-statistician and a pupil of Dr Walter Shewhart. During the Second World War, his statistical methods were used by the American industry to step up production significantly but quickly faded from use when "normal life" returned in 1945. Deming was asked to assist with a post-war census in Japan and was invited to speak to the Japanese Union of Scientists and Engineers; those who attended his first sessions were the founders of Toyota and Sony. His message to these business leaders was surprisingly simple: improving quality will reduce expenses while increasing productivity and market share.

Toward the end of his life, Deming began to get recognition in the USA for his ideas, which ran contrary to 'prevailing business wisdom'. In 1980, he was featured in an NBC television documentary called "If Japan can... Why can't we?" and then in a series of videos now sold as "The Deming Library". He also began to write more extensively and for popular consumption. A good place to start is Deming's "Out of the Crisis", in which he describes many of his statistical techniques. More importantly is what Deming referred to as 'Profound Knowledge' - the understanding of underlying principles, both good and bad, that can affect business processes deeply. He identified fourteen points for business (as well as some 'deadly diseases', of which I may write in due course). In 1986, he wrote, "The 14 points are a basis for transformation of [American] industry. Adoption and action on the 14 points are a signal that management intend to stay in business and aim to protect investors and jobs. Such a system formed the basis for lessons for top management in Japan in 1950 and in subsequent years. The 14 points apply anywhere, to small organisations as well as to large ones, to the service industry as well as to manufacturing. They apply to a division within a company." He listed the 14 points:

1. Create constancy of purpose toward improvement of product and service, with the aim to become competitive and to stay in business, and to provide jobs.
2. Adopt the new philosophy. We are in a new economic age. Western management must awaken to the challenge, must learn their responsibilities, and take on leadership for change.
3. Cease dependence on inspection to achieve quality. Eliminate the need for inspection on a mass basis by building quality into the product in the first place.
4. End the practice of awarding business on the basis of price tag. Instead, minimise total cost. Move towards a single supplier for any one item, on a long-term relationship of loyalty and trust.
5. Improve constantly and forever the system of production and service, to improve quality and productivity, and thus constantly decrease costs.
6. Institute training on the job.
7. Institute leadership. The aim of supervision should be to help people and machines and gadgets to do a better job. Supervision of management is in need of an overhaul, as well as supervision of production workers.
8. Drive out fear, so that everyone may work effectively for the company.
9. Break down barriers between departments. People in research, design, sales, and production must work as a team, to foresee problems of production and in use that may be encountered with the product or service.
10. Eliminate slogans, exhortations, and targets for the workforce asking for zero defects and new levels of productivity. Such exhortations only create adversarial relationships, as the bulk of the causes of low quality and low productivity belong to the system and thus lie beyond the power of the work force.
11. a. Eliminate work standards (quotas) on the factory floor. Substitute leadership.
b. Eliminate management by objective. Eliminate management by numbers, numerical goals. Substitute leadership.
12. a. Remove barriers that rob the hourly paid worker of his right to pride in workmanship. The responsibility of supervisors must be changed from sheer numbers to quality.
b. Remove barriers that rob people in management and engineering of their right to pride in workmanship. This means, inter alia, abolishment of the annual or merit rating and management by objective.
13. Institute a vigorous program of education and self-improvement.
14. Put everybody in the company to work to accomplish the transformation. The transformation is everybody's job.

I'll address how these might apply in health care - and the 'deadly diseases' that we may have to confront - in the next blog.

What is quality health care? What is the Ideal?

One of the problems with "quality" is that defining it sometimes seems to be like nailing down fog: everyone has some vague sense of what they mean but a clear description is elusive. So what does 'quality' mean for health care in the UK?

According to the Oxford English Dictionary, quality is "the standard of something as measured against other things of a similar kind; the degree of excellence of something" or "general excellence of standard or level". The 'industry standard' definition is that in ISO 9000: "the degree to which a set of inherent characteristics fulfils requirements".

While these are drily accurate, they are not particularly inspiring for a doctor, nurse or health care manager. I think we can do better. After she read an analysis of Toyota's DNA when the company was at its height, an American nurse, Cindy Jimmerson RN, developed a health care equivalent of the 'Ideal' at the heart of Spear & Bowen's paper. I have tweaked it a little (see below), but I suggest this as what we should strive for:
* To deliver what the patient wants & needs, defect free**
* ...one by one, customized to each individual patient
* ...on demand, exactly as requested
* With an immediate response to problems or changes
* With no waste
* In an environment safe for patients, staff & clinicians: physically, emotionally & professionally

**: Jimmerson had only "what the patient needs": I have met enough patients who are clear about the treatment that they do or do not want to make me want to add the further clause. For example, a patient may want surgery for inoperable lung cancer: they may want it, but it is not appropriate; another patient may need surgery for a perfectly operable but decline clinical advice.

We should still aim to get it right (whatever 'it' is), when it should be done, without waste. And, of course, for any change, the acid test is: does it move us toward or away from the Ideal?