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"