Abstract
W Edwards Deming. Out of the crisis. Boston, MA: MIT Press, 1982
Improving the quality and safety of health care remains a policy and practice priority. Over the last two decades, a number of specialist agencies have been established to advise and guide on quality improvement, such as the Institute for Health Improvement in the US and NHS Improving Quality in England. These have been influential in promoting particular frameworks and techniques for quality improvement, such as the Model for Improvement, Lean, Six Sigma and total quality management. 1 Despite the growing popularity of these approaches, they do not always lead to the improvement promised by their advocates. In part, this stems from problems in their translation and implementation in health care. Linked to this, these approaches are often promoted in the form of tools or methods, such as the plan-do-study-act cycle, process mapping and statistical process control charts. They give limited consideration to the underlying theories or assumptions on which they are based2,3 and the particular socio-economic histories from which they emerged.
W Edwards Deming’s Out of the crisis has arguably made the most significant contribution to the quality movement in general and health care in particular. First published in 1982 in the USA, it issued an urgent call to transform the management of American industry. The timing was significant because it addressed the apparent decline in US manufacturing and sought learning from high-performing post-war industries, especially those in Japan. His driver was to improve the quality and efficiency of industrial processes in order to keep companies in business (and therefore the people of America in employment) and to ensure American industries were competitive on an international scale. He recognized that to achieve this, it was necessary to set customer satisfaction as the primary goal so as to ensure repeat business and loyal customers. His work introduced many of the concepts and frameworks that have become common in management scholarship and practice, including total quality management, The Model for Improvement. The Deming Management Method is, however, much broader than the use of specific quality improvement methods, and might instead be seen as a new philosophy of improvement, encapsulated in 14 imperative statements. 4
The imperative statements act as principles for transformation, to guide the way in which an entire organization functions. The dual drivers of this approach are customer satisfaction and employee wellbeing, both of which are seen as necessary and interdependent for ensuring organizational success.
Although Deming is better known for his use of statistics (‘In god we trust, all others must bring data’), he was also a natural qualitative researcher. His imperative statements were developed through extensive experience of working on the frontline of quality improvement in various settings. Throughout the book, Deming shares these conversations and observations to support the points he outlines in his management plan. Through these conversations, he shows how the majority of workers seek job satisfaction through doing their job well but often experience frustrations that make it difficult to realize this goal. This can be seen in the following discussion he had with a production worker:
Worker: Our work is difficult because so many people are absent. We have to try and do their work and ours too. We have a hard time to keep up, and the quality suffers.
Deming: Why are people absent?
Worker: They don’t like the work.
Deming: Why not?
Worker: We can't do good work.
Deming: Why can't you do good work?
Worker: Too much rush. Anything goes. The foreman must meet his quota. We don’t like it that way, so people stay at home.
At the heart of Deming’s philosophy is the recognition that achieving pride in one’s work is essential to quality. Whether it is faulty equipment, lack of training or lack of response from management when things go wrong, they are likely to reduce pride in workmanship. Failure to address these systemic issues is likely to cause demoralization and absenteeism, prevent quality improvement and miss opportunities for organizational learning. To address the barriers that ‘rob the hourly worker of their right to pride of workmanship’, Deming advocates good management and leadership, including the use of process management practices, to fix systemic issues. He argues that faults in the system can only be improved with support from leaders and managers who are able to introduce changes and modify resources or system elements that are beyond the authority of frontline workers. But far from laying the fault at the feet of the managers, Deming also recognizes they equally can be restrained by quotas and targets that do not support a quality agenda, and often lack the tools or skills to improve quality.
Aspects of Deming’s management approach have been widely adopted within health care 5 but evidence of the effectiveness of his approach remains limited.6,7 Research has revealed that the use of quality improvement methods in health care is often poorly executed and that there is low fidelity in adhering to the core principles that underpin the methods.3,8,9 This suggests that the full benefits of applying the Deming approach in health care have yet to be realized.
What would Deming make of our health services today? Would he recognize the voices of his foreman and production worker in our nurses, doctors and allied health professionals? Would he empathize with the managers who are unable to solve the quality challenges they face?
Deming would likely observe key differences between health care and the industries settings his work was based on. The health care workforce has high levels of professionalism and autonomy and their work is focused on highly skilled problem-solving, which is in contrast to the predominantly automated and linear manufacturing processes he studied.
He would likely recognize the challenges that arise from these differences. There has been a lack of professional engagement with quality improvement which in part stems from conflicts that arise as ‘policy makers’ and managers introduce bureaucratic practices including greater standardization of care and codification of knowledge which was previously held exclusively by professionals, thereby challenging their autonomy and professional status.10,11
But perhaps, he would be less surprised about the magnitude in which these challenges have manifested if he examined how quality improvement has been implemented. Whilst initial translations of his approach covered the breadth of issues raised by the 14 imperative statements, increasing numbers of translations and simplifications have tended to reduce the broader philosophical approach to a discrete set of tools and methods such as process mapping, plan-do-study-act cycles and statistical process control charts. These methods have typically been applied to individual quality improvement projects rather than adopted as an organizational way of working and therefore tend to only produce small-scale and localized productivity gains. 2 Increasingly evidence indicates the challenges of applying such an approach without wider organizational support to resolve and overcome barriers to change or resolve issues that lie outside the scope of influence of the initial project team. 12
The paradox between the original philosophy of Deming’s Management Method and its adoption in health care is apparent. A true understanding and knowledge of how to apply quality improvement in practice is often lacking, and as such quality improvement has become a ‘hollow’ slogan of intent ‘rather than an indication of meaningful action. This is’ in direct contradiction of Deming’s call to eliminate slogans, noting that they always create adversarial relationships. Likewise, plan-do-study-act cycles have become a panacea to solving health care problems but are often used with low fidelity and in isolation from the wider methods and philosophy of Deming’s approach. 7 Applying quality improvement methods in isolation from organizational and leadership commitment to quality management is unlikely to achieve the full potential of this approach.2,3
Similarly, divorcing quality improvement from the emotional drivers of frontline staff that allow them to take pride in their work is unlikely to result in professional engagement. Deming’s work emphasizes the importance of ensuring that the interests of managers and professionals are working together towards a common quality goal. A lack of investment in understanding perspectives of health care professionals and managers and how they can work collaboratively to define a quality agenda is reflected in the challenges of professional engagement with quality improvement.
There are examples of institutional outliers who have transformed their systems using organizational adoption of quality improvement approaches3,14 but such practice is often the result of many years of investment in building capacity and applying and tailoring quality improvement approaches to their local setting. In general, the wider issues of leadership and organizational learning capability have been overlooked, or deemed too challenging, in the promotion and commercialization of the Deming approach in healthcare systems.
To realize the full benefits of Deming’s Management Method, it is necessary for health care to look beyond individual tools and methods and embrace the full philosophy of his approach. Health care organizations need to eliminate the slogans of quality improvement and take meaningful action. They need to work in collaboration with managers, professionals and patients to remove the many barriers that rob them of pride in their work and deliver improved services for patients.