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Davis Balestracci

Health Care

Isn’t It Time We Consider the Overlooked Problems?

Ponderings after another IHI forum

Published: Monday, December 12, 2011 - 13:26

I recently attended the annual forum of the Institute for Healthcare Improvement (IHI), which is probably the leading health improvement organization in the world. The forum has grown from under 100 attendees in 1989 to almost 6,000 this year—half of whom were there for the first time—with now thousands more virtual participants. It has become a cliché that invokes my gag reflex when participants say, “Oh, I go to get my batteries charged.” And I always wonder, on hearing this, Why were they drained?


Actually, participants should be going to get their batteries turbo-charged; health care improvement efforts have exploded during the last 20 years. Based on Everett Rogers’ diffusion of innovations model, health care improvement “innovators” and “early adopters” have now given way to the “early majority” and “late majority” masses. These groups tend to be more mainstream personalities rather than troublemakers. Many are still new to quality; often they have been assigned a job in quality to avoid a layoff.

Health care improvement has caught up to industrial improvement. So much so that in many cases, quality has become an excruciatingly formal, bureaucratic sub-business entrenched in 20th-century management. At the IHI forum, for instance, most of the presentations were:
• Project results on obvious problems that continually march into execs’ offices, these results motivated at times by outside forces “outraged” by yet another media horror story
• Sessions offering “advanced tools”
• Trendy academic models on improvement, change, culture, spread, and “getting physician buy-in”
• A hapless chief exec bumbling through a platitude-laden speech about how “committed” to quality his organization is

Oh, and many Quality 101 sessions on basic tools were closed because they were full.

Maybe it’s time to step back from the frantic activity and heed the advice of Heero Hacquebord, a mentor of mine: “It’s not the problems that march into your office that are important. The most important are the problems no one is aware of.”

Here are four lessons I wish health care would learn.

Lesson No. 1: “Examples without theory teach nothing.”

As W. Edwards Deming emphasized repeatedly, you can’t copy your way to quality. You, or one of your execs, might see a project presentation and be impressed. So what?

Deming further challenges:
“You cannot hear what you do not understand.”
“Information is not knowledge. Let's not confuse the two.”
“You do not install knowledge.”

And most important:
“If you do not know how to ask the right question, you accomplish nothing.”

Keeping the Pareto principle in mind, most presentations like the ones I attended are show and tells about how the presenters solved the 20 percent of their process that was causing 80 percent of their problems. You might be working on the same clinical issue, but your vital 20-percent area of opportunity will probably be different—as will your cultural issues in implementing the solution.

In such cases, I would challenge you to ask whether your solution moved a “big dot” in the boardroom, i.e., did the alleged savings actually manifest? If so, were these indicated by a run chart of a financial indicator—without a trend line? Was the project or solution ever put on a high-level meeting agenda, and if so, was it at the beginning or end of the meeting? (See my post last month for more about this.)

Realize: Many times, any resemblance between what is described and what really went on is purely coincidental.

Suggestion: As I have recommended many times, read Brian Joiner’s Fourth Generation Management (McGraw-Hill, 1994), the absolute best book on sound improvement theory. You will ask much better questions, come up with much deeper solutions, and be able to spot a project “sanitization” a mile away.

Bright spot: I attended a session by Bellin Health called “Frameworks for Achieving and Sustaining Strategic Results,” which was the best session I have attended in almost 20 years. They used sound theory to stop work on (by their admission) literally hundreds of projects like these. Instead, they aligned from top-to-bottom to work on what really matters to their future. They had the results to show it, and they did not occur overnight.

Lesson No. 2: You don't need more or advanced tools

Some of the advanced tool sessions make my palms sweat. Only 1 to 2 percent of people need advanced knowledge of improvement tools, especially statistical tools. From what I've seen, advanced tools should be used only to solve very specialized problems. So trust these experts and realize that you have too much other improvement work to do using basic, standard tools. These should neither be the domain of an elite, anointed few nor have a Ninja mystique (like belts) surrounding them.

Realize: Everyone in a culture needs to deeply understand the concept of process and how to distinguish between common and special causes of variation. This means everyone, including executives.

Back in the 1980s, an executive made the mistake of bragging to Deming that he had just purchased a $3 million computer, to which the old curmudgeon replied, “Too bad. What you needed was $300,000 worth of brains.”

Suggestion: To accomplish improved thinking, your organizational education process probably needs some major innovation.

Lesson No. 3: Process-oriented thinking and tools are necessary but insufficient

It is inevitable: New thinking, tools, and information all will hit the invisible wall of organizational culture—the perceptions, feelings, and attitudes that affect the relationships through which all this new information must flow. Let me give you two “laws” of improvement presented decades ago in the first edition of The TEAM Handbook (Oriel, second ed. 1996):
1. “Things are the way they are because they got that way.”
2. “Unless you understand how they got that way, they are going to stay that way.”

After any results are presented, do the presenters gloss over the critical issue of integrating the solution into the culture? If they do, or don't even hint at how difficult it is, beware. The implication is that the logic of any solution sells itself. Don't buy it! Were the C-suite execs involved? How did they handle the frontline physician subculture and inevitable underground sabotage? Were the results still in place six months later? Once again, did the C-suite crowd show a simple run chart that demonstrated results and held gains—without a trend line?

Realize: Given the way organizations are currently designed and managed, leaders have little knowledge about true process performance and the effects of system interactions (the problems no one is aware of).

Why conferences rarely change behaviors

So, your “batteries are recharged,” you go back with all these good ideas for changing other people’s behaviors, and your culture awaits. Do you expect everyone to say thank you? Quite the contrary: Culture is waiting to eat your best intentions for lunch.

As consultant Jim Clemmer says, “Too often, companies rely on lectures (‘spray and pray’), inspirational speeches or videos, discussion groups and simulation exercises. While these methods may get high marks from participants, research (ignored by many training professionals) shows they rarely change behavior on the job. Knowing isn’t the same as doing; good intentions are too easily crushed by old habits. Theoretical or inspirational training approaches are where the rubber meets the sky.”

This applies both to the conference sessions you attend and your subsequent efforts to educate and change cultural behaviors on your return. Many of the academic models presented also break down because they, too, fall victim to this “where the rubber meets the sky” syndrome.

Improvement efforts are drowning in bolt-on projects and best efforts by hard-working people. However, despite all this well-meaning activity, has the frontline—and bottom line—truly noticed any differences? What about your patients? In other words, have any improvements been built in to your culture's DNA?

Bolted on vs. built in

In 1994 Hacquebord published an article in Quality Management in Health Care that analyzed his back surgery through the lens of W. Edwards Deming's improvement theory. I’ve asked several nurse and doctor friends to read it, and they concur: Despite IHI campaigns and all efforts at improvement, everything he describes could have happened yesterday. So what's missing from current efforts, and why haven’t organizations evolved from a “bolt on” to a “built in” improvement environment?

Hacquebord makes several incisive points that are probably root causes of many of the comments health care organizations receive from patients:
• Quality has to start with the provider. Be careful here: Patients don’t know what they want (although they are fast learners) but can only judge what they have received. Patient feedback is indeed important, but it is only a small part of the many facets of transformation needed to build improvement into organizational DNA.

• Stop focusing on “full customer satisfaction” unless and until your workforce knows its jobs. Hacquebord’s hospital stay was rife with inconsistent interactions with various personnel (variation), which caused him ongoing frustration. No patient-satisfaction survey using a 1-to-5 scale will give you this vital information. “Management should also use customer data to identify who is within the limits of variability inherent in the system, and who (if anyone) is outside the system and therefore in need of special help,” says Hacquebord. “A supervisor's job is to help subordinates improve.”

• Improving quality means staying ahead of customers, i.e., anticipating their needs for care, information, and assistance from staff. (Hacquebord: “I believe that I suffered often and needlessly during my hospital stay because of the lack of forward thinking of the people who were caring for me.”)

• Improving quality also includes customer education. (Hacquebord: “I was struck by how often I was left feeling misinformed or confused.”)

In addition to relating his experience as a patient, Hacquebord then put on his consultant hat. “To improve quality, we need to be able to predict quality; this requires continually updated theories and use of data,” he says. “While the health care professionals I came in contact with collected and recorded a great deal of data about me during my stay, it is not clear to me that this information was fully utilized to improve my care or the care of future patients.”

Beware of customer satisfaction surveys by outside agencies

This deadly plague that diverts precious resources currently seems to be confined to the United States, but I'm sure there are signs of it elsewhere. Many of these surveys are now mandated and used to determine reimbursement, and that includes penalties for being in an arbitrarily chosen “bottom percentile”—and in some cases even for being below the average. For most organizations I visit, the time, energy, and money spent on obtaining, analyzing, and using this information is sheer waste. There is also the troubling issue of relying on results from only those patients who choose to respond to a survey.

The scenario usually described to me concerning these surveys goes like this: C-suite executives and middle management in essence throw tantrums in reaction to the most recent survey result's “color” (red, yellow, green), after which there’s a misguided, renewed emphasis on accountability to meet (arbitrary) goals. One group even went around every week and planted red, yellow, or green flags on each unit.

Frightened people can be quick learners. Following an unfavorable survey, the goal becomes to get a good number without necessarily improving patient satisfaction in the process. As Deming said, “Statistics on performance do not help you improve performance.”

The solution in many cases? Send the frontline to “smile or else” training, of course. Deming also said, “For every problem, there is a solution: simple, obvious, and wrong!”

Ironically, the survey results are really closer to reflecting executive efforts as leaders, those who created the culture in which patients received care.


I have just related my experiences as a consultant within an industry whose workers, I have no doubt, care deeply about delivering excellent quality care. These dedicated people work in processes “perfectly designed to get the results they are already getting” and that are also perfectly designed to take up more than 100 percent of people’s time. Most of these people incorrectly equate quality with working very hard. But then, as Hacquebord's experience showed, there are also people who just sleepwalk through their jobs. Why is the process perfectly designed to allow people like this to come to work with that attitude?

I’ve had a shocking realization: I may have just described many organizations’ improvement process as well.

Writer Mariela Dabbah sums it up perfectly:
“Enough of attending meetings that lead to building a bridge to nowhere, enough of asking what I’m supposed to ask rather than what needs to be asked, enough of praising people who are undeserving of praise, enough of valuing form over substance, enough of accepting good when what is needed is outstanding, enough of enabling people to act as victims when they need to take personal responsibility.

“Inevitably, this kind of shift doesn’t happen unless a substantial number of leaders put their collective foot down and say, 'Enough!' in unison."

I'm left with three questions:
1. If Hacquebord's experience from 20 years ago could have happened yesterday, what’s really improved? What's missing? What are quality professionals going to do about it?

2. Before going overboard to involve “the customer” and survey “satisfaction” every which way, how do you ensure that your workforce knows its jobs? What are quality professionals going to do about it?

3. If you are sick of all the passionate lip service about improvement, what are you going to do about it?

I sat next to a VP of nursing on the bus to the airport. She had given a presentation at the forum and ended our conversation by saying, “It’s all about increasing throughput while decreasing costs.” Indeed. Spoken like a true qualicrat.

As you know from my articles, I've said, “Enough!” Who wants to join me?


About The Author

Davis Balestracci’s picture

Davis Balestracci

Davis Balestracci is a past chair of ASQ’s statistics division. He has synthesized W. Edwards Deming’s philosophy as Deming intended—as an approach to leadership—in the second edition of Data Sanity (Medical Group Management Association, 2015), with a foreword by Donald Berwick, M.D. Shipped free or as an ebook, Data Sanity offers a new way of thinking using a common organizational language based in process and understanding variation (data sanity), applied to everyday data and management. It also integrates Balestracci’s 20 years of studying organizational psychology into an “improvement as built in” approach as opposed to most current “quality as bolt-on” programs. Balestracci would love to wake up your conferences with his dynamic style and entertaining insights into the places where process, statistics, organizational culture, and quality meet.