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Davis Balestracci

Health Care

How Many Cylinders Are Firing in Your Improvement Efforts?

Expand your quality role and help others understand theirs

Published: Monday, November 20, 2017 - 13:03

During the early 1990s, I was president of the Twin Cities Deming Forum. I had a wonderful board to work with, one of whom was Doug Augustine, our self-appointed provocateur. Doug was a 71-year-old retired Lutheran minister, and we all loved him because he always pulled us right back to earth with his bluntly truthful observations and followed through on every commitment he made.

After W. Edwards Deming’s death in 1993, we tried to keep things alive, but attendance started to drop off significantly. We offered innovative meetings to grow in practice of Deming’s philosophy, but our members wanted static and, for lack of a better term, traditional “Deming Sunday School,” chapter and verse.

After a year of this, we were all frustrated, and Doug finally “named” it during one board meeting: “Are we in the ‘entertainment’ business, or are we in the ‘changing the world’ business? I want the latter; our members want the former. I say we pull the plug on the forum.”

He was right. Exactly one year after Deming’s death, we did. I have often used his quote to challenge groups and even myself as I’ve considered potential consulting work.

Doug has since passed away. He was an avid reader and wrote book reviews for us. In 1993, he said, “I just read Firing on All Cylinders [by Jim Clemmer], and it just might be the best quality book I have ever read.” I quickly bought a copy, read it, and agreed. Clemmer’s ongoing thinking and publications have been seminal in my improvement journey.

Does your culture perceive improvement efforts as ‘entertainment’ or truly ‘changing their world?’

In Firing on All Cylinders, Clemmer talks about five levels of executive commitment. Regarding customer service, where is your executive team on the continuum below?

1. Permission
This allows managers or staff support people to proceed as long as it doesn’t cost too much and disrupt the “real business.”

2. Lip service
This level of commitment gives speeches and writes memos exhorting everyone to improve service/quality. Some budgets and resources are allocated to a piecemeal series of improvement programs. There is no strategic service/quality improvement plan, the process is not part of operational management’s responsibilities, and the executive is not personally involved in education or training. If the CEO were invited to speak at a conference, she would have a speech written for her.

3. Passionate lip service
The executive attends an abbreviated overview of the training being given to everyone else. Some elements of a deployment process are shakily in place. Passionate stump speeches urge everyone to “get going.” When asked to speak at conferences, such CEOs deliver speeches laden with platitudes and vague “calls to action.”

4. Involved leadership
The executive attends all training in its entirety then gets trained to deliver the introductory education, awareness, and skill-development sessions. Service/quality improvement is the first item on all meeting agendas and priority lists. Managers are held accountable and rewarded for their contributions to continuous improvement. The executive group leads the process management process. There is a strong and comprehensive deployment process—infrastructure, planning and reporting, and assigned responsibilities—in place. When asked to speak at conferences, a well-coordinated team is sent.

5. Strategic service/quality leadership
Day-to-day operating decisions have been delegated to the myriad, increasingly autonomous improvement teams. The majority of the executive’s time is spent with customers, suppliers, teams, and managers gathering input for long-term direction and “managing the organization’s context” by providing meaning through the vision and values.

So, where is your organization? If in doubt, think about what schedules, budgets, meeting agendas and content, and promotions telegraph (Don’t play naïve on me: You can indeed tell).

My observations since 1993

Most organizations I visit are at Level 2, either trying to implement the “magic bullet du jour” or still seeking it. A scheduled meeting with the executive always gets cancelled because “You have to understand; something came up.”

Several organizations are at Level 3, and the story I get from any execs bears no resemblance either to what I observe or learn from speaking with the frontline. (Healthcare folks: One frontline person sincerely asked me, “Davis, is this IHI [Institute for Healthcare Improvement] a cult?”)

In listening to presentations at various conferences, there might be some semblances of Level 4, but even then, my intuition often senses a Level 3 experience sanitized to appear like Level 4, especially when teams described above seem to deliver an obviously canned “show and tell.”

I have heard one, maybe two, presentations that seemed genuinely Level 5 or making major progress toward it.

Executive team assessment

Still not sure where your organization falls? Honestly fill out the survey from Clemmer below based on your everyday experiences with the executive team. Assign a value from one to five to each question, with one being “not at all” and five being “absolutely,” and add the values up at the end. Even better, have the executive team fill it out, too—and note the gaps in your perceptions.

To what extent are you prepared to:

1. Invest a substantial amount of personal and organizational time over a three- to five-year period in service/quality improvement?

2. Hold line managers accountable for service/quality improvement as much as for financial results?

3. Regularly review and reinforce service/quality improvement efforts?

4. Commit the financial and human resources needed for a full deployment?

5. Integrate improvement efforts with current strategic and financial planning?

6. Revise or replace personal habits or organizational systems and processes that hinder service/quality improvement?

7. Bring employee teams heavily into the improvement planning and implementation process?

8. Invest a minimum of 10 to 12 days per year in your own continuous education, learning, and skill development?

9. Seek continuous feedback on how well you are perceived to be signaling your service/quality vision and core values?

10. Ensure that coordinators and facilitators/trainers have plenty of training and highly visible support?

11. Personally lead steering committees, process and project improvement teams, become a trainer, and use data-based tools and techniques in decision making?

12. Maintain a steady and continuous stream of education and awareness across the whole organization?

Total score:

Interpreting your score

Think of this not only in the context of today, but also when it was originally written in 1992. A quality emphasis was still quite new, especially in healthcare. How might you have scored it then? If you’re relatively new to an organization, is there someone you can ask about executive commitment during the past 25 years in line with the assessment’s questions? Does history help Clemmer’s observations make sense, or do they still seem overly strict? What does your culture continue to tolerate?

If your score was less than 45 points
Don’t bother packing yet—you’re not going anywhere. If you set out now, you’ll just strand everyone in the wilderness and build better cynics for the next time you announce a new destination. You and your management team need to take a serious look at what is blocking your commitment and work to strengthen it before you say anything to anyone about higher service/quality.

If your score was between 46 and 55 points
You need to be cautious. There may not be enough commitment to take your organization through the long haul. A frank discussion of what is holding back full-scale commitment is needed.

Your role goes far beyond being a ‘bolt-on’ qualicrat!

For many organizations, the current major skills deficiencies are rooted in managers and executives misunderstanding their role and the skills they so badly need to effectively lead their teams and organization through these changing times. I daresay: If your culture has morphed you into a “bolt-on” qualicrat, there is this danger in your improvement leadership as well. What does this imply for the vision you need to facilitate?

Expand your role and help them understand theirs.

Firing on All Cylinders was a revelation when I first read it in 1993, and its content is still sound. Clemmer has released sections as free podcasts. Maybe you’d like his company during your work commute?


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.