Quality: 4 Ways We Make It Harder Than It Has to Be

A colleague of mine recently had a close brush with a common barrier to quality service. As he lay on the operating table at Stanford University Hospital, ready to undergo a hip replacement, the team performing his surgery assembled. The surgeon, nurses, and the anesthesiologist all introduced themselves to each other. My colleague teaches operations and, unfortunately for his peace of mind, he knows the data that show that team performance is better when the team has worked together and tacit coordination skills develop.

J. Richard Hackman of Harvard studied airline "incidents" and found the same thing - crews that had more experience working together did a better job. Of course there is a point beyond which more experience no longer has any effect, but few organizations get to that point.

Believing in the Power of Simplicity
Fortunately my colleague's operation went fine, but his general point is important: the steps required to make quantum improvements in quality and other outcomes are often trivial. And because the necessary actions do seem so simple, ironically, organizations of all types frequently don't bother with them. As Greg Brenneman, former COO of Continental Airlines has written, simplicity is a huge barrier to competitive imitation and to taking action, because people think, "if it were that simple, we would already have done it."

Donald Berwick, formerly of the Institute of Healthcare Improvement, created the 100,000 lives project to institute practices that could reduce the many thousands of unnecessary deaths occurring in hospitals. The project was successful - one estimate was that over 120,000 lives were saved - by focusing on easy, simple actions. For example, Berwick ensured that beds of patients at risk of pneumonia were elevated at a 45 degree angle by giving power to everyone, ranging from nurses to nurses aids to janitors, to intervene to ensure the bed was at the proper angle, denoted by a mark on the wall.

Berwick's initiative also focused on hand washing, which, outside of surgery, is done only about 60% of the time. That's why during the SARS crisis in Asia a few years ago, the primary vector for the spread of the disease was the hands of healthcare workers. None of this is news to readers of physician Atul Gawande's Better, a book that has important insights for improving the operations of all sorts of organizations.

The Big Idea
Another obstacle to embracing the seemingly simple interventions that bring significant improvements is the search for the "one big idea." People steeped in the actual work of improving quality invariably echo Gawande's comments that dramatic improvements in outcomes arise not from some big change but from doing numerous, seemingly small things better. Before its recent quality issues, Toyota achieved dramatic improvements in quality and productivity over decades by implementing thousands of ideas from people at all levels, while U.S. car makers focused on automation and other big technological fixes.

Maintaining Focus
Yet another barrier to sustained quality improvement is boredom. Operational excellence requires not just focusing on numerous small steps and activities, but maintaining that focus over time. After Ford Motor Company engaged W. Edwards Deming to help with its quality improvements in the 1980s, the company became enamored with technology and the Internet in the late 1990s, losing its focus on quality and suffering product problems and greater costs.

As we have learned in the domain of educational reform, almost anything is possible for some period of time and on a small scale. What is much more difficult is scaling improvement efforts and maintaining them over a protracted period of time.

Developing Teams
And one more issue looms for organizations serious about quality-continuity in employment. My colleague talked to his nurses at Stanford and learned that few worked at Stanford full time or exclusively. They traveled from hospital to hospital, and in some cases worked for registries that operated as suppliers of contract labor. In a world of downsized, outsourced work, with dissatisfied employees prone to turn over at the first opportunity from organizations that show little loyalty to their employees, it is hard to assemble experienced teams that enjoy the benefits of learning from having worked together.

The secrets to quality - in health care, in education, or in companies - are not that difficult. And as the quality movement has so often demonstrated, quality is not only "free," it actually saves money. In health care, preventing pneumonia and infections saves not only lives but the cost of additional medical treatment. Experienced flight crews not only result in safer flights but are better able to operate the plane efficiently. Experienced production employees working in teams can suggest improvements to processes and help each other learn and improve their productivity.

Making things better and cheaper is actually not that difficult. The question is: when are organizations of all kinds going to act on these lessons, to the benefit of us all?