Back to basics with W. Edwards Deming

Citation

Gourlay, R. (2003), "Back to basics with W. Edwards Deming", International Journal of Health Care Quality Assurance, Vol. 16 No. 5. https://doi.org/10.1108/ijhcqa.2003.06216eaa.001

Back to basics with W. Edwards Deming

Back to basics with W.Edwards Deming

It is sometimes worthwhile to explore a few fundamentals and consider how apposite and relevant they are for today.

The text for this editorial is a selection of W. Edwards Deming's "14 points". It will be recalled that these "points" were aimed at US businesses which, after the Second World War, Deming saw to be in crisis.

The state of health care in the advanced economies may not be in such a state of crisis, but there is certainly alarm in many governments about escalating costs not being met with escalating performance in volume or quality terms. For example, in the UK's National Health Service (NHS) there have been a plethora of structural reforms that have achieved little except an increase in management costs and a slow-down in managerial achievements.

The belief that changing structures will result in some improvements in performance seems endemic in the minds of those politicians accountable to the electorate for the provision of quality health care. Even as we write the UK government is proposing radical changes to the corporate governance of the hospital trusts, which it is hoped will allow local "stakeholders" to have a greater say in the management of the trusts.

It is being proposed as the "democratisation" of the NHS, as though such a management philosophy will naturally deliver improved management. There is little evidence that this is likely to do so.

Referring back to Deming's 14 points, the first one is to "create constancy of purpose" towards improvement of products and services. Many trust chief executives have something similar in their mission statements ranging from aspiration to be "pathfinders" to "becoming a world-class medical centre". There is no doubt that such aspirations do create a positive culture which embraces the staff and patients.

The fly in the ointment is the frequent intervention of political reactions based on knee jerk responses to events. These divert management attention away from the mission to deal with whatever structure changes are being proposed by the "centre".

Deming's third point is to cease dependence on inspection to achieve quality. Here Deming is arguing for the need to build quality into the product or service so that inspection becomes unnecessary. Broadening the point slightly, there is little doubt that in the NHS through the Commission for Health-Care Improvement (CHI) considerable improvements have been achieved in the quality of services through CHI's review of services. These concentrate on being rigorous in their attention policies and practices of clinical governance in the reviewed trust. The success of CHI is in part its process of review rather than an inspectorial judgement. The publication of CHI's findings is sufficient to galvanise action. Again, though, constancy of purpose is being put on the shelf. Politicians are now requiring CHI to become more of an audit and inspection body than a review body. The difference in language might be small but the potential difference in modus operandi can thwart the development of a non-blame culture which is slowly being engendered in the NHS.

Leadership and supervision form the fourth point of Deming's 14 points. Once again the NHS is embarking on some good initiatives such as leadership training programmes for consultants and others; but again good intentions are being scuppered by carelessly developed staff management policies such as those to do with consultants, where professionals are being treated as though they could not be trusted to do a good day's work.

"Drive out fear" is Deming's eighth point. For many managers and especially chief executives fear is a fairly constant companion, especially where targets are concerned. Failure to meet these centrally generated targets over a period of time can result in job loss and career termination. Even now some concern is being expressed about the source of chief executives as tenure in post is relatively short-lived for the majority of them.

Points 10 and 11 are to do with creating a performance culture not based on externally imposed numbers and targets. Here Deming directly challenges the current obsession with targets, which are distorting priorities both clinical and managerial. It has got to the stage where some managers are fiddling the figures and it leads to curious situations such as a week recently when the trusts' total attention was directed at A&E's waiting times. In this example trusts had a week to reach certain targets. Many trusts in this week completely changed their working patterns to ensure compliance with the target. After the week was over one assumes that things returned to normal. Targets can also be an embarrassment to those who set them and it is being alleged that the criteria for achieving some targets are being relaxed to enable more hospitals to request "foundation" status.

In summary, what is needed is a well developed vision of quality management based on Deming's points that provides a constancy of purpose and a set of explicit criteria against which initiatives and innovations can be tested. In this way there is more likely to be a coherent approach to management which is guided and influenced by well considered and tested policies and not first reactions to some crisis or innovations being developed elsewhere. It is essential that clinical governance is kept high on the agenda as it provides the needed framework for quality management. Consequently it is equally important that the CHI Improvement is able to keep its review processes working and not slip into a vehicle of punishment based on audit and inspection only.

Robin Gourlay