Friday 9 August 2013

How to make hospitals safe

Back in the 1940s, the great American theorist of ‘total quality’ W. Edwards Deming warned that assembly lines, in themselves, are not efficient at all.  Hence the huge problems with safety and care that is causing the NHS such angst at the moment.  Hence the effective campaign by Deming's vicar on earth, John Seddon, to reform public services away from the assembly line model.

Deming’s story is rather peculiar, because he found that his fellow Americans were not quite ready for this message, so he took his ideas to Japan after the Second World War, and was enormously influential.

Efficiency is all about getting things right first time, he said, because then you don’t have to do it again. He was astonished at how much the American factory system wasted, in materials and time, just by failing to pay attention to quality. The result was the enormous sums of money were spent by organisations just to put right the mistakes they had made – and splitting up jobs means more mistakes.

“Let’s make toast the American way,” Deming used to say. “I’ll burn, you scrape.”

I've looked all the way through Don Berwick's report for the government on improving care standards in the NHS, and Deming's name doesn't appear at all.  But his spirit is clearly abroad, because Berwick's commitment to openness and transparency, and an end to the blame culture, carries the Deming stamp.

More about Deming and Seddon in my book The Human Element.  But back to the Berwick report.  It got a good kicking from the influential NHS blogger Roy Lilley, and you can see why: there is a great deal of rhetoric in there - and if the NHS ran on rhetoric, hospitals would now be enjoying a hefty surplus.

It is one thing to say that care standards and safety should be the first priority of the NHS, but then nobody says it wasn't.  The real question is how to guarantee and improve standards despite all the other pressures.

But Berwick, Obama's former health advisor, deserves more credit.  The commitment to no-blame is a bold gear-change for the prevailing culture, which insists that mistakes and poor care are always the fault of someone in particular who must be disciplined, or even gaoled.

What Deming suggests, and what Seddon explains today, is that you can't under-rate the system.  Whatever the rhetoric says, if the system encourages poor care by treating the NHS like an assembly line - that is what you will get: poor care and an assembly line.

Deming’s idea of tackling poor quality in factories was to use ‘quality circles’ of staff, where these issues could be discussed without blame, as Berwick suggests. In companies like Toyota, every member of staff famously has the power to turn off the assembly line whenever they see something wrong.

Three decades later, it was clear that Japanese industry was a good deal more efficient and effective than their American competitors.  Yet it wasn’t until 1978 that Deming began to have any impact on his own country. Ten years later, there were 50 Deming societies across the USA. 

Twenty years later, they were gone again. Quality circles were not an innovation that the IT consultants could earn much from, and quality management was quickly swept away by ‘Re-engineering’, and all the rest of the disastrous McKinseyite mush of controlling IT systems and one-dimensional measures.

Those who believe that industrial assembly lines can be applied to all human work were once more in control, and with disastrous results.  That is why Berwick's report is potentially important: it has provided a potential antidote to the sick targets and compliance system: transparency and commitment to quality.

He even, sensibly rejected, compulsory candour - a rule where you have to tell patients about mistakes - because he knew the bureaucracy would kick in and regulated candour would substitute for good care.

This isn't about IT.  It is about human skills and human co-operation.  Despite the rhetoric, not because of it, Don Berwick's report could turn out to be important. 

1 comment:

Richard T said...

It is also worth recalling what Herzburg (the motivation guru) said about motivation - if you want people to do a good job, give them a good job to do.