Paul Levy
Posted 11/07/11 on Not Running a Hospital
Dr. Brent James last week was awarded Columbia Business School’s W. Edwards Deming Center for Quality, Productivity and Competitiveness. As described in the press release:
The Deming Cup grew from the center’s drive to highlight the achievements of business practitioners who adhere to and promote excellence in operations – the Deming Center’s area of focus. This award is given annually to an individual who has made outstanding contributions in the area of operations and has established a culture of continuous improvement within their respective organization.
Dr. James was recognized for his pioneering work in applying quality improvement techniques that were originally developed by W. Edwards Deming and others, in order to help create and implement a “system” model at Intermountain, in which physicians study process and outcomes data to determine the types of care that are most effective.
Imagine that, improving clinical care is consistent with efficiency in the health care system. This has to be another lie, just like that stuff about Pronovost saving lives and reducing costs by reducing the rate of central line associated bloodstream infections. Or assertions by that trio of fraud, Spear, Toussaint, and Kaplan.
This stuff can’t be true. If it were everybody would be doing it. Right?
Back on January 15, 2009, I published a post entitled “What does it take?“, in which I expressed frustration with the slow pace of process improvement in hospitals. What followed in the comments was a virtual seminar by some of the country’s leaders in the field. They are still worth checking out. Brent offered his point of view:
Paul, you have put your finger on what I regard as THE core task of the present generation of the healing professions. It is very clear that we are in the midst of a transition. The term of art that is usually used to describe the present state – and which Don Berwick so eloquently explained (at least, at the level that an individual physician would experience it) – is “the craft of medicine.” It’s the idea that every physician (or nurse, or technician, or administrator, etc.) is a personal expert, relying primarily on their personal commitment to excellence. In a very real sense, every physician occupies his/her own universe, with its own reality, truths, physical constants. As a physician I might say to a colleague, “What works for you, works for you. What works for me, works for me. Let’s both stay focused on the patient – our core fiduciary commitment to put the patient first in all things – and that will guarantee the best possible results.”
David Eddy said it most eloquently: This core assumption of the craft of medicine is scientifically untenable.
As a direct result of some solid research around this fact, the healing professions are in the midst of a major sea-change, a once-in-a-century shift: We’re moving from “medicine practiced as individual heroism” to “medicine as a team sport.” The kinds of tools you’re talking about make perfect sense in a team setting, but almost no sense within the craft of medicine.
Don is right in calling it culture change. However, we are well past the tipping point. There is strong evidence that the professions have committed to a new course and are actively moving. It’s the difference between 5% of the profession “getting it” (where we are now), and moving to a point where it is standard, accepted, background business essentially all of the time.
The key change concept was perhaps best expressed by Winston Churchill: “People like to change; they just don’t like to be changed.”
I am also deeply impressed by Roger’s classic text on change: Diffusion of Innovation. He describes bottom-up change, by sharing results (both data and word of mouth) from initial thought leaders (his “early adopters”). That has worked very well for us, and makes the change fun – rather than something that a bunch of external “know nothings” are trying to do to you.
Care And Cost 
A perfect illustration of just how far behind this industry is from just about every other mature industry in this country. I was personally using Deming’s principles of continuous improvement in a manufacturing plant over 20 years ago and even then it was already considered to be commonplace in manufacturing. I believe it’s taken this long for healthcare to “get it” because the underlying principle in any continuous improvement cycle is that “what gets measured, gets managed” and that requires transparency…something this industry has fought tooth and nail under the guise of being a craft or art form. I accept that not every situation in medicine follows a neat algorithm however I think any practitioner would readily admit off the record that at least 80% of what they do, they do as part of a repeatable process. It’s time for the wizard to come out from behind the curtain.