Grandpa spending quality time with grand daughter

Quality Thinking About Quality – Part One: What is Quality?

Now that’s an odd title.  “Quality Thinking About Quality”.   We typically don’t think of the attribute of quality as having anything to do with the act of thinking.  There’s a good reason for this.  Because it doesn’t.  Using the noun quality as modifier of the gerund thinking is simply incongruous.  It makes no sense.

What is quality?  How do we define it?  It’s actually quite difficult to come up with a good definition of quality.  To paraphrase Supreme Court Justice Potter Stewart, even though we may not be able to define it, we know quality when we see it.  Not just see it, however: hear it, smell it, touch it and taste it.  Quality implies physicality.  It is a characteristic of physical things and as such is accessible by our physical senses.  We can see the quality built into an expensive wristwatch or a piece of fine jewelry.  We can hear the quality in a high fidelity recording of a symphony orchestra.  We can smell the quality of a fine leather handbag.  We can touch the quality of a beautifully crafted piece of furniture.  We can taste the quality of the freshest sushi. 

In our daily lives, we never associate non-physical things like a service or a process or health care with the attribute of quality.  We don’t describe a teeth cleaning at the dentist’s office as a “quality cleaning.”  That would be odd.  We use other words to describe it.  It was a thorough cleaning.  A painless cleaning.  A careful cleaning.  We don’t comment that our airplane flight was a “quality flight.”  We might say that it was a smooth flight.  An on-time flight.  A comfortable flight.  We don’t evaluate the service at a restaurant as having been “quality service.”  We tell our friends that it was fast service.  Attentive.  Knowledgeable.  Friendly.

So when health care administrators and regulators and bureaucrats talk about quality, we start to experience cognitive dissonance.  We’ve never thought about nursing or doctoring as gradable in terms of quality. If a patient experiences nausea after surgery, is this really an indicator of the quality of anesthesia care?  The truth is that when health care bureaucrats talk about quality they are actually talking about performance, or more precisely, performance that leads to certain outcomes.  And conflating quality with performance is not merely a semantic slip.  Confusing the two can actually make things worse.

Consider the performance of, say, an automobile.  If we wish to improve it, we cannot do so by simply demanding such.  If the vehicle has not been engineered to produce the desired performance, no amount of demanding will change things.  And if we continue to flog the car in hopes of realizing better performance, chances are we will break it.  To get the performance we seek, we need to engineer the vehicle accordingly.  The same is true of health care systems.  If we want better “quality” (performance) out of the system, we simply cannot demand more and more of it.  Such demands place undue stress on the system and can contribute to its breakdown. 

Consider a hospital or any of its component parts as a system.  We should first establish who owns the system.  That is, who is authorized to make ownership decisions about the system?  It is critical to understand that the workers in the system do not own it.  They are not empowered to make ownership decisions.  They can tweak the system.  They can decide, for example, where to hang a bulletin board.  But they cannot make major decisions about renovations or expansions or capital purchases.  Only the senior management can make these types of decisions.  The senior management owns the system.  The workers do not.

Now if a performance demand—from any source—is placed on the system and the system was not designed to meet that demand, the workers in the system have only three options. 

One, they can fail to meet the demand

This is the least attractive option.  Administrators, managers, inspectors don’t like it when hospitals fail to meet demands.  If a hospital fails an inspection, people tend to get disciplined, demoted or dismissed.

Two, they can distort the system to make it appear as though they are meeting the demand. 

The inspection agency demands that hospital hallways be free of obstacles.  But the hospital was not designed with enough storage space for the obstacles.  On any given day the hallways are full of obstacles.  But when the inspectors arrive, the obstacles magically disappear.  As soon as the inspectors depart the obstacles reappear.  The workers distort the system to make it appear as though they are meeting the demand.

Three, they can distort the data to make it appear as though they are meeting the demand.

Administrators demand that a high percentage of first cases start on time.  But the system has not been designed to produce this result reliably.  If the patient gets wheeled into the OR a few minutes late, the workers agree together to document an on-time start.  They distort the data to make it appear as though they are meeting the demand.

Again, simply demanding better “quality” (performance) of a system than it was designed to produce adds more burdens to the system.  Pile enough burdens on the system and you increase the likelihood that it will fail.  Pile enough bricks in the trunk of your vehicle and you increase the likelihood that it will break.

In Part Two, I will consider examples of vexing “quality” problems in health care, how the standard approaches to quality (performance) improvement have been inadequate, and how we might make progress with innovative thinking, tools and techniques.