You are on page 1of 10

HEALTHCARE

Can the Gurus’
Concepts Cure
Healthcare?
by Don M. Nielsen, M.D., Martin D. Merry, M.D., Paul M. Schyve, M.D., and Maureen Bisognano

Q

uality in healthcare is one of the most serious
challenges facing the United States. Costs
have become staggering, overwhelming government and industry at all levels. The healthcare system itself is unbelievably complicated and redundant.
Individuals are demanding more and better care and

In 50 Words
Or Less
• For Crosby, leadership is essential to zero defects
and doing it right the first time.
• Transformation is the most important of Deming’s
14 points.
• Feigenbaum points to evidence based medicine
and identifying the customer.
• Juran’s trilogy means building quality into
processes from the start.

pharmaceuticals. Errors are widespread. Our population is aging.
At times, the problems seem unsolvable.
Quality Progress knew the words of quality gurus
Philip Crosby, W. Edwards Deming, Armand V.
Feigenbaum and Joseph M. Juran would have
meaning in today’s efforts to improve quality in
healthcare.
We asked four prominent representatives of the
movement for quality in healthcare to write about
one quality guru’s principles as they apply to this
growing segment of our economy:
• “What Crosby Says” by Don M. Nielsen, M.D.,
American Hospital Assn.
• “What Deming Says” by Martin D. Merry,
M.D., clinician, educator and improvement
consultant.
• “What Feigenbaum Says” by Paul M. Schyve,
M.D., Joint Commission on Accreditation of
Healthcare Organizations.
• “What Juran Says” by Maureen Bisognano,
Institute for Healthcare Improvement.
Presented together, the gurus’ principles can
perhaps provide a foundation as our society tackles the seeming Catch-22 of managing costs while
improving the quality of care.
QUALITY PROGRESS

I SEPTEMBER 2004 I 25

not appraisal. Crosby is best known for two concepts: 1. Crosby intended for defects to be found before the final product was produced or service provided.2 Dramatic changes have occurred in our thinking as we speak of leaders’ responsibility to lead the effort in establishing a culture of safety within their organizations. 1 . However.org Think now of what has occurred since the publication of the Institute of Medicine’s report To Err Is Human. Nielsen. he would be experiencing a mixture of sadness and joy with the content of today’s quality debates. and workers (employees) followed that lead. 2. By emphasizing prevention. He would be sad because many debates center on how incentives are needed to improve quality. In conjunction with the emphasis placed on management responsibility. Again. Patient Safety I think Crosby would also be pleased by another key aspect of the patient safety effort—preventing harm to hospital patients.3 Without this commitment from leadership. In his experience. Crosby intended for defects to be found before the final product was produced or service provided. 26 I SEPTEMBER 2004 I www. employees and visitors. Today’s leaders of healthcare organizations are expected to have established the prevention of harm to patients as an organizational priority and to visibly demonstrate their commitment to this priority. If Phil Crosby were alive today. This is the basis for today’s emphasis on root cause analysis and failure mode effects analysis.” . His belief in the latter precept was so firm it became the first of his 14 steps to quality improvement: Make it clear management is committed to quality.asq. his other key message was that prevention was critical for quality performance. His refusal to accept this premise led to his concept of zero defects and his belief that the ultimate organizational responsibility for quality rested with management. Zero defects. An outgrowth of this emphasis on prevention and measurement was the development of the high reliability organization in which causes of special variation are eliminated and the focus is on another of Crosby’s absolutes of quality management: The performance standard must be zero defects. At the American Hospital Assn. This idea resonates with the message found in today’s safety efforts: System defects are the primary cause of errors that harm patients.4 By emphasizing prevention. Crosby emphasized this approach as one of his 14 steps to quality improvement: Measure processes to determine where current and potential quality problems lie. M. It was his belief management (leadership) set the tone for quality. a culture of safety will never become established within a healthcare organization. He would also be saddened by the continuing debate about whether there is a business case for quality and would not understand the failure of some healthcare leaders to assume responsibility for continually making quality and quality improvement ongoing priorities within their organizations.D.. This belief became articulated as one of his four absolutes of quality management: The system for causing quality is prevention. Central to the development of these concepts was the basic philosophy of ultimate management responsibility. It is in this area that many of the things he advocated are evident today.HEALTHCARE What Crosby Says by Don M. this concept has been a constant among all the winners of our Quest for Quality Award. not “that’s close enough. Do it right the first time. Crosby found leaders frequently accepted the fact that error was inevitable and therefore tolerated its occurrence. Only by carefully evaluating how processes function within each system and understanding how harm could potentially result will patient safety be improved. I believe he would be smiling because of what has occurred in efforts related to patient safety.

2. www.html. Philip B. 1979. This belief is analogous to what is emphasized in today’s patient safety efforts when employees. continue to tolerate and accept a healthcare system that fails to meet the expectations of patients. 1999. DON M. Nielsen is a member of ASQ. 4. He believed the employees who are involved in the production of the product or provision of the service know best where process defects occur as opposed to those who are responsible for quality control. Quality Is Free. 3. employees need to be integrally involved in identifying where improvements can be made in the processes of production or service. 1984. hospital leadership needs to continue to identify patient safety as an organizational priority and emphasize that all employees have a responsibility to ensure harm does not occur to a patient. patients and visitors are asked to report on near misses and actual errors so improvement opportunities can be identified. To Err Is Human. Crosby.. National Academy Press. Through conscious application of these precepts and other quality techniques. is senior vice president for quality leadership for the American Hospital Assn. However. REFERENCES 1.org/aha/awards-events/quest_for_quality/ index. M.. QUALITY PROGRESS I SEPTEMBER 2004 I 27 . for this reporting effort to be successful. Studies continue to document the widespread overuse. He earned his medical degree at the University of California. we have not been as successful using them to improve the overall quality of patient care. underuse and misuse of a variety of diagnostic and therapeutic interventions. While today’s efforts to improve patient safety have utilized many of Crosby’s concepts. Philip B. While Crosby would likely be pleased at how healthcare has incorporated many of his precepts in the patient safety improvement efforts. Institute of Medicine. NIELSEN.Crosby noted if prevention is to be central to improving quality. as individuals and organizations. Crosby.D.. process measurement and employee involvement.aha. McGraw-Hill Book Co. Quality Without Tears. and focus on commitment to doing it right the first time and zero defects. I believe he would be bewildered by our continuing debate as to whether there is a business case for quality and not understand how we. prevention. McGraw-Hill Book Co. Los Angeles. We would be wise to heed many of Crosby’s precepts concerning the need for leadership commitment. we can make tremendous strides. Crosby predicted these important tenets through another two of his 14 steps to quality improvement: Raise the quality awareness and personal concern of all employees. in Chicago. and encourage employees to communicate to management the obstacles they face in attaining their improvement goals. he would note that quality improvement never ends.

indicate that for all their promise. after nearly 200 years of development in other sectors. assisted by the Juran Institute. While the caregivers themselves work out of a craft hierarchy with physicians at the top. In contrast. exhortations and targets for the workforce (4). It is now more than 15 years since this event. Merry. In speculating on how Deming might view 2004 healthcare through the lens of his famous 14 points and his concept of profound knowledge. specifically such phenomena as top-down. consumer electronics and automobiles have experienced. derive from a preindustrial revolution craft mind-set. is deplorable. • Point six: Institute training (4-5). even Malcolm 28 I SEPTEMBER 2004 I www. Healthcare’s culture. in particular its clinical aspects. it is not surprising the craft culture aligns with Deming in some aspects. W. Pediatricians Donald Berwick and Paul Batalden. such as emphasis on education and personal development. While there are presently many outstanding examples of continuing success for the quality management sciences in healthcare. command and control management and assembly lines and negative employee motivation techniques. the quality management sciences have nowhere duplicated in healthcare the revolutionary impact that. The culture is hierarchical. volunteer quality experts from manufacturing and other industries and more than 20 pioneering healthcare provider organizations. the industrial revolution finally reached the U. • Point thirteen: Encourage education and selfimprovement for everyone (4-5). High Marks • Point three: Cease dependence on mass inspection (4). and with a grant from the John A. While healthcare’s craft tradition and culture create serious problems from the perspective of many of Deming’s points. Juran was himself a keynote speaker at this landmark event. presenter after presenter recounted stories documenting the successful application to healthcare of quality management practices developed over the prior 50 years by such luminaries as Walter Shewhart. Indeed.HEALTHCARE What Deming Says by Martin D. • Point ten: Eliminate slogans. and essentially blind to systems thinking. few would argue these sciences have fulfilled their early promise. to its credit. for example.org Baldrige National Quality Award recipients. Additionally. Edwards Deming and Joseph Juran. with notable exceptions such as its Baldrige recipients. healthcare system. M. but Most agree healthcare’s system of production and service. manifest most publicly in the form of unacceptable numbers of medical errors (defects) and consequent patient harm. nurses and technicians) who actually deliver patient care. a caveat is in order.asq. builds in such notions as lifelong learning and continuous professional development throughout one’s career. built around the craftsperson. Deming’s ideas derive from a mature industrial society. they have generally not experienced many negative effects of the industrial revolution. they have protected the clinical caregivers— the true craftspersons (such as physicians. I will evaluate each of Deming’s 14 points by a subjective assessment on a scale from 0 (point not met at all) to 5 (Deming would be truly pleased). who is the presumed source of quality. the craft culture. In 1987. but comes up seriously short where Deming’s points derive especially from elements of his system of profound knowledge. At its 1988 summative conference. healthcare’s relatively huge defect rates. This national demonstration project was an unqualified success. led a project that first introduced modern quality management principles and practices into healthcare.S.D. it is arguably the learning science tradition . 10 and 11 are Deming’s antidotes to these phenomena. Points 3. Hartford Foundation. • Point eleven: Eliminate numerical quotas (4). even death. So.

silos within silos. as its ultimate point of leverage. recent years have witnessed the emergence of large purchasing cooperatives that generally have adopted the practice of awarding business to suppliers largely based on price and not necessarily on the values related to quality and long-term relationships so emphasized by Deming. • Point nine: Break down barriers between staff areas (0-1). Pride in workmanship is a given in the craft tradition and culture. have been creating professional and organizational silos since 1917. The challenge now for this craft culture’s learning and self-improvement tradition will be to encompass entirely new areas of vitally important learning that are not emanating from learning science. Six Sigma. such as reprimand. the year the American College of Surgeons Hospital Standardization Program (which otherwise significantly improved the quality of hospital care over the next 35 years) divided hospitals into two lines of accountability: those of physicians (the medical staff) and those of administration. The former is a direct. the loss of pride in workmanship represents one of the most distressing elements of present-day healthcare. It is likely Deming would be most distressed as he measured healthcare against these crucial six points. complex delivery systems. Specifically. This tradition generates self-motivated craftpersons who don’t need the externally generated call for training. This siloing has proceeded relentlessly ever since with the proliferation of medical specialties and subspecialties and division of the hospital into ever more departments and geographic areas. Not related to managerial incompetence but instead to a seemingly exponentially increasing level of complexity in healthcare facilities. paralyzing complexity. increasing paperwork. education and self-improvement that Deming saw in the industrial workforce. Medium Scores • Point four: End the practice of awarding business on the basis of price tag alone (2-3). though unintended. consequence of the craft culture’s learning science and regulatory traditions. fines and removal from practice. Further. Fear and fragmentation are rampant in modern healthcare systems. • Point eight: Drive out fear (1).of professional commitment to lifelong learning that has contributed so greatly to healthcare’s marvelous technological achievements of the 20th century. • Point seven: Adopt and institute leadership (1-2). impossible regulations. the learning science tradition has unintentionally also created an unrealistic. Perhaps the most pernicious legacy of healthcare’s craft culture is the paralyzing fragmentation that today afflicts especially large. Deming would be truly alarmed at this dark element of healthcare’s craft culture and undoubtedly a strong advocate of current moves toward blame free and just cultures in healthcare. the regulatory tradition uses punishment. but modern developments in healthcare have caused some erosion of healthcare’s prior strength vis-à-vis these two points. perfectionist “one must never make an error” culture. By the millennium. the work environment of many caregivers is approaching the nightmarish. but this strength has been severely eroded in some healthcare delivery systems. overly demanding patients. social sciences addressing organizational development and teamwork). Caregivers fear making an error and the consequences of error for the patient and themselves. This tradition thus only compounds the fear. hospitals had become organizational labyrinths. in particular. Healthcare’s craft culture has largely protected caregivers from two phenomena that Deming judged pernicious. Long Way To Go • Point one: Create constancy of purpose for improvement of product and service (1). careful and vigilant craftspersons. but instead from the management science traditions (such as human factors. • Point twelve: Remove barriers that rob people of pride in workmanship (2-3). One hears the laments every day: not enough time. • Point two: Adopt the new philosophy (1-2). Hospitals. Caregivers and managers have truly been robbed of their past pride in workmanship. • Point five: Improve constantly and forever the system of production and service (1). not enough staff. with any cross functionality constituting an almost miracle of QUALITY PROGRESS I SEPTEMBER 2004 I 29 . While this situation must turn around at some point in the future. no sense of teamwork. While its intent has been to train responsible.

D. Martin D. 3135.1 Donald Berwick of the Institute for Healthcare Improvement identified Armand V. As the overwhelming evidence of medical error and unacceptable levels of patient harm make clear. including mergers. society and change. improves quality and removes the causes of failure to help people do a better job with less effort. explicitly or implicitly. undone mergers and spin-offs—all illustrating lack of constancy of purpose. pp. is a clinician. even given Deming’s lifelong frustration with how slow many of his audiences were in grasping his call for transformational change. He would observe a diminishing number of healthcare organizations clinging to 19th century ways of doing things. 2000. he would not be surprised to observe the widespread faddism of the 1990s. and for Reducing Operating Costs and Losses. 2000. He would observe healthcare’s Baldrige winners (and a small cadre of others) and award them a full 5 of 5. this industry is in need of a quantum leap in its performance capability. The working conditions of complex hospitals in particular would not be siloed if healthcare leaders as a group had adopted Deming’s profound knowledge philosophy of appreciation for a system. is deplorable. he would observe few healthcare cultures in which continuous improvement is truly embedded. acquisitions. he would not see an amorphous mass.” Quality Progress. But. Feigenbaum argued for rejecting an .D. are beginning to probe the depths of his system of profound knowledge. W. Deming called for nothing less than such a transformation for American managerial thinking generally. M. W. Deming would today see far too much reactive behavior on the part of both caregivers and institutions and far too little genuine pursuit of constant improvement.asq. Merry. Edwards. it is a way of managing an organization. healthcare today. paperback reprint. incremental extension of healthcare’s 20th century practices and processes. M. Transformation The healthcare world we must now together create does not represent a linear. M.. Since a small number of healthcare leaders have internalized Deming’s notions of leadership. he 30 I SEPTEMBER 2004 I www.2 While the latest edition (1991) is entitled simply Total Quality Control. What Feigenbaum Says by Paul M. rather. Schyve. In his 14th point. in sharp contrast to healthcare’s Baldrige recipients and growing cadre of leaders who. And the results of this management include higher reliability and a reduction in operating costs. Total Quality Control: Engineering and Management: The Technical and Managerial Field for Improving Product Quality. Merry earned his doctorate in medicine from McGill University in Montreal. Indeed. “Healthcare’s Need for Revolutionary Change. He is a member of ASQ. MARTIN D. To a large extent this situation is implicit evidence of healthcare’s failure to develop the type of leader Deming calls for: one who transforms his or her organization. most agree healthcare’s system of production and service. with notable exceptions such as its Baldrige recipients.. Feigenbaum as one of a handful of “visionary theorists” who had developed a new approach to quality that should be applied to healthcare. MIT Press. BIBLIOGRAPHY Deming.. In his 1989 New England Journal of Medicine article that introduced continuous improvement to healthcare. It is hard to conceive of an organizational structure less conducive to fulfilling Deming’s dictum regarding the need for cross functional cooperation. He is also associate clinical professor of health management and policy at the University of New Hampshire. educator and med- ical organization improvement consultant.3 the 1961 title provides a synopsis of Feigenbaum’s teaching: Total quality control is not a collection of technical projects and motivational initiatives. paperback reprint. Deming. Feigenbaum introduced the term “total quality control” in his 1961 book. theory of knowledge and psychology of individuals.S. MIT Press. Were his spirit to look down on U.D. Likewise. Including Its Reliability.org would still be pleased. MERRY. In 1951. Out of the Crisis. Edwards.HEALTHCARE human adaptation to an organizational nightmare. The New Economics. knowledge of variation. improves the performance of man and machine. September 2003.

Patient As Customer One of the elements of professionalism is the obligation to evaluate the technical performance of one’s professional peers. Feigenbaum’s ideas need to be applied at the societal level. • They do not want their healthcare to be simply a commodity—like a manufactured good—exchanged between themselves (as customer) and a provider for money. they desire a trusted relationship in which healthcare professionals use their knowledge for the good of the patient—regardless of the patient’s ability to pay. The focus is on satisfying the customer. not just at the level of the individual QUALITY PROGRESS I SEPTEMBER 2004 I 31 . is his assertion that It is in everyone’s interest for customers of healthcare to base their satisfaction on evidence based medicine. The patient may be fully satisfied despite poor technical quality or may be dissatisfied despite good technical quality. “The key is recognition that quality is what the customer—not the company—says it is. accreditors. the public will judge quality primarily by what they can experience and assess. Thus. such as waiting times.inspect and correct approach to quality control and adopting a preventive approach that begins with the design of the product (or service) and continues through its production. Rather. when they do. they are not the most critical aspects of quality of care with respect to health outcomes. Patients usually express trust in their own physicians but less so in the healthcare system or organizations. While these factors impact the accessibility of care and health outcomes. engineering. engineering. while patients recognize they may not have the information to judge the technical quality of the care. Total quality control is an effective system for integrating the quality development. hide the results. regulators) to do so for them. How are these ideas being applied in healthcare? Is quality in healthcare defined by the customer? In the preface to his 1991 book. To the extent healthcare is seen as a public good (rather than simply the exchange of a commodity between private parties) based on society’s obligation to alleviate sickness in its members. they assume professionals do. It is in everyone’s interest for customers of healthcare to base their satisfaction on evidence based medicine. Part of this mistrust results from the public’s perception that the healthcare system and provider organizations have often failed to evaluate quality and.” This concept is only partially applicable to healthcare. Product and service quality can be defined as the total composite product and service characteristics of marketing. Most patients have indicated the following: • They often do not know how to judge the technical or scientific aspects of healthcare and must rely on others (professionals. Feigenbaum writes. but the science is often unknown to patients. the public does not have a purely market based view of healthcare—a view that would facilitate Feigenbaum’s approach. sale and service.4 Today. and they are often unable to judge technical quality. Until practitioners and organizations provide the public with information on technical quality and help them use it. manufacture and maintenance through which the product and service in use will meet the expectations of the customer. customers define quality relevant to healthcare? Yes! First. 2. response time of nurses and the care environment. and operating costs are reduced. Feigenbaum’s basic concepts are found in two definitions:5 1. This obligation suggests there are aspects of quality in professional performance that cannot be adequately judged by most customers/patients. the effort is integrated organizationwide. Society As Customer A second reason Feigenbaum’s view of the customer is relevant in healthcare is related to who the customer is. So. production and service at the most economical levels that allow for full customer satisfaction. maintenance and improvement efforts of the various groups in an organization to enable marketing. Today we emphasize evidence based medicine. all designed to satisfy the customer.

leaders of healthcare organizations have recognized that quality throughout an organization is based on quality from the top. The Institute of Medicine’s 2001 report Crossing the Quality Chasm describes the need to redesign the system to achieve the aims that will satisfy all of us. • External failure costs. External failures can also lead to more care (such as readmission. the healthcare provider can be financially disadvantaged. 6 Organizationwide Quality Control If Feigenbaum’s focus on satisfying customers must be adapted to healthcare. . but usually not of a market commodity. caused by defective and nonconforming materials and products that do 32 I SEPTEMBER 2004 I www. it develops only gradually within an organization. While the cost of the failure will be eliminated for the patient and the payer. Feigenbaum argues that while total quality control will improve an organization’s financial success. little adaptation is needed. Feigenbaum’s ideas must be applied at the healthcare system level to align incentives if his ideas are to be fully successful at the practitioner and healthcare organization level. In a healthcare organization. thereby generating more revenue. Therefore. Total quality control needs to be applied not just to practitioners’ offices. As Feigenbaum writes.” He classifies quality costs as follows:8 • Prevention costs. which include quality planning and other costs associated with preventing nonconformance and defects. Boards often do not understand the importance of total quality control or what it takes to achieve it. additional office services and laboratory testing). And the costs of failure for the customer often outweigh the external failure costs to the producer. incurred in evaluating product quality to maintain established quality levels. not conflicting business objectives.asq. “A hallmark of good management is personal leadership in mobilizing the quality knowledge.HEALTHCARE patient. But failure to understand the principles that underlie his idea and the differences between healthcare and other products or services and between patients and other customers. First. healthcare organizations and health plans. Many case studies in manufacturing and service companies demonstrate investment in prevention costs is far outweighed by savings in internal and external failure costs. The public is the customer of a public good. reducing failures through total quality control in healthcare—unlike other industries—can reduce the bottom line. skill and positive attitudes of everyone in the organization… . • Appraisal costs. And. because the patient is not always able to adequately judge technical quality. Feigenbaum expresses it this way: “Quality and cost are complementary. and failure to use the principles to adapt his idea to these differences. it is the “how” that many struggle with. This paradox—those who invest are not necessarily the recipients of the benefit—is often a characteristic of a public good. Is Feigenbaum’s idea of total quality control relevant to healthcare. its CEO—need the permission and encouragement of the organization’s external leaders—its board—to invest in quality improvement. and Feigenbaum’s ideas need to be applied to society as customer. This is known as “misaligned and perverse incentives” in healthcare. but are focused exclusively on the immediate financial bottom line. caused by defective and nonconforming products reaching the customer. Studies of specific projects that were designed to improve quality are often unable to demonstrate a positive return on investment for the provider. corrective services or movement into a higher diagnostic related group in the federal payment classification system.”7 Most healthcare leaders today subscribe to this statement. practitioner and healthcare organization. Costs Turning to a third fundamental idea of Feigenbaum—that total quality control reduces operating costs—the need for adaptation and for system redesign are again evident in healthcare. what about his position that quality control must be integrated organizationwide? Here.org not meet company quality specifications. • Internal failure costs. will diminish its effectiveness in improving the quality and safety of care. through fees for additional. but also to the health system as a whole if we are to successfully cross the quality chasm. its senior internal leaders—for example. and will it continue to be? Certainly. But in healthcare there is a paradox: Sometimes internal failures lead to an increase in revenue. there may be no shift in market to the improved organization.

As an example of quality planning. from anticoagulants and developing a culture of safety. He taught me to see the cost of variation. hundreds of hospitals use the trilogy as a key organizing principle. for example. LA. I saw these as isolated events. 6. equipment failures and downtime. Total Quality Control. 1951.V. Feigenbaum. Supplies thrown out in the trash are waste. McGraw-Hill. McGraw-Hill.REFERENCES 1. A. Institute of Medicine Committee on Quality of Health Care in America. 1991. enabling them to identify delays earlier so they can restore process capability and implement service recovery with patients immediately. the lab specimen that is lost. PAUL M. decreasing harm Juran’s advice was to “staple yourself to the process”—that is. used the quality planning process to design its new health center. An infection is a preventable problem. Baton Rouge General Health Center in Baton Rouge. 7. National Academy Press. Berwick. I met Joseph Juran in 1987 and worked with him in the early ’90s. each of which requires different tubing and all of which the nurses have to learn how to use. walk the process every step of the way and observe it closely. is senior vice president of the Joint Commission on Accreditation of Healthcare Organizations. patient centered processes and a trained and effective staff. Total Quality Control: Engineering and Management. and I set up a team and charged it with using the tools of the trilogy to meet the hospital’s promises to patients. M. Juran helped me see defects where I had never noticed them before. quality control and quality improvement. Oakbrook Terrace. 3. I see them as part of a process. IL.M. such as using several different IV pumps. Practice and Administration. Total Quality Control. Quality control is about maintaining the performance of a process. A. third edition. In fact. A. OSF Medical Center in Bloomington. He earned his medical degree at the University of Rochester in New York. Quality Control: Principles. Total Quality Control. many emergency departments now monitor waiting times with control charts and spreadsheets. IL. handoffs and process flaws.D. 4. 53-56. walk the process every step of the way and observe it closely. reduced the number of adverse drug events per 1. Feigenbaum. now.V. When I was CEO of Massachusetts Respiratory Hospital. Quality improvement is about changing a process to improve its performance. 2. As an example of quality control. third edition. “Continuous Improvement as an Ideal in Healthcare.000 doses by more than 50% primarily by implementing processes to reconcile medications and by improving the dispensing process. revised.. Ibid. A waiting room full of patients is a defect. Feigenbaum.” New England Journal of Medicine. see reference 3. D. 1989. 320. Learn To See What Juran Says by Maureen Bisognano Most hospitals today are familiar with the Juran trilogy: quality planning. I immediately recognized delays. 2001. QUALITY PROGRESS I SEPTEMBER 2004 I 33 . Feigenbaum. pp. Feigenbaum. OSF also used control charts to monitor these core processes and its improvement progress over time. 5. He taught me to see—to look at processes in an entirely different way. third edition. McGraw-Hill. such as an X-ray that needs to be repeated because it wasn’t done correctly the first time. which opened with a new and innovative physical plant. I sought to provoke dramatic improvements in flow and reductions in delays. Juran taught me about the cost of poor quality. 1961.V. 8. Juran’s advice was to “staple yourself to the process”—that is. Vol. Crossing the Quality Chasm: A New Health System for the 21st Century. Quality planning is about building quality into a process right from the start. see reference 3. Hundreds of healthcare organizations work with the Institute for Healthcare Improvement (IHI) every year to accomplish this. SCHYVE. Before.

please post your remarks on the Quality Progress Discussion Board at www. is developing a system of care that aims to create a continuous flow of information and continuity of care centered around the patient.org. • Establish the quality goals. “You can’t separate one person’s contribution. His influence on me. MA. I think of Juran just over my shoulder. . In healthcare. Celebrate Success REFERENCE Juran taught me to celebrate success and give recognition. Godfrey. Juran taught me recognition and celebration had to be connected to quality results. Today. In everything I do as a leader at IHI. You need to recognize that the entire team achieved the best results and recognize everyone.org. Bisognano is a member of ASQ and a former treasurer of the Society. fifth edition.org Practicing What He Preaches Juran personally practices what he preaches. He has taken good care of himself. A few hospitals are shining examples of what many more have yet to learn. He says that providing customer satisfaction needs to be the chief operating goal. McGraw-Hill.” I began to follow frontline improvements closely. In healthcare. we haven’t yet put these two things together very well. the job of establishing quality goals. parents have a key role in designing care. • Review progress. or e-mail them to editor@asq. • Give recognition. One of the most important of Juran’s principles 1. I see things through my “Juran glasses. Bisognano earned a master’s degree in nursing administration from the State University of New York in Albany. I could hire a quality assurance manager and let that person be in charge of quality. a notfor-profit organization in Boston.HEALTHCARE 34 We were able to achieve dramatic cost savings by focusing on waste and by teaching staff how to “see” it and remove it using improvement methods. • Stimulate quality improvement. Someone in the public relations department would write a speech for me.1 Leaders must: • Serve on the quality council. we recognized two people (one nurse and one nonnurse) as employees of the month. MAUREEN BISOGNANO is executive vice president and COO at the Institute for Healthcare Improvement. 1999. According to Juran. and his good health at age 100 is the indisputable result. • Provide quality oriented training. many leaders are establishing aims such as “reduce hospital mortality by 20% in the next year” or “achieve open access” so every patient can see a physician on the same day he or she requests an appointment. J. He is careful with his diet. that we still need to learn to apply in healthcare is customer focus.B. I used to think this happened on a personal level.” The good news is the more I look. Juran’s Quality Handbook. the more I recognize that his influence on healthcare is pervasive. Please comment If you would like to comment on this article. As a leader. I learned from Juran that certain tasks can’t be delegated.asq. My own employees came to me and said.asq. WA. I SEPTEMBER 2004 I www. Everywhere I look in healthcare. The community of Whatcom County in Bellingham. The celebrations became more closely connected to meaningful changes for patients and were more sincere recognition of performance excellence. I now know my task as a leader is to establish firm but stretch quality goals that are deployed through the work of teams. and I would deliver it and have my picture taken with the two winners. Previously she was senior vice president of the Juran Intitute. I used to think setting goals was a matter of encouraging others to do better. At Cincinnati Children’s Hospital Medical Center. quality consists of two things: providing the features the customer needs and ensuring freedom from deficiencies. Juran changed my perspective on the role of a CEO and made visible the tasks of a leader that couldn’t be delegated—above all. He tracks his vital signs with control charts. Juran and A. • Revise the reward system. • Provide the needed resources. has been profound. we used to think quality could be delegated. both personally and professionally.M. In my hospital.