"Hold everybody accountable? Ridiculous!" -- W. Edwards Deming
Are you perfectly designed to have things that "shouldn't" happen... happen?
Many of you in healthcare are knee deep in root cause analyses from the healthcare insurance industry's increasing intolerance of and refusal to pay for treatments for never events -- shocking, many times tragic, occurrences they attribute to gross incompetence.
Balestracci belt certification exam scenario: a hospital leader comes to you desperate to reduce these unplanned high costs. They hand you some quarterly data saying, “I don’t understand it. For the first 1-1/2 years, we trended down until we got a zero. Why couldn't we stay there? We've had five more quarters of zero, but we’ve also had three separate occurrences of a totally unacceptable three events. The last three years, we've been doing
all the root cause analyses when events occur. I was ready to really get tough and say, ‘No never events…or else!’ and make a public example of the next one. But someone suggested I come to you for the answer. They said you have a funny way of looking at data called a control chart. Do one, then tell me how to deal with this.”
A bit blindsided, you construct the chart below – this hospital’s never events for the past 19 quarters:
(I hope you’ve all concluded that the process performance is common cause. Now what?)
The executive looks at you intently and says, “The Board is really on my back about this. We have an executive meeting in 10 minutes. I’ll put you first on the agenda. We need your recommendations.”
Thirty years ago, I would have frozen in sheer panic!
"You have one chance to train a worker*…only one so don’t muff it." -- W. Edwards Deming
* Instead of "train a worker," substitute "convince an executive"
(doing it well is still no guarantee
I cringe as I think back to how I might have responded, "doing my best” :
“The chart shows common cause variation, which means you are perfectly designed for this level of performance. Dr. Deming says in Point 10 that 94 percent of the causes of low quality belong to the system and thus lie beyond the power of the work force. Only management can address them.
"Dr. Deming also says in Point 10 to eliminate the use of slogans, posters, and exhortations demanding zero defects from the workforce. Dr. Deming says in Point 12 that you need to create an atmosphere where people can take pride in their work and have joy. In Point 8, Dr. Deming says that you should drive out fear. Maybe that's the point you should focus on, especially given the tension these events cause.”
I hope your resume is up to date if you try this approach, especially when they most likely scream at you: “What is this ‘perfectly designed’ garbage? AND it’s our fault? Are you saying we as executives have to accept this level? How dare you! Quality is our top priority! There is NO WAY we are going to tolerate a quarter with even two events, never mind three or more! We are holding YOU accountable for making
these go away – no more ‘Dr. Deming says,’ no more ’94 percent of problems are management’s fault,’ and, please, no more red bead experiment demonstrations! It’s time for results, not more alibis…and obviously more competent and thorough root cause analyses and a workforce that takes 'accountability' more seriously.”
Once again, you “do your best” : "Since it’s common cause, we need a total redesign of some vital processes. Even though Dr. Deming says it's your job, I can do it, but it will need your support every step of the way – especially as we benchmark, test, and implement the new ideas."
...the myth of "It's common cause, so we need a totally redesigned process" strategy
You convene a large group of "key stakeholders" including lots of front-line people ("Dr. Deming says" the front-line has all the answers). You ask, “What causes never events?” and proceed to brainstorm yet another Ishikawa cause-and-effect diagram-from-hell overflowing with "good ideas." You continue your thorough work by researching the Institute for Healthcare Improvement (IHI) databases and published quality improvement (QI)
literature for “best practices” to test and implement. Maybe you even run a few rapid cycle PDSA experiments.
Been there? Care to predict how this will end?
Vague solutions to vague problems yield vague results
If all the executives do is continue to do what they’re doing (treating each never event as a special cause, i.e. root cause analysis), they will indeed get “0” a nontrivial amount of the time. They will no doubt attribute any zero to the brainstormed solutions (especially theirs).
Meanwhile, there is a quarter of five events ticking somewhere in the future "just because” (like the day you get all the red lights, then stuck behind a school bus and/or garbage truck on your way to work). In other words, the executives are indeed accepting this level of performance (~1 to 12 never events a year) despite their righteously indignant protestations to the contrary.
Common cause? You do NOT (necessarily) need to redesign!
Common cause strategies are one of the hardest (yet, paradoxically, simplest) lessons to learn. Here is my final video for you, which talks about them:
(to make it functional, copy and paste, substituting: y**t*be (dot) = "youtube.")
https://www.y**t*be (dot) com/watch?v=8l21BQPoed4&list=PL8A2OpniaYn7IayqKCWCMo96ZL-AC3yxr&index=5
They don’t necessarily have to heavily involve high level leaders and management, which is to your advantage. When your efforts get results that move important “big dots” in the C-suite, it will get you deserved attention, respect, and credibility and have leaders solicit you on other “big dot” situations…and you will now know what to do to solve them.
I'm always here as an ally and mentor and easy to find. I'll even help you plot your first "dot."
With warm regards, best wishes, and gratitude for your readership,
Chapter 2 of Data Sanity contains 10 everyday real data scenarios representing opportunities that will enhance your credibility and gain deserved respect for your role
- Data Sanity was designed to create dialogue between executives and improvement practitioners while simultaneously creating a common organizational language for everyone – to embed “improvement” into leadership and organizational DNA. [eBook also available]
- A very valuable adjunct resource: I have shared the outstanding, easy-to-use run and control chart macro BPChart with over a thousand of you over the years. Its developer, my respected colleague Mike Mercer, has now made it available as a commercial product. Given the current prices of software, it is a steal! (I want to make it clear that I have no commercial interest)
- Click here for more information, contact Mike via e-mail or through his web site, and he will get the ball rolling (great guy!): Mike@MercerQualityConsulting.com
- I have a simplified tutorial that I would be delighted to share with you (contact me) -- it teaches the "20 percent of BPChart that will solve 80 percent of your problems."
Transforming organizations by creating transformed colleagues