Sunday, September 20, 2009

Making Sense of Alphabet Soup

Patti Crome, RN, MA, CNA, FACMPE
Principal, Rona Consulting Group

CQI/TQM, Six Sigma, TPS…how does one deal with the alphabet soup and decide which quality method being used in health care today is right for their organization? Some of us remember our introduction to what was known as Continuous Quality Improvement (CQI), others may be familiar with Total Quality Management (TQM). Together with our clinical colleagues we were relieved there was finally a shift from a cost only focus to quality, actually stemming from Deming’s PDCA (Plan-Do-Check-Act) cycle of improvement.

TQM has a very clear focus on quality consciousness. It emphasizes that every organization has a direct customer and needs to understand what the customer needs and how to achieve quality with zero defects. This philosophy is engrained in a quality initiative referred to as the Toyota Way. This method was developed in the 1960’s when automobile manufacturer, Toyota, set a goal to win the prestigious Deming Prize, which rewards companies’ major advances in quality improvement. Toyota won the prize twice. TQM is powerful and became one very central piece of the Toyota Way (Liker and Hoseus, 2008).

A little later Six Sigma came on the health care scene. Based on TQM, Six Sigma boasts bottom line results that can be measured in dollars and cents. At its best, this method teaches problem solving throughout the organization but at its worst, it reverts back to the cost-only philosophy of organizational improvement. Lean Six Sigma is a compilation of tools and training focused on isolated projects to drive down unit costs… it tends to be results oriented and top down (Liker and Hoseus, 2008).

Another quality initiative known as the Toyota Production System (TPS), commonly known as “Lean—the ‘Toyota Way,’” is based on two pillars: continuous improvement and respect for people. Respect for people includes not only having a relentless focus on what is important to the patient (eliminating wait time, waste or non-value added work and emphasizing the services they are willing to pay for), but also, respect for the employees, recognizing they have the understanding and knowledge of the work being performed. In this method, the front line employees work with the patients and know the opportunities for improvement and more importantly, they are given the authority to design necessary changes and implement them as standard work. This system becomes both a “bottom up” and “top down” improvement method. Toyota Way “Leaders,” as opposed to the “Black Belts” in Six Sigma, must establish the vision, support the improvements and hold people accountable for the standard work designed in the improvement processes.

Standard work and accountability are both key to creating a quality patient environment, yet many times in health care, one or both are lacking. As Taiichi Ohno, one of the founders of the Toyota Management System says, “Without standards there can be no improvement (Womack and Jones, 1996).”

Lean methods adopted from the Toyota Management System are very powerful in supporting the pursuit of perfection that is desperately needed to transform health care today. Using the scientific method and focusing on the customer—our patients—will result in significant gains in patient quality when the role of the employee is kept central to that improvement work. The transformation will not be easy, but our patients and our staff deserve no less.

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