TQM without Context

Total Quality Management (TQM) and continuous quality improvement (CQI) have not had the expected results in healthcare. Much effort and resources and enthusiasm has been spent. Some have said the TQM and CQI don't work in healthcare.

Let's look deeper.

The language and tools of TQM were developed by and for engineers. They have worked wonders in organizations that have an engineering culture. Deming became the hero of JUSE, the Union of Japanese Science and Engineering. Deming's methods and language have worked well at Ford Motor Company.

Many doctors and nurses have held that healthcare is different. They are right. Their saying it proves it. Engineers love this stuff. Healthcare workers, by and large, don't. Why? Well the tradition and culture of medicine is most decidedly not one of engineering.

Engineers welcome tools, run charts, flow charts, and statistics. Healthcare professionals welcome personal experience, mentors, stories, and hands on experience. Healthcare professionals experience their jobs as chaotic, interrupted, human, challenging... Anything but predictable or production line like. The culture of health care is different than that of manufacturing. Trying to work against a culture is frustrating for everyone. What would working with the culture (beliefs, assumptions, and behaviors) of healhtcare be like?

Click here to see schematic overview.

Lately, long after TQM revolutionized Japanese industry (but not their healthcare) another perspective on quality arrived upon the scene. It is now referred to as High Reliability Organizations (HROs). It has to do with reducing the damage from the unpredictable and the unexpected. It has to do with vigilance and team work. It fits the culture of healhtcare, at its best.

Even more recently, the field of psychology know as "positive psychology" has been crafted into a very effective approach to change, one that is as natural as water running down hill. The common approach to change "management" is decidedly like pushing water up hill. This newly crafted approach is called "Appreciative Inquiry". My experience tells me that any person who has succeeded in helping a group through change practiced these principles whether they had a name for it or not.

Even more recently a hardy group of consultants have crafted approaches to large group interventions and finally they discovered philosophy (Terms of Engagement) to match their methods. The general idea is that you should engage all the people that will be affected in implementing any change and you should do this as far up stream as possible. Preferably before decisions have been made about what to do. Start at the opportunity / problem conceptualization stage if possible.

During the time that these other methods have unfolded the world has gotten complex, really complex. It is not the world of the 50's. Engineering ideas and the organizational theory taught to the current MBA graduates don't work. Systems thinking, System Dynamics, Chaos theories, Complexity theories, Emergence theories all are needed (really) to understand the environment--external and internal (though even that distinction is a trap).

Finally there is Sensemaking. Here it really gets fun with Karl Weick. And Mr. David Snowden finally integrated the field of Knowledge Management with this other stuff.

In my humble opinion the Learning Organizations that Peter Senge (The Fifth Discipline) popularized in the early 90's are finally becoming a possibility.

I will pick this up later... Gotta go to bed.

© Copyright 2004 Marcus Pierson, MD . Last update: 7/26/2004; 9:32:37 PM . This theme was created for WWPP by Jack F. Mancilla