In one of his comedy routines, comedian Jeff Foxworthy said: "My family has been in this country for over 300 years; why don't we own anything?"

I'd like you to consider that the same is true of quality, especially in healthcare. Quality improvement has been around since the 1920s when Shewhart worked at Western Electric. Why don't we see control charts, Paretos and histograms everywhere?

The IHI exhibits improvement posters from all over the country. Few, if any, show signs of using quality tools.

Meanwhile, the Institute of Medicine (IOM) estimates that $750 Billion of healthcare spend is for waste and rework. According to the Wall Street Journal, a 20% reduction in these costs would pay for healthcare reform. A 100% reduction would cut the U.S. deficit in half.

It's time to stop admiring the problem, set BHAGs for improvement and start driving healthcare toward zero defects.

Well said, Mr. Balestracci: Ron Snee's Holism agrees with Ed Rickett's Non-Teleological thinking, that I am fighting for. For too long we have been accustomed to the ants' swarm eating an elephant bite by bite: instead of viewing the ants' swarm and the elephant as systemic bodies, we saw the meal as a systematic process, which is a totally different vision. You may probably know that I live in Italy, where Healthcare can be rated from null to ten, not necessarily from South to North: Lombardy - Milan is a notorious reference - is considered a Healthcare Champion in the whole European Union; if that is a truth, I would never wish anybody living in Lombardy to fall ill, unless affordable for private care. But it's just the same as Education: there is something basically wrong in the governmental management practices of so crucial social services. No management TECHNIQUE will ever help, unless management COMMITMENT equals the ants' swarm hunger for an elephant. Not for the swarm itself ... Thank you.

I loved the lead-in to this article; Davis provides superb context to the problem. I have little doubt that you could take comments from just about any Quality leader at any Quality-related keynote in the past 30 years and find similar themes and statements.

As is my wont, I go back to Deming; he warned that if management continued to be ignorant of what he called the System of Profound Knowledge, organizations would continue to stumble along. Twenty years after his death, I see very little evidence that anyone has learned much. Most businesses (and some hospitals) are more concerned with creating value (money) for shareholders rather than creating value for customers. Waste is everywhere, and it is especially egregious in high-margin, hostage-customer enterprises like healthcare. Most business statistics courses still teach nothing but enumerative studies; managers remember statistics as a confusing math course with a lot of weird double-triple-negative language around something called "hypothesis testing." Control charts are just "too complex" for these managers, so if any metrics are tracked, it's usually in a red-green idiot light dashboard. Everyone gets a t-shirt when it's green, wrist slaps for red. The line for green and red is usually some arbitrary goal, without any consideration of Davis's question--usually just some number picked to satisfy the CFO's hunger for predictions of growth.

As for holistic or systems thinking, it has unfortunately become--in many ways--politicised. Trying to manage any part of the healthcare system as a system runs you into the danger of being accused of advocating socialism, usually by someone who can't define socialism beyond its tenuous association with Stalin. Healthcare insurance is, undeniably, an inherently socialistic enterprise, though; the young and healthy subsidize the old and feeble. The fact that the young and healthy have little appreciation for how quickly you end up old and feeble should have nothing to do with how the system is managed. To optimize the system you need to have everyone in it, so that record-keeping can become consistent and portable, so that knowledge can be quickly shared and diffused throughout the system, and so that the universal risk pool minimizes insurance premiums. These are just facts, knowable to anyone with a modicum of understanding of variation and general systems theory. Whether or not we SHOULD run healthcare (and education) as a system should not be debatable...HOW we do that should be the subject for discussion. But that statement requires that most people have a modicum of understanding...

Good article. I agree we should be measuring the right things right.

I am not sure there is enough trust for truly “high performance cultures” as defined by Jim Clemmer’s chart in many regulated organizations. A good governance structure and change management process can help senior management let go a little and enable them to get comfortable with “self-directed” teams with “proper oversight”. It also provides for better senior management immersion in improvement initiatives, controls the amount of change that the organization is permitted to assimilate, and with senior management involvement improves change enculturation to better help maintain the gain. In regulated environments, hybrid systems where diverse groups are enabled to carry out their own ideas but with change control and management oversight is better than traditional management or “increasing participation” modalities, but perhaps is perhaps a bit more stifling than freewheeling high performance cultures. A side benefit may be that improvements are better retained with senior management embedded, especially with appropriate measures and tracking, than in freewheeling cultures because people are less likely to go back to their old ways of doing things when the improvement project is over. This has been a plague of six sigma project failures in many companies and could be a way of improving the success rate.