CQI In Complex Industries
The distinction between Total Quality Management and Continuous Quality Improvement is that CQI has been modified for healthcare environments. While earlier postings discuss the success of TQM on the factory floor and in production operations, it may be helpful to contrast that side of industry with something more akin to healthcare, such as information technology (especially, software design and development).
Interestingly, both production operations and information technology have been the subject of “off shoring,” in order to achieve cost-reduction benefits through lower wages. The quality of products produced overseas, however, have varied significantly between these two broadly-defined industries. US consumers benefit from the lower costs of both, but the quality of Prod Ops products manufactured overseas remains acceptable, while, anecdotally, there has been mixed success with off-shoring of software programming.
Even if we place both on a level playing field, the success of quality improvement within manufacturing has varied significantly in comparison to information technology. The quality of automobiles produced in Korea and India are nearly on par with those produced out of Detroit and Japan — with cars manufactured in China following not far behind. India’s Tata motors, for example, is now producing the first sub-$3000 car, with robust sales in, and for, the rugged terrain of rural Africa – with plans for export to the United States soon. Industry analysts indicate that cars coming from China are less than a decade behind those produced in Korea, while those exported from Korea are increasingly popular among US consumers.
Software, even if programmed exclusively in the United States, on the other hand, remains suspect when it comes to product quality. It is common convention that the consumer should wait until the second version is released before considering purchase. Software designed by Microsoft, whose production standards are at the highest level, are famous for their interminable sequence of “service packs.” By definition, service packs represent tacit admission of poor quality, if we adopt the standard espoused by Philip Crosby – who maintained that “no defects” is the only acceptable standard, given the debilitating cost of rework, redesign, and repair. If nothing else, service packs are designed to reform flaws identified following purchase by the cash-paying public.
In fact, Microsoft Vista’s failure to achieve projected sales and replace XP Professional as the industry-standard is largely attributable to consumers awaiting reform of flaws lampooned in Apple commercials. It seems an epidemic of service packs is no longer sufficient to satisfy today’s software consumer. Having survived the instability death-march required to make XP viable and productive, the customer sees no reason to downgrade into an upgrade.
So, why is it that quality improvement initiatives reliably work within production operations but are less reliable in software design and development? Unlike healthcare, both are closed systems, where the producer controls every aspect of the production process. In fact, software development is more closed than production operations, given lower reliance on externally-produced work-in-processed goods, less production equipment and required maintenance, and a better-educated workforce. Is it possible that the complexity of product creation explains the difference? It would certainly make sense that increased complexity accounts for increased variation.
If this is the case, we should consider where healthcare resides along the complexity scale between production operations and information technology. If believing medicine is simple in comparison to information technology, to quote Desi Arnaz, healthcare has “some ‘splaining to do.” On the other hand, if we are more akin to information technology, our complexity may explain our variation.
In healthcare, complexity is a point of pride – the nail on which we hang our credibility, warrant the title of “doctor,” and support wages that exceed the average. In fact, information technology is positively simple in comparison to the physics, chemistry, and biology of human anatomy. Of course, variation remains abundant in healthcare, even if productively employing Continuous Quality Improvement. If more complex, we can hardly do better than information technology.
But that is not the relevant question – it is just the precursor. The more pertinent question is whether Continuous Quality Improvement is likely to narrow healthcare variation (and, thereby, render a benefit to patient and practitioner) in comparison to its absence. To get at this, let’s ask a more simple question. Specifically, after more than 15 years of mandated / compelled CQI employment within healthcare, has it reliably promoted an improvement in health care quality and outcomes? The IOM reports, the Dartmouth Healthcare Atlas, and the Rand study suggest the answer is no. To what can CQI advocates point in opposition?
Personally, I believe CQI can not be productively compelled, any more than a two-year-old can be required to eat asparagus. Where CQI is perceived as distasteful, its prospects for success approach zero, but, where it becomes ensconced within the corporate culture and progresses beyond “flavor of the month” standing, its prospects for success approach 100%, precisely because of health care’s complexity.
It is in that complexity that inefficiency and poor performance reside and become hidden. Bacteria thrives where moisture is sustained, and moisture is sustained where airflow is lacking and evaporation cannot take place. Complex settings are like fractals, in which the nooks and crannies are abundant. Their complexity of inlets are easily observed on gross inspection, and are replicated ad nausea at each level of magnification — compartmentalizing and segregating pockets of negative space, where exposure to the free-flowing air of oversight becomes limited.
The same is true in organizations that are complex in their design, structure, and function. Where a maze of sequestered specialization resides, the airflow of scrutiny and oversight is diminished, the septic bacteria of inefficiency from inbred group-think thrives, and, like the warmth and moisture of petri dish in a darkened room, exposure to the light and wind of the outside world may seem undesirable in comparison. But it is the combat and contest of the outside world where challenges reside, growth becomes possible, and advancement is compelled (rather than nurtured).
It seems likely, to me, at least, that CQI is not that which can be required or mandated, but it is, instead, that which exceptional organizations do to become exceptional. Done right, it is where ideas confront challenge, growth is expected, success and failure are measured, and persistence, in the face of intermittent setbacks, are expected along the road to achievement. Viewed in this light, quality improvement becomes a differential and competitive advantage, made all the more so because it is so difficult for the competition to duplicate.
