The price of nonconformance

Great anger and frustration has been directed at parts (occasionally the whole) of The National  Health Service for failing patients; for refusing to admit it happened, or happens; for refusing to accept accountability or responsibility; for refusing to undertake or even permit the open and public discussion of such failures; and for persistent bullying and victimisation of staff who resist or break ranks to the extent of becoming whistleblowers.

The two serious issues of ‘poor care’ and bullying of employees – and we must accept there is more than anecdotal evidence that they exist – are not independent.

It should be self-evident that the provision of quality care is more than the achievement of a simple ‘outcome’. We experience treatment and care of ourselves and others not as components in a manufacturing or repair process; and as much more than ‘customers’ or ‘clients’. There is a qualitative difference between our response to the experience of healthcare and our delight with or disappointment with any poor service or poor product we receive or purchase. Healthcare alone entails truly life changing events, actions and decisions.

It follows that the management vocabulary of ‘customer experience’ or ‘satisfaction’ as applied to commercial transactions is wholly inadequate either to describe how care should feel to the patient  (or the patient’s family and friends, who each have their own experience of the care) or how NHS staff (including but not only clinicians) should measure, and deliver, that care.

“In a true zero-defects approach, there are no unimportant items.” (Philip Crosby)

Quality Management (the management of quality) developed in manufacturing industries, and there have been reservations ever since as to its applicability to service industries, let alone public service delivery. Yet the fundamental rules from which Deming, Juran and Crosby developed their ideas – that every employee is responsible and accountable for quality, and that quality is what the service feels like to the recipient, not to the people delivering it; that almost is not good enough; that  measurement is useful, but targets destructive; that organisations are about people, and that what should be demanded of people is constant attention to quality and not acceptance of poor quality or undeliverable targets; provide the means by which the NHS might overcome issues of both bullying and poor care.

This is not the pitiable argument that private sector is better than public: far from it, because these lessons of quality management have not been absorbed or applied in much of the private sector, where they have been driven out by cost-cutting, exploitation of employees, and command-and- control management. Corporations driven by the demands of shareholders or owners with a simplistic single target of “maximising” profit cannot be quality organisations.

An organisation driven by profit is wholly inappropriate to healthcare because of this; and more so because the life-changing experience of the patient and the patient’s family and friends cannot be monetarised, or changed into a monetary transaction. No amount of money can be equated to the saving of your child’s life and health: no amount of financial compensation for poor care can redeem the loss and unnecessary suffering.

Lessons taught by the ‘gurus’ of quality management – Deming, Crosby, and Juran – are applicable even so, not least because root causes of poor quality of care in the NHS must be located in management; because management – most significantly the most senior management, the “leadership” – creates the culture of the organisation: that is, the way everyone else behaves.

“Quality is the result of a carefully constructed cultural environment. It has to be the fabric of the organisation, not part of the fabric.” (Philip Crosby)

What is clear from the work of these three quality ‘gurus’ is that everyone should feel both responsible and accountable for the quality of their work – and , more significantly, each others’ quality of work.

This entails a collaborative culture, where everyone openly shares success and failure. What is also clear is that a failure of quality may yet occur: what is crucial is how people react to it; and what is  vital to understand is what would make people react inappropriately, by accepting or hiding the failure.

“Remove barriers that rob workers and people in management of their right to having pride in their work. This means, for example, abolishment of the annual or merit rating and of management by objective.” (W Edwards Deming his 12th of 14 Points)

A contrast can be made with the organisational culture which results from the use of arbitrary numerical targets.

One effect of targets might be explained thus: give a person or team a numerical target together with any slightest hint that a reward depends  upon achieving it – or punishment will follow on failure to achieve it – and that target will be achieved.

Whatever the consequences.

Arbitrary numerical targets are associated with an organisational culture in which employees are forced to look upwards in the management chain for direction, and not outwards and around for service improvement. Such targets create cultures not only of short-termism, but also of fear (fear of the consequence of not meeting targets) and ultimately of stupidity (as sense is abandoned in desperation to achieve targets).

The most prominent reason for this association is that it is highly probable (almost certain) that the targets met were set with insufficient knowledge of the behaviour of the system and with unreliable assumptions as to the impacts on service. In particular, and most importantly for safety and care considerations, the gap in knowledge is with regard to the effectiveness of the system .

It’s vital not to confuse efficiency with effectiveness when evaluating individual processes or entire systems: the efficiency is measured in units of cost or resources to produce a given outcome; the effectiveness is the impact on the person the service is delivered for (or to), and should include the totality of their experience of the service.

The word “fear” in the earlier paragraph is deliberately chosen. The cascading of targets down management chains is not only a means by which managers shed responsibility and accountability onto the people they manage, but the source of a “command and control” culture in which managers demonstrate machismo by demanding (and apparently delivering) “stretch” targets of their underlings.

For National Health Service management, it can be imagined that this fear is amplified by the arrangement under which failure to achieve some targets will trigger an intervention from Monitor.

This, in a  phrase apparently used by Sir Robert Francis, is the kiss-up, kick-down culture.

What is important to imagine is that what is hollowed out by command-and-control is the human relationship between manager and managed. The manager (including those managing other managers) comes to divide his team into deliverers and blockers, for and against, compliant and problematic. Bullying becomes the sole and normal interaction by which the manager attempts to direct his staff to deliver his targets. But fostering a cultural norm of bullying – bad enough of itself – is not the only deleterious impact of management by targets.

Targets do not only make people act out of fear: it makes them act dishonestly. The typical problem faced by an employee is that he/she does not have sufficient control or influence over the systems (the processes, formal and informal; the budgetary, resourcing and other constraints such the actions of staff outside their management sphere) in which he/she actually works, to achieve the targets set.

That limits the responses available. Option 1 is to escalate through management, something  unfunnily referred to in a target culture as a “career-limiting” move. Option 2 is to withdraw, and find another job. Option 3 is to fabricate the numbers required without actually producing them. Option 4 is to achieve the targets set. (Option 5 is to blow the whistle. Option 6 is to fail:  two other “career-limiting” moves. )

Achieving the targets (Option 4) under such conditions calls upon (often great) ingenuity – and no little deviousness – to make the numbers add up. Once the numbers add up, the line manager  incorporates them as evidence of meeting his targets, as does his line manager, rolling right up to the very top of the management chain. Dishonesty and denial are incorporated into the organisational culture; more fear is accumulated; accountability is denied (blame can always be passed  downwards); and the information provided by and used by the organisation becomes increasingly inaccurate and irrelevant. Management and overall effectiveness of the organisation enter a tailspin and then a nosedive as each successive round of targets is created from data rendered more unreliable by the previous round.

It is highly probable – indeed (as some systems experts argue) inevitable – that a significant and negative impact of setting and achieving numerical targets is an overall reduction in the effectiveness of the service delivered – that experience of receiving the service.

Consider this example from housing repairs and reimagine it to be the experience of a patient seeking treatment – or even from an NHS trust:

The target here states that emergency repairs should be carried out within 24 hours, 7 working days if it is deemed to be urgent and 28 working days if it is a routine repair. This sounds plausible and a large majority of housing organisations score highly against the target. The reality of performance from the customer’s perspective is very different. When organisations study their services as a system, they understand that the true purpose of the system is to fix the problem in as few visits as possible. When the organisation begins to measure true end-to-end time (from the customer’s point of view), they discover that it can take as long as 220 days! It is possible to meet the target and yet it can take up to 10 visits to fix a problem. Each report is counted as an individual job. To meet the target, the result may be a patch repair instead of a permanent repair. Target met? Tick. Customer experience? Terrible.” (Quoted from Vanguard Systems Thinking)

Consider having to deliver a target of seeing, treating, admitting or discharging every arrival at Accident and Emergency within a target time of 4hrs from arrival and the threat of Monitor: what is the the relationship between the target and “the true purpose of the system”? Or more importantly, consider arriving at A&E as a patient: what do you see as “the true purpose of the system”?

The patient – by definition vulnerable, with the old perhaps particularly so – can thus be caught in a perfect storm of misdirected effort, incomprehensibly stupid processes and behaviours and – because some who are kicked down and under pressure to do the impossible lose sense of their real purpose – lack of care or in exceptionally bad situations, real harm.

“… these obstacles have their origin in prior managerial practices. It is therefore important to avoid any atmosphere of blame. The emphasis should be on what to do differently, and on the methods for making the needed changes.” (Joseph Juran on human obstacles to quality)

The challenge for the NHS – particularly NHS England, which is, as a direct and intended result of the Health and Social Care Act 2012, now permanently cursed with unplanned and incoherent restructuring and reorganisation – is to escape the target culture and to remake itself as a quality organisation. This cannot be imposed upon it by regulatory bodies, let alone those which themselves are marked by poor quality, unachievable targets, and bullying.

The mark of a quality organisation is that everyone is – and feels – accountable and responsible for identifying and making visible errors and defects in the service. The mark of poor quality is the failure to identify and remediate poor errors in service. This is transparency and openness, as opposed to dishonesty and unaccountability. It requires collaboration and leadership, the opposites of command- and-control and “kiss-up, kick-down”. Quality demands unwavering attention to the experience of the recipient of the service, not on your manager or your targets.

Philip Crosby taught that there are four Absolutes of quality:

  1. Quality is defined as conformance to requirements.
  2. The system for causing quality is prevention, not appraisal.
  3. The performance standard must be Zero Defects, not “that’s close enough”.
  4. The measurement of quality is the Price of Nonconformance, not indices.

The first Absolute requires everyone involved to fully understand requirements (what the patient both needs and deserves as a human being), and to meet them at the performance standard (Absolute 3 – no-one may accept anything less than perfection). Absolute 2 states that occasional – or even regular – outside audit cannot and will not produce quality (though it might assure its existence, which is what audit is for): prevention of all substandard service is what is required.

And The Price of Nonconformance?

In terms of care the Price of Nonconformance is harm, is unnecessary suffering or even death; and suffering extended to family and friends.

One example from manufacturing:  the behaviour which perhaps most distinguished the Toyota way from its US competition when it surged to dominance in the US market was that of any employee signalling (sometimes literally, by using flags) or if necessary stopping a part of the production if a problem was noticed.

“Mr Ohno used to say that no problem discovered when stopping the [assembly] line should wait longer than tomorrow morning to be fixed. Because …we know we will have the same problem tomorrow.” (Fuji Cho, former President, Toyota Motor Corporation)

The culture which its management tries perpetually to recreate within Toyota – and this seen as an important role of management – is that it is everyone’s responsibility to seek out, identify, report, and resolve problems. Resolution is done through seeking the root causes of the problems and changing processes, behaviour, or equipment as necessary to prevent problems recurring.

“Prevention, not appraisal”.

In such a culture a whistleblower would be unnecessary, because openness about errors and failures of quality is demanded of everyone. Moreover, such a culture would demand peer organisational unit involvement to prevent errors in place of external inspection with threat of sanction by a specially created regulatory body.

“What is important is that the error went through eight people who did not see it. We are supposed to be inspecting the work when it comes to us. And the guy at the end of the line is supposed to inspect everything. This should never have got to the assembly line. Now we as a team are embarrassed because we did not do our jobs.” (Toyota worker responds to a component reaching next stage of production with a missing pin – Liker, The Toyota Way)

Three closing observations: this “bottom-up” approach to quality suggests that political interference must be kept to a minimum. A Secretary of State for Health should be accountable for the whole of the system, and responsible for the provision of healthcare: but absolutely not a dispenser of system changes and solutions. Secondly, the NHS cannot develop a zero-defect culture as a commissioning body, and it will be extremely difficult to assure quality where performance is obscured by “commercial in confidence” clauses. Thirdly, constant attention to quality is a long-term approach: the NHS must be secured from frequent and constant reorganisation.

The question everyone should be asking is by how much the quality of NHS management and the quality of NHS care, and the safety of patients, will be reduced by disorganising, fragmenting, and leaving the NHS without leadership.


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