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TQM, Health Care, and the Federal Government

Posted in Government

(Originally Posted 2/13/2014)

TQM, Total Quality Management, was a 1980’s, 1990’s buzzword that, as all buzzwords eventually do, has pretty much vanished from the language of management. But the validity of the organizational principles on which it was based is clear. Those basic principles, as I remember them are:

  1. Top leadership must establish clear objectives and goals for the organization and communicate those throughout the organization.
  2. All activities of all individuals, teams, and units must be based on an understanding of and be closely linked to the goals of the total organization.
  3. Standards and status quo maintenance are forbidden; the objective is always continuous improvement.
  4. The goal is prevention of, rather than detection and sorting of, defects, including bad decisions, with the goal of error-free operation.
  5. Improved control of processes, including management processes, leading to less variability, greater reproducibility, and fewer defects, errors, problems, and waste is always the primary route to continuous improvement and the primary responsibility of leaders and managers and employees at all levels of the organization.
  6. About 80% of defects, errors, problems, and waste are caused by about 20% of the sources of such. Data based measures must be established in order to determine these sources, and the highest priority must always be given to the 20%.
  7. Complete fact- and data-based diagnostic journeys must be completed and validated before leaping to solutions.
  8. Solutions must be preventive rather than compensating or correcting, must be permanent in nature, and must become institutionalized.
  • The fundamental basis for all the above is a belief that improved quality, properly understood, and reduced cost (waste) are opposite sides of the same coin and together determine the success of any enterprise, private, public, or government, non-profit or for profit, manufacturing or service.

There are many lists of these principles, with different slants, developed by various consultants who offered their services to companies and organizations anxious for improvement. At one point, the buzzword became Customer Satisfaction. Of course that is generally true, but I always liked the Steve Jobs quote: “Customers don’t know what they want until you show them.”  One list of principles in Wikipedia is attributed to the US Navy, an early adopter of TQM.

A problem in TQM implementation was that it often tended to start at the bottom with “Quality Circles” and other low level teams, management seeing it as a way to get the employees to get busy and do what management wanted them to do. The unfortunate result of that often was organizations and groups running off in various directions, sometimes doing quite well in achieving objectives that had nothing to do with success of the total enterprise. That is why Dr. W. Edwards Deming, one of the two or three most prominent gurus, normally refused to talk to management groups unless the CEO was present. Use of TQM principles at the top of any effort, including careful identification of issues and disciplined diagnostic journeys will almost always result in organizational and staffing improvements and will always result in clearer direction for the separate teams and organizations.

So, a reasonable question might be about whether and how to apply TQM principles to the issue of health care from the viewpoint of the federal government?  There is a single clear purpose of our federal government: preservation of life, liberty, and freedom to pursue happiness. While it is true that the founding fathers built in a certain level of chaos with the essential “balance of powers” concept, no CEO with the power to unilaterally dictate objectives and goals, I think it is clear that they intended the branches of government to work together to provide leadership in the accomplishment of that single clear purpose.

With respect to the health care law, had I been president and wanted to apply TQM principles, I might have identified lack of accessibility to health care by 20% of the population as a serious and significant problem contrary to life, liberty, and freedom to pursue happiness. If so, I would have worked with both parties, from a position of neutrality, and away from the eyes of the media, to get buy in on the seriousness of that problem and agreement that it deserved our attention. Then I would have appointed a cross functional bipartisan team to analyze the data and identify the major causes of lack of access to health care. I would want to know how much is due to poverty, how much due to poor choices, how much due to insurance company policies on pre-existing conditions, etc. I would have kept my mouth shut, except for asking questions perhaps, as they worked.  I would have resisted the temptation, always my biggest problem in using this technique, to jump right to a solution.

I am very comfortable that such a process would not have led to anything remotely resembling the ACA. I can imagine it might have led to gradual reduction in the age at which Medicare becomes available and, for fiscal sustainability, a restriction of Medicare availability to people below certain income or wealth levels. It might also have led to a loosening of restrictions on access to Medicaid. It might have led to a mandatory insurance pool, with participation by all insurers with government contracts, for people with pre-existing conditions. It might have led to establishment of free medical clinics in counties nationwide. It would not have led to a takeover and expansion of the insurance industry and a requirement that everybody do business with that industry or be penalized by the IRS.

So, now we have a bulky, clunky, burdensome new system, with various new taxes and restrictions on freedom, overlaid on everything that was already there, passed by one party only, establishing a new entitlement that will grow as long as our debt can stand it and then shrink along with other entitlements such that health care on average will suffer, with implementation of key provisions being continuously delayed because of unforeseen difficulties and, maybe, looming elections.

And it is obvious that, even for the simple task of designing the website to support the ACA, no principles of TQM were successfully employed, even at that low level of the organization. The fatally flawed approach to the health care access issue was obvious when the CEO assembled and led the Feb 27, 2010, “bipartisan” meeting of congressional leaders on health care and publicly admonished Senator John McCain: “Let me just make this point, John, because we are not campaigning anymore. The election is over.”

TQM principles are valid, but have to be applied at the top to be successful.