How Do We Change Healthcare?
The thought provoking article by Dr. Martin Merry, "Healthcare's Need for Revolutionary Change" (September 2003, p. 31), leaves one asking, "So, how do you change it?" The medical establishment is caught up and weighed down in more than key assumptions and beliefs. It is caught in a codependent relationship with an unhealthy health financing system--if that morass even deserves to be called a system.
Medical care is shackled by irrational payment mechanisms. Until health financing is reformed, Merry's proposed paradigm shift will sputter ineffectively.
To achieve his laudable aims, a complete overhaul of the medical financing system is needed, starting with a professional oversight body free from political and commercial pressures, able to encourage rational, cost effective quality care by incentives rather than Biblical regulations. This may be possible.
Anyone interested in more information should take a look at "An Innovative Proposal for the Health Care System of the United States," published in the May 2003 issue of Pediatrics. It is available at
I congratulate Merry for thinking outside the box. Let's examine these issues more closely and see if it is possible to achieve such revolutionary concepts to enable affordable quality.
GLENN AUSTIN, M.D.
Seven Taxonomies Are Fundamental, Practical
The seven taxonomies discussed in "The Seven Deadly Sins of Quality Management" by John Dew (September 2003, p. 59) are the most fundamental, down to earth and practical observations I've read on root cause analysis.
I am an active member of the National Aerospace and Defense Contractors Accreditation Program (NADCAP) and a voting member on the NADCAP heat treat task group. Root cause and corrective action are the greatest areas of weakness in the entire defense contractor base. Dew deserves a standing ovation for his article.
He states, "An appropriate rule of thumb is ... to dig until you reach the point of admitting something really embarrassing about the organization." This is something he has obviously learned from experience. His practical approach is what's been lacking in industry seminars and classes.
We live in a real world with real people performing real jobs. The mechanics of quality control should never overshadow the understanding that people still manufacture products, perform tasks and are responsible for making quality decisions every day.
New Britain, CT
Article Will Help Members Deal With Management
Rarely do I gush about anything, let alone articles in association publications, but I want to make an exception for John Dew's article.
The only way he could improve the article would be to eliminate the word quality from the title so it applies to all management. Schedules, politics and budgets fall more in the purview of general management than quality management, but arrogance and autocratic behaviors have universal application.
Every member of ASQ should have a copy of this article in his or her ammunition pouch when dealing with management on any issue.
Process Improvement Article Gives Bad Advice
I was disappointed in Tom Dolan's article, "Best Practices in Process Improvement" (August 2003, p. 23). It didn't contain many new ideas, and it passed along some very bad, very common advice.
Of the 10 processes identified by Dolan, only three (maybe four) are processes; the remainder are departments or programs. HR, accounting and customer service and satisfaction are not processes, no matter how many times the thousands of members of the Benchmarking Exchange might mistakenly think they are.
Dolan also says a process improvement team made up of representatives from all functional groups, customers and stakeholders will sink under its own weight. His statement sounds nice but has a few flaws:
- Customer needs and requirements are best represented with accurate, reliable data and should be addressed with focus groups or focused work groups. Customer representatives on teams expect to be listened to, even if they don't represent all your customers.
- Mixing employees and managers on a team will not bring out the best in either group. Contexts of knowledge and priorities will be too diverse. It may sound like a good idea, but it will bog down a team. Team membership should be based on expertise on the process as it is and as it must become and on what is required to get it there (if that is already decided). It may sound undemocratic, but then process improvement isn't a voting issue--getting results is what counts.
DAVID N. WILLIAMS
Williams Alliance International
Author's Response: David Williams seems biased against corporate style improvement methodologies. The intent of the article was to share information about best practices in process improvement currently in use.
One of my objectives was to encourage readers to take an active role in process improvement and encourage management to provide the appropriate resources and time required for change.
Process improvement is not something that can be delegated to an outside consultant. The recommendations in this article were gathered from over 560 people around the world who are actively involved in process improvement projects.
For additional information, please visit http://220.127.116.11/Surveys/Tbe1/results.cfm to see the summarized survey responses.
The Benchmarking Exchange
Corrective Actions Needed To Eliminate Variables
What caught my eye in Tom Dolan's article was his survey respondents' identification of the five biggest problems with process improvement implementation.
Of the 300 respondents, 52% said acceptance of results by senior executives, 68% said acceptance of results by department heads, 91% said lack of human resources to implement changes, 61% said lack of financial resources to implement changes, and 60% said communicating results. This information comes as no surprise to me; I have experienced each of these obstacles in my career.
I kept hoping to read about a new strategy for eliminating these problems, but I found none, other than the tried and failed, "Keep pounding your head against the wall; those bricks will loosen up sooner or later."
In my experience, upper management decides which, if any, process improvement projects get the green light. And, in my experience, any projects allowed to move forward tend to be either a desperate attempt to quell a raging inferno or some safe side process that won't disturb the status quo and won't cost anything. So, even if management permits an improvement project, you still have the five problems to hurdle before any improvement can be realized.
Instead of continually approaching upper management with proposals for process improvement projects, why don't we apply some or all of Dolan's top 10 process improvement tools (see Figure 3, p. 25) to determine the root cause of the five biggest process improvement problems and the corrective actions required to eliminate them?
I think Dolan's article is detailed and informative, and I don't mean to take anything away from it. I started to think about the five problems listed, and the more I thought about them, the more they seemed to become constants instead of variables. What I'd really like to see are some corrective actions that could eliminate them.
JIL Information Systems
Lands' End Takes Pride in Its CSRs
As an active ASQ member, I regularly read Quality Progress and always look forward to articles related to customer service and the contact center industry.
A comment in Susan E. Daniels' most recent article leaves me a bit perplexed, though ("A Model for Customer Service," August 2003, p. 30). After talking about the difficult job ASQ's 18 customer service representatives (CSRs) have in deciphering the wants and needs of customers, she states, "It's certainly not like taking orders over the phone for Lands' End, the giant catalog and internet merchant." Wow!
Clearly ASQ's small team of CSRs deals with some tricky questions, but try fielding questions and directing calls from members of People for the Ethical Treatment of Animals who are unhappy we sell leather products and vendors wanting someone in our business-to-business division to purchase their trinkets. Of course, those calls are in the minority.
The majority of our calls come from customers who are leaving on vacation, don't know what the weather will be like or what the dress code will be and would like a new wardrobe, including a swimsuit to fit their particular body style.
On top of that, Lands' End products are now in nearly 900 Sears stores across the nation, so we are receiving a whole host of new questions, about everything from product assortment to state sales tax rates. To quote the article, "It's not easy," but somehow we manage to train and communicate with nearly 2,000 CSRs in five contact centers. We also maintain world renowned customer service that makes all the internal processes virtually transparent.
Like ASQ's center, Lands' End does not use any automated phone systems, cross-trains representatives in all aspects of customer service and provides extensive training (four weeks for new hires and 20 hours per year ongoing). Unlike ASQ's center, we are open 24/7, with domestic operations spread across four cities and international operations in four countries.
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