Washing Away ‘Never Events’?

Healthcare professionals recommend ways to prevent medical errors

Medicare will no longer pay hospitals for additional care resulting from some hospital-acquired infections or medical errors,1 but there are many ways to head off these "never events" and enhance the quality of care a patient receives.

It can start by simply washing your hands the right way.

That’s what many healthcare quality professionals said in a recent ASQ survey that addresses the Medicare policy change, which took effect Oct. 1.

"Hand washing is still the most important thing that anyone can do to prevent hospital-acquired conditions," said James M. Levett, a cardiothoracic and vascular surgeon who chairs ASQ’s Healthcare Division.

The survey is the source of ASQ’s latest Quarterly Quality Report, "To Err Is Human—But Don’t Expect to Get Paid for It."

The ASQ report offers suggestions on how healthcare institutions can prevent never events—medical errors that are preventable, clearly identifiable and serious in their consequences for patients—from happening.

Among the suggestions are:

  • Using pre and post-operative checklists.
  • Marking surgical sites clearly on bodies of patients before surgeries.
  • Requiring verbal confirmation of prescriptions from pharmacists ordered over the phone.
    There are a number of technologies healthcare providers can implement to reduce errors, including:
  • Computerized physician order entry systems.
  • Automated process checklists.
  • Intravenous smart pumps and computerized adverse drug event monitoring.
  • Barcodes on medications.
  • Electronic patient records.
  • Radio frequency identification systems.

The report also includes suggestions for patients on what they can do to reduce the likelihood of being the victim of a medical error when they are hospitalized.

One hundred and eighty respondents weighed in on what procedures and technologies can help that cause.

To view or download the entire report, visit www.asq.org/quality-report/reports/200810.html.


  1. Brett Kryzkowski, "Hospitals Prep for Policy Change," Quality Progress, April 2008, p. 14.


Keynote Speakers Bring Much to Table

Co-founder of Ben & Jerry’s and former Starbucks CEO to speak next year in Minneapolis

Leaders from two powerhouse corporations are sure to create a buzz without any need for sweets or caffeine.

The co-founder of Ben & Jerry’s ice cream and the former chairman and president of Starbucks Coffee are scheduled to keynote next year’s ASQ World Conference on Quality and Improvement May 18–20 in Minneapolis.

Jerry Greenfield, who partnered with Ben Cohen to build a $300 million ice cream empire, will talk business, social responsibility and creative management during the conference, which takes place at the Minneapolis Convention Center.

Howard Behar, who led Starbucks in the 1990s before retiring in 2003, recently authored It’s Not About the Coffee: Leadership Principles From a Life at Starbucks.

Other speakers to be featured at the conference include:

  • Kam Gupta, president of Continuous Improvement Technology.
  • Kurt Holweger and Karim Houry, the Depository Trust and Clearing Corp.

More than 90 breakout sessions on quality-related topics, including the popular "After 5" informal and interactive presentations, also are scheduled.

Organizers are planning three "mini-conferences" to be held concurrently with the ASQ World Conference: the Quality Institute for Healthcare, the Quality Institute for Software and the Quality in Sustainability conferences.

One registration fee covers admission for all conferences.

For conference updates, go to http://wcqi.asq.org.


QP looks back on an event or person that made a difference in the history of quality.

Nov. 19, 1935

Jack Welch was born in Peabody, MA, on this date.

Welch graduated from the University of Massachusetts-Amherst in 1957 with a degree in chemical engineering. Welch later got his master’s degree and doctorate at the University of Illinois at Urbana-Champaign before joining General Electric (GE) as a junior engineer in 1960. Twelve years later, Welch became a vice president. He continued to move up the ladder and was named chairman and CEO in 1981.

Welch is known for his innovative management strategies and leadership style. In particular, Welch adapted Motorola’s Six Sigma quality program in 1985 and used it throughout GE. Some have credited Six Sigma for "changing the DNA" of GE and changing the way it operates.

Under Welch’s watch, GE became more streamlined and competitive, leading to record-setting revenues. During his 20 years of leadership as chairman and CEO, the value of the company increased from $13 billion to $700 billion.

In 1999, Fortune named Welch the "Manager of the Century," and the Financial Times recently named him one of the three most admired business leaders in the world today.

Today, Welch is an author, columnist and speaker.


General Electric, www.ge.com/company/history/bios/john_welch.html.

Wikipedia, http://en.wikipedia.org/wiki/Jack_Welch.


Shaping Quality and SR

Members discuss designing business case

ASQ member leaders representing different divisions and sections met with ASQ President Roberto Saco last month in Milwaukee to discuss ways to design ASQ’s social responsibility (SR) business case.

The meeting included guest speakers from two Milwaukee-based companies, Miller Compressing and Alterra Coffee, who offered their perspectives
on integrating SR into business.

Small group exercises, as well as other discussions among the 20 participants, focused on how ASQ and quality can remain a force in defining and furthering SR.

ASQ has given SR much attention in recent months:

  • ASQ’s 2008 Future of Quality study, released in September, identified SR as the No. 2 driving force that will shape the future.
  • ASQ’s board in May elevated the SR initiative to an essential activity for ASQ’S 2008–2009 fiscal year.

ASQ organizers want to hear from others with ideas about their efforts and opinions related to SR.

Visit www.theSRO.org and describe what you think makes an organization socially responsible.


SR Standard Moves Ahead to Committee

ISO 26000, the future standard providing guidance on social responsibility (SR), has moved from the status of working draft to committee draft.

This change, according to the International Organization for Standardization (ISO), indicates a high level of consensus is being established among stakeholders in the ISO working group on SR.

The decision to move to the committee draft stage was reached in September in Santiago, Chile, at one of the largest ISO standards development meetings ever held. Nearly 400 experts from 76 ISO member countries and organizations attended.

ISO 26000 is expected to be published in 2010. For further information about the standard, visit www.iso.org/sr.


Quick Poll RESULTS

Each month at www.qualityprogress.com, visitors can take a short, informal survey, and we post the results. Here are the numbers from a recent Quick Poll:

Which presidential candidate would do more to advance quality?

  • Barack Obama 63.4%
  • John McCain 35.5%

Visit QP’s homepage to answer the most recent Quick Poll question posted:

"Because of the state of the global economy, are you worried that your quality department, positions and projects will be among your company’s cuts?"

  • Yes
  • No

Capitol Q

David Levy and Dale Weeks have joined ASQ’s public policy advisory council. This group advises ASQ’s office of the president on issues and public policy matters, including ASQ’s presence in Washington, D.C. The appointments were announced by the council’s chair, Kay Kendall… ASQ has been meeting with representatives of the Small Business Administration. Topics include quality training and developing a small business network… A congressional hearing might be in the works early next year to highlight the benefits of the Malcolm Baldrige National Quality Award. The hearing would feature Baldrige recipients discussing the benefits of the program.

Capitol Q is a regular Keeping Current feature that highlights ASQ’s advocacy efforts with government leaders. More detailed information about ASQ’s legislative activity and other issues and activities can be found at ASQ’s advocacy room at www.asq.org/advocacy/index.html.


Toy testing labs can get certified

Laboratories that test children’s products can now be accredited under new requirements from the Consumer Product Safety Commission.

The accreditation will signal a laboratory’s competency and capability in performing the tests on children’s products.

The American National Standards Institute (ANSI) and the ANSI-AS National Accreditation Board/ACLASS announced that ACLASS will offer this accreditation of the laboratories.

The Consumer Product Safety Improvement Act requires these laboratories to be accredited against the international standard ISO/IEC 17025, General Requirements for the Competence of Testing and Calibration Laboratories.

For more information, visit ANSI’s website at www.ansi.org/news_publications/news_story.aspx?menuid=7&articleid=1968.


Share Your Ideas on Outsourcing

A soon-to-be-released Quality Press book expands on the August 2008 QP article "In the Know," which proposes a body of knowledge (BoK) dedicated to quality in outsourcing.

Because outsourcing is a relatively new area of discussion for quality and the BoK covers a broad range of topics, The ASQ Outsourcing Handbook delves deeper into outsourcing needs in various segments of industry.

Senior management-level executives, program or project leaders involved in outsourcing or anyone with decision-making responsibilities in quality, supply chain management or procurement is invited to participate in a survey that will help determine areas of emphasis in the book. The survey can be found at www.asq.org/knowledge-center/global-issues/index.html.

Send comments or questions to authors@asq.org.


Children’s Tale Teaches Quality

For the first time, ASQ Quality Press has published a children’s book, a tale about a little girl struggling with schoolwork who learns how to use quality tools to become more organized and focused.

Claire Anne and the Talking Hat was written by Barbara Cleary, a consultant and a K-12 teacher at the Miami Valley School in Dayton, OH, and is illustrated by Mike Kasun.

The book costs $9.95 for ASQ members and $16.95 for nonmembers. Visit the ASQ store at www.asq.org/store to order copies.


Certification Forum Slated

The American National Standards Institute is co-sponsoring a forum of industry stakeholders aimed at enhancing food safety through third-party certification.

The event will be held Dec. 2–3 in Washington, D.C., with co-sponsors including the Grocery Manufacturers Association, National Fisheries Institute and Seafood Products Association.

Participants will discuss how conformity-based solutions can build consumer confidence in food safety and strengthen the global supply chain.

Agenda details and registration information can be found at www.ansi.org/events.


Dimensional Measurement Interface Standard Developed

Researchers at the National Institute of Standards and Technology (NIST) are working to enable Wi-Fi-quality information standards for manufacturing metrology systems.

In this pursuit, NIST researchers and their industry partners have developed the dimensional measurement interface standard (DMIS), which is a language for performing dimensional measurements that will allow program portability without requiring translators.

The NIST-developed testing software is the basis of a new DMIS certification program. For details on DMIS, visit www.isd.mel.nist.gov/projects/metrology_interoperability.

Short Runs

THE AMERICAN STATISTICAL Association has announced support for ElectionAudits.org’s "Principles and Best Practices for Post-Election Audits 2008." The principles were developed by election officials, public advocates, computer scientists, statisticians, political scientists and legislators. The principles cover risk-limiting audits, addressing discrepancies and continuing the audit, and comprehensiveness. The complete list of principles and their details can be viewed at http://electionaudits.org/principles.

"GLOBAL AUTOMOTIVE Perspectives 2008," a PricewaterhouseCoopers (PWC) report, discusses challenges facing the auto industry, such as fuel costs, carbon dioxide emission reductions, shifts in consumer behavior and a challenging economic climate. PWC says, "Great opportunities exist for the automakers and suppliers who will be able to deliver solutions to this structural industry transformation." A full version of the report can be found at www.pwc.com.

ENGINEERS WEEK 2009 will be held Feb. 15–21. The event features several programs designed to encourage precollege young people to study engineering and go into the field. For information on the event and volunteer opportunities, go to www.eweek.org.

A SURVEY of more than 300 aerospace manufacturing professionals by the Society of Manufacturing Engineers has revealed the biggest quality issues facing manufacturers today. More than half of those surveyed indicated a need to understand information on the latest technologies and acquire updated skills in the areas of measurement, inspection and data analysis. The survey also uncovered daily quality challenges, such as lead-time pressures, supplier quality issues and inaccurate data. For more information, visit www.sme.org.

ASQ News

QUALITY OF LIFE   To highlight quality as a way to improve the lives of others, ASQ wants its members to submit stories about their community involvement. Stories will be collected and shared in ASQ Weekly. Send your stories to qualityforlife@asq.org. A blog written by ASQ board member Kay Kendall has also been established to offer insight and inspiration on the value of quality as a means to improve the lives of others. Visit the blog at www4.asq.org/blogs/quality-life.

MEXICO CONFERENCE  Peter L. Andres, ASQ’s president-elect, is scheduled to speak about innovation at the 3rd International Quality Congress later this month in Mexico. The conference, organized by ASQ and the University of Technology of Leon, promotes the culture of quality to the education system and 1,300 students. It will be held Nov. 13–14 at the Poliforum Leon in Guanajuato.

NEW ASQ BLOG Terry Holliday, the superintendent of Iredell-Statesville Schools in North Carolina, has been selected to write an education blog for ASQ. The blog will address how leaders can drive improvement. Visit the blog at www4.asq.org/blogs/


The article "Flip the Switch" (October 2008, pp. 50–55) discussed root cause analysis and included two examples: park rangers combating a deteriorating Washington, D.C., monument and John Snow searching for answers about a mysterious illness in a London neighborhood in the 1850s. The former example should have been more clearly attributed to a CD-ROM produced by the Juran Institute in 1995 called The Quality Minutes.

Who’s Who in Q

Name: Linda McGill Boasmond.

Residence: Chicago.

Education: Bachelor’s of science degree in chemistry, DePaul University, Chicago.

Introduction to quality: In 1998, Boasmond was hired as quality assurance (QA) chemist at Witco Corp. in Blue Island, IL. She advanced to QA coordinator for ISO 9000 and later was promoted to corporate QA manager, with responsibilities covering nine of Witco’s 52 plants.

Current job: Owner and president of Cedar Concepts Corp., a chemical manufacturer based in Chicago.

Previous jobs: Worked in quality assurance at W.R. Grace’s construction products division, and was technical director/quality assurance for Cedar Concepts before becoming president.

ASQ activities: Member of Chicago chapter.

Other activities/achievements: Upgrading Cedar Concept’s ISO 9001 certification to 9001:2000.

Recent honor: Women’s Business Development Center 2008 Entrepreneurial Woman of The Year "Rising Star" Award.

Personal: Married.

Favorite ways to relax: Exercising, visiting the spa, traveling, taking young people on educational trips and volunteering at her church.

Quality quote: "Quality" has become a generic buzzword encompassing so much—reduced cost, improved productivity, less rework, standardization and improved customer service. I liken quality to the security process at airports. You have to take something apart, put it through a scanning machine, and examine all the pieces, but still try to get it to its destination on time. It may seem like a lot of trouble, but it’s worth it.



The number of finalists for ASQ’s Education Team Excellence Award. The finalists are:

  • Metro Technology Centers, Oklahoma City.
  • Alliance Business Academy, Bangalore, India.
  • Eagle Ridge Middle School, Rio Rancho, NM.
  • Hampton City Schools, Hampton, VA.

At this month’s 16th annual National Quality Education Conference in Reno, NV, the four will be showcased for their improvement efforts. Each finalist team will present its project live during the conference. Scoring will be conducted by a team of judges from across the country.


This month’s Web Watch focuses on design of experiments (DoE). For more quality-related websites, visit www.asq.org.

Hadamard Matrixes (www.research.att.com/~njas/hadamard/index.html)

For the mathematically adventurous, the library of Hadamard matrixes at N.J.A. Sloane’s site is a great resource when considering this Plackett-Burnman feature.

20 Key Elements of a Product Realization Process (www.prosci.com/prp1.htm)

Prosci’s Business Process Reengineering Online Learning Center home page is not specifically a DoE site. It does, however, list 20 key elements of a sound product realization process, many of which address tools of DoE. The site also includes a list of the 56 best practices of the product realization process, including testing skills, and design and manufacturing analysis.

Process and Product Improvement With DoE (www.qualityi2.com/doe.htm)

The home page of Qi2, a consulting and training firm, offers a course on DoE with an emphasis on Taguchi. In outlining the course, this site briefly describes DoE, lists its benefits and highlights Taguchi’s methods.

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