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Is PDCA Enough?

Submitted By: Dan Chauncey

“The definition of insanity is doing the same thing over and over again and expecting different results.”—ALBERT EINSTEIN

Although plan-do-check-act (PDCA) was developed originally by the father of statistical quality control, Walter A. Shewhart, W. Edwards Deming, who was his student, later went on to develop Total Quality Management (TQM) and became a founding father of management science in his own right. Deming’s application of PDCA (and PDSA) called for managers to hypothesize, develop, and plan improvements; implement and do the improvements, almost as if performing a scientific experiment; checking, studying, and evaluating the outcomes and results; and then acting based on considered analysis to instill the change on a continued basis until it could be improved further. In so doing, Deming applied the principles of scientific management to the aim of perpetually improving organizations.

Supplementing PDCA with FOCUS, Hospital Corporation of America added yet another acronym to the vernacular—find-organize-clarify-understand-select (FOCUS). In the FOCUS-PDCA paradigm, preceding PDCA, FOCUS calls for finding an improvement opportunity, organizing an improvement team, clarifying the current state of the process, understanding the causes for variation in the process, and selecting the improvement.

Is the traditional FOCUS-PDCA sufficient to truly solve today’s healthcare problems and transform the industry? Hospitals have long used Performance Improvement in Healthcare the tools and methodologies of FOCUS-PDCA for performance improvement. Hospital Corporation of America (HCA) adapted Deming’s PDCA and added the FOCUS portion specifically to help hospitals select their most inefficient and troublesome areas for improvement. This methodology was started in the late 1980s and has been expanded across the entire industry over the past 20 years.

The United States has the most costly healthcare system in the world, and its performance ranks poorly in comparison with other countries. Yet FOCUS-PDCA continues to be used by many hospitals as their primary performance-improvement approach. Historically, FOCUS-PDCA has shown some degree of success in improving healthcare processes. Still, most of these successes have been reactive in nature and generally have not improved financial results.

FOCUS-PDCA does not cultivate the breakthroughs for which an integrated approach to performance improvement is ideally suited. In essence, it is no longer adequate. For example, a nurse in the intensive-care unit (ICU) was concerned about having the tools she needed for her patients, so she began stashing them away. The hoarding of supplies in the ICU was the tipping point in creating supply-chain issues, which correspondingly resulted in even more shortages. This is the type of problem that is not normally addressed by FOCUS-PDCA.

Today’s healthcare processes involve extensively broken or misplaced steps with multiple handoffs, too many decision points, and a host of inadequately managed constraints. If they can be resolved with traditional FOCUS-PDCA, then all is well and good. Typically, however, all is not well. For so many of today’s hospitals, the improvements are often short-lived and require endless rework.

No matter how people try, until the underlying system is fixed, sustained improvement will be impossible. In their article, “Moving Quality to the Top of the Hospital Agenda, ” Byrnes and Fifer state that a quiet revolution is taking place that places quality improvement and overall performance improvement as the link between better outcomes (i.e., patient safety and delivery of care) and lower costs. This revolution includes the allocation of resources for quality programs and the discussion of quality at the operational meetings of executive leadership teams. Successful deployment of performance improvement approaches such as Lean healthcare or Lean Six Sigma for healthcare requires a leadership involvement and a structured approach to proactive project selection.

I think that in 2008, Dr. Geary Rummler, the National President, International Society for Performance Improvement (ISPI), said it best:

“And now there are turf wars between competing process improvement philosophies, methodologies and technologies. Crazy, counterproductive stuff.”

In every industry, but certainly in healthcare, it should be the right tool for the right problem, at the right time! Reactive approaches are not working…healthcare organizations must begin proactively attacking waste and poor quality before it impacts patients or organizational financial viability! I believe that the answer Lean Six Sigma for healthcare combined with Constraints Management to form an integrated approach is proving itself one deployment at a time.

Read more about how modern Performance Improvement methods are working in healthcare in Performance Improvement for Healthcare: Leading Change with Lean, Six Sigma, and Constraints Management available from McGraw-Hill in September 2011.

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