High-quality health care: do Deming or die

The cost of providing care is rising rapidly and not just in the UK: it’s an issue facing health care leaders across the world. Yet, through persistence and an unswerving pursuit of better value, some providers are making massive progress in achieving high-quality care at a lower cost. So what can we learn from them?

I recently spent four days understanding what lies at the heart of one of America’s greatest health care organisations, Intermountain Healthcare. During this time I observed one of the world's most prolific leaders in the field of health quality improvement, Dr Brent James, begin delivering the Advanced Training Programme (ATP). Participation in this programme is part of leadership development for clinicians at Intermountain; it aims to give them the understanding and tools needed to conduct quality improvement projects and internal quality improvement training. 

So, what are the merits of the ATP? And how has it led to a shift in the culture of the organisation?  

On one level the most striking insights come from some ‘simple’ truths. At the heart of the ATP is a motivation to deliver the best care for patients, but not by defining doctors as ‘good’ or ‘bad’. The approach to learning is based on the assumption that clinicians can change how they practise, something that was reinforced many times in the foundation module. 

The volume of information that clinicians have to absorb grows every year and can become overwhelming. Alongside the ATP, Intermountain is committed to managing knowledge across the organisation but allowing it to be customised in a systematic way that enables clinicians to evolve their protocols for the purpose of quality improvement and share these changes. Variations are observed and the differences between theory and reality are challenged. Dr James was clear that ‘the best patient care does not reside in one individual, every doctor has something to learn and teach’. The ATP is part of acculturation at Intermountain.

This discipline, which I witnessed first-hand during a visit to the labour ward, focuses on the processes of care delivery that sit within every treatment pathway, and not on the clinicians who execute the processes. It seeks to promote a learning culture where ‘better has no limits’. Individual team members were able to describe the part they had to play in quality improvement because they had helped to define their roles at the start of the project. When teams are involved in this way they are more engaged with the process, leading to quality improvement projects that deliver sustainable culture change.

Quoting Winston Churchill, Dr James reminded the latest ATP cohort that ‘people like to change, they just don’t like to be changed.’

This culture is also present in Intermountain’s primary care work, for example in the development of clinical protocols for diabetes care. Here, frontline GPs, nurses and diabetologists review their core practice as an integrated team, share new research ideas and help to integrate new care models into the decision support system.

Much of the ATP is derived from Dr James’s interpretations of the quality theorist W Edwards Deming’s work on process management theory. For example, Dr James applies Deming’s principle that a dependence on inspection to achieve quality creates a culture in which excellence does not flourish. The ATP has enabled Intermountain to create a culture in which quality has been built into its core processes and can therefore be continually improved. Clinical quality based on clinical integration is the organisation's business strategy. It benefits from strong leadership from its CEO, visible, unswerving ‘thought leadership’ from Dr James, an investment in building organisational skills and an infrastructure to support performance. 

Twenty years’ dedication to the principles of clinical integration have contributed to Intermountain’s undisputed lead in the low-cost (by US standards) high-quality provider league. Leaders in health and care in the UK could look to Intermountain as a model for balancing the need for quick management action with more strategic leadership to create a sustainable plan for achieving better quality care at lower cost.

Dr James’s words – ‘do Deming or die’ – still ring in my ears.

  • Vijaya will be talking about Intermountain and Mayo Clinic and what the NHS could learn from their approaches to quality improvement at her masterclass on 23 September

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#544569 Pearl Baker
Independent Mental Health advocate & Advisor/Carer

Oh dear, where do I begin. Mental Health individuals are difficult to motivate, often on high medication. Care Plans no more!

Where does this leave the Utopia for the mentally? exactly where they have been for years, at the bottom of the pile, please don't attempt to insult my intelligence by saying things can improve or are improving if they no longer have any support to motivate them.

My close colleague who cares for two relatives in her home, describes the current position as a 'lovely building but the entire fabric has disintegrated' the 'care and support system' is completely broken.

Words fail me, it would be great if there is any cost involved at all in supporting the mentally ill. The Care Act 2014 just as well not exist.

#544576 Claire Williamson
Managing Director
Care About People

Really interesting article and always great to share and learn from other healthcare providers across the world. For me and working closely with front line staff is that people want to change but the biggest constraint to this is the historic command and control culture that brings inflexibility and poor decision making. Empowering leaders on the ground to make local decisions will not only provide high quality and safe services to patients but would allow more effective management of the money. Allowing and supporting leaders to do this will make all the difference.

#544578 Vijaya Nath
Director Leadership Developement
The King's Fund

Claire glad the blog was useful and reinforced your interest in looking at learning from others.
I am currently with a cohort of 18 Leaders who will be looking at many organisations' approaches to Quality and Leadership in Seattle .
So far the biggest learning is the investment in developing capability in leadership and QI . In austere times the organisations we are studying retained a commitment to developing their clinical and non clinical staff.
I hope that we are able to develop and support our leaders in health & care in the coming period despite challenges . It creates a culture which promotes excellence in patient care .Thank you for your comment .

#544580 Dr Julia Wheatley
Chief Medical Analyst
Medical Risk Services Ltd

Extremely interesting blog. This fits with my companies ideas about improving the quality of care provided by our clients. However, the quote "Deming’s principle that a dependence on inspection to achieve quality creates a culture in which excellence does not flourish." made me smile - how to we apply this to the culture of revalidation in UK medicine?

#544584 Vijaya Nath
Director , Leadership Development
The King's Fund

Thank you Julia . I think the short answer and the longer more sustainable route is to go for commitment as opposed to compliance . System needs both but as we wrote in our Revalidation study what matters most is what the Dr does when one is watching .

#544898 Faisal Ali
Admin consultant
Remedial Hospital

Interesting Blog , i basically from Pakistan where such perception of Deming or OPDCA doesn't exist much, could you be more elaborated or share some simple practicing norms where this culture or control and care may be developed as you stated that you are currently working with the cohort of 18 leaders, or at least what tangibles you recommend to develop such kind of pool

#544986 simon cunningham
consultant in obgyn & lead for obstetric risk
royal stoke university hospital

Thankyou for putting this up. If I understand it correctly Intermountain healthcare managed to link frontline care processes to organisational information capacity and management infrastructure. My experience is that any attempt to directly embed data systems that link outcome results to care delivery decisions receives poor engagement. What do you think gives their metrics 'reliability' and 'meaning' and what lessons could we take from that?

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