W. Edwards Deming on Management: Application to Modern Healthcare

Today there is a trend for doctors to join large groups rather than opening individual practices. Good management is of paramount importance to the success of the practice and the group.

Many of W. Edwards Deming’s principles of management are philosophical, whereas others are more programmatic. All are transformative in nature. The points were first presented in Deming’s book Out of the Crisis.(1) This articles condenses the “14 points for management” that he presented in that book.

• Create constancy of purpose toward improvement of product and service, with the aim to become competitive, to stay in business, and to provide jobs. Medicine, in its quest to treat illness, has always challenged the status quo. For example, in 1847, Ignaz Semmelweis suggested that if physicians washed their hands before delivering babies in the maternity ward, sepsis in the mother and neonatal mortality could be significantly reduced. And Dr. Barry Marshall challenged the status quo in 1986 by suggesting that stomach ulcers were the result of the bacterium Helicobacter pylori, not stress and hyperacidity. For that challenge to the status quo Marshall received a Nobel Prize. It is necessary to make changes in how we practice medicine. In the age of the e-patient, we have to recognize that patients will have searched their symptoms and disease condition on the Internet. They are likely to arrive with dozens of articles that result in a more educated and sophisticated patient requiring more discussion and patient education in order to reach a treatment plan. Patients want to participate in the decision-making process. Shared decision-making is going to be an inescapable feature of patient care as we move forward in the 21st century.

• Adopt a new vocabulary. We are in a new economic age. Western management must awaken to the challenge, learn its responsibilities, and take on leadership for change. We must begin to think of patients as customers. The word “customer” is not a dirty word and should be part of our medical lexicon. Let’s be honest with ourselves: patients/customers are doing us a favor by allowing us to take care of their medical problems. Doctors and staff have to go out of their way to ensure that every patient has a positive experience at each and every interaction with the doctor and the practice. This even includes the first telephone interaction between a new patient and the receptionist. A potential patient who is put on hold or directed through a complicated phone tree and has to wait 20 or 30 minutes to speak to a human often will just hang up and go elsewhere for his or her medical care.

• Cease dependence on inspection to achieve quality. Eliminate the need for inspection on a mass basis by building quality into the product in the first place. We need to surround ourselves with staff that don’t need “babysitting” or micromanaging. We need to hire self-starters who know what needs to be done and then accomplish the necessary action steps without being monitored. Leadership requires setting the example (e.g., being an on-time physician and learning the art of delegating to others). Doctors should do only those things that cannot be done by anyone else in the practice. Everything else should be delegated. For example, we might consider using a scribe to take the history of the present illness, the review of systems, and the past medical history. It is not necessary to go to medical school to ask about surgical history and how many cigarettes or alcoholic drinks are consumed each day. This can be delegated to someone else while the doctor performs procedures or makes decisions that only can be done by someone with the doctor’s skills and training.

• Minimize total cost. Deming stated that successful management means ending the practice of awarding business on the basis of price tag. Instead, minimize total cost. Move toward a single supplier for any one item, and establish a long-term relationship of loyalty and trust. Today we have buying consortiums that buy in large volume and can reduce the cost of supplies, especially costly drugs and equipment. One example is group purchasing organizations (GPOs). Contracting suppliers can be a long and difficult process, and can require a significant amount of time and energy for busy practice leaders. With all of the challenges in health care today, GPOs aim to assist practices in these negotiations by taking a group-purchasing approach and negotiating on behalf of member practices, thus helping to control costs.

• Improve constantly, and permanently, the system of production and service, to improve quality and productivity, and thus constantly decrease costs. Find ways to increase the efficiency and productivity of the way you practice. One example is the shared medical appointment (SMA), which provides an opportunity to see several patients at the same time, thereby improving the efficiency of the practice. For instance, if a practice has a large number of patients with diabetes, the doctor, physician assistant, or nurse practitioner can meet with several patients simultaneously, thus improving efficiency and productivity. The SMA is designed to facilitate patient access while preventing physician burnout due to repeating the same clinical advice to patients with the chronic conditions encountered on a daily basis. The SMA allows patient group interaction in a unique setting that allows patients to understand each other’s problems and journeys.

• Institute training on the job. Practices that are most successful are constantly increasing the skills and knowledge of the staff. A successful practice will budget time and money to increase the skills of its staff.

• Institute leadership by implementing new technology. The aim of supervision should be to help people do a better job. We have amazing technology at our disposal that can make us more efficient and more productive. For example, HouseCalls (www.housecalls.com ) allows patients to receive their lab results without any voice contact between the doctor and the patient. The same technology also can be used to notify patients of impending appointments, thus decreasing the number of patient no-shows.

• Drive out fear, so that everyone may work effectively for the company. Don’t penalize other physicians and staff members for trying something new. As long as the behavior is in the best interest of the patient, any new effort or idea is worth trying. Not every new idea or project will be successful, but by always looking for new ways and ideas to make the practice better, patient satisfaction and productivity will also improve.

• Break down barriers among departments. People in scheduling, billing, nursing, and IT must work as a team, to foresee problems in the doctor–patient interaction.

• Eliminate slogans, exhortations, and targets for the work force asking for zero defects and new levels of productivity. The only exception is a vision or a mission statement, which provides the roadmap for the practice. In my practice, the mission statement is “This office is committed: 1) to excellence, 2) to providing the best healthcare for our patients, and 3) to the persistent attention to the little details because we think they make a big difference.” This pledge is displayed in the reception area, the employee lounge, and all of the examination rooms. The mission statement informs patients of what they can expect from the doctor and his or her staff, and it sets the tone for a productive relationship. Remember, a practice without a vision is likely to be a practice that vanishes! It is imperative to remove all barriers that rob the employee of his/her right to pride of workmanship and performance. It is far better to reward employees if they do something right rather than to punish them when they make a mistake. A good management principle is that a pat on the back is far better than a kick in the pants!

• Institute a vigorous program of education and self-improvement. Always look for ways to enhance the skills of your staff. Staff, like doctors, need continuous medical education. Just as the doctor who has been in practice for 25 years cannot use the same skills, drugs, and treatments that he or she was using upon graduation from medical school or completing his or her training, your staff also needs continuous improvement. This can best be achieved by more education and additional training.

• Put everybody in the practice to work to accomplish the transformation. The transformation is everybody’s job. Continuous improvement is not only for the physicians in the practice but also for everyone, including the file clerk, the billing office, and the receptionist. Strive to do better. Strive to make a difference. Strive to give every patient a positive experience. If you do, you will have happy and satisfied patients, a happy staff, and, yes, a very happy and successful doctor.

Bottom Line: Modern healthcare is going to require more hands-on leadership skills. Unfortunately, most physicians have little or no training in leadership. Deming has provided principles that can help guide the contemporary physician’s practice with leadership skills that will enhance the skills of the doctors and the staff and, ultimately, provide better care for our patients.

Reference

1. Deming WE. Out of the Crisis. Cambridge, MA: MIT, Center for Advanced Educational Services; 1986.