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Inspection doesn’t work! NHS needs TQM not CQC, writes Roy Lilley

Roy Lilley, 26 October 2013

See also:

The Best Workplace: improving quality through staff involvement

The Duty of Care: practical guidance for healthcare professionals

Here’s a little factoid that might just get you over the line in a pub quiz.  Or it might be one of those dinner party jaw-droppers.  Over the Clawson Stilton and Taylor Fladgate port you might want to casually mention: “Did you know, there are 30,000 components in a modern car?”  Not many people know that…

Interestin' innit? 

It’s probably more interesting than you’ve ever thought.  Why?  Ask yourself this: how is it that people on the other side of the world, often with a poor education, can assemble 30,000 bits and pieces into a shiny new automobile; ship it to Europe; and drive it straight off the boat…  and warranty it for five years… and expect it to work flawlessly for 200,000 miles?

The answer is total quality management. TQM had its genesis in post-war Japan, a country, at that time, famous for shoddy manufacture.  Japan’s strategy switched to the new 'total quality' approach. Rather than relying purely on product inspection, Japanese manufacturers focused on improving all organisational processes through the people who used them.

As a result, Japan was able to produce higher-quality exports at lower prices, reaching into the US market and causing American managers to reach for the aspirin. 

American managers were taken by surprise. They thought any competition from the Japanese would come in the form of price, not quality. Japan increased its share in American markets, causing widespread economic effects in the United States. Manufacturers began losing market share, organisations began shipping jobs overseas, and the economy suffered a way-out-of-whack trade balance.

How did it happen? In the mid-1940s, the physicist, later turned pioneering management guru, William Edwards Deming, was sent by the US government to Japan. Their food production was wrecked and parts of Japan were starving.  Deming’s ‘statistical quality control’ techniques proved a winner and he was rewarded and later lauded by the Emperor Hirohito.

Deming went on to develop his ‘14 Points for Management’, the third of which says: "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."

The NHS has been ‘inspecting’ for quality in the NHS since 1999 when the predecessor of the present Care Quality Commission was born.  Since then we have had 'learning from inspection',' light touch inspection', 'regulatory inspection' and the latest Chief Inspector of Inspection.

Still the complaints about care quality roll in.  Still patients are marooned in their own faeces, starved, dehydrated, forgotten in pain, ignored, overlooked and messed about.  The latest news is that 25% of our hospital Trusts have been pronounced potentially unsafe and dangerous -- the news brought to us by the organisation that has been conducting inspections for 14 years.

When do you think they might wake up and realise what industry knows, service organisations take for granted and every MBA student learns in the first year of their studies: ‘Inspection doesn’t work!’?

The car industry doesn’t inspect the finished car; it makes sure every step of the way is done properly by well-trained and resourced people who know what they are doing, are happy to be doing it and are proud to be part of it.

There is an institutional arrogance at the heart of the NHS that it knows better about everything and in all circumstances. Inspecting hospitals sounds good in the headline world of newspapers and sound-bite public opinion. Politicians play to the gallery; the staff at the CQC are the luckless cast who know in their hearts they are in pursuit of a foolish enterprise.

When Deming wasn’t guru-ing he composed music for the organ. He rewrote the national anthem to make it easier for people to hit the high notes. He used it as a metaphor for management: don't blame the singers (workers) if the song is written poorly (the system is the problem); instead, rewrite the music (fix the system).

So next time you are at a dinner party and in the pub you can ask: what has a hungry Japanese bloke got to do with safe hospitals?  You can dazzle everyone with the answer.

  • Roy Lilley is a health writer and commentator. @RoyLilley
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