One of my favorite newspaper writers is Ed Wallace of my local Fort Worth Star-Telegram. Wallace appears in the Sunday automotive section and usually writes about broader business issues beyond cars. His most recent column (“The Fall and Rise of Automotive Quality“) made me think about the current state of healthcare quality and how we might look back 30 or 40 years from now.
It's well known that the “Detroit Three” (formerly the “Big Three”) of Ford, GM, and Chrysler started to hit the skids business wise due to low mileage and poor quality, as compared to the Japanese imports, starting in the 1970s. Wallace points out that quality didn't GET bad in the 1970s… it was always bad and it had been accepted as normal until Toyota and others proved you could build high quality cars at a low price (or any price).
Wallace highlights what car buyers accepted as a necessary evil when buying a car, writing “the forgiving public believed producing large and complex mechanical devices simply involves too many parts and processes for nothing to go wrong.” How often do we hear that in healthcare today, that the delivery of care is too complex for it to be defect free?
Wallace reminds the modern reader that “Big Bill” Knudsen planned to improve quality in the following way when he took over Chevrolet in 1924:
“they would hang small-mesh nets beneath the entire undercarriage of all Chevrolets. These nets would catch all the screws and parts that came loose while driving.”
Talk about not getting to the root cause of the problem! Wallace also writes of the 1949 Fords that would get occupants soaked when going through a car wash. He recounts (as written about in The Machine That Changed the World
So what led to car buyers demanding better quality? The foreign competition raising the bar is certainly part of it. Wallace recounts how car buyer financing expanded beyond 36 months. Before the 70s, car buyers kept a car, on average, less than three years. Quality problems were more likely experienced by the second owner. But as car buyers kept their cars longer, they demanded better quality.
As Wallace writes:
As stated recently in this column, the greatest untold automotive story of this past decade is the fact that no company builds a truly bad product anymore. Of course, that doesn't mean that things can't go wrong. But the days of fenders painted in similar but different colors, or massive rattles within months, or even A/C compressors falling off because a bolt wasn't tightened are history.
- Give the wrong medication (or wrong dose) to patients so frequently, with the harm being far worse than a mismatched dashboard
- Not always practice proper hand hygiene or not always follow proven checklists for managing central lines, leading to unnecessary and preventable infections and death
- Sometimes skip the so-called “universal protocol” before a surgical procedure, leading to preventable errors or mishaps
- Mix up patient specimens in the lab due to a lack of error proofing and good processes
As Wallace points out, it was easy to blame the hourly workers and bad individuals for poor car quality, but it really tied back to management, systems, and culture (battles still being fought in the Detroit Three today, even though their results have improved).I hope someday we look back and say “can you believe healthcare quality used to be so bad?” and “can you believe we used to blame and sometimes jail so-called bad apples instead of focusing on systems?”
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Nice post Mark. I think this is one of the key benefits of having a Kaizen culture, in that you seldom accept the status quo as being all there can be, or the best there can be.
The problem I suspect for many companies is that for many they only know what they already know. There is a homogenity to the employees, with most hired because they are good at what the company already does well.
Thankfully with social media tools it has never been easier to open the lid on innovation, and attract input from all quarters.
We can talk about the bad old days, but I recently saw a 1952 Chevy, still in use in Argentina, where the owner was selling hats sitting on it. He noticed my interest and tried selling me a hat, but I asked him “how much for the car?”. I don’t think he understood English. (I will be posting a picture on my facebook). And I haven’t been to Cuba to see all the relics from the 50’s there. Our consumers want the latest and greatest. People complained in the 50’s about “planned obsolesence”. How many people have thrown away 2-year-old iPhones to get the latest and greatest?
I’m sure it’s likewise in health care. I was looking at a time line in a Chilean museum, and similar to the Apollo 11 benchmark, 1966 was the first heart transplant. How much we have improved since then!
Along with the horror stories, there are many more people doing their jobs right with the technology and resources we have. Unless there is a catastrophe similar to the library in Alexandria burning (nuclear war and loss of internet / computer databases?), I suspect people will look back in another 40 years and say how bad and primative we are today. I suppose it’s continuous improvement. In Santiago Chile, there is a tall building built in the shape of a 90’s cell phone with the fixed antenna. People ask “what is that?”
I think there are two different dimensions of quality — product innovation and quality/process improvement. A heart transplant is like the development of a new automotive technology (like an electric/hybrid drive system). The new innovation isn’t real helpful if you can’t deliver it reliably (without causing preventable errors in surgery or breaking down after 10,000 miles). We have some great leaps along with some continuous improvement.
As I tried to say in the post, the quality problems weren’t/aren’t the fault of the hard working individuals in both industries. These are system problems, primarily.