Recently, I visited the US for a close-up study tour of three major American healthcare organisations. Organised by our partners at Catalysis, the trip provided valuable insights into the continuous quality improvement (CQI) programmes at Cleveland Clinic, Ohio Health and UMass Memorial Health.
It was a brilliant trip; a real eye-opener and even better than I expected. And it left me in no doubt about the value of being able to see for yourself how these super-successful organisations run their operations.
However, don’t be fooled into thinking you can cut and paste everything they do over there into an organisation over here.
Done properly, CQI takes time. At UMass, for example, they’ve been doing it for 20 years. Their manual on how to run every single piece of standard work within the organisation is incredibly comprehensive, covering everything from setting strategy through to delivering daily performance and improvement. They’re on version 17 of it now, reinforcing how this remains a never-ending work in progress.
The scope of that manual immediately suggests an incredibly rigid organisation, where so much of how you do your work is likely to be pre-determined. To some extent, it is rigid and standardised. But it’s also an organisation where innovation is encouraged; where everyone is empowered to make improvements in their particular area.
They’ve got this whole tight-and-loose thing going on. Standard processes are tightly enforced but staff also have a huge amount of freedom to suggest and make improvements. There’s obviously a degree of tension between those two positions – but it just works and people buy into it. Striking that balance of rigidity and flexibility was my first big take-away from the trip.
Focus on how, not what
The next was the focus on behaviours that I saw across the board. The primary focus was on how staff did something while following the afore-mentioned processes, ahead of the results they delivered. Expected behaviours were articulated in extensive frameworks against which staff were assessed and self-assessed. That’s what could get you fired – if you failed to meet those expected behavioural standards or didn’t follow the process.
That shows confidence in the management systems, implying that if you behave in the right way and follow the standard work processes, then the desired results will come.
There was also an interesting point about so-called “below the line” behaviours – i.e. when people are superficially supportive but their true behaviour undermines what the organisation is trying to achieve. There was zero tolerance for that.
All the way to the top
Something else I loved to see were the highly structured, tiered management huddles that constituted these organisations’ daily management systems. Run from the bottom up, these provide opportunities for raising issues, suggesting fixes and making improvement suggestions.
Staff are empowered to act directly on these huddles’ outputs – but anything that does require escalating is taken by a manager into the huddle at the next level up, which happens immediately afterwards.
In this way, meetings that start at ward level at, say, 08:30 can have escalated a potentially major issue all the way to the exec team huddle by lunchtime, meaning that serious problems aren’t allowed to simply drift. It’s another facet of a well-organised system that just works.
As the trip ended, Eric Dickson, the UMass CEO, said I was welcome to take a copy of his UMass manual – for all the good it would do me.
As I said, CQI at this scale is a long-term gig. Those three organisations have been at this for years, with CEOs (all of whom are clinicians, interestingly) who have stayed in post for a considerable time. You can’t just flick something like that on. But you can go to watch and learn from some of the best in the business. If you get the chance, you absolutely should.
