Some Notes on Management in a Hospital by W. Edwards Deming

We used to publish a newsletter. In the Fall 2006 Deming Interaction we published an excerpt from an article by Dr. Deming: Some Notes on Management in a Hospital [the link that we broke has been removed] (published in 1990 in the Journal of the Society of Health Systems).

In the lecture discussed from our last blog post I learned something I didn’t know (or had forgotten): Stu Hunter said that the precipitating event that caused W. Edwards Deming to go into the hospital (at the age of 89) was him being stabbed during a mugging.

The article by Dr. Deming chronicles a list of events that seem to point to the need for improvement of the processes in place at the hospital.

The man that designed the shower had obviously never used one. The shower head, when not held by hand, can only dangle and flood the floor. There is a tiny shelf in the shower big enough to hold only a wafer of soap. There is only one bar to hold on to. Use of this shower would be a risky business without a friend close by for rescue. Somebody sold somebody a bill of goods.

I haven’t had a hospital stay, but from my many stays in hotels I am disappointed how often basic consideration of the usability of the bathroom and shower seem to only be understandable if the species that designed the shower were not human and didn’t understand how they were used.

In one case Dr. Deming discovers he wasn’t given the drip that had been setup. He had to take the initiative to bring this to the attention of the head nurse:

The head nurse returned to say that the nurse that was to give the infusion had recorded the infusion as given. It is possible that she recorded it in advance, with the intention to give it, and did not correct the record. Is this the regular procedure, to record intentions? Who would know?

An unsuspecting physician, looking at the record for his patient, would assume that the infusion had been given, and could draw wrong inferences about how the patient had been doing on the drug. In my case, as it turned out, no harm. But how would he know? A nurse, or a physician, has a right to suppose that the medication was delivered as ordered and as recorded.

What is the purpose of the record? To inform the physician about intentions, or to tell him what happened?

As with all the many problems Dr. Deming found he saw the system failures. He understood the futility of blaming an individual for the natural result of bad systems.

The Fettuccini Alfredo for dinner Monday night was the best ever, with three packets of parmesan cheese, as good as any Fettuccini Alfredo that I ever had this side of Rome. The broccoli soup was delicious. The beautiful looking apple dumpling was hot and tempting.

Fifteen hours elapse between dinner and breakfast. I was hungry in the middle of the night, first night. Fortunately had candy bars on hand.

I have learned how to acquire and store up food like a squirrel if I get hungry during the night. I order for dinner milk as well as coffee, set the milk aside for use during the night.

The quality of the food was excellent. The processes around feeding patients however seem in dire need of substantial improvement.

…My nurse of the moment put on a hot towel this afternoon. “I’ll be back in 20 minutes, and if I don’t come, please ring.” Sixty-five minutes later I pressed the button. A helper came in and explained to me that this was not her kind of job, so she cancelled the light for the nurse and went off. Thirty minutes later I rang again for the nurse. The same helper came and observed again that the job was not in her line of duty, so again she cancelled the light and went off.

The solution was simple, for me – merely discard the towel and insulation myself, with the rules or against the rules. The same event recurred another day.

This experience leads to questions and guidelines. Why should an aide, unable to perform the task, cancel the light?

It is even more difficult than usual to avoid blaming people when you are being forced to suffer. But even in this situation Dr. Deming understood the problems were a natural result of poor processes not of failures by individuals to do their best.

What is the moral of all this? What have we learned? One answer: the Superintendent of the hospital needs to learn something about supervision. Only he can make the changes in procedure and responsibility that are required.

Talks between physicians and nurses, even with the head nurse, accomplish nothing.
The same problems that I have noted will continue. A physician cannot change the system. A head nurse cannot change the system. Meanwhile, who would know? To work harder will not solve the problem. The nurses couldn’t work any harder.

Great things are being done to improve health care management in the decades since W. Edwards Deming wrote his article. But, sadly, many patients today will find a very similar experience to the one Dr. Deming had. We need to do a much better job of improving the management of our organizations, in hospitals and elsewhere. The progress we have made is real but the progress we have not made is much greater. We need to do better at improving the management of our organizations.

Have you experienced what it is like to be a customer of your organization? Maybe you should consider it. As Dr. Deming’s experience shows, a mindful person can learn a great deal about what customers experience. Many organizations would benefit from such an exercise (but what can be learned depends a great deal on how well the customer understand viewing the organization as a system so pay attention to that reality).

Related: Healthcare, Paradigm Shifts and the Influence of W.E. DemingCustomer Focus with a Deming PerspectiveAsk patients what one thing could be improved (get actionable information based on an understanding of psychology)

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6 Responses

  1. Mark Graban says:

    I didn’t know he had been stabbed!

    I agree that many things haven’t changed since the publication of that article.

    Some hospitals are, thankfully, using “3P” and “Lean Design” methods to make sure details are being anticipated… such as a hook for a patient to hang their IV bag when using the bathroom. Little details matter for safety and satisfaction.

    The problems we see in healthcare today are indeed system problems. We need more than everybody doing their individual best, as Dr. Deming said.

    Here is an article I saw recently about a hospital CEO experiencing things as a patient. Why can’t a CEO or CNO or other executives pay attention to the details, seeing what problems face their patients and staff, as part of their actual leadership role??

    One of the leaders in the Lean healthcare movement, Dr. Charles Kenagy, got his passion for improvement after he broke his neck and had to be treated by the healthcare system. He saw the flaws first hand. But again, leaders need to pay attention to this without being injured or getting sick themselves.

  2. Brian Moody says:

    Great article. I am reminded of my Lean experiences with a large, rural hospital system. I often encouraged improvement teams to experience care delivery paths(Gemba walks). I likened it to the concept of “mystery shopping.” It is one thing to hear about the challenges from VOC channels – yet a uniquely different experience to live it.

  3. Tim says:

    Excellent article. Thank you for sharing!

  4. Lloyd Gough says:

    Broke my leg cross country skiing. Been involved with auto manufacturing for many years. Deming’s perspectives and lean have always been fascinating.

  1. January 5, 2017

    […] It became my mission and driving focus – to help create better workplaces that didn’t beat people down, crushing their spirits. Sadly, these same forces of destruction exist in too many healthcare organizations today. That’s also something I will cover in a future post, along with my reactions to Dr. Deming’s “Notes on Management in a Hospital,” as John Hunter blogged about earlier this year. […]

  2. January 30, 2017

    […] was happy to see John Hunter share the article on the Deming Institute blog last year, along with some context. It had been published in the journal of the Society for Health Systems […]

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