Over the last few months, I have been reading older books. Our patient postie has delivered a steady stream of second hand books to our door. I’ve taken to putting a cushion under the letterbox so that the books don’t get damaged in the last three feet of their journey. (Our postie, originally from the Netherlands, is multi-talented. I once came home to a note inside my door saying only ‘Ibsen‘. After five minutes of puzzling, I realised that the postie had left an-oversized parcel inside a doll’s house in the garden.)
I’ve learnt a lot from the books I’ve read, including the realisation that a new book does not necessarily mean new ideas. This is not surprising: quality improvement has been around for a long time. Some of the early books were written by people with thirty years experience. There is enormous learned experience in many of these works.
This week, I’ve been reading ‘What is Quality Control?‘ by Kaoru Ishikawa. The book was originally published in Japanese in 1981, over a third of a century ago, based on work Ishikawa had undertaken dating back to the 1950s. Ishikawa will be familiar to many as the originator of what Deming termed ‘the Ishikawa diagram’ – often called a fishbone diagram. His career spanned decades, and he is particularly associated with quality control. Interviews with Eiji Toyoda make it clear that Toyota did not only use Lean, but actively encouraged other approaches, including quality circles. Ishikawa’s book fills in some of the gaps.
There is enough material in this book for a year of blog posts, but I want to pick up a discussion about half way through the book. Ishikawa lists six requirements of quality control, which are widely relevant to quality improvement work in general, and to the philosophy of Lean in particular:
1. Quality first – not short-term profit first.
2. Consumer orientation – not product orientation. Think from the standpoint of the other party.
3. The next process is your customer – breaking down the barrier of sectionalism.
4. Using facts and data to make presentations – utilisation of statistical methods.
5. Respect for humanity as a management philosophy – full participatory management.
6. Cross-function management.
I have left the wording of the 1985 English translation unchanged, and many of the terms relate to industry. The ideas link well to Lean healthcare despite their industrial origins.
Lean in healthcare assumes that quality has a value in its own right, and that a focus on quality will deliver benefits. Putting patients first is a core Lean healthcare assumption, while the use of facts and data is the very breath of Lean: my colleague, Gavin Hookway, has a poster that he designed that says ‘don’t guess: go to the gemba’ – go the place that work is done to see what is actually happening.
Assuming that you are providing a service, looking at patient flow over a process, rather than individual departmental actions, and trusting staff to identify and make improvements, are also key Lean assumptions. Quality improvement, whatever term is used to describe it, has similar assumptions, and similar aims.These principles are as relevant today as when Ishikawa developed them.