Doing it right the first time.

Since 1979, Philip B. Crosby, Founder and Chairman of Philip Crosby Associates, Winter Park, Fla., has been applying the quality principles that he developed and applied at ITT for a variety of clients. About 900 firms, 200 of them in the Fortune 500, have gone through the process that he recommends for the development of a corporate attitude of quality. Earlier this year, Physician Executive interviewed Mr. Crosby. We talked about his general approach to issues of quality in products and services, and began to make the connection between his quality theories and their application in the health care industry.

"All work is a process."

"Quality has to be defined as conformance to requirements, not as goodness. "

"The system for causing quality is prevention, not appraisal."

"The performance standard must be zero defects, not That's close enough."

"The measurement of quality is the price of nonconformance, not indices."

The concepts at the right guide Philip Crosby's work in quality improvement. And he believes that the concepts apply across the board, to health care organizations as to automobile manufacturers and the that health care is changing. Not that long ago," he says, "nobody was in charge. There was an administrator of the hospital, but nobody was really in charge. Physicians had power, but the organization was essentially a happening."

Mr. Crosby says that technological and structural changes in the health care system have obsoleted that helter-skelter approach. But the changes have also led to a greater demand for quality in the provision of services. There is no modifier on quality, you will note. Quality is neither good nor bad, high nor low. That is a part of the notion of quality that Mr. Crosby sells and that has been successful for the many companies he has consulted for.

Mr. Crosby points to the uneasy relationship between hospitals and physicians as evidence of an inattention to quality in the system. Administration keeps demanding more and more paperwork from doctors. But doctors don't want to fill out forms. They want to treat patients. At my company, I don't fin out forms. None of our top managers and professionals do. We arrange for that. And hospitals should arrange for people to fill out the paperwork and leave doctors and nurses to care for patients." Mr. Crosby says that the failure to relieve doctors of the burden of paperwork is more indicative of the power struggle in the health care system than it is of any notions of quality and its attainment.

The problem, Mr. Crosby says, is that health care organizations are "departmentalized" By tradition, or inertia, certain departments are expected to do certain things. The laboratory does lab work, the laundry cleans linens, and doctors (and nurses) do paperwork. Quality improvement requires that the entire organization be energised to attend to quality. It has to be a corporate mission, committed to at the top and communicated effectively throughout the organization," he says. All of the organizational units have to work together on it. There has to be a common understanding of what quality is."

To attend to quality, Mr. Crosby says, everyone has to know what the requirements are. It is very important, he says, that the organization view quality as meeting some expectations. "It has nothing to do with goodness, except as meeting standards is good. Quality starts with the setting of requirements for everyone. Its measurement entails the degree to which those requirements are met."

Mr. Crosby says that the trouble with the goodness criteria is that it is too subjective. "There is no high, good, or low quality. There is only quality--expectations--and how they have been met." If you want people to do things right the first time, he says, you have to tell them exactly what it is that you expect. If you want them to learn from their mistakes, you have to have clearly understood expectations against which they can measure their performance.

It is prevention that drives the quest for quality, Mr. Crosby says. If the requirements have been spelled out in an understandable and understood way, and if the requirements are the correct requirements, quality should result. All of this educational process and striving for agreement is meant to prevent errors. When errors occur, it must be assumed, he says, that the requirements need adjustment.

The other point that Mr. Crosby stresses is that the first assumption in the face of an error should not be human error, followed by blame-setting. "Failure to attain quality,' he says, "almost always means that some fault lies in the requirements for the work. If the requirements have been set properly and communicated understandably, quality will result. Conformance with requirements will be achieved."

And, he says, under these circumstances, quality is always Zero Defects." What is sad, he says, is the amount of money and resources that are given, in most companies, to the correction of errors. "There is always time and money to do things over, to get them right the second time. The goal of quality is perfection the first time. And perfection is attainable," he says. "Just remember. The definition is conformance with requirements. Quality is meeting those requirements. Perfection is meeting the requirements the first and every time." If the requirements are set correctly, he says, that is an attainable goal.

The price of nonconformance with requirements, Mr. Crosby says, is high. Probably 40 percent of the price of our products and services, he says, comes from the need to make products over and provide services repeatedly because of mistakes. If the requirements for the jobs involved are thoroughly understood and conformed with, he says, there are no errors. And the profits on the products and services go up. They are not eaten up by errors, he says.

Mr. Crosby makes it dear that he is not describing an instantly errorfree organization. "If the proper culture has been installed by top management and if that culture has been transmitted throughout the organization, errors will be lessons. People win learn from them. And they will not recur." Mostly, he says, the errors will come from improper requirements.

"It win be the requirements that will have to be changed."

"The health care world is a world of imprecise information," Mr. Crosby says. Health care managers don't deal with the organization as a whole. "There is no overall culture. And it is the overall culture that needs to be put into place so that attention to quality can begin," he says. The job of top management is to establish the culture that encourages attention to quality and that rewards conformance with requirements. "The culture has to be pervasive," he says. "First top management has to accept and operate on the basis of these concepts of quality. Then it has to help the rest of the organization accept them."

In the courses that Mr. Crosby's company runs on quality improvement techniques, top managers from all kinds of environments learn together. He believes this is important in that it helps to eliminate the "I'm different" syndrome. "When there are bankers, food service operators, foundry owners, and a whole raft of different people, they can all hear that the others have similar problems, that they are not so different."

This learning together has application within the organization itself. "Work is a process," Mr. Crosby says. "All the different jobs have to work together if attainment of quality is to be possible. The most talented and wonderful brain surgeon would get nowhere without a whole team of people, each meeting his or her own requirements. The brain surgeon has to understand that his or her work is related to the work of others in a process by which quality is attained because everyone has conformed with the requirements of their jobs." Everyone in the process depends on others. Because of this interdependence, it is critical, he says, that the culture of quality is instilled organizationwide.

"The organization has to have a policy, a common understanding, that it will deliver defectfree products and services on time," Mr. Crosby says. "Every organization must have this policy. Health care organizations are struggling because they can't get past statements such as, The patient's health is our primary concern.' They fall back on how different they are from others and on patient care as an excuse not to deal with quality in an effective way."

So where does all this leave physician executives. Two things are said most often about the profession. One, it is the bridge between practicing physicians and management. Second, the most significant part of the physician executive's job is concern for the quality of the services that the organization offers. How does the physician executive fit into the quality scheme that Mr. Crosby describes? He believes that physicians in organizations can be instrumental in ensuring that top management gets the quality message. "Nothing will change unless commitment is first gained from the top. The organization will continue to muddle around. Administration has to make the cultural changes that get things started."

Mr. Crosby says that it is best if the requirements that will be used to define quality are set close to the point at which the requirements will be met. Doctors, he says, should be the ones who set the requirements, or standards of practice, for the organization. They can be held to conformance with those standards, he says, but they will be happier setting the standards themselves. Physician executives, because they understand both medicine and management, can be helpful in ensuring that the organizational culture and the requirements of the organization ensure that happiness. And these steps, he says, will go far in bringing quality to the organization's services. o

T H E A U T H O R

Wesley Curry is Editorial Director of the American College of Physician Executives, Tampa, Fla.

Further Reading

For more than 20 years, Philip Crosby has been writing on the issue of quality, building and enlarging on the concepts that he has used effectively both in the industrial world and in his consulting and teaching. All of the following books are published by the McGraw-Hill Publishing Co. Only Cutting the Cost of Quality is out of print. The remainder should be available through local bookstores, and all should be available in most libraries.

Cutting the Cost of Quality, 1966.

The Art of Getting Your Own Sweet Way, 1972 (second edition in 1982).

Quality is Free., The Art of Making Quality Certain, 1979.

Quality Without Tears: The Art of Hassle Free Management, 1984.

Running Things: The Att of Making Things Happen, 1986.

The Eternally Successful Organization: The Art of Causing corporate Wellness, 1988.

Let's Talk Quality., 99 Questions You Always wanted to Ask Phil Crosby, 1989.